Christopher R. McHenry

Determinants of mortality for necrotizing soft-tissue infections.

OBJECTIVE The authors determined the risk factors of mortality in patients with necrotizing soft-tissue infections (NSTIs) and examined the incidence and mortality from NSTI secondary to Streptococcus pyogenes. METHODS All patients with NSTIs who were treated between January 1989 and June 1994 were analyzed for presentation, etiology, factors important in pathogenesis and treatment, and mortality. RESULTS Sixty-five patients were identified with NSTIs secondary to postoperative wound complications (18), trauma (15), cutaneous disease (15), idiopathic causes (10), perirectal abscesses (3), strangulated hernias (2), and subcutaneous injections (2). Necrotizing soft-tissue infections were polymicrobial in 45 patients (69%). S. pyogenes was isolated in only 17% of the NSTIs, but accounted for 53% of monomicrobial infections. Eight of ten idiopathic infections were caused by a single bacterium (p = 0.0005), whereas 82% of postoperative infections were polymicrobial. An average of 3.3 operative debridements per patient and amputation in 12 patients were necessary to control infection. The overall mortality was 29%; mortality from S. pyogenes infection was only 18%. The average time from admission to operation was 90 hours in nonsurvivors versus 25 hours in survivors (p = 0.0002). Other risk factors previously associated with the development of NSTIs did not affect mortality. CONCLUSIONS Early debridement of NSTI was associated with a significant decrease in mortality. S. pyogenes infection was the most common cause of monomicrobial NSTI, but was not associated with an increased mortality.

Prospective management of nodal metastases in differentiated thyroid cancer

Previous studies have concluded that lymph node metastases do not affect survival rates in patients with differentiated thyroid carcinoma and, therefore, nodal metastasis has not been evaluated as a prognostic factor in recent definitions of risk groups. To determine the significance of nodal disease, we reviewed 227 consecutive patients with differentiated thyroid carcinoma (173 with papillary, 37 with follicular, and 17 with Hürthle cell carcinoma). Of 70 (31%) patients with lymph node metastases (14 [20%] palpable preoperatively and 56 [80%] detected by routine sampling of middle and lower cervical nodes), 13 (19%) developed a recurrence compared with only 3 of 157 (2%) without nodal disease (p less than 0.01). Sixty-eight patients were treated with modified neck dissection, 63 of whom received adjuvant radioiodine. There were 10 recurrences in 63 patients (16%) who had been treated with radioiodine, compared with 3 recurrences in 7 (42%) patients who did not receive adjuvant radioiodine. Follow-up ranged from 2 to 28 years, with a mean of 8 years. Involvement of the lymph nodes was a marker for systemic disease occurring synchronously in 4 of 5 patients who presented with distant metastases and preceding systemic recurrence in 9 of 10 patients. Four patients (2%), all with lymph node metastases (three with concomitant extrathyroidal invasion and one with systemic metastases at initial presentation), died of thyroid carcinoma. Cervical lymph node metastases were associated with a higher incidence of recurrence and occurred synchronously or preceded the development of distant metastases in 13 of 15 (87%) patients. Although these findings were not statistically significant for overall survival, they lend support to routine cervical lymph node sampling for detection of and modified neck dissection with adjuvant radioiodine therapy for treatment of lymph node metastases. Such measures should reduce the subsequent recurrence rate and permit early detection and treatment of systemic disease.

Follicular or Hu ̈rthle cell neoplasm of the thyroid: Can clinical factors be used to predict carcinoma and determine extent of thyroidectomy?

BACKGROUND Fine-needle aspiration biopsy (FNAB) and frozen section exam are of limited or no value in distinguishing benign and malignant follicular or Hürthle cell neoplasms of the thyroid gland. METHODS Patients who underwent thyroidectomy for treatment of a follicular or Hürthle cell neoplasm between 1990 and 1998 were identified and evaluated for age, gender, head and neck irradiation, nodule size, and cytologic atypia to determine whether clinical factors were predictive of carcinoma. RESULTS Of the 352 patients evaluated for nodular thyroid disease, 75 (21%) underwent thyroidectomy after an indeterminate FNAB finding, 66 with follicular and 9 with a Hürthle cell neoplasm. Seventeen (23%) of the patients had carcinoma-follicular variant of papillary (10), follicular (6), and Hürthle cell (1). Carcinoma was diagnosed in 15 of 64 women and 2 of 11 men (P > .05). The mean age was 43 +/- 21 years and 50 +/- 16 years, respectively, in patients with and without carcinoma (P > . 05). Three patients had previous neck irradiation and none had carcinoma. Mean nodule size was 4.2 +/- 2.7 cm and 4.3 +/- 3.5 cm, respectively, in patients with and without carcinoma (P > . 05). Cytologic atypia was present in 8 of 17 patients with carcinoma and 20 of 58 patients without carcinoma (P > .05). CONCLUSIONS Clinical factors were not helpful in predicting carcinoma in patients with an indeterminate FNAB finding and thus cannot be used to reliably select patients for more extensive thyroidectomy.

The utility of routine frozen section examination for intraoperative diagnosis of thyroid cancer

BACKGROUND The value of routine frozen section examination for intraoperative diagnosis of thyroid cancer and determination of extent of thyroidectomy is controversial and needs to be evaluated on an institution to institution basis. METHODS A prospective evaluation of 76 patients with nodular thyroid disease who had an adequate fine needle aspiration biopsy (FNAB) underwent thyroidectomy with routine thyroid frozen section examination. A direct comparison of FNAB and frozen section examination, along with a cost benefit analysis of frozen section examination, was completed. RESULTS The thyroid pathology was carcinoma in 24, follicular adenoma in 24, multinodular goiter in 24, thyroiditis in 3, and a cyst in 1 patient. The sensitivity, specificity, and accuracy of frozen section examination were 93%, 100%, and 97%, respectively, compared with 88%, 89%, and 91% for FNAB (P > 0.05). Diagnosis was deferred in 38 patients (50%) in whom frozen section examination showed a follicular neoplasm. One to 6 frozen section examinations were obtained per patient with alteration in intraoperative management in only 2 patients (3%) at a charge of

Acute Bacterial Suppurative Thyroiditis: A Clinical Review and Expert Opinion

246 to

Is nodule size an independent predictor of thyroid malignancy

606 per patient and a total charge of

Life-threatening neck hematoma complicating thyroid and parathyroid surgery.

26,040. CONCLUSION In patients with an adequate FNAB, frozen section examination rarely affected intraoperative decision making in thyroid surgery and its routine use was not cost effective.

Is deep vein thrombosis surveillance warranted in high-risk trauma patients?

BACKGROUND Acute suppurative thyroiditis (AST) resulting from a bacterial infection is an infrequent but potentially life-threatening endocrine emergency. Traditional management of this disease has been surgery in conjunction with targeted antibiotic therapy. Recent nonrandomized reports of small series have demonstrated good outcomes using less invasive approaches. No randomized clinical trials have been performed. Here, we provide a review of the literature and an approach to this problem based on expert opinion. METHODS The literature was reviewed utilizing PubMed, and a representative case of AST was presented to a panel of experts. Endocrinology, surgery, and infectious disease experts responded to a series of questions regarding diagnosis, management, prognosis, and harm. RESULTS Combining a broad spectrum of clinical expertise and the published literature, the authors suggest a clinical algorithm as a guide to management, addressing both diagnosis and acute and long-term management. CONCLUSIONS Published studies indicate a trend toward less invasive management during active inflammation and infection and regarding definite therapy. Remaining questions are presented to foster an evidence-based approach to this disease. Ideally, future randomized, controlled trials will provide data to improve the therapy and outcome of AST.

Is preoperative iodine 123 meta-iodobenzylguanidine scintigraphy routinely necessary before initial adrenalectomy for pheochromocytoma? ☆

BACKGROUND A decision to proceed with thyroidectomy or to perform more extensive thyroidectomy based on nodule size is controversial. It was our hypothesis that larger nodules are more likely to be malignant, and, as a result, nodule size may be useful for guiding operative decision making. METHODS Data was obtained from a prospectively maintained database for patients with nodular thyroid disease evaluated from 1990 to 2007. Logistic regression analysis was performed to determine if there was a significant relationship between nodule size and malignancy based on final pathology. The relationship of nodule size and malignancy was further evaluated for specific diagnostic categories of fine needle aspiration biopsy (FNAB). RESULTS 1023 patients were evaluated for nodular thyroid disease and 676 underwent thyroidectomy. Mean size was 4.4 +/- 2.4 cm for benign and 3.3 +/- 2.2 cm for malignant nodules (P < .05). The size of benign and malignant nodules, as a function of FNAB, was not significantly different. CONCLUSION Increasing nodule size was not predictive of thyroid malignancy suggesting that it should not be used in lieu of FNAB for therapeutic decision making.

Yield of repeat fine-needle aspiration biopsy and rate of malignancy in patients with atypia or follicular lesion of undetermined significance: The impact of the Bethesda System for Reporting Thyroid Cytopathology

BACKGROUND Observation following thyroidectomy and parathyroidectomy has been progressively shortened. The challenge has been to reduce the duration of postoperative observation without jeopardizing patient safety. METHODS A retrospective review of patients who underwent thyroidectomy and/or parathyroidectomy between July 1990 and March 2007 was completed to determine the frequency of life-threatening hematoma and hospital readmission and their impact on postoperative observation. RESULTS Of 1,050 patients, life-threatening hematoma developed in 6 (.6%) patients, 5 following bilateral and 1 following unilateral thyroidectomy. Hematoma developed 10 minutes to 7 days postoperatively, four within 4 hours, one at 21 hours, and one at 7 days. Twelve patients were readmitted an average of 5 days postoperatively for hypocalcemia, hematoma, infection, or respiratory distress. CONCLUSION Without factors contributing to bleeding, unilateral thyroidectomy and parathyroidectomy can be performed as an ambulatory procedure. To maximize safety, we recommend 4-hour and 23-hour observation following unilateral and bilateral thyroidectomy, respectively.