James R. Starling

A comprehensive evaluation of perioperative adjuncts during minimally invasive parathyroidectomy: which is most reliable?

Objective:To determine the utility of several perioperative adjuncts for parathyroid localization during parathyroid surgery, we prospectively compared the accuracy of sestamibi–single photon emission computed tomography (SPECT) scanning, radioguided surgery, and intraoperative parathyroid hormone (ioPTH) testing. Summary and Background Data:Minimally invasive parathyroidectomy (MIP) is rapidly becoming the procedure of choice in patients with primary hyperparathyroidism (HPT). Several perioperative adjuncts can be used to localize parathyroid adenomas, including sestamibi-SPECT scanning, radioguided surgery, and ioPTH testing. However, the relative value of each of these technologies is unclear. Methods:Between March 2001 through September 2004, 254 patients with primary HPT underwent parathyroidectomy. All patients had preoperative imaging studies and underwent radioguided surgery with a gamma probe and ioPTH testing. The use of each perioperative adjunct was determined based on the intraoperative findings. Results:The mean age of patients was 61 ± 1 year. The mean calcium and parathyroid hormone levels were 11.4 ± 0.1 mg/dL and 136 ± 6 pg/mL, respectively. Of the 254 patients, 206 (81%) had a single parathyroid adenoma, 28 (11%) had double adenomas, 19 (8%) had hyperplasia, and one had parathyroid cancer. All resected parathyroid glands were hypercellular (mean weight = 895 ± 86 mg). The cure rate after parathyroidectomy was 98%. The positive predictive values for sestamibi scanning, radioguided surgery, and ioPTH testing were 81%, 88%, and 99.5%, respectively. Conclusions:This series is one of the largest to date that prospectively compares the use of sestamibi scanning, radioguided surgery, and ioPTH testing. Of all the perioperative adjuncts used during parathyroid surgery, ioPTH testing has the highest sensitivity, positive predictive value, and accuracy. Thus, the inherent variability of sestamibi scanning and radioguided techniques emphasizes the critical role of ioPTH testing during parathyroid surgery.

Radioguided Parathyroidectomy Is Equally Effective for Both Adenomatous and Hyperplastic Glands

Objective To determine the utility of radioguided parathyroidectomy for patients with hyperparathyroidism, we studied the properties of 180 resected, hyperfunctioning parathyroid glands. Summary and Background Data Radioguided resection of hyperfunctioning parathyroid glands has been shown to be technically feasible in patients with parathyroid adenomas. Radioguided excision may obviate the need for intraoperative frozen section because excised parathyroid adenomas uniformly have radionuclide ex vivo counts >20% of background. The feasibility and applicability of radioguided techniques for patients with parathyroid hyperplasia are unclear. Methods Between March 2001 and September 2002, 102 patients underwent neck exploration for primary (n = 77) and secondary/tertiary (n = 25) hyperparathyroidism. All patients received an injection of 10 mCi of Tc-99m sestamibi the day of surgery. Using a gamma probe, intraoperative scanning was performed, looking for in vivo radionuclide counts > background to localize abnormal parathyroid glands. After excision, radionuclide counts of each ex vivo parathyroid gland were determined and expressed as a percentage of background counts. Results Although patients with single adenomas had higher mean background radionuclide counts, the average in vivo counts of all enlarged glands were higher than background. Notably, in vivo counts did not differ between adenomatous and hyperplastic glands, suggesting equal sensitivity for intraoperative gamma detection. Ectopically located glands were identified in 22 cases and all were accurately localized using the gamma probe. Postresection, mean ex vivo radionuclide counts were highest in the single parathyroid adenomas and lowest in hyperplastic glands. Importantly, in all hyperplastic glands, the ex vivo counts were >20%. Conclusions In patients with hyperparathyroidism, radioguided surgery is a sensitive adjunct for the intraoperative localization of both adenomatous and hyperplastic glands. In this series, all 180 enlarged parathyroids were located with the gamma probe. We have also shown that the “>20% rule” for ex vivo counts not only applies to parathyroid adenomas but also to hyperplastic glands. Therefore, radioguided resection is equally effective and informative for both adenomatous and hyperplastic glands.

Lessons learned from the first 100 cases in a new minimally invasive bariatric surgery program

Background:Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is a technically demanding procedure with a steep learning curve. Experienced laparoscopic surgeons and bariatric surgeons can learn from the outcomes and complications of their initial experience in LRYGBP.n Methods: Between August of 2002 and July of 2003, we performed our first 100 LRYGBPs. Our surgical technique involves the ante-colic, ante-gastric placement of the Roux-limb. A 21-mm circular stapler is used to create the gastrojejunostomy. The stapler anvil is placed transgastrically.n Results:The mean preoperative BMI was 49.7 kg/m2 (range 37-70). 12% of patients were male. Early complications (14%) included 3 leaks, 4 bleeding episodes and 2 gastrogastric fistulas. There was 1 peri-operative mortality and 1 conversion to laparotomy. Late complications (17%) included stenosis of the gastrojejunostomy which occurred in 14 patients. Leaks occurred more commonly in males (16% vs 1%, P<0.05). Elevated BMI was also found to be a risk factor for leak (BMI 58.7 leak vs 49.3 no leak, P<0.05). Stenosis was often associated with other complications such as leak or marginal ulcer. Stenosis responded well to endoscopic dilation. Co-morbid medical conditions responded to weight loss in all patients, regardless of initial BMI. Mean excess weight loss was 69% at 1 year, but varied according to preoperative BMI. Conclusions: Careful recording of patient outcomes and complications is important, particularly in a new minimally invasive bariatric surgery program. Review and analysis of specific complications may help to minimize the occurrence of similar subsequent complications.

A 25-Year Single Institution Analysis of Health, Practice, and Fate of General Surgeons

Objective:The objective of this study was to analyze nearly 3 decades of surgical residents from an established training program to carefully define individual outcomes on personal and professional health and practice satisfaction. Summary Background Data:A paucity of data exists regarding the health and related practice issues of surgeons postresidency training. Despite several studies examining surgeon burnout and alcohol dependency problems, there have been no detailed reports defining health problems in practicing surgeons or preventive health patterns in this physician population. Important practice factors, including family and practice stress, that may impact on surgical career longevity and satisfaction have similarly received minimal focused examination. Methods:All former surgery residents at the University of Wisconsin from 1978 to 2002 were contacted. Detailed direct interview or phone contact was made to ensure confidentiality and to obtain reliable data. Interviews concentrated on serious health and practice issues since residency completion. Results:One hundred ten of 114 (97%) former residents were contacted. There were 100 males and 14 females with 2 deaths (accident, suicide). Including deaths and those lost to follow up, 15 (13.2%) were nonpracticing; 5 voluntarily (3 planned, 1 accident, 1 arthritis) and 4 involuntarily (alcohol/substance dependency). Eighty-nine percent were married or remarried with a 21.4% divorce rate postresidency. Major health issues occurred in 32% of all surveyed and in 50% of those ages ≥50. Only 10% reported complete lack of weekly exercise activity with 62% exercising at least 3 times per week. Body mass index increased from 23.9 ± 1.5 kg/m2 (age <40) to 26.6 ± 3.0 kg/m2 (P = 0.009) by age ≥50. Alcohol dependency was confirmed in 7.3%. Overall, 75% of surgeons surveyed were satisfied with their practice/career. Conclusion:Despite a high job satisfaction rate, surgeon health may be compromised in up to 50% by age ≥50, with a 20% voluntary or involuntary retirement rate. Alcohol dependency occurred in up to 7.3% of surgeons, which contributed to the practice attrition rate. The success and length of a career in surgery is defined by postresidency factors rarely examined during training and include major and minor health issues, preventive health patterns/exercise, alcohol use or dependency, family life, and practice satisfaction. Surgeons mentoring during the course of surgical training should be improved to inform of important health and practice issues and consequences.

The impact of circular stapler diameter on the incidence of gastrojejunostomy stenosis and weight loss following laparoscopic Roux-en-Y gastric bypass.

BackgroundGastrojejunostomy stenosis after laparoscopic Roux-en-Y gastric bypass is a common occurrence. The incidence varies widely among reported series. We evaluated the impact of circular stapler size on the rate of stenosis and weight loss.MethodsOur initial technique utilized a 21-mm circular stapler to construct the gastrojejunostomy. We switched to a 25-mm stapler after a large preliminary experience. Stenosis was confirmed by endoscopy in patients complaining of the inability to eat or excessive vomiting, and was defined as a gastrojejunostomy diameter less than that of a therapeutic endoscope (11-mm).ResultsStenosis occurred in 23 of 145 patients (15.9%) with a 21-mm gastrojejunostomy. Five of 81 patients with a 25-mm circular stapled anastomosis have developed a stenosis (6.2%, p = 0.03). Weight loss was similar for each sized stapler at 6 and 12 months.ConclusionsThe use of a 25-mm circular stapler in laparoscopic gastric bypass is preferable to a 21-mm stapler. The larger stapler is associated with a significantly decreased incidence of gastrojejunostomy stenosis without compromising early weight loss.

Radioguided parathyroidectomy in patients with secondary and tertiary hyperparathyroidism.

BACKGROUND To date there have been no reports on the feasibility of radioguided parathyroidectomy (RGP) in patients with secondary and tertiary hyperparathyroidism. METHODS Twenty-three consecutive patients with secondary (n=5) or tertiary hyperparathyroidism (n=18) underwent RGP. Patients were injected with 10 mCi of technetium 99-sestamibi before surgery. All parathyroid glands were localized during operation with a neoprobe. RESULTS The mean patient age was 50+/-3 years. The mean preoperative calcium and intact parathyroid hormone levels were 11.0+/-0.3 mg/dL and 400+/-107 pg/mL, respectively. Eighteen patients had 3- or 4-gland hyperplasia, 2 had double adenomas, 2 had forearm graft hyperplasia, 1 had 6-gland disease, and 3 had ectopic glands. All hyperplastic glands had ex vivo counts >20% of background (mean, 63%+/-6%), making frozen section unnecessary. When compared with 66 historical control subjects who underwent surgery without radioguidance for tertiary hyperparathyroidism, patients undergoing RGP had decreased operative times (96+/-8 minutes vs 151+/-15 minutes; P<.001) and lengths of stay (1.3+/-0.1 days vs 3.7+/-0.3 days; P<.001). CONCLUSIONS RGP in patients with secondary and tertiary hyperparathyroidism is feasible, may reduce operative time, and permits omission of frozen section. Thus RGP appears to be a useful adjunct in the treatment of secondary and tertiary hyperparathyroidism.

Long-Term Follow-Up of Patients With Tertiary Hyperparathyroidism Treated by Resection of a Single or Double Adenoma

ObjectiveTo determine whether patients with tertiary hyperparathyroidism due to single- or two-gland disease undergoing limited resection have similar long-term outcomes compared with patients with hyperplasia undergoing subtotal or total parathyroidectomy. Summary Background DataTertiary hyperparathyroidism occurs in less than 2% of patients after renal transplantation. Approximately 30% of these cases are caused by one or two hyperfunctioning glands. Nevertheless, the standard operation for this disease has been subtotal or total parathyroidectomy with autotransplantation. MethodsSeventy-one patients underwent surgery for tertiary hyperparathyroidism. At the time of surgery, 19 patients who had a single or double adenoma underwent limited resection of the enlarged glands only (adenoma group). The remaining 52 patients with three- or four-gland hyperplasia had subtotal or total parathyroidectomy with implantation (hyper group). Long-term cure rates between the two groups were compared. ResultsIn the adenoma group, 7 patients had a single adenoma and 12 underwent resection of a double adenoma. In the hyper group, 49 patients had subtotal and 3 had total parathyroidectomies. After surgery, 70 of 71 patients (99%) were cured of their hypercalcemia. The incidence of postoperative transient hypocalcemia was significantly higher in the hyper group (27% vs. 5%). No patients in either group had permanent hypocalcemia requiring long-term supplementation. With up to 16 years of follow-up, there have been no recurrences in the adenoma group, whereas three patients (6%) in the hyper group have had recurrent or persistent hyperparathyroidism. ConclusionsPatients with tertiary hyperparathyroidism who underwent limited resection of a single or double adenoma only had equivalent long-term cure rates compared with patients undergoing more extensive resections. Therefore, the authors recommend in patients with tertiary hyperparathyroidism and enlargement of only one or two parathyroid glands that the resection be limited to these abnormal glands only.

Management of paraesophageal hernia with a selective approach to antireflux surgery

BACKGROUND The role of an antireflux procedure in the management of paraesophageal hernia is controversial. To address this issue, we reviewed our experience with selective use of antireflux procedures in patients with pure paraesophageal hernia (type II; n = 26) and those with a partial sliding component (type III; n = 11). PATIENTS AND METHODS Surgical repair was performed on diagnosis in all 37 patients. Competency of the lower esophageal sphincter was evaluated on the basis of reflux symptoms, and objectively, with endoscopy in 21 patients and 24-hour esophageal pH studies in 17 patients. Repair included an antireflux procedure in 11 patients, as indicated by reflux disease. RESULTS Preoperatively, 80% of both type II and type III patients reported obstructive symptoms. Reflux symptoms were present in 27% of patients--19% of type II and 45% of type III patients. Endoscopy revealed esophagitis in 5 cases, and 24-hour pH studies indicated significant reflux in 3 of 17 patients. There were no operative deaths and 1 recurrence. Symptoms improved in 92% of patients after surgery. Medically manageable reflux was identified in 2 patients. CONCLUSIONS Frequent obstructive symptoms and the potential for gastric volvulus indicate elective repair of paraesophageal hernia on diagnosis. Significant gastroesophageal reflux is less common, especially in type II patients, and excellent symptomatic results are obtained with selective application of an antireflux procedure.

Fine-needle aspiration optimizes surgical management in patients with thyroid cancer

BackgroundFine-needle aspiration (FNA) is accurate in diagnosing papillary, medullary, and anaplastic thyroid cancer, as well as lymphoma. Although many surgeons routinely perform FNA before surgery, some question whether FNA influences operative management. Therefore, to determine whether FNA affects surgical management in patients with thyroid cancer, we reviewed our experience.MethodsA total of 442 consecutive patients underwent thyroid surgery at 1 academic center. Of these, 411 had surgery for an index nodule in the absence of previous radiation or familial thyroid cancer. FNA, operative, and permanent histology findings were reviewed.ResultsThe average patient age was 46 years, and 79% were female. A total of 211 patients (51%) had a preoperative FNA, and 71 (17%) had a final diagnosis of cancer. The sensitivity and specificity of FNA for thyroid cancer were 89% and 92%, respectively. In the FNA group, 1 (2.4%) of 41 patients with papillary thyroid cancer required completion thyroidectomy. In contrast, in the no-FNA group, 4 (40%) of 10 patients with papillary thyroid cancer required a second operation. No patient in the FNA group received thyroid resection for lymphoma, whereas three (100%) of three patients with lymphoma in the no-FNA group were treated surgically. A total of 98% of the FNA group, compared with 54% of the no-FNA group, received optimal surgical treatment for thyroid cancer.ConclusionsFNA is a sensitive and specific test for the diagnosis of thyroid cancer, allowing definitive initial surgery and avoiding unnecessary procedures. Therefore, we recommend routine use of preoperative thyroid FNA, even in those patients in whom a resection is already planned.

Laparoscopic gastric bypass results in decreased prescription medication costs within 6 months.

The prevalence of obesity has reached epidemic proportions. The treatment of obesity-related health conditions is costly. Although laparoscopic gastric bypass is expensive, health care costs in obese patients should decrease with subsequent weight loss and overall improved health. Specifically, monthly prescription medication costs should decrease quickly after surgery. Fifty consecutive laparoscopic gastric bypass patients at a university-based bariatric surgery program were enrolled in the study. Medication consumption was prospectively recorded in a database. Patients’ monthly prescription (not over-the-counter) medication costs before surgery and 6 months postoperatively were calculated. Retail costs were determined by a query to drugstore.com, an online pharmacy. Generic drugs were selected when appropriate. Costs for diabetic supplies and monitoring were not included in this analysis. Patients were mostly female (86%). Mean body mass index preoperatively was 51 kg/m2. Mean excess weight loss at 6 months was 52%. Patients took an average of 3.7 prescription medications before surgery compared with 1.7 after surgery (P < 0.05). All patients took nonprescription nutritional supplements, including multivitamins, oral vitamin B12, and calcium postoperatively. Laparoscopic gastric bypass resulted in a significant improvement in comorbid health conditions as early as 6 months after surgery. In an unselected group of patients, this led to a substantial overall mean monthly prescription medication cost savings, especially in those with gastroesophageal reflux disease, hypertension, diabetes, and hypercholesterolemia.