Rudolf Roka

Laryngeal recurrent nerve injury in surgery for benign thyroid diseases: effect of nerve dissection and impact of individual surgeon in more than 27,000 nerves at risk.

ObjectiveTo evaluate the effect of recurrent nerve dissection on the incidence of recurrent laryngeal nerve injury (RLNI) and to analyze the performance of individual surgeons. Summary Background DataDissection of the recurrent nerve is mandatory in total thyroidectomy, but its relative merit in less extensive resections is not clear. The reported rates of RLNI differ widely; this may reflect a variation in the performance of individual surgeons. MethodsThe authors studied the incidence of RLNI in primary surgery for benign thyroid disease during three periods in a single center. In period 1 (1979–1990; 9,385 consecutive patients, 15,865 nerves at risk), the recurrent nerve was not exposed. In period 2 (1991–1998; 6,128 patients, 10,548 nerves at risk), dissection of the recurrent nerve was the standard procedure. Global outcome and individual performance in these two periods were compared and presented to the surgeons. The effect of this quality control procedure was tested in 1999 (period 3; 930 patients, 1,561 nerves at risk). ResultsExposure of the recurrent nerve significantly reduced the global rate of postoperative and permanent RLNI. Some but not all surgeons improved their results by recurrent nerve dissection (e.g., permanent RLNI rates ranged from 0% to 1.1%). The documented significant differences in individual performances did not affect the outcome in period 3. The extent of nerve dissection was a source of variability; the rate of permanent RLNI averaged 0.9%, 0.3%, and 0.1% for surgeons who only localized, partially exposed, and completely dissected the recurrent nerve, respectively. ConclusionsRecurrent nerve dissection significantly reduces the risk of RLNI. Extensive dissection facilitates visual control of nerve integrity during resection and is therefore superior to a more limited exposure of the nerve. Quality control can improve the global outcome and identify the variability in individual performance. This cannot be eliminated by merely confronting surgeons with comparative data; hence, it is important to search for the underlying causes.

Jejunal Grafts for Reconstructing a Phonatory Neoglottis in Laryngectomized Patients

SummaryAfter laryngopharyngectomy and reconstruction of the upper digestive tract, a free jejunal graft can be anastomosed in an isoperistaltic direction end-to-end to the trachea and the hypopharynx in order to form a shunt for vocal rehabilitation. Following placement of the shunt, no special care is required nor does any patient show any aspiration. Because of a low-flow resistance of the shunt, patients so treated possess long-lasting phonation with loud and modulated voices.

Dietary Changes after Vertical Banded Gastroplasty

Background: Gastric restriction surgery relies on obstruction to oral intake by formation of a gastric pouch. Therefore, the therapeutic effect is closely related to intolerance for different types of food, and an ingestion of an unbalanced diet. We investigated dietary changes after VBG and their associations with therapeutic success. Methods: 70 patients (4 men, 66 women, median age 32) with a median preoperative BMI of 44.6 were examined ≥ 3 years after VBG. Weight reduction, nutritional changes (type ofdiet,number of daily meals,amount of food that could be ingested, intolerance for different types of food, frequency of vomiting), satisfaction with results, and willingness to undergo the operation once again were investigated. Results: The average reduction of the BMI was 13, with sufficient weight loss in 80%. 36% were eating a solid, 43% a soft, and 21% a liquid diet. Weight reduction did not depend on the type of diet eaten but on the ingestion of sweets. 93% indicated they could take only small amounts of food. The average number of daily meals was 3. 76% reported an intolerance for some type of food (most often meat, fruit, or vegetable). Vomiting was the most common problem and occurred in 71%. 71% indicated a high level of satisfaction with the results of the operation, and 96% said they would undergo the operation again. Conclusions:The investigation demonstrated successful weight reduction despite dietary changes in 80% of patients after VBG. Weight reduction was not influenced by type of diet but depended on consumption of sweets.

Evaluation of glucose tolerance, insulin secretion, and insulin action in patients with primary hyperparathyroidism before and after surgery

SummaryGlucose tolerance, insulin secretion, and insulin sensitivity were evaluated in 8 asymptomatic patients with primary hyperparathyroidism (PHPT) before and at least 8 weeks after surgical correction of PHPT by means of the hyperglycemic clamp technique. In addition, 15 sex- and agematched control subjects were investigated for comparative reasons by the same technique. Glucose metabolized (M) during the hyperglycemic clamp was not significantly (NS) different between patients with PHPT and controls (7.9±2.3 vs. 6.3±1.9 mg/kg/min). However, insulin secretion (I) was significantly elevated in patients with PHPT compared to controls (87±17 vs. 45±12 μU/ml,P<0.05). The calculated insulin sensitivity index, (M/I) was significantly reduced in PHPT compared to controls (11.0±2.1 vs. 15.2±1.4 mg/kg/min per μU/ml×100,P<0.05). Comparing patients with PHPT before and after surgery, the M value, which is a measure of glucose tolerance, was not significantly different (7.9±2.3 vs. 7.8±1.5 mg/kg/min). However, insulin secretion was significantly lower after surgical correction of PHPT compared to the preoperative situation (48±9 μU/ml vs. 87±17 μU/7 ml,P<0.01). The calculated M/I rose significantly after surgery compared to the preoperative value (11±2.1 vs. 17.6±2.7 mg/kg/min per μU/ml ×100,P<0.001). We conclude that disturbed carbohydrate metabolism such as insulin hypersecretion and insulin resistance, in patients with PHPT is an early finding in this disease and that these early disturbances in glucose metabolism are, however, fully reversible. Correction of disturbed carbohydrate metabolism in PHPT might be a distinct argument for early surgical intervention in this disease.

Establishment of primary cultures from human colonic tissue during tumor progression: Vitamin‐D responses and vitamin‐D‐receptor expression

Primary cultures derived from pre‐cancerous and cancerous human colon tissue are essential for understanding normal and abnormal growth function in the large intestine. Here presented are (i) the methodology for routine establishment of primary cultures of normal, adenoma‐ and carcinoma‐derived cells, and (ii) data for the apparently protective role of vitamin‐D compounds in colon carcinogenesis. The steroid hormone 1,25‐dihydroxyvitamin D3 and some non‐hypercalcemic analogs reduce the high mitotic rate of adenoma cells to that of normal colonocytes. After vitamin‐D treatment, tumor cells are less proliferative and differentiation is enhanced. Primary‐colon‐cancer cultures display a mosaic pattern of vitamin‐D‐receptor expression, at the mRNA level and at the protein level, with varying intensity of expression in positive cells. This suggests that, in human colorectal tumors in vivo, a large fraction of cells will respond to genomic action of vitamin‐D compounds. Int. J. Cancer 75:467–472, 1998.

Treatment of Gastro-Jejunal Leakage and Fistulization after Gastric Bypass with Coated Self-Expanding Stents

Leakage and fistulization of the gastro-jejunostomy have been the major drawback of Roux-en-Y gastric bypass (RYGBP) surgery. Most authors agree that operative treatment is the mainstay of therapy in patients with signs of sepsis. However, intestinal contents causing localized infection may impede healing of sutured leaks in some patients, and fistulas develop. Because the anastomosis cannot be disconnected or exteriorized for anatomical reasons, other forms of treatment have to be applied. The following case-reports describe a technique with implantation of coated self-expanding stents. Leakage of the gastro-jejunostomy occurred in one patient 3 days after RYGBP and resulted in formation of a fistula. A fistula developed in a second patient 63 days after RYGBP. Coated self-extending stents were implanted endoscopically in both patients on postoperative days 19 and 67. Enteral nutrition could be started 6 days later. Stents were removed 2 months after implantation without problems. Weight loss and quality of life 7 and 21 months after stent removal have been excellent in both patients. Implantation of coated self-expanding stents was an effective and minimally invasive option for gastro-jejunal anastomotic fistulas after RYGBP where surgical repair was not possible. In these cases, application of stents allows septic source control without any other intervention.

Band slippage--a potentially life-threatening complication after laparoscopic adjustable gastric banding.

Background: Although gastric bands are safe and effective devices, severe late complications may develop in rare cases. Patients: 3 patients were treated for complete dysphagia after slippage of gastric bands. 2 of the patients were admitted for severe dehydration, 1 of whom developed cerebral venous infarction. Ischemia of the gastric pouch occurred in 1 patient. Results: All 3 patients survived after successful medical therapy and surgical removal of the bands. Bariatric reoperations were performed in 2 patients (gastric sleeve resection, gastric bypass). Conclusion: Complete dysphagia on the basis of band slippage represents a life-threatening acute event, which may occur even years after implantation. Patients and doctors should be informed about this long-term risk of gastric banding.

Hemangioendothelioma of the thyroid gland--true endothelioma or anaplastic carcinoma?

After a critical histological re-examination of 26 cases of malignant hemangioendothelioma of the thyroid, and a comparison with 51 cases of anaplastic spindle and giant cell carcinoma, it becomes obvious that traumatic and shrinkage artefacts due to fixation, as well as superimposition of neoplastic and repair processes due to regressive changes--almost always seen in malignant hemangioendothelioma associated nodular goiter--may be misinterpreted as neoplastic vascular spaces (and therefore angioblastic tumour differentiation). Focal epithelial arrangements of tumour cells often observed in these malignant hemangioendotheliomas and the lack of objective light microscopic differential diagnostic criteria of anaplastic spindle and giant cell carcinoma make the high incidence of endotheliomas of the thyroid in European endemic goiter regions very questionable. Compared with anaplastic spindle and giant cell carcinoma, the incidence for (1) extrathyroid tumours that infiltrate into the trachea or the oesophagus, (2) lymph node metastases and (3) distant metastases is not statistically different in malignant hemangioendothelioma. Therefore we conclude that the tumours classified as malignant hemangioendothelioma in goitrous areas represent a special growth pattern of anaplastic spindle and giant cell carcinoma within adenomatous glands rather than a distinct tumour type.

Differential diagnosis of benign and malign pancreatic masses with 18F-fluordeoxyglucose-positron emission tomography recorded with a dual-head coincidence gamma camera.

Introduction Metabolic imaging using 18F-fluordeoxyglucose and a ring-positron emission tomography camera is an established method in the differential diagnosis of pancreatic masses. Ring-positron emission tomography cameras, however, are expensive and available in only few specialized centres. The aim of this study was to investigate how far 18F-fluordeoxyglucose scan with a conventional dual-head gamma-camera could differentiate between benign and malign pancreatic masses. Material and methods Forty-one patients (male/female: 25/16; mean age: 64.0 years; range: 41–86 years) with a pancreatic mass detected by ultrasound, computed tomography or MRI were included. In all patients 18F-fluordeoxyglucose scan was performed after overnight fasting and injection of 4 mCi 18F-fluordeoxyglucose using an ADAC Vertex MCD dual head gamma-camera (ADAC; Milpitas, California, USA), equipped with a 5/8-inch NaI-crystal. Images were acquired through a 180° grade rotation in the three dimensional mode. The chosen matrix was 128×128×16, a Butterworthfilter (ADAC) was used and data were transferred into visible sinograms via Fourier-Rebinning. Coronar, sagittal and transversal slices of 3.9 mm thickness each were acquired. Focal tracer enhancement was suspicious for a malignoma and therefore regarded as positive, diffuse or no tracer uptake was suspicious for a benign process and was regarded as negative for cancer. Definition of gold standards A diagnosis of cancer had to be confirmed histologically by specimens obtained by 18G-needle biopsy, surgical resection or at autopsy. A diagnosis of an inflammatory mass was considered proven, if no carcinoma could be found histologically in the surgically resected mass or at autopsy, or if there was no progression of the disease during a follow-up of at least 12 months. Results In 22 patients carcinoma was diagnosed (pancreatic cancer: n=17; endocrine tumour: n=3; carcinoma of the common bile duct: n=2). 18F-fluordeoxyglucose scan showed a focal tracer enhancement in 19 of these 22 patients (sensitivity: 86.4%). False negative results were acquired in two patients with cancer of the common bile duct and in one patient with poorly controlled insulin-dependent diabetes mellitus. In 19 patients the final diagnosis was an inflammatory pancreatic mass. 18F-fluordeoxyglucose scan showed a diffuse tracer enhancement in 15 of these 19 patients (specificity: 78.9%). False positive results were acquired in three patients whose blood tests showed signs of an acute episode of chronic pancreatitis. Positive and negative predictive values of 18F-fluordeoxyglucose scan were 82.6% and 83.3%, respectively. Conclusion 18F-fluordeoxyglucose scan with a conventional dual-head gamma-camera is a highly sensitive and specific method in the differential diagnosis of benign and malign pancreatic masses.

Parathyreoidektomie und Autotransplantation beim renalen Hyperparathyreoidismus

SummaryDuring total parathyroidectomy and autotransplantation 140 enlarged glands were removed in 35 hemodialyzed patients (normocalcemic:n =14; hypercalcemic:n = 21). The crosssections of all glands were classified intraoperatively. Diffuse hyperplastic (type 1) and nodular hyperplastic (type 2) glands could be distinguished. Using a stereo-magnifier (magnification: × 10 − × 16), type 1a- (stromal fat cells!) and type lbglands (without stromal fat cells!) could be differentiated. Those areas were also found between the nodules of type 2-glands. Significantly, nodular hyperplastic glands predominated in hypercalcemic patients (χ2-Test:p < 0.001). The colour of the nodules on the cross-sections of type 2-glands correlated with the predominating cell type (“dark”: nodule of oxyphile cells; “medium”: nodule of chief cells; “light”: nodule of ‘degenerating’ oxyphile cells). As sign of proliferation the mitotic index was elevated (>1:10000) in type 1b-glands, in type 1 b-like areas and in nodules of type 2-glands. These areas should not be used for autotransplantation.ZusammenfassungIm Rahmen der totalen Parathyreoidektomie und Autotransplantation wegen therapieresistentem renalen Hyperparathyreoidismus wurden bei 35 Hämodialysepatienten (normocalciämisch:n =14; hypercalciämisch:n = 21) insgesamt 140 vergrößerte Epithelkörperchen entfernt und am Querschnitt intraoperativ klassifiziert. Ohne Hilfsmittel war nur die Unterscheidung von diffusen (Typ 1) und nodulär hyperplastischen (Typ 2) Drüsen möglich. Innerhalb der Typ 1-Drüsen konnten unter Verwendung einer Stereolupe (10-und 16fache Vergrößerung) in Typ 1a- (Fettzellen!) und Typ 1b-Drüsen (Fehlen von Fettzellen!) differenziert werden. Ähnlich aufgebaute Areale fanden sich auch zwischen den Knoten der inhomogen aufgebauten Typ 2-Drüsen. Nodulär hyperplastische Drüsen kamen signifikant häufiger bei hypercalciamischen Patienten vor (χ2-Test:p <0,001). Unterschiedliche Farbschattierungen am frischen Querschnitt der Typ 2-Drüsen erlaubten Rückschlüsse auf den cellulären Aufbau der durch Bindegewebssepten isolierten Knoten („dunkel”: oxyphile Zellknoten; „mittel”: Hauptzellknoten; „hell”: Knoten aus überwiegend degenerierenden` oxyphilen Zellen). Vor allem in Typ 1b-Düsen und Typ 1bähnlichen Arealen sowie in den isolierten Knoten der Typ 2-Drüsen fand sich ein erhöhter Mitoseindex (> 1:10 000) als Zeichen einer erhöhten Proliferation. Diese Areale sollten von einer Autotransplantation ausgeschlossen werden.