Sherman, Randy MD; Crabtree, Thomas G. MD; Carmona, Richard H. MD, MPH; Jaffe, Bernard M. MD Author Information

un, streptomycin, Hanks' balanced salt solution (lOx), and fetal calf serum were obtained from Grand Island Biological Co., Grand Island, N. V.; nigrosin was from Sigma Chemical Co. , St. Louis, Mo. ; Mycostatin was from E. A. Squibb Co., New York, N. Y.; potassium penicillin was from Eli Lilly & Co.', Indianapolis, Ind.; streptomycin was from Pfizer Laboratories, New York, N. Y.; absolute ethyl alcohol was from U. S. Industrial Chemical Co., New York, N. Y.; trichloroacetic acid was from Fischer Chemical Co., Fair Lawn, N. J.; and diethyl ether was from Mallinckrodt Chem icals, St. Louis, Mo. Inoculationwith Tumor Cells. Mice bearing large s.c. B-16 melanoma tumors were killed. The tumors were rapidly removed with the use of sterile technique; washed in Hanks' balanced salt solution containing 2.5% penicillin (200 units/ ml), 0.2% streptomycin (0.1 ng/mI), and 0.1% Mycostatmn (100 units/mI); and placed in modified McCoy's Medium 5A containing 15% heated fetal calf serum, penicillin (100 units/mi), and streptomycin (0.1 mg/mI). The washed tu mors were finely minced, and cells were separated by passage through a 120 mesh stainless steel grid. The cell suspensions were washed twice with McCoy's medium containing penicillin and streptomycin, but not fetal calf serum. Cell counts were performed with a hemocytometer. Cell viability was determined by the use of a vital dye exclusion technique (21) with the use of nigrosin (0.2%). Cell suspensions were adjusted to contain either 10@or 106 viable ceils/0.2 ml of McCoy's medium containing penicillin and streptomycin, but not fetal calf serum. Under light ether anesthesia, 78 8-week-old female C57BL/6J mice were given s.c. injections in the left flank of 0.2 ml of medium containing viable tumor cells (39 each with 10@ and with 10. cells) from single-cell suspensions. Administrationof Prostaglandins.Di-M-PGE2was dis solved in absolute ethanol (200 pg/mi) and maintained as a stock solution at 4°. The final concentration of prosta glandin for injection was made daily by diluting the etha nolic solution 1:4 in sterile 0.9% NaCI solution. Each mouse received 5 @gof di-M-PGE2 i.p. in a total of 0.1 ml of solvent. Control diluents were absolute ethanol (without prostaglandin) prepared identically. Measurementof TumorSize. Eachmousewasexamined daily by palpation, and the day of appearance of the tumors was noted. When tumors became visible, they were mea sumedin at least 2 dimensions with calipers. Tumor volumes were calculated as spheres if the major and minor diameters did not vary by more than 40%; if they did, volumes were calculated as cylinders (40% of the mice in both groups). Neither ulcerated nor necrotic tumors were utilized for any

Annals of Surgery: February 2004 - Volume 239 - Issue 2 - p 293-294 doi: 10.1097/01.sla.0000111742.79186.f9

The potential advantages of living-related segmental small bowel transplantation include better matching; lessening the risk and severity of rejection; minimizing the need for immunosuppressive drugs and decreasing their side effects; protecting the intestinal integrity and preventing bacterial translocation; and obviating space limitations for grafts. In contrast, shorter lengths of bowel (segments) absorb less than entire intestines, and there is a small but definite risk of donation for the donor. The technical questions still being studied include the use of portal versus systemic drainage, the segment of intestine to be transplanted (ileum versus jejunum), and the need for an ostomy and the timing of its closure. The recent experience with living-related segmental transplants includes three at Tulane, a 4-year survivor in Kiel, Germany), and several others (for a total of about 15) in the United States, China, Japan, and England. There have been few transplants between identical twins; one at Stanford functioned for several years. Overall, the results have been good, but considerably more experience is needed before the exact role of this technique is completely established.

The classical presentation of primary hyperparathyroidism, ''moans, bones, groans,'' is no longer commonly seen since the diagnosis of hypercalcemia is now made much earlier with the routine use of the SMA 12. In the past 8 1/2 years, 85 patients underwent cervical exploration in our institution for primary hyperparathyroidism. There were 34 male and 51 female patients, ranging in age from 18-84 years. The specific symptoms included hypertension in 40 patients, generalized weakness in 25, renal stones in 14, psychiatric problems in 2, and bone changes on X-ray in 4. Forty-one patients were totally asymptomatic. The diagnosis was made mainly on the basis of history, serum calcium and phosphorous levels, parathormone assay, and 24-hour urinary calcium studies. Preoperative localization studies were performed in 38 patients. Thallium technetium subtraction scans, when positive, were very helpful. The surgical approach involved stepwise exploration of both sides of the neck with identification of all four parathyroid glands. In patients with uniglandular pathology (87%), the adenoma was removed with biopsy of at least one normal gland. In multiglandular disease, the abnormal glands were removed. Frozen section was routinely performed to confirm the presence of parathyroid tissue and no attempt was made to pathologically distinguish adenoma from hyperplasia. Two patients had parathyroid carcinoma. In three patients, serum calcium levels did not fall, resulting in an operative success rate of 96%. One patient treated by subtotal parathyroidectomy developed permanent hypoparathyroidism and one other patient developed temporary hypocalcemia. Only a single patient developed vocal cord palsy. Early exploration in patients with primary hyperparathyroidism is indicated. The basic diagnostic workup is sufficient for initial exploration. It is important to distinguish uniglandular from multiglandular pathology after careful bilateral exploration and identification of all four parathyroid glands.

In the past, it was generally advised that every patient undergoing thyroid surgery have a drain placed because of the fear of post-operative hematoma. In the past 9 years, we have performed 400 thyroidectomies. For the first 6 years, we drained the operative site in most of thyroid procedures. However, it was apparent from our experience that drains had very little effect on the prevention of post-operative hematoma or of seroma. As a matter of fact, all four patients who required re-exploration in our initial series had drains in place. As a result of this experience over the past 3 years, during which time we have performed 150 thyroidectomies, we have used drains selectively. The indications for draining the thyroid bed have been the presence of a large dead space, operation for a large substernal goiter, and subtotal thyroidectomy for either large, multinodular goiter or for Graves' disease. Thus, among 150 recent thyroidectomies, we have drained only 35, and avoided drains in 115 patients. Though this is not a prospective study, we found no difference in the overall outcome whether drains were employed or not. Most patients who had no drains were ready for discharge within 24-48 hours of surgery. Since it may be difficult to perform a randomized prospective trial examining the use of drains in thyroid surgery, we propose that drains should be utilized only selectively for thyroid surgery.

Persistent gene lymphadenopathy has been well described in patients with seropositivity to the human immunodeficiency virus (HIV). Moreover, isolated enlargement of the parotid gland and parotid lymphadenopathy have been noted much more frequently over the past few years. Histologically, these lesions demonstrate follicular hyperplasia, cystic dilatation of the ducts fined by pseudo-stratified squamous epithelium, and lymphocytic infiltrates. They are generally considered to be benign lymphoepithelial lesions of the parotid or hyperplastic periparotid lymph nodes. The relationship of this entity to the AIDS-related complex (ARC) and the subsequent development of AIDS is not clear.Over the past 7 years, we have seen 50 patients with parotid enlargement in whom the diagnosis of benign lymphoepithelial lesion was made. Fine-needle aspiration was performed in 32 patients. Although not conclusively diagnostic, needle aspirates ruled out primary salivary glandular pathology. Most patients gave a history of intravenous drug abuse. HIV tests have been performed on a routine basis only in the last 2 years, and these were positive in the majority of the patients.Thirty-five patients underwent surgical excision. In the initial 20 patients, we routinely performed parotid exploration, identification of the facial nerve, and superficial parotidectomy. In the last 15 patients, we changed our surgical approach to parotid exploration and excision of the mass in the tail of the parotid. The exposure of the posterior belly of the digastric muscle, with identification and removal of the deep jugular node, has become routine. In each case, we found an enlarged lymph node in the deep jugular region, which was not clinically palpable preoperatively. The rate of surgical complications was minimal, and, after resection of the mass, patients improved symptomatically. If the patient shows obvious signs of AIDS, a nonsurgical approach with repeated aspirations should be considered, and treatment with zidovudine offered.

The success of parathyroid surgery is based on accurate localization of normal and abnormal parathyroid glands, knowledge of the pathologic conditions, and meticulous dissection during removal of the abnormal glands. Although parathyroid localization is essential in cases requiring re-exploration, there is considerable controversy regarding the indications for localization studies prior to primary exploration, since the success rate for surgery exceeds 90% to 95%. However, in specific circumstances, including diagnostic problems, technical considerations, and high-risk patient factors, preoperative parathyroid localization assists the operating surgeon even during the primary cervical exploration. The purpose of this paper is to define these specific circumstances and discuss the appropriate studies.

BACKGROUND:Completion thyroidectomy can most accurately be described as reexploration of the neck to remove the contralateral thyroid lobe. This procedure has commonly been performed when the histopathologic condition of the ipsilateral thyroid lobe reveals papillary or follicular carcinoma of the thyroid. Because of a definitely increased risk of complications with completion thyroidectomy, avoiding its routine use is important. The purpose of this paper is to define the specific indications for completion thyroidectomy.METHODS:Over the past 9 years, we have performed 400 thyroidectomies; the patients ranged in age from 18 to 88 years. Although we have routinely used preoperative needle biopsy and intraoperative frozen section, decisions regarding the extent of thyroidectomy have been based on the gross findings at operation, taking into consideration such prognostic factors as patient age, tumor grade and size, the presence of extracapsular spread or distant metastasis, and associated risk factors. The minimal procedure for solitary thyroid nodule has been lobectomy with isthmusectomy. If the contralateral lobe is grossly normal, lobectomy with isthmusectomy has also been the maximal operation in most of patients. Very few specific indications exist for removal of the opposite lobe.RESULTS:Only three patients underwent completion thyroidectomy. All three patients had aggressive follicular carcinoma requiring radioactive iodine ablation, and all were referred after the initial surgery. We have not performed completion thyroidectomy on any of the patients on whom we initially operated.CONCLUSIONS:The most common indication considered for completion thyroidectomy is a frozen section diagnosis of a benign follicular adenoma that is subsequently changed on permanent pathologic condition to follicular carcinoma based on the presence of capsular and/or vascular invasion. However, if minimal invasion has occurred, no difference exists in survival related to the extent of the thyroidectomy. Local recurrence in the contralateral lobe occurs in less than 10% of the time. Because completion thyroidectomy carries more risks, it should be avoided in most patients when possible. The definitive decision should be made during the initial operation based on gross findings, prognostic factors, and frozen section, and this plan should only be changed to mandate completion thyroidectomy in select circumstances.

Tracheomalacia may result from large intrathoracic goiters. Due to the chronic compression, particularly within the confines of the thoracic inlet, the tracheal wall weakens, with disintegration of some of the cartilaginous rings. Tracheomalacia can cause acute airway distress, particularly during the postoperative period, and may occasionally result in death. The other major cause of tracheomalacia is related to either prolonged endotracheal intubation or over-inflation of the tracheostomy cuff. While various techniques such as internal stenting, external support devices, tracheostomy, and tracheal resection have been used based on individual circumstances, no one method appears to be perfect.To further study this difficult problem, an experimental model of tracheomalacia was created in eight dogs. Six to seven rings of the tracheal cartilages were dissected submucosally. More than half of the circumference of the tracheal rings was resected. The tracheal walls were reconstructed with polytetrafluoroethylene (PTFE) grafts. The grafts strengthened the tracheal wall without causing luminal constriction. Tracheostomy was not performed on any of the dogs. All dogs tolerated the procedure well and were extubated at the conclusion of the experiment.The dogs were followed for 4 to 6 months and then sacrificed so that the tracheal wall could be examined histologically. There was considerable fibrosis leading to stiff neotrachea. The results of this experimental technique for prosthetic reconstruction to counteract problems simulating tracheomalacia are very encouraging.

It has generally been considered that the cricoid cartilage is essential for maintaining airway continuity. The purpose of this experimental study was to test this concept by evaluating the effects of subtotal excision of the canine cricoid cartilage. Eight adult mongrel dogs were studied. They received general anesthesia and were intubated. By using a vertical midline incision, the cricoid cartilage was exposed. Subtotal cricoid resection was performed by submucosal dissection; the mucosal continuity was not violated. The resultant defect in the cricoid cartilage was reconstructed with a polytetrafluoroethylene (PTFE) graft which was sutured in place with prolene sutures. All the dogs were extubated immediately after surgery. None required tracheostomy or ventilatory support and none had any respiratory problems during the follow-up period. They were all able to eat soon after surgery. The animals were followed for up to 4 to 6 months and then sacrificed to permit evaluation of the condition of the airway and subglottic space. There was fibrous scarring outside the graft but no evidence of airway narrowing. Despite submucosal fibrosis, the mucosa appeared normal. The data documented that dogs tolerate subtotal cricoid resection very well and develop no subglottic stenosis. The resultant defect in the cricoid cartilage can readily be reconstructed with a PTFE graft.

Ethanol has been shown to reduce serum calcium in multiple animal studies. However, in human studies done using lower doses of alcohol, only inconclusive results have been obtained. This study was undertaken to evaluate the effects of varying doses of oral ethanol on total serum calcium. Fifteen adult mongrel dogs (17-25 kg) were divided into three groups which differed in the dosage of ethanol given. Group I animals received 0.5 g/kg of ethanol; Group II, 1.0 g/kg ethanol; and Group III, 2.0 g/kg of ethanol. Venous blood was sampled for estimation of concentrations of total serum calcium and ethanol. In the animals in Group I, serum calcium levels were unchanged by the ethanol. In both Groups II and III, significant reductions in serum calcium were demonstrated, which occurred within 5 min of intoxication. The mean decrease in serum calcium in Group III animals was significantly greater than that in either Group I and II. We conclude that the rapid hypocalcemic effect requires a threshold amount of ethanol before it becomes chemically evident. This critical value in dogs approximated 1 g/kg which results in a mean peak serum alcohol concentration of 117 +/- 6 mg/dl.

This study was performed to examine the effect of transplantation, and thus extrinsic denervation, of the small intestine on intraluminal release of serotonin and substance P. Heterotopic 40-cm-long proximal (jejunal) small intestinal isografts were performed in six 200- to 250-g adult male Lewis rats under general anesthesia. Bowel ends were exteriorized as ostomies. Six Lewis rats with neurovascularly intact 40-cm proximal small bowel Thiry-Vella loops exteriorized as ostomies served as the control animals. On the seventh postoperative day, the intestinal loops were perfused at 0.5 ml/min for three 10-min periods with normal saline followed by an equilibrium period and then for three 10-min periods with 20% dextrose. Perfusates were collected for each period and levels of serotonin and substance P were determined by radioimmunoassay. Intraluminal serotonin levels rose from 29 ± 9 ng/ml during saline perfusion to 115 ± 28 ng/ml during intestinal perfusion with 20% dextrose in the innervated loops and from 21 ± 7 ng/ml to 94 ± 26 ng/ml in the transplanted loops. While there was a statistically significant increase in mean intraluminal serotonin levels following perfusion with 20% dextrose in both the control and transplant groups, there was no difference in the intraluminal serotonin response between controls and transplant recipients. In contrast, 20% dextrose had no effect on luminal release of substance P in either group. These results indicate that extrinsic denervation of the small intestine has no effect on the intraluminal serotonin response to stimulation and suggest that serotonin and substance P are not released into the intestinal lumen by the same regulatory mechanisms.

This study was initiated to evaluate the role of serotonin in cholera toxin-induced jejunal secretion of water and electrolytes. Chronic Thiry-Vella loops, constructed in six dogs, were perfused with an isosmotic neutral perfusate containing [14C]polyethylene glycol as the recovery marker. Fluxes of water, sodium, chloride and potassium were calculated and immunoreactive serotonin levels were measured in blood and effluent perfusates. Intraluminal application of 20 micrograms of cholera toxin induced secretion; fluxes of water (basal, 32.3 +/- 11.1; 6 hr, -541 +/- 35 microliter/min), sodium (basal, 9.0 +/- 2.8; 6 hr, -78.3 +/- 5.6 microEq/min), chloride (basal, 3.8 +/- 1.5; 6 hr, -65.7 +/- 4.0 muEq/min) and potassium (basal, 0.10 +/- 0.08; 6 hr, -2.80 +/- 0.18 muEq/min) were all significantly different from basal. Serum electrolytes remained normal, except that potassium fell from 4.9 +/- 0.5 to 3.9 +/- 0.2 mEq/l. Although circulating serotonin levels did not change from base line (180.9 +/- 29.3 ng/ml), effluent concentrations increased significantly from 68.2 +/- 4.6 to 81.1 +/- 5.0 ng/ml (at 3 hr) and jejunal outputs increased from 136.6 +/- 10.2 to 205.1 +/- 10.1 ng/min (at 6 hr). In a separate set of experiments, verapamil was infused i.v. (12.5 micrograms/kg/min) during the 4th hr in four dogs exposed to cholera toxin. The lower dose of toxin (5 micrograms) induced secretion which was unaffected by the calcium channel blocker. In another series of studies, ketanserin (a 5-HT2 receptor blocker) was infused i.v. at 33 micrograms/kg/min during the 4th hr in four additional dogs exposed to the lower dose of cholera toxin. This potent serotonin antagonist failed to inhibit cholera toxin-induced jejunal secretion.(ABSTRACT TRUNCATED AT 250 WORDS)