Recurrent and persistence primary hyperparathyroidism occurs more frequently in patients with double adenomas

Introduction

The incidence of recurrent primary hyperparathyroidism (PHPT) had been reported to be between 1% and 10%. The purpose of this study was to examine if patients with multigland disease have a different recurrence rate.

Methodology

A retrospective analysis of a prospectively collected database was performed on patients with PHPT who underwent parathyroidectomy at one institution between 2001 and 2013. Patients who underwent initial parathyroidectomy with at least 6 mo of follow-up were included and were divided into three groups according to operative notes: single adenoma (SA), double adenoma (DA), and hyperplasia (HP). An elevated postoperative serum calcium level within 6 mo of surgery was defined as a persistent disease, whereas an elevated calcium after 6 mo was defined as a recurrence.

Results

In total, 1402 patients met inclusion criteria, and the success rate of parathyroidectomy was 98.4%. The mean age was 60 ± 14 y and 78.5% were female. Among them, 1097 patients (78%) had SA, 124 patients (9%) had DA, and 181 patients had HP (13%). The rate of persistent PHPT was higher among patients with DA (4%) versus SA (1.3%) and HP (2.2%) (P = 0.0049). Moreover, the recurrence rate was higher among patients with DA (7.3%) versus SA (1.7%) and HP (4.4%) (P = 0.0005) with identical median follow-up time. The median of the follow-up was 11 mo for patients with SA, 12.5 for patients with DA, and 12 for patients with HP (P = 0.1603).

Conclusions

Recurrent and persistent PHPT occur more frequently in patients with DA. These data suggest that DA in some cases could represent asymmetric or asynchronous hyperplasia. Therefore, patients with DA may warrant more rigorous intraoperative scrutiny and more vigilant monitoring after parathyroidectomy.     

Elevated parathyroid hormone after parathyroidectomy delays symptom improvement

Background

Curative parathyroidectomy for primary hyperparathyroidism (PHPT) resolves various nonspecific symptoms related to the disease. Between 8% and 40% of patients with normocalcemia after parathyroidectomy have persistently elevated parathyroid hormone (ePTH) levels at follow-up. We investigated whether ePTH in the early postoperative period was associated with the timing of symptom improvement.

Materials and methods

This prospective study included adult patients with PHPT who underwent curative parathyroidectomy from November 2011 to September 2012. Biochemical testing at 2 wk postoperatively identified ePTH (defined as PTH > 72 pg/mL) versus normal PTH (nPTH). A questionnaire administered pre- and post-operatively at 6 wk and 6 mo asked patients to rate the frequency of 18 symptoms of PHPT on a five-point Likert scale. Student t-tests were used to compare pre- with postoperative changes in scores for individual symptoms.

Results

Of 194 patients who underwent parathyroidectomy, 129 (66%) participated in the study. Preoperatively, all patients were symptomatic, with a mean of 13 ± 4 symptoms. Two weeks postoperatively, 20 patients (16%) had ePTH. The percentage of patients with postoperative improvement for individual symptoms was compared between groups. At the early time point (6 wk), the ePTH group showed less improvement in 14 of 18 symptoms. This difference reached statistical significance for four symptoms: anxiety, constipation, thirst, and polyuria. By the 6-mo time point, these differences had resolved, and symptom improvement was similar between groups.

Conclusions

ePTH after curative parathyroidectomy may result in a delay in symptom improvement 6 wk postoperatively; however, this difference resolves in 6 mo.     

Comparison of surgical outcomes between papillary thyroid cancer patients treated with the Harmonic ACE scalpel and LigaSure Precise instrument during conventional thyroidectomy: a single-blind prospective randomized controlled trial

Background

The aim of this study was to evaluate the safety and efficacy of thyroidectomy using the Harmonic ACE scalpel (HS) or the LigaSure Precise (LS) instrument in conventional thyroidectomy.

Materials and methods

A prospective, randomized controlled trial was performed. Between August 2011 and June 2012, 832 patients who required thyroidectomy for papillary thyroid cancer were randomized into groups treated with either the HS or the LS instrument. Operative time and surgical morbidities were analyzed.

Results

A total of 320 patients (HS group, N = 164; LS instrument group, N = 156) were randomized for analysis according to the intention-to-treat principle. There were no statistically significant differences in the operative times (HS group versus LS instrument group: 71.93 ± 18.26 versus 75.15 ± 20.13; P = 0.423), postoperative transient hypoparathyroidism (13.4% versus 14.1%; P = 0.858), and permanent recurrent laryngeal nerve injuries between the two groups.

Conclusions

In this study, both hemostatic devices were safe and effective in terms of postoperative results and complications without any differences.     

Clinical outcomes following bowel resection versus reduction of intussusception

Background

Intussusception is most commonly managed with air-contrast reduction. However, when this fails, emergent operation with resection or manual reduction is indicated. It is not known if there are advantages to resection compared with manual reduction.

Methods

A retrospective review of all patients receiving operative care for intussusception from February 2000 to December 2011. Patients undergoing intestinal resection were compared with those treated with manual reduction alone.

Results

Of 111 patients, 49 underwent resection and 62 underwent manual reduction. Mean (±SD) time to oral intake favored manual reduction (2.1 ± 1.2 versus 2.6 ± 1.2 d, respectively, P = 0.05). Manual reduction was associated with a greater need for repeat imaging (47% versus 18%, P = 0.002) and the only recurrences were with manual reduction (8% versus 0%, P = 0.1). Mean duration of stay was no different (P = 0.36), nor was the need for reoperation (P = 0.9).

Conclusions

Patients undergoing manual reduction have an increased number of radiographic imaging procedures. The surgeon should have a low threshold for resection for intussusceptions requiring operative management.     

Initial assessment on the impact of crystalloids versus colloids during damage control resuscitation

Background

High ratios of fresh frozen plasma:packed red blood cells in damage control resuscitation (DCR) are associated with increased survival. The impact of volume and type of resuscitative fluid used during high ratio transfusion has not been analyzed. We hypothesize a difference in outcomes based on the type and quantity of resuscitative fluid used in patients that received high ratio DCR.

Methods

A matched case control study of patients who received transfusions of ≥ four units of PRBC during damage control surgery over 4 1/2 y, was conducted at a Level I Trauma Center. All patients received a high ratio DCR, >1:2 of fresh frozen plasma:packed red blood cells. Demographics and outcomes of the type and quantity of resuscitative fluids used in combination with high ratio DCR were compared and analyzed. A Kaplan-Meier survival analysis was computed among four groups: colloid (median quantity = 1.0 L), <3 L crystalloid, 3–6 L crystalloid, and >6 L crystalloid.

Results

There were 56 patients included in the analysis (28 in the crystalloid group and 28 in the colloid group). Demographics were statistically similar. Intraoperative median units of PRBC: crystalloid versus colloid groups was 13 (IQR 8-21) versus 16 (IQR 12–19), P = 0.135; median units of FFP: 12 (IQR 7–18) versus 12 (IQR 10–18), P = 0.440. OR for 10-d mortality in the crystalloid group was 8.41 [95% CI 1.65–42.76 (P = 0.01)]. Kaplan-Meier survival analysis demonstrated lowest mortality in the colloid group and higher mortality with increasing amounts of crystalloid (P = 0.029).

Conclusions

During high ratio DCR, resuscitation with higher volumes of crystalloids was associated with an overall decreased survival, whereas low volumes of colloid use were associated with increased survival. In order to improve outcomes without diluting the survival benefit of hemostatic resuscitation, guidelines should focus on effective low volume resuscitation when high ratio DCR is used. A multi-institutional analysis is needed in order to validate these results.     

Laparoscopic pyloromyotomy: comparing the arthrotomy knife to the Bovie blade

Background

Laparoscopic pyloromyotomy was performed at our institution using an arthrotomy knife until it became unavailable in 2010. Thus, we adapted the use of the blunt Bovie tip, which can be used with or without electrocautery to perform the myotomy. This study compared the outcomes between using the arthrotomy knife versus the Bovie blade in laparoscopic pyloromyotomies.

Materials and methods

Retrospective review was performed on all laparoscopic pyloromyotomy patients from October 2007 to September 2012. Arthrotomy knife pyloromyotomy patients were compared with those performed with the Bovie blade. Patient demographics, diagnostic measurements, electrolyte levels, length of stay, operative time, and complications were compared.

Results

A total of 381 patients were included, with 191 in the arthrotomy group and 190 in the Bovie blade group. No significant differences existed between groups in age, weight, gender, pyloric dimensions, electrolyte levels, or length of stay. Mean operative times were 15.8 ± 5.6 min with knife and 16.4 ± 5.3 min for Bovie blade (P = 0.24). In the arthrotomy knife group, there was one incomplete pyloromyotomy and one omental herniation. There was one wound infection in each group. Readmission rate was greater in the arthrotomy knife group (5.7%) versus the Bovie blade group (3.1%).

Conclusions

The Bovie blade appears to offer no objective disadvantages compared with the arthrotomy knife when performing laparoscopic pyloromyotomy.     

Expanding the indications for laparoscopic retroperitoneal adrenalectomy: experience with 81 resections

Background

Laparoscopic retroperitoneal (RP) adrenalectomy has gained popularity as the preferred approach over transabdominal (TA) method; however, surgeons have been reluctant to offer this operation to obese patients because of the concerns over inadequate working space and overall perceived higher rate of complications. The aim of the present study was to evaluate the feasibility and safety of RP adrenalectomy compared with TA adrenalectomy, specifically in morbidly obese patients.

Methods

All laparoscopic adrenalectomies performed at our institution between 2004 and 2012 were reviewed retrospectively. Presenting features, operative characteristics, and postoperative outcomes were evaluated. Complications were graded using Clavien system. Continuous variables were compared using Student t-test. Categorical variables were compared using χ²-test. Prediction models were constructed using linear or logistic regression as appropriate.

Results

Eighty-one RP and 130 TA procedures were performed, 26 (12.3%) and 60 (28.4%), respectively in obese patients (BMI > 30). Among the obese patients, operative time and estimated blood loss were less for RP (90 versus 130 min; P < 0.001 and 0 versus 50 mL; P < 0.001). Differences in the length of stay, overall mortality, incidence and severity of postoperative complications, and rates of readmission were not statistically significant between RP and TA procedures for all comers and in the obese patients. Controlling the operative characteristics and patient-specific factors, neither operative approach nor obesity was found to independently predict the postoperative complications.

Conclusions

Laparoscopic RP adrenalectomy is a safe and feasible technique for obese patients. In the obese patients and for all comers, it offers shorter operative time, decreased estimated blood loss, with comparable length of stay and morbidity and mortality rates. We therefore recommend that this technique should be considered for patients undergoing adrenal resection.     

The role of clinical care pathways: an experience with distal pancreatectomy

Background

Previous studies have indicated that clinical pathways may shorten hospital length of stay (HLOS) among patients undergoing distal pancreatectomy (DP). Here, we evaluate an institutional standardized care pathway (SCP) for patients undergoing DP.

Materials and methods

A retrospective review of patients undergoing DP from November 2006 to November 2012 was completed. Patients treated before and after implementation of the SCP were compared. Multivariable linear regression was then performed to identify independent predictors of HLOS.

Results

There were no differences in patient characteristics between SCP (n = 50) and pre-SCP patients (n = 100). Laparoscopic technique (62% versus 13%, P < 0.001), splenectomy (52% versus 38%, P = 0.117), and concomitant major organ resection (24% versus 13%, P = 0.106) were more common among SCP patients. Overall, important complication rates were similar (24% versus 26%, P = 0.842). SCP patients resumed a normal diet earlier (4 versus 5 d, P = 0.025) and had shorter HLOS (6 versus 7 d, P = 0.026). There was no increase in 30-d resurgery or readmission. In univariate comparison, SCP, cancer diagnoses, intraductal papillary mucinous neoplasm diagnoses, neoadjuvant therapy, operative technique, major organ resection, and feeding tube placement were associated with HLOS; however, after multivariable adjustment, only laparoscopic technique (−33%, P = 0.001), concomitant major organ resection (+38%, P < 0.001), and feeding tube placement (+68%, P < 0.001) were independent predictors of HLOS.

Conclusions

Implementation of a clinical pathway did not improve HLOS at our institution. The increasing use of laparoscopy likely accounts for shorter HLOS in the SCP cohort. In the future, it will be important to identify clinical scenarios most likely to benefit from implementation of a clinical pathway.     

Identifying predictors of a difficult thyroidectomy

Background

A Thyroidectomy Difficulty Scale (TDS) was previously developed that identified more difficult operations, which correlated with longer operative times and higher complication rates. The purpose of this study was to identify preoperative variables predictive of a more difficult thyroidectomy using the TDS.

Methods

A four item, 20-point TDS, was used to score the difficulty of thyroid operations. Patient and disease factors were recorded for each patient. Difficult thyroidectomy and non-difficult thyroidectomy (NDT) patients were compared. A final multivariate logistic regression model was constructed with significant (P < 0.05) variables from a univariate analysis.

Results

A total of 189 patients were scored using TDS. Of them, 69 (36.5%) suffered from hyperthyroidism, 42 (22.2%) from Hashimotos, 34 (18.0%) from thyroid cancer, and 36 (19.0%) from multinodular goiter. Among hyperthyroid patients, the DT group had a greater number preoperatively treated with Lugols potassium iodide (81.6% DT versus 58.1% NDT, P = 0.032), presence of ophthalmopathy (31.6% DT versus 9.7% NDT, P = 0.028), and presence of (>4 IU/mL) antithyroglobulin antibodies (34.2% DT versus 12.9% NDT, P = 0.05). Using multivariate analysis, hyperthyroidism (odds ratio [OR], 4.35, 95% confidence interval [CI], 1.23–15.36, P = 0.02), presence of antithyroglobulin antibody (OR, 3.51, 95% CI, 1.28–9.66, P = 0.015), and high (>150 ng/mL) thyroglobulin (OR, 2.61, 95% CI, 1.06–6.42, P = 0.037) were independently associated with DT.

Conclusions

Using TDS, we demonstrated that a diagnosis of hyperthyroidism, preoperative elevation of serum thyroglobulin, and antithyroglobulin antibodies are associated with DT. This tool can assist surgeons in counseling patients regarding personalized operative risk and improve OR scheduling.     

Significance of rebounding parathyroid hormone levels during parathyroidectomy

Background

Using minimally invasive parathyroidectomy (MIP), most surgeons require a 50% decline in intraoperative parathyroid hormone (IoPTH) to determine cure, but the significance of IoPTH kinetics occurring after this drop remains unknown. The aim of this study was to determine the impact of IoPTH levels that first meet criteria for cure, but then increase again, or rebound, between 10 and 15 min postexcision.

Methods

We conducted a retrospective review of patients undergoing initial parathyroidectomy for primary hyperparathyroidism at our institution from 2001 to 2011. Rebound IoPTH was defined as an increase in parathyroid hormone ≥5 pg/mL after achieving the 50% drop required for cure. Comparisons were evaluated with the Student t-test, chi-square test, or Fisher exact test where appropriate.

Results

Of the 1386 patients who met selection criteria, 86 (6.2%) patients exhibited rebound IoPTH. The mean magnitude of rebound was 13.8 ± 3.6 pg/mL. Compared with those not displaying rebound, more patients with rebound IoPTH were treated with open parathyroidectomy rather than MIP (10.8% versus 4.5%, P < 0.01). The recurrence rate among those with rebound IoPTH was more than double that of the patients without rebound IoPTH (5.8% versus 2.2%, P = 0.03). Magnitude of rebound, however, did not correlate with recurrence. The rate of persistent disease was not different between those with and without rebound IoPTH. Rebound was a much better indicator of recurrence than patients whose final IoPTH levels were not within the normal range.

Conclusions

Rebound IoPTH is more common in patients who develop recurrent hyperparathyroidism. Therefore, surgeons should closely monitor patients with rebound IoPTH for disease recurrence.     

Radioguided parathyroidectomy effective in pediatric patients

Background

Radioguided parathyroidectomy (RGP) has been shown to be effective in adult patients with hyperparathyroidism (HPT), but the utility of RGP in pediatric patients has not been systematically examined. It is not known if adult criteria for radioactive counts can accurately detect hyperfunctioning parathyroid glands in pediatric patients. The purpose of our study was to determine the utility of RGP in children with primary HPT.

Materials and methods

A retrospective review of our prospectively maintained single-institution database for patients who underwent a RGP for primary HPT identified 1694 adult and 19 pediatric patients aged 19 y or younger. From the adult population, we selected a control group matched three to one for gland weight and gender and compared pre- and postoperative laboratory values, surgical findings, pathology, and radioguidance values between the control and the pediatric groups.

Results

Excised glands from pediatric patients were smaller than those in the total adult population (437 ± 60 mg versus 718 ± 31 mg, P = 0.0004). When controlled for gland weight, ex vivo counts as a percentage of background were lower in the pediatric group (51% ± 5% versus 91% ± 11%, P = 0.04). However, ex vivo radionuclide counts >20% of the background were found in 100% of pediatric patients and 95% of the adult-matched control group.

Conclusions

All pediatric patients met the adult detection criteria for parathyroid tissue removal when a RGP was performed, and 100% cure was achieved. We conclude that RGP is a useful treatment option for pediatric patients with primary HPT.     

Diabetes remission and glycemic response to pre-bariatric surgery diet

Background

Before bariatric surgery, some patients with type 2 diabetes mellitus (T2DM) experience improvement in blood glucose control and reduced insulin requirements while on a preoperative low-calorie diet (LCD). We hypothesized that patients who exhibit a significant glycemic response to this diet are more likely to experience remission of their diabetes in the postoperative period.

Materials and methods

Insulin-dependent T2DM patients undergoing bariatric surgery between August 2006 and February 2011 were eligible for inclusion. Insulin requirements at day 0 and 10 of the LCD were compared. Patients with a ≥50% reduction in total insulin dosage to maintain appropriate blood glucose control were considered rapid responders to the preoperative LCD. All others were non–rapid responders. We analyzed T2DM remission rates up to 1 y postoperatively.

Results

A total of 51 patients met inclusion criteria and 29 were categorized as rapid responders (57%). The remaining 22 were considered non–rapid responders (43%). The two groups did not differ demographically. Rapid responders had greater T2DM remission rates at 6 (44% versus 13.6%; P = 0.02) and 12 mo (72.7% versus 5.9%; P < 0.01). In patients undergoing laparoscopic gastric bypass, rapid responders showed greater excess weight loss at 3 mo (40.1% versus 28.2%; P < 0.01), 6 mo (55.2% versus 40.2%; P < 0.01), and 12 mo (67.7% versus 47.3%; P < 0.01).

Conclusions

Insulin-dependent T2DM bariatric surgery patients who display a rapid glycemic response to the preoperative LCD are more likely to experience early remission of T2DM postoperatively and greater weight loss.     

Impact of a blood conservation program on 30-day morbidity and mortality: a cohort study

Background

There are little published data on outcomes of blood conservation (BC) patients after noncardiac surgery. The objective of this study was to compare the surgical outcomes of patients enrolled in our BC program with that of the general population of surgical patients.

Methods

BC patients at our institution undergoing various surgical procedures were identified from the 2007–2009 National Surgical Quality Improvement Program database and compared with a cohort of conventional care (CC) patients matched by age, gender, and surgical procedure. Univariate and multiple logistic regression analyses were performed to evaluate 30-d postoperative outcomes.

Results

One hundred twenty BC patients were compared with 238 CC patients. The two groups were similar for all preoperative variables except smoking, which was lower in the BC group. On univariate analysis, BC patients had similar mean operating time (148 versus 155 min; P = 0.5), length of stay (5.9 versus 5.5 d; P = 0.7), and rate of return to the operating room (7.5% versus 5.5%; P = 0.4) compared with CC patients. BC and CC patients had similar 30-d morbidity (18% versus 14%; P = 0.3) and mortality rates (1.6% versus 1.3%; P = 1.0), respectively. On multivariable analysis, enrollment in the BC program had no impact on postoperative 30-d morbidity (odds ratio, 1.78; 95% confidence interval, 0.71–4.47) or 30-d mortality (unadjusted odds ratio, 1.33; 95% confidence interval, 0.22–8.05).

Conclusions

Short-term postoperative outcomes in BC patients are similar to the general population, and these patients should not be denied surgical treatment based on their unwillingness to receive blood products.     

Should clopidogrel be discontinued before laparoscopic cholecystectomy?

Background

The perioperative management of clopidogrel remains an area of controversy.

Methods

An institutional review board-approved retrospective review of patients undergoing a laparoscopic cholecystectomy while on clopidogrel from 2008 to 2012 was performed. These patients were then matched with a nonclopidogrel cohort based on American Society of Anesthesiologists score and emergent or elective surgery. Intraoperative estimated blood loss, operative time, length of stay, and 30-day morbidity were compared.

Results

Thirty-six clopidogrel and 36 control patient records were analyzed. There were no significant differences in age, body mass index, sex, or incidence of coronary artery disease, diabetes, hyperlipidemia, and congestive heart failure. Estimated blood loss averaged 50 mL in the clopidogrel group and 47 mL in the control group (P = nonsignificant). There were no significant differences in operative time, 30-day morbidity, or length of stay between the 2 groups.

Conclusions

Laparoscopic cholecystectomy performed on patients maintained on clopidogrel during the perioperative period did not produce an increase in blood loss, operative time, 30-day morbidity, or length of stay.     

Topic usage of kaolin-impregnated gauze as a hemostatic in tonsillectomy

Background

The main postoperative complications after tonsillectomy are due to bleeding, and effective hemostasis may lead to a reduction of overall postoperative morbidity. This study was undertaken to determine the efficacy and safety of a novel kaolin-based hemostatic dressing in tonsillectomy.

Methods

A pilot, single-blind, open label study was performed in patients aged 3–20 y with history of chronic or hypertrophic tonsillitis. Cold dissection tonsillectomy (CDT) + ligature was performed by the same surgeon. Hemostasis on each tonsillar fossa was achieved using kaolin-impregnated gauze (KG; study group) or standard surgical cotton gauze (CG; control). Time to complete hemostasis, operative time, intraoperative blood loss, pain score, analgesic use, and return to normal diet and activity were recorded for all children.

Results

A total of 230 patients with a mean age of 8.0 y (138 in the study group and 92 in the control group) were included in the study. Both operative time and intraoperative blood loss were significantly reduced in the KG group (P < 0.0001) versus the CG group. At 5 min, 84.8% patients using the KG successfully achieved complete hemostasis versus 34.8% in the CG group where standard gauze controlled bleeding only partially. Results show significantly less pain for the KG group at 6- and 12-h postoperative when compared with the CG group (P < 0.0001). Also, the KG group required less analgesic medications, returned to normal diet and normal activities faster than the CG group (P < 0.01).

Conclusions

Preliminary findings show that the KG is effective and safe in managing surgical bleeding after tonsillectomy. In addition to rapid bleeding control, the dressing causes minimal inflammation and pain and allows patients to quickly return to normal activities. This novel dressing is a promising tool for ear, nose and throat surgical hemostasis.     

Feasibility and safety of single-incision laparoscopic splenectomy: a systematic review

Objective

The aim of this review was to evaluate the feasibility, safety, and potential benefits of single-incision laparoscopic splenectomy (SILS-Sp).

Methods

We conducted a systemic review of literature between 2009 and 2012 to retrieve all relevant articles.

Results

A total of 29 studies with 105 patients undergoing SILS-Sp were reviewed. Fifteen studies used a commercially available single-port device. The range of body mass index was 14.7–41.4 kg/m². Six studies described combined operations including cholecystectomy (n = 8), mesh-pexy (n = 1), and pericardial devascularizaion (n = 1). The ranges of operative times and estimated blood losses were 28–420 min and 0–350 mL, respectively. Of 105 patients, three patients (2.9%) required additional ports, two patients (1.9%) were converted to open, and three patients (2.9%) to conventional multiport laparoscopic splenectomy (overall conversion rate, 4.8%). Postoperative bleeding occurred in two patients (1.9%) who both required reoperation. Overall mortality was 0% (0/105). The length of postoperative stay varied across reports (1–11 d). Among four comparative studies, one showed greater estimated blood loss and lower numeric pain rating scale score in the SILS-Sp group than in the multiport laparoscopic splenectomy group (206.25 ± 142.45 versus 111.11 ± 99.58 mL) and (3.81 ± 0.91 versus 4.56 ± 1.29), respectively. Another comparative study showed that SILS-Sp was associated with a shorter operative time (92.5 versus 172 min; P = 0.003), lower conversion rate, equivalent length of hospital stay, reduced mortality, similar morbidity, and comparable postoperative narcotic requirements.

Conclusions

In early series of highly selected patients, SILS-Sp appears to be feasible and safe when performed by experienced laparoscopic surgeons. However, as an emerging operation, publication bias is a factor that should be considered before we can draw an objective conclusion.     

The incidence of thyroid cancer by f ine needle aspiration varies by age and gender

Background

Fine needle aspiration (FNA) is the standard to evaluate thyroid nodules for malignancy. The aim of this study was to determine the influence of patient age and gender on the rate of thyroid nodule malignancy by FNA.

Methods

A database of 3981 consecutive patients who underwent thyroid FNA between 2002 and 2009 was reviewed. The percentages of benign, indeterminate, and malignant biopsies based on patient age and gender were determined. Statistical analysis was performed using SPSS (SPSS Inc, Chicago, IL).

Results

Our patient population included 2766 women (mean age ± SD, 52 ± 15.2) and 964 men (mean age ± SD, 59 ± 13.8). Of the 3722 (93.5%) patients with diagnostic FNAs, 196 (5.3%) had malignant FNA cytology. Malignant FNAs were twice as frequent in patients age ≤45 versus those >45 (8.1% versus 4.0%, P < 0.001). Overall, men had more indeterminate (10.2% versus 6.3%, P < 0.001) and malignant (6.7% versus 4.8%, P = 0.034) FNAs than women. Malignant FNAs in men were greatest in patients over age 45 (6.0% versus 3.2%, P = 0.001). The incidence of malignant FNAs for women peaked in their age 30s (10.4%), whereas the incidence of malignant FNAs for men peaked 10 y later in their age 40s (12.1%). Both men and women had the lowest incidence of malignant FNAs in their age 70s (2.3% and 1.9%, respectively).

Conclusions

The typical 5% risk of thyroid nodule malignancy on FNA varies depending on a patient’s age and gender. A patient’s age and gender should, therefore, be considered when counseling someone of his or her risk of thyroid cancer by FNA.     

Laterality of central venous sampling: lack of effect on the accuracy of intraoperative parathyroid hormone monitoring

Background

The purpose of this study was to determine if laterality of internal jugular vein (IJV) sampling affects the accuracy of intraoperative parathyroid hormone (PTH) monitoring during parathyroidectomy for primary hyperparathyroidism.

Methods

In this study, 109 patients underwent parathyroidectomy (82 with unilateral disease, 27 with multigland disease). PTH samples were taken from both the left and the right IJV at these time points: preincision (baseline) and then at 5, 10, and, in selected patients, 20 minutes after excision. The Miami criterion was used to determine operative success.

Results

In all 109 patients combined, the mean decreases in intraoperative PTH levels were 73.8 ± 22.2% for the left IJV and 71.9 ± 23.0% for the right IJV (P = .22). The Miami criterion was met in 105 patients: in 100 (95%) left IJV samples and 99 (94%) right IJV samples (P = 1.00).

Conclusions

No difference was found in the accuracy of intraoperative PTH monitoring between patients' left and right IJV samples. Central venous laterality did not affect fulfillment of the Miami criterion.     

Suture versus preperitoneal polypropylene mesh for elective umbilical hernia repairs

Background

Repair of primary ventral hernias (PVH) such as umbilical hernias is a common surgical procedure. There is a paucity of risk-adjusted data comparing suture versus mesh repair of these hernias. We compared preperitoneal polypropylene (PP) repair versus suture repair for elective umbilical hernia repair.

Methods

A retrospective review of all elective open PVH repairs at a single institution from 2000–2010 was performed. Only patients with suture or PP repair of umbilical hernias were included. Univariate analysis was conducted and propensity for treatment-adjusted multivariate logistic regression.

Results

There were 442 elective open PVH repairs performed; 392 met our inclusion criteria. Of these patients, 126 (32.1%) had a PP repair and 266 (67.9%) underwent suture repair. Median (range) follow-up was 60 mo (1–143). Patients who underwent PP repair had more surgical site infections (SSIs; 19.8% versus 7.9%, P < 0.01) and seromas (14.3% versus 4.1%, P < 0.01). There was no difference in recurrence (5.6% versus 7.5%, P = 0.53). On propensity score–adjusted multivariate analysis, we found that body mass index (odds ratio [OR], 1.10) and smoking status (OR, 2.3) were associated with recurrence. Mesh (OR, 2.34) and American Society of Anesthesiologists (OR, 1.95) were associated with SSI. Only mesh (OR, 3.41) was associated with seroma formation.

Conclusions

Although there was a trend toward more recurrence with suture repair in our study, this was not statistically significant. Mesh repair was associated with more SSI and seromas. Further prospective randomized controlled trial is needed to clarify the role of suture and mesh repair in PVH.