Melanie L. Richards

An Optimal Algorithm for Intraoperative Parathyroid Hormone Monitoring

BACKGROUND A minimally invasive approach to primary hyperparathyroidism is equivalent to bilateral exploration when intraoperative parathyroid hormone (IOPTH) monitoring is used. The optimal strategy for the monitoring has been debated. HYPOTHESIS There exists an optimal strategy for IOPTH monitoring. DESIGN Retrospective study. SETTING Tertiary referral hospital. PATIENTS AND METHODS A total of 1882 patients underwent parathyroidectomy for primary hyperparathyroidism with IOPTH monitoring. Successful exploration was defined as a 50% or more decline in IOPTH level from baseline and a normal or near-normal IOPTH level at 10 minutes postexcision. These results were compared with those of alternative strategies for IOPTH monitoring, including a 50% decline at 10 minutes, 50% decline at 5 minutes, and normal IOPTH levels at 10 minutes, using the preoperative parathyroid level as baseline. RESULTS A curative operation was performed in 1830 patients (97.2%). The current strategy had a sensitivity of 96% and an accuracy of 95%. Multiglandular disease was present in 271 patients (14.5%); 134 of 1858 patients (7.2%) whose outcomes failed to reach curative criteria had confirmed multiglandular disease. Using only a 50% decline from baseline as the curative criterion would result in a failed operation in 22.4% of patients with multiglandular disease. A 50% decline at 10 minutes was 96% sensitive and 94% accurate. A 5-minute value was 79% sensitive and 80% accurate. With use of the 5-minute value, unnecessary bilateral exploration would have been performed in 272 of 1460 patients (18.6%) compared with 62 of 1750 patients (3.5%) when using a 10-minute value. A normal 10-minute value is 91% sensitive and 90% accurate. CONCLUSIONS A 10-minute postexcision IOPTH level that decreased 50% from baseline and is normal or near normal is highly successful. Relying on a 50% decrease alone increases the rate of operative failure in patients with multiglandular disease.

Regression of type II gastric carcinoids in multiple endocrine neoplasia type 1 patients with Zollinger-Ellison syndrome after surgical excision of all gastrinomas

Enterochromaffin-like (ECL) tumors are documented in patients with hypergastrinemia secondary to chronic atrophic gastritis or with Zollinger-Ellison syndrome and multiple endocrine neoplasia type 1 (ZES-MEN-1). In patients with ECL tumors and atrophic gastritis, normogastrinemia after antrectomy has resulted in resolution, regression, or stabilization of ECL tumors. The natural history of ECL tumors associated with ZES-MEN-1 following normalization of gastrin levels after gastrinoma resection has not been previously reported. The purpose of this study was to determine the course of ECL tumors in patients with ZES-MEN-1 following normalization of serum gastrin levels after gastrinoma resection. Two patients with ZES-MEN-1 had biopsy-proven ECL tumors on endoscopic evaluation. They then underwent surgical exploration that included distal pancreatectomy, enucleation of pancreatic head tumors, duodenotomy with excision of submucosal tumors, and peripancreatic lymphadenectomy. Gastric ECL tumors larger than 1.0 cm were locally excised. Patients underwent long-term follow-up with biochemical and endoscopic surveillance. Normogastrinemia was achieved and sustained following gastrinoma resection in two patients with ZES-MEN-1. Periodic endoscopic surveillance over a 6-year period showed complete resolution of the ECL tumors. The development of ECL tumors associated with ZES-MEN-1 is multifactorial. Studies identified a genetic influence on tumor growth with loss of heterozygosity at the MEN-1 gene locus in ECL tumors. The resolution of ECL tumors in ZES-MEN-1 patients who are normogastrinemic indicates that an elevated gastrin level is a primary initiator for development of these tumors. Therefore both genetic defects and hypergastrinemia are causative agents. Normalization of serum gastrin levels is critical for the prevention of aggressive forms of ECL tumors.

Laparoscopic cholecystectomy for biliary dyskinesia: Correlation of preoperative cholecystokinin cholescintigraphy results with postoperative outcome

BackgroundA gallbladder ejection fraction (EF) on cholescintigraphy of less than 35% after cholecystokinin (CCK) has been considered to be pathophysiologic and an indication for laparoscopic cholecystectomy (LC).MethodsAll patients undergoing LC for biliary dyskinesia between 1994 and 2001 were prospectively entered into a database. These patients were retrospectively evaluated with regard to demographics, the number of preoperative studies obtained, postoperative symptoms, and the number of postoperative studies obtained.ResultsSixty patients underwent LC for biliary dyskinesia. The mean gallbladder EF was 14%, and 75% of patients were asymptomatic postoperatively. Persistent symptoms prompted further investigation in 6% of patients with a gallbladder EF <14% and in 35% of patients with an EF between 14 and 35% (p = 0.05).ConclusionLaparoscopic cholecystectomy alleviated symptoms in 94% of patients with a gallbladder EF <14% after CCK injection. The diagnostic significance of a preoperative CCK cholescintigram (EF 14–35%) needs further investigation.

Early conversion for gangrenous cholecystitis: impact on outcome

BackgroundEarly conversion from laparoscopic to open cholecystectomy for patients with gangrenous cholecystitis has been advocated. This study investigated the impact of early conversion on patient outcome.MethodsData from all patients with gangrenous cholecystitis undergoing laparoscopic cholecystectomy between 1992 and 2002 whose procedure had been converted to open surgery were prospectively collected and analyzed. Morbidity, length of stay, intensive care unit admission, and operative time served as outcome measures.ResultsOf the 97 patients in the study, 33 underwent conversion to open cholecystectomy. The conversion was early for 24% of the patients, after the initial dissection, for 33% and after an extended attempt at completion of the laparoscopic cholecystectomy for 37%. There was no difference in the overall morbidity among the groups, whereas the length of hospital stay appeared to be longer in the early conversion group. The operative time was significantly shorter after early conversion (p < 0.01, chi-square test).ConclusionLaparoscopic cholecystectomy is not feasible for all patients with gangrenous cholecystitis. However, a concerted effort to perform the cholecystectomy with the minimally invasive approach does not have an adverse impact on patient outcome and is likely to benefit patients although it poses a moderate risk of conversion.

Rectal bleeding in a woman with a thyroid mass.

CLINICAL PRESENTATION: (Dr. D. Wiley) A 32-yearold Caucasian woman presented with an enlarging right neck mass. The mass had been present for 2 years and was associated with dysphagia. She has had no hoarseness or symptoms of respiratory compression. She had been clinically euthyroid. She had no history of radiation exposure or therapy. Medical history was significant for a newly diagnosed irondeficient anemia. The patient was adopted after the death of her mother in her mid-thirties. The patient’s adoptive mother stated that her natural mother had a colostomy. There was no known family history of thyroid disease. Review of systems was remarkable for oligomenorrhea, dyspareunia, and hematochezia. On physical examination, the patient had a marfanoid body habitus with a height of 6 0 and a weight of 122#. There were multiple nodules consistent with fibromas located primarily on her face. Her thyroid was nodular with a dominant 6-cm mass in the right lobe. No cervical lymphadenopathy was palpable. Her heart was regular, lungs were clear to auscultation, breasts were without masses, and her abdominal examination benign. Rectal examination was significant for guaiac-positive stool, and no masses were palpable. Laboratory findings at this time included a normal thyroidstimulating hormone level of 0.6 uIU/ml and a hemoglobin level of 13.0 g/dl. A fine-needle aspiration of the right thyroid mass was suspicious for papillary thyroid carcinoma. Colonoscopy identified pancolonic polyposis, consistent with familial adenomatous polyposis. Multiple biopsies throughout the colon and rectum identified tubulovillous and adenomatous polyps on histopathology. An upper endoscopic evaluation identified multiple adenomatous duodenal polyps measuring 1 to 2 mm in size. A computed tomography (CT) of the abdomen and pelvis at this time was unremarkable. Bilateral mammography was negative for malignancy. The patient underwent a total thyroidectomy without complication. Final pathology confirmed a bilateral multifocal papillary carcinoma with the largest lesion measuring 6 cm. There were 4 separate foci, 2 in each lobe. Two of these were classic papillary and the other 2, including the 6-cm lesion, had atypical patterns. These lesions were more solid with less differentiation and the presence of “squamous morules” (Fig. 1). There was no evidence of lymph node metastases.

Chest pain in a woman with Marfan syndrome

CLINICAL PRESENTATION: (Dr. C. Lewis) A 32-yearold Hispanic woman with Marfan syndrome presented to the emergency room following the acute onset of left-sided chest pain radiating to her back and left shoulder. In addition, she described mild shortness of breath without cough, hemoptysis, or neurologic symptoms. Her medical history was significant for ectopia lentis as child, but she did not meet clinical criteria for Marfan syndrome until age 26 years. At that time, she developed chest pain and was found on imaging studies to have a chronic ascending aortic dissection. She underwent aortic root and aortic valve replacement using the Bentall technique. The ascending graft required revision in 1997. This was followed by the development of a Stanford type B aortic dissection, which was managed nonoperatively. She has peripheral vascular disease and hypertension, for which she takes verapamil and metoprolol. She has been on chronic anti-coagulation for her prosthetic aortic valve. Her history is also significant for a posterior hip dislocation in 1996. No known family history of Marfan syndrome exists. On initial examination, the patient was tearful and in moderate distress. Her breathing was labored, with a respiratory rate of 40 breaths/minute. Her blood pressure was 130/88, and her heart rate was regular at 129 beats/minute. On auscultation, she had diminished breath sounds at the left lung base. The right lung was clear. The radial pulse was 2 on the right and 1 on the left. Femoral pulses were 2 on the right and 1 on the left. The distal lower extremities were cool but viable, with trace pedal pulses bilaterally. Neurologic function was grossly intact. A chest radiograph was obtained that showed a widened mediastinum (12.5 cm) and a left pleural effusion (Fig. 1). An aortic dissection with a possible rupture was suspected, and she was started on esmolol and nipride drips. Laboratory studies included a hematocrit of 31.9, a platelet count of 458,000, an international normalized ratio (INR) of 2.2, and a partial thromboplastin (PTT) of 31.1. The patient was resuscitated with intravenous fluids and a transfusion of fresh frozen plasma (FFP). A chest computed tomographic (CT) scan was obtained. The CT scan identified her known type B dissection (Crawford type III) from the thoracic aorta beginning after the left subclavian artery and extending to the aortic bifurcation (Figs. 2 and 3). A large left hemothorax was present, and the right kidney was atrophic. A diagnosis of a ruptured descending aortic aneurysm was made, and the descending thoracic aorta was repaired using cardiopulmonary bypass. Intraoperatively, the patient received 16 units of packed red blood cells (PRBCs), 10 units of FFP, 20 units of cryoprecipitate, and 2 units of platelets. She was extubated and removed from intravenous antihypertensive medications by postoperative day 2. On hospital day 9, she was discharged without complications on metoprolol, fosinopril, and coumadin. At 3 weeks postoperatively, she complained of back pain. A CT scan was obtained that identified a probable pseudoaneurysm at the level of the proximal descending aorta. The aneurysmal dilation measured 5.1 cm. The patient was referred to vascular surgery. An arteriogram further defined the descending thoracic aneurysm and a pseudoaneurysm originating at the T-7 vertebral body (Figs. 4 and 5).

Calcified hepatic cyst

CLINICAL PRESENTATION: (Dr. E. Wiley) A 55-yearold Hispanic man was referred to the general surgery service by his primary care physician for management of a liver lesion. At his initial presentation, the patient had complained of 3 months of persistent but mild mid-epigastric pain associated with slight anorexia but no apparent weight loss. He denied fever, nausea, vomiting, or change in bowel habits, and his symptoms gradually resolved with only conservative measures. However, an abdominal computed tomographic (CT) scan obtained early in his evaluation demonstrated an unsuspected, large, calcified cyst in the right lobe of the liver (Fig. 1). Otherwise, his medical history was unremarkable, without previous operations, hospitalizations, or abdominal trauma. He described occasional social drinking but denied smoking or the use of illicit drugs. He was employed as a truck driver, and his international travel was limited to northern Mexico. On examination, the patient was alert, oriented, ambulatory, and comfortable. His blood pressure was 110/78 with a regular pulse and appropriate respirations. His heart and lungs appeared unremarkable, whereas his abdomen was scaphoid, soft, and nontender, with no palpable masses or organomegaly. All laboratory values were within normal limits with the hematocrit 41.2%, the white blood cell count 7800, and the total bilirubin 0.5 mg/dL. A hepatitis panel was negative, and both the amebic serology and the echinococcal enzyme-linked immunosorbent assay (ELISA) were nondiagnostic.

Back pain and fever

CLINICAL PRESENTATION: (Dr. A. Kushner) A 54year-old Mexican-American woman presented to the emergency center approximately 3 months after falling on her hip while mopping a floor. She denied loss of consciousness or any subsequent difficulty walking. However, during the past month, she had developed increasingly severe pain in her lower back. She had been seen in a local physician’s office and treated for a urinary tract infection with antibiotics and muscle relaxants, but the pain had worsened and subjective fevers had developed. By history, the patient was generally healthy and had not been previously hospitalized. She denied hypertension, diabetes, or cardiac or pulmonary diseases. She had undergone no previous operations and was receiving no chronic or prescription medications. She denied the use of alcohol, cigarettes, or illicit drugs. On examination, the patient appeared alert but acutely uncomfortable with a fever of 101°, a regular pulse of 98, and a blood pressure of 120/72 mm Hg. Her cardiopulmonary examination was normal, and her abdomen was flat and soft without masses, organomegaly, or tenderness. However, her back was moderately tender to percussion in the lumbar area, especially on the right side. In addition, marked discomfort was present with extreme flexion or external rotation of the right hip. Sensorimotor function was intact in all extremities, and deep tendon reflexes were symmetric and brisk. Laboratory results were unremarkable except for a white blood cell count of 16,600. All liver function tests and the serum creatinine and blood urea nitrogen values were normal. A contrast-enhanced computed tomographic (CT) scan of the abdomen and pelvis demonstrated a large, loculated fluid collection within the right iliopsoas muscle compartment (Fig. 1). Right-sided hydronephrosis was also present and was associated with dilation of the ureter proximal to the area of inflammation. Osteolysis was noted in the vertebral body that was adjacent to the fluid collection. All abdominal and pelvic viscera appeared normal. GROUP DISCUSSION: (Faculty) It was agreed that the presence of a well-defined inflammatory collection within the psoas muscle mandates rigorous therapy with antibiotics and drainage. Several discussants suggested that interventional radiological methods should be used to gain initial control and that operative therapy should be reserved for intractable cases or radiological failures. Neurosurgical consultation was considered advisable to assist in the management of the apparent vertebral and disk infection.

Gallbladder mass in a sexagenarian.

CLINICAL PRESENTATION: (Dr. J. Metersky) A 69year-old white man was referred for management of a symptomatic ventral hernia, but during his preoperative evaluation he was found to have microhematuria. A subsequent computed tomographic (CT) intravenous pyelogram demonstrated an enhancing 3.8-cm mass originating in the gallbladder with apparent extension into the hepatic parenchyma (Fig. 1). In retrospect, the patient acknowledged a recent onset of mild, steady supraumbilical pain but denied nausea, vomiting, fever, or weight loss. There was no history of jaundice, itching, acholic stools, or dark urine. The patient’s medical history was positive for non–insulin dependent diabetes mellitus and moderate hypertension; his present medications included metformin, glyburide, and metoprolol. In addition, a recent urinary tract infection had been successfully treated with antibiotics. An umbilical hernia had been repaired 2 years previously. On examination, the patient was an alert, slightly obese man with a blood pressure of 134/88 and a regular pulse. His sclera were not icteric and his cardiorespiratory findings were normal. Abdominal palpation revealed a protuberant but soft abdomen without masses or organomegaly. There was slight deep tenderness localized to the supraumbilical area and associated with a small fascial defect in the site of the previous ventral herniorrhaphy. The genitourinary examination was normal, and the rectal examination revealed a symmetrically enlarged prostate but a negative fecal occult blood test. The laboratory evaluation returned a hematocrit of 46.8% with a white blood cell count of 8900 and normal blood urea nitrogen and creatinine. The total bilirubin was 0.4 mg/dl with an alkaline phosphatase of 100 units and normal hepatic enzymes. The serum carcinoembryonic antigen was 5.8. An abdominal ultrasound confirmed the presence of a cholecystic mass lesion and uncovered a single large gallstone (3.7 cm) in the infundibulum. No neoplastic involvement could be visualized in the portal vein or the duodenum. A CT-guided fine needle aspirate of the gallbladder mass returned a diagnosis of adenocarcinoma. An endoscopic ultrasound study showed no apparent extension of the tumor through the muscularis of the gallbladder and no involvement of the extrahepatic ductal system or duodenum (Fig. 2). GROUP DISCUSSION: (Dr. W. E. Strodel and faculty) It was generally agreed that cholecystectomy with major hepatic resection and regional lymphadenectomy would be required to achieve cure. Because of the CT scan findings suggesting extensive disease, it was suggested that a diagnostic/staging laparoscopy might help to avoid an unnecessary celiotomy.

Painful axillary mass in a middle-aged woman

CLINICAL PRESENTATION: (Dr. J. McNeil) A 57-yearold African-American woman was seen in the surgery clinic because of a painful left axillary mass that had been present for 6 weeks. During that time, the mass had markedly increased in size and had developed a foul-smelling purulent drainage. A mammogram performed 4 years earlier had been interpreted as normal, and no family history of breast disease existed. The patient’s medical history included hypertension and 10-packyears of tobacco abuse. She denied previous surgery. A review of systems was significant for a 30-pound weight loss over 5 months associated with intermittent fevers, chills, and night sweats. In addition, the patient described chronic fatigue and generalized myalgias. On physical examination, the patient was alert, oriented, and afebrile with stable vital signs. Her examination was significant for a 10 3 12-cm fungating mass located in the lateral aspect of her left breast with extension into the axilla (Fig. 1). The right breast and the remainder of her examination were unremarkable. Laboratory evaluation revealed a white blood cell count of 30,300, a hematocrit of 31.3 and a platelet count of 965,000. The serum chemistries included sodium 127, potassium 3.1, chloride 87, bicarbonate 23, and a calcium increased to 14.2. All renal and liver function tests were within the normal range. The patient was hospitalized for further management, including pain control, intravenous antibiotics, and treatment of the hypercalcemia. A computed tomography (CT) scan of the chest was obtained (Fig. 2). The left breast mass measured 12 3 12 cm and showed evidence of marked necrosis. Involvement of the underlying musculature as well as adjacent axillary lymphadenopathy appeared to exist. Two cystic areas suggestive of either necrotic lymph nodes or fluid collections were also visualized. Thoracic and abdominal CT imaging studies showed no evidence of distant metastases. Likewise, a bone scan and spine films were negative for definitive bony metastases. The patient underwent ultrasound-guided drainage of 500 ml of serosanguinous fluid, and a core biopsy specimen was obtained. Pathologic examination confirmed a grade 3 invasive ductal carcinoma. The tumor was estrogen receptor negative, progesterone receptor negative, borderline positive for c-erbB2/HER-2 oncoprotein, and positive for p53 tumor suppressor gene product. The Ki67 proliferation index was 53%. The medical oncology service was consulted, and chemotherapy was initiated with cyclophosphamide and doxorubicin. The patient was subsequently discharged on her eighth hospital day.