Muriel Mathonnet

Effect of postoperative antibiotic administration on postoperative infection following cholecystectomy for acute calculous cholecystitis: a randomized clinical trial.

IMPORTANCE Ninety percent of cases of acute calculous cholecystitis are of mild (grade I) or moderate (grade II) severity. Although the preoperative and intraoperative antibiotic management of acute calculous cholecystitis has been standardized, few data exist on the utility of postoperative antibiotic treatment. OBJECTIVE To determine the effect of postoperative amoxicillin plus clavulanic acid on infection rates after cholecystectomy. DESIGN, SETTING, AND PATIENTS A total of 414 patients treated at 17 medical centers for grade I or II acute calculous cholecystitis and who received 2 g of amoxicillin plus clavulanic acid 3 times a day while in the hospital before and once at the time of surgery were randomized after surgery to an open-label, noninferiority, randomized clinical trial between May 2010 and August 2012. INTERVENTIONS After surgery, no antibiotics or continue with the preoperative antibiotic regimen 3 times daily for 5 days. MAIN OUTCOMES AND MEASURES The proportion of postoperative surgical site or distant infections recorded before or at the 4-week follow-up visit. RESULTS An imputed intention-to-treat analysis of 414 patients showed that the postoperative infection rates were 17% (35 of 207) in the nontreatment group and 15% (31 of 207) in the antibiotic group (absolute difference, 1.93%; 95% CI, -8.98% to 5.12%). In the per-protocol analysis, which involved 338 patients, the corresponding rates were both 13% (absolute difference, 0.3%; 95% CI, -5.0% to 6.3%). Based on a noninferiority margin of 11%, the lack of postoperative antibiotic treatment was not associated with worse outcomes than antibiotic treatment. Bile cultures showed that 60.9% were pathogen free. Both groups had similar Clavien complication severity outcomes: 195 patients (94.2%) in the nontreatment group had a score of 0 to I and 2 patients (0.97%) had a score of III to V, and 182 patients (87.8%) in the antibiotic group had a score of 0 to I and 4 patients (1.93%) had a score of III to V. CONCLUSIONS AND RELEVANCE Among patients with mild or moderate calculous cholecystitis who received preoperative and intraoperative antibiotics, lack of postoperative treatment with amoxicillin plus clavulanic acid did not result in a greater incidence of postoperative infections. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01015417.

Multicenter Study of 19 Aortopulmonary Window Parathyroid Tumors: The Challenge of Embryologic Origin

BackgroundEctopic abnormal parathyroid glands are relatively common in the superior mediastinum but are rarely situated in the aortopulmonary window (APW). The embryological origin of these abnormal parathyroid glands is controversial. The purpose of this investigation was to investigate the embryological origin and the surgical management of abnormal parathyroid glands situated in the APW.MethodsThe databases of patients operated on for primary, secondary, and tertiary hyperparathyroidism at eight European medical centers with a special interest in endocrine surgery were reviewed to identify those with APW adenomas. Demographic features, localization procedures, and perioperative and pathology findings were documented. The embryological origin was determined based on the number and position of identified parathyroid glands.ResultsNineteen (0.24%) APW parathyroid tumors were identified in 7,869 patients who underwent an operation for hyperparathyroidism (HPT) and 181 patients (2.3%) with mediastinal abnormal parathyroid glands. Ten patients had primary, eight had secondary, and one had tertiary HPT. Sixteen patients had undergone previous unsuccessful cervical exploration. In three patients, an APW adenoma was suspected by preoperative localization studies and was cured at the initial operation. Sixteen patients had persistent HPT of whom 15 were reoperated, resulting in 6 failures. Evaluation of 17 patients who had bilateral neck exploration allowed us to determine the most probable origin of the APW parathyroid tumors: 12 were supernumerary, 4 appeared to originate from a superior, and 1 from an inferior gland.ConclusionsAbnormal parathyroid glands situated in the APW are rare and usually identified after an unsuccessful cervical exploration. Preoperative imaging of the mediastinum and neck are essential. The origin of these ectopically situated tumors is probably, as suggested by our data, from a supernumerary fifth parathyroid gland or from abnormal migration of a superior parathyroid gland during the embryologic development.

Factors predictive of lymph node metastasis in the follicular variant of papillary thyroid carcinoma

The treatment of papillary thyroid carcinomas larger than 1 cm usually consists of total thyroidectomy and central lymph node dissection (LND). In patients with the follicular variant of papillary thyroid carcinoma (FVPTC), preoperative cytology and intraoperative frozen‐section analysis cannot always establish the diagnosis. The aim of this study was to evaluate predictive factors for lymph node metastasis in patients with FVPTC and to identify patients who might benefit from LND.

Laparoscopic Versus Open Surgery for Gastric Gastrointestinal Stromal Tumors: What Is the Impact on Postoperative Outcome and Oncologic Results?

OBJECTIVES The aim of the study was to compare the postoperative and oncologic outcomes of laparoscopic versus open surgery for gastric gastrointestinal stromal tumors (gGISTs). BACKGROUND The feasibility of the laparoscopic approach for gGIST resection has been demonstrated; however, its impact on outcomes, particularly its oncologic safety for tumors greater than 5 cm, remains unknown. METHODS Among 1413 patients treated for a GIST in 61 European centers between 2001 and 2013, patients who underwent primary resection for a gGIST smaller than 20 cm (N = 666), by either laparoscopy (group L, n = 282) or open surgery (group O, n = 384), were compared. Multivariable analyses and propensity score matching were used to compensate for differences in baseline characteristics. RESULTS In-hospital mortality and morbidity rates in groups L and O were 0.4% versus 2.1% (P = 0.086) and 11.3% vs 19.5% (P = 0.004), respectively. Laparoscopic resection was independently protective against in-hospital morbidity (odds ratio 0.54, P = 0.014). The rate of R0 resection was 95.7% in group L and 92.7% in group O (P = 0.103). After 1:1 propensity score matching (n = 224), the groups were comparable according to age, sex, tumor location and size, mitotic index, American Society of Anesthesiology score, and the extent of surgical resection. After adjustment for BMI, overall morbidity (10.3% vs 19.6%; P = 0.005), surgical morbidity (4.9% vs 9.8%; P = 0.048), and medical morbidity (6.2% vs 13.4%; P = 0.01) were significantly lower in group L. Five-year recurrence-free survival was significantly better in group L (91.7% vs 85.2%; P = 0.011). In tumors greater than 5 cm, in-hospital morbidity and 5-year recurrence-free survival were similar between the groups (P = 0.255 and P = 0.423, respectively). CONCLUSIONS Laparoscopic resection for gGISTs is associated with favorable short-term outcomes without compromising oncologic results.

Sporadic primary hyperparathyroidism.

Primary hyperparathyroidism (HPT1) is a common endocrine disorder, which is asymptomatic in 80% of cases. The diagnosis is ordinarily easily made, based on an inappropriately elevated parathormone level (PTH) in the face of hypercalcemia. In 85% of cases, HPT1 is due to hormone secretion from a single parathyroid gland (uniglandular disease) and the remaining patients have multiglandular disease. The best localization study is MIBI scintigraphy (methoxy isobutyl isonitrile) coupled with the results of a neck ultrasound exam (sensitivity >95%). Other investigations are reserved for patients with persistent or recurrent HPT1 post-surgery. Surgery is the only cure. The surgical approach may include a bilateral cervical exploration, a unilateral approach under local anesthesia, or focused minimally invasive (video-assisted or totally endoscopic) approaches. A decrease in PTH level measured intraoperatively of greater than 50% is predictive of cure in more than 97% of cases. Surgery is recommended even for moderate HPT1 and for very elderly patients because improvement in both the quality of life and bone density have been proven in these situations. The role of medical treatment is limited. Persistent or recurrent HPT1 requires a meticulous diagnostic approach and management in surgical centers with expertise. Persistent elevation of PTH postoperatively without hypercalcemia does not mandate further exploration. The prognosis of normocalcemic patients with elevated postoperative PTH levels remains uncertain.

Pancréatite aiguë et hyperparathyroïdie primaire : étude multicentrique de l’Association francophone de chirurgie endocrinienne

BACKGROUND Primary hyperparathyroidism is an unusual cause of acute pancreatitis. The aim of this study was to analyse data from multiple centers concerning patients with primary hyperparathyroidism and associated acute pancreatitis and to analyze potential predictive factors. METHODS In this retrospective multicentric study, 19 patients were identified (Group A) with the associated diagnoses of acute pancreatitis and primary hyperparathyroidism. Their clinical data was compared to that of a control group of 65 patients (group B) with primary hyperparathyroidism without acute pancreatitis. RESULTS Age, parathormone levels and pathology (uni/multiglandular disease) were similar between the two groups. The mean plasma calcium level was significantly higher in group A (12.64 mg/100ml) than in group B patients without pancreatitis (11.28 mg/100ml) (p<0.0001). CONCLUSION This study confirms the causal relationship between primary hyperparathyroidism and acute pancreatitis. The degree of hypercalcemia may play an important role in this association. Calcium levels should be measured in all patients with acute pancreatitis.

What is the care pathway of patients who undergo thyroid surgery in France and its potential pitfalls? A national cohort

Context The rate of thyroid cancer is increasing in France, as well as concerns about overdiagnosis and treatment. Objectives To examine the care pathway of patients who undergo thyroid surgery in France and detect potential pitfalls. Design A large observational study based on medical reimbursements, 2009–2011. Setting Data from the Sniiram (National Health Insurance Information System). Patients Patients with thyroid surgery in 2010, classified into 4 groups: thyroid cancer, benign nodule, goitre or multiple nodules, other (hyperthyroidism, head–neck cancer). Main outcome measures Medical investigations during, prior and after thyroidectomy. Results A total of 35 367 patients underwent surgery (mean age 51 years, 80% women): 17% had a reported diagnosis of thyroid cancer, 20% benign nodule, 38% goitre or multiple nodules and 25% another diagnosis. The ratio of thyroidectomies with cancer over thyroidectomies with benign nodule was 0.8 and varied across regions. In the year preceding surgery, 82% of patients had an investigation by thyroid ultrasonography, 21% thyroid scintigraphy, 34% fine-needle aspiration cytology, 40% serum calcitonin assay and 54% serum calcium assay. In the following year, all patients with total thyroidectomy and 44% of patients with partial thyroidectomy and a diagnosis of benign nodule were taking thyroid hormone therapy. 100 patients had been reoperated for a compressive haematoma and 63 died during the first month, half of whom had been operated for cancer. Mean rates of recurrent laryngeal nerve injury and hypocalcaemia (requiring blood tests plus treatments within 4–12 months) were estimated at 1.5% and 3.4%, respectively, and were higher in the cancer group (2.3% and 5.7%). Conclusions This almost nationwide study demonstrates the suboptimal management of patients prior to thyroidectomy in France. It suggests overdiagnosis and potential harms to patients, and calls for a review of the relevance of thyroidectomy, particularly with regard to microcancers.

Tumeurs malignes de la surrénale : Contribution du CCAFU au référentiel INCa

Les tumeurs malignes de la surrenale sont soit des tumeurs primitives : carcinomes corticosurrenaliens (ou corticosurrenalomes malins) et pheochromocytomes malins, soit des tumeurs secondaires : localisations metastatiques surrenaliennes. Les tumeurs de la surrenale sont frequentes, mais elles sont rarement malignes. Les incidentalomes surrenaliens ont une frequence d’environ 5 % sur les examens tomodensitometriques de l’abdomen [1] et des series autopsiques [2]. La probabilite qu’un incidentalome surrenalien soit une tumeur maligne est faible (5 %) [3], voire nulle [4]. Les adenomes corticosurrenaliens (75 %) et les myelolipomes (6 %) sont les tumeurs benignes les plus frequentes [4]. En revanche, en cas d’antecedent de cancer, les incidentalomes surrenaliens sont plus frequents (9 a 13 %) avec une probabilite de 26 a 36 % d’etre une metastase surrenalienne [1]. Les carcinomes corticosurrenaliens (CCS) sont des tumeurs rares qui representent moins de 0,2 % des cancers (incidence annuelle de 0,5 a 2 par million). Ils sont plus frequents chez les femmes (sex ratio de 1,5), avec deux pics d’incidence : dans l’enfance (avant 5 ans) et entre 30 et 50 ans [5]. Ce sont des tumeurs agressives dont le taux global de survie a 5 ans varie de 16 a 38 % [5]. Les pheochromocytomes dits malins (PCM) representent environ 10 % de l’ensemble des pheochromocytomes, dont l’incidence annuelle est de 6 par million [6]. Un pic de frequence est observe entre 30 et 40 ans. En l’absence de criteres histologiques formels, le PCM est defini par l’existence de localisations secondaires dans des organes depourvus de tissu chromaffine (foie, poumon, os...). Ils sont plus frequents en cas de pheochromocytomes extrasurrenaliens ou paragangliomes (30-40 %). Le diagnostic de malignite peut etre difficile a etablir d’emblee. Le taux de survie a 5 ans varie de 40 a 74 % [7]. Les localisations metastatiques surrenaliennes sont les tumeurs malignes de la surrenale les plus frequentes. Les cancers primitifs sont en premier lieu : cancer du poumon, cancer du rein, cancer du sein, melanome malin, cancer de l’estomac, cancer colorectal et lymphome. Une localisation surrenalienne isolee est rare, mais reste souvent confinee a l’interieur de la capsule surrenalienne, d’ou l’interet d’une chirurgie d’exerese [8].

Effect of parathyroidectomy on quality of life and non-specific symptoms in normocalcaemic primary hyperparathyroidism

Normocalcaemic primary hyperparathyroidism (NcPHPT) is a new clinical entity being diagnosed increasingly among patients with mild primary hyperparathyroidism (PHPT). The aim of this study was to evaluate quality of life and non‐specific symptoms before and after parathyroidectomy in patients with NcPHPT compared with those with hypercalcaemic mild PHPT (Hc‐m‐PHPT).

[Acute pancreatitis and primary hyperparathyroidism: a multicentric study by the Francophone Association of Endocrine Surgeons] : Pancréatite aiguë et hyperparathyroïdie primaire : étude multicentrique de l'Association francophone de chirurgie endocrinienne

BACKGROUND Primary hyperparathyroidism is an unusual cause of acute pancreatitis. The aim of this study was to analyse data from multiple centers concerning patients with primary hyperparathyroidism and associated acute pancreatitis and to analyze potential predictive factors. METHODS In this retrospective multicentric study, 19 patients were identified (Group A) with the associated diagnoses of acute pancreatitis and primary hyperparathyroidism. Their clinical data was compared to that of a control group of 65 patients (group B) with primary hyperparathyroidism without acute pancreatitis. RESULTS Age, parathormone levels and pathology (uni/multiglandular disease) were similar between the two groups. The mean plasma calcium level was significantly higher in group A (12.64 mg/100ml) than in group B patients without pancreatitis (11.28 mg/100ml) (p<0.0001). CONCLUSION This study confirms the causal relationship between primary hyperparathyroidism and acute pancreatitis. The degree of hypercalcemia may play an important role in this association. Calcium levels should be measured in all patients with acute pancreatitis.