Background
In the current guidelines for differentiated thyroid cancer (DTC), computed tomography (CT) of the neck has a limited role. The authors hypothesized that adding CT to the workup of ...clinically low-risk DTC size 4 cm or smaller changes the surgical management for a portion of patients due to detection of clinically significant lymph node metastases not located by ultrasound of the neck.
Methods
A prospective cohort of DTC patients at an academic referral center between 2012 and 2016 was reviewed. All the patients with fine-needle aspiration cytopathology results suspicious for malignancy or malignant tumor (Bethesda category 5 or 6, respectively) underwent CT before surgery. Clinically low-risk DTC patients were selected if they had a tumor diameter of 4 cm or less and no evidence for local invasion or suspicious lymph nodes seen on ultrasound. Outcomes focused on alteration of the surgical plan based on CT and correlation with pathology.
Results
The CT findings for 25 (22.5%) of 111 patients with clinically low-risk DTC led to a change in surgical management. Of these 25 patients, 16 (14.4% of the entire cohort) benefited due to the removal of clinically significant lymph node disease not seen on ultrasound. Categorization of the group that had a change in management showed that 6 (85.7%) of 7 lateral neck dissections and 10 (55.6%) of 18 central neck dissections (CND) harbored metastatic nodes larger than 2 mm.
Conclusions
In the group with clinically low-risk DTC, CT changed surgical management for a substantial number of the patients with clinically significant nodal disease not detected by ultrasound. This highlights the fact that in certain practice settings, adding CT to the preoperative staging may be favorable for the detection of nodal metastasis.
Background
European nutritional guidelines recommend routine use of enteral feeding after pancreaticoduodenectomy (PD) whereas American guidelines do not. Data on the efficacy and, especially, ...complications of the various feeding strategies after PD are scarce.
Methods
Retrospective monocenter cohort study in 144 consecutive patients who underwent PD during a period wherein the routine post-PD feeding strategy changed twice. Patients not receiving nutritional support (n=15) were excluded. Complications were graded according to the Clavien-Dindo classification and the International Study Group of Pancreatic Surgery (ISGPS) definitions. Analysis was by intention-to-treat. Primary endpoint was the time to resumption of normal oral intake.
Results
129 patients undergoing PD (111 pylorus preserving) were included. 44 patients (34%) received enteral nutrition via nasojejunal tube (NJT), 48 patients (37%) via jejunostomy tube (JT) and 37 patients (29%) received total parenteral nutrition (TPN). Groups were comparable with respect to baseline characteristics, Clavien ≥II complications (
P
=0.99), in-hospital stay (
P
=0.83) and mortality (
P
=0.21). There were no differences in time to resumption of normal oral intake (primary endpoint; NJT/JT/TPN: median 13, 16 and 14 days,
P
=0.15) and incidence of delayed gastric emptying (
P=
0.30). Duration of enteral nutrition was shorter in the NJT- compared to the JT- group (median 8 vs. 12 days,
P
=0.02). Tube related complications occurred mainly in the NJT-group (34% dislodgement). In the JT-group, relaparotomy was performed in three patients (6%) because of JT-leakage or strangulation leading to death in one patient (2%). Wound infections were most common in the TPN group (NJT/JT/TPN: 16%, 6% and 30%,
P
=0.02).
Conclusion
None of the analysed feeding strategies was found superior with respect to time to resumption of normal oral intake, morbidity and mortality. Each strategy was associated with specific complications. Nasojejunal tubes dislodged in a third of patients, jejunostomy tubes caused few but potentially life-threatening bowel strangulation and TPN doubled the risk of infections.
Clinical Spectrum of Pheochromocytoma Guerrero, Marlon A., MD; Schreinemakers, Jennifer M.J., MD; Vriens, Menno R., MD, PhD ...
Journal of the American College of Surgeons,
12/2009, Letnik:
209, Številka:
6
Journal Article
Recenzirano
Background Pheochromocytomas vary in presentation, tumor size, and in catecholamine production. Whether pheochromocytoma size correlates with hormone levels, clinical presentation, and perioperative ...complications is not known. The goal of this study was to determine if tumor size and hormone level correlate according to the clinical presentation at diagnosis. Study Design We retrospectively analyzed all patients who underwent an adrenalectomy with a diagnosis of a pheochromocytoma from February 1996 to October 2008. We grouped patients according to their clinical presentation at diagnosis (routine biochemical screening, incidentaloma, classic symptoms, pheochromocytoma crisis) and obtained preoperative radiographic tumor size and catecholamine hormone levels. ANOVA was used for the group effects and the Kruskal–Wallis rank test was used for pairwise comparison between groups with the Sidak/Bonferroni method for multiplicity adjustment according to age, tumor size, and hormone level. The Pearson correlation coefficient was then calculated to determine if hormone level correlated with tumor size. Results Eighty-one of 107 patients had data available for complete analysis. The average age at diagnosis for all patients was 47.1 years, and the average tumor size was 4.9 cm. The average highest hormone ratio among all patients was 27.4. Tumor size and hormone ratio levels differed among all groups (p ≤ 0.03). A direct correlation (p = 0.014) was apparent between tumor size and hormone level. Complication rates also differed among the four groups of patients (p ≤ 0.02). Conclusions Our study showed that tumor size directly correlates with hormone level. Smaller tumors tend to secrete lower levels of catecholamines, but larger tumors have a wider variation in secretory potential. Larger tumors, however, produced the highest hormone ratios.
Background Preoperative imaging in patients with primary hyperparathyroidism and a previous parathyroid operation is essential; however, performance of conventional imaging is poor in this subgroup. ...Magnetic resonance imaging appears to be a good alternative, though overall evidence remains scarce. We retrospectively investigated the performance of magnetic resonance imaging in patients with and without a previous parathyroid operation, with a separate comparison for dynamic gadolinium-enhanced magnetic resonance imaging. Methods All patients undergoing magnetic resonance imaging prior to parathyroidectomy for primary hyperparathyroidism (first time or recurrent) between January 2000 and August 2015 at a high-volume, tertiary care, referral center for endocrine operations were included. We compared the sensitivity and positive predictive value of magnetic resonance imaging with conventional ultrasound and sestamibi on a per-lesion level. Results A total of 3,450 patients underwent parathyroidectomy, of which 84 patients with recurrent ( n = 10) or persistent ( n = 74) disease and 41 patients with a primary operation were included. Magnetic resonance imaging had a sensitivity and positive predictive value of 79.9% and 84.7%, respectively, and performance was good in both patients with and without a previous parathyroid operation. Adding magnetic resonance imaging to the combination of ultrasound and sestamibi resulted in a significant increase in sensitivity from 75.2% to 91.5%. Dynamic magnetic resonance imaging produced excellent results in the reoperative group, with sensitivity and a positive predictive value of 90.1%. Conclusion Technologic advances have enabled faster and more accurate magnetic resonance imaging protocols, making magnetic resonance imaging an excellent alternative modality without associated ionizing radiation. Our study shows that the sensitivity of multimodality imaging for parathyroid adenomas improved significantly with the use of conventional and dynamic magnetic resonance imaging, even in the case of recurrent or persistent disease.
OBJECTIVE:To study the feasibility and impact of a nationwide training program in minimally invasive distal pancreatectomy (MIDP).
SUMMARY OF BACKGROUND DATA:Superior outcomes of MIDP compared with ...open distal pancreatectomy have been reported. In the Netherlands (2005 to 2013) only 10% of distal pancreatectomies were in a minimally invasive fashion and 85% of surgeons welcomed MIDP training. The feasibility and impact of a nationwide training program is unknown.
METHODS:From 2014 to 2015, 32 pancreatic surgeons from 17 centers participated in a nationwide training program in MIDP, including detailed technique description, video training, and proctoring on-site. Outcomes of MIDP before training (2005–2013) were compared with outcomes after training (2014–2015).
RESULTS:In total, 201 patients were included; 71 underwent MIDP in 9 years before training versus 130 in 22 months after training (7-fold increase, P < 0.001). The conversion rate (38% n = 27 vs 8% n = 11, P < 0.001) and blood loss were lower after training and more pancreatic adenocarcinomas were resected (7 10% vs 28 22%, P = 0.03), with comparable R0-resection rates (4/7 57% vs 19/28 68%, P = 0.67). Clavien-Dindo score ≥III complications (15 21% vs 19 15%, P = 0.24) and pancreatic fistulas (20 28% vs 41 32%, P = 0.62) were not significantly different. Length of hospital stay was shorter after training (9 7–12 vs 7 5–8 days, P < 0.001). Thirty-day mortality was 3% vs 0% (P = 0.12).
CONCLUSION:A nationwide MIDP training program was feasible and followed by a steep increase in the use of MIDP, also in patients with pancreatic cancer, and decreased conversion rates. Future studies should determine whether such a training program is applicable in other settings.
Background
Primary hyperparathyroidism is the most common manifestation of multiple endocrine neoplasia type 1 (MEN1). Guidelines advocate subtotal parathyroidectomy (STP) or total parathyroidectomy ...with autotransplantation due to high prevalence of multiglandular disease; however, both are associated with a significant risk of permanent hypoparathyroidism. More accurate imaging and use of intraoperative PTH levels may allow a less extensive initial parathyroidectomy (unilateral clearance, removing both parathyroids with cervical thymectomy) in selected MEN1 patients with primary hyperparathyroidism.
Methods
We performed a retrospective cohort study at a high-volume tertiary medical center including patients with MEN1 and primary hyperparathyroidism, who underwent STP or unilateral clearance as their initial surgery from 1995 to 2015. Unilateral clearance was offered to patients who had concordant sestamibi and ultrasound showing a single enlarged parathyroid gland. For both the groups, we compared rates of persistent/recurrent disease and permanent hypoparathyroidism.
Results
Eight patients had unilateral clearance and 16 had STP. Subtotal parathyroidectomy patients were younger (37 vs 52 years). One patient in each group had persistent disease. One (13 %) unilateral clearance and five (31 %) STP patients had recurrent hyperparathyroidism after a mean follow-up of 47 and 68 months (
p
= 0.62). No unilateral clearance patients and two of 16 SPT patients had permanent hypoparathyroidism (
p
= 0.54).
Conclusions
Some MEN1 patients with primary hyperparathyroidism who have concordant localizing studies may be selected for unilateral clearance as an alternative to STP. For appropriately selected MEN1 patients, unilateral clearance can achieve similar results as STP and has no risk of permanent hypoparathyroidism, and may facilitate possible future reoperations.
Insulin-producing pancreatic neuroendocrine tumors (PanNETs)/insulinomas are generally considered to be indolent tumors with an excellent prognosis after complete resection. However, some insulinomas ...have a poor prognosis due to relapses and metastatic disease. Recently, studies in non-functional PanNETs indicated that behavior can be stratified according to alpha- and beta-cell differentiation, as defined by expression of the transcription factors ARX and PDX1, respectively. It is unknown whether similar mechanisms play a role in insulinomas. Therefore, we determined ARX and PDX1 expression in a cohort of 35 sporadic primary insulinomas and two liver metastases of inoperable primary insulinomas. In addition, WHO grade and loss of ATRX or DAXX were determined by immunohistochemistry, and alternative lengthening of telomeres (ALT) and
CDKN2A
status by fluorescence in situ hybridization. These findings were correlated with tumor characteristics and clinical follow-up data. In total, five out of 37 insulinoma patients developed metastatic disease. Metastatic insulinomas were all larger than 3 cm, whereas the indolent insulinomas were smaller (
p
value < 0.05). All three primary insulinomas that metastasized showed ARX expression, 2/3 showed ALT, and 1/3 had a homozygous deletion of
CDKN2A
as opposed to absence of ARX expression, ALT, or
CDKN2A
deletions in the 32 non-metastatic cases. The two liver metastases also showed ARX expression and ALT (2/2). The presence of ARX expression, which is usually absent in beta-cells, and genetic alterations not seen in indolent insulinomas strongly suggest a distinct tumorigenic mechanism in malignant insulinomas, with similarities to non-functional PanNETs. These observations may inform future follow-up strategies after insulinoma surgery.
To provide for Coronavirus Disease 2019 (COVID-19) healthcare capacity, (surgical oncology) guidelines were established, forcing to alter the timing of performing surgical procedures. It is essential ...to determine whether these guidelines have led to disease progression. This study aims to give an insight into the number of surgical oncology procedures performed during the pandemic and provide information on short-term clinical outcomes.
A systematic literature search was performed on all COVID-19 articles including operated patients, published before March 21, 2022. Meta-analysis was performed to visualize the number of performed surgical oncology procedures during the pandemic compared to the pre-pandemic period. Random effects models were used for evaluating short-term clinical outcomes.
Twenty-four studies containing 6762 patients who underwent a surgical oncology procedure during the pandemic were included. The number of performed surgical procedures for an oncological pathology decreased (−26.4%) during the pandemic. The number of performed surgical procedures for breast cancer remained stable (+0.3%). Moreover, no difference was identified in the number of ≥T2 (OR 1.00, P = 0.989), ≥T3 (OR 0.95, P = 0.778), ≥N1 (OR 1.01, P = 0.964) and major postoperative complications (OR 1.55, P = 0.134) during the pandemic.
The number of performed surgical oncology procedures during the COVID-19 pandemic decreased. In addition, the number of performed surgical breast cancer procedures remained stable. Oncological staging and major postoperative complications showed no significant difference compared to pre-pandemic practice. During future pandemics, the performed surgical oncology practice during the first wave of the COVID-19 pandemic seems appropriate for short-term results.
•The number of performed surgical oncology procedures decreased during the pandemic.•The number of performed surgical breast cancer procedures remained stable during the pandemic.•Oncological staging showed no significant difference compared to pre-pandemic care.•No significant difference was seen in major postoperative complications compared to the pre-pandemic.
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