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Purpose: Lifelong follow-up after endovascular abdominal aortic aneurysm repair (EVAR) is recommended due to a continued risk of complications, especially if the first postoperative imaging shows abnormal findings. We studied the long-term outcomes in patients with abnormalities on the first postoperative computed tomography angiography (CTA) following EVAR. Materials and Methods: This is a retrospective study of all consecutive patients who underwent elective EVAR for nonruptured abdominal aortic aneurysm (AAA) between January 2007 and January 2012 in 16 Dutch hospitals with follow-up until December 2018. Patients were included if the first postoperative CTA showed one of the following abnormal findings: endoleak type I–IV, endograft kinking, infection, or limb occlusion. AAA diameter, complications, and secondary interventions during follow-up were registered. Primary endpoint was overall survival, and other endpoints were secondary interventions and intervention-free survival. Kaplan-Meier analyses were used to estimate overall and intervention-free survival. Cox regression analyses were used to identify the association of independent determinants with survival and secondary interventions. Results: A total of 502 patients had abnormal findings on the first postoperative CTA after EVAR and had a median follow-up (interquartile range IQR) of 83.0 months (59.0). The estimated overall survival rate at 1, 5, and 10 years was 84.7%, 51.0%, and 30.8%, respectively. Age [hazard ratio (HR) 1.06, 95% confidence interval (CI) 1.05 to 1.10] and American Society of Anesthesiologists (ASA) classification (ASA IV HR 3.20, 95% CI 1.99 to 5.15) were significantly associated with all-cause mortality. Overall, 167 of the 502 patients (33.3%) underwent 238 secondary interventions in total. Fifty-eight patients (12%) underwent an intervention based on a finding on the first postoperative CTA. Overall survival was 38.4% for patients with secondary interventions and 44.5% for patients without (log rank; p=0.166). The intervention-free survival rate at 1, 5, and 10 years was 82.9%, 61.3%, and 45.6%, respectively. Conclusions: Patients with abnormalities on the first postoperative CTA after elective EVAR for infrarenal AAA cannot be discharged from regular imaging follow-up due to a high risk of secondary interventions. Patients who had a secondary intervention had similar overall survival as those without secondary interventions.

There is a suggestion that the medical disciplinary committees (MDC) in the Netherlands are making more severe rulings on medical professionals. In a 10-year analysis of MDC rulings, it appears that complaints made by patients are more frequently being judged to be well-founded, and that the measures being taken are more severe. The authors conclude that there is a numerical basis for the increasing severity of the rulings. However, a numerical trend as such does not constitute proof of this, as the way in which the ruling is arrived at is unknown. A more thorough analysis of the patient complaints, the ruling and the underlying arguments is necessary. The authors also make some other statements that can be refuted. The importance of the possible influence of the increasing complexity of health care as a factor in the increase in complaints to the MDC is not addressed.

Background Studies comparing laparoscopic and open appendicectomy are difficult to interpret owing to several types of bias, and the results often seem of limited clinical importance. National audits can be valuable to provide insight into outcomes following appendicectomy at a population level. Methods A prospective, observational, resident-led, nationwide audit was carried out over a period of 2 months, including all consecutive adult patients who had surgery for suspected acute appendicitis. Complications after laparoscopic and open appendicectomy were compared by means of logistic regression analysis; subgroup analyses were performed for patients with complicated appendicitis. Results A total of 1975 patients were included from 62 participating Dutch hospitals. A normal appendix was seen in 3·3 per cent of patients. Appendicectomy was performed for acute appendicitis in 1378 patients, who were analysed. All but three patients underwent preoperative imaging. Laparoscopy was used in 79·5 per cent of patients; the conversion rate was 3·4 per cent. A histologically normal appendix was found in 2·2 per cent. Superficial surgical-site infection was less common in the laparoscopic group (odds ratio 0·25, 95 per cent c.i. 0·14 to 0·44; P < 0·001). The rate of intra-abdominal abscess formation was not significantly different following laparoscopic or open surgery (odds ratio 1·71, 0·80 to 3·63; P = 0·166). Similar findings were observed in patients with complicated appendicitis. Conclusion Management of acute appendicitis in the Netherlands is preferably performed laparoscopically, characterized by a low conversion rate. Fewer superficial surgical-site infections occurred with laparoscopy, although the rate of abscess formation was no different from that following open surgery. A low normal appendix rate is the presumed effect of a mandatory preoperative imaging strategy.

All abdominal surgical procedures have a certain risk/benefit ratio. Recently, the way surgeons come to a decision whether to operate, or not, was discussed in the Annals of Surgery. First, the assessment of the decision for an operative versus a non-operative strategy was addressed on the basis of clinical vignettes. The perceptions concerning risk/benefit balance varied considerably between surgeons and these perceptions predicted the decision to operate. In a second paper, surgeons were randomized to either an arm in which they were exposed to a risk calculator or to a control arm. The decisions of the risk-calculator arm were less varied, but did not alter the likelihood of recommending an operation. Perhaps surgeons decide to operate or not rather intuitively, based on clinical and laboratory information. Alternatively, they may consider the statistically significant difference in risk/benefit to be less relevant. A better insight into surgeons' decision making and the way in which they weigh benefits against risks is very useful, but it is proving to be a considerable research challenge.

Structured assessments form a mandatory part of Dutch Medical Specialist Training, but create administrative workload for both the staff and supervisors. One could argue that the quality of the narrative feedback is more important than the extensive reporting in learning portfolios, and that the focus should be on continuous on-the-job coaching.

Background: The ability of laparoscopic techniques to treat malignant disease is controversial. We developed a rat model to assess metabolic and oncological effects of laparoscopic surgery. Methods: Experiment I. The postoperative body weight in 10 rats having laparoscopic bowel resection (group I), 10 rats having open bowel resection (group II) and 5 rats having anesthesia only (group III) was determined. Experiment II. Tumor take was scored in 11 rats having laparoscopic bowel resection (group IV), 11 rats having open bowel resection (group V), 6 rats having CO 2 pneumoperitoneum without bowel resection (group VI) and 6 rats having anesthesia only (group VII). All rats had CC531 cancer cells injected intraperitoneally postoperatively. Results: Experiment I. Body weight loss in group I compared to group II (p

An aneurysm of the abdominal aorta (AAA) is part of the atherososclerotic spectrum of diseases. The disease is characterized by a localized dilatation of the infrarenal artery and rupture of the weakened segment is now responsible for more than 15.000 annual deaths in the US alone. The pathology of AAA is complex and poorly understood. It is generally conceived that AAA is characterized by a localized general pro-inflammatory response and an accompanying protease imbalance that is held responsible for the progressive weakening of the aortic wall. The exact inflammatory pathways that drive aneurysm progression and that distinguish AAA from occlusive atherosclerotic disease have not yet been identified. We previously reported a 21-fold increase in CXCL8 mRNA expression and an approx. 300-fold increase in CXCL8 protein levels in human AAA, as compared to human occlusive atherosclerotic disease (p We now performed a histological and protein analysis of human AAA and human occlusive atherosoclerotic disease, showing abundant presence of the CXCL8 receptors CXCR1 and 2 as well as increased ERK phosphorylation in AAA. Evaluation on cellular level identified abundant neutrophils (fully absent in atherosoclerosis) as well as increased neovascularization as clear distinctive features of AAA, a finding that is consistent with increased CXCL8 signaling. To test a putative role of CXCL8/CXCR1-2 system in AAA we next tested whether the oral CXCR2 antagonist DF2156A prevents aneurysm formation in the elastase model, a well established model of the disease. This study showed that a once daily dose of 15mg/kg DF2156A fully abrogates aneurysm formation in the elastase model (71.86% aortic diameter growth in 14 days (SEM 4.88) in untreated animals vs. 17.66% growth (SEM 1.71) in animals treated with DF2156A) (p In conclusion, these studies identify activation of the CXCL8/CXCR1-2 pathway as a distinctive feature of AAA and characterize this pathway as a potential target for the stabilization of AAA.

It is currently unclear whether the parallels between abdominal aortic aneurysms (AAAs) and chronic obstructive pulmonary disease (COPD) are explained by common risk factors alone, such as cigarette smoking, or by a predetermined cause. Given the persistent controversy with regard to the association between AAA and COPD, we studied this association in depth.We conducted a case-control study comparing patients with a small AAA (maximum infrarenal diameter 35-50 mm, n = 221) with controls diagnosed with peripheral artery disease (PAD, n = 87). The controls were matched to the cases for lifetime cigarette smoking. Pulmonary function was measured by spirometry, and all subjects completed a questionnaire on medical history and smoking habits (current, former and never smokers).Aneurysm patients were similar to controls with respect to gender (p = 0.71), lifetime cigarette smoking (39 vs. 34 pack years, p = 0.23) and history of cardiovascular disease (45% vs. 55%, p = 0.12). Aneurysm patients had more airway obstruction (forced expiratory volume in 1 s/forced vital capacity (FEV1/FVC) (0.69 ± 0.12 vs. 0.78 ± 0.11, p0.001)), which was most pronounced in never smokers (0.73 ± 0.07 vs. 0.86 ± 0.07, p0.001). COPD was more prevalent in aneurysm patients (44%; 98/221) than in controls (20%; 17/87) (adjusted odds ratio (OR) 3.0; 95% confidence interval (95%CI) 1.6-5.5, p0.001). In particular, a major proportion of AAA patients was newly diagnosed with COPD; only 40 of 98 patients (41%) with COPD (mild, moderate or severe/very severe) were known before with obstructive pulmonary defects and received treatment.This study confirms an association between AAA and COPD and shows that this association is independent from smoking. Findings also demonstrate that COPD is under-diagnosed in AAA patients.

The TGF-β superfamily members transforming growth factor-β (TGF-β/Activin) and bone morphogenetic proteins (BMP) have been implicated in the pathogenesis of atherosclerosis. However, their role in human disease remains controversial. In this study we used Smad phosphorylation as a read out for TGF-β and BMP signaling during the initiation, progression and (de)stabilization of human atherosclerotic disease.A systematic analysis was performed in 114 peri-renal aortic patches (stained with Movat Pentachrome, HE, pSmad2, pSmad1,5,8 and PAI-1) covering the entire atherosclerotic spectrum (van Dijk, 2010). Immunostaining against T-cells (CD3) and monocytes and macrophages (CD68) was used to explore a putative association between TGF-β and BMP signaling and vascular inflammation.Smad phosphorylation was present within the normal arterial wall in approximately 10% of the endothelial cells and intimal smooth muscle cells. A significant increase in pSmad2 and pSmad1,5,8 positivity was found in non-progressive lesions (50% positivity). No further increase or decrease was found in the progressive atherosclerotic lesions, vulnerable and stabilized lesions. No association was found between TGF-β and BMP signaling and CD3 and CD68 expression, nor cap thickness.Activation of the TGF-β and BMP pathways is an early event in atherosclerotic lesion formation. No significant relationships were found between Smad phosphorylation and vessel wall inflammation or plaque vulnerability.

This systematic review aimed to evaluate the efficacy, morbidity and mortality of laparoscopic peritoneal lavage for patients with perforated diverticulitis.We searched PubMed, EMBASE, Web of Science, the Cochrane Library and CINAHL databases, Google Scholar and five major publisher websites without language restriction. All articles which reported the use of laparoscopic peritoneal lavage for patients with perforated diverticulitis were included.Two prospective cohort studies, nine retrospective case series and two case reports reporting 231 patients were selected for data extraction. Most (77%) patients had purulent peritonitis (Hinchey III). Laparoscopic peritoneal lavage successfully controlled abdominal and systemic sepsis in 95.7% of patients. Mortality was 1.7%, morbidity 10.4% and only four (1.7%) of the 231 patients received a colostomy.There have been no publications of high methodological quality on laparoscopic peritoneal lavage for patients with perforated colonic diverticulitis. The published papers do, however, show promising results, with high efficacy, low mortality, low morbidity and a minimal need for a colostomy.

Recent evidence indicates that bone marrow mononuclear cells (BMC) promote collateral vessel formation in patients with severe peripheral arterial disease (PAD). However, aspects concerning optimal administration mode, durability and long-term safety require consideration. Combined intra-arterial (IA) plus intramuscular (IM) BMC delivery may be more effective than exclusive intramuscular injections. The aim of this study was to evaluate feasibility, safety and effect of exclusive IM versus combined IM+IA delivery of autologous BMC in patients who were not candidates for surgical or endovascular treatment.Twenty-seven patients were treated with either combined IA+IM (N=12) or sole IM (N=15) administration of autologous BMC. Efficacy was assessed after 1, 6 and 12 months. Limb salvage, pain-free walking distance, ankle-brachial pressure index (ABI) and pain scores were evaluated.There were no adverse reactions related to injection of the cells. Three patients died within the first year of follow-up due to non-procedure related causes. Two patients in the IA+IM group required limb amputation because of ongoing critical ischemia versus 7 patients in the IM group (P=0.17). BMC treatment in the remaining patients resulted in a significant and sustained (12 months) improvement. Pain-free walking distance improved from 81+/-56 meters at baseline to 257+/-126 meters at t=6 months (P=0.0002). Mean ABI increased 23% after 6 months (P=0.01) and pain score reduced for up to 50% as shown by Brief Pain Inventory (P=0.001).Both IM and combined IM/IA delivery of autologous BMC are safe, and result in relevant and sustained improvement in a considerable proportion of patients with severe PAD who are not amenable for conventional treatment.

In 2 patients, men aged 73 and 66 undergoing physical and ultrasound examinations for complaints of abdominal pain, an aneurysm of the abdominal aorta (AAA) with a diameter of 7-8 cm was discovered. Both their blood pressure and heart rate were normal. The older man then underwent a CT scan as did the younger man after being observed overnight. They both proved to have a ruptured AAA. They were operated on and recovered well. It can be problematic to diagnose a ruptured AAA quickly in patients with abdominal and back pain, AAA on ultrasound and normal haemodynamic parameters. In this situation an emergency CT scan will visualize any retroperitoneal haematoma and the patient can undergo an emergency operation. If the CT scan does not show any rupture there is time for preoperative preparations before performing a semi-elective procedure.

To assess the necessity to operate on non-incarcerated inguinal hernia in children within 7 days of diagnosis.Retrospective.Data on 360 children, 0-10 years old (104 girls and 256 boys) who were operated on for inguinal hernia between 1 January 1993-31 December 2001 at the St. Elisabeth Hospital in Tilburg, the Netherlands, were collected from the medical records. These data included sex, age, interval between diagnosis and repair, recurrence, incarceration, length of hospitalisation and complications.In the group of 113 children 0-1 years old, 137 inguinal hernias were repaired, ofwhich 16 were incarcerated on presentation. The interval between diagnosis and repair was known in 93 of 121 cases: 37 hernias were repaired within 7 days and 56 at a later stage. In the latter group, there was one case of secondary incarceration (1.8%; 95% CI: 0-5.4). The number needed to treat was 56. In the group of 247 children 1-10 years old, 269 inguinal hernias were repaired, of which 8 were primarily incarcerated. The interval between diagnosis and repair was known in 208 of 261 cases: 34 hernias were repaired within 7 days and 174 at a later stage. In the latter group, 3 hernias incarcerated secondarily (1.7%; 95% CI: 0-3.7). The number needed to treat was 58. In the group of non-incarcerated hernias 1 complication occurred, in the group of incarcerated hernias none. The mean length of hospitalisation of children with non-incarcerated hernia was 0.85 days, and of children with incarcerated hernia 2.4 days.In children with a non-incarcerated inguinal hernia who are waiting for an operation, the risk of secondary incarceration and complications is 2% which we do not think is enough reason to carry out an elective hernia-repair procedure within 7 days.

Thoracoscopic resection of the first through the fourth thoracic sympathetic ganglion for palmary and axillary hyperhidrosis and Raynaud's syndrome is associated with a high initial success rate. However, the reported incidence of compensatory hyperhidrosis of the trunk and legs and Horner's syndrome are high. This study assesses the results of thoracoscopic sympathectomy limited to transection of the interganglionic trunk or resection of one or two thoracic ganglia.Twenty-eight thoracoscopic sympathectomies were done for dystrophy of the hand (n = 9), palmar and axillary hyperhidrosis (n = 6), and Raynaud's syndrome (n = 4). The extent of sympathectomy varied from interganglionic division between the second and third ganglion (n = 12), to resection of the third ganglion (n = 12), to resection of the second and third ganglion (n = 4).Sympathectomy resulted initially in relief of symptoms in all cases. Horner's syndrome did not occur.After a median follow-up of 11 months, two of nine patients with dystrophy judged the result of operation as good. All patients with hyperhidrosis and Raynaud's syndrome judged the result of sympathectomy as good. Compensatory hyperhidrosis was experienced by two patients with dystrophy of the hand who had removal of the second and third sympathetic ganglion.

Two patients, a man aged 65 years and a woman aged 75 years, developed chylous ascites after emergency abdominal aortic aneurysm repair. Both patients were still on artificial ventilation at the time of diagnosis. The first symptoms were high ventilation pressure, elevated diaphragm and abdominal distension. The patients were treated conservatively with drainage, and the man was also given tube feeding without long-chain triglycerides. The man recovered, while the woman died of sepsis. Chylous ascites is an unusual complication of retroperitoneal surgery. Abdominal paracentesis is a simple means to confirm the diagnosis. Initial treatment consists of draining the chylus, and a medium-chain triglyceride diet or total parenteral nutrition. When this fails, more invasive treatment is required, consisting of direct lymphatic repair or peritoneovenous shunting. In mechanically ventilated patients, gradually progressive symptoms of abdominal hypertension after surgery in the retroperitoneal space should arouse suspicion of this complication.

We encountered significant liver fibrosis in a healthy young patient undergoing laparoscopic cholecystectomy for symptomatic gallstone disease. Twelve months prior to cholecystectomy the patient underwent multiple extracorporeal shock-wave lithotripsy (ESWL) sessions with adjuvant oral bile-acid therapy. Since the site of fibrosis corresponded clearly to the shock-wave transmission path, which was in accordance with animal studies, it was concluded that this liver fibrosis was a side effect of biliary ESWL. Based on these findings and the literature, we conclude that further assessment of the long-term safety of ESWL is still warranted, especially in patients undergoing multiple ESWL sessions.

To evaluate the treatment of patients with differentiated (papillary or follicular) thyroid cancer in general hospitals in the south-east of the Netherlands during the period 1983-1996, in relation to the 1987 national consensus recommendations.Population-based, retrospective, descriptive.For the period 1 January 1983-31 December 1996, data on the histology, TNM-stage and treatment (hospital, specialist, type of operation, referral for 131I therapy) of all 236 patients with differentiated thyroid cancer were obtained from the cancer registry of the Comprehensive Cancer Centre South, Eindhoven, the Netherlands. The treatment was compared with the recommendations from the consensus meeting in 1987.Data on 219 patients (137 papillary, 82 follicular thyroid carcinoma) treated in the general hospitals in the region were studied; the 17 remaining patients had been referred from outside the region. Patients were treated at all hospitals in the region; the number of specialists per hospital able to treat thyroid carcinoma (internist and/or surgeon) was limited. In total 79% of the patients underwent a (near-)total thyroidectomy, half of them in two phases, and in 12% of the cases combined with regional lymph node dissection. In the majority of cases, surgical treatment was in accordance with the consensus recommendations: 65-100% of the cases per hospital. The proportion of patients referred for 131I therapy varied from 17% to 90%; referral was more frequent in the case of larger tumours and/or metastases. Of the 24 patients with a small papillary carcinoma without metastases, 79% were not referred for 131I therapy.The recommendations laid down in the consensus meeting in 1987 were known and appeared to be followed for surgical treatment but for subsequent 131I therapy they appeared to be interpreted differently. A review of the consensus guidelines seems to be worthwhile.

BackgroundConventional repair of recurrent inguinal hernia is associated with a re-recurrence rate as high as 35 per cent. Endoscopic mesh repair has promising results regarding both recurrence and complication rates.MethodsIn a retrospective review, the results of endoscopic totally extraperitoneal repair were evaluated in 104 patients with 108 recurrent hernias. Follow-up was at least 1 year. Type of recurrence, time of occurrence after previous repair, duration of surgery, complications, duration of hospital stay and number of re-recurrences were evaluated.ResultsFollow-up ranged from 12 to 29 (mean 16) months. Forty-three recurrences were direct, 41 indirect and 15 combined; one was a femoral hernia. Median time to previous operation was 36 months (range 8 days to 42 years). Median duration of surgery was 63 (range 25–160) min. While there were no complications during operation, 12 patients (12 per cent) had a postoperative complication. Two direct re-recurrences (2 per cent) occurred as a result of inadequate positioning of the prosthetic mesh.ConclusionThe endoscopic totally extraperitoneal technique is safe and effective for the repair of recurrent inguinal hernia.

The ability of laparoscopic techniques to treat malignant disease is controversial. We developed a rat model to assess metabolic and oncological effects of laparoscopic surgery.Experiment I. The postoperative body weight in 10 rats having laparoscopic bowel resection (group I), 10 rats having open bowel resection (group II) and 5 rats having anesthesia only (group III) was determined. Experiment II. Tumor take was scored in 11 rats having laparoscopic bowel resection (group IV), 11 rats having open bowel resection (group V), 6 rats having CO2 pneumoperitoneum without bowel resection (group VI) and 6 rats having anesthesia only (group VII). All rats had CC531 cancer cells injected intraperitoneally postoperatively.Experiment I. Body weight loss in group I compared to group II (p0.036). Rats of group III lost no weight postoperatively. Experiment II. Tumor take was less in the subcutis (p=0.005), parietal peritoneum (p0.001) and bowel anastomosis (p=0.021) in group IV compared to group V. Tumor take was significantly greater at all sites except for subcutis in group VI compared to VII (all p0.022).Laparoscopic surgery is associated with less postoperative weight loss and less tumor take compared to open surgery. CO2 insufflation appears to increase tumor take.

(1993). Review: Detection and Management of Common Bile Duct Stones in the Era of Laparoscopic Cholecystectomy. Scandinavian Journal of Gastroenterology: Vol. 28, No. 11, pp. 929-933.

The accuracy of clinical diagnosis and fine-needle aspiration biopsy (FNAB) was evaluated in a total of 495 patients of whom 183 were operated upon within 6 months after FNAB and 312 were not. Operated patients were divided into three subgroups with high, moderate or low suspicion of malignant neoplasms on clinical grounds. Histological examination revealed an overall malignant neoplasm rate of 23%. The rate, i.e. the positive predictive value, was 74% for the subgroup with high clinical suspicion, vs 14% and 10% respectively for the subgroups with moderate and low clinical suspicion. The sensitivity of a high clinical suspicion was 60% and the specificity 93%. The overall sensitivity of FNAB was 93% in the operated group and probably not less than 87% in all patients studied; specificity was 71% and 84% respectively for these groups. The overall positive predictive value of a positive cytology result (malignant or uncertain) was 48%. In the subgroups with moderate or low clinical suspicion which are more representative of a non-university setting, the average predictive value was 27%. In our opinion all patients in the group with high clinical suspicion need surgical treatment, regardless of the FNAB result; those with lower degrees of clinical suspicion and malignant or uncertain FNAB result should also undergo diagnostic surgical exploration.

The accuracy of clinical diagnosis and fine-needle aspiration biopsy (FNAB) was evaluated in 169 patients surgically treated for nodular thyroid disease. Patients were divided into three groups with high, moderate, or low suspicion of malignant neoplasms on clinical grounds without previous knowledge of cytologic or histologic results. Histologic examination revealed an overall malignant neoplasm rate of 23%; the rate was 71%, 14%, and 11% for the groups with high, moderate, and low suspicion, respectively. The FNAB diagnostic interpretations of malignant and uncertain were considered positive. Overall sensitivity, specificity, and accuracy for FNAB were 92%, 71%, and 75%, respectively. Sensitivity in the high-, moderate-, and low-suspicion groups was 95%, 89%, and 88%, respectively; specificity was 88%, 72%, and 67%, respectively; and accuracy was 93%, 75%, and 69%, respectively. In our opinion, all patients in the group with high clinical suspicion need surgical treatment whatever the FNAB result; those with lower degrees of clinical suspicion and malignant or uncertain FNAB result [corrected] should also undergo surgery.

The management of two groups of patients with papillary carcinoma of the thyroid gland (n = 165) was evaluated retrospectively. Total thyroidectomy was the standard procedure in both groups, but the peroperative diagnosis and treatment of metastases to the regional lymph nodes differed. In group 1 (n = 84), only clinically positive lymph nodes were resected, and if residual postoperative 131I uptake was found, an ablation dose of 131I was given. In group 2 (n = 81), all of the tissue in the tracheoesophageal groove was removed routinely at total thyroidectomy and frozen section was done of the lymph nodes lying along the internal jugular vein. If metastases were found, a modified radical dissection of the neck was performed on the affected side. The two patient groups were comparable with regard to risk factors--local tumor stage, age and sex. Almost twice as many patients were found to have metastases to the lymph nodes in group 2. There was no significant difference in the ten year over-all or recurrence free survival time between the two groups. In group 1, there were more recurrences on the explored side of the neck but fewer distant metastases; however, both findings were not significant. In group 2, significantly more instances of hypoparathyroidism and palsy of the accessory nerve were found (p less than 0.05). Thus, when a more extensive search was carried out, more metastases to the lymph node were discovered and treated, but this did not prevent recurrences in the neck nor did it improve survival time. This approach resulted in more postoperative morbidity. There seems to be no justification for prophylactic removal of regional lymph nodes in instances of papillary carcinoma of the thyroid gland, but modified radical neck dissection may be beneficial if clinically suspect regional lymph nodes are present in the lateral part of the neck.