Patterns of disease in patients at a tertiary referral centre requiring reoperative parathyroidectomy

INTRODUCTION

Reoperative parathyroidectomy is required when there is persistent or recurrent hyperparathyroidism following the initial surgery (at least 5% of parathyroidectomies nationally). By convention, 'persistent disease' is defined as the situation where the patient has not been cured by the first operation. The term 'recurrent hyperparathyroidism' is used when the patient was confirmed to be biochemically cured for six months from the first operation but has hyperparathyroidism after this date. Reoperative surgery is associated with higher rates of postoperative complications as well as a greater rate of failure to cure. The aim of our study was to review our departmental experience of reoperative parathyroidectomy, with a view to identify patterns of disease persistence and recurrence.

METHODS

Using a departmental database, patients were identified who had undergone reoperative parathyroidectomy between 2006 and 2014. All the pre, intra and postoperative information was documented including the operative note so as to record the location of the abnormal parathyroid gland found at reoperation.

RESULTS

Almost two-thirds (63%) of patients had negative, equivocal or discordant conventional imaging so secondary investigative tools were required frequently. The majority of abnormal glands were found in eutopic locations. The most common locations for ectopic glands were intrathyroidal, mediastinal and intrathymic. A third (33%) of the patients had multigland disease and over a quarter (28%) had coexisting thyroid disease.

CONCLUSIONS

Persistent hyperparathyroidism represents a challenging patient subgroup for which access to all radiological modalities and intraoperative parathyroid hormone monitoring are required. Patient selection for reintervention is a key determinant in the reoperation cure rate.

Systematic review and meta-analysis of retroperitoneoscopic versus laparoscopic adrenalectomy

BACKGROUND

Laparoscopic adrenalectomy (LA) has replaced open adrenalectomy as the standard operation for non-malignant adrenal tumours. Retroperitoneoscopic adrenalectomy (RA) is an increasingly popular alternative minimally invasive approach. Advocates of each technique claim its superiority, but the issue has yet to be resolved and conclusions are complicated by the existence of a lateral (LRA) and true posterior (PRA) RA.

METHODS

A literature search was performed for all comparative studies of RA versus LA. Meta-analysis was performed according to PRISMA guidelines. Odds ratios and standardized mean differences (SMD) were used to compare dichotomous and continuous outcomes respectively.

RESULTS

Twenty-two studies were included, reporting on 1257 LAs, 471 LRAs and 238 PRAs. Both PRA and LRA were associated with a reduced length of hospital stay: SMD - 1·45 (95 per cent confidence interval - 2·76 to - 0·14) and - 0·54 (-1·04 to - 0·03) days respectively compared with LA. Interstudy heterogeneity was present throughout the comparisons of hospital stay. When considering only the two randomized clinical trials (RCTs) there was no statistically significant difference in this outcome. One RCT, however, found a reduction in the median time to convalescence of 2·4 weeks in the LRA group. There were no differences in duration of operation, blood loss, time to ambulation and oral intake, or complication rates between techniques.

CONCLUSION

RA overall has equivalent outcomes to LA but may be associated with a shorter hospital stay.

Diagnostic accuracy and value of magnetic resonance imaging (MRI) in planning exenterative pelvic surgery for advanced colorectal pelvic cancer

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Background: Exenterative pelvic surgery is challenging and has been used in colorectal surgery to manage patients with advanced colorectal pelvic cancer. Resection of the tumor needs to be performed en-bloc and if feasible, without exposing the tumor, since this can compromise resection margins. This can only be performed through careful pre-operative staging. This study aimed to assess the diagnostic accuracy of MRI in detecting colorectal tumor invasion into seven intrapelvic compartments and its value in planning exenterative pelvic surgery.

Methods: Sixty four consecutive patients underwent preoperative MRI planning for exenterative surgery, for locally advanced (n= 23) and recurrent (n= 41) pelvic colorectal cancer. Two radiologists reported tumor invasion for each of the seven anatomic surgical resection compartments and were blinded to histopathology and intraoperative reference standards. Sensitivity, specificity and predictive values were calculated for each compartments. Kaplan-Meier methodology was used to calculate survival rates. Interobserver agreement was assessed using Cohen's Kappa coefficient (k).

Results: The sensitivity of MRI was ≥93.3% in all except for the lateral compartment where it was 89.3%. Its specificity for the posterior (82.2%), anterior below (86.4%) the peritoneal reflection compartments was lower compared to the rest of the compartments. MRI diagnosis of lateral (OR= 11.41, p= 0.033), anterior compartment above the peritoneal reflection (OR= 3.14, p= 0.005) and multicompartmental involvement (OR= 1.99, p<0.001) was associated with higher risk of incomplete resection which was subsequently found to be significant factor in predicting overall and disease free survival (p<0.05). The agreement between the two radiologists was found to be either good or very good for all the compartments (k>0.72).

Conclusions: MRI is highly accurate in predicting tumor invasion within the intrapelvic compartments and it should be the pre-operative staging modality of choice when considering exenterative surgery for patients with locally advanced colorectal pelvic cancer.

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The role of laparoscopy and laparoscopic ultrasound in the preoperative staging of pancreatico-biliary cancers--A meta-analysis

BACKGROUND

Staging laparoscopy (SL) may prevent non-therapeutic laparotomy in patients with otherwise resectable pancreatico-biliary cancers, but evidence is inconclusive. This meta-analysis aims to ascertain the true benefit of SL.

METHODS

All studies undertaking SL as a diagnostic sieve were included and data homogenised. Standard meta-analytical tools with emphasis on sensitivity testing and meta-regression to detect the cause for heterogeneity between studies were used.

RESULTS

29 studies satisfied the criteria. 3305 patients underwent SL of which 12 were incomplete. Morbidity (n = 15) and mortality (n = 1) was low. True yield of SL for pancreatic/perpancreatic cancers (PPC) was 25% (95% CI 24-27) with a Diagnostic Odds Ratio (DOR) of 104 (95% CI 48-227). Resection rate improved from 61% to 80%. For proximal biliary cancers (PBC), SL increased the curative resection rate from 27% to 50%, with true yield of 47% (95% CI 42-52) and a DOR 61 (95% CI 19-189). Sub-group analysis for detection of liver and peritoneal lesions demonstrated a sensitivity of 88% (95% CI 83-92) and 92% (95% CI 84-96) for PPC; 83% (95% CI 69-92) and 93% (95% CI 81-99) for PBC, respectively. There was no between-study heterogeneity for peritoneal lesions. However for detection of local invasion, sensitivity was low: 58% (95% CI 51-65) for PPC and only 34% (95% CI 22-47) for PBC. Meta-regression did not reveal any cause for the observed heterogeneity between studies.

CONCLUSION

SL offers significant benefit to patients with resectable pancreatico-biliary cancers in avoiding non-therapeutic laparotomy and should be adopted in routine clinical practice in a judicious algorithm.

WITHDRAWN: Meta-analysis: the use of adhesion prevention membranes in abdominal surgery

Ahead of Print article withdrawn by publisher.

Prospective multicentre evaluation of adverse outcomes following treatment for complicated diverticular disease

Background

The choice of operation for complicated diverticular disease is contentious. The aim of this study was to investigate adverse events following restorative (primary resection and anastomosis, PRA) and non-restorative (Hartmann's procedure, HP) surgery for complicated diverticular disease.

Methods

Five hundred and thirty-nine patients who presented with complicated diverticular disease in 42 centres over a 12-month period from January 2003 were considered for the study. Data were collected prospectively from 248 patients (46·0 per cent) who underwent PRA and 167 (31·0 per cent) who had HP. A propensity score was developed for case-mix adjustment. Multifactorial logistic regression was used to evaluate differences in operative outcomes.

Results

Mortality, surgical and medical complication rates were 4·0, 31·0 and 13·7 per cent respectively after PRA, and 23·4, 53·3 and 40·7 per cent for HP (all P &lt; 0·001). After adjusting for the propensity score, the HP group had a 2·1- and 1·9-fold increase in medical and surgical complications respectively compared with those who had PRA, whereas the operative mortality rate was not significantly different. Non-colorectal surgeons performed a significantly higher proportion of HPs in the non-elective setting than colorectal surgeons (80·6 versus 60·4 per cent; χ2 = 8·31, 1 d.f., P = 0·004).

Conclusion

PRA with or without a proximal diversion is more often performed non-electively by specialist colorectal surgeons. It may be a safe procedure for complicated diverticular disease in selected patients as it may be associated with fewer postoperative adverse events.

Long-term, health-related, quality of life comparison in patients undergoing single stage vs staged resection for complicated diverticular disease

OBJECTIVE

To evaluate long-term health-related quality of life, for single-staged and staged resections following reversal, for complicated diverticular disease.

PATIENTS AND METHODS

Between 1981 and 2003, 188 patients undergoing single stage (n = 158) or staged resection (n = 30) completed the SF-36 questionnaire. Health-related quality of life (HRQL) was compared between the two groups and the US normal population based on the eight domains of the SF-36. HRQL analysis was also performed at various time intervals. The effect of age and postoperative complications on HRQL was also determined. Functional and postoperative outcomes were also assessed.

RESULTS

The single and staged resection groups differed in the presence of comorbidity, degree of peritoneal contamination and operative urgency. No difference in functional outcomes or HRQL was found, even after analysing time-interval subgroups. Social functioning and general health was substantially worse in both groups when compared to US norms. Ageing was found to significantly reduce physical functioning (P < 0.001) and physical and emotional role limitations (P < 0.001 for both). Post-operative complications significantly reduced scores when compared to patients without complications, for physical functioning (63.57 vs 78.7, respectively; P < 0.001), physical role limitation (80.65 vs 86.9, respectively; P < 0.001) and bodily pain (66.67 vs 74.81, respectively; P < 0.01).

CONCLUSIONS

No significant difference in long-term HRQL was found in patients undergoing single staged or staged resection for complicated diverticular disease. There was significant impact of ageing and postoperative complications on physical health. Prospective studies that include pre-operative data on HRQL are required to compare the two operative techniques, with emphasis on quality of life of patients left with a permanent stoma.

Comparison of laparoscopic and open ileocecal resection for Crohn's disease: a metaanalysis

BACKGROUND

The role of laparoscopic surgery for patients with ileocecal Crohn's disease is a contentious issue. This metaanalysis aimed to compare open resection with laparoscopically assisted resection for ileocecal Crohn's disease.

METHODS

A literature search of the Medline, Ovid, Embase, and Cochrane databases was performed to identify comparative studies reporting outcomes for both laparoscopic and open ileocecal resection. Metaanalytical techniques were applied to identify differences in outcomes between the two groups. Sensitivity analysis was undertaken to evaluate the heterogeneity of the study.

RESULTS

Of 20 studies identified by literature review, 15 satisfied the criteria for inclusion in the study. These included outcomes for 783 patients, 338 (43.2%) of whom had undergone laparoscopic resection, with an overall conversion rate to open surgery of 6.8%. The operative time was significantly longer in the laparoscopic group, by 29.6 min (p = 0.002), although the blood loss and complications in the two groups were similar. In terms of postoperative recovery, the laparoscopic patients had a significantly shorter time for recovery of their enteric function and a shorter hospital stay, by 2.7 days (p < 0.001).

CONCLUSIONS

For selected patients with noncomplicated ileocecal Crohn's disease, laparoscopic resection offered substantial advantages in terms of more rapid resolution of postoperative ileus and shortened hospital stay. There was no increase in complications, as compared with open surgery. The contraindications to laparoscopic approaches for Crohn's disease remain undefined.