Dr. Riju R. Menon

Background: The association between primary hyperparathyroidism (PHPT) and acute pancreatitis (AP) is well known. However, the causal association is disputed.

Aims: The present cohort study of PHPT patients was done: (1) to assess the prevalence of AP and (2) to assess the effect of successful parathyroidectomy in preventing further recurrence.

Materials and Methods: Case records of patients admitted with AP during the study period were reviewed. Diagnosis of PHPT among this group was based on serum level of corrected calcium and parathyroid hormone. Review of records of patients who were successfully operated for PHPT was done. Records of patients treated with confirmed diagnosis of AP during the study period were reviewed. Variables used for analysis were serum levels of calcium (adjusted to serum albumin), phosphate, intact parathyroid hormone, 25-OH-Vitamin D, alkaline phosphatase, and estimated glomerular filtration rate (eGFR). For continuous/numerical variables with two groups, Mann–Whitney U-test was applied. Multivariate regression analysis was done if the univariate analysis showed significance (P < 0.05).

Results: There were 13 (7.5%) patients with confirmed diagnosis of AP and serum calcium level significantly elevated in this group. There was a linear association of serum calcium with AP. Successful parathyroidectomy prevented further episodes in 11 (84.6%) of patients. There was 2% prevalence of PHPT among 558 patients with AP.

Conclusions: Hypercalcemia in PHPT patients was significantly associated with AP and early parathyroidectomy prevented further recurrence.

Introductíon:
Goiter is a very common problem dealt with by surgeons. Surgical treatment of thyroid requires removal of a part (hemi) or whole of the gland (total thyroidectomy). The external branch of the superior laryngeal nerve (EBSLN) is an important but less researched structure to be preserved during surgery. Various studies have described the incidence of different types of EBSLN, but have not described regarding the relationship between the change in volume of the gland to the nerve

Materials and Methods:
A prospective analysis of 100 patients who underwent total thyroidectomy in our department was done. All patients underwent preoperative ultrasonography and the volume of the gland was calculated. Intraoperatively, the EBSLN was identified and preserved prior to ligating the superior thyroid vessels. The nerve was classified as per the Cernea classification. The gland was divided into high and low volume, taking 20 ml as the cutoff. The incidence of Type 2 nerve in a low-volume gland was compared with that of a high-volume gland.

Results:
In 100 patients (200 nerves), 191 nerves were identified. The nerve was type 1 in 56/200 (28%), Type 2a in 116/200 (58%), and Type 2b in 19/200 (9%) patients. In large-volume glands, Type 2 nerve was more common (87%).

Conclusion:
Dissection of thyroid gland requires expertise to preserve the EBSLN. Large volume glands pose a more difficult challenge, as the gland is more closer to the nerve.

Varicose veins, a common disease in surgical practice, has vexed surgeons for ages, due to its various problems. We hereby present a pilot study of 80 consecutive patients who underwent anatomical and haemodynamic evaluation at the time of Tren-delenberg procedure. Aim 1.To study the location of the saphenofemoral junction(SFJ) in relation to the pubic tubercle. 2.To locate variations in the pattern of tributaries around the SFJ 3.To analyse the haemodynamics of the SFJ Materials and methods 80 consecutive patients who underwent Trendelenberg procedure from August 2007 to August 2008 are presented. Radiological and clinical evaluation were done and patients were subjected to Trendelenberg procedure at which time position of the Sapheno-Femoral junction(SFJ) in relation to pubic tubercle was measured, also noting nature and number of tributaries. A demonstration of the severity of reflux was made and all the information was noted and computed. Results We found that in the Indian patient the position of the SFJ was higher and more medial than the Western counterpart. There were fewer tributaries in the Indian patient. The external pudendal artery was seen more commonly in the Indian patient and could act as a landmark for identification of the SFJ. Conclusion SFJ was seen at a much higher point contrary to the popular anatomy. High incision using the pubic tubercle as the reference point gives good exposure for flush ligation and identification of the tributaries at the SFJ thereby preventing inadequate primary surgery. In our study, there are between 4-5 tributaries at the SFJ and these need to be completely identified and disconnected. Deep external pudendal artery is seen as it goes laterally at the lower border of the cribriform facia and forms a good marker of the termination of GSV and presence of the SFJ.

Chronic inflammatory diseases of the non-lactating breasts cause considerable difficulty in diagnosis and treatment. There is a spectrum of aetiological factors ranging from infection to autoimmune disorders. The disease causes considerable morbidity and psychological distress in relatively young females. The study aimed to analyse the spectrum of chronic disease and to formulate a treatment protocol.

Method: Female patients with histological confirmation of inflammatory disease of the breast in the non-lactational phase were included in the study. The patients were categorized based on histological findings supplemented with immunohistochemical staining with CD3 and CD20 antibodies.

Result: Out of 50 patients included in the study, 38 patients (76%) were diagnosed as idiopathic granulomatous mastitis (IGM) and 12 (24%) patients as periductal mastitis (PD). The possible aetiology of IGM was localized autoimmunity as evidenced by the infiltration of CD3 positive T lymphocyte. Systemic prednisolone was given for 6 months and 95.6% patients were disease-free after 24months. Out of 15 patients who did not receive prednisolone, only 2 patients were disease-free after 24 months (p&nbsp;=&nbsp;.003).

Conclusion: Idiopathic granulomatous mastitis is an uncommon inflammatory disease of the non-lactating breast. The combination of limited surgical treatment and systemic prednisolone given for 6 months effectively controls the disease as well as prevents recurrence.

Lithium salts are widely used in psychiatric practice and are known to induce thyroid dysfunction. Lithium-induced parathyroid dysfunction is rare. We are reporting a case of hyperparathyroidism in a 28-year-old female patient who was on lithium carbonate for 2 years, when she developed osteopenia and girdle girdle-type muscle weakness. Biochemical parameters showed hyperparathyroidism with shift of calcium creatinine clearance ratio to 0.013, indicating an error in threshold of calcium sensing receptor. The patient eventually required parathyroidectomy and the histology of the gland showed atypical features.

Sir,
Differentiated thyroid cancer may coexist with hyperthyroidism. Cancer cell mass is less functional and appears as cold nodule in thyroid scintigraphy. Cancer cell mass rarely becomes site of excess hormone production. When thyroid cancer cell mass occupies a scintigraphically hot, functionally autonomous thyroid nodule and if thyrotoxicosis is attributable exclusively to this nodule, as shown by clinical and histologic correlation, a toxic thyroid carcinoma is diagnosed.[1] We are reporting case feature which coincides well with the above mentioned diagnosis.

Chronic venous disorders are a major health problem due to their wide prevalence and socio-economic considerations. This book is a comprehensive manual providing state- of- the- art information on the diagnosis and management of these common problems. Till recently venous disorders have been getting secondary attention as compared to their arterial counterpart. However, the last two decades witnessed major technological advancements and therapeutic strategies for these problems. Written with a surgical perspective, this monograph covers the latest developments and recommended procedures in an easy-to-read format guiding the surgeon to prepare a rational treatment plan. Supplemented with numerous figures and illustrations, the chapters update the readers with how to evaluate such patients in their practices, selection criteria for appropriate procedures and how to manage the complications. The book includes basics of venous disorders, primary varicose veins and recurrence after surgery, chronic venous insufficiency, venous ulcers and congenital venous malformations. Detailed coverage of endo-venous procedures such as radio-frequency ablation, laser ablation and foam sclerotherapy are additional essential features of this book. Primarily intended for the practicing general surgeon, this volume is also relevant for residents in general surgery and vascular surgery.