Trends in minimally invasive and open inguinal hernia repair: an analysis of ACGME general surgery case logs

BACKGROUND

Groin hernia repair is one of the most commonly performed surgical procedures and is often performed by surgical interns and junior residents. While traditionally performed open, minimally invasive (MIS) groin hernia repair has become an increasingly popular approach. The purpose of this study was to determine the trends in MIS and open inguinal and femoral hernia repair in general surgery residency training over the past two decades.

METHODS

Accreditation Council for Graduate Medical Education (ACGME) national case log data of general surgery residents from 1999 through 2022 were reviewed. We collected means and standard deviations of open and MIS inguinal and femoral hernia repairs. Linear regression and ANOVA were used to identify trends in the average annual number of open and MIS hernia repairs logged by residents. Cases were distinguished between level of resident trainees: surgeon-chief (SC) and surgeon-junior (SJ).

RESULTS

From July 1999 to June 2022, the average annual MIS inguinal and femoral hernia repairs logged by general surgery residents significantly increased, from 7.6 to 47.9 cases (p < 0.001), and the average annual open inguinal and femoral hernia repairs logged by general surgery residents significantly decreased, from 51.9 to 39.7 cases (p < 0.001). SJ resident results were consistent with this overall trend. For SC residents, the volume of both MIS and open hernia repairs significantly increased (p < 0.001).

CONCLUSIONS

ACGME case log data indicates a trend of general surgery residents logging overall fewer numbers of open inguinal and femoral hernia repairs, and a larger proportion of open repairs by chief residents. This trend warrants attention and further study as it may represent a skill or knowledge gap with significant impact of surgical training.

High-volume endocrine surgeons perform thyroid surgery at decreased cost despite increased case relative value units

BACKGROUND

Healthcare systems are transitioning to value-based payment models based on analysis of quality over cost. To gain an understanding of the relationship between surgeon volume and health care costs, we compared the direct costs of thyroidectomy performed by dedicated high-volume endocrine surgeons and low-volume surgeons within a large health care system.

METHODS

We evaluated all thyroid surgeries performed within a single billing year at a single health care system. We defined high-volume surgeons as those who treated >50 thyroid cases yearly and compared them to low-volume surgeons. To account for multicomponent procedures, we added the relative value units for the components of the cases. Then, we divided them into low-relative value units, intermediate-relative value units, and high-relative value units groups. We analyzed categorical and continuous variables using the χ2 analysis and Wilcoxon rank sum test, respectively.

RESULTS

We identified 674 thyroidectomy procedures performed by 27 surgeons, of whom 6 high-volume surgeons performed 79% of cases. Relative value unit distribution differed between the groups, with high-volume surgeons performing more intermediate-relative value unit (58% vs 34.7%, P < .01) and high-relative value unit (24.6% vs 20.6%, P < .01) cases, whereas low-volume surgeons performed more low-relative value unit cases (45% vs 17%, P < .01). Overall, high-volume surgeons incurred a 26% reduction in total costs (P < .01) and a 33% reduction in discretionary expenses (P < .01) across all relative value unit groups.

CONCLUSION

High-volume endocrine surgeons perform thyroid procedures at a lower cost than their low-volume counterparts, a difference that is magnified when stratified by relative value unit groups.

Bilateral exploration in primary hyperparathyroidism: Double adenoma distribution and biochemical patterns over two decades

BACKGROUND

We investigated if anatomic patterns of abnormal parathyroid glands have ch anged for primary hyperparathyroidism (pHPT) as atypical biochemical presentation (normohormonal and normocalcemic) has increased.

METHODS

Retrospective review of patients with pHPT who underwent routine bilateral neck exploration.

RESULTS

2762 patients were included. The "late" cohort (2014-2020) exhibited lower preoperative calcium (10.8 vs 11.1 ​mg/dL; P ​= ​0.001) and PTH levels (101 vs. 146 ​pg/mL; P ​= ​0.001) compared to the "early" cohort (2000-2006). Patients with atypical biochemical profiles increased from 25.5% to 31.3% (P ​< ​0.001). The prevalence of single adenoma (SA) decreased (66.1% vs 58.9%, P ​= ​0.02) while the proportion of double adenoma (DA) increased (17.3% vs. 22.6%, P ​< ​0.01). Upper parathyroid adenoma(s) remained the most common finding for SA and DA in both time points.

CONCLUSIONS

Despite changes in patient characteristics, single upper adenoma and bilateral double upper adenomas remain the most common findings for patients with pHPT.

Are 99mTC-Sestamibi Single Photon Emission Computed Tomography Scan Results Associated to the Parathyroid Cell Type in Primary Hyperparathyroidism?

INTRODUCTION

99mTC-sestamibi scintigraphy (SPECT-CT) is a common imaging modality for parathyroid localization in primary hyperparathyroidism (PHPT). Prior studies have suggested that the cellular composition of parathyroid adenomas influences SPECT-CT imaging results. Other biochemical and anatomical factors may also play a role in false negative results. Therefore, after controlling for confounding variables, we sought to determine whether the histologic composition of parathyroid adenomas is associated to SPECT-CT results in patients with single gland disease causing PHPT.

METHODS

A retrospective review of patients with PHPT due to confirmed single gland disease was performed over a 2-y period. A 1:1 propensity score matching was done between patients with positive and negative SPECT-CT results with regard to demographical, biochemical, and anatomical characteristics followed by blinded pathologic examination of cell composition in the matched pairs.

RESULTS

Five hundred forty two patients underwent routine four gland exploration and 287 (53%) patients were found to have a single adenoma. Of those, 26% had a negative SPECT-CT result. There were significant differences between groups with regards to biochemical profile, gland location, and gland size. All of which became nonsignificant after propensity score matching. Adenomas were primarily composed of chief cells, with no difference between groups (95% versus 97%, P = 0.30). In the positive SPECT-CT group, chief cells were the dominant cell type in 68% of the cases, followed by mixed type (13%), oxyphil cells (12%), and clear cells (7%). This was similar to the negative SPECT-CT group (P = 0.22).

CONCLUSIONS

While certain patient's clinical characteristics are associated with SPECT-CT imaging results, histologic cell type is not significantly associated.

Outcomes of Thyroidectomy During the COVID-19 Pandemic: A NSQIP Analysis

BACKGROUND

The coronavirus disease 19 (COVID-19) has had a profound impact on our healthcare system. Surgery in particular faced significant challenges related to allocation of resources and equitable patient selection, resulting in a delay in non-emergent procedures. We sought to study the impact of the COVID-19 pandemic on patient outcomes after thyroidectomy.

METHODS

This was a cross-sectional study using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database that included all thyroidectomies from 2018 to 2020. The primary outcome evaluated was surgical outcomes during 2020, the first year of the pandemic, compared to years preceding the pandemic. Factors associated with adverse postoperative outcomes during the study period were included in a multivariate analysis.

RESULTS

The volume of thyroidectomy procedures in 2020 decreased 16.4% when compared to the preceding years. During 2020, there was a significant increase in mortality (0.14% vs. 0.07%, p = 0.03), unplanned intubation (0.45% vs. 0.27%, p < 0.01) and cardiac arrest (0.11% vs. 0.03%, p < 0.01), while other complications remained stable. Undergoing surgery in 2020 remained as a risk factor for mortality in a multivariate analysis (OR 2.4 95% CI 1.3-4.4).

CONCLUSION

The first year of the COVID-19 pandemic had a significant impact on outcomes after thyroidectomy resulting in increased mortality. As the world recovers, there will likely be an increase number of patients seeking care who were unable to obtain it during the pandemic. Close attention should be placed on the outcomes which were altered during the pandemic.

Detection of near-infrared autofluorescence from adrenal neoplasms: An initial experience

BACKGROUND AND OBJECTIVES

Fluorescence from adrenal tumors can be detected with near-infrared imaging after injection with indocyanine green. However, it is unknown if adrenal tumors exhibit autofluorescence. The aim of this study was to determine whether adrenal tumors emit near-infrared autofluorescence (NIRAF).

METHODS

This was a prospective study of patients who underwent minimally invasive adrenalectomy at a tertiary center. Intraoperative images were analyzed to detect NIRAF with a 750 nm camera. Descriptive and comparative statistical analyses were performed.

RESULTS

Twenty-five adrenalectomies were examined. Only 11 tumors (44%), that originated from the cortex exhibited autofluorescence. A contrast distinction between the tumor and retroperitoneum was observed in 23 patients, whereas a contrast distinction between the tumor and normal adrenocortical tissue was seen in 12 patients. The overall fluorescence intensity of adrenal tumors was found to be variable and ranging between 0.3 and 5.6 times that of the background tissue. Pheochromocytoma, malignancy and adrenal cyst did not demonstrate NIRAF.

CONCLUSION

This is the first study to show that adrenocortical tissue can demonstrate NIRAF. The pattern of fluorescence was similar to that observed after indocyanine green injection in our historical experience. NIRAF has a potential to be used as an intraoperative optical adjunct during adrenalectomy.

Surgical Management of Normocalcemic Primary Hyperparathyroidism and the Impact of Intraoperative Parathyroid Hormone Testing on Outcome

Objective To review our surgical experience and the impact of intraoperative parathyroid hormone (IOPTH) testing among patients with normocalcemic primary hyperparathyroidism. Study Design Case series with chart review. Setting Academic referral hospital. Subject and Methods Normocalcemic hyperparathyroidism (NCHPT) patients were identified with normal-range blood ionized calcium and serum elevated parathyroid hormone. Patient demographics, intraoperative findings, IOPTH dynamics, and biochemical outcomes were compared with those of classic primary hyperparathyroidism (PHPT) patients. Results Of the 2120 patients who underwent parathyroidectomy, 616 patients met the inclusion criteria: 119 (19.5%) patients had NCHPT, and 497 (80.5%) had classic PHPT. NCHPT patients had higher rates of multigland hyperplasia as compared with classic PHPT (12% vs 4%, P = .002) and smaller gland size ( P < .001). Of 119 NCHPT patients, 114 (97%) achieved >50% drop in IOPTH intraoperatively, as opposed to 492 (99%) among 497 classic PHPT patients ( P = .014). IOPTH drop >50% had an equivalent positive predictive value for long-term cure in both groups. Conclusions Surgeons treating NCHPT patients should suspect the presence of multigland disease and have a low threshold for converting to bilateral exploration depending on IOPTH decay dynamics.

The incidence of vocal fold motion impairment after primary thyroid and parathyroid surgery for a single high-volume academic surgeon determined by pre- and immediate post-operative fiberoptic laryngoscopy

BACKGROUND

Vocal fold motion impairment (VFMI) is a well-recognized complication of thyroid and parathyroid surgery. Preoperative counseling requires a thorough understanding of the incidence, risk factors, and value of early diagnosis of postoperative VFMI. Our objective is to describe the incidence of and risk factors for VFMI for a single high-volume academic surgeon, and to assess the utility of immediate postoperative fiberoptic laryngoscopy (FOL) in early diagnosis of VFMI.

METHODS

Retrospective cohort study of patients undergoing primary thyroid and parathyroid procedures by a single high-volume surgeon at an academic tertiary care center. All patients underwent preoperative and immediate postoperative FOL. The primary outcome was incidence of VFMI, either temporary (<1 year) or permanent (1 year or more). The unit of analysis was number of recurrent laryngeal nerves (RLN) at risk. Risk factors for VFMI were analyzed using logistic regression, reporting unadjusted and adjusted odds ratios (OR and aOR) and 95% confidence intervals (CI).

RESULTS

The study population comprised 1547 patients undergoing 1580 procedures for a total of 2527 nerves at risk, excluding the 27 nerves found to have motion impairment on preoperative FOL. Sixty-seven new incidents of VFMI were identified on postoperative FOL, with an additional six new incidents detected after voice complaints prompted FOL upon follow-up. Thus, the incidence of postoperative VFMI was 2.9% of RLNs at risk (73 of 2527). The sensitivity and negative predictive value of immediate postoperative FOL were 92% and 99.8% respectively. Permanent VFMI occurred in 9 cases (0.4%), 3 of which were from intentional RLN transection for malignancy. Odds of VFMI were significantly lower after parathyroidectomy (aOR = 0.1, 95%CI = 0.01-0.8 compared with hemithryoidectomy) and higher with central neck dissection (aOR = 2.4, 95CI = 1.0-5.9). Among cases of malignancy, odds of VFMI increased significantly with increasing T-stage (adjusted p_trend<0.001).

CONCLUSION

VFMI is rare and usually temporary after primary thyroid and parathyroid procedures, with increased risk associated with larger primary malignancies and the inclusion of central neck dissection. Immediate postoperative FOL is useful for early detection of VFMI that may allow for clear definition of temporary and permanent immobility rehabilitation especially if there is evidence to support early intervention.

Multicenter Assessment of Antibiotic Prophylaxis Spectrum on Surgical Infections in Head and Neck Cancer Microvascular Reconstruction

Objective

To characterize and identify risk factors for 30-day surgical site infections (SSIs) in patients with head and neck cancer who underwent microvascular reconstruction.

Study Design

Cross-sectional study with nested case-control design.

Setting

Nine American tertiary care centers.

Subjects and Methods

Hospitalized patients were included if they underwent head and neck cancer microvascular reconstruction from January 2003 to March 2016. Cases were defined as patients who developed 30-day SSI; controls were patients without SSI at 30 days. Postoperative antibiotic prophylaxis (POABP) regimens were categorized by Gram-negative (GN) spectrum: no GN coverage, enteric GN coverage, and enteric with antipseudomonal GN coverage. All POABP regimens retained activity against anaerobes and Gram-positive bacteria. Thirty-day prevalence of and risk factors for SSI were evaluated.

Results

A total of 1307 patients were included. Thirty-day SSI occurred in 189 (15%) patients; median time to SSI was 11.5 days (interquartile range, 7-17). Organisms were isolated in 59% of SSI; methicillin-resistant Staphylococcus aureus (6%) and Pseudomonas aeruginosa (9%) were uncommon. A total of 1003 (77%) patients had POABP data: no GN (17%), enteric GN (52%), and antipseudomonal GN (31%). Variables independently associated with 30-day SSI were as follows: female sex (adjusted odds ratio [aOR], 1.6; 95% CI, 1.1-2.2), no GN POABP (aOR, 2.2; 95% CI, 1.5-3.3), and surgical duration ≥11.8 hours (aOR, 1.9; 95% CI, 1.3-2.7). Longer POABP durations (≥6 days) or antipseudomonal POABP had no association with SSI.

Conclusions

POABP without GN coverage was significantly associated with SSI and should be avoided. Antipseudomonal POABP or longer prophylaxis durations (≥6 days) were not protective against SSI. Antimicrobial stewardship interventions should be made to limit unnecessary antibiotic exposures, prevent the emergence of resistant organisms, and improve patient outcomes.

Transoral thyroidectomy and parathyroidectomy - A North American series of robotic and endoscopic transoral approaches to the central neck

OBJECTIVE

Most thyroid surgery in North America is completed via a cervical incision, which leaves a permanent scar. Approaches without cutaneous incisions offer aesthetic advantages. This series represents the largest series of transoral vestibular approaches to the central neck in North America, and the first published reports of robotic transoral vestibular thyroidectomy for thyroid carcinoma.

MATERIALS AND METHODS

Data was prospectively collected for patients that underwent transoral vestibular approach thyroidectomy and/or parathyroidectomy between April 2016 and February 2017.

RESULTS

Fifteen patients underwent the procedure for removal of the thyroid (n=12), parathyroid (n=2) or both thyroid and parathyroid glands (n=1). The first case was converted to an open procedure. Fourteen were completed through these remote access incisions, including patients with a body mass index as high as 44. There were no permanent complications. The postoperative median Dermatology Life Quality Index score was 3, which indicates a small effect on quality of life.

CONCLUSION

The transoral vestibular approach to the central neck is a promising technique for patients who desire to optimize aesthetics.

Indications and extent of central neck dissection for papillary thyroid cancer: An American Head and Neck Society Consensus Statement

BACKGROUND

The primary purposes of this interdisciplinary consensus statement were to review the relevant indications for central neck dissection (CND) in patients with papillary thyroid cancer (PTC) and to outline the appropriate extent and relevant techniques required to accomplish a safe and effective CND.

METHODS

A writing group convened by the American Head and Neck Society (AHNS) Endocrine Committee was tasked with identifying the important clinical elements to consider when managing the central neck compartment in patients with PTC based on available evidence in the literature, and the group's collective experience. The position statement paper was then submitted to the full Endocrine Committee, Education Committee, and AHNS Council.

RESULTS

This consensus statement was developed to inform the clinical decision-making process when managing the central neck compartment in patients with PTC from the AHNS. This document is intended to provide clarity through definitions as well as a basic guideline from which to manage the central neck. It is our hope that this improves the quality and reduces variation in management of the central neck, facilitates communication, and furthers research for patients with thyroid cancer.

CONCLUSION

This represents, in our opinion, contemporary optimal surgical care for this patient population and is endorsed by the American Head and Neck Society. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1269-1279, 2017.

Transoral robotic thyroidectomy: a preclinical feasibility study using the da Vinci Xi platform

Transoral thyroid surgery allows the surgeon to conceal incisions within the oral cavity without significantly increasing the amount of required dissection. TORT provides an ideal scarless, midline access to the thyroid gland and bilateral central neck compartments. This approach, however, presents multiple technical challenges. Herein, we present our experience using the latest generation robotic surgical system to accomplish transoral robotic thyroidectomy (TORT). In two human cadavers, the da Vinci Xi surgical system (Intuitive Surgical, Sunnyvale, CA, USA) was used to complete TORT. Total thyroidectomy and bilateral central neck dissection was successfully completed in both cadavers. The da Vinci Xi platform offered several technologic advantages over previous robotic generations including overhead docking, narrower arms, and improved range of motion allowing for improved execution of previously described TORT techniques.

Proof of Concept of a Tracheoesophageal Voice Prosthesis Insufflator for Speech Production After Total Laryngectomy

IMPORTANCE

There may have a variety of reasons why patients are unable to produce tracheoesophageal speech after total laryngectomy (TL) including poor pulmonary reserve or other comorbidities that prevent adequate stoma occlusion and intratracheal pressure to voice. Other patients find it difficult, uncomfortable, or socially awkward to manually occlude the stoma with the finger or thumb.

OBJECTIVE

The study aimed to assess the feasibility of achieving TE speech with a prototype TE voice prosthesis insufflator (TEVPI).

DESIGN, SETTING, AND PARTICIPANTS

We prospectively assessed the feasibility of achieving TE speech with a commercially available continuous positive airway pressure device in six TL patients.

INTERVENTION

The intervention is the use of a prototype TEVPI.

MAIN OUTCOMES AND MEASURES

A battery of acoustic and perceptual metrics were obtained and compared between TEVPI speech and standard tracheoesophageal voice prosthesis (TEVP) speech.

RESULTS

Voicing was accomplished with the TEVPI in five of six participants. On average, the duration of phonation with TEVPI was shorter, not as loud, and perceived to be more difficult to produce compared to TEVP speech.

CONCLUSIONS AND RELEVANCE

The TEVPI is a feasible, hands-free solution for restoring speech after TL. Although the current model produced inferior acoustic metrics compared with standard TEVP speech, further modification and refinement of the device has the potential to produce much improved speech.

Characterizing the operative findings and utility of intraoperative parathyroid hormone (IOPTH) monitoring in patients with normal baseline IOPTH and normohormonal primary hyperparathyroidism

BACKGROUND

During parathyroidectomy with intraoperative parathyroid hormone monitoring, the successful removal of a hypersecreting gland(s) resulting in normocalcemia is indicated by a >50% decrease in intraoperative parathyroid hormone level, typically into the normal range. Some patients, however, will have baseline parathyroid hormone levels within the normal range. We sought to determine the utility of intraoperative parathyroid hormone testing in these patients.

METHODS

We retrospectively studied all patients who underwent parathyroidectomy for primary hyperparathyroidism at our institution over a 10-year period.

RESULTS

Overall, 317 (17%) patients had parathyroid hormone within the normal range at the onset of operation (baseline intraoperative parathyroid hormone), and 1,544 (83%) had classic primary hyperparathyroidism. The intraoperative parathyroid hormone degradation was slower in normal baseline intraoperative parathyroid hormone patients than classic primary hyperparathyroidism patients, though this did not reach statistical significance (P < .254). A >50% intraoperative parathyroid hormone decrease predicted cure in 98.7% of normal baseline patients and 98.8% of classic primary hyperparathyroidism patients (P = .810). Normal baseline patients had a lesser cure rate the longer it took to achieve a 50% decrease intraoperatively; however, the cure rate was constant at any time point the 50% decrease occurred in patients with classic primary hyperparathyroidism (P < .05).

CONCLUSION

The 50% rule delineating operative cure can be applied with equal confidence to patients with normal range, baseline intraoperative parathyroid hormone. Moreover, the time at which the 50% drop is achieved impacts operative success rates in these patients.

Minimally invasive and remote-access thyroid surgery in the era of the 2015 American Thyroid Association guidelines

Thyroid surgery has evolved throughout the years from being one of the most dangerous surgeries to becoming one of the safest surgical procedures performed today. Recent technologic innovations have allowed surgeons to remove the thyroid gland from a remote site while avoiding visible neck scars. There are many endoscopic approaches for thyroidectomy. The most common cervical approach is the minimally invasive video‐assisted technique developed by Miccoli et al. The robotic transaxillary and axillary breast approaches avoid a neck scar and have been demonstrated to be safe and effective in international populations. Novel approaches under investigation include face‐lift robotic thyroidectomy and the transoral approach. This article aims to provide the reader with an overview of the current minimally invasive and alternate‐site approaches used and their capability to assist the surgeons in accomplishing remote‐access thyroid surgery under the scope of the 2015 American Thyroid Association Guidelines.

Intestinal Lymphangiectasia: Insights on Management and Literature Review

Patient: Male, 24

Final Diagnosis: Intestinal lymphangiectasia

Symptoms: Frequent episodes of diarrhea • recurrent infections • swelling in the lower limbs

Medication: Octreotide • MCT oils

Clinical Procedure: Endoscopic exam • Doppler ultrasound study • abdominal CT scan

Specialty: Gastroenterology and Hepatology

A meta-analysis examining the independent association between thyroid nodule size and malignancy

BACKGROUND

Tumor size is recognized as an important predictor of malignancy in many types of cancers. However, there is no clear line of characterization when it comes to the association between thyroid nodule size and malignancy risk prediction; and the current data remains inconsistent across different studies. The aim of our study is to examine the association between nodule size and malignancy using meta-analysis of the current literature.

METHODS

Data sources were gathered through systemic search of PubMed, Embase and other scientific databases for articles published between January 1, 1996 and June 1, 2013. A reference group with nodule sizes <3 cm was set as a control group. Two other nodule size categories were established and these included nodules from 3-5.9 cm and nodules ≥6 cm in size. Primary outcome was a histologically proven malignancy per nodule size category. The effect sizes of clinicopathologic parameters, which are the quantitative measures of association strength between two variables, were calculated by the means of odds ratios (OR). The effect sizes were then combined using a random-effects model.

RESULTS

Seven studies met our inclusion criteria with 10,817 thyroid nodules evaluated. Malignancy was identified in 2,206 (20.4%) nodules. After adjusting for patient age and gender, nodules that measured 3-5.9 cm had a 26% greater malignancy risk compared to those measuring <3 cm [OR, 1.26; 95% confidence interval (CI): 1.13-1.39]. However, nodules 6 cm or larger had a 16% lower risk of malignancy compared to those measuring <3 cm (OR, 0.84; 95% CI: 0.73-0.98).

CONCLUSIONS

Thyroid nodule size predicts cancer risk. However, a threshold effect of thyroid nodule size 6 cm or greater is significantly associated with a more benign disease.

Zollinger-Ellison Syndrome Associated with von Recklinghausen Disease: Case Report and Literature Review

BACKGROUND

Pancreatic endocrine tumors (PETs) are rare and can occur as part of neurofibromatosis type 1 (NF1). Gastrinomas are functional PETs that are rarely associated with NF1. Only two cases of their occurrence have been reported in the literature.

CASE REPORT

A 28-year-old woman was admitted for further evaluation of epigastric soreness, heartburn, nausea, vomiting, diarrhea, and a significant weight loss. Physical examination was remarkable for cutaneous findings (axillary freckling and multiple café-au-lait spots) as well as neurofibromas (dermal, plexiform). A diagnosis of NF1 was confirmed. Esophagogastroduodenoscopy (EGD) revealed multiple ulcers in the duodenum and the upper jejunum. A fasting gastrin level exceeded ten times the normal limit. An abdominal multi-slice 128 computed tomography (CT) scan revealed an oval mass of 26 mm in diameter adjacent to the second section of the duodenum. The patient was examined carefully to rule out multiple endocrine neoplasia type 1 (MEN1). Surgical resection was performed and a gastrinoma, causing Zollinger-Ellison syndrome (ZES), was diagnosed by histological examinations of the extirpated mass. The serum gastrin level decreased to normal limits shortly after surgery. Continuous follow-up revealed that the symptoms and the EGD findings completely resolved without recurrences.

CONCLUSIONS

Although NF1 has common skeletal, visual, neurological, and cardiovascular complications, it also has a rare association with duodenal or pancreatic gastrinomas. Vigilance for this possible association is important to promote timely and careful management to help eliminate serious and potentially life-threatening complications.

Effect of Gene Expression Classifier Molecular Testing on the Surgical Decision-Making Process for Patients With Thyroid Nodules

IMPORTANCE

Commercial molecular testing, such as the gene expression classifier (GEC), is now being used in the work up of cytologically indeterminate thyroid nodules. While this test may be helpful in ruling out malignancy in a thyroid nodule, its effect on surgical decision making has yet to be fully defined.

OBJECTIVE

We aimed to determine the effect and outcome of GEC test results on the decision-making process for patients with thyroid nodules presenting for surgical consultation.

DESIGN, SETTING, AND PARTICIPANTS

A surgical management algorithm was developed that incorporated individual Bethesda System for Reporting Thyroid Cytopathology classifications, in addition to clinical, laboratory, and radiological findings. We then retrospectively applied this algorithm to 273 consecutive patients with thyroid nodules and GEC test results who had presented for surgical consultation between February 1, 2012, and December 31, 2014.

INTERVENTIONS

GEC testing.

MAIN OUTCOMES AND MEASURES

Changes in management were recorded to identify the effect of GEC testing on the surgical decision-making process. An alteration in management of 20% of cases was considered significant.

RESULTS

Of the 273 consecutive patients assessed by the GEC, mean (SD) age was 50.8 (14.7) years, 204 (74.7%) were female, and the mean (SD) nodule size was 2.4 (1.3) cm. Test results were suspicious for 233 (85.3%); benign for 31 (11.4%); and indeterminate for 8 (2.9%). The GEC test was also positive for medullary thyroid cancer for 1 patient (0.4%). The GEC test was correctly used as a rule-out test in only 127 patients (46.5%) with indeterminate nodules who lacked a clinical indication for surgery. The clinical management plan of only 23 (8.4%) patients was altered as a result of GEC test results, and of these 23 patients who proceeded to surgery, 16 patients (72.7%) were found to be inappropriately overtreated relative to postoperative histopathology analysis. We found that GEC testing did not affect the surgical decision-making process in 250 (91.6%) of our patients. In 146 cases, the use of GEC testing was not clinically indicated, and the test was being overused in patients for whom the results would not change surgical management. The positive predictive value of the GEC test for cytologically indeterminate nodules was 42.1%, and the negative predictive value was 83.3%.

CONCLUSIONS AND RELEVANCE

The GEC testing did not significantly affect the surgical decision-making process. Gene expression classifier testing is often used incorrectly and is overused in patients for whom the results would not change management. The GEC test demonstrated a lower than expected negative predictive value, and there was evidence of overtreatment among patients whose treatment was altered based on this test.

Minimally invasive parathyroid surgery

Traditionally, bilateral cervical exploration for localization of all four parathyroid glands and removal of any that are grossly enlarged has been the standard surgical treatment for primary hyperparathyroidism (PHPT). With the advances in preoperative localization studies and greater public demand for less invasive procedures, novel targeted, minimally invasive techniques to the parathyroid glands have been described and practiced over the past 2 decades. Minimally invasive parathyroidectomy (MIP) can be done either through the standard Kocher incision, a smaller midline incision, with video assistance (purely endoscopic and video-assisted techniques), or through an ectopically placed, extracervical, incision. In current practice, once PHPT is diagnosed, preoperative evaluation using high-resolution radiographic imaging to localize the offending parathyroid gland is essential if MIP is to be considered. The imaging study results suggest where the surgeon should begin the focused procedure and serve as a road map to allow tailoring of an efficient, imaging-guided dissection while eliminating the unnecessary dissection of multiple glands or a bilateral exploration. Intraoperative parathyroid hormone (IOPTH) levels may be measured during the procedure, or a gamma probe used during radioguided parathyroidectomy, to ascertain that the correct gland has been excised and that no other hyperfunctional tissue is present. MIP has many advantages over the traditional bilateral, four-gland exploration. MIP can be performed using local anesthesia, requires less operative time, results in fewer complications, and offers an improved cosmetic result and greater patient satisfaction. Additional advantages of MIP are earlier hospital discharge and decreased overall associated costs. This article aims to address the considerations for accomplishing MIP, including the role of preoperative imaging studies, intraoperative adjuncts, and surgical techniques.

Robotic-assisted laparoscopic adrenalectomy for an adrenal adenoma

The patient was referred for management of a left adrenal incidentaloma. Preoperative CT scan and MRI showed focal calcification. Here we are presenting this video demonstrating robotic-assisted laparoscopic adrenalectomy for left adrenal mass.

Incidental thyroid nodules and thyroid cancer: considerations before determining management

The worldwide incidence of thyroid cancer is increasing substantially, almost exclusively attributable to small papillary thyroid cancers. Increased use of diagnostic imaging is considered the most likely explanation for this reported rise, but other factors may also be contributing. The increase in health care expenditures related to managing these presumably low-risk cancers, without a clear patient benefit, has resulted in a backlash against the early detection of thyroid cancer. Currently, there is no way to confidently predict which incidentally detected thyroid nodule may be the precursor to a more aggressive process. Predictions such as these would require more accurate characterization of the biology of individual thyroid cancers than is currently possible. With time, we might prove our ability to confidently differentiate low-risk from high-risk thyroid cancers, but until that happens, routine screening for thyroid cancer by imaging billed as a "health checkup" should not be performed. However, incidentally detected thyroid nodules should be reported, and a clear medical team management plan should be developed. Our ethical responsibility is to provide patients with objective, evidence-based information about their disease status, not to assume that we know what is best for them by selectively withholding information. In addition, providing patients with psychosocial assistance will help them process the information necessary to make informed decisions that will provide them with the most value when a small thyroid nodule or cancer is incidentally identified. Herein, we summarize the epidemiological data for disease incidence, discuss some controversies in disease management, and outline the key elements and ethical considerations of informed decision making as they apply to managing incidentally detected thyroid nodules and thyroid cancer.

Voice outcomes following reoperative central neck dissection for recurrent/persistent thyroid cancer

OBJECTIVES/HYPOTHESIS

We aimed to assess voice outcomes following reoperative central neck dissection (RCND) to characterize postoperative voice difficulties experienced, determine the natural progression of vocal recovery, and identify risk factors for the development of voice disorders postoperatively.

STUDY DESIGN

Prospective cohort study.

METHODS

Consecutive patients with recurrent/persistent thyroid cancer who were deemed appropriate candidates for RCND were eligible for participation in this study. A battery of voice evaluation measures was administered both preoperatively and 2 to 4 weeks postoperatively.

RESULTS

Twenty consecutive patients were included. Postoperatively, six (30%) new incidents of vocal fold motion impairment (VFMI) were identified, with two (10%) being due to intentional recurrent laryngeal nerve (RLN) transection. On 1-year follow-up, two patients had full restoration of vocal fold mobility and four had persistent VFMI. No preoperative voice/laryngeal exam factors were predictive of postoperative VFMI. Clinically relevant change in postoperative Voice Handicap Index score was absent in all patients without VFMI and present in five of six patients with VFMI (P=.0004). Patients with VFMI had significantly poorer overall dysphonia grade, less glottic closure, and elevated jitter in contrast to those individuals without VFMI. Patients with malignant tissue in the remnant thyroid were four times more likely to develop VFMI than those with central neck lymph node metastases alone (P=.06).

CONCLUSION

Patients undergoing RCND are at risk for postoperative VFMI, even when the RLN is anatomically preserved, with subsequent impact on quality of life. Presence of malignant disease in the remnant thyroid appears to be the best predictor for postoperative VFMI.

LEVEL OF EVIDENCE

2b.

Early predictors of hypocalcemia after total thyroidectomy: an analysis of 304 patients using a short-stay monitoring protocol

IMPORTANCE

Postoperative hypocalcemia is common after total thyroidectomy, and perioperative monitoring of serum calcium levels is arguably the primary reason for overnight hospitalization. Confidently predicting which patients will not develop significant hypocalcemia may allow for a safe earlier discharge.

OBJECTIVE

To examine associations of patient characteristics with hypocalcemia, duration of hospitalization, and postoperative intact parathyroid hormone (IPTH) level after total thyroidectomy.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective study of consecutive patients who underwent total thyroidectomy by a single high-volume surgeon between February 1, 2010, and November 30, 2012. Postoperative serum 25-hydroxyvitamin D (vitamin D), calcium, and IPTH levels were tested within 6 to 8 hours after surgery. Mild hypocalcemia was defined as any postoperative serum calcium level of less than 8.4 to 8.0 mg/dL. Significant hypocalcemia was defined as any postoperative serum calcium level of less than 8.0 mg/dL or the development of hypocalcemia-related symptoms.

INTERVENTIONS

Total thyroidectomy.

MAIN OUTCOMES AND MEASURES

Associations of patient demographic and clinical characteristics and laboratory values with postoperative mild and significant hypocalcemia were examined using univariate analysis, and independent predictors of hypocalcemia, duration of hospitalization, and IPTH level were determined using multivariate analysis.

RESULTS

Overall, 304 total thyroidectomies were performed. Mild and significant hypocalcemia occurred in 68 (22.4%) and 91 (29.9%) patients, respectively, of which the majority were female (P = .003). The development of significant hypocalcemia was associated with postoperative IPTH level (P < .001). On multivariate analysis, males had a decreased risk of developing mild (odds ratio, 0.37 [95% CI, 0.16-0.85]) and significant (odds ratio, 0.57 [95% CI, 0.09-0.78]) hypocalcemia. Every 10-pg/mL increase in postoperative IPTH level predicted a 43% decreased risk of significant hypocalcemia (P < .001) and an 18% decreased risk of hospitalization beyond 24 hours (P = .03). Presence of malignant neoplasm carried a 27% risk of mild hypocalcemia (P = .02). There was a progressively increasing risk of lower IPTH levels for each parathyroid gland inadvertently resected or autotransplanted. Male sex and African American race were independently predictive of higher IPTH levels.

CONCLUSIONS AND RELEVANCE

Low postoperative IPTH level, female sex, and presence of malignant neoplasm are all significant, independent predictors of hypocalcemia after total thyroidectomy. Clinicians should consider these variables when deciding how to best manage or prevent postoperative hypocalcemia.

Correlation of final evoked potential amplitudes on intraoperative electromyography of the recurrent laryngeal nerve with immediate postoperative vocal fold function after thyroid and parathyroid surgery

IMPORTANCE

Thyroid and parathyroid surgery are among the most common operations in the United States. Recurrent laryngeal nerve (RLN) injury is an infrequent but potentially detrimental complication.

OBJECTIVE

To correlate the final evoked potential amplitudes on intraoperative electromyography (EMG) after stimulation of the RLN with immediate postoperative vocal fold function after thyroid and parathyroid surgery.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective observational study at a tertiary academic medical center. We included 674 patients (with 1000 nerves at risk) undergoing thyroid or parathyroid surgery from July 1, 2008, through June 30, 2012.

INTERVENTIONS

Thyroid and parathyroid surgery.

MAIN OUTCOMES AND MEASURES

The association of final evoked potential amplitudes on EMG after thyroid and parathyroid surgery with vocal fold function as determined by postoperative fiberoptic laryngoscopy.

RESULTS

Three patients experienced permanent vocal fold paresis (VFP) secondary to intraoperative RLN transection. Of the remaining 997 RLNs at risk, 22 (2.2%) in 20 patients exhibited temporary VFP on fiberoptic laryngoscopy after extubation. Eighteen patients experienced unilateral temporary VFP, and 2 experienced bilateral VFP without the need for tracheostomy or reintubation. Of the 22 RLNs, postdissection EMG amplitudes were less than 200 µV (true-positive findings) in 21 and at least 200 µV (false-negative finding) in 1. Of the 975 RLNs (97.5%) with normal function, postdissection EMG amplitudes were at least 200 µV (true-negative findings) in 967 and less than 200 µV (false-positive findings) in 8. In regard to immediate postoperative VFP, sensitivity, specificity, positive and negative predictive values, and accuracy of postdissection EMG amplitudes of less than 200 µV were 95.5%, 99.2%, 72.4%, 99.9%, and 99.1%, respectively.

CONCLUSIONS AND RELEVANCE

Intraoperative nerve monitoring of the RLN with EMG provides real-time information regarding neurophysiologic function of the RLN and can predict immediate postoperative VFP reliably when a cutoff of 200 µV is used. The high negative predictive value means that the surgeon can presume with confidence that the RLN has not been injured in the presence of a potential of at least 200 µV. This information would be useful in patients for whom bilateral thyroid surgery is being considered.

The role of the robotic-assisted transaxillary gasless approach for the removal of parathyroid adenomas

BACKGROUND

We sought to describe a robotic technique of transaxillary gasless parathyroidectomy for the management of primary hyperparathyroidism (PHPT) due to a parathyroid adenoma.

METHODS

All consecutive patients who underwent robotic parathyroidectomy for a parathyroid adenoma by a single surgeon were included. Data was obtained by a retrospective review of patients' medical charts.

RESULTS

Nine patients with confirmed PHPT underwent robotic parathyroidectomy. Curative resection was established in all patients with the aid of intraoperative parathyroid hormone monitoring. One patient required bilateral cervical exploration of multiglandular disease. There were no complications. Patients were followed up for a period exceeding 6 months without any evidence of persistent or recurrent hyperparathyroidism.

CONCLUSIONS

Our initial experience demonstrates that this technique is safe and effective for the treatment of PHPT. We believe that the use of robotic technology for endoscopic parathyroid surgeries could overcome the limitations of conventional techniques in the management of parathyroid lesions.

The impact of surgical volume on racial disparity in thyroid and parathyroid surgery

PURPOSE

The aim of this study was to evaluate the association between surgeon volume and patient outcomes among different race ethnicities undergoing thyroid or parathyroid surgery.

METHODS

The nationwide inpatient sample was used to identify all thyroidectomy and parathyroidectomy admissions from 2003 to 2009, using International Classification of Diseases, 9th Clinical Modification (ICD-9-CM) procedure codes. Race, demographic, and clinical characteristics of patients were collected, along with surgeon volume, to predict the length of stay (LOS), complication rates, mortality, and total charges by racial group, using univariate and multivariate analyses.

RESULTS

A total of 106,314 thyroid and parathyroid surgeries were included in the current analysis. Of these patients, 54 % were Caucasian, 11 % African American, 7 % Hispanic, and 3 % Asian. Mean LOS was longer for African American patients (4 ± 8.7 days) than for Caucasians (2.3 ± 5.5 days) [p < 0.001]. African Americans had higher overall complications (16.8 %) compared with Caucasians (11 %), Hispanics (13.5 %), and Asians (12 %) [p < 0.001]. In-hospital mortality was higher for African Americans (0.8 %) compared with that from other race groups (0.3 %) [p < 0.001]. Mean total charges were significantly higher for African Americans ($33,292 ± $67,387) compared with those for Caucasians ($22,855 ± $40,167) (p < 0.001). African Americans had less access to intermediate- (10-99 cases) and high- (>100 cases) volume surgeons compared with Caucasians-45 versus 49 %, and 16 versus 19 %, respectively (p < 0.001). Higher surgeon volume was associated with improved outcomes (p < 0.001). Racial disparity in all investigated outcomes was still significantly evident even after stratification by surgeon volume.

CONCLUSION

Higher surgeon volume is associated with improved patient outcomes. However, our data suggests that the observed racial disparities in thyroid and parathyroid surgery go beyond access to quality healthcare providers.

Thyroidectomy for Graves' disease: a feasibility study of the robotic transaxillary approach

INTRODUCTION

Graves' disease (GD) is considered a relative contraindication for endoscopic approaches to the thyroid gland, due to a larger gland size and increased vascularity.

METHODS

A retrospective analysis of a single surgeon's experience was performed. We included all patients who underwent thyroidectomy for the treatment of GD over a 3-year period.

RESULTS

Twenty-five patients with GD were identified. Twelve of them underwent robotic thyroidectomy and 13 patients underwent conventional thyroidectomy. Age, gender, and BMI were similar in both groups (p > 0.05). The conventional approach allowed for resection of larger thyroid volumes (147.3 ± 153.6 ml), as compared to the robotic approach (62.3 ± 47.8 ml, p = 0.08). The average total operative times were similar in both groups (p = 0.98). There was no difference with respect to intraoperative blood loss (p = 0.49), duration of hospital stay (p = 0.38), and complication rates (p = 0.99).

CONCLUSION

Robotic thyroidectomy is feasible and can be safely performed in appropriately selected patients with GD.

Thyroid hormone replacement therapy, surveillance ultrasonography, and fine-needle aspiration after hemithyroidectomy

OBJECTIVES

We undertook a retrospective analysis of a single surgeon's experience at a tertiary care teaching hospital to determine the rates of surveillance ultrasound, fine-needle aspiration (FNA), and the need for thyroid hormone replacement therapy (THRT) after hemithyroidectomy.

METHODS

The study population comprised 120 consecutive patients who underwent hemithyroidectomy by one surgeon from January 2008 to June 2011. The medical records were reviewed for preoperative and postoperative calcium levels, fiberoptic direct laryngoscopy examination of vocal fold mobility, postoperative complications, final pathology, and postoperative follow-up.

RESULTS

Fifteen patients required completion thyroidectomy for malignancy and were excluded from the surveillance analysis. Of the remaining 105 patients, 10 (9.5%) required postoperative THRT. The likelihood for THRT was significantly associated with increased age (p = 0.01) and the presence of thyroiditis (p = 0.04). Other factors, such as gender, body mass index, residual thyroid volume, and presence of contralateral lobe nodules, were not significantly associated with this likelihood (p > 0.05). Twenty-three patients (21.9%) were followed with surveillance ultrasound, of whom 12 (11.4%) underwent FNA for nodule(s) in the contralateral lobe. Seventy-eight percent of patients did not require any long-term postoperative surveillance. There were no instances of permanent recurrent laryngeal nerve injury or hypoparathyroidism.

CONCLUSIONS

Hemithyroidectomy is an effective and efficient option for the management of benign and suspicious thyroid nodules. However, patients of increased age and/or with thyroiditis are at higher risk for postoperative hypothyroidism, and should be counseled to consider total thyroidectomy to avoid the need for long-term surveillance and the possible need for a second operation.

Robotic liver resection: initial experience with three-arm robotic and single-port robotic technique

Robotic liver surgery was found to offer advantages not inherent in conventional laparoscopic liver resection.

Background and Objective:

Robotic-assisted surgery offers a solution to fundamental limitations of conventional laparoscopic surgery, and its use is gaining wide popularity. However, the application of this technology has yet to be established in hepatic surgery.

Methods:

A retrospective analysis of our prospectively collected liver surgery database was performed. Over a 6-month period, all consecutive patients who underwent robotic-assisted hepatic resection for a liver neoplasm were included. Demographics, operative time, and morbidity encountered were evaluated.

Results:

A total of 7 robotic-assisted liver resections were performed, including 2 robotic-assisted single-port access liver resections with the da Vinci-Si Surgical System (Intuitive Surgical Sunnyvalle, Calif.) USA. The mean age was 44.6 years (range, 21–68 years); there were 5 male and 2 female patients. The mean operative time (± SD) was 61.4 ± 26.7 minutes; the mean operative console time (± SD) was 38.2 ± 23 minutes. No conversions were required. The mean blood loss was 100.7 mL (range, 10–200 mL). The mean hospital stay (± SD) was 2 ± 0.4 days. No postoperative morbidity related to the procedure or death was encountered.

Conclusion:

Our initial experience with robotic liver resection confirms that this technique is both feasible and safe. Robotic-assisted technology appears to improve the precision and ergonomics of single-access surgery while preserving the known benefits of laparoscopic surgery, including cosmesis, minimal morbidity, and faster recovery.

Outcomes of laparoscopic and open resection for neuroendocrine liver metastases

BACKGROUND

We sought to compare the outcomes in patients with hepatic carcinoid tumor metastases treated with open versus laparoscopic liver resection.

METHODS

A retrospective analysis of our liver surgery database was performed. All patients who underwent liver resection for hepatic carcinoid tumor metastases were included. Patients were divided into 2 groups depending on the surgical approach. Patients with concomitant primary and metastatic liver lesions underwent open resection.

RESULTS

Thirty-six patients underwent resection over a 10-year period (21 open and 15 laparoscopic). Both groups were similar in terms of gender, body mass index, tumor size, incidence of carcinoid syndrome, and extent of resection (P > .05). The laparoscopic group had less mean operative time (2.7 vs 5.4 hours), less mean blood loss (158.3 vs 538.9 mL), and a shorter hospital stay (3.2 vs 7.5 days; P < .05 for all). Complications were similar in both groups (20% vs 33%; P = .21). Two laparoscopic cases required conversion. The 3-year disease-free survival for the laparoscopic group was 73.3% compared to 47.6% for the open group (P = .2).

CONCLUSION

To our knowledge, this is the first reported study comparing laparoscopic versus open liver resection in the treatment of liver metastases from carcinoid tumors. Our series confirms that selective cases can safely be managed laparoscopically.

What is the best definitive treatment for Graves' disease? A systematic review of the existing literature

BACKGROUND

The management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists for Graves' disease (GD) include any of the following modalities: (131)I therapy, antithyroid medication, or thyroidectomy. No in-depth analysis has been performed comparing the treatment options, even though a single treatment option seems to be universally accepted.

METHODS

A systematic review of the literature was performed to examine contemporary literature between 2001 and 2011 evaluating the management options of GD. We compiled retrospective and prospective studies analyzing surgery and radioactive iodine. Outcomes of interest included postoperative hypothyroidism, euthyroidism, and persistent or recurrent hyperthyroidism without supplementation. Success was defined as postoperative euthyroidism or hypothyroidism. Failure was defined as persistent or recurrent hyperthyroidism.

RESULTS

Of the 14,245 patients, 4,546 underwent surgery [3,158 patients had subtotal thyroidectomy (STT) and 1,388 had total thyroidectomy (TT)] and 9,699 had radioactive iodine. The radioactive iodine group consisted of 2,383 patients receiving 1-10 mCi, 1,558 patients receiving 11-15 mCi, 516 patients receiving >15 mCi, and 5,242 patients receiving an unspecified amount. Surgery was found to be 3.44 times more likely to be successful than radioactive iodine (p < 0.001). STT and TT were found to be 2.33 and 94.45 times more likely to be successful than radioactive iodine (p < 0.001), respectively.

CONCLUSIONS

On the basis of the outcomes analyzed, surgery appears to be the most successful in the management of GD, with TT being the preferred surgical option.