Nathalie Chereau

Recurrence of papillary thyroid carcinoma with lateral cervical node metastases: Predictive factors and operative management

BACKGROUND Lateral neck lymph node (LN) metastases (N1b) have been identified as independent risk factors of recurrence in patients with papillary thyroid carcinoma (PTC). OBJECTIVE This study aimed to determine the predictive factors of recurrence in N1b PTC patients and to clarify the postoperative event patterns. METHODS All patients who underwent operation for N1b PTC between 1978 and 2012 were reviewed. The median follow-up period was 6.5 years. RESULTS In total, 344 N1b patients were included. Twenty-four patients (7%) were lost to long-term follow-up. Among the remaining 320 patients, the mean (± SD) follow-up time was 8.9 ± 8.8 years (median, 6.5; range, 2-36.4). Eighty-two patients (26%) presented with lymph node recurrence (LR). Multivariate analyses showed that LN metastases with extracapsular extension and the LN ratio (ratio between the number of N1 and number of resected LN) in the lateral compartment were independent predictors of recurrent disease. The median time to reoperation was 19 months (range, 3-173), with 79% of reoperations occurring within 2 years after the initial thyroidectomy. Reoperations for LR (75 patients) were performed in 76% of the patients with a focused minimal access approach or selective LN dissection. After curative reoperative surgery for recurrence, complications occurred in 6 patients (8%), including a 1% permanent complication rate. CONCLUSION Extranodal extension of LN metastases and the LN ratio in the lateral compartment are prognostic factors for recurrence. In most cases, reoperation for LR can be performed with a focused minimal access approach, with a low morbidity rate.

Prognosis of papillary thyroid carcinoma in elderly patients after thyroid resection: A retrospective cohort analysis

AbstractThe size of the elderly population and the incidence of papillary thyroid carcinoma (PTC) in this group appear to be rapidly increasing, although published information based on more detailed older age groupings are lacking.This study aimed to determine the clinical features and outcomes of elderly patients in PTC.All consecutive patients who received surgery for PTC in our Department from 1978 to 2014 were included. We compared 3 patient groups: young (<65 years), older (65–75 years), and very old patients (>75 years). Total thyroidectomy was performed with lymph node (LN) dissection in most cases, and radioiodine therapy was administered as needed.A total of 3835 patients (3257 young patients, 450 older patients, and 128 very old patients) were identified. Very old patients were more likely to have advanced (III/IV) tumor, nodes, metastases (TNM) stage, greater tumor size, number of tumors, and extracapsular invasion compared with young and older patients. For the 2289 patients with LN dissection (60%), metastatic LNs were more frequent in the very old group (44%) than in the other groups (34% young and 33% older patients) (P = 0.01). Very old patients had more frequent distant metastases (5%) than the older (2%) and young groups (1%) (P < 0.001). The overall postoperative morbidity was not significantly different between the 3 age groups. Recurrence was documented in 202 (6.2%) young, 29 (6.4%) older, and 15 (11.7%) very old PTC patients (P = 0.04). The 5-year disease-free survival was 81.3% for very old, 92.9% for older, and 94.7% for young group (P < 0.001).Very old patients should be considered high-risk PTC patients and their therapeutic strategy may benefit from aggressive treatment.

Hypocalcemia after thyroidectomy in patients with a history of bariatric surgery.

BACKGROUND Hypocalcemia is a common complication after total thyroidectomy. Previous bariatric surgery could be a higher factor risk for hypocalcemia due to alterations in calcium absorption and vitamin D deficiency. OBJECTIVES To evaluate incidence and factors involved in the risk of hypocalcemia (transient and permanent) and the postoperative outcomes of these patients after total thyroidectomy. SETTING University hospital in Paris, France. METHODS All patients who had previously undergone obesity surgery (i.e., Roux-en-Y gastric bypass, sleeve gastrectomy, or adjustable gastric band) who had a total thyroidectomy from 2006 to 2015 were included. No patient was lost to follow-up. Each patient was matched 1:1 with a patient who had no previous bariatric surgery for age, gender, body mass index, and year of surgery. RESULTS Forty-eight patients were identified (43 female; mean age 48.9±9.2 yr). Nineteen patients (40%) had a postoperative hypocalcemia: transient in 14 patients (29.2%) and permanent in 5 patients (10.4%). No significant predictive clinical or biochemical factors were found for hypocalcemia risk, except for the type of bariatric procedure: Bypass surgery had a 2-fold increased risk of hypocalcemia compared to others procedures (60% versus 30%, P = .05). In the matched pair analysis, the risk of hypocalcemia was significantly higher in patients with previous bariatric surgery than in the matched cohort (40% versus 15%, P = .006). CONCLUSION Patients with previous bariatric surgery have an increased risk for hypocalcemia after total thyroidectomy, especially after Roux-en-Y gastric bypass. Careful and prolonged follow-up of calcium, vitamin D, and parathyroid hormone levels should be suggested for these patients.

Day Surgery for Acute Appendicitis in Adults: A Prospective Series of 102 Patients

Aim: To report the results of a consecutive series of day surgery appendectomy (DSA) for acute appendicitis. Methods: Selection criteria for DSA were as follows: body mass index<28 kg/m2, white cell count <15,000/mL, C-reactive protein<30 mg/L, no radiological signs of perforation, and appendix diameter ⩽10 mm. All patients with radiologically proven appendicitis and 4 or 5 criteria were proposed for DSA and prospectively included. Results: A total of 102 patients (female=39.2%) were operated between January 1, 2013 and January 5, 2015 with a median age of 29.5 years [interquartile range (IQR), 23 to 37 y]. Diagnosis was mainly supported by computed tomographic scan (75.5%). About 60 patients (59%) were reconvened on the next morning for surgery with oral antibiotics. The median operative time was 40 minutes (IQR, 30 to 52 min), and 92 (90%) patients were discharged on day 0 after a postoperative period of 5h:12min (IQR, 4h:14min to 6h:33min). The overall median hospital length of stay was 8h:04min (IQR, 6h:46min to 10h:23min). Surgical morbidity was 6.9% (n=7), with 1.9% (n=2) major complications. Conclusions: DSA is a safe procedure for selected patients; it reduces the hospital length of stay without increasing morbidity.

Symposium Celebrating Women Surgeons Around the World

We must thank Dr. Sanziana Roman for organizing this symposium about women in surgery. Powerful testimonials from women surgeons, from Europe to the United States, from Africa to Australia and Asia. Each of them is different, as it reflects the culture of the place where their career took place. However, they all have in common the struggle to establish themselves in the surgical profession, traditionally a male-dominated field. Over the last two decades, the situation has clearly improved. Today in most medical schools about 50% of the students are women, and a similar percentage is present in many surgical residency programs. Twenty-one Departments of Surgery in the United States are led by women, a major change as compared to only 5 years ago. Much more must be done to establish a work environment where women are as welcomed and respected as men; where they are accepted as surgeons, and not as women surgeons, treasuring the contribution they can give. We do hope that this symposium will be inspirational for women and men in the surgical field and be enlightening and educational for all, promoting a culture of collegiality and mutual understanding. The glass ceiling has been cracked, it is now time to break it for good. Marco G. Patti, MD, FACS Past President, International Society of Surgery

Hartmann’s reversal after colonic perforation or anastomosis leakage, is it the same procedure? A retrospective study of 150 patients

PurposeThe high morbidity rates reported might influence surgeons’ decisions of whether to perform Hartmann’s reversal (HR). Our aim was to report the results of HR after “primary” Hartmann’s procedure (HP) or in redo surgery for failed anastomosis.MethodsAll patients operated between 2007 and 2015 were included. Data and postoperative course were obtained from a review of medical records and databases.ResultsOne hundred fifty patients (age 60, range (20–91) years, 62% male) were included. Eighty-six patients (57%) were ASA ≥ 2. HP was mostly performed for diverticulitis (29.3%) and anastomotic leakage (24%). HR was possible in 145(97%) patients including six with previous failed attempt. Overall morbidity was 22.7% including 11.7% severe complications (Dindo 3–4). Operative blood loss and Charlson comorbidity index were the only significant risk factor for postoperative pelvic complications (p = 0.03; p = 0.0002, respectively).ConclusionsIn a colorectal tertiary center, HR was feasible in 97% with a low morbidity and a 3.4% anastomotic leakage rate.