Michael B. Flynn

Minimally invasive radioguided parathyroidectomy

Background: Minimally invasive radioguided parathyroidectomy (MIRP) combines technetium sestamibi scan, intraoperative gamma probe, methylene blue dye, and measurement of circulating parathyroid hormone (PTH) levels. Study Design: All patients presented with biochemically proved primary hyperparathyroidism. A technetium sestamibi scan was performed preoperatively. Technetium sestamibi and methylene blue dye (7.5 mg/kg) were administered IV on the day of operation. Operative dissection was directed by the gamma probe. Blood samples for PTH assay were obtained before and after excision of an abnormal gland. When an appropriate decrease in the PTH assay was obtained, the exploration was concluded. Persistent PTH elevation instigated further neck exploration. Results: Thirty-six consecutive patients were explored for untreated primary hyperparathyroidism and three for recurrent hyperparathyroidism. Hypercalcemia was corrected in all 39 patients. A single adenoma was found in 32 of 36 patients with untreated primary hyperparathyroidism, and a single abnormal gland was identified in all of those with recurrent hyperparathyroidism. Persistently elevated PTH prompted further exploration in two patients, identifying a second abnormal gland in one and hyperplasia in the other. Minor local complications occurred in 8% (3 of 39) of the patients. Forty-four percent (16 of 36) of the patients were discharged on the day of operation and 83% (30 of 36) within 23 hours after the initial neck exploration for primary hyperparathyroidism. Comparison of charges for MIRP with charges for “standard” neck exploration revealed lower costs with MIRP because of decreased duration of the operation, anesthesia, and hospital stay, and elimination of intraoperative histologic analysis. Conclusions: MIRP is a safe and effective procedure, resulting in the correction of hypercalcemia in all patients. The combination of intraoperative gamma probe and methylene blue dye allows rapid identification of the abnormal gland with minimal dissection through a small incision. PTH assay after excision provides biochemical confirmation that the abnormal gland has been removed. Most patients undergoing MIRP can be treated on an outpatient basis. Low postoperative complications, a small incision, and rapid return to normal activities resulted in very high patient acceptance of the procedure. (J Am Coll Surg 2000;191:24-31.

Local complications after surgical resection for thyroid carcinoma

BACKGROUND One of the issues in the debate surrounding the extent of thyroid excision for localized, well-differentiated thyroid cancer is the low morbidity rate reported after all degrees of thyroid resection. This study was conducted to determine morbidity and mortality after surgical resection for thyroid cancer. MATERIALS AND METHODS Ninety-one patients with thyroid carcinoma were identified from tumor registries at a university, veterans administration, and private hospital over a 36-year period. Forty-five patients (49%) underwent total thyroidectomy, 28 (31%) subtotal thyroidectomy, and 18 (20%) thyroid lobectomy. RESULTS Permanent postoperative local complications occurred in 4% of patients. Forty-four patients (48%) experienced temporary local complications: transient hypocalcemia in 38 (42%), airway obstruction in 3 (3%), postoperative bleeding in 2 (2%), and recurrent laryngeal nerve injury in 1 (1%). The local complication rate increased in direct relationship to the extent of thyroid resection. There were no postoperative deaths. CONCLUSION The most frequent underreported morbidity after thyroid resection is transient hypocalcemia. Compared to other life-threatening or permanent postoperative complications that could occur, transient hypocalcemia is relatively less important, and the significance of its identification is predominantly economic.

Irradiation of nasopharyngeal carcinoma: correlations with treatment factors and stage.

Eighty patients with nasopharyngeal carcinoma were treated with radiotherapy in the Radiation Center at the University of Louisville from January 1955 to December 1980. Among the patients were 70 whites, nine blacks and one Chinese; their ages ranged from eight to 82 years. There was a 40% recurrence rate within the nasopharynx, and a 29% recurrence rate within neck nodes. The five year survival and relapse-free survival rates of the entire group were 36 and 33%, respectively. Forty-nine patients died of cancer, four patients died of intercurrent disease and eight patients were lost to follow-up. Nineteen patients are alive and free of disease. Factors considered in this study included tumor and nodal status, the presence of cranial neuropathy, the size and area irradiated, and dose delivered. Primary site relapse was not demonstrated to be dependent on T group or nodal status, but was likely to be related to inadequacy of original treatment volume and dose. A higher survival was noted with our lymphoepithelioma category (p = .056).

Preoperative outpatient nutritional support of patients with squamous cancer of the upper aerodigestive tract

In this study, 59 percent of the patients with squamous cancer of the upper aerodigestive tract were considered malnourished by the independent evaluation of a registered dietitian. Malnourished patients tended to present in a more advanced stage of disease, underwent more extensive operative procedures, had more complications, experienced longer hospital stay, and had a higher proportion of irradiated patients compared with patients who were nutritionally healthy. Malnourished patients who received nutritional support preoperatively demonstrated lower complication rates and shorter lengths of hospital stay compared with malnourished patients who underwent similar operative procedures without preoperative nutritional supplementation.

Evaluation of size in prognosis of oral cancer

Greatest surface diameter of a cancer, together with suspicion of regional node metastasis, forms the basis for prognosis through the clinical TNM staging system for many cancers. In oral cancer, however, surface size sometimes fails to correlate, or sometimes inversely correlates, with tumor aggressiveness. To shed light on the value of measuring size per se, 155 consecutive oral squamous cancers, treated by surgery, radiation, or a combination, were analyzed to find the degree of correlation between greatest surface measurement and pathologic nodal spread and control of cancer. In tumors less than 2 cm, size correlated with very few nodal metastases and with good prognoses; in tumors greater than 2 cm, increasing size did not show a corresponding increase in pathologic node metastasis or significantly worsening outcomes except for a few very large cancers invading adjacent structures. In conclusion, greatest surface diameter of an oral cancer, when greater than 2 cm, is an unreliable predictor of tumor behavior per se. A small pilot study suggests that tumor thickness may be a better predictor. A formal study of this is planned. Cancer 58:158–162, 1986.

Microvascular free tissue transfer in head and neck and esophageal surgery

Successful reconstruction for excisional defects of the head and neck and esophagus was accomplished in 93 percent of our patients using microvascular free tissue transfer. Complete failure occurred in 7 percent of the patients. Major defects after head and neck cancer surgery constituted the main indication for use of microvascular free tissue transfer for reconstruction. Ninety-four percent of the patients had undergone an extensive excisional procedure. A wide range of cutaneous, myocutaneous, and osteocutaneous free flaps, as well as free bowel autotransfers were used. Complete failure was three times higher in the previously irradiated patients (4 of 41 patients) compared with nonirradiated patients (1 of 34 patients). Morbidity and mortality rates were consistent with expected ranges in patients who were undergoing major head and neck resection. Donor site complications occurred in 23 percent. Thin flaps are favored for reconstruction of anterior defects in the oral cavity, whereas bulkier flaps are more suitable for deeper defects in the oropharynx and hypopharynx. The advantages are both aesthetic and functional. The free jejunal autograft is considered the reconstructive method of choice for defects produced by laryngopharyngoesophagectomy. Highly developed and sophisticated microsurgical skills continue to be the mainstay of success. The implication of free tissue transfer failure, especially for defects of the upper aerodigestive tract, are impressive in terms of morbidity, mortality, and cost. These considerations limit the application of this method of reconstruction to centers that have sophisticated and productive reconstructive surgeons with microsurgical skills.

Marginal resection of the mandible in the management of squamous cancer of the floor of the mouth

Abstract Over a fifteen year period, marginal resection of the mandible was used as all or part of the initial treatment of twenty-three selected patients with squamous cancer of the floor of the mouth. All patients were classified as T 1 or T 2 on the basis of the extent of the primary tumor. The lesions were lying in the gingivolingual gutter close to the lingual surface of the mandible. Local control rates were obtained that were comparable to the local control rates obtained with other surgical procedures including wider bone excision and with irradiation for patients of the same T classification.

Primary Squamous Cell Carcinoma of the Parotid Gland: The Importance of Correct Histological Diagnosis

Background: Primary squamous cell carcinoma of the parotid is an uncommon, aggressive malignancy with a poor prognosis. The diagnosis is made after excluding metastasis from other sites in the head and neck or other primary malignancies of the parotid.Methods: Tumor registry data from 1974 to 1994 were reviewed at three University of Louisville- affiliated hospitals. Of 370 parotid tumors, 40 (11%) were initially classified as squamous cell carcinoma of the parotid. Chart review and histological specimen re-examination were conducted to confirm diagnosis.Results: Only 8 (2%) of the 370 cases, were considered true primary squamous cell carcinoma of the parotid. Patients with metastases to the parotid from primary sites within the upper aerodigestive tract or skin of the head and neck region and high-grade mucoepidermoid carcinoma of the parotid were excluded. Facial nerve dysfunction was a presenting complaint in three patients. Two patients presented with American Joint Committee on Cancer (AJC) clinical stage III disease and six with AJC stage IV disease. All patients were treated with total parotidectomy and radiotherapy. One patient (12%) is alive and free of disease. Median survival was 13 months (range, 11 months–7 years).Conclusions: Primary squamous cell carcinoma of the parotid is uncommon, occurring in 2% of parotid neoplasms at our institution. This is an aggressive malignancy, usually presenting in advanced stage and with facial nerve involvement or cervical metastases. Prognosis is poor even with radical surgery and adjunctive radiotherapy. Careful clinical and histological review is necessary to differentiate primary squamous cancer of the parotid from metastases or other primary parotid malignancy.

Toxic metabolic encephalopathy after parathyroidectomy with methylene blue localization

OBJECTIVE: To determine the correlation between methylene blue use and toxic metabolic encephalopathy in patients undergoing surgery for primary hyperparathyroidism. STUDY DESIGN AND SETTING: A retrospective study of 193 patients was performed to collect demographic, perioperative, and postoperative data. Patients were divided into two groups: Group A (postoperative neurological sequelae) and Group B (no neurological sequelae). All data points were compared between the groups. RESULTS: Twelve of 193 patients were placed in Group A; 181 patients were placed in Group B. Ten patients in Group A were female, and 10 patients were older than 60 years. Of the patients in Group A, 100% were taking a serotonin reuptake inhibitor (SRI). In Group B, 8.8% of patients were taking an SRI. CONCLUSION: All the patients who experienced transient neurological events were taking an SRI. A correlation can be made between methylene blue infusion and SRI usage. SIGNIFICANCE: Patients taking SRIs may represent a high-risk group for postoperative neurological events when methylene blue is utilized.

Reconstruction with free bowel autografts after pharyngoesophageal or laryngopharyngoesophageal resection

Reliability has become a foremost requirement in pharyngoesophageal reconstruction because of the disastrous consequences after a failure. Our institution has achieved a 97 percent success rate using the free bowel autograft. We believe that this represents a significant accomplishment and designates the free bowel autograft as the reconstructive method of choice after pharyngoesophageal resection.