Need for an Individualized and Aggressive Management of Multinodular Goiters of Endemic Zones by Specially Trained Surgeons: Experience in Western Nepal

Background The goals of the present study were to explore the presentation of multinodular goiter (MNG) and solitary thyroid nodules (STN) in the sub-Himalayan belt, including the risk of malignancy, and to evaluate whether specialized surgeon training in endocrine surgery has an effect on reducing complications. Methods This retrospective study (1998–2003) analyzed 624 patients with thyroid disorders seen in the thyroid clinic of a tertiary care hospital in western Nepal. The findings included 67.7% (n = 423: euthyroid, 297, toxic, 126) multinodular goiters (MNG) and 18.5% (n = 116) STN. Rest of patients of other thyroid disorders were excluded from the study. Ultrasonography and fine-needle aspiration cytology (FNAC) were the available diagnostic adjuncts. To evaluate the role of surgeon training, outcomes were compared between patients cared for by surgeons specially trained in endocrine surgery and those who were not. Prognostic markers indicated aggressiveness of cancers. Results Of the 539 MNG and STN patients in this series, 236 underwent operation. Of these, 25.7% (139/539) were toxic, and 11.31% had associated carcinoma. Aggressive cancers, like poorly differentiated (4.9%) and anaplastic types (18%), were more common than in series of patients from iodine-sufficient regions. Patients 40–55 years of age were more likely to have toxicity, and those > 60 years of age were more likely to have aggressive cancers. Postoperative complication rates were lower in the group treated by surgeons who had special training in endocrine surgery. Conclusions There is a higher incidence of toxicity and malignancy in MNG in an endemic goiter zone. The limited diagnostic and therapeutic facilities in the region under study warrant a high degree of clinical suspicion and judgment, sound knowledge of thyroid physiology, thorough interpretation of hormone test results, and meticulous surgical techniques. The treatment must be individualized with consideration of humanitarian and socioeconomic factors, without compromising the quality of care and its long-term consequences. Aggressive management of malignancy and toxicity with total thyroidectomy is needed as primary therapy in many instances. However, subtotal excision is more useful in carefully selected cases with a small remnant. Specialized training in thyroid surgery appears to be valuable in reducing complications.     

Renal Function and Urine Drainage after Conservative or Operative Treatment of Primary (Obstructive) Megaureter in Infants and Children

We examined renal function and urinary drainage of children with primary megaureter (PMU) in dependence on conservative or operative treatment. Material and methods: The retrospective analysis covering the years 1994 to 2000 comprised children at an age of 0–7 years with 35 PMU. Sonography, dynamic MAG3 renography as well as endogenic creatinine clearance (GFR) were used to assess drainage and the renal function. Temporary urinary diversion was established in fourteen patients of both groups. In 14 children with 16 PMU a ureteroneocystostomy (UNC) was performed. The average observation period was 30 months (11–108). ResultsThe children of the UNC group differed from the non-neoimplanted group in the age at diagnosis (10.5 vs. < 1 months), higher degrees of hydronephrosis on average, a more distinct dilatation of the ureter as well as renographically significant obstruction. Children of the non-UNC group, including four children with a type B drainage curve (O’Reilly), had an unimpaired differential renal function or improved during the observation period (initially 51% vs. 50.5% at the end). In neoimplantation group the differential function improved from 32.5% to 38.5% (p<0.05) and obstruction resolved with one exception. Conclusion: Given a higher-grade PMU with a reduced function of the kidneys and a significant impaired drainage pattern and/or symptoms, neoimplantation without temporary diversion has proved to be an efficient renoprotective method. Furthermore, data clearly justify a conservative approach without urinary diversion in infants with large asymptomatic PMU.     

Adrenaloma: A Call for More Aggressive Management

p = 0.001). Of the 57 resected tumors, 23 were cortical adenomas, 7 myelolipomas, 8 adrenal cysts, 11 nodular hyperplasias, 2 primary adenocarcinomas, 2 metastatic carcinomas, and 4 pheochromocytomas. The mean diameter was 5.89 cm and the mean weight 114.07 g. The mean diameter of the resected primary adenocarcinomas was 3.0 cm and 4.5 cm, respectively. The operative mortality was zero and the perioperative morbidity minimal. The mean operating time was 137 minutes (range 60–240 minutes). The posterior approach had the shortest operating time and the laparoscopic approach the shortest hospital stay and the least postoperative need for narcotics. During the 6.2 years mean follow-up period, five patients with preoperative hypertension remained normotensive, and both patients with the resected primary adenocarcinomas are alive without recurrence. We suggest a more liberal surgical approach to patients with adrenalomas because: (1) even small tumors can be malignant or potentially lethal (e.g., pheochromocytomas); (2) some tumors that appear to be nonfunctioning may in reality be functioning; and (3) other nonfunctioning tumors may, with time (and without prior notice), function. The low risk of adrenalectomy especially via the laparoscopic approach can provide an early definitive diagnosis and treatment, avoiding the cost of repeated CT scans and other studies as suggested by the currently prevailing conservative management of these tumors.     

成人先天性巨输尿管症37例诊疗分析

目的：探讨成人先天性巨输尿管症（CM）的诊治方法.方法：回顾性分析37例成人CM的临床资料：男18例,女19例.左侧18例,右侧10例,双侧9例.超声检查、静脉尿路造影（IVU）检查提示输尿管全段扩张伴肾盂积水22例,输尿管下段扩张9例.IVU不显影或显影不清13例;同位素肾动态显像检查提示患肾不同程度损害.手术治疗34例,其中行肾输尿管切除术2例,输尿管膀胱再植术32例.间断性双J管置入1例,保守观察2例.结果：随访32例,随访时间4个月～20年.患侧肾输尿管积水减轻29例,无明显变化3例.结论：成人CM的诊断主要依据影像学检查.治疗原则为解除梗阻、尽量保留息肾功能,应根据输尿管扩张程度选择输尿管折叠或裁剪加输尿管膀胱再植术,吻合方法推荐Lich-Gregoir术式;肾功能良好、无明显症状者可保守治疗.     

ASO Author Reflections: Changes in Primary Treatment Strategy for Invasive Lobular Carcinoma Highlight the Need for Better Predictors of Therapy Response

Annals of Surgical Oncology -     

A Prospective Management Strategy for Heterotaxy Syndrome with Intestinal Rotation Abnormalities: Imaging Does Not Predict Need for Surgery

PurposeHeterotaxy syndrome (HS) affects right-left anatomical development in 3% of children with congenital heart disease. Commonly, these patients have intestinal rotation abnormalities (IRA) that differ from typical malrotation. In this prospective study, we examine the development of a management pathway, imaging findings, and clinical course of patients with HS and IRA.MethodsAfter literature review, a multispecialty focus group designed a pathway for HS. Participants from a single institution were prospectively enrolled from 2016 to 2019. They underwent an abdominal ultrasound and UGI, however timing was variable based on symptoms. Symptomatic IRA was defined as feeding intolerance, bilious or non-bilious vomiting, bloating, severe reflux, and intermittent pain or abdominal distention. Screening for symptoms occurred every three months for the first two years and then annually.Results18 participants were followed for a median of 5.0 years. Three clinical categories were identified: 1) asymptomatic, not requiring intestinal surgery, 72.2%, 2) symptomatic with feeding intolerance or failure to thrive requiring gastrostomy placement and diagnostic laparoscopy with Ladd procedure, 16.7%, and 3) symptomatic requiring urgent exploration for suspicion of volvulus, 11.1%. Need for surgery did not necessarily correlate with US and/or UGI findings.ConclusionsIn children with HS and IRA, postnatal imaging did not inform the need for intestinal surgery. Although rare, volvulus or other forms of proximal obstruction can be anticipated, and symptomatic patients should be offered surgical intervention. A multidisciplinary care pathway for patients with HS and IRA can coordinate care and help counsel families on the likelihood of needing intestinal surgery for IRA.Level of EvidenceLevel II.Type of StudyProspective Cohort Study.     

Liver Transplantation for Primary Biliary Cirrhosis: Results of Aggressive Corticosteroid Withdrawal

IntroductionA subset of patients with primary biliary cirrhosis (PBC) may require long-term corticosteroid (CS) therapy following liver transplantation (OLT) due to concern over the possibility of recurrence. Our center has attempted to minimize CS use in all of our OLT recipients. In this study, we review our experience in this cohort to determine (1) patient outcome including PBC recurrence following transplantation and (2) the long-term requirement for CS use in PBC patients.MethodsFrom 1988 to 2006, 1102 OLTs were performed in 1032 adults at the University of Colorado, of which 70 patients (6.8%) with PBC received 74 allografts. Bivariate and multivariate analyses were used to evaluate predictors of CS withdrawal. Thirteen potential predictors of CS discontinuation were considered: age, gender, body mass index (BMI), race, type of graft (cadaveric or living donor [LD]), recurrence of PBC, warm ischemia time, and immunosuppressant.ResultsOverall survival at 5 years was 85%. The 1-, 5-, and 10-year recurrence-free survivals were 90%, 72%, and 54%, respectively. PBC recurred in 18 patients (25.7%). Of these, none received a second transplant due to disease recurrence. At the time of last follow-up, 73% of recipients were steroid free. Independent predictors of CS discontinuation are age (>54; P = .0059) and LD graft type (P = .0008). Conversely, cyclosporine (P = .0007), female gender (P = .0216), and BMI > 31 (P = .0306) were negatively associated with CS withdraw. Importantly, steroid discontinuation did not influence PBC recurrence.ConclusionsWhile long-term outcomes in PBC patients are favorable, disease recurrence can generally be managed medically without the need for a second transplant. Using an aggressive CS minimization approach, nearly three-quarters of the patients were CS free at the time of last follow-up. Increasing age and LD grafts were associated with successful CS withdraw. Conversely, cyclosporine use, female gender, and increasing BMI were associated with unsuccessful steroid discontinuation.     

Psychiatric Assessment and Management of Clients Undergoing Cosmetic Surgery: Overview and Need for an Integrated Approach

Background  Psychiatric disorders are more common among people undergoing cosmetic procedures than the general population and evaluating mental health can be cumbersome for plastic surgeons. We aim to summarize the available literature in this regard and propose an integrated approach to psychiatric assessment and management of mental health issues among this group. Methods  Electronic search of MEDLINE, Google Scholar, and PsycINFO databases was done to identify relevant peer-reviewed English language articles from inception till April 2020. Generated abstracts were screened for their eligibility. Included articles were grouped according to their thematic focus under the following headings; prevalence of psychiatric morbidity among clients posted for cosmetic surgery, assessment tools, and management of psychiatric morbidity in relation to undergoing cosmetic surgery. Results  A total of 120 articles were reviewed. The prevalence of psychiatric disorder in patients undergoing cosmetic surgery was 4 to 57% for body dysmorphic disorder (BDD); the corresponding figures for depression, anxiety, and personality disorder were 4.8 to 25.8, 10.8 to 22, and 0 to 53%, respectively. A range of tools have been used to assess these disorders and specific measures are also available to assess clinical outcomes following surgery. Screening for these disorders is essential to prevent unnecessary surgical procedures, as well as to ensure timely management of the psychiatric comorbidity. Conclusion  Psychiatric morbidity is a common concomitant in cosmetic surgery. A structured and integrated approach to evaluation and management of psychiatric morbidity will help to optimize postsurgical outcomes.     

Primary Retroperitoneal Soft Tissue Sarcomas: Results of Aggressive Surgical Treatment

A retrospective study was undertaken to evaluate the results of surgical treatment in a series of patients with primary retroperitoneal sarcomas consecutively treated by the same surgical team. The hospital records of 42 patients with primary retroperitoneal sarcomas who underwent surgical exploration at our unit from 1984 to 1995 were reviewed. A univariate analysis was used to identify the main clinical, pathologic, and treatment-related factors affecting long-term survival. Twenty-five patients (59.6%) underwent radical surgery. The 5-year survival and 5-year disease-free survival after radical resection were 48.1% and 38.8%, respectively. According to the univariate analysis of survival tumor classification (T), stage and gross surgical margins significantly affected prognosis. The study indicates that even though there are predetermined and unmodifiable tumor-related factors, such as tumor classification (T) and stage, that influence survival in patients with retroperitoneal sarcomas, wide surgical excision offers a concrete chance for long-term survival.     

Obstructive pneumonia: an indication for surgery in mega aorta syndrome

A 76-year-old woman with annuloaortic ectasia, aortic regurgitation, and aneurysmal dilatation extending from the root to mid descending aorta presented with symptoms of bronchial compression and obstructive pneumonitis. Despite vigorous antibiotic treatment and physiotherapy, the pneumonitis persisted with clinical and radiologic deterioration. An emergency operation was performed to relieve bronchial compression. The operation comprised homograft aortic root replacement with prosthetic replacement of the arch and descending aorta. Postoperatively the pneumonia rapidly resolved.     

Inflammatory Breast Cancer: Patterns of Failure and the Case for Aggressive Locoregional Management

Annals of Surgical Oncology - Inflammatory breast cancer (IBC) is a rare and aggressive subtype. This study analyzes the patterns of failure in patients with IBC treated at our institution. We...