Gustavo Fernandez-Ranvier

Transoral endoscopic thyroidectomy vestibular approach with intraoperative nerve monitoring

BackgroundTransoral endoscopic thyroidectomy by a vestibular approach (TOETVA) is a novel technique for thyroid gland excision. Compared to the transaxillary endoscopic and bilateral axillo-breast approaches, which require substantial dissection to reach the thyroid gland, TOETVA provides the most direct access to the target organ.MethodsThe aim of this video is to provide a step-by-step overview of TOETVA and demonstrate how to set up and utilize intraoperative nerve monitoring.ResultsThree incisions are placed in the vestibular region of the oral cavity just below the lower lip for placement of 2 lateral 5-mm trocars and 1 centrally placed 11-mm trocar. Insufflation to 6xa0mm Hg is used to maintain the working spacing. Using a 2-handed technique and triangulation, the thyroid gland is mobilized, taking care to identify and preserve the relevant cervical anatomy.ConclusionTOETVA is safe and feasible and provides an excellent cosmetic outcome with the most confidentially compared to the other remote access endoscopic approaches.

Insights into beta cell regeneration for diabetes via integration of molecular landscapes in human insulinomas

Although diabetes results in part from a deficiency of normal pancreatic beta cells, inducing human beta cells to regenerate is difficult. Reasoning that insulinomas hold the “genomic recipe” for beta cell expansion, we surveyed 38 human insulinomas to obtain insights into therapeutic pathways for beta cell regeneration. An integrative analysis of whole-exome and RNA-sequencing data was employed to extensively characterize the genomic and molecular landscape of insulinomas relative to normal beta cells. Here, we show at the pathway level that the majority of the insulinomas display mutations, copy number variants and/or dysregulation of epigenetic modifying genes, most prominently in the polycomb and trithorax families. Importantly, these processes are coupled to co-expression network modules associated with cell proliferation, revealing candidates for inducing beta cell regeneration. Validation of key computational predictions supports the concept that understanding the molecular complexity of insulinoma may be a valuable approach to diabetes drug discovery.Diabetes results in part from a deficiency of functional pancreatic beta cells. Here, the authors study the genomic and epigenetic landscapes of human insulinomas to gain insight into possible pathways for therapeutic beta cell regeneration, highlighting epigenetic genes and pathways.

Is bariatric surgery effective for co-morbidity resolution in the super-obese patients?

BACKGROUNDnType 2 diabetes (T2D), obstructive sleep apnea (OSA), hypertension (HTN), and hyperlipidemia (HLD) are common co-morbidities that are strongly associated with obesity.nnnOBJECTIVEnThe purpose of this study was to compare the rate of obesity-related co-morbidity remission and percent total body weight loss of super-obese patients with a body mass index (BMI) ≥50 kg/m2 with bariatric patients who have a BMI of 30 to 49.9 kg/m2.nnnSETTINGnAcademic hospital, United States.nnnMETHODSnA retrospective analysis of outcomes of a prospectively maintained database was done on obese patients with a diagnosis of ≥1 co-morbidity (T2D, OSA, HTN, or HLD) who at the time of initial visit had undergone either a sleeve gastrectomy or a Roux-en-Y gastric bypass at our hospital between 2011 and 2015. The patients were stratified based on their preoperative BMI class, BMI of 30 to 49.9 kg/m2 versus BMI ≥50 kg/m2.nnnRESULTSnOf the 930 patients, 732 underwent sleeve gastrectomy and 198 underwent Roux-en-Y gastric bypass. The 6-month follow-up co-morbidity remission rates for patients with a BMI of 30 to 49.9 kg/m2 (nu202f=u202f759) versus super-obese patients (nu202f=u202f171) were 46.0% and 36.7% (Pu202f=u202f.348) for T2D; 75.0% and 73.2% (Pu202f=u202f.772) for OSA; 35.0% and 22.0% (Pu202f=u202f.142) for HTN; and 37.0% and 21.0% (Pu202f=u202f.081) for HLD, respectively. The 1-year follow-up co-morbidity remission rates for patients with a BMI of 30 to 49.9 kg/m2 versus super-obese patients were 54.2% and 45.5% (Pu202f=u202f.460) for T2D; 87.0% and 89.7% (Pu202f=u202f.649) for OSA; 37.4% and 23.9% (Pu202f=u202f.081) for HTN; and 43.2% and 34.6% (Pu202f=u202f.422) for HLD, respectively. Furthermore, there was no difference in the mean percent total weight loss for patients with a preoperative BMI of 30 to 49.9 kg/m2 versus the super-obese at the 6-month (21.4%, 20.9%, Pu202f=u202f.612) and 1-year (28.0%, 30.7%, Pu202f=u202f.107) follow-ups.nnnCONCLUSIONnIn our study, preoperative BMI did not have an impact on postoperative co-morbidity remission rates or percent total body weight loss. Future studies should investigate the effect of other factors, such as disease severity and duration.

Resolution of Symptomatic Obstructive Sleep Apnea Not Impacted by Preoperative Body Mass Index, Choice of Operation Between Sleeve Gastrectomy and Roux-en-Y Gastric Bypass Surgery, or Severity

BackgroundObstructive sleep apnea (OSA) is a serious obesity-associated disorder that causes significant short- and long-term medical consequences.ObjectiveThe objective of this study is to compare the 6-month and 1-year postoperative symptomatic OSA remission rates of patients undergoing bariatric surgery based on their preoperative body mass index (BMI) stratification, type of bariatric operation—sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB)—and OSA severity.MethodsWe retrospectively analyzed 297 obese patients with a diagnosis of OSA who had undergone either SG or RYGB between 2011 and 2015.ResultsThe overall 6-month symptomatic OSA remission rate for patients (nxa0=u2009255) was 74.5%. At 6xa0months, patients with a preoperative BMI of 30–34.9xa0kg/m2 (class I), 35–39.9xa0kg/m2 (class II), and 40+u2009kg/m2 (class III) had 100, 70.0, and 75.0% (pxa0=u20090.2164) remission rates, respectively. The 6-month remission rates for SG and RYGB were 75.3 and 70.8% (pxa0=u20090.5165), respectively. The overall 1-year symptomatic OSA remission rate for patients (nxa0=u2009162) was 87.1%. At 1xa0year, class I, II, and III patients had 100, 85.7, and 87.5% (pxa0=u20090.5740) remission rates, respectively. The 1-year remission rates for SG and RYGB were 89.2 and 81.2% (pxa0=u20090.2189), respectively. A sub-analysis (nxa0=u200969) based on preoperative OSA severity levels did not affect the remission outcome at either the 6-month (pxa0=u20090.3670) or 1-year (pxa0=u20090.3004) follow-up.ConclusionMost obese patients experience symptomatic remission of their OSA after bariatric surgery, regardless of their preoperative BMI, choice of operation, or OSA severity.

Preoperative insulin therapy as a marker for type 2 diabetes remission in obese patients after bariatric surgery

BACKGROUNDnObesity not only increases the chances of developing diabetes-one of the top causes of death in the United States-but it also results in further medical complications.nnnOBJECTIVEnTo compare the 6-month and 1-year postoperative remission rates of type 2 diabetic (T2D) patients after bariatric surgery based on preoperative glycosylated hemoglobin (A1C) stratification and pharmacologic therapy: insulin-dependent diabetic (IDD) versus noninsulin-dependent diabetic (NIDD).nnnSETTINGnAcademic hospital, United States.nnnMETHODSnWe retrospectively analyzed a prospectively maintained database of 186 obese patients with a diagnosis T2D who had undergone either a sleeve gastrectomy or a Roux-en-Y gastric bypass surgery at our hospital.nnnRESULTSnAt 6 months (n = 180), patients who were stratified by preoperative A1C levels (<6.5; ≥6.5 to<8; ≥8) had 70.5%, 51.7%, and 30.0% remission rates (P<.001) and at 1 year (n = 118) patients had 72.0%, 54.0%, and 42.8% remission rates (P = .053), respectively. When patients were substratified by preoperative pharmacologic therapy, IDD and NIDD patients had different remission rates within the same A1C level. At 6-months follow-up within A1C ≥6.5 to<8 (IDD versus NIDD), the remission rate was 23.5% versus 64.1% (odds ratio [OR]: .173, confidence interval [CI]: .0471, .6308, P = .0079), and within A1C ≥8 the remission was 24.0% versus 37.5% (OR: .5263, CI: .2115, 1.3096, P = .1676), respectively. At 1-year follow-up within A1C ≥6.5 to<8, the remission rate was 30.0% versus 62.9% (OR: .2521, CI: .0529, 1.2019, P = .0838), and within A1C ≥8 the remission was 31.4% versus 61.9% (OR: .2821, CI: .0908, .8762, P = .0286), respectively. Furthermore, when IDD patients were compared between A1C ≥6.5 to<8 and A1C ≥8 the remission rates were nearly identical, and for NIDD patients A1C was not significantly associated with remission regardless of the level, except at 6 months.nnnCONCLUSIONnWhile a difference was observed between overall A1C levels-the lower the A1C level, the higher the remission rate-IDD patients had lower remission rates than NIDD patients irrespective of A1C levels; further, IDD patients performed similarly across A1C levels.

Minimally invasive adrenal surgery: virtue or vice?

Adrenocortical carcinoma (ACC) is a rare malignancy associated with poor prognosis despite available treatments. In patients with localized or locally advanced disease, complete resection with negative margins offers the only potential for cure. Unfortunately, most patients develop local and distant recurrence following initial resection highlighting the importance of meticulous surgical technique in the hands of an experienced surgeon. While minimally invasive surgery (MIS) has supplanted open surgery for small to medium-sized benign adrenal tumors, controversy surrounds the use of MIS for resection of ACC. We sought to provide an overview of the key oncological principles in the surgical management of ACC and to critically review the literature comparing outcomes between the open and MIS approaches.