Background The incidence of thyroid nodules increases with age and little information is available regarding the risks of thyroid surgery in elderly patients. The aim of this study was to determine ...whether thyroid surgery in patients ≥80 is associated with higher complication rates. Methods Out of 3,568 patients undergoing thyroid surgery between July 2001 and October 2007 at a single institution, the records of 90 consecutive patients ≥80 years were reviewed retrospectively and compared with a cohort of 242 randomly selected patients aged 18–79, who underwent thyroid surgery during the same time period. Clinical variables included age, gender, pre-operative diagnosis, substernal component, previous surgery, final pathology, length of stay, comorbidities, American Society of Anesthesiologists (ASA) score, body mass index, postoperative complications, and mortality. Results Preoperative indications for surgery included benign disease in 51% vs 39%, suspected malignancy in 19% vs 26%, and suspected follicular neoplasms in 30% vs 35% in the octogenarian patient group (≥80 years old) vs the younger patient cohort ( P = NS). Octogenarians had 20% significant malignancy on final pathology vs 27% in the younger cohort ( P = NS). The overall complication rate in the octogenarian group was 24% vs 9% in the younger cohort ( P < .001). Male gender and ASA ≥3 were found to be independent risk factors for perioperative complications after thyroid surgery, while age alone was not. Conclusion Age ≥80 is associated with higher morbidity after thyroid surgery, although not independently. Earlier operative intervention may be advised in those at high risk for disease progression, whereas follow-up strategies without operation may be advised for others.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Surgery for Graves’ disease: a 25-year perspective Phitayakorn, Roy, M.D., M.H.P.E; Morales-Garcia, Dieter, M.D; Wanderer, Jonathan, M.D ...
The American journal of surgery,
11/2013, Volume:
206, Issue:
5
Journal Article
Peer reviewed
Abstract Background Optimal treatment of Graves’ disease (GD) remains controversial. The authors retrospectively reviewed the surgical cases of GD at a single academic tertiary center. Methods ...Demographic, clinical, and surgical data were analyzed for all patients with GD undergoing thyroidectomy over 25 years, in 3 periods: 1985 to 1993 (n = 32), 1994 to 2002 (n = 91), and 2003 to 2010 (n = 177). Results There were 300 patients with GD (85.7% women; mean age, 39.3 years; median length of follow-up, 24.6 months). Overall, perioperative morbidity occurred in 36 patients (12.0%), and there was no mortality. Thyroidectomy-specific morbidity was very low, and the incidental malignancy rate was 10.3%. Conclusions Surgical treatment of GD has a very high safety profile, with low perioperative and thyroidectomy-specific morbidity, even in patients with overt hyperthyroidism. Incidental malignancy in patients with GD is not uncommon.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Background
Strategies for localizing parathyroid pathology preoperatively vary in cost and accuracy. Our purpose was to compute and compare comprehensive costs associated with common localization ...strategies.
Methods
A decision-analytic model was developed to evaluate comprehensive, short-term costs of parathyroid localization strategies for patients with primary hyperparathyroidism. Eight strategies were compared. Probabilities of accurate localization were extracted from the literature, and costs associated with each strategy were based on 2011 Medicare reimbursement schedules. Differential cost considerations included outpatient versus inpatient surgeries, operative time, and costs of imaging. Sensitivity analyses were performed to determine effects of variability in key model parameters upon model results.
Results
Ultrasound (US) followed by 4D-CT was the least expensive strategy ($5,901), followed by US alone ($6,028), and 4D-CT alone ($6,110). Strategies including sestamibi (SM) were more expensive, with associated expenditures of up to $6,329 for contemporaneous US and SM. Four-gland, bilateral neck exploration (BNE) was the most expensive strategy ($6,824). Differences in cost were dependent upon differences in the sensitivity of each strategy for detecting single-gland disease, which determined the proportion of patients able to undergo outpatient minimally invasive parathyroidectomy. In sensitivity analysis, US alone was preferred over US followed by 4D-CT only when both the sensitivity of US alone for detecting an adenoma was ≥94 %, and the sensitivity of 4D-CT following negative US was ≤39 %. 4D-CT alone was the least costly strategy when US sensitivity was ≤31 %.
Conclusions
Among commonly used strategies for preoperative localization of parathyroid pathology, US followed by selective 4D-CT is the least expensive.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background Studies have not established the optimal role for prophylaxis after surgery for Crohn's disease. Some suggest treatment should be initiated within the first month after surgery, whereas ...others advocate targeted treatment after endoscopic recurrence. In the present study, we compared the efficacy of these competing approaches. Methods One hundred and ninety-nine Crohn's disease patients who underwent ileocecectomy between September 1993 and April 2008 were retrospectively divided into 3 groups based on treatment timing: immediate, tailored, and none. Groups were compared for differences in demographics, pathology, and surgical technique (Chi-square, ANOVA). Rate of symptomatic recurrence (Chi-square), and time to symptomatic recurrence were analyzed (log rank, multivariate Cox proportional hazards). Results Sixty-nine (34.7%) received immediate prophylaxis, 32 (16.1%) received tailored prophylaxis, and 98 (49.3%) did not receive any prophylaxis. The groups were similar, though patients receiving immediate prophylaxis were younger and less likely to be lost to follow-up. At 5 years, 62 (31.2%) patients had endoscopic, 46 (23.1%) had symptomatic, and 22 (11%) had surgical recurrences. On simple univariate analysis, patients treated in a tailored fashion at time of endoscopic recurrence appeared more likely than patients treated with immediate prophylaxis to have symptomatic recurrence (43.7% vs 28.9%; P = .02), However, when censored for length of follow-up on multivariate analysis, the only enduring predictor of symptomatic recurrence was Charlson Comorbidity Index ( P = .048). Timing of treatment, medicine used for immunoprophylaxis, age, history of prior resection, presence of active disease, and type of anastomosis were not predictive of symptomatic recurrence. Conclusion Patients offered prophylaxis tailored to endoscopic recurrence have a similar time to symptomatic recurrence as those offered prophylaxis immediately. This suggests that a tailored treatment within a strict protocol of preemptive endoscopic surveilance may be reasonable.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
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A Large Pelvic Ganglioneuroma in a Middle-Aged Man Gomes, Hannah Ananda Bougleux; Hodin, Richard A; Stapleton, Sahael M
Journal of gastrointestinal surgery,
10/2021, Volume:
25, Issue:
10
Journal Article
Peer reviewed
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EMUNI, FZAB, GEOZS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Fibrosis and tissue stiffening are hallmarks of inflammatory bowel disease (IBD). We have hypothesized that the increased stiffness directly contributes to the dysregulation of the epithelial cell ...homeostasis in IBD. Here, we aim to determine the impact of tissue stiffening on the fate and function of the intestinal stem cells (ISCs).
We developed a long-term culture system consisting of 2.5-dimensional intestinal organoids grown on a hydrogel matrix with tunable stiffness. Single-cell RNA sequencing provided stiffness-regulated transcriptional signatures of the ISCs and their differentiated progeny. YAP-knockout and YAP-overexpression mice were used to manipulate YAP expression. In addition, we analyzed colon samples from murine colitis models and human IBD samples to assess the impact of stiffness on ISCs in vivo.
We demonstrated that increasing the stiffness potently reduced the population of LGR5+ ISCs and KI-67+–proliferating cells. Conversely, cells expressing the stem cell marker, olfactomedin-4, became dominant in the crypt-like compartments and pervaded the villus-like regions. Concomitantly, stiffening prompted the ISCs to preferentially differentiate toward goblet cells. Mechanistically, stiffening increased the expression of cytosolic YAP, driving the extension of olfactomedin-4+ cells into the villus-like regions, while it induced the nuclear translocation of YAP, leading to preferential differentiation of ISCs toward goblet cells. Furthermore, analysis of colon samples from murine colitis models and patients with IBD demonstrated cellular and molecular remodeling reminiscent of those observed in vitro.
Collectively, our findings highlight that matrix stiffness potently regulates the stemness of ISCs and their differentiation trajectory, supporting the hypothesis that fibrosis-induced gut stiffening plays a direct role in epithelial remodeling in IBD.
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Intestinal tissue stiffening, due to fibrosis, in inflammatory bowel disease reduces the population and stemness of the intestinal stem cells and promotes their differentiation toward goblet cells.
Previous associations between surgeon volume with adrenalectomy outcomes examined only a sample of procedures. We performed an analysis of all adrenalectomies performed in New York state to assess ...the effect of surgeon volume and specialty on clinical outcomes.
Adrenalectomies performed in adults were identified from the New York Statewide Planning and Research Cooperative System from 2000–2014. Surgeon specialty, volume, and patient demographics were assessed. High volume was defined using a significance threshold at ≥4 adrenalectomies per year. Outcome variables included in-hospital mortality, duration of stay, and in-hospital complications.
A total of 6,054 adrenalectomies were included. Median patient age was 56 years; 41.9% were men and 68.3% were white. Urologists (n = 462) performed 46.8% of adrenalectomies, general surgeons (n = 599) performed 35.0%, and endocrine surgeons (n = 23) performed 18.1%. Significantly more endocrine surgeons were high-volume compared with urologists and general surgeons (65.2% vs 10.2% and 6.7%, respectively, P < .001). High-volume surgeons had significantly lower mortality compared with low-volume surgeons (0.56% vs 1.25%, P = .004) and a lower rate of complications (10.2% vs 16.4%, P = < .001). Endocrine surgeons were more likely to perform laparoscopic procedures (34.8% vs 22.4% general surgeons and 27.7% US, P < .001) and had the lowest median hospital duration of stay (2 days vs 4 days general surgeons and 3 days urologists, P < .001). After risk adjustment, low surgeon volume was an independent predictor of inpatient complications (odds ratio = 0.96, P = .002).
Patients with adrenal disease should be referred to surgeons based on adrenalectomy volume regardless of specialty, but most endocrine surgeons that perform adrenalectomy are high-volume for the procedure.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
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