Comparison of laparoscopic versus open adrenalectomy: results from American College of Surgeons-National Surgery Quality Improvement Project

Background

Although the existing literature suggests that laparoscopic adrenalectomy may be associated with less postoperative morbidity than open adrenalectomy, a comparison of the two approaches has not been published using American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) data. The objective of our analysis was to compare the 30-d outcomes after laparoscopic versus open adrenalectomy using this data source.

Methods

The ACS-NSQIP Participant User Files for 2005–2010 were used for this retrospective analysis, which included all patients with (1) a primary Current Procedural Terminology code for open or laparoscopic adrenalectomy and (2) a postoperative International Classification of Diseases, Ninth Revision (ICD-9) code for adrenal gland pathology. Primary outcomes were 30-d postoperative mortality, overall complication rate, and length of postoperative hospitalization. The association between surgical approach and primary outcomes were determined after adjusting for a comprehensive array of patient- and procedure-related factors.

Results

A total of 3100 patients were included for analysis (644 undergoing open versus 2456 undergoing laparoscopic adrenalectomy). Patients undergoing a laparoscopic procedure had significantly lower postoperative morbidity and shorter length of stay than patients undergoing an open procedure after adjustment for patient- and procedure-related factors. Similar findings were demonstrated for all indications, including malignancy.

Conclusions

To our knowledge, the present study represents the largest comparison to date of laparoscopic versus open adrenalectomy. Our findings suggest that the laparoscopic approach is associated with sizeable reductions in postoperative morbidity and length of postoperative hospitalization.     

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.     

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.     

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.     

Increased complication rate in obese patients undergoing laparoscopic adrenalectomy

Objectives:

Laparoscopic adrenalectomy has become the standard of care for resection of adrenal masses, with extremely low morbidity and mortality. This study investigates the difference in outcomes in patients who underwent laparoscopic adrenalectomy, comparing obese with healthy weight patients.

Methods:

A retrospective chart review was performed on patients undergoing laparoscopic adrenalectomy between January 2000 and February 2010. Intraoperative and postoperative complications in the patients were compared. A patient with a body mass index >30kg/m² was considered obese.

Results:

Eighty patients underwent laparoscopic adrenalectomy between January 2000 and February 2010. Forty-nine patients (61%) were considered obese based on the body mass index criteria. Operative time, estimated blood loss, and length of stay did not differ significantly between the 2 cohort groups. There was no 30-day mortality in the population. There were 9 complications in the obese population and no complications in the healthy weight population (P<.011). Four obese patients had intraoperative complications, and 5 obese patients had postoperative morbidity.

Conclusions:

A significant increase occurred in intraoperative and postoperative complications for obese individuals undergoing laparoscopic adrenalectomy compared with healthy weight individuals. However, high body mass index should not preclude elective laparoscopic adrenalectomy.     

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.     

Blowhole colostomy for the urgent management of distal large bowel obstruction

Background

Complete obstruction of the distal colon or rectum often presents as a surgical emergency. This study evaluated the efficacy of blowhole colostomy versus transverse loop colostomy for the emergent management of distal large intestinal obstruction.

Methods

Retrospective chart review of all colostomy procedures (CPT 44320) performed for complete distal large bowel obstruction during the past 6 y in a university hospital practice was undertaken. Blowhole was compared with loop colostomy with a primary endpoint of successful colonic decompression.

Results

One hundred forty-one patients underwent colostomy creation during the study period. Of these, 61 were completed for acute obstruction of the distal colon or rectum (19 blowhole versus 42 loop colostomy). No differences between study groups were seen in age, gender, body mass index, malnutrition, American Society of Anesthesiology class, time to liquid or regular diet, 30-d or inhospital mortality, or rates of complications. Patients undergoing blowhole colostomy had significantly higher cecal diameters at diagnosis (9.14 versus 7.31 cm, P = 0.0035). Operative time was shorter in blowhole procedures (43 versus 51 min, P = 0.017). Postoperative length of stay was significantly shorter for blowhole colostomy (6 versus 8 d, P = 0.014). The primary endpoint of successful colonic decompression was met in all colostomy patients.

Conclusions

Diverting blowhole colostomy is a safe, quick, and effective procedure for the urgent management of distal colonic obstruction associated with obstipation and massive distention.     

Obesity,Prostate-Specific Antigen Nadir,and Biochemical Recurrence After Radical Prostatectomy: Biology or Technique? Results from the SEARCH Database

Background

Obesity is associated with an increased risk of biochemical recurrence (BCR) after radical prostatectomy (RP). It is unclear whether this is due to technical challenges related to operating on obese men or other biologic factors.

Objective

To examine whether obesity predicts higher prostate-specific antigen (PSA) nadir (as a measure of residual PSA-producing tissue) after RP and if this accounts for the greater BCR risk in obese men.

Design, setting, and participants

A retrospective analysis of 1038 RP patients from 2001 to 2010 in the multicenter US Veterans Administration–based Shared Equal Access Regional Cancer Hospital database with median follow-up of 41 mo.

Intervention

All patients underwent RP.

Outcome measurements and statistical analysis

We evaluated the relationship between body mass index (BMI) and ultrasensitive PSA nadir within 6 mo after RP. Adjusted proportional hazards models were used to examine the association between BMI and BCR with and without PSA nadir.

Results and limitations

Mean BMI was 28.5 kg/m². Higher BMI was associated with higher PSA nadir on both univariable (p = 0.001) and multivariable analyses (p < 0.001). Increased BMI was associated with increased BCR risk (hazard ratio [HR]: 1.06; p = 0.007). Adjusting for PSA nadir slightly attenuated, but did not eliminate, this association (HR: 1.04, p = 0.043). When stratified by PSA nadir, obesity only significantly predicted BCR in men with an undetectable nadir (p = 0.006). Unfortunately, other clinically relevant end points such as metastasis or mortality were not available.

Conclusions

Obese men are more likely to have a higher PSA nadir, suggesting that either more advanced disease or technical issues confound an ideal operation. However, even after adjusting for the increased PSA nadir, obesity remained predictive of BCR, suggesting that tumors in obese men are growing faster. This provides further support for the idea that obesity is biologically associated with prostate cancer progression.     

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.     

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.     

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.     

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.     

T-cell activation Rho GTPase–activating protein expression varies with inflammation location and severity in Crohn's disease

Background

The T-cell activation Rho GTPase–activating protein (TAGAP) gene has a regulatory role in T cell activation. We have previously suggested a correlation between the TAGAP-associated single nucleotide polymorphism rs212388 and protection from anal sepsis in Crohn's disease (CD) patients. The present study sought to evaluate TAGAP's expression in colonic tissue of CD patients with varying disease severity and location.

Materials and methods

Five transverse, 17 left, and five sigmoid colectomy specimens from 27 CD patients with varying disease severity (16 male, mean age at diagnosis 26.4 ± 2.2 y) were evaluated for TAGAP messenger RNA expression. Fisher exact, Mann–Whitney, and Welch two-sample t-tests were used for statistical evaluation. Immunohistochemistry confirmed results.

Results

Patients with tissue demonstrating lower TAGAP messenger RNA expression (less than the overall mean) were younger at diagnosis (mean age 21.1 ± 6.3 versus 32.5 ± 13 y, P = 0.009). Increased TAGAP expression was seen in moderate or severely diseased tissue versus tissue with no or mild disease (RQ = 1.3 ± 0.34 versus 0.53 ± 0.09, P = 0.050). This was the most dramatic in the sigmoid colon (P = 0.041). TAGAP expression was increased in more distal tissue with a significant difference seen when comparing transverse versus sigmoid colon with moderate or severe disease (0.51 ± 0.14 versus 1.9 ± 0.37, P = 0.049).

Conclusions

Colonic expression of TAGAP in CD patients varied according to disease severity and location, being the most elevated in patients with severe disease in the sigmoid colon. Whether changes in TAGAP expression are a result of disease response or inherent to the disease pathophysiology itself remains to be determined. This gene warrants further investigation for its role in CD.     

Novamin infusion: a new method to cure postoperative shivering with hypothermia

Background

Postoperative shivering is a frequent complication of surgery in developing countries and there is no satisfying method to treat it, let alone to cure it. We studied whether intravenous amino acid (AA) infusion can cure postoperative shivering in the postanesthesia care unit.

Methods

Sixty postanesthesia care unit patients with shivering grade 2 or higher and tympanic temperature <36°C received randomly either infusion of Novamin 18 AAs (2 mL/kg/h), pethidine (0.5 mg/kg), or tramadol (1 mg/kg). Tympanic temperature, shivering grade, and thermal comfort were assessed every 5 min for 60 min. Blood glucose and lactic acid concentrations were measured before and after treatment. Postoperative nausea and vomiting were also recorded.

Results

Shivering stopped within 5 min in the pethidine and tramadol groups versus 90% stopped within 15 min in AA group. There were five cases of reshivering in the tramadol group versus none in the AA or pethidine groups. Tympanic temperature increased slowly in all patients but increased significantly faster in the AA group. Thermal comfort improved significantly faster in the AA group versus the other two groups, thermal comfort was significantly higher in the tramadol versus the pethidine group ≥35 min. Blood glucose concentration in AA group increased to 135.18 ± 9.18 mg/dL. There were some cases of nausea and vomiting in pethidine and tramadol groups but none in the AA group.

Conclusion

Novamin infusion can stop postoperative shivering and alleviates hypothermia and improves thermal comfort more effectively than tramadol and pethidine with less nausea and vomiting and causes a clinically acceptable blood glucose increase with no reshivering episodes.     

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.     

Resident participation and postoperative outcomes in adrenal surgery

Background

The changing paradigm of surgical residency training has raised concerns about the effects on the quality of training. The purpose of this study is to identify if resident participation in laparoscopic adrenalectomy (LA) and open adrenalectomy (OA) cases is associated with deleterious outcomes.

Materials and methods

This is a retrospective study using the American College of Surgeons National Surgical Quality Improvement Program database. Data from patients undergoing LA and OA from 2005 to 2010 were queried. Preoperative variables as well as intra- and post-operative outcomes for each procedure were evaluated. Multivariate logistic regression was used to analyze if resident participation was associated with significant differences in outcomes, compared with no resident participation. Subset analysis was done to determine possible differences in outcomes based on the level of resident participating, divided into junior (Post Graduate Year [PGY]1–3), senior (PGY4–5), or fellow (≥PGY6) levels.

Results

A total of 3219 adrenalectomies were performed. Of these, 735 (22.8%) were OAs and 2484 (77.2%) were LAs. Residents were involved in 2582 (80.2%) surgeries, which comprised 1985 (76.9%) LAs and 597 (23.1%) OAs. Senior residents or fellows performed majority of the cases (85.2%). Mean operative time was significantly higher with resident participation in LA (P < 0.0001) and OA group (P < 0.0001). On multivariate analysis, resident participation was not associated with significant differences in the operative outcomes of 30-d mortality or postoperative complications after laparoscopic or OA.

Conclusions

Although resident participation does increase operative time in LA and OA, this does not appear to be clinically significant and does not result in adverse patient outcomes.     

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.