Detecting and defining hypothyroidism after hemithyroidectomy

BACKGROUND: The incidence of hypothyroidism after hemithyroidectomy for benign thyroid disease remains uncertain. This study examines the incidence, natural history, and the factors contributing to hypothyroidism after hemithyroidectomy. METHODS: A retrospective review of patients undergoing hemithyroidectomy over 37 months was performed. The incidence of postoperative hypothyroidism was based on thyrotropin values and clinical symptoms. The relationship between hypothyroidism and lymphocytic infiltration of the removed gland was investigated using stepwise logistic regression. RESULTS: Twelve of 66 patients (18%) became biochemically hypothyroid postoperatively. Four of the 12 patients (33%) subsequently became euthyroid without intervention. Of the remaining 8 patients, 4 (50%) had significant lymphocytic infiltration in the resected gland compared with 10 (19%) of the 54 euthyroid patients. Lymphocytic infiltration was associated with hypothyroidism but was age dependent. CONCLUSIONS: A minority of patients become hypothyroid after hemithyroidectomy. Some patients with biochemical hypothyroidism will become euthyroid without intervention. The impact of lymphocytic infiltrate on hypothyroidism after hemithyroidectomy is age dependent.     

Preoperative sex steroids are significant predictors of early biochemical recurrence after radical prostatectomy

Purpose

We sought the association of preoperative serum total testosterone (tT), hypogonadism, 17β estradiol (E₂), and sex hormone-binding globulin (SHBG) with early biochemical recurrence (BCR) after radical prostatectomy (RP).

Methods

Sex steroids were assessed the day before surgery (7–11 a.m.) in a cohort of 605 patients with a median follow-up of 24 months following RP. Cox regression models tested the association between predictors [including age, body mass index (BMI), prostate-specific antigen (PSA), clinical stage, biopsy Gleason scores, tT, hypogonadism, E₂, and SHBG] and early BCR (defined as a PSA ≥ 0.1 ng/ml that occurred within 24 months after RP).

Results

Early BCR was found in 34 (5.6 %) patients. Patients with BCR did not differ in terms of age, BMI, serum PSA, tT, E₂, and SHBG levels, rate of hypogonadism, and clinical stage as compared with those without BCR (all p ≥ 0.05). Conversely, patients with BCR showed a greater prevalence of biopsy Gleason scores ≥4 + 3 (all p ≤ 0.001). At multivariable Cox regression analysis, tT [hazard ratio (HR): 1.43; p = 0.03] E₂ (HR: 1.05; p = 0.04), SHBG (HR: 1.29; p = 0.02), and biopsy Gleason scores equal to 4 + 3 (HR: 3.37; p = 0.04) and ≥8 (HR: 20.06; p < 0.001) achieved independent predictor status for early BCR. Conversely, no significant associations were found for all the other predictors.

Conclusions

Current findings show that preoperative serum sex steroids are independent predictors of early BCR in a homogeneous, large cohort of nonscreened patients treated with RP.     

Thyroid function after hemithyroidectomy for benign nodules

In order to assess the need for thyroxine therapy to maintain normal thyroid function in patients who have undergone hemithyroidectomy for benign solitary nodules, pre- and postoperative serum thyroxine (T₄) and serum thyrotropin (TSH) concentrations were measured in a prospective study on 103 patients. Thyroid function measurements were normal before the operation. Postoperative thyroid function tests showed a significant reduction of serum T₄ at 3 years and a significant elevation of serum TSH between 6 months and 3 years after surgery, but the altered levels remained within the normal range. Thirteen patients had abnormal postoperative thyroid function tests. Eight patients had subnormal T₄ levels, which were accompanied by concomitant increases in TSH levels above normal in 3 individuals. Five patients had supranormal TSH values associated with normal T₄ levels, but only 1 of them showed clinical recurrence of a goiter. These observations suggest that most patients remain clinically and biochemically euthyroid after hemithyroidectomy. Thus, routine replacement thyroxine therapy is not necessary to prevent biochemical hypothyroidism, but it may be indicated in the few patients in whom a subnormal T₄ level develops. The clinical significance of these subtle changes in serum T₄ and TSH within the normal range is not clear especially with respect to goiter recurrence.

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Resumen Con el propósito de determinar la necesidad de terapia con tiroxina para el mantenimiento de función tiroidea normal en pacientes que han sido sometidos a hemitiroidectomía por nódulos tiroideos benignos, se midieron las concentraciones pre- y postoperatorias de T₄ y de TSH en un estudio prospectivo realizado en 103 pacientes. Las mediciones de función tiroidea aparecieron normales antes de la operación. Las pruebas postoperatorias de función tiroidea mostraron una reducción significativa de T₄ sérica a los 3 años y una elevación significativa de TSH entre 6 meses y 3 años después de la cirugía, pero tales niveles alterados permanecieron dentro del rango normal. Trece pacientes exhibieron pruebas postoperatorias de función tiroidea anormales. Ocho pacientes presentaron niveles subnormales de T₄, los cuales se acompanaron de elevaciones concomitantes, por encima del nivel normal, de TSH en 3 individuos. Cinco pacientes presentaron valores supranormales de TSH asociados con niveles normales de T₄, pero solo 1 de ellos desarrolló recurrencia clínica del bocio. Estas observaciones sugieren que la mayoría de los pacientes permanecen clinica y bioquímicamente eutiroideos después de la hemitiroidectomía. Por consiguiente, la terapia rutinaria de reemplazo con tiroxina no es necesaria para la prevención del hipotiroidismo bioquímico, pero puede estar indicada en los pocos pacientes que desarrollen un nivel subnormal de T₄ sérico. La significación clínica de estos sutiles cambios que se presentan dentro de los niveles normales de T₄ y de TSH no es clara en lo que se refiere a la posibilidad de recurrencia del bocio.

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Résumé Au cours d'une étude prospective concernant 103 sujets, les concentrations dans le sérum de la T₄ et de la TSH ont été dosées en préopératoire et en postopératoire dans le but de savoir s'il était nécessaire de leur donner de la thyroxine pour maintenir une fonction thyroïdienne normale après qu'ils aient subi une hémithyroïdectomie pour traiter un noyau thyroïdien bénin. Les dosages étaient normaux avant l'intervention. Les tests après l'opération ont montré une réduction significative du T₄ sérique après 3 ans et une élévation également significative de TSH de 6 mois à 3 ans après l'exérèse mais ces variations restaient dans les limites de la normale. Treize opérés ont présenté des tests fonctionnels thyroïdiens anormaux. Huit d'entre eux présentaient un dosage au-dessous de la normale de T₄ qui s'accompagnait 3 fois d'une élévation de TSH au-dessus de la normale. Les 5 autres avaient des taux de TSH supérieurs à la normale avec des taux normaux de T₄ mais un seul présentait une récidive clinique de goitre. Ces observations suggèrent que la majorité des opérés qui ont subi une hémithyroïdectomie restent cliniquement et biologiquement euthyroïdiens. Par conséquent, l'emploi classique de la thyroxine en postopératoire n'est pas nécessaire pour prévenir un éventuel hypothyroïdisme mais il peut être indiqué chez quelques opérés chez qui apparait un dosage de T₄ dont le taux est inférieur à la normale. La signification clinique de ces modifications discrètes du taux sérique de T₄ et de TSH n'est pas évidente, en particulier en ce qui concerne la récidive du goitre.

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Presented at the International Association of Endocrine Surgeons in Paris, September 1985.

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Supported by grants from the University Research Grants Committee, the Medical Faculty Research Grant Fund, and the Pauline Chan Medical Research Fund of the University of Hong Kong.     

Anatomic predictors for late mortality after standard endovascular aneurysm repair

ObjectiveAbdominal aortic aneurysm (AAA) management involves a decision process that takes into account anatomic characteristics, surgical risks, patients' preferences, and expected survival. Whereas larger AAA diameter has been associated with increased mortality after both standard endovascular aneurysm repair (EVAR) and open repair, it is unclear whether survival after EVAR is influenced by other anatomic characteristics. The purpose of this study was to determine the importance of baseline anatomic features on survival after EVAR.MethodsAll patients treated at a tertiary teaching center with EVAR for intact standard infrarenal AAA from 2000 to 2014 were included. The civil data registry was queried to determine survival status; causes of death were obtained from death certificates. The primary study end point was to determine the impact of baseline morphologic features on all-cause and cardiovascular mortality after EVAR.ResultsThis study included 404 EVAR patients (12.1% women; mean age, 73 years) with a median follow-up of 5.8 years (interquartile range, 3.1-7.4 years). The 5- and 10-year overall survival rates for the entire population after EVAR were 70% (95% confidence interval [CI], 66%-75%) and 43% (95% CI, 37%-50%), respectively. Only AAA diameter >70 mm (hazard ratio [HR], 1.75; 95% CI, 1.20-3.56) was identified as an independent anatomic predictor of all-cause mortality. Death due to cardiovascular causes occurred in 60 (38.5%) patients. Aneurysm-related mortality was responsible for six of the cardiovascular-related deaths. In multivariable analysis, both neck diameter ≥30 mm (HR, 2.16; 95% CI, 1.05-4.43) and AAA diameter >70 mm (HR, 2.45; 95% CI, 1.34-4.46) were identified as independent morphologic risk factors for cardiovascular mortality, whereas >25% circumferential neck thrombus (HR, 0.32; 95% CI, 0.13-0.77) was protective.ConclusionsThis study suggests that patients with AAA diameters >70 mm are at increased risk of all-cause and cardiovascular mortality. In addition, patients with infrarenal neck diameters ≥30 mm have a greater risk of cardiovascular mortality, although AAA-related deaths were not more frequent in this group of patients. Consequently, a more aggressive management of cardiovascular medical comorbidities may be warranted to improve survival after standard EVAR in these patients.     

Race and prostate weight as independent predictors for biochemical recurrence after radical prostatectomy

We hypothesized that factors beyond pathological stage, grade, PSA and margin status would be important predictors of biochemical recurrence (BCR) after radical prostatectomy (RP). A cohort of 3194 patients who underwent RP between 1988 and 2007 and who had neither neoadjuvant therapy nor postoperative adjuvant hormonal therapy was retrieved from the Duke Prostate Center database. Age, prostate-specific antigen (PSA), pathological Gleason score (pG), lymph node status, seminal vesicle invasion (SVI), extracapsular extension (ECE), positive surgical margin (PSM) status, year of surgery, race, adjuvant radiation therapy (XRT), percent tumor involvement in the RP specimen and prostate weight were evaluated as possible predictors of BCR in multivariate Cox regression analysis. BCR was defined as a PSA of 0.2 ng ml(-1) or higher at least 30 days after surgery. A nomogram was developed from the Cox model. Predictive accuracy was obtained by calculating bias-corrected Harrell's c and by bootstrap calibration. In multivariate analysis, PSA (hazard ratio 1.39 (95% confidence interval 1.29-1.51)), ECE (1.22 (1.04-1.44)), pG score (1.38 (1.14-1.68), 2.23 (1.76-2.84), 2.69 (2.12-3.40) for pG 3+4, 4+3, >7, respectively), SVI (1.72 (1.40-2.12)), PSM (2.05 (1.73-2.42)), year of surgery (0.65 (0.54-0.77)), African-American race (1.37 (1.13-1.66)), adjuvant XRT (0.19 (0.11-0.34)) and prostate weight (0.83 (0.76-0.92)) were identified as independent predictors of BCR (P< or =0.018 for all factors). Predictive accuracy of the nomogram was 0.75. Race and prostate weight were independent predictors for BCR after RP. By incorporating these variables, we developed a nomogram, which provides a highly accurate means for estimating risk of BCR after RP.     

Thyroid auto-antibodies, lymphocytic infiltration and the development of post-operative hypothyroidism following hemithyroidectomy for non-toxic nodular goitre

BACKGROUND: Auto-immune thyroiditis, associated with detectable thyroid auto-antibodies (TAAs) and lymphocytic infiltration into the gland, is known to be associated with progressive development of hypothyroidism. This study examines those patients who required surgical treatment of non-toxic nodular goitre by hemithyroidectomy to determine whether the presence of TAAs in the circulation and/or lymphocytic infiltration of the gland resulted in a significant degree of post-operative hypothyroidism. METHOD: This was a prospective study, with data collected retrospectively. All patients operated on for thyroid disease in the unit over a 5-year period were documented, and those patients treated by hemithyroidectomy for non-toxic nodular goitre formed the study group. TAAs were measured, histology re-examined and patients followed up for at least 2 years to detect clinical or sub-clinical hypothyroidism. RESULTS: Of the 158 patients who comprised the study group, 38 (24.1%) developed hypothyroidism. Forty-one (25.9%) had circulating levels of TAAs, 31 of these (75.6%) having high levels. Of these 41 patients, 22 (53.7%) became hypothyroid. Twenty (64.5%) of the 31 patients with high levels of TAAs required post-operative thyroxine. Of the remaining 117 patients with no detectable TAAs, only 16 (13.7%) became hypothyroid. CONCLUSION: All patients requiring treatment by hemithyroidectomy should have circulating TAA measurements carried out pre-operatively. If positive, they should be followed up indefinitely because of the strong possibility (P < 0.001) of the development of hypothyroidism.     

Cognition and adjustment after late and early operation for ruptured aneurysm

Does early aneurysm operation, while lowering the overall management mortality, result in an unacceptable morbidity in terms of increased cognitive disturbances and psychosocial maladjustment? The present study evaluates quality of life, degree of cognitive dysfunction, and adjustment of 93 patients with satisfactory neurological recoveries after operations for ruptured supratentorial aneurysms. All patients had been in neurological Grades I to III (Hunt and Hess) after subarachnoid hemorrhage (SAH). Fifty-five patients were operated upon during the acute state, i.e., within 72 hours after bleeding (early surgery = ES), and 38 patients had been subjected to late surgery (LS), i.e., were operated on 9 days or more after SAH. Each patient was subjected to a clinical interview and a comprehensive neuropsychological investigation. The time interval between SAH and assessment varied between 12 and 103 months (mean, 56 months). The results confirm that there are indication of cognitive malfunctioning and psychosocial disturbances of varying severity and distribution in patients who have undergone LS. The pattern and distribution of sequelae after LS did not differ substantially from that in patients subjected to ES. The results offer strong support to the concept that remaining disturbances in cognition are mainly related to the impact of the initial hemorrhage per se. In patients with anterior communicating artery aneurysms, a larger decrease in tempo and perceptual vigilance was noted, suggesting that the subfrontal midline structures are particularly involved in processes demanding flexibility, attention, and capacity to adapt to novel demands in a perceptual situation.     

Histological and clinical predictors of early and late renal outcome in ANCA-associated vasculitis.

BACKGROUND: Renal involvement remains a major determinant in antineutrophil cytoplasmic autoantibody-associated small vessel vasculitis (AASV). While some patients may develop persistent renal damage, others have a favourable outcome. METHODS: To identify patients at risk for poor renal outcome, we evaluated 95 renal biopsies (67 initial biopsies and 28 repeat biopsies) of 67 patients with AASV for the presence and extent of active (AI) and chronic (CI) lesions, retrospectively. AI, CI, levels of proteinuria and dose of cyclophosphamide (CYC) were related to renal outcome. RESULTS: Recovery of renal function in patients initially dialysis dependent was associated with a lower CI compared with patients who remained on dialysis (P<0.001), while AI did not differ significantly. In these patients, age <65 years revealed a positive predictive value of 85% for renal function recovery. Patients initially requiring dialysis exhibited a higher AI and CI compared with those who did not. Renal function in long-term follow-up correlated with CI and the amount of proteinuria. This relationship increased with time, exhibiting at 4 years a correlation coefficient of 0.607 for CI (P<0.01) and of 0.775 for proteinuria (P<0.001). Follow-up biopsies showed a more pronounced CI compared with initial biopsies (P<0.001). None of the investigated initial parameters was predictive for renal relapse. However, there was a relationship between dose and duration of CYC and time to relapse. Compared with the initial biopsy, repeat biopsies of eight patients with a creeping serum creatinine in clinical remission showed a decrease of AI (P<0.001) while CI increased rapidly. These patients also had less initial CYC (NS). CONCLUSIONS: These data suggest that in AASV, evaluation of renal histopathology is helpful in predicting early and late renal outcome. Chronicity and proteinuria were the best determinants of poor renal prognosis. Activity may regress under therapy, while chronicity may progress despite treatment. The amount of CYC seems to influence the occurrence of early relapses and renal survival.     

Completion pancreatectomy for postoperative peritonitis after pancreaticoduodenectomy: early and late outcome

HYPOTHESIS: Completion pancreatectomy in patients with pancreatic leakage associated with postoperative peritonitis after pancreaticoduodenectomy is a viable salvage procedure. DESIGN: Retrospective analysis from a cohort of consecutive patients admitted between January 1, 1989, and December 31, 1999, for postoperative peritonitis originating from pancreaticojejunostomy leakage. SETTING: Tertiary referral center with surgical intensive care unit specializing in the treatment of intra-abdominal sepsis. PATIENTS: Eight consecutive patients with postoperative peritonitis originating from pancreaticojejunostomy after pancreaticoduodenectomy, with a mean Acute Physiology and Chronic Health Evaluation II score of 18.6. We excluded patients with pancreatic fistulas or abscesses amenable to percutaneous drainage or other conservative treatment. INTERVENTION: Completion pancreatectomy. MAIN OUTCOME MEASURES: Mortality, morbidity, and long-term outcome, which was assessed by interview. RESULTS: Three patients died in the postoperative period: 2 required early reoperation during the postoperative period and died of hemorrhage and sepsis, and 1 died of multiorgan failure without reoperation. Recurrence of carcinoma was responsible for late death of 2 other patients. CONCLUSIONS: Postoperative peritonitis after pancreaticoduodenectomy still has high mortality; however, completion pancreatectomy may represent the only means to achieve source control of infection in cases of postoperative peritonitis.     

Causes and predictors of early re-admission after surgery for a fracture of the hip

The aim of this study was to examine the rates and potential risk factors for 28-day re-admission following a fracture of the hip at a high-volume tertiary care hospital. We retrospectively reviewed 467 consecutive patients with a fracture of the hip treated in the course of one year. Causes and risk factors for unplanned 28-day re-admissions were examined using univariate and multivariate analysis, including the difference in one-year mortality. A total of 55 patients (11.8%) were re-admitted within 28 days of discharge. The most common causes were pneumonia in 15 patients (27.3%), dehydration and renal dysfunction in ten (18.2%) and deteriorating mobility in ten (18.2%). A moderate correlation was found between chest infection during the initial admission and subsequent re-admission with pneumonia (r = 0.44, p < 0.001). A significantly higher mortality rate at one year was seen in the re-admission group (41.8% (23 of 55) vs. 18.7% (77 of 412), p < 0.001). Logistic regression analysis identified advancing age, admission source, and the comorbidities of diabetes and neurological disorders as the strongest predictors for re-admission. Early re-admission following hip fracture surgery is predominantly due to medical causes and is associated with higher one-year mortality. The risk factors for re-admission can have implications for performance-based pay initiatives in the NHS. Multidisciplinary management in reducing post-operative active clinical problems may reduce early re-admission.     

Results and predictors of early and late outcomes of coronary artery bypass graft surgery in octogenarians

OBJECTIVES: The aim of this study was to investigate early and late outcomes of coronary artery bypass graft (CABG) surgery in a large cohort of octogenarian patients. The results were compared with 2 other age groups including septuagenarians and patients <70 years old. DESIGN: A retrospective study of consecutive patients undergoing CABG surgery using a computerized database based on the New York State Department of Health registry. Data collection was performed prospectively. Setting: A university hospital (single institution). PARTICIPANTS: Two thousand nine hundred eighty-five patients undergoing CABG surgery including 282 (9.4%) octogenarians, 852 (28.6%) septuagenarians, and 1851 (62%) patients younger than 70 years old. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patient characteristics, hospital mortality, morbidity, length of stay, and long-term survival were analyzed. Octogenarians were more likely female and presented significantly more often with comorbidities such as heart failure, an ejection fraction <30%, peripheral vascular disease, and aortic calcification. Crude hospital mortality was 4.6% (n = 13) in octogenarians compared with 2.2% (n = 19) in septuagenarians and 2.4% (n = 44) in patients <70 years old (p = 0.067). Respiratory failure and gastrointestinal complications occurred more frequently in octogenarians. The stroke rate was 1.6% and similar in the 3 age groups. In multivariate logistic regression analysis, age >80 years was not a predictor of hospital mortality. The length of stay was significantly higher in octogenarians compared with nonoctogenarians (16 +/- 24 days v 10 +/- 13 days, p < 0.001). Five-year survival was 63% +/- 4% in octogenarians and was similar to that of an age- and sex-matched general US population. CONCLUSIONS: Excellent results after CABG surgery can be expected in octogenarians, with a minimal increase in postoperative mortality and acceptable postoperative morbidity. Respiratory failure is the main postoperative complication in octogenarians. Recent advances in operative techniques and perioperative management have contributed in improving surgical outcome in these patients compared with historic reports.