Jennifer H. Kuo

Renal Transplant Wound Complications in the Modern Era of Obesity

BACKGROUND Obesity is a known risk factor for wound complications following kidney transplantation (KTX), and obese transplant candidates are often encouraged to lose weight. The implications of this weight loss for post-KTX wound healing and morbidity have not been examined. Our aim was to study potential risk factors for post-KTX wound complications, with a specific focus on a history of significant weight loss. METHODS Single-center retrospective review of all KTX recipients ≥ 18 y performed 04/2004-03/2009. We studied potential donor-, transplant-, and recipient-related risk factors for wound complications by univariate and multivariate analyses. Graft and patient survival comparisons were done by Kaplan-Meier curves and two-sided log-rank test. RESULTS Overall wound complication incidence among the 487 study recipients was 6.4%. Significant independent risk factors for wound complications were BMI (odds ratio [OR] = 1.14 per 1 kg/m(2) increase), and history of significant weight loss (OR = 13.46), peri-KTX transfusion (OR = 5.42), and desensitization (OR = 60.34). Wound complications had no significant impact on graft and patient survival. CONCLUSIONS Our study demonstrates for the first time that besides BMI, pre-KTX desensitization, and peri-KTX transfusion, a history of significant pre-KTX weight loss is also an independent risk factor for post-KTX wound complications (potentially at least in part due to body contour changes resulting in an unfavorable abdominal panniculus). Further study of KTX candidates who have lost a significant amount of weight is warranted to (1) identify the exact causes for their increased propensity for complications and (2) devise measures to minimize added cost and morbidity. Finally, our findings suggest that the impact of weight loss on the outcomes of non-transplant operations also warrants further investigation.

Nonfunctional Pancreatic Neuroendocrine Tumors

Pancreatic neuroendocrine tumors are a group of rare, heterogeneous neoplasms that have been increasing in incidence the past few decades largely because of the diagnosis of pancreatic incidentalomas on cross-sectional imaging. Although these tumors are classically associated with clinical syndromes that result from excess secretion of particular hormones, most pancreatic neuroendocrine tumors are nonfunctional tumors presenting with symptoms secondary to mass effect, metastatic disease, or as incidental findings. This article reviews the diagnostic algorithm, surgical management, and available systemic therapies for nonfunctional pancreatic neuroendocrine tumors.

Breast cancer in thyroid cancer survivors: An analysis of the Surveillance, Epidemiology, and End Results-9 database

BACKGROUND We sought to further elucidate the increased risk for breast cancer among survivors of thyroid cancer. METHODS Using the Surveillance, Epidemiology, and End Results-9 database, we conducted a retrospective cohort analysis on women ≥ 18 years of age with breast and thyroid cancer from 1973 to 2011. RESULTS A total of 707,678 breast cancer patients and 53,853 thyroid cancer patients were included; 1,750 patients developed breast cancer after a preceding diagnosis of thyroid cancer (T1B). Age-specific risk for breast cancer was greater among thyroid cancer survivors. Incidence trends showed a significant age-time interaction and suggested a difference in thyroid cancer biology as well as a treatment effect. Compared with patients with thyroid cancer only, T1B patients were older with smaller cancers, had more follicular thyroid cancers, and fewer patients received radioactive iodine. T1B patients developed breast cancer earlier than the general population, had more estrogen receptor/progesterone receptor-positive and mixed invasive tumor histology, but smaller tumors, and there is no significant difference in the number of lymph nodes involved or radiation therapy. CONCLUSION Thyroid cancer survivors are at greater risk for developing breast cancer than the general population. These patients develop breast cancer early, have more estrogen receptor/progesterone receptor-positive tumors, and have a greater incidence of mixed invasive cancer. Recognition of this association between thyroid and breast cancer should prompt vigilant screening in thyroid cancer survivors and further investigation into the relationship of these 2 diseases.

Differences in single gland and multigland disease are seen in low biochemical profile primary hyperparathyroidism

Background. Primary hyperparathyroidism is characterized by increased levels of serum calcium and parathyroid hormone. Recently, 2 additional mild biochemical profiles have emerged, normocalcemic and normohormonal primary hyperparathyroidism. We reviewed our surgical experience of mild biochemical profile patients and compared them with classic primary hyperparathyroidism patients. Methods. This is a single institution, retrospective cohort review of all patients who underwent parathyroidectomy for primary hyperparathyroidism from 2006–2012. Preoperative and intraoperative variables were analyzed. Univariable analysis was performed with analysis of variance and the χ2 test. A logistic regression was performed to identify significantly independent predictor variables for multigland disease. Results. A total of 573 patients underwent parathyroidectomy for primary hyperparathyroidism (classic, n = 405; normohormonal, n = 96; normocalcemic, n = 72). Normocalcemic primary hyperparathyroidism was associated with multigland disease in 43 (45%, P < .001) patients as compared with the normohormonal (7, 10%) and classic (36, 9%) groups. On logistic regression, significant predictors for multigland disease were the normocalcemic subtype and positive family history. Twelve month biochemical normalization rates after operative treatment were >98% in all 3 groups. Conclusion. Our series shows that normocalcemic primary hyperparathyroidism is associated with a high incidence of multigland disease. Normohormonal disease is similar to classic disease patients with >90% presenting with single adenomas. Excellent rates of biochemical normalization can be obtained by operative treatment in all 3 groups.

Panniculectomy in end-stage renal disease: Six-year experience of performing panniculectomy in preparation for renal transplant

BackgroundPatients with end-stage renal disease evaluated for renal transplantation are frequently declined secondary to obesity and decreased functional status. As a result, many of these patients lose weight intentionally in an effort to gain candidacy on the transplant waiting list. This frequently produces a panniculus encompassing the lower abdominal surgical site used for renal transplantation. These patients are declined for renal transplantation secondary to predictable wound-healing complications. Materials and MethodsWe previously identified significant weight loss (>10 kg) before renal transplantation as a risk factor for wound-healing complications after kidney transplant. Since that time, we have successfully performed 21 panniculectomies in renal transplant candidates (5 men and 16 women) with an average age of 55 years (range, 27–67 years) and an average body mass index of 30.2 kg/m2 (range, 24.5–38.7 kg/m2) after significant weight loss, with an average maximum weight loss before panniculectomy of 37.7 kg (range, 5.5–83.2 kg), and median body mass index decrease before panniculectomy of 14 kg/m2 (range, 2.0–23.6 kg/m2). ResultsWe observed minor wound-healing complications (cellulitis or superficial wound separation) in 8 patients (38%), major wound-healing complications (hematoma, seroma, or unplanned return to the operating room) in 3 patients (14%), and no medical complications (defined as urinary tract infection, pulmonary embolism, pneumonia, deep venous thrombosis, central venous access loss, or myocardial infarction). Seventeen patients have been relisted on the transplant waiting list. Of the patients who have not been relisted on the transplant waiting list, no patient had his or her candidacy delayed secondary to complications of their panniculectomy. Of the patients who have been relisted, 6 have undergone transplantation. Of these 6 patients, no one has experienced wound-healing complications, 1 patient experienced delayed graft function and 1 patient experienced mild transaminitis resolved by discontinuing statin therapy. ConclusionsPanniculectomies in preparation for renal transplant may be performed in patients with end-stage renal disease with an acceptable complication rate, converting previously ineligible patients into eligible candidates for kidney transplant. It also seems those who undergo panniculectomy before kidney transplant may expect to have lower rates of wound complications after their transplant had they not had a panniculectomy.

Endocrine surgery in present-day academia.

BACKGROUND Endocrine surgery is a specialty that is evolving constantly. In this study, we sought to delineate the practice patterns of surgeons taking care of endocrine diseases in present-day academic centers. METHODS A review of the Faculty Practice Solutions Center database was conducted for the years 2005, 2009, and 2013. Practice patterns were determined by International Classification of Diseases, 9th Revision and Current Procedural Terminology codes, and analyzed for practice composition, regional variability, and volume of endocrine operations. RESULTS Of 97 national academic centers, 52 were identified to have 120 practicing American Association of Endocrine Surgeons (AAES) surgeons in the study. On average, endocrine operations comprise ∼65% of the AAES surgeons practice, and 51% are considered high-volume surgeons for thyroidectomy, parathyroidectomy, and adrenalectomy. Most non-AAES surgeons who perform endocrine operations are otolaryngologists (24.5%) and other general surgeons (18.5%). Overall, non-AAES surgeons perform the majority of endocrine operations at academic institutions (61.6%), and low-volume surgeons perform most of these operations (55.6%). CONCLUSION Research has shown that high-volume surgeons have improved outcomes. Even in academia, however, the majority of endocrine operations are performed by low-volume surgeons, suggesting that there is an opportunity for expanding the number of surgeons with expertise in endocrine surgery in present-day academic centers.

Rigid sternal fixation versus modified wire technique for poststernotomy closures: A retrospective cost analysis

Background Rigid sternal fixation (RSF) has been shown to reduce sternal wound complications in high-risk patients. However, the higher initial cost continues to deter its use. This study evaluates the cost of caring for high-risk sternotomy patients who underwent RSF compared with those who underwent sternal closure with a modified wire technique (MWT). Methods A retrospective single institution review of high-risk patients who underwent MWT (n = 45) and RSF (n = 30) for primary sternal closure from 2006 to 2009 was conducted. Total hospital cost, revenue, and net cost associated with surgery and subsequent care were analyzed. Results Overall rates of wound dehiscence and wound infections (superficial and deep) were higher in MWT patients (n = 14, 13, and 7, respectively) than RSF patients (n = 3, 2, and 0, respectively; P < 0.05). Modified wire technique patients also required more operations (mean ± SEM: 0.4 ± 0.1 vs 0.1 ± 0.1; P = 0.045), and had longer follow-up time (55.0 ± 9.1 vs 13.4 ± 10.5 days; P = 0.004). Overall, the hospital suffered a greater loss caring for MWT patients (US

Panniculectomy in preparation for renal transplantation: a new indication for an old procedure to reduce renal transplantation-associated wound complications.

18,903 ± 2,160) than RSF patients (US

Bone mineral density changes after parathyroidectomy are dependent on biochemical profile

8,935 ± 2,647). Modified wire technique patients who developed a complication had higher costs associated with their operative hospitalization, outpatient care, and home health than RSF patients (total net loss: US

Pre-operative localization of abnormal parathyroid tissue by 99m Tc-sestamibi in primary hyperparathyroidism using four-quadrant site analysis: an evaluation of the predictive value of vitamin D deficiency

41,436 ± 7327 vs US