Substernal and intrathoracic goiter. Reconsideration of surgical approach

Thirty-one patients were operated on for benign thyromegaly extending to the thorax in an 11-year period at the University of Alabama in Birmingham. Neck mass (65%), dysphagia (36%), and dyspnea (32%) were the most common symptoms. All patients were euthyroid. Five patients had previous thyroid surgery. A thyroid scan was performed on 24-patients. Fourteen (58%) suggested a thoracic extension while ten (42%) failed to identify a thoracic extension. The indications for resection were increasing symptoms, increasing size despite the use of dessicated thyroid therapy, and to establish a diagnosis. The left thyroid lobe extended into the thorax more frequently (70%) than the right. Most patients had multinodular goiter (94%). Three patients had occult carcinoma (10%) and two patients had Hashimoto's disease. Median sternotomy combined with a collar incision to provide exposure for excision of intrathoracic thyroid extension was used in six patients. There was no operative mortality. There was no increase in operative morbidity and a slight increase in average stay from 5.3 days with a collar incision alone to 6.8 days with the combined incisions. Median sternotomy does not increase morbidity or mortality. Specific indications for more liberal use of sternotomy extension of a collar incision are proposed for the management of substernal and intrathoracic goiters.     

胸内甲状腺肿的外科治疗(附18例报告)

胸骨后甲状腺肿,具有较为特殊的临床表现和病理类型,手术时有一定的难度.我院于2002年至2005年经手术及病理证实为胸骨后甲状腺肿18例.现将其临床表现、诊断及术式选择的体会报告如下.……     

Transclavicular approach for brachial plexus reconstruction

Brachial plexus injuries requiring extensive exposure might benefit from a transclavicular approach. At a level 1 trauma center, 20 patients underwent surgical intervention for brachial plexus injuries, 10 via a transclavicular approach. For 5 patients, the transclavicular approach was accomplished through osteotomy with a technique presented herein, and for the other 5, through an established nonunion. All osteotomies and nonunions healed. No hardware-related complications occurred. We think that in the appropriate setting, a transclavicular approach facilitates exposure, decreases surgical time, and is associated with minimal risk.     

Results of surgical treatment in multinodular goiter with an intrathoracic component

PURPOSE: (1) To determine the clinical profile of intrathoracic multinodular goiter (IMG); (2) to evaluate the results of surgery, and (3) to analyze the incidence of malignancy and its evolution. METHODS: Two hundred and forty-seven operated cases of IMG were reviewed. These cases of IMG had all been diagnosed according to Eschapse's definition (>3cm below the sternal manubrium). The morbidity and postoperative evolution were analyzed. A comparative study was carried out on a group of 425 cases of nonintrathoracic goiter. We applied the chi(2) test, Student's t-test, and a logistical regression analysis. RESULTS: Intrathoracic MG occurs in patients over 60 years of age, with goiter which has a long evolution time (>12 years), and more than 60% are symptomatic. Oral tracheal intubation was difficult in 10% (n = 24) of the cases, and 7 required the use of a fibrobronchoscope. In 8 cases (3%) a thoracic approach was necessary. Morbidity occurred in 24% (n = 59), most notably 29 recurring lesions (12%), of which 2 were definitive (0.8%), and 31 hypoparathyroidisms (13%), of which 1 was definitive (0.4%). No significant difference was found in the postsurgical morbidity between the intrathoracic MG and the nonintrathoracic cases. Regarding the remission of the symptoms, the results were excellent. In 14 cases (5.7%) thyroid carcinoma was related with, most of these being papillary microcarcinoma. In 10 of the 49 cases of partial surgery (20%) a relapse of the goiter was observed. CONCLUSIONS: Intrathoracic MG is usually asymptomatic and it occurs in goiter with a long time of evolution. Surgery is a good therapeutic option given that the goiter can be removed via the neck, with low morbidity, a remission of the symptoms, malignancy is ruled out, and recurrence can be avoided if a total thyroidectomy is performed.     

Life-threatening giant mediastinal goiter: a surgical challenge

Mediastinal goiter is a well known benign disease, usually resectable through a cervical approach with minimal morbidity and mortality. Only occasionally a median sternotomy or a lateral thoracotomy may be required. The present case is worthy of presentation because of the exceptional dimension of the disease and the surgical challenge that it presented. In a 72-year-old woman a large intrathoracic goiter of the right thorax caused a severe dyspnoea due to an important contralateral mediastinal shift with compression of the lung, superior vena cava system and trachea. At surgical exploration, through a cervico-sternotomic approach, the mediastinal structures dislocation and the strong adherences between the anomalous neovascularized capsula of the mass and the surrounding structures, complicated the surgical dissection. An accidental lesion of the innominate artery required its reimplantation on the ascending aorta. An immense mass, was finally removed and pathological examination revealed a rare case of neovascularized, pseudosarcomatoid capsula among a benign hyperplastic proliferation. In spite of its benign nature, a giant goiter caused a life-threatening compression of the respiratory tract and lung parenchyma in this patient. The dimension of the lesions, the mediastinal anatomy alterations and the severe intraoperative haemorrhage represented major technical difficulties during surgical resection.     

An alternative surgical approach for aortic infective endocarditis: vegetectomy

We describe a case of successful vegetectomy of the aortic valves for early infective endocarditis. An aortic vegetectomy was performed as an alternative to valve replacement for a 54-year-old man with three vegetations and mild regurgitation in aortic valve due to infective endocarditis. Postoperative clinical course was without signs of recurrent infection after follow-up of 19 months, and transesophageal echocardiography demonstrated aortic valve competence. We would suggest that vegetectomy with valve sparing may be a viable option in the context of early infective endocarditis involved aortic valve in selected patients.     

An alternative aerosol delivery system for amiloride.

BACKGROUND--The advent of novel treatments such as aerosolized amiloride are potentially useful additions to the therapeutic options available for the treatment of cystic fibrosis. Unfortunately, amiloride and other aerosolized drugs such as antibiotics are generally administered via jet nebulisers which are time consuming to use, and thus limit the acceptance and efficacy of these forms of treatment. In vitro experiments were performed in order to determine whether amiloride could be administered in dry powder form using a Turbohaler. METHODS--Amiloride was micronised and loaded into 200 micrograms Turbohalers. The dose delivered per actuation and particle size distribution of the generated aerosol were assessed using a flow of 60 l/min through the Turbohaler. The dose of amiloride delivered was measured by collecting the aerosol on a filter and the quantity of drug was assayed by an ultraviolet spectrophotometric method. The particle size distribution was assessed using a Malvern MasterSizer laser particle sizer and compared with that generated by a commercially available 200 micrograms budesonide Turbohaler. RESULTS--The mean (SD) dose delivered per actuation was 246.3 (40.4) micrograms. The volume median diameter of the amiloride aerosol was 3.80 (0.68) micron compared with 3.07 (1.47) microns for budesonide. CONCLUSIONS--These results suggest that therapeutic doses of micronised amiloride could be delivered effectively and conveniently as a dry powder aerosol using a Turbohaler.     

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目的 探讨胸内甲状腺肿的诊断方法及手术方式。方法 收集1958－2000年间经病理证实为胸内甲状腺肿65例。结果 主要依靠临床症状、X线、同位素扫描、CT检查诊断。肿物下极在主动脉弓上缘水平以上者41例（63．1％），在此水平以下者24例（36．9％）。均行手术治疗，手术径路分为颈部领式切口41例（63．1％），低位领式切口加胸骨正中切开11例（17．0％），开胸18例（12．3％），颈胸联合切口3例（4．6％），胸骨正中切开2例（3．0％）。术后并发症发生率15．4％，其中喉返神经损伤发生率7．7％；死亡率为1．5％。结论 手术切除是胸内甲状腺肿的首选治疗方法，喉返神经务是术后主要并发症，应注意预防其发生。并依据肿物不同情况采取不同的手术径路，宜先行衣领式切口，估计操作困难，病变达主动脉弓下者，应行胸骨切开或开胸处理。     

An alternative approach for management of the congenital giant inguinal hernia in neonates

Whereas inguinal hernias are commonly encountered in the neonatal population, giant hernias containing the entire small bowel and with complete inguinal floor disruption are significantly less common. These cases present clinical and technical challenges with the obliteration of normal anatomy and an attenuation of the expected abdominal domain. There is a scant literature available describing these hernias or their management in neonates. In this case report, we describe a neonate who presented with a giant unilateral inguinal scrotal hernia complicated by in utero perforation. This was managed by open herniorrhaphy, orchidopexy, and diagnostic laparoscopy.