Arnold Komisar

Surgical management of thyroid masses: Assessing the need for frozen section evaluation

Objective/Hypothesis: To determine the need for intraoperative frozen section to guide the extent of thyroid surgery in the presence of an adequate preoperative fine‐needle aspiration (FNA) finding. Methods: Charts of patients who presented from 1995 to 1998 to the two senior authors were reviewed. A total of 82 patients were found who satisfied the inclusion criteria of having both an adequate FNA and frozen section. The extent of surgery was based on the frozen section finding for all the patients in this study. The authors looked at the number of cases in which the surgical management would be changed if the frozen section was not obtained and the surgical decision was based only on preoperative FNA and intraoperative findings. Results: FNA revealed papillary carcinoma in 18 patients that was confirmed by intraoperative frozen section and final pathology. In the remaining 64 patients, the FNA diagnosis was either benign or suspicious. When routine frozen section was done, 61 of these 64 patients were found to have either benign pathology or pathological diagnosis that was deferred to permanent section. Only three patients were found to have malignancy on frozen section that was missed by FNA. Of these three patients, two had obvious findings of malignancy at the time of surgery. This leaves only one patient with carcinoma that was missed by FNA and intraoperative findings but detected by the intraoperative frozen section. Conclusion: Of the 82 patients in this study, only one extra case of malignancy would be missed by elimination of the routine use of intraoperative frozen section. The authors conclude that the routine use of intraoperative frozen section may be unnecessary. The use of an adequate preoperative FNA together with sound clinical judgment at time of surgery can adequately guide the extent of surgical resection.

Long‐term follow‐up after subtotal parathyroidectomy in patients with renal failure

Objectives/Hypothesis: The most appropriate type of surgery for hyperparathyroidism secondary to renal failure remains controversial. We report a 5‐year experience of patients with hyperparathyroidism secondary to end‐stage renal disease who underwent subtotal parathyroidectomy. We believe that this is the procedure of choice, offering several advantages over total parathyroidectomy with and without reimplantation. Study Design: Retrospective review. Methods: Review of 14 consecutive renal failure patients who underwent subtotal parathyroidectomy by one surgeon (A.K.) was performed. Follow‐up ranged from 4 to 54 months. All patients were receiving chronic maintenance dialysis. All patients came to surgery with clinical symptoms of parathyroid bone disease, elevated serum calcium levels (10.1–12.4 mg/dL), and intact parathyroid hormone levels (619–4160 pg/mL), despite maximal medical therapy. At exploration four glands were identified in all patients and three and a half were removed. Results: All patients experienced symptomatic relief postoperatively with normalization or near‐normalization of serum calcium concentration and intact parathyroid hormone concentrations. One patient developed recurrent disease 4 months after surgery, and on re‐exploration a supernumerary substernal gland was identified. A second patient developed recurrent symptoms 4 years after surgery and at the time of this writing was awaiting re‐exploration. Conclusions: All patients had either resolution of or marked improvement in their subjective complaints. There have been no cases of permanent hypoparathyroidism. We believe that subtotal parathyroidectomy is the best procedure for patients with refractory symptoms of secondary hyperparathyroidism.

Experience with the Wilkie procedure for sialorrhea.

Sialorrhea (drooling) is most commonly seen in children with cerebral palsy or mental retardation. Surgical procedures for the control of sialorrhea include salivary gland excision, parasympathetic nerve section, and salivary duct ligation and/or rerouting. Eighteen children between the ages of 5 and 17 years underwent bilateral submandibular gland excision and rerouting of Stensens duct (Wilkie procedure). All children had severe drooling associated with cerebral palsy or mental retardation. Follow-up at 7 years showed satisfactory control of sialorrhea in 16 of 18 patients (89%). There was one major complication: Xerostomia. Our results indicate that submandibular gland excision together with parotid duct retropositioning provides effective control of sialorrhea in most cases. Unfavorable head and mandibular posturing seemed to cause persistent sialorrhea in one case.

Tongue paralysis following head trauma

Paralysis of the tongue due to isolated bilateral hypoglossal nerve palsy is a rare occurrence. Due to a trauma the cause in our case may have been a traction injury to both hypoglossal nerves at the base of skull. In some cases a contributing factor may be malformation of the skull base. Most cases have a good prognosis for recovery.

Diagnostic value of the preoperative sestamibi scan in intraoperative localization of parathyroid adenomas: a case study.

A retrospective chart review of 43 patients who underwent technetium 99m (Tc‐99m) sestamibi scans from June 1995 to January 1997 was performed. Only those who underwent subsequent parathyroid exploration with excision were included in the study. Twenty subjects (13 women and seven men) were included in the study. Ages ranged from 21 to 84 years (mean, 58 years). All patients had laboratory values and clinical findings consistent with primary hyperparathyroidism. Two patients had preoperative magnetic resonance imaging (MRI) scans (one patient with recurrent disease), and one had a preoperative computed tomography (CT) scan. The remaining patients had the sestamibi scan as the only preoperative localization study. There were 18 pathologic diagnoses of parathyroid adenoma and two of parathyroid hyperplasia. Sestamibi failed to correctly identify the location of the parathyroid lesion in two cases. In 18 cases the preoperative sestamibi scan correctly localized the lesion, a predictive value of 90%. We conclude that the Tc‐99m sestamibi scan is an accurate preoperative tool that can be used as a single modality to localize parathyroid adenomas.

Predicting outcome in aged and severely ill patients with prolonged respiratory failure.

Objectives: Consultations for tracheotomy are often sought on aged and severely ill patients with respiratory insufficiency. This patient population has high short-term mortality rates and is difficult to stratify on the basis of expected outcome. We examined whether APACHE III (Acute Physiology and Chronic Health Evaluation III) scores or neurologic status assessment (NSA) scores in sedated individuals are predictive of outcome. Methods: We performed a retrospective study examining aged patients who underwent tracheotomy for respiratory insufficiency and prolonged intubation. The APACHE III scores (n = 30) and NSA (based on a modified Glasgow Coma Scale) scores (n = 37) were calculated before tracheotomy. All patients were mildly sedated. Using APACHE III and NSA scores as predictor variables and using death and ability to be weaned from the ventilator as outcome variables, we performed a Kaplan-Meier survival analysis and a Cox proportional hazard regression. Results: The APACHE III was not significantly predictive of either outcome. Higher NSA scores were associated with increased survival rates (log rank = 19.7, p < .0001) and longer median survival (88 days versus 16 days for lower scorers). Higher NSA scores also predicted a higher rate of ventilator independence. Conclusions: Neurologic function in sedated patients (and not APACHE III scores) can be used to stratify aged individuals with respiratory insufficiency on the basis of expected outcome.

Ambulatory pH Monitoring in the Management of Reflux

Ambulatory pH monitoring is a useful tool in the diagnosis and treatment of different esophageal and pharyngeal complaints. We have studied its use in an office setting in 15 patients with suspected gastroesophageal reflux disease (GERD). The patients were monitored for at least 18 hours while wearing a two-channel probe at home. Data obtained confirmed severe GERD in 6 patients and chest pain without GERD in 2 patients. Two patients continued to have symptoms in spite of appropriate therapy, while 2 untreated patients had symptoms of GERD with normal pH studies. We feel this technique is relatively safe and cost-effective and causes minimal disruption of the patients life-style, while enabling the physician to monitor therapy and help achieve a good therapeutic outcome.