Exploring the Efficacy of the Paula Method of Muscle Exercises in Managing Low Anterior Resection Syndrome Using an Integrative Approach: A Preliminary Study

Background

Low anterior resection syndrome (LARS) is a post-proctectomy consequence characterized by variable and unpredictable bowel function, including clustering, urgency, and incontinence, which significantly impacts the quality of life. Currently, there is no established gold-standard therapy for LARS.

Primary Study Objective

This study aimed to evaluate the effectiveness of the Paula method of exercise as part of an integrative treatment approach for patients with LARS.

Design

This preliminary study utilized a single-arm pretest-posttest design.

Setting

The study was conducted at a tertiary care medical center.

Participants

Five patients diagnosed with LARS completed the study.

Intervention

Participants underwent twelve weeks of individualized Paula method exercise sessions. Two questionnaires were employed to assess the severity of LARS and quality of life.

Primary Outcome Measures

(1) Low Anterior Resection Syndrome (LARS) Score; (2) Memorial Sloan Kettering Cancer Bowel Function Instrument (MSK-BFI); (3) Global Quality-of-Life (QOLS) Score ‎.

Results

All participants completing the 12-week Paula exercise regimen reported no difficulty in engaging with the exercises. Statistically significant improvements were observed in both the LARS score and MSK-BFI (P = .039 and P = .043, respectively, Wilcoxon Rank Sum test). While there were improvements in the global quality-of-life score and functional scales of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, these improvements did not reach statistical significance.

Conclusions

This preliminary study suggests that patients with LARS can successfully complete a 12-week exercise program using the Paula method, resulting in improved LARS scores. However, further investigation through larger, multicenter, randomized controlled trials is necessary to establish the efficacy of these exercises as a treatment for LARS.

Incidence and Risk Factors for Low Anterior Resection Syndrome following Trans-Anal Total Mesorectal Excision

BACKGROUND

Trans-anal total mesorectal excision (Ta-TME) is a novel approach for the resection of rectal cancer. Low anterior resection syndrome (LARS) is a frequent functional disorder that might follow restorative proctectomy. Data regarding bowel function after Ta-TME are scarce. The aim of this study was to evaluate the incidence and risk factors for the development of LARS following Ta-TME.

METHODS

A prospectively maintained database of all patients who underwent Ta-TME for rectal cancer at our institution was reviewed. All patients who were operated on from January 2018 to December 2021 were evaluated. The LARS score questionnaire was used via telephone interviews. Incidence, severity and risk factors for LARS were evaluated.

RESULTS

Eighty-five patients underwent Ta-TME for rectal cancer between January 2018 and December 2021. Thirty-five patients were excluded due to ostomy status, death, local disease recurrence, ileal pouch or lack of compliance. Fifty patients were included in the analysis. LARS was diagnosed in 76% of patients. Anastomosis distance from dentate line was identified as a risk factor for LARS via multivariate analysis (p = 0.042). Neo-adjuvant therapy, hand sewn anastomosis and anastomotic leak did not increase the risk of LARS.

CONCLUSION

LARS is a frequent condition following ta-TME, as it is used for other approaches to low anterior resection. Anastomosis distance from dentate line is an independent risk factor for LARS. In this study neo-adjuvant therapy, hand sewn anastomosis and anastomotic leak did not increase the risk of LARS. Further studies with longer follow-up times are required to better understand the functional outcomes following Ta-TME.

Higher Rates of Complicated Appendicitis During the COVID-19 Pandemic: A Year-to-Year Analysis

INTRODUCTION

The COVID-19 pandemic impacted presentation, management strategies, and patient outcomes of numerous medical conditions. The aim of this study is to perform a year-to-year comparison of clinical outcomes of patients with acute appendicitis (AA) before and during the pandemic.

METHODS

Patients treated for AA during the initial 12-mo period of the pandemic at our institute were compared to those treated for AA during the 12-mo period before. Clinical and laboratory parameters, treatment strategies, intraoperative findings, pathology reports, and postoperative outcomes were compared.

RESULTS

During the study period, 541 patients presented with AA. The median (interquartile range) age was 28 (21-40) y and 292 (54%) were males. 262 (48%) patients presented during the pre-COVID-19 period, while 279 patients (52%) presented during the COVID 19 pandemic. The groups were comparable for baseline clinical data and imaging results upon index admission. There was no significant difference in rate of nonoperative treatment between the Pre-COVID-19 and During-COVID-19 eras (51% versus 53%, P = 0.6) as well as the success rate of such treatment (95.4% versus 96.4%, P = 0.3). Significantly more patients presented with a periappendicular abscess during COVID-19 (4.6% versus 1.1%, P = 0.01) and median (interquartile range) operative time was significantly longer (78 (61-90) versus 32.5 (27-45) min, P < 0.001). Pathology reports revealed a higher rate of perforated appendicitis during COVID-19 (27.4% versus 10.2%, P < 0.001).

CONCLUSIONS

Patients with AA present with higher rates of perforated and complicated appendicitis during the COVID-19 pandemic. The success rates of nonoperative management in selected patients with noncomplicated AA did not change during the pandemic and is a safe, feasible, option.

A patient tailored approach to the surgical treatment of hemorrhoids leads to equal satisfaction following hemorrhoidectomy, stapled hemorrhoidopexy or a combination of both

PURPOSE

Up to 20% of patients suffering from symptomatic hemorrhoids will require surgery. Excisional hemorrhoidectomy (EH) and stapled hemorrhoidopexy (SH) are both standard and safe procedures. While SH has a short-term advantage of faster recovery and lower postoperative pain, its long-term efficacy is debatable. This study aims to compare the outcomes of EH, SH, and a combined procedure of both.

METHODS

A retrospective study compared the outcomes of patients treated surgically for hemorrhoids over a 5-year period. Eligible patients were asked by phone to complete a questionnaire evaluating recurrent symptoms, fecal incontinence, satisfaction, and self-assessed improvement in quality of life (QOL).

RESULTS

This study included 362 patients, of whom 215 underwent SH, 99 underwent EH, and 48 underwent a combined procedure. No statistically significant differences were found between groups regarding complications, symptoms recurrence, or fecal incontinence. Combined procedure patients had significantly higher self-assessed improvement in QOL (P=0.04).

CONCLUSION

In patients with symptomatic hemorrhoids, a tailored approach to symptomatic hemorrhoids is associated with high satisfaction rates and self-assessed improvement in QOL.

The biophysical property of the limbal niche maintains stemness through YAP

The cell fate decisions of stem cells (SCs) largely depend on signals from their microenvironment (niche). However, very little is known about how biochemical niche cues control cell behavior in vivo. To address this question, we focused on the corneal epithelial SC model in which the SC niche, known as the limbus, is spatially segregated from the differentiation compartment. We report that the unique biomechanical property of the limbus supports the nuclear localization and function of Yes-associated protein (YAP), a putative mediator of the mechanotransduction pathway. Perturbation of tissue stiffness or YAP activity affects SC function as well as tissue integrity under homeostasis and significantly inhibited the regeneration of the SC population following SC depletion. In vitro experiments revealed that substrates with the rigidity of the corneal differentiation compartment inhibit nuclear YAP localization and induce differentiation, a mechanism that is mediated by the TGFβ-SMAD2/3 pathway. Taken together, these results indicate that SC sense biomechanical niche signals and that manipulation of mechano-sensory machinery or its downstream biochemical output may bear fruits in SC expansion for regenerative therapy.

A Comparison of Outcomes in Medullary Thyroid Carcinoma Patients With and Without a Preoperative Diagnosis: A Multicenter Retrospective Cohort Study

Background: Cytological limitations pose a challenge to preoperative diagnosis of medullary thyroid carcinoma (MTC) and therefore, a significant subset of patients is only diagnosed postoperatively. The objective of this study was to investigate the impact of knowledge of a preoperative MTC diagnosis on disease management and outcomes. Methods: Multicenter, retrospective, cohort study of MTC patients treated in Israel from January 2000 to June 2021. We compared cohorts of patients according to the presence or absence of a preoperative MTC diagnosis. Results: Ninety-four patients with histologically confirmed MTC were included (mean age 56.2 ± 14.3 years, 43% males). Fifty-three patients (56%) had a preoperative MTC diagnosis (preop-Dx group), and 41 (44%) were confirmed only postoperatively (no-Dx group). The extent of surgical resection, including completion procedures, was as follows: total thyroidectomy in 83% versus 100% (p = 0.002), central lymph node dissection (LND) in 46% versus 98% (p < 0.001), ipsilateral lateral LND in 36% versus 79% (p < 0.001), and contralateral lateral LND in 17% versus 28% (NS), in the no-Dx versus the preop-Dx group, respectively. Pathology confirmed a smaller median tumor size of 16 ± 17.4 mm versus 23 ± 14.0 mm (p = 0.09), a higher proportion of micro-MTC (size ≤10 mm) 32% versus 15% (p = 0.03), and a higher rate of co-occurrence of follicular cell-derived carcinoma 24% versus 4% (p = 0.003), in the no-Dx compared to the preop-Dx group, respectively. The rates of extrathyroidal and extranodal tumor extension were not significantly different between the groups. At the last follow-up, the biochemical cure was attained in 55% [CI 0.38-0.71] compared to 64% [CI 0.50-0.77] of the no-Dx and the preop-Dx group, respectively (p = 0.41). After the exclusion of patients with micro-MTC, biochemical cure was more commonly achieved in the preop-Dx group (33% [CI 0.14-0.52] vs. 62% [CI 0.46-0.77], p = 0.04). Preop-Dx patients had improved overall survival compared to the no-Dx group (log-rank p = 0.04) over a median follow-up of 82 months (interquartile range [IQR] 30-153). Conclusions: Preoperatively, the diagnosis of MTC is often missed. An accurate preoperative diagnosis of MTC may enable guideline-concordant surgical treatment and ultimately contribute to an overall survival benefit in MTC patients.

Use of fluorescence imaging and indocyanine green during colorectal surgery: Results of an intercontinental Delphi survey

BACKGROUND

Fluorescence imaging with indocyanine green is increasingly being used in colorectal surgery to assess anastomotic perfusion, and to detect sentinel lymph nodes.

METHODS

In this 2-round, online, Delphi survey, 35 international experts were asked to vote on 69 statements pertaining to patient preparation and contraindications to fluorescence imaging during colorectal surgery, indications, technical aspects, potential advantages/disadvantages, and effectiveness versus limitations, and training and research. Methodological steps were adopted during survey design to minimize risk of bias.

RESULTS

More than 70% consensus was reached on 60 of 69 statements, including moderate-strong consensus regarding fluorescence imaging's value assessing anastomotic perfusion and leak risk, but not on its value mapping sentinel nodes. Similarly, although consensus was reached regarding most technical aspects of its use assessing anastomoses, little consensus was achieved for lymph-node assessments. Evaluating anastomoses, experts agreed that the optimum total indocyanine green dose and timing are 5 to 10 mg and 30 to 60 seconds pre-evaluation, indocyanine green should be dosed milligram/kilogram, lines should be flushed with saline, and indocyanine green can be readministered if bright perfusion is not achieved, although how long surgeons should wait remains unknown. The only consensus achieved for lymph-node assessments was that 2 to 4 injection points are needed. Ninety-six percent and 100% consensus were reached that fluorescence imaging will increase in practice and research over the next decade, respectively.

CONCLUSION

Although further research remains necessary, fluorescence imaging appears to have value assessing anastomotic perfusion, but its value for lymph-node mapping remains questionable.

Elective minimally invasive surgery for sigmoid diverticulitis: operative outcomes of patients with complicated versus uncomplicated disease

AIM

The aim of this work was to compare the results of elective minimally invasive surgery between patients with complicated sigmoid diverticulitis and those with uncomplicated disease.

METHOD

An institutional review board-approved database was searched for all consecutive patients who underwent elective minimally invasive surgery, including laparoscopic, hand-assisted and robotic sigmoidectomy, for diverticulitis between 2010 and 2017; they were classified according to the modified Hinchey classification as having complicated (abscess, fistula, stricture, obstruction, bleeding or previous perforation) versus uncomplicated disease. Data recorded included baseline demographics, indications for surgery, operative details and complications.

RESULTS

Three hundred and twenty-five patients underwent elective sigmoidectomy for complicated (n = 105) and uncomplicated (n = 220) diverticulitis. Surgical indications for complicated disease were abscess (n = 74), stricture (n = 14), fistula (n = 28) and bleeding (n = 7). The two groups were statistically comparable for age, gender, body mass index and American Society of Anesthesiologists score. Patients with complicated disease had higher rates of concomitant loop ileostomy creation (9.5% vs. 0.9%, p < 0.001) and synchronous resections (9.5% vs. 2.7%, p = 0.01), higher volumes of blood loss (177 ± 140 vs. 125 ± 92 ml, p < 0.001), longer length of stay (5.6 ± 3 vs. 4.8 ± 2 days, p = 0.04) and longer operating time (218.2 ± 59 vs. 185.8 ± 63 min, p < 0.001). There were no significant differences in anastomotic leakage (3% vs. 1%, p = 0.3), conversion to laparotomy (4.8% vs. 2.3%, p = 0.3) or overall complications (36% vs. 25.9%, p = 0.06) for complicated versus uncomplicated disease, respectively.

CONCLUSION

Minimally invasive surgery for complicated diverticulitis resulted in higher rates of construction of proximal ileostomy and synchronous resections and longer operating times and length of hospital stay. Otherwise, it has outcomes that are not significantly different from the results recorded in patients with uncomplicated disease.

External sphincter-sparing anal fistulotomy (ESSAF): a simplified technique for the treatment of fistula-in-ano

BACKGROUND

Fistula-in-ano due to cryptoglandular disease is a common condition. While a simple anal fistula can be treated successfully by a fistulotomy, the risk of potential damage to the anal sphincters and subsequent poor functional outcomes persist in a large portion of patients with complex fistulae. Several sphincter-preserving treatment procedures have been described for complex fistulae over the past 3 decades, with variable results and complication rates, and no procedure is proven to be superior to the others. We developed external sphincter-sparing anal fistulotomy (ESSAF), a reproducible simple modification of the ligation of intersphincteric fistula tract (LIFT) technique for the treatment of complex fistula-in-ano.. The aim of the present study was to describe the technique and our outcomes.

METHODS

This was a retrospective review of all patients who underwent ESSAF for a complex anal fistula at our institution from January 2014 to December 2019. The primary outcome measure of this study was the primary fistula healing rate. Secondary outcome measures included fecal and/or gas incontinence and postoperative complications. During the ESSAF procedure, the mucosa and skin overlying the fistula tract are incised to allow complete exposure of the sphincter complex. Then the internal sphincter muscle fibers overlying the tract are divided and the tract is meticulously curetted and debrided. Next, the internal opening of the tract traversing the external sphincter muscle is suture-ligated with absorbable sutures. Then, a minimal amount of mucosa is advanced and the incision is partially closed with absorbable sutures, while its external portion is left open for drainage.

RESULTS

Fifty-nine patients [43 males, median age was 50 years (range 36-63 years)] underwent ESSAF for complex anal fistula during the study period. Mean follow-up was 12 ± 14.7 months. Of the 59 patients, 42 (71.2%) experienced fistula closure, with a median healing time of 8 weeks (IQR 4-16 weeks). None of the patients developed significant anal incontinence following the procedure. One patient (1.7%) suffered from soiling and another patient (1.7%) developed postoperative bleeding. There were no infectious complications. Of the 17 patients (28.8%) who failed to heal successfully, 9 (15.2%) did not heal primarily and 8 (16%) experienced recurrence after complete healing. Thirteen (76%) of these patients underwent reoperation with complete recovery after ESSAF (n = 4), fistulotomy (n = 8) or endorectal advancement flap (ERAF) (n = 1). Overall ESSAF initiated recovery in 93.2% of the patients.

CONCLUSIONS

ESSAF is a feasible, safe, reproducible and effective sphincter-sparing procedure for the treatment of complex anal fistulae.

Does caffeine enhance bowel recovery after elective colorectal resection? A prospective double-blinded randomized clinical trial

BACKGROUND

Postoperative ileus is a common condition following abdominal surgery. Previous studies have shown the positive effects of coffee on gastrointestinal motility. The aim of this study was to assess whether caffeine is the stimulatory agent in coffee that triggers bowel motility and thus may reduce the duration of postoperative ileus.

METHODS

This was a single-centered, prospective, randomized controlled, double-blinded clinical trial. Patients scheduled to undergo elective laparoscopic colectomy between November 2017 and March 2019 were randomly assigned to receive either oral caffeine (100 mg three times daily) or placebo following the procedure. Primary endpoints were time to first flatus and time to first bowel movement. Secondary endpoints were time to tolerate a solid, low-residue diet and length of hospital stay. Registration number: NCT03097900.

RESULTS

Seventy patients were included, [35 males, median age 56 years (range 19-79 years)]. After the exclusion of 12 patients, there were 30 patients in the caffeine group and 28 patients in the placebo group. The first passage of stool in the caffeine group occurred 18 h earlier than in the placebo group (p = 0.012); other endpoints did not reach statistical significance. No caffeine-related adverse events were observed.

CONCLUSION

Caffeine consumption following colectomy is safe, leads to a significantly shorter time to first bowel movement, and may thus potentially lead to a shorter postoperative hospital stay.

Staple Line Leaks Following Laparoscopic Sleeve Gastrectomy: Low Efficacy of the Over-the-Scope Clip

PURPOSE

The over-the-scope clip (OTSC) enables non-surgical management of gastrointestinal defects. The aim of this study was to report our experience with OTSC for patients with staple line leaks following laparoscopic sleeve gastrectomy (LSG).

MATERIALS AND METHODS

A prospectively maintained IRB-approved institutional database was queried for all patients treated with OTSC for staple line leaks following LSG from 2010 to 2018. Primary outcome was complete resolution of leak following OTSC. Secondary outcome was the number of additional procedures needed following OTSC.

RESULTS

Twenty-six patients (13 males, 13 females) were treated with OTSC for staple line leaks following LSG. The median age was 35 years (range 18-62), and mean body mass index was 44 kg/m2. The median time from index operation to leak diagnosis and from leak diagnosis to OTSC was 18 days (range 2-118), and 6 days (range 1-120), respectively. The initial endoscopic treatment was OTSC (n = 19), stent (n = 5), clip (n = 1), and clip and biologic glue (n = 1). OTSC alone led to final resolution of leak in 8 patients (31%) within 43 days of clip deployment (range 5-87). Five leaks resolved after a combination of OTSC and stent (19%) and one leak (4%) resolved after endoscopic suturing following a failed OTSC. Eleven patients (42%) failed endoscopic management and underwent total gastrectomy and esophagojejunostomy. One mortality (4%) was noted. The number of additional endoscopic sessions ranged from 1 to 10 (median 2).

CONCLUSIONS

OTSC carries a low success rate for controlling staple line leaks following LSG.

Thyroidectomy Practice After Implementation of the 2015 American Thyroid Association Guidelines on Surgical Options for Patients With Well-Differentiated Thyroid Carcinoma

Importance

The recommended extent of surgery for well-differentiated thyroid carcinoma has been modified considerably in the updated 2015 American Thyroid Association guidelines published in January 2016. To date, the changes in clinical practice after publication of these new guidelines have not been demonstrated.

Objective

The aim of this study was to evaluate clinical practice changes associated with implementation of the updated guidelines on the surgical procedure rates of total thyroidectomy, thyroid lobectomy, and completion thyroidectomy at a single tertiary medical center.

Design, Setting, and Participants

This is a retrospective cohort study of 169 patients at the Hadassah-Hebrew University Medical Center, Jerusalem, Israel. Patients with pathologically proved, well-differentiated thyroid carcinoma who underwent surgery between January 1, 2013, and December 31, 2014, were compared with patients who underwent surgery from January 1 to December 31, 2016. A total of 434 thyroidectomy procedures were performed during the study period, and 251 had pathologically proved, well-differentiated thyroid carcinoma. Patients with tumors larger than 4 cm, involved lymph nodes, or bilateral nodules were excluded.

Main Outcomes and Measures

Primary outcomes were the rate of up-front total thyroidectomy vs lobectomy and the rates of completion thyroidectomy before and after the implementation of the new guidelines.

Results

Of the 169 patients in the final analysis, 118 (69.8%) were included from 2013 to 2014 and 51 (30.2%) in 2016. The mean (SD) age for the entire cohort was 44 (13.8) years, and 129 (76.3%) were women. Up-front total thyroidectomy was performed in 72 of 118 patients (61.0%) prior to the 2015 American Thyroid Association guidelines and 16 of 51 (31.4%) following their implementation (odds ratio, 0.29; 95% CI, 0.14-0.59). The rate of completion thyroidectomy also significantly decreased between these periods (73.9% vs 20.0%; odds ratio, 0.09; 95% CI, 0.04-0.19).

Conclusions and Relevance

The updated 2015 American Thyroid Association guidelines implementation was associated with a significant decrease in the rates of both up-front total thyroidectomy and completion thyroidectomy. According to these findings, only 1 of 5 patients who undergoes thyroid lobectomy will require a completion procedure.

Transanal total mesorectal excision for rectal cancer with indocyanine green fluorescence angiography

BACKGROUND

The aim of this study was to evaluate the impact of fluorescence angiography (FA) on any change in proximal resection margin and/or anastomotic leak (AL) following transanal total mesorectal excision (TaTME) for rectal cancer (RC).

METHODS

This retrospective cohort study was conducted at two centers by three senior surgeons. Both institutions' prospectively maintained Institutional Review Board-approved databases were retrospectively queried for all consecutive patients between July 2015 and May 2017 who had laparoscopic hybrid trans-abdominal total mesorectal excision (TME) and TaTME for RC with colorectal or coloanal anastomosis < 10 cm from the anal verge. All patients had intraoperative FA to assess colonic perfusion of the planned proximal resection margin before bowel transection and after construction of the anastomosis. Primary outcomes measured any changes in proximal resection margins and AL rates.

RESULTS

Fifty-four patients (31 males; mean age 63 ± 12 years) were included; 30 (55%) of whom received neoadjuvant chemoradiation. The average anastomotic height was 3.6 cm from the anal verge and 8 (14.5%) patients required intersphincteric dissection. Forty-six patients (85%) had loop ileostomy. FA led to a change in the proximal resection margin in 10 patients (18.5%), one of whom had AL on postoperative day 3 requiring diagnostic laparoscopy and loop ileostomy. A second patient, without a change in the proximal resection margin, also had an AL. The overall AL rate was 3.7%.

CONCLUSIONS

FA changed the planned proximal resection margin in 18.5% of patients, possibly accounting for the relatively low AL rate. FA is imperfect, and subjective but does have the potential to improve outcomes.

Next-Generation Sequencing Identifies a Highly Accurate miRNA Panel That Distinguishes Well-Differentiated Thyroid Cancer from Benign Thyroid Nodules

Background: Fine needle aspiration biopsy (FNAB) is the gold-standard procedure for diagnosing malignant thyroid nodules. Indeterminate cytology is identified in 10% to 40% of cases, and molecular testing may guide management in this setting. Current commercial options are expensive, and are either sensitive or specific. The aim of this study was to utilize next-generation sequencing (NGS) technology to identify informative diversities in the miRNA expression profile of benign versus malignant thyroid nodules.Methods:Ex vivo FNAB samples were obtained from thyroid specimens of patients who underwent thyroidectomy at a referral center. miRNA levels were determined using NGS and multiplexing technologies. Statistical analyses identified differences between normal and malignant samples and miRNA expression profiles that associate with malignancy were established. The accuracy of the miRNA signature in predicting histologic malignancy was validated using a group of patient specimens with indeterminate cytology results.Results: A total of 274 samples were obtained from 102 patients undergoing thyroidectomy. Of these samples, 71% were benign and 29% were malignant. Nineteen miRNAs were identified as statistically different between benign and malignant samples and were used to classify 35 additional nodules with indeterminate cytology (validation). The miRNA panel's sensitivity, specificity, negative and positive predictive values, and overall accuracy were 91%, 100%, 87%, 100%, and 94%, respectively.Conclusions: Using NGS technology, we identified a panel of 19 miRNAs that may be utilized to distinguish benign from malignant thyroid nodules with indeterminate cytology.Impact: Our panel may classify indeterminate thyroid nodules at higher accuracy than commercially available molecular tests. Cancer Epidemiol Biomarkers Prev; 27(8); 858-63. ©2018 AACR.

Preoperative localization modalities in primary hyperparathyroidism: Correlation with postoperative cure

BACKGROUND

Accurate preoperative localization is critical to the success of minimally invasive parathyroidectomy. This investigation aimed to assess the correlation among preoperative imaging results, intraoperative findings, and postoperative cure rates in patients undergoing operation for primary hyperparathyroidism.

METHODS

A retrospective review of all patients who underwent operation for primary hyperparathyroidism between June 2010 and March 2016 was performed.

RESULTS

During the study period, 398 patients underwent parathyroidectomy. The overall cure rate was 97.5%. The ultrasonography performed by the surgeon was superior to the ultrasonography performed by the radiologist and to the sestamibi scan in lateralizing the adenoma correctly (80% vs 62% vs 70%, P < .001, respectively), and had the greatest sensitivity (93%) and accuracy (80%) among all tests (P < .001). Age ≥65 was found to be associated with lesser cure rates (94% vs 99.2%, P = .003). The number of positive preoperative studies correlated with cure rate, ranging from 80% for patients with 0 positive studies, to 100% in those with 4 positive studies (P = .0004). In patients with a negative sestamibi and an ultrasonography performed by the radiologist, there was no significant difference in the cure rates among those with no preoperative computed tomography, a positive preoperative computed tomography, or a negative preoperative computed tomography.

CONCLUSION

An ultrasonography performed by an experienced surgeon is an extremely valuable preoperative localization modality. The cure rate obtained is proportional to the number of positive imaging studies. In patients with negative ultrasonography performed by a nonexperienced radiologist and a negative sestamibi scan, the performance of computed tomography does not seem to increase cure rate. Patients with no positive preoperative scans represent a challenging subgroup, with cure rates of approximately 80%.

Delayed Laparoscopic Cholecystectomy for Acute Calculous Cholecystitis: Is it Time for a Change?

BACKGROUND

Our aim was to evaluate the advantages and limitations of delayed laparoscopic cholecystectomy (LC) in a tertiary center.

MATERIALS AND METHODS

A retrospective analysis of all patients admitted to our institution with acute calculous cholecystitis (ACC) between January 2003 and December of 2012 was performed. Data collected included patient demographics and comorbidities, presenting symptoms, laboratory findings, imaging results, length of stay (LOS), time to surgery, and surgical complications.

RESULTS

A total of 1078 patients were admitted with ACC. There were 593 females (55%), and the mean age was 57 ± 0.6 years. Mean LOS at initial admission, re-admission until surgery, and following surgery was 7.9 ± 0.2, 1.5 ± 0.1, and 3.4 ± 0.2 days, respectively. Percutaneous cholecystostomy (PC) tube was inserted in 24% of the patients. Only 640 (59%) patients eventually underwent LC. Mean time to surgery was 97 ± 9.8 days, and 16.4% of patients were readmitted in this time period resulting in a mean total LOS of 10.6 ± 0.2 days. Conversion rate to open surgery was 5.8% and bile duct injury occurred in 1.1%. Postoperative complications occurred in 9.8% of the patients, and 30-day mortality was 0.6%. Patients with more severe inflammation according to Tokyo Criteria grade were more likely to undergo PC, were more likely to be readmitted while waiting for LC, and also had more postoperative complications.

CONCLUSIONS

Delayed LC is associated with significant loss of follow-up, long LOS, and higher than expected use of PC. Conversion rates are lower than in the literature while rates of bile duct injury and mortality are comparable. We believe these data as well as the available literature are sufficient to change our hospital policy regarding the surgical treatment of ACC from delayed to early same admission surgery in appropriate cases.

Sacral neuromodulation for the treatment of faecal incontinence following proctectomy

AIM

This study assessed the effectiveness of sacral neuromodulation (SNM) for faecal incontinence (FI) following proctectomy with colorectal or coloanal anastomosis.

METHODS

An Institutional Review Board (IRB)-approved database identified patients treated for FI following proctectomy (SNM-P) for benign or malignant disease, who were matched 1:1 according to preoperative Cleveland Clinic Florida Faecal Incontinence Scores (CCF-FIS) with patients without proctectomy (SNM-NP). Primary outcome was change in CCF-FIS.

RESULTS

Twelve patients (seven women) were in the SNM-P group and 12 (all women) were in the SNM-NP group. In the SNM-P group, six patients underwent proctectomy for low rectal cancer and five received neoadjuvant chemoradiation. Five patients had handsewn anastomosis, and one had stapled coloanal anastomosis. One lead explantation occurred after a failed 2-week SNM percutaneous trial. Six patients underwent proctectomy for benign conditions. Within-group analyses revealed significant improvement in CCF-FIS in the SNM-P group (reduction from a score of 18 to a score of 14; P = 0.02), which was more profound for benign disease (reduction from 14.5 to 8.5) than for rectal cancer (reduction from 19.5 to 15). SNM was explanted in 66% and 33% of patients after proctectomy for malignant and benign conditions, respectively. In the SNM-NP group, 41% underwent overlapping sphincteroplasty. One patient received chemoradiation for anal cancer. Within-group analysis for the SNM-NP group showed significant improvement in CCF-FIS (a reduction from 17.5 to 4.0; P = 0.003). There was significant improvement in CCF-FIS in patients without previous proctectomy (mean delta CCF-FIS: 11.1 vs 4.7; P = 0.011). Analysis of covariance (ANCOVA) reaffirmed that controls outperformed proctectomy patients (P = 0.006).

CONCLUSION

SNM for FI after proctectomy appears less effective than SNM in patients without proctectomy, with high device explantation rates, particularly after neoadjuvant chemoradiation and proctectomy for low rectal cancer.

Clinical role of fluorescence imaging in colorectal surgery - a review

INTRODUCTION

Anastomotic leak (AL) after colorectal surgery is a devastating complication; decreased blood perfusion is an important risk factor. Surgeons rely on subjective measures to assess bowel perfusion. Fluorescence imaging (FI) with indocyanine green (ICG) provides a real-time objective assessment of intestinal perfusion. Areas covered: A PubMed search using the terms 'fluorescence imaging', 'indocyanine green', 'colon and rectal surgery' was undertaken. Sixteen articles between 2010 to present were identified. Main outcomes were leak rate reduction, change in surgical plan, and technical feasibility. Change in surgical strategy due to FI was recorded in 11 studies. Two case control studies showed overall reduction of 4% and 12% in AL rate and one showed no change in AL rate between groups. Expert commentary: According to the available literature, FI is technically feasible and alters surgical strategy in a non-negligible number of patients possibly effecting AL rates.

The Clinical Utility of Over-the-Scope Clip for the Treatment of Gastrointestinal Defects

BACKGROUND

The over-the-scope clip (OTSC) is a novel endoscopic tool that enables non-surgical management of gastrointestinal (GI) defects. The aim of this study was to report our experience with OTSC for patients with GI defects.

METHODS

A prospectively maintained IRB-approved institutional database was queried for all patients treated with OTSC from 2012 to 2015. Primary outcome was the clinical success of the OTSC for the individual indication. Secondary outcome was the number of additional procedures needed following OTSC.

RESULTS

Fifty-one patients were treated with OTSC: upper GI (UGI) 30 and lower GI (LGI) 21. GI leak (n = 24; UGI = 12, LGI = 12) and fistulae (n = 17; UGI = 8, LGI = 9) were the most common indications. Overall success rate for the treatment of leaks was 59 % [UGI 66 % vs. LGI 33 % (p = 0.1)]. A lower success rate (35 %) was noted for fistulae [UGI 62 % vs. LGI 0 % (p = 0.001)]. Success rates for UGI perforation, bleeding, and stent anchoring indications were 75, 75, and 50 %, respectively. Additional endoscopic or surgical interventions following OTSC were indicated in 68.6 % of the patients.

CONCLUSIONS

OTSC appears to have additional value in treating UGI defects. However, lower success rates for LGI defects were noted, specifically for fistulae. Most patients require an additional endoscopic or surgical procedure after one OTSC application.

Ultrasound evaluation of visceral and subcutaneous fat reduction in morbidly obese subjects undergoing laparoscopic gastric banding, sleeve gastrectomy, and Roux-en-Y gastric bypass: a prospective comparison study

BACKGROUND

Visceral fat (VF) plays a major role in the development of metabolic syndrome associated with obesity. The aim of our study is to compare VF and subcutaneous fat (SCF) reduction measured by ultrasonography (US) after laparoscopic adjustable gastric banding (LAGB), laparoscopic sleeve gastrectomy (LSG), and laparoscopic Roux-En-Y gastric bypass (LRYGB).

METHODS

Thirty-nine morbidly obese patients were prospectively evaluated by US before surgery and 3, 6, and 12 months following surgery to determine VF and SCF thickness.

RESULTS

Three statistically comparable groups of morbidly obese patients underwent LRYGB (n = 13), LSG (n = 15), and LAGB (n = 11). The three groups did not differ in initial age, gender, body mass index (BMI), VF, or SCF. Final excess weight loss (EWL%) was highest after LSG and LRYGB followed by LAGB (81 ± 5.8 vs. 69.5 ± 4.5 vs. 43.4 ± 5.2, p < 0.001). LSG and LRYGB were significantly more efficient in VF reduction (ΔVF) compared with LAGB (7.1 ± 0.5 vs. 5.6 ± 0.6 vs. 3.6 ± 0.8, p = 0.004). SCF reduction (ΔSCF) was also highest after LSG followed by LRYGB and LAGB (3 ± 0.2 vs. 2.2 ± 0.4 vs. 1.9 ± 0.4, p = 0.08). The change in fat distribution, determined as Δ(VF/SCF), showed a preferential VF reduction in the LSG and LRYGB patients compared with patients that underwent LAGB (0.59 ± 0.1 vs. 0.52 ± 0.2 vs. 0.19 ± 0.2, p = 0.42). In a subgroup analysis comparing only LSG to LRYGB, no statistically significant difference was seen in EWL%, ΔVF, ΔSCF, or in fat distribution Δ(VF/SCF).

CONCLUSION

LSG and LRYGB show better preferential and overall VF reduction than LAGB. US may serve as a simple tool of evaluating postoperative fat distribution.

Percutaneous cholecystostomy is safe and effective option for acute calculous cholecystitis in select group of high-risk patients

PURPOSE

In high-risk patients with acute calculous cholecystitis (ACC), percutaneous cholecystostomy (PC) can serve as a bridging option to cholecystectomy [laparoscopic cholecystectomy (LC)] or as definitive treatment. The purpose of this study was to identify predictors of the need for permanent PC.

METHODS

Data from 257 PCs performed for ACC (mean age 67.3 ± 14) was collected for a 10-year period. Demographic and clinical characteristics at initial admission, co-morbidities were analyzed. Patients who underwent interval LC were defined as the surgery group (SG; n = 163, 63.4 %) and the remaining patients as the non-SG (NSG; n = 94, 36.6 %).

RESULTS

Patients in the SG were significantly younger and had a shorter length of hospital stay (p < 0.01). The rate of coronary artery disease (CAD; 63.2 vs. 20.2 %), chronic renal failure (14.9 vs. 6.1 %), and the mean number of co-morbidities (2.2 vs. 1.4) were significantly higher in the NSG. Sepsis at admission was more common in the NSG (19.1 vs. 4.9 %, p < 0.001). 56 patients (34.4 %) in the SG and 24 patients (25.5 %) in the NSG developed tube-related complications. In hospital mortality was similar between the groups. Multivariate analysis showed that age ≥75, increased alkaline phosphatase (ALK-P), history of CAD, were predictors of PC as a definite treatment in this high-risk group of patients with ACC.

CONCLUSIONS

High operative risk due to older age and CAD preclude LC in more than one-third of patients following PC especially presenting with sepsis and elevated ALK-P. This study suggests that PC could be a safe treatment option in this select group of high-risk patients.

The animal gut as a melting pot for horizontal gene transfer

In this minireview, we examine horizontal gene transfer (HGT) events in the mammalian gastrointestinal tract and their role in the evolutionary adaptation of microorganisms to the gut environment. We explore the notion of the mammalian gut as a melting pot of genetic exchange, resulting in the large extent of HGT occurrence.

Concurrent Medullary, Papillary, and Follicular Thyroid Carcinomas and Simultaneous Cushing's Syndrome

BACKGROUND

Papillary thyroid carcinoma is the most common thyroid cancer (85%). Follicular thyroid carcinoma is the second most common type of thyroid cancer, accounting for up to 10% of all thyroid cancers. Medullary thyroid carcinoma accounts for only 5-8% of thyroid cancers. Concurrent medullary, follicular, and papillary carcinomas of the thyroid gland are extremely rare and reported scarcely.

CASE REPORT

A 72-year-old male presented with nonspecific neck pain. The workup revealed a nodular thyroid gland with a follicular lesion on fine-needle aspiration. Total thyroidectomy was performed and pathological examination identified a 25-mm follicular carcinoma, two papillary microcarcinomas, and two medullary microcarcinomas. The genetic workup was negative and no other family members were diagnosed with any endocrinopathy. Two months after surgery, the patient was diagnosed with Cushing's syndrome that was treated with laparoscopic left adrenalectomy. On 3-year follow-up, the patient is asymptomatic with no evidence of recurrent disease.

CONCLUSION

We present a rare case of a patient with follicular, papillary, and medullary thyroid carcinoma, and Cushing's syndrome. To date, no known genetic mutation or syndrome can account for this combination of neoplastic thyroid and adrenal pathologies, although future research may prove differently.

Colon Cancer Associated Transcript-1 (CCAT1) Expression in Adenocarcinoma of the Stomach

Background: Long non-coding RNAs (lncRNAs) have been shown to have functional roles in cancer biology and are dys-regulated in many tumors. Colon Cancer Associated Transcript -1 (CCAT1) is a lncRNA, previously shown to be significantly up-regulated in colon cancer. The aim of this study is to determine expression levels of CCAT1 in gastric carcinoma (GC).

Methods: Tissue samples were obtained from patients undergoing resection for gastric carcinoma (n=19). For each patient, tumor tissue and normal appearing gastric mucosa were taken. Normal gastric tissues obtained from morbidly obese patients, undergoing laparoscopic sleeve gastrectomy served as normal controls (n=19). A human gastric carcinoma cell line (AGS) served as positive control. RNA was extracted from all tissue samples and CCAT1 expression was analyzed using quantitative real time-PCR (qRT-PCR).

Results: Low expression of CCAT1 was identified in normal gastric mucosa samples obtained from morbidly obese patients [mean Relative Quantity (RQ) = 1.95±0.4]. AGS human gastric carcinoma cell line showed an elevated level of CCAT1 expression (RQ=8.02). Expression levels of CCAT1 were approximately 10.8 fold higher in GC samples than in samples taken from the negative control group (RQ=21.1±5 vs. RQ=1.95±0.4, respectively, p<0.001). Interestingly, CCAT1 expression was significantly overexpressed in adjacent normal tissues when compared to the negative control group (RQ = 15.25±2 vs. RQ=1.95±0.4, respectively, p<0.001). Tissues obtained from recurrent GC cases showed the highest expression levels (RQ = 88.8±31; p<0.001). Expression levels increased with tumor stage (T4- 36.4±15, T3- 16.1±6, T2- 4.7±1), however this did not reach statistical significance (p=0.2). There was no difference in CCAT1 expression between intestinal and diffuse type GC (RQ=22.4±7 vs. 22.4±16, respectively, p=0.9). Within the normal gastric tissue samples, no significant difference in CCAT1 expression was observed in helicobacter pylori negative and positive patients (RQ= 2.4±0.9 vs. 0.93±0.2, respectively, p=0.13).

Conclusion: CCAT1 is up-regulated in gastric cancer, and may serve as a potential bio-marker for early detection and surveillance.

Comparison of laparoscopic versus open approach to gastrostomy tubes

BACKGROUND AND OBJECTIVES

Gastrostomy tube insertion for enteral access may be performed through laparotomy (open) or through the laparoscopic approach. This study's purpose is to compare outcomes of these different approaches.

METHODS

A retrospective chart review of all patients (age >18 years) who underwent insertion of a gastrostomy tube as a single elective procedure between 2004 and 2012 was performed. Primary end points included postoperative overall and tube-related morbidity, tube revision rates, and operative time.

RESULTS

During the study period, 71 patients had a gastrostomy tube inserted via either the open (n 46) or the laparoscopic (n 25) approach. Preoperative variables including age, gender, body mass index, albumin, and American Society of Anesthesiologists score were statistically comparable between groups. There was no difference in rates of previous upper abdominal surgery (24% vs 26%, P = .590) or gastric surgery (12% vs 13%, P = .720) in the laparoscopic and open groups, respectively. Previous percutaneous endoscopic gastrostomy tube insertion rates were higher in the laparoscopic group (32% vs 6.5%, P = .005). Operative time was significantly longer in the laparoscopic group (76.8 ± 7 vs 55.8 ± 3, P = .003) but was not affected by previous abdominal surgery or higher body mass index. Overall morbidity, tube-related morbidity, and tube revision rates were similar between groups. However, there was a trend toward increased major complication rates in the open group (6.5% vs 0%, P = .190).

CONCLUSION

Laparoscopic gastrostomy tube insertion is safe and feasible, even in patients who have had prior upper abdominal surgery. Patients with a prolonged prognosis, obesity, and intact neurologic capacity may benefit the most from this approach.

Role of laparoscopy in rectal cancer: A review

Despite established evidence on the advantages of laparoscopy in colon cancer resection, the use of laparoscopy for rectal cancer resection is still controversial. The initial concern was mainly regarding the feasibility of laparoscopy to achieve an adequate total mesorectal excision specimen. These concerns have been raised following early studies demonstrating higher rates of circumferential margins positivity following laparoscopic resection, as compared to open surgery. Similar to colon resection, patients undergoing laparoscopic rectal cancer resection are expected to benefit from a shorter length of hospital stay, less analgesic requirements, and a faster recovery of bowel function. In the past decade there have been an increasing number of large scale clinical trials investigating the oncological and perioperative outcomes of laparoscopic rectal cancer resection. In this review we summarize the current literature available on laparoscopic rectal cancer surgery.

The Diagnostic and Prognostic Role of microRNA in Colorectal Cancer - a Comprehensive review

The discovery of microRNA, a group of regulatory short RNA fragments, has added a new dimension to the diagnosis and management of neoplastic diseases. Differential expression of microRNA in a unique pattern in a wide range of tumor types enables researches to develop a microRNA-based assay for source identification of metastatic disease of unknown origin. This is just one example of many microRNA-based cancer diagnostic and prognostic assays in various phases of clinical research.

Since colorectal cancer (CRC) is a phenotypic expression of multiple molecular pathways including chromosomal instability (CIN), micro-satellite instability (MIS) and CpG islands promoter hypermethylation (CIMP), there is no one-unique pattern of microRNA expression expected in this disease and indeed, there are multiple reports published, describing different patterns of microRNA expression in CRC.

The scope of this manuscript is to provide a comprehensive review of the scientific literature describing the dysregulation of and the potential role for microRNA in the management of CRC. A Pubmed search was conducted using the following MeSH terms, "microRNA" and "colorectal cancer". Of the 493 publications screened, there were 57 papers describing dysregulation of microRNA in CRC.

Role of antibiotic therapy in mild acute calculus cholecystitis: a prospective randomized controlled trial

BACKGROUND

Current recommendations for treating acute calculus cholecystitis include the use of intravenous antibiotics, although these recommendations were never tested scientifically. The aim of this study was to evaluate the role of intravenous antibiotic therapy in patients with mild acute calculus cholecystitis.

METHODS

In this prospective, randomized controlled trial, 84 patients with a diagnosis of mild acute calculus cholecystitis were randomly assigned to supportive treatment only or supportive treatment with intravenous antibiotic treatment (42 patients in each arm). Patients were followed through their index admission and until delayed laparoscopic cholecystectomy was performed.

RESULTS

The two study groups did not differ in their demographic data or in the clinical presentation and disease severity. Analysis was conducted on the intent-to-treat basis. Patients in the intravenous antibiotics arm resumed a liquid diet earlier (1.7 vs. 2.2 days, p = 0.02) but did not significantly differ in resumption of regular diet (2.8 vs. 3.2 days, p = 0.16) or hospital length of stay (LOS) (3.9 vs. 3.8 days, p = 0.89). Patients in the intravenous antibiotics arm had rates of percutaneous cholecystostomy tube placement (12 vs. 5 %, p = 0.43), readmissions (19 vs. 13 %, p = 0.73), and perioperative course similar to those not receiving antibiotics. The overall hospital LOS, including initial hospitalization and subsequent cholecystectomy, was similar for both groups (5.6 vs. 5.1 days, p = 0.29). Eight (19 %) patients in the supportive arm were crossed over to the intravenous antibiotic arm during the index admission.

CONCLUSIONS

Intravenous antibiotic treatment does not improve the hospital course or early outcome in most of the patients with mild acute calculus cholecystitis.

Differentiating benign from malignant thyroid nodules using micro ribonucleic acid amplification in residual cells obtained by fine needle aspiration biopsy

BACKGROUND

Fine needle aspiration biopsy (FNAB) is the most commonly used diagnostic tool to differentiate benign from malignant thyroid nodules. Nevertheless, some FNAB cytology results are not definite. In such cases diagnostic thyroid lobectomy is performed with malignancy rate on final histopathology ranging at 15%-75%. The aim of this study was to improve on the accuracy of FNAB-based cytology by amplification of microRNAs (micro ribonucleic acids [miRs]) from the residual cells left in the FNAB needle after submission for cytology.

METHODS

Residual cells were collected from the needle cup after FNAB cytology of 77 consecutive patients with thyroid nodules. miR-enriched RNA was extracted for all patients with cytology showing either follicular lesion or suspicion for malignancy (n=11). The expression of miR-21, -31, -146b, -187, -221, and -222 was determined using real-time polymerase chain reaction. Results were compared with final surgical histopathology.

RESULTS

RNA was successfully extracted from all FNAB specimens. Five patients had FNAB cytology suspicious for malignancy. The miR panel was positive in all five (100%). Six patients had follicular lesions on FNAB. The miR panel was positive in three of four patients (75%) with confirmed malignancy and was negative in two of two (0%) patients with benign pathology results. This corresponded to a specificity of 100%, sensitivity of 88%, and accuracy of 90%.

CONCLUSIONS

RNA extraction from FNAB residual cells is feasible, and a miR panel amplified from the extracted RNA seems like a promising diagnostic tool in this limited number of patients.

Comparison of pediatric appendectomy outcomes between pediatric surgeons and general surgery residents

BACKGROUND

Appendectomy is the most common urgent procedure in children, and surgical outcomes may be affected by the surgeon's experience. This study's aim is to compare appendectomy outcomes performed by pediatric surgeons (PSs) and general surgery residents (GSRs).

MATERIALS AND METHODS

A retrospective review of all patients younger than 16y treated for appendicitis at two different campuses of the same institution during the years 2008-2009 was performed. Appendectomies were performed by PS in one campus and GSR in the other. Primary end points included postoperative morbidity and hospital length of stay.

RESULTS

During the study period, 246 (61%) patients were operated by senior GSR (postgraduate year 5-7) versus 157 (39%) patients by PS. There was no significant difference in patients' characteristics at presentation to the emergency room and the rate of appendeceal perforation (11% versus 15%, P=0.32), and noninfectious appendicitis (5% versus 5% P=0.78) also was similar. Laparoscopic surgery was performed more commonly by GSR (16% versus 9%, P=0.02) with shorter operating time (54±1.5 versus 60±2.1, P=0.01). Interestingly, the emergency room to operating room time was shorter for GSR group (419±14 versus 529±24min, P<0.001). The hospital length of stay was shorter for the GSR group (4.0±0.2 versus 4.5±0.2, P=0.03), and broad-spectrum antibiotics were used less commonly (20% versus 53%, P<0.0001) and so was home antibiotics continuation (13% versus 30%, P<0.0001). Nevertheless, postoperative complication rate was similar (5% versus 7%, P=0.29) and so was the rate of readmissions (2% versus 5%, P=0.52).

CONCLUSIONS

The results of this study suggest that the presence of a PS does not affect the outcomes of appendectomies.

Development of a microRNA-based molecular assay for the detection of papillary thyroid carcinoma in aspiration biopsy samples

BACKGROUND

Although thyroid nodules are common and diagnosed in over 5% of the adult population, only 5% harbor malignancy. Patients with clinically suspicious thyroid nodules need to undergo fine-needle aspiration biopsy (FNAB). The main limitation of FNAB remains indeterminate cytopathology. Only 20%-30% of the indeterminate nodules harbor malignancy, and therefore up to 80% of patients undergo unnecessary thyroidectomy. The aim of this study was to identify and validate a panel of microRNAs (miRNAs) that could serve as a platform for an FNAB-based diagnostic for thyroid neoplasms.

METHODS

The study population included 27 consecutive patients undergoing total thyroidectomy for FNAB-based papillary thyroid cancer (n = 20) and benign disorders (n = 7). Aspiration biopsy was performed from the index lesion and from the opposite lobe normal tissue in all study patients at the time of operation. RNA was extracted from all aspiration biopsy samples. Quantitative polymerase chain reaction on a panel of previously selected miRNAs was performed. Polymerase chain reaction results were compared with final histopathology. miRNA from tumor tissues was amplified using the highest value of each miRNA expression in normal tissue as a threshold for malignancy detection.

RESULTS

Diagnostic characteristics were most favorable for mir-221 in differentiating benign from malignant thyroid pathology. mir-221 was overexpressed in 19 patients (p < 0.0001) with a sensitive yield of 95%. Specificity, negative and positive predictive value, and accuracy of the miRNA panel were 100%, 96%, 100%, and 98%, respectively.

CONCLUSIONS

miRNA quantification for differential diagnosis of thyroid neoplasms within aspiration biopsy samples is feasible and may improve the accuracy of FNAB cytology.

Multifocality in well-differentiated thyroid carcinomas calls for total thyroidectomy

BACKGROUND

Multifocality is an important factor when recommending surgery for papillary thyroid cancer (PTC). The aim of this study is to assess the incidence and characterize the spread pattern of multifocal PTC (mPTC) in patients undergoing total thyroidectomy.

METHODS

All thyroidectomies performed between 2003 and 2008 were reviewed identifying 289 patients. Data were obtained for demographics, clinical data, and histopathological findings.

RESULTS

Of the patients with papillary carcinoma, mPTC was identified in 150 patients (57%), of which 71% had lesions in the contralateral lobe. There were no significant differences in multifocality rate for gender, pathology type, and all tumor size subgroups including ≤1 cm. Pathology examination of representative sections versus the entire gland examination resulted in a significantly lower incidence of contralateral disease (P = .04).

CONCLUSIONS

Multifocal and contralateral lesions are common in PTC and their incidence is not related to tumor size. Pathology entire gland examination is strongly recommended to properly assess the rate of mPTC.

Medical students and general surgery--Israel's National Survey: lifestyle is not the sole issue

BACKGROUND

In recent years, a significant decline in the number of medical school graduates who choose general surgery as a career has been noted in Israel. The aim of this study is to characterize the factors that deter Israeli medical students from choosing general surgery. Previous studies in the United States identified lifestyle and financial issues as the most important factors.

METHODS

A web-based survey was distributed to graduating medical students throughout Israel. The survey covered different factors and aspects affecting career choice, requiring participants to rate their choices with a 1-5 score.

RESULTS

In all, 218 surveys were completed; 72 (33%) students considered general surgery before the surgical clerkship versus only 48 (22%) students after. Professional interest and satisfaction (4.7) were ranked as the most important factors for choosing a residency, followed by an amiable working atmosphere (4.3). The 2 strongest deterrents from general surgery were doctors' inter-relationships (3.5) and compromised lifestyle (3.3). The decision to avoid surgery can be reversed by improving both lifestyle (3.5) and inter-relationships (3.0), but it is less influenced by a substantial increase in residents' salary.

CONCLUSIONS

More medical graduates would consider general surgery as a career option if the lifestyle and inter-relationships were perceived as better. An increase in monetary reward did not seem to have a paramount impact among Israeli medical graduates. The surgical clerkship is an important turning point in the students' attitude toward surgery as a career and efforts must be made to improve students' experience significantly during this clerkship.