Total Thyroidectomy is Associated with Increased Risk of Complications for Low- and High-Volume Surgeons

Background

There has been an increased use of total thyroidectomy (TT), including in the management of benign thyroid diseases. We sought to compare the risk of complications between TT and unilateral thyroidectomy (UT) and to evaluate the effect of surgeon’s experience on outcomes.

Methods

Nationwide Inpatient Sample from 2003 to 2009 was used to perform cross-sectional analysis of all adult patients who underwent TT and UT for benign or malignant conditions. Logistic regression was used to evaluate outcomes and to provide correlation between outcome and surgeon volume. Surgeon volume was categorized as low or high (performing <10 or >99 thyroid operations/year, respectively).

Results

A total of 62,722 procedures were included. Most cases were TT (57.9 %) performed for benign disease. There was a significantly increased risk of complication after TT compared to UT (20.4 vs. 10.8 %: p < 0.0001). High-volume surgeons performed only 5.0 % of the procedures overall, with 62.6 % of the high-volume surgeon procedures being TTs. Low-volume surgeons were more likely to have postoperative complications after TT compared to high-volume surgeons (odds ratio 1.53, 95 % confidence interval 1.12, 2.11, p = 0.0083). Mean charges were significantly higher for TT compared to lobectomy ($19,365 vs. $15,602, p < 0.0001), and length of stay was longer for TT compared to lobectomy (1.63 vs. 1.29 days, p < 0.0001).

Conclusions

TT is associated with a significantly higher risk of complications compared to UT even among high-volume surgeons. Higher surgeon volume is associated with improved patient outcomes.     

Laparoscopic Techniques Enable Peritoneal Dialysis in the Difficult Abdomen

Background and Objectives:

Continuous ambulatory peritoneal dialysis has become an increasingly popular modality of renal replacement therapy. Laparoscopic placement of peritoneal dialysis catheters may help overcome previous barriers to peritoneal dialysis, such as previous abdominal surgical procedures or the presence of hernias, without incurring substantially greater risks.

Methods:

We performed a retrospective review of 120 consecutive patients who underwent attempted laparoscopic peritoneal dialysis catheter placement between July 2009 and June 2014 by a single surgeon. Patient and catheter characteristics and outcomes were compared between patients with and without complications, as well as between patients with a history of major abdominal surgery and those without such a history.

Results:

Laparoscopic peritoneal dialysis catheter placement was aborted in 4 patients because of an inability to safely achieve sufficient access to the abdominal cavity through dissection; these patients were excluded from subsequent analysis. The mean follow-up period was 18.8 ± 12.9 months. Fifty-five patients had a history of major abdominal surgery compared with 61 without such a history. No significant difference was observed with respect to age, race, sex, or body mass index between groups. Notably, more adjunctive procedures were required in patients with previous abdominal surgery, including adhesiolysis (60.0% vs 4.9%, P < .0001) and hernia repair (12.7% vs 1.6%, P = .026). Postoperative catheter complications were not significantly different between patients with and patients without a history of abdominal surgery (29.1% vs 32.8%, P = .667). Both unassisted (56.8% vs 65.0%, P = .397) and overall (72.7% vs 76.7%, P = .647) 1-year catheter survival rates were similar between patients with and patients without previous surgery, and the overall 1-year survival rate improved to 83.9% on exclusion of patients who stopped peritoneal dialysis for nonsurgical reasons.

Conclusions:

Laparoscopic peritoneal dialysis catheter placement offers a chance to establish peritoneal dialysis access in patients traditionally viewed as noncandidates for this modality. Despite the potential risks incurred because of additional procedures at the time of catheter placement in these complicated cases, these patients can achieve good long-term peritoneal dialysis access with an aggressive surgical approach.     

Proangiogenic scaffolds as functional templates for cardiac tissue engineering

We demonstrate here a cardiac tissue-engineering strategy addressing multicellular organization, integration into host myocardium, and directional cues to reconstruct the functional architecture of heart muscle. Microtemplating is used to shape poly(2-hydroxyethyl methacrylate-co-methacrylic acid) hydrogel into a tissue-engineering scaffold with architectures driving heart tissue integration. The construct contains parallel channels to organize cardiomyocyte bundles, supported by micrometer-sized, spherical, interconnected pores that enhance angiogenesis while reducing scarring. Surface-modified scaffolds were seeded with human ES cell-derived cardiomyocytes and cultured in vitro. Cardiomyocytes survived and proliferated for 2 wk in scaffolds, reaching adult heart densities. Cardiac implantation of acellular scaffolds with pore diameters of 30–40 μm showed angiogenesis and reduced fibrotic response, coinciding with a shift in macrophage phenotype toward the M2 state. This work establishes a foundation for spatially controlled cardiac tissue engineering by providing discrete compartments for cardiomyocytes and stroma in a scaffold that enhances vascularization and integration while controlling the inflammatory response.     

Thrombin-antithrombin III-complex & fibrin degradation products in plasma: surgery and postoperative deep venous thrombosis

Thrombin-antithrombin-III complexes (TAT) & D-dimer in plasma, and fibrin(ogen) degradation products (FDP) in serum, were measured in 48 patients subjected to total hip arthroplasty. Blood samples were collected on days -1, 0, 1, 3, 7 and 10. Five patients developed postoperative deep vein thrombosis (DVT) diagnosed by venography. A characteristic pattern of TAT and D-dimer secondary to surgery was demonstrated. A poor correlation was found between ELISA- and latex-D-dimer concentrations after the operation. Patients with DVT had significantly higher TAT-levels preoperatively, and on day 0, 7 and 10. The concentration of FDP was significantly elevated in patients with DVT on day 7 and that of ELISA D-dimer on days 0 & 10. None of the assays are clinically valuable for purposes of postoperative screening for DVT. The preoperative plasma TAT concentration may represent a valuable predictive marker of postoperative DVT.     

Experiences with nesidioblastosis

Highly differentiated processes relating to insulin-generating cells of the endocrine pancreas are covered by the term of nesidioblastosis. The disease is primarily characterised by persistent hypoglycaemia, and it affects newborns and young infants. Diffuse nesidioblastosis is predominant, as compared to focal processes. So called ductulo-insular complexes are characteristic immunohistochemical manifestations. While dietary and medicamentous therapies (diazoxide) usually failed to be effective, surgical removal so far has worked better than any other approach (subtotal and total pancreatectomy). Adequate early diagnosis should be established and pancreatectomy performed even before irreversible cerebral damage is caused by glucose deficit. Operations for subtotal or total pancreatectomy were performed on five children with nesidioblastosis at the Department of Paediatric Surgery in Erfurt, over the last two years. Epilepsy continued to be manifest in one of the five. Success eventually depends on close cooperation between paediatrics and paediatric surgery.     

Vestibular toxicity following netilmicin therapy in the neonatal period

Thirty-seven children treated with netilmicin during the neonatal period were seen at follow-up at the age of 2-4 years to investigate for possible vestibular damage caused by netilmicin therapy. No definite vestibular damage could be found in these 37 patients, including three patients in whom greatly elevated serum concentrations of netilmicin had been measured. The present study confirms previous findings in adults showing a low ototoxicity of netilmicin.