Thyroid pathology in the aged]

Following a review of the literature on this topic, the authors examine all patients with thyroid pathologies who were admitted to the 1st Institute of Surgical Pathology of the University of Pavia between 1-1-1974 and 31-12-1990. Only patients aged over 65 were included in the study and were subdivided into two groups, namely those aged between 65-74 (3rd age) and those over 75 (4th age). Particular attention was focused on the type of pathology (benign or malignant), other pathologies associated to the basic pathology, the type of operation performed and, in the case of malignant diseases, the histological type of tumour and any metastasis. The results of this series were then compared to those reported elsewhere. The Authors conclude that thyroid pathologies in geriatric patients are very important since, given that at this age the gland is becoming atrophic, the onset of disease often occurs before the age of 65 and symptoms in these patients are imprecise. In view of the good results obtained, it is always worth operating in order to give the patient a reasonable life expectancy, especially in those cases with collateral disorders (compression) caused by the thyroid mass.     

Arteritis in aged patients]

Gangrene is the usual reason for admission to a surgical unit in elderly patients with peripheral vascular disease. It is often the first sign of arterial disease occurring in a foot with satisfactory skin and may be triggered off by trauma or infection. Obstruction at various levels of the profunda femoris artery, of the main leg arteries with calcification of the media, are the usual characteristics, whether the patient is diabetic or not. This explains why reconstructive vascular surgery is rarely possible but this, nevertheless, remains the best chance for obtaining healing of trophic disorders with limited removal of the toes. No failure was observed in cases of axillo-femoral or femoro-femoral by-pass. But, as in diabetics, one may, in elderly patients with gangrene, attempt to conserve weight-bearing areas thanks to medical treatment in association in some cases with lumbar sympathectomy when the patient's general condition makes this possible. The mortality is low when patients are selected for operation and depending on the surgical technique adopted, e.g. sub-cutaneous by-pass or surgery of the origin of the profunda femoris. The mortality is less than 7 p. 100 during the first month (one death in 31 vascular operations, one death in 40 sympathectomies), but the mortality during the first 6 months exceeds 20 p. 100 due to cardiac, or cerebral complications or urinary infection. The prevention of digestive symptoms, nutritional, renal or urinary complications, and electrolyte disturbances is essential together with physiotherapy and reduction in time spent in hospital, for example, the patient may be sent home and treated by the district nurse. 135 patients with arteritis, including 48 diabetics, aged over 70 years, admitted to hospital in 1971 at the Saint-Joseph hospital, illustrate these findings. 109 patients with 114 diseased limbs, had gangrene or ischemic ulcer. Out of 80 survivors, beyond 6 months, i.e. 84 limbs, in 75 cases the weight bearing areas were preserved, in 9 cases amputation was necessary but in 8 of these it was possible to carry out amputation below the knee and walking was possible. These functional results justify attempts to maintain weight bearing areas or, at least, the knee, whatever the duration of healing or amputation of a toe or of the metatarsus; in Syme's amputation of the leg, healing requires 2 to 4 months.     

Urinary lithotripsy in children. Multicenter study of the Pediatric Urology Study Group]

The authors present the results of a survey conducted among French paediatric urologists belonging to the Groupe d'Etudes en Urologie Pédiatrique (GEUP) (Paediatric Urology Study Group). This study, based on 122 cases observed in 13 centres, is not exhaustive, but is nevertheless statistically significant. The preoperative assessment confirms the usual findings of urinary stones in children: pyelonephritis, haematuria and abdominal pain, the usual presenting complaint, concomitant malformative uropathy (10% of cases) and a predominance of calcium stones. More than 200 stones were treated, larger than 10 millimeters in diameter in one-third of cases. Renal stones, mainly caliceal (more than 50%), included 11 staghorn calculi. This study also included 22 ureteric stones, mainly in the pelvic ureter, and 2 bladder stones. Lithotripsy was ultrasound-guided in 2/3 of cases and required general anaesthesia in about 3/4 of cases. Ureteric catheterization was required in 19 infants preoperatively, but in only 2 infants (stein strasse) postoperatively. One or two lithotripsy sessions were sufficient in most cases, but 4 sessions were necessary in 5 patients, to the same kidney in 1 case. The mean hospital stay was 2 to 3 days, but the procedure was performed on an outpatient basis in 15 cases. The immediate postoperative course was uneventful and asymptomatic. This survey revealed about 10% of complete failures, corresponding to solitary caliceal stones in 2/3 of cases; 29 partial failures were essentially due to lower caliceal stones and staghorn calculi; 84 successes (stone-free), mainly pelvic or simple caliceal stones. Scintigraphy did not reveal any immediate postoperative impairment of renal function. This study reported a success rate of about 70%, regardless of the type of apparatus used. Assessment of the results of ESWL requires sufficient follow-up both concerning the outcome of fragmented stones and evaluation of possible functional repercussions. This survey defines the main indications: although ESWL can be applied to most stones, some stones constitute poor indications (cystine stones, stenotic malformative uropathy) or dubious indications: small lower caliceal stones, densely calcified staghorn calculi in older children. This study confirmed the efficacy and low morbidity of ESWL in children. A prospective study needs to be conducted according to a rigorous protocol in order to refine the technique and indications while reducing the possible long-term risks.     

Acute arterial obstructions of the limbs in the aged]

131 cases of acute arterial obstruction were treated during 1973-1977, 70 (52%) of these cases were seen in patients of over 70 years of age and 20 out of them died during the first two months of the surgical treatment, 8 patients were amputed. The long term evaluation of 40 patients who survived for more than two months after the surgical treatment shows a very high mortality (14 of the 40 surviving patients died during the first two years of the surgical treatment). Satisfactory results were obtained in 18 patients. The long term results after arterial obstruction in old patients has high mortality and the number of amputations is directly proportional to the delay before commencement of the surgical treatment.