Multivariate Analysis of Risk Factors for Postoperative Complications in Benign Goiter Surgery: Prospective Multicenter Study in Germany

Risk factors for postoperative complications of benign goiter surgery have not been investigated systematically. To this end, a prospective multicenter study (January 1 through December 31, 1998) was conducted involving 7266 patients with surgery for benign goiter from 45 East German hospitals. High-volume providers (>150 operations per year) performed 69% (5042/7266), intermediate-volume providers 27% (50–150), and low-volume providers 4% (258/7266) of operations. Among the hospital groups, the pattern of thyroid disease did not vary significantly, but there was a trend that small-volume providers tended to perform more operations for uninodular goiter and high-volume providers treated more patients with Graves' disease and recurrent goiter. Extent of resection (p < 0.0001) and remnant size (multinodular goiter and recurrent goiter, p < 0.001), differed significantly, with total thyroidectomy being performed more often in hospitals with more than 150 operations compared to hospitals with an operative volume of less than 150 procedures per year. Despite the larger extent of resection and smaller remnant size, rates of recurrent laryngeal nerve (RLN) palsy or hypoparathyroidism were not increased. When the logistic regression analyses were fitted to evaluate the impact of risk factors on transient and permanent RLN palsy and hypoparathyroidism, larger extent of resection [relative risk (RR) 1.5–2.1] and recurrent goiter (RR 1.8–3.4) consistently evolved as independent risk factors. With hypoparathyroidism, additional significant factors included patient gender (RR 2.1–2.4), hospital operative volume (RR 0.8–1.5), and Graves' disease (RR 2.8). Unlike parathyroid gland identification during hypoparathyroidism, RLN identification (RR 1.6) significantly (p= 0.01) reduced permanent RLN palsy rates. The multivariate analyses clearly confirmed the pivotal role of routine RLN identification, independent of the extent of the thyroid resection. These findings might help hospitals with lower operative volumes to identify patients at increased risk whom they might consider for specialist care.     

Five meters of H(2)O: the pressure at the urinary bladder neck during human ejaculation

BACKGROUND: There are no data in the literature on pressure changes in the prostatic urethra during ejaculation. In healthy men, it has always been postulated that there must be a pressure gradient in order to prevent retrograde ejaculation, but scientific proof for that is pending. METHODS: In five healthy male volunteers, the pressure profile in the prostatic urethra was registered during ejaculation, using a 10 French balloon catheter with 16 pressure channels. The channels were arranged in pairs at 5-mm intervals, beginning just below the balloon at the bladder neck and extending down to the external urethral sphincter. RESULTS: In the proximal part of the prostatic urethra, a pressure of up to 500 cm of H(2)O was measured in all subjects. Contrary to that, pressures did not exceed 400 cm of H(2)O distally to the verumontanum. CONCLUSIONS: A novel method to register the pressure profile in the lower urinary tract during ejaculation (ejaculomanometry) is presented. This study adds to the knowledge of the normal physiology of reproductive function and may be useful in the evaluation of male sexual and reproductive disorders.     

Pure primary choriocarcinoma of the urinary bladder with long-term survival

Choriocarcinoma was diagnosed in a 77-year-old woman with an acute massive, painless hematuria. One year after anterior pelvic exenteration and ileal conduit, the beta-human chorionic gonadotropin level increased to 934 mIU/mL without any sign of tumor progression. After six courses of chemotherapy (vincristine, actinomycin, and cyclophosphamide), the beta-human chorionic gonadotropin levels returned to normal. To our knowledge, this is the fourth case of pure choriocarcinoma in the bladder, with the longest survival time of 33 months so far.     

High prognostic value of p16INK4 alterations in gastrointestinal stromal tumors.

PURPOSE: Gastrointestinal stromal tumors (GISTs) represent a distinctive (but histologically heterogeneous) group of neoplasms, the malignant potential of which is often uncertain. To determine the prognostic relevance of p16INK4 alterations in GISTs, we investigated a larger group of GISTs and correlated the genetic findings with clinicopathological factors and patient survival. MATERIAL AND METHODS: We evaluated the methylation status of the promotor by methylation-specific polymerase chain reaction (PCR), the presence of mutations by PCR-SSCP-sequencing, the loss of heterozygosity at the p16INK4 locus (using the c5.1 marker), and the immunohistochemical expression of p16INK4 protein in 43 GISTs in 39 patients. RESULTS: p16INK4 alterations were found in 25 of 43 GISTs (58.1%), with benign, borderline, or malignant GISTs showing no differences in the type and frequency of alteration. p16INK4 alterations were correlated with a loss of p16INK4 protein expression (P <.01). Patients who had tumors with p16INK4 alterations had a poorer prognosis than patients with tumors without such alterations (P =.02). There was a high predictive value for p16INK4 alterations only in the group of benign and borderline GISTs (P <.01) with regard to clinical outcome. Univariate Cox's proportional hazard regression analysis revealed a strong correlation between p16INK4 alterations, tumor size, mitotic index, and overall survival (P <.02), whereas multivariate Cox's analysis confirmed only p16INK4 alterations as an independent prognostic factor. CONCLUSION: We believe that the evaluation of p16INK4 alteration status is a helpful prognosticator, particularly in the benign and borderline groups of GISTs.     

Die kongenitale Tibiapseudarthrose

Congenital pseudarthrosis of the tibia (CPT) is one of the most challenging conditions in paediatric orthopaedics. The history of CPT treatment is characterised by repeatedly ineffective surgical interventions with the inevitable outcome of severe disability. Most procedures failed to account for the complexity of the problem. The past two decades have witnessed more experience having been gained with the Ilizarov technique. This method provides a comprehensive approach to all aspects of CPT problem, allowing the surgeon to simultaneously address the problems of union as well as those of deformity, length discrepancy joint function, ankle valgus and weight bearing. It appears that the goal to achieve stable fusion before the child begins school is attainable. In the pre-pseudoarthrotic stage, bracing should be preferred to surgery until the patient is in an older age group. This study reports on the results of 19 patients: 15 have finished treatment, and 14 of them with a stable fusion at follow-up. The results were highly encouraging in reaching the ultimate goal of avoiding amputation and achieving a well-functioning limb.     

A Clinical and Histologic Comparison of Percutaneous Dilational Versus Conventional Surgical Tracheostomy

To directly compare percutaneous dilational tracheostomy (PDT) with conventional surgical tracheostomy, a prospective study was performed in 83 patients requiring tracheostomy for prolonged mechanical ventilation in the intensive care unit or after surgery for a large tumor in the upper respirodigestive tract. Median follow-up was 355 days after PDT and 338 days after conventional tracheostomy. The overall morbidity rate was significantly lower with PDT than with conventional tracheostomy (6.4% vs 36.1%; P < 0.001). Compared with conventional tracheostomy, PDT was also associated with a significantly lower incidence of postoperative bleeding (2.1% vs 13.9%; P < 0.05) and postoperative wound infection (0% vs 22.2%; P < 0.001). There were no clinical signs of laryngotracheal stenosis in either group. In conclusion, PDT is a simple, fast, safe bedside procedure that is associated with significantly lower morbidity than standard surgical tracheostomy.     

Sport related proximal femoral fractures: a retrospective review of 31 cases treated in an eight year period

In an eight year period, 31 patients with proximal femoral fractures resulting from sports accidents were treated by implantation of either a Gamma nail or a dynamic hip screw. Return to work or sports and the time to bone healing did not differ very much between the treatments. Gamma nailing was clearly the best with regard to stability and time to full mobilisation (4.5 days), but required 39 minutes to perform compared with insertion of a dynamic hip screw (27 minutes). The incidence of complications and malalignments did not differ very much between the two, although, when Gamma nailing was first used in the authors' clinic, more intraoperative complications occurred than with the dynamic hip screw. Stable pertrochanteric fractures may be treated with a dynamic hip screw. Unstable pertrochanteric or subtrochanteric fractures are treated with a Gamma nail at the authors' institution.     

Flexible tantalum stents for the treatment of renovascular hypertension: a 10-year experience

The aim of this study was to determine long-term success of flexible tantalum stents for the treatment of ostial and truncal renal artery stenosis. Since 1989, flexible tantalum stents (type Strecker) were implanted in 34 patients (36 arteries, 25 ostial lesions, 11 truncal lesions) with uncontrollable renovascular hypertension, 9 of them in association with renal insufficiency. Stents were placed unilaterally in 32 patients, and bilaterally in 2 patients for the treatment of renal artery stenosis. Thirty-five of 36 lesions were atherosclerotic, including 5 recurrencies after previous percutaneous transluminal renal angioplasty (PTRA). One patient had Takayasu arteritis. Stents were implanted after unsuccessful PTRA of 11 truncal and 23 ostial lesions, and as a primary procedure in 2 ostial lesions. Follow-up examinations included blood pressure measurement, determination of serum creatinine level, color duplex sonography, or angiography. The technical success rate was 92 %. Technical failure included incorrect stent placement (1 of 36 lesions, 2.8 %), and stent dislocation (2 of 36 lesions, 5.6 %), and two stents were retrieved percutaneously. In one case of Takayasu arteritis, residual stenosis of 40 % was observed. After technically successful stent placement, 77 % of patients became normotensive with or without medication. In the remaining patients there was partial improvement with blood pressure between 140 and 180 mmHg. Renal function improved in 76 % of patients (completely in 3 of 8, 38 %; and partially in 3 of 8, 38 %). Primary patency rate including all stented lesions and initial technical failures was 82.4 % ± 6.8 (1 year) and 82.4 % ± 9.2 (3 years). After technically successful stent placement, patency rates were 89.9 ± 5.6 % (1 year), and 89.9 ± 7.6 % (3 years). For ostial lesions, primary patency rate was 87.9 ± 6.7 % (1 year) and 87.9 ± 9.2 % (3 years). Placement of flexible tantalum stents in renal arteries is technically demanding, especially in ostial lesions. Once placed successfully, stent patency rate is excellent. Received: 8 December 1999; Accepted: 23 February 2000     

Complete atrioventricular septal defect associated with tetralogy of Fallot. Favourable outcome of transatrial transpulmonary repair

BACKGROUND: Complete correction of atrioventricular septal defect (AVSD) associated with tetralogy of Fallot (TOF) has been reported to account for an increased surgical risk. Impaired right ventricular function after classic transventricular repair, residual outflow tract stenosis, and incompetence of the pulmonary or atrioventricular valves are considered to be essential factors affecting the results. METHODS: From 3/95 to 6/98 six consecutive patients with AVSD and TOF underwent repair (age 18 months to 7.3 years) using a combined transatrial-transpulmonary approach. RV outflow tract balloon dilatation preceded transatrial correction in 4 patients. Pulmonary annulotomy but not transanular patching was necessary in 4 cases. The septal defects were closed by two separate patches using a Dacron patch with short depth and anterior extension for the ventricular component. RESULTS: All patients survived and had stable sinus rhythm. Echocardiography demonstrated mild, but hemodynamically insignificant mitral regurgitation in two and tricuspid regurgitation in four patients. Right ventricle to pulmonary artery gradients ranged from 5 to 35 mmHg (mean 24.2 mmHg) without progression. During follow-up ranging from 4 months to 3.5 years (mean 16.8 months) no reoperation was necessary. CONCLUSIONS: The transatrial-transpulmonary approach for correction of AVSD with TOF contributes to improved results after repair of this rare combination of defects.