Localization procedures in patients requiring reoperation for hyperparathyroidism

Numerous techniques have been described for the preoperative localization of hyperfunctioning parathyroid glands. During the past 2 years, 18 patients have had operations for persistent (14) or recurrent (4) hyperparathyroidism. One or more hyperfunctioning parathyroid glands were identified at operation in all but 1 patient and all but 2 patients became normocalcemic.Eighteen patients had ultrasonography, 17 patients had computed tomography (CT) scanning, and 13 patients had selective venous sampling (SVS) for parathyroid hormone (PTH) assay. These studies correctly identified the lesion(s) in 9 (50%), 8 (47%), and 9 (69%) of the patients, respectively. In 3 patients, probable parathyroid tumors were identified by ultrasonography and confirmed by aspiration biopsy cytology under ultrasonic guidance. All had parathyroid tumors confirmed at operation. The smallest tumor localized by ultrasonography was 0.6×0.6×0.6 cm and by CT scanning was 0.9×0.9×0.8 cm. There was 1 false-positive CT scan and 1 false-positive SVS. In the 2 patients who failed to become normocalcemic no localization study was positive. One of these patients subsequently had a 0.6×0.6×0.5 cm mediastinal adenoma localized by CT scan, nuclear magnetic resonance, and SVS. The tumor was removed via median sternotomy and the patient is now normocalcemic.Digital angiography has recently been helpful for mapping out the venous pattern for venous sampling for PTH. Ultrasonography and CT scanning complemented each other, since one or the other of these studies was positive in 15 patients, yet only 2 patients had both a positive ultrasound and CT scan. When any 2 localizing tests suggested the same site for the parathyroid lesion, the tumor was found in all cases.One patient developed post-pericardotomy syndrome after a medium sternotomy, but there were no other complications. Localization procedures expedite surgical treatment, decrease morbidity, and are strongly recommended in patients requiring reoperation for hyperparathyroidism.

---

Resumen Numerosos métodos de localización preoperatoria de glándulas paratiroides hiperfuncionantes han sido descritos. En el curso de los últimos dos años se han realizado operaciones en 18 pacientes con hiperparatiroidismo persistente (14) o recurrente (4). Una o más glándulas paratiroides hiperfuncionantes fueron identificadas en el curso de la operación en todos los pacientes, con una excepción, y todos los pacientes se convirtieron en normocalcémicos.Se realizó ultrasonografía en 18 pacientes, tomografía computadorizada (TC) en 17 y determinaciones venosas selectivas (DVS) de hormona paratiroidea (PTH) en 13; tales exámenes identificaron correctamente la lesión en 9 (50%), 8 (47%) y 9 (69%) del grupo total de pacientes, respectivamente. En tres casos se identificó la presencia de probables tumores paratiroideos por ultrasonografía y fue confirmada por medio de la citología o biopsia de aspiración bajo guía ultrasonográfica. Todos presentaban tumores paratiroideos que fueron confirmados en la operación. El más pequeño tumor localizado por ultrasonografía medía 0,6×0,6×0,6 cm, y por TC 0,9×0,9× 0,8 cm. Se presentaron un resultado falso positivo en CT y un falso positivo en DVS. En 2 pacientes en quienes no se logró la hipercalcemia, ninguno de los estudios de localización fue positivo. Uno de estos pacientes ulteriormente presentó un adenoma mediastinal de 0,6×0,6×0,5 cm, localizado por medio de TC, resonancia magnética nuclear y DVS; tal tumor fue resecado por vía de una esternotomía mediana, y el paciente se encuentra actualmente normocalcémico.La angiografía digital ha probado recientemente ser de utilidad para delinear el patrón venosa para la DVS. La ultrasonografía y la TC aparecen como estudios complementarios, puesto que el uno o el otro de estos estudios se hallo positivo en 15 pacientes y, sin embargo, sólo dos pacientes exhibieron la ultrasonografía y la TC conjuntamente positivas. Cuando uno de los dos exámenes de localización sugirió la misma ubicación de la lesión paratiroidea, se encontró siempre la presencia de un tumor. Un paciente desarrolló el síndrome de postpericardiotomía después de la esternotomía mediana, pero no hubo otras complicaciones. Los procedimientos de localización hacen más expedito el procedimiento quirúrgico, disminuyen la morbilidad y deben ser vehementemente recomendados en pacientes que requieran reoperación por hiperparatiroidismo.

---

Résumé De nombreuses méthodes ont été décrites pour déterminer le siège des parathyroïdes hyperfonctionnelles avant l'intervention. Au cours des deux dernières années 18 malades ont été opérés pour hyperparathyroidisme persistant (14) ou récidivant (4). Une ou plusieurs glandes responsables furent découvertes chez 17 sujets et 16 présentèrent une calcémie normale après l'opération.Dix-huit sujets furent soumis à une exploration par ultra-sons, 17 à une tomodensitométrie et 13 subirent un prélèvement sanguin veineux sélectif pour doser l'hormone parathyroïdienne, ces explorations permettant de localiser la lésion ou les lésions respectivement dans 9 (50%), 8 (47%) et 9 (69%) des cas. Chez 3 sujets la tumeur fut localisée par l'ultrasonographie et confirmée par la biopsie aspiration guidée par l'exploration aux ultra-sons. Tous les opérés présentaient une tumeur parathyroïdienne à l'intervention. La plus petite tumeur détectée par l'ultrasonographie mesurait 0,6×0,6 ×0,6 cm, celle par la tomodensitométrie 0,9×0,9 ×0,8 cm.Au passif de la tomodensitométrie s'inscrit un faux positif, au dosage sanguin un faux positif également. Chez les deux opérés dont le taux de calcémie ne revint pas à la normale, les explorations ne permirent pas d'abord de localiser la tumeur mais chez l'un des deux patients la tomodensitométrie, la résonance nucléaire magnétique et le dosage de l'hormone parathyroïdienne dans le sang permirent ultérieurement de découvrir un adénome (0,6×0,6×0,5 cm) médiastinal qui fut extirpé avec un plein succès.L'angiographie digitalisée s'est montrée utile pour définir la distribution du système veineux parathyroïdien et pour procéder aux prélèvements sanguins électifs.L'ultrasonographie et la tomodensitométrie sont des méthodes complémentaires puisque l'une ou l'autre de ces méthodes s'est montrée positive chez 15 sujets cependant que couplées ces deux explorations furent positives seulement chez 2 sujets.Quand l'une de ces deux explorations s'est montrée positive la tumeur fut toujours découverte au lieu déterminé par le test exploratoire.L'opéré pour adénome parathyroïdien médiastinal développa un syndrome secondaire à la péricardotomie mais tous les autres opérés n'accusèrent aucune complication.Les méthodes qui permettent de déterminer le siège des tumeurs parathyroïdiennes facilitent le traitement chirurgical et diminuent le taux de la morbidité. On peut les considérer comme indispensables, chez les malades qui doivent être ré-opérés pour hyperparathyroidisme.

---

---

Presented at the International Association of Endocrine Surgeons at Hamburg, September 1983.

---

Supported in part by the Medical Research Service of the Veterans Administration Medical Center.     

Laparoscopic reoperation for failed antireflux procedures.

BACKGROUND: Laparoscopic fundoplication has become the criterion standard for the surgical treatment of gastroesophageal reflux disease. Recently, several patients were referred with recurrent symptoms of gastroesophageal reflux disease or severe dysphagia following previous antireflux surgery for possible laparoscopic reoperation. HYPOTHESIS: To determine the safety and efficacy of this procedure. DESIGN: Case series, consecutive sample. SETTING: University-affiliated and community tertiary care hospitals. PATIENTS: Prospective study of 27 consecutive patients undergoing attempted laparoscopic reoperation for symptoms of recurrent gastroesophageal reflux disease or intractable dysphagia following antireflux surgery. Patients were available for follow-up for 1 to 60 months postoperatively. INTERVENTIONS: All patients underwent preoperative workup and attempted laparoscopic reoperation for treatment of symptoms. MAIN OUTCOME MEASURES: Data were collected on preoperative symptoms and evaluation, operative time, blood loss, time to regular diet, length of hospitalization, morbidity, mortality, and long-term results. RESULTS: Twenty-six patients underwent successful laparoscopic operations, with no mortality and minimal morbidity. One patient underwent conversion to open laparotomy and then developed a proximal gastric leak, which was treated conservatively. Twenty-four patients began a liquid diet by postoperative day 1, and most were discharged from the hospital by postoperative day 3. One patient required dilation for postoperative dysphagia. The remaining patients are doing well and none have required treatment with acid-reducing medication. CONCLUSIONS: Although technically challenging, laparoscopic reoperation for recurrent gastroesophageal reflux disease can be performed safely and with excellent results. In the hands of experienced endoscopic surgeons, patients who have undergone unsuccessful antireflux surgery should be offered laparoscopic reoperation.     

Late laparoscopic reoperation of failed antireflux procedures

Failures of antireflux procedures occur in 5% to 10% of the patients. Our objective is to report our experience with laparoscopic management of failed antireflux operations. Of 1698 patients who underwent laparoscopic treatment of gastroesophageal reflux disease (GERD), 53 were reoperations following either a previous open or laparoscopic antireflux procedure. The indications for surgical reoperation were persistent or recurrent GERD in 35 patients (66%), presence of paraesophageal hiatal hernia in 4 (7.5%), and severe dysphagia in 14 (26.4%). Hospital stay varied from 1 to 8 days, with an average of 1.2 days. Conversion to open laparotomy occurred in 10 patients (18.8%). The main causes for persistent or recurrent GERD were herniation (n=20) and disruption (n=12) of the fundoplication. Two patients had both herniation and disruption of the fundoplication. The main reason for severe dysphagia was tight hiatus. The most common reoperations were hiatal repair for hernia correction (n=26), redo fundoplication (n=16), and widening of the hiatus (n=12). Two patients had both hiatal repair and redo fundoplication. Intra (n=5) and postoperative (n=16) complications were frequent, but they were usually minor. There was no mortality. The present study demonstrated that laparoscopic reoperation for failed antireflux procedures may be performed safely in most patients with excellent result, low severe morbidity, and no mortality.     

Clinical results of reoperation after failed highly selective vagotomy

The results after reoperation after failed highly selective vagotomy during a 10 year period have been reviewed retrospectively. Forty of 306 patients (13 percent) underwent reoperation due to recurrent ulcer (25 patients), severe dyspepsia without proved recurrence (12 patients), and gastric stasis without recurrence (3 patients). In the first two groups, 16 patients had a second vagotomy and 17 underwent partial gastrectomy, 10 with gastroduodenostomy and 7 with gastrojejunostomy. The need for a second reoperation was disquietingly high after both revagotomy (5 of 16 patients) and partial gastrectomy with gastroduodenostomy (4 of 10 patients). These results contrasted with a successful outcome in all seven patients who underwent reoperation with partial gastrectomy and gastrojejunostomy. At the time of follow-up, 85 percent of the reoperated patients (34 of 40 patients) were in Visick grade 1 or 2 as determined by their own judgement.     

Laparoscopic reoperation after failed antireflux surgery

INTRODUCTION: Laparoscopic surgery for the treatment of gastroesophageal reflux disease has been established as being safe, effective, and the best alternative to continuous life-long medical therapy. Antireflux surgery is not, however, devoid of complications and failures. Treatment of these patients represents a major challenge, especially when reoperation is indicated. PATIENTS: One-hundred consecutive patients had a reoperation in our clinic. Previous antireflux procedures were laparoscopic (52 patients), laparotomy (39 patients), and thoracotomy (9 patients). RESULTS: Peri- or postoperative complications occurred in 30 patients (30%). Operative complications were stomach perforation (14), significant bleeding (6), esophageal mucosal perforation (4), gastrocutaneous fistula (2), small bowel enterotomy followed by fistula (1), and tension pneumothorax (1). Reoperation was required in only 2 patients because of a missed stomach perforation or persistent chest leak. The conversion rate (from laparoscopic to open procedure) was 17% overall. CONCLUSION: Laparoscopic reoperation after a failed antireflux procedure is a major surgical challenge, and it is not devoid of morbidity. The surgeon must have extensive experience in laparoscopic surgery and should be able to perform reoperative open surgery through the abdomen and chest. Laparoscopic redo surgery is feasible with good results. Many patients in whom previous open surgery has failed enjoy the advantages of a laparoscopic redo procedure.     

Results of reoperation for failed aortocoronary bypass grafts.

Thirty-one patients underwent reoperation for failure of one or more previous aortocoronary bypass grafts. Thirty-nine grafts were replaced. Twenty-four grafts were constructed to vessels not thought to be significantly diseased at initial operation. There were no early or late deaths. Postoperative morbidity was comparable to initial prodecures. Of 24 patients followed up for more than six months., 62% clearly experienced improvement without evidence of perioperative or postoperative infarction. Reoperation for failed aortocoronary bypass grafts can be achieved without excess risk, but with long-term results less optimistic than initial procedures.     

Symptomatic and functional outcome after laparoscopic reoperation for failed antireflux surgery

BACKGROUND: The aim was to determine symptomatic and functional outcome after reoperative antireflux surgery for recurrent reflux, persistent dysphagia and severe gas bloat, using a primarily laparoscopic surgical approach. METHODS: This was a retrospective analysis of prospectively collected data from 118 patients, of whom 70 had reoperative surgery for recurrent reflux, 35 for dysphagia and 13 for gas bloat. DeMeester scores before and 1 year after surgery, functional symptoms after surgery and overall patient satisfaction were analysed. RESULTS: Reoperation was completed laparoscopically in 101 patients (85.6 per cent), in 28 after previous open hiatal surgery. The operation was converted from an initial laparoscopic approach to open surgery in 17 patients. One-year follow-up data were available for 104 patients (88.1 per cent). After reoperation for recurrent reflux, 84 per cent had a DeMeester heartburn score of zero or one, and 87 per cent had a regurgitation score of zero or one. After reoperation for dysphagia, 21 of 32 patients had a dysphagia score of zero or one, with improvement observed in 25. All patients undergoing reoperation for severe gas bloat were satisfied with the outcome 1 year after operation. CONCLUSION: Revisional surgery for recurrent reflux using a laparoscopic approach offered high rates of success and patient satisfaction. Swallowing returned to normal in two-thirds of patients after reoperation.     

急腹症行腹腔镜手术失败后再手术原因分析

目的分析急腹症患者行腹腔镜手术失败的原因,探讨腹腔镜急腹症手术中应注意的事项。方法回顾性分析2006年5月至2011年3月间广东省惠州市中心人民医院收治的17例急腹症行腹腔镜手术后失败再手术患者的临床资料。结果17例再手术患者中男11例．女6例,年龄16～68岁：上消化道穿孔修补术后8例,阑尾切除术后8例,消化道出血行小肠部分切除术后1例。再手术原因：腹腔脓肿13例,其中4例合并内瘘;回盲部牙签异物残留1例;回盲部淋巴瘤并梗阻1例：右侧闭孔疝1例：小肠血管畸形出血1例。12例患者经保守治疗无效后行再次腹腔镜探查手术,其中5例顺利完成腹腔镜手术,7例中转开腹手术;另有5例行急诊开腹探查手术。所有患者均救治成功,术后7～21d痊愈出院。结论腹腔镜技术应用于外科急腹症时,须严格掌握腔镜探查指征和遵循手术操作规范．对于病情特殊、诊断及手术有难度者应及时中转开腹。     

Outcomes after redo procedures for failed mesenteric revascularization

This report examines results of mesenteric revascularization following a failed splanchnic revascularization. Patients undergoing repeat mesenteric revascularization from January 1985 to July 2002 were identified from a prospectively maintained registry. Data recorded included procedures performed, perioperative mortality, complications, and operative indications. Patients who had embolic events were excluded. Eighty-six patients underwent 105 mesenteric interventions in this time period; 22 patients underwent 33 repeat mesenteric revascularization procedures. There were 25 single-vessel bypasses, 3 multivessel reconstructions, 3 angioplasty procedures (1 open, 2 percutaneous), and 2 graft thrombectomies. Complications occurred in 33.3%. Perioperative mortality was 6.1%, all in patients with acute mesenteric ischemia. One- and 4-year primary patency for repeat mesenteric revascularization was 73.5% and 62.2%, respectively, and survival for repeat mesenteric revascularization was 85.9% and 75.5%, respectively. Patients surgically treated for mesenteric ischemia can require additional interventions. Repeat revascularization effectively prolongs survival when an earlier intervention fails.     

Results of reoperation for failed microvascular decompression

Summary Among 64 patients with hemifacial spasm (HFS) and 60 with trigeminal neuralgia (TN) treated by microvascular decompression (MVD), repeated MVD performed on 3 cases with HFS resulted in the absence of spasm in all cases. In 7 cases with TN, this technique resulted in complete remission in 2, recurrence in 3, and no pain relief in 2 cases. MVD was more effective on HFS than on TN in repeated procedures as well as for initial treatment. The cause of recurrence of HFS was attributed to the inadequate cushion effect of muscle as a prosthesis, while that for TN was suspected to be related more to post-operative fibrotic adhesions formed around the fifth nerve.     

Results of reoperation for failed epilepsy surgery

A total of 37 patients who failed epilepsy surgery were evaluated with magnetic resonance imaging and long-term scalp electroencephalographic monitoring before reoperation. Repeat surgery involved focal resections after initial focal resections (30 cases) or stereotactic lesions (one case), or focal resections following anterior corpus callosotomy (six cases). Patients with initial focal resections followed by enlargement of the original operative site had the most successful outcome, especially those with complex partial seizures of temporal lobe origin. The most common cause for poor outcome of the original operation in patients with temporal lobe epilepsy was insufficient hippocampal resection. Patients who were most likely to benefit from reoperation were: 1) those with initially incompletely resected structural lesions; 2) those who were initially evaluated with invasive ictal monitoring; and 3) those who underwent further resection of the initial operative site rather than resection of a different cortical region.     

腹腔镜下腹股沟疝手术失败后再手术原因分析

目的：分析腹股沟疝患者行腹腔镜手术失败的原因,探讨腹腔镜腹股沟疝手术中应注意的事项。方法回顾性分析2003年8月至2013年1月间收治的17例腹股沟疝行腹腔镜手术后失败再手术患者的临床资料。结果再手术原因：复发9例,补片感染1例,小肠漏1例,肠壁疝1例,线结反应2例,膀胱损伤1例,脐部切口裂开1例,阴囊血肿1例,髂血管损伤1例。6例再次行腹腔镜探查手术,11例行开腹手术,所有患者均手术成功,术后2～15 d痊愈出院。结论腹腔镜技术应用于腹股沟疝时,在严格掌握腔镜手术指征和遵循手术操作规范。对于病情特殊,手术有难度者应及时中转开腹。术后应密切注意并发症的发生,及时处理并发症。     

Cryosurgery of focal lesions of the liver in patients requiring reoperation

Cryosurgery ++ (cryoresection and cryodestruction) was carried out in 21 of a group of 43 patients (48.8%) during resection and +re-resection of the liver in repeated operations. One patient died. It was found that cryodestruction combined with radical and palliative resections of the liver in reoperations improved the late-term results of the operation significantly. With the use of cryotechniques, blood loss is reduced and intraoperative dissemination of the tumour cells and alveococcus and recurrences in the postoperative period are prevented.     

A novel repair for patients with atrioventricular septal defect requiring reoperation for left atrioventricular valve regurgitation.

OBJECTIVE: Left atrioventricular valve regurgitation (LAVVR) is the most frequent indication for reoperation following atrioventricular septal defect (AVSD) repair. We estimate from our experience that within 10 years of initial repair, 14% of patients undergoing repair of atrioventricular septal defect (AVSD) require reoperation for this complication. We have developed a novel leaflet augmentation technique for LAVVR which may avoid failure of conventional repair and/or the need for valve replacement. METHOD: The novel technique consists of insertion of a glutaraldehyde-treated autologous pericardial patch to augment the bridging leaflets of the atrioventricular valve. We describe the outcome of eight patients in whom this technique was used and compared them to 68 other patients with AVSD undergoing reoperation for LAVVR by either conventional repair (n=54) or valve replacement (n=14). RESULTS: There were no early deaths or major complications following patch repair. The mean follow-up is 2.3 years (range 1-8.5 years) during which there were no late deaths. Two patients underwent reintervention at 3.5 and 5 years after patch repair for LAVVR and were successfully rerepaired. Mild residual LAVVR was seen at last echocardiography in six patients and mild to moderate in two. These results compare favorably with the 68 patients who underwent conventional surgery. The 3-year freedom from reoperation was 86% for both repair groups. Dysplastic valve tissue appears to be a major risk factor for failure of conventional repair or for valve replacement. Failure of conventional valve repair led to valve replacement in six of seven patients. CONCLUSIONS: For patients with late LAVVR after AVSD repair, pericardial leaflet augmentation is durable and may avoid failure of conventional repair or valve replacement in patients with dysplastic valves.     

Balanced conscious sedation with intravenous induction and inhalational maintenance for patients requiring endoscopic and/or surgical procedures

BACKGROUND AND OBJECTIVE: The use of inhalation sedation with sub-anaesthetic concentrations of sevoflurane and nitrous oxide mixture is expected to reduce amounts of intravenous sedative drugs needed to produce a balanced sedation with the benefits of having reduced side-effects. METHODS: Eighty-two patients requiring endoscopic and/or surgical procedures under conscious sedation and local anaesthesia were recruited for this pilot study. Conscious sedation was induced with a titrated dose of midazolam and propofol given intravenously until the clinical end-point of conscious sedation was achieved. Subsequently, during the procedure, the patient was asked to breathe sevoflurane 0.1-0.3% and a fixed ratio of 40% nitrous oxide in oxygen given through a face mask. RESULTS: In 78 patients (95.1%), the treatment was completed successfully. Patients were discharged back to the wards within 4-16 min (10.1) without significant side-effects. Treatment was satisfactorily accepted by 38 patients (48.7%) and considered excellent by 40 patients (51.3%). CONCLUSIONS: The use of titrated doses of intravenous sedative drugs for induction of conscious sedation followed by the use of low concentrations (0.1-0.3%) of sevoflurane combined with 40% nitrous oxide for maintenance of conscious sedation in patients requiring endoscopic and/or surgical procedures under local anaesthesia, has the potential advantages of reducing amounts of intravenous sedative drugs, less likelihood of problems from drug side-effects and fast recovery and discharge time. Further investigations to establish the technique are currently in progress.