The records of 506 patients with histologically proven nodular goitre treated by thyroidectomy between January 1966 and July 1988 were reviewed. There were 21 patients with thyroid carcinoma in nodular goitre giving a proportion of 4.1%. There was an almost equal ratio of papillary to follicular carcinomas in the patients with malignancy occurring in a multinodular goitre (1 1 papillary to 9 follicular). One had an anaplastic lesion. These patients had swelling for a longer period, 9.1 1 years, as compared with an average of 5.48 years for those with only nodular goitre (P= < 0.01) using the Student's I-test. The male to female ratio in those with multinodular goitre alone was 1 : 10.8 while in those with carcinoma in multinodular goitre was 1 : 3.2. Comparing these two groups, the odds ratio of malignancy among males was 2.82 (95% confidence limits of the odds ratio being 1.4-5.5). This indicates that males with multinodular goitre had a significantly higher chance of developing a malignancy, Chi-squared value 5.74 (P < 0.05).
Wound infection occurred after 14.3 per cent of 433 open heart operations. In 309, saphenous veins were harvested for coronary artery bypass grafting (CABG) and 8.7 per cent of sternal wounds and 12.9 per cent of leg wounds were infected. Only 1.6 per cent of the remaining 124 patients who had open heart operations without leg surgery suffered sternal wound infections. In the CABG group sternal infection was theatre-related and significantly associated with length of pre-operative stay, diabetes and re-operation. Similar organisms were isolated from both leg and sternal wounds which suggest that organisms were transferred from legs to sternum with the veins. No clinically relevant cross infection was demonstrated. Skin disinfection and surgical technique seem more important than antibiotic prophylaxis in the control of these infections.
Correspondence to: M. V. BrairnbridgeThe management of oesophageal perforation is still controversial. The numerous operative techniques and the place of conservative management have recently been reviewed'. Spontaneous rupture of the oesophagus is often recognized late which complicates management. The value of closed chest drainage with irrigation following debridement of the pleura at thoracoscopy is described. Case reportA 51-year-old man presented to the casualty department with a 2 h history of sudden onset of dyspnoea and left sided chest pain. Examination revealed a shocked, tachypnoeic patient with the signs of a left hydropneumothorax. Chest radiography ( Figure I ) showed a left pneumothorax with a basal effusion, mediastinal shift to the right and surgical emphysema in the subcutaneous tissues of the neck. 4 diagnosis of leftsided tension pneumothorax with an effusion was made. An intercostal drain was inserted and produced symptomatic relief. Repeat radiography showed decrease of the effusion but incomplete re-expansion of the lung.Over the first 12 h following admission, 3000ml of dark brown fluid drained from the chest. Culture of this fluid showed a growth of Enterobacter cloacae. A diagnosis of oesophageal perforation was suspected on the fourth day following admission and the patient was referred to the cardiothoracic surgical department. The diagnosis was confirmed by barium swallow.Thoracoscopy and irrigation of the left pleural space was then performed. The space contained loculated purulent fluid but no oesophageal tear was seen. The pleural space was thoroughly debrided and irrigated until clean. Apical and basal intercostal chest drains were inserted, a feeding jejunostomy was performed and the absence of any intraperitoneal perforation was confirmed.Irrigation of the pleural space was performed once daily with 1 per cent noxythiolin solution and once daily with normal saline, until culture of the emuent fluid became sterile. Jejunostomy feeding was continued for 6 weeks until repeat barium swallow showed no further oesophageal leak when the apical irrigating chest drain was removed. The basal drain was removed two weeks later after three consecutive sterile cultures had been obtained.Six months following initial presentation the patient was asymptomatic and the chest radiograph had returned to normal apart from some pleural thickening at the left base.
Thirty-one children with primary peritonitis were studied. Most of them had been healthy prior to the onset of peritonitis and only one had nephrotic syndrome. There were 27 girls and four boys. The predominant organism in girls was pneumococcus, and in boys staphylococcus. The causative organisms, identified in 27 children, were all Gram positive. Most of the children were between four and 10 years of age. The onset of their illness was sudden with fever, vomiting and abdominal pain. Since in recent years, primary pneumococcal peritonitis has been the commonest type of peritonitis in young girls, our earlier policy of routine laparotomy for peritonitis was given up and in girls aged between four and ten, an attempt at initial pre-operative diagnosis was made by Gram's staining of peritoneal aspirate or vaginal swab. If Gram positive peritonitis was diagnosed, early cases were treated with antibiotics alone and late cases with antibiotics and minilaparotomy for drainage of pus. There was one death. Morbidity and mortality were higher when the period without treatment exceeded one week. The contribution of pre-operative diagnosis by Gram's staining to the provision of optimum treatment is emphasized.
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