Rosebel Monteiro

Trends and disparities in education between specialties in thyroid and parathyroid surgery: An analysis of 55,402 NSQIP patients

PURPOSE To determine practice patterns/outcomes and educational opportunities in endocrine surgery by resident involvement in general surgery (GS) and otolaryngology (ENT). METHODS We queried the American College of Surgeon National Surgical Quality Improvement Program for thyroid/parathyroid operations. Resident involvement was categorized by postgraduate year (PGY) and specialty. RESULTS Of 38,257 thyroid patients, attendings alone performed 28% in GS versus 65% in ENT, and of 17,145 parathyroid patients, 22.1% vs 66.5%. Of GS cases done with housestaff, the percentages with junior residents (PGY1-3), senior residents (PGY4,5), and fellows were 42%, 50%, and 7%, respectively, whereas for ENT operations, the percentages were 35%, 46%, and 16%. For parathyroidectomies, the percentages were 41.1%/46.8%/12.1% vs 38.7%/45.9%/15.5%. Operative time was less for GS (115 minutes) versus ENT (123 minutes). Time in the operating room increased with increasing PGY in ENT, but not in GS. Case complexity and outcomes were similar. Duration of hospital stay was greater in ENT. CONCLUSION No differences exist in case complexity between specialties. More thyroid/parathyroid operations are performed with residents in GS; junior residents in GS perform a large percentage of these cases (∼40%), indicating early exposure to endocrine surgery and balanced experience between resident levels with minimal effect of fellows. Although junior residents receive exposure in ENT, a greater proportion is performed by fellows. Outcomes were similar by resident level, except operative time, which was greater for ENT at all levels. Ultimately, equal outcomes but lesser operating times and durations of hospital stay are seen with GS residents than their ENT counterparts.

Predictors of recurrence in pheochromocytoma

BACKGROUND The recurrence rate of pheochromocytoma after adrenalectomy is 6.5-16.5%. This study aims to identify predictors of recurrence and optimal biochemical testing and imaging for detecting the recurrence of pheochromocytoma. METHODS In this retrospective study we reviewed all patients who underwent adrenalectomy for pheochromocytoma during a 14-year period at a single institution. RESULTS One hundred thirty-five patients had adrenalectomy for pheochromocytoma. Eight patients (6%) developed recurrent disease. The median time from initial operation to diagnosis of recurrence was 35 months. On multivariate analysis, tumor size >5 cm was an independent predictor of recurrence. One patient with recurrence died, 4 had stable disease, 2 had progression of disease, and 1 was cured. Recurrence was diagnosed by increases in plasma and/or urinary metanephrines and positive imaging in 6 patients (75%), and by positive imaging and normal biochemical levels in 2 patients (25%). CONCLUSION Patients with large tumors (>5 cm) should be followed vigilantly for recurrence. Because 25% of patients with recurrence had normal biochemical levels, we recommend routine imaging and testing of plasma or urinary metanephrines for prompt diagnosis of recurrence.

Line-associated thrombosis as the major cause of hospital-acquired deep vein thromboses: an analysis from National Surgical Quality Improvement Program data and a call to reassess prophylaxis strategies

BACKGROUND Quality improvement has mitigated the occurrence of postoperative deep vein thromboses (DVTs); however, despite adherence to protocols, they continue to occur. This study aimed to characterize their rate and distribution at our institution, and appropriate use of thromboprophylaxis. METHODS Local American College of Surgeons National Surgical Quality Improvement Program data were queried for general surgery cases complicated by DVT from 2009 to 2011. Medical records were evaluated to ascertain the following: classify DVTs by site, ascertain if appropriate prophylactic measures were instituted, evaluate treatment instituted, evaluate the occurrence of a PE if the DVT was line-associated, and if so, the indication for the central line. RESULTS Of 1,857 patients, 39 had postoperative DVTs (2.1%). Fourteen lower-extremity (35.9%) DVTs, 4 central (10%) DVTs, and 21 upper-extremity (53.8%) DVTs (UEDVTs) were captured. All but 2 had appropriate thromboprophylaxis. All but one UEDVT was line-associated. Diagnoses were prompted by symptoms in 72% of the patients. Pulmonary emboli developed in 3 of 39 patients. CONCLUSIONS An unexpected finding was that line-associated UEDVTs comprised over half of all DVTs, mostly in patients without cancer. This analysis highlights the need for more selective central-line use; choosing peripheral access may reduce DVT rates further. Improved pharmacoprophylaxis protocols would likely benefit this population.

Diffuse malignant epithelioid mesothelioma in a background of benign multicystic peritoneal mesothelioma: a case report and review of the literature

Peritoneal mesotheliomas are unusual entities with diverse origins and outcomes. Both benign and malignant variants exist. Benign multicystic peritoneal mesotheliomas (BMPMs), also known as multiple or multilocular peritoneal inclusion cysts, are extremely rare tumours arising from the peritoneal mesothelium covering the abdominal serous cavity. Even though these entities are considered benign tumours, BMPMs tend to recur after surgical resection, and in two cases have been reported to undergo malignant transformation. In contrast, diffuse malignant peritoneal mesotheliomas, while also quite rare, are the second most common form of malignant mesothelioma after the pleural variety with extremely high mortality and poor response to many treatments to date. We present a rare case of diffuse malignant peritoneal mesothelioma within a large component of a BMPM in a young man admitted to our service.

Importance of surgeon-performed ultrasound in the preoperative nodal assessment of patients with potential thyroid malignancy

Introduction. A comprehensive cervical ultrasound evaluation is essential in the operative planning of patients with thyroid disease. Reliance on radiographic reports alone may result in incomplete operative management as pathologic lymph nodes are often not palpable and evaluation of the lateral neck is not routine. This study examined the role of surgeon‐performed ultrasound in the evaluation of patients who underwent lateral neck dissection for thyroid cancer. Methods. We conducted a retrospective review of a prospectively maintained database of patients who underwent therapeutic lymph node dissection for thyroid cancer between 2001 and 2016 at our tertiary referral center. All patients had surgeon‐performed ultrasound preoperatively by 1 of 7 endocrine surgeons. These findings were compared with prereferral imaging studies to determine the value of surgeon‐performed ultrasound to their overall treatment. Results. Of 92 patients who underwent thyroidectomy with lateral neck dissection, 97% had prereferral imaging of the neck (ultrasonography, computed tomography, positron emission tomography). Of these patients, nodal disease was suggested by computed tomography scanning in 70.8% and by ultrasonography in 54%. Of all patients, 45% had positive lateral neck nodes detected only on surgeon‐performed ultrasound despite prior neck imaging. Nodal disease was identified in 50% of patients with only 1 study and 50% of patients with greater than 1 study before surgeon‐performed ultrasound. Of patients with nodes detected by surgeon‐performed ultrasound, only 67% had a prereferral diagnosis of thyroid cancer. Conclusions. Our data demonstrate that reliance on standard preoperative imaging alone would have led to an incorrect initial operation in 45% of our patients. Awareness of the limitations of prereferral imaging is important for surgeons treating patients with thyroid and parathyroid disease. Surgeon‐performed ultrasound is a useful tool in the diagnosis and accurate staging of patients.

Diagnostic Laparoscopy Prior to Neoadjuvant Therapy in Pancreatic Cancer Is High Yield: an Analysis of Outcomes and Costs

BackgroundThere is currently no standardized regimen for management of borderline resectable pancreatic cancer (BRPC), and treatment includes varying sequences of surgery, chemotherapy, and/or radiation. This study examines the diagnostic yield and cost of performing staging diagnostic laparoscopy (SDL) prior to neoadjuvant therapy (NAT) in BRPC.MethodsSequential patients treated for BRPC between January 2010 and October 2013 were included. SDL was adopted in a staged fashion due to surgeon preference, and included biopsy of visible lesions and washings for cytology. Cost ratios (CRs) were calculated to compare the direct cost of the SDL versus no-SDL groups and to compare patients with positive versus negative SDL.ResultsOf 116 patients evaluated for BRPC, 75 patients underwent SDL and 19 (25%) revealed occult metastatic disease. Sixteen patients had a positive biopsy and three had positive cytology alone. There was no difference in overall treatment cost (CR 0.95, 95% CI 0.62–1.37), oncologic treatment (CR 0.66, 95% CI 0.32–1.23), or remaining surgical treatment (CR 1.14, 95% CI 0.77–1.71) for patients who underwent SDL compared to those who did not. Patients with a positive SDL incurred lower overall cost compared to those with a negative SDL (CR 0.23, 95% CI 0.16–0.32) due to lack of further surgery or radiation, and less intensive chemotherapy regimens.ConclusionsSDL prior to NAT is a useful adjunct to CT to diagnose occult metastatic disease in BRPC.

Antimesenteric jejunal diverticulosis after a remote history of necrotising enterocolitis: a case report

Jejunal diverticulosis is a rare, acquired pathology of the small bowel. While most patients are asymptomatic, the condition is difficult to diagnose. It may present with chronic abdominal pain, diarrhoea, bloating and complications including malabsorption, diverticulitis, bleeding, intestinal obstruction or perforation. This is a case presentation of a 27-year-old woman with a history of necrotising enterocolitis (NEC) requiring surgical resection as a premature newborn who presented with recurrent abdominal pain and was found to have several small bowel diverticula intraoperatively. She underwent resection with complete resolution of symptoms over a 2-year follow-up. This is the first case report to suggest that small bowel diverticular disease as a long-term complication of NEC may result in chronic morbidity in long-term survivors.

Analysis of postoperative biochemical values and clinical outcomes after adrenalectomy for primary aldosteronism

Background. Primary aldosteronism causes hypertension and hypokalemia and is often surgically treatable. Diagnosis includes elevated plasma aldosterone, suppressed plasma renin activity, and elevated aldosterone renin ratio. Adrenalectomy improves hypertension and hypokalemia. Postoperative plasma aldosterone and plasma renin activity may be useful in documenting cure or failure. Method. A retrospective analysis of patients who underwent adrenalectomy for primary aldosteronism from 2010 to 2016 was performed, analyzing preoperative and postoperative plasma aldosterone, plasma renin activity, hypertension, and hypokalemia. The utility of postoperative testing was assessed. Clinical cure was defined as improved hypertension control and resolution of potassium loss. Biochemical cure was defined as aldosterone renin ratio reduction to <23.6. Results. Forty‐four patients were included; 20 had plasma aldosterone and plasma renin activity checked on postoperative day 1. In the study, 40/44 (91%) were clinically cured. All clinical failures had of biochemical failure at follow‐up. Postoperative day 1aldosterone renin ratio <23.6 had PPV of 95% for clinical cure. Cured patients had mean plasma aldosterone drop of 33.1 ng/dL on postoperative day 1; noncured patient experienced 3.9 ng/dL increase. A cutoff of plasma aldosterone decrease of 10 ng/dL had high positive predictive value for clinical cure. Conclusion. Changes in plasma aldosterone and plasma renin activity after adrenalectomy correlate with improved hypertension and hypokalemia. The biochemical impact of adrenalectomy manifests as early as postoperative day 1. We propose a plasma aldosterone decrease of 10 ng/dL as a criterion to predict clinical cure.

Su1851 Long-Term Outcomes of Combined Endoscopic/Laparoscopic Intragastric Enucleation of Gastric Stromal Tumors

S A T A b st ra ct s endophytic or in anatomically difficult locations. This technique allowed patients to avoid an extensive resection. Endoscopic resection alone was associated with a positive deep margin, which the push-pull technique managed with a laparoscopic, full-thickness, R0 resection site resection. In highly selected populations, this hybrid push pull technique may represent an improvement over standard endoscopic or laparoscopic management for gastric GISTs.

Mo1587 Pre-Operative Radiographic Findings Predictive of Laparoscopic Conversion to Open Procedures in Crohn's Disease

Purpose: Enhanced recovery after surgery (ERAS) lowers complications and shortens lengths of stay (LOS) compared with standard recovery. A key management strategy of ERAS protocols, especially if goal-directed fluid management is not available, is restrictive fluid management. However, it is unknown whether this is a safe strategy. Thus we aimed to evaluate whether restrictive fluid management was associated with increased acute kidney injury. Methods: We performed a retrospective review of consecutive patients undergoing abdominal surgery by a single ERAS-trained colorectal surgeon at an academic medical center from 1/11/2012 8/15/2013. Demographics, operative data, and short-term (30-day) outcomes are presented. Univariate analysis assessed between group differences to test the hypothesis that ERAS patients managed with restrictive fluids did not have an increased rate of post-operative acute kidney injury. Results are reported as median (interquartile range) or frequency (proportion). Results: One hundred twenty-eight patients were included: 82 (64%) ERAS and 46 (36%) STD recovery. Patient in the two groups were of similar age (52.4 vs. 54.8 years old, p=0.74), and BMI (26.8 vs. 27.4 kg/m2, p=0.98). Similar proportions underwent protectomy (22% vs. 28%, p=0.52), but more ERAS patients underwent minimally invasive surgery (61% vs. 41%, p=0.04), primary anastomosis (61% vs. 43%, p=0.04), and fewer had an ostomy (40% vs. 63%, p=0.02). Perioperative fluids (in cc/kg/hour) and creatinine levels are shown in Table 1. There was a trend towards ERAS patients receiving significantly less intra-operative fluids (p=0.07), and ERAS patients made significantly less urine intra-operatively (p=0.04). Post-operatively ERAS patients received significantly less IV fluids on POD#1 and POD#2 (p<0.0001), but had similar urine output on POD#1 and a trend toward reduced UOP on POD#2 (p=0.06). A total of 11 patients (8.6%) had a peak post-op creatinine ≥1.5; of these 8 (73%) recovered to <1.5 except three patients (2 ERAS1 malignant ureteral obstruction, 1 chronic renal insufficiency; 1 STD contrast induced nephropathy). No patients in the series required dialysis. ERAS patients, compared with STD patients, had earlier bowel function (POD 1.7 vs. 2.3, p=0.02), and shorter LOS 4 (36) vs. 6 (4-7) days, p=0.0002, and a similar readmission rate (8.5% vs. 10.9%, p=0.75), and need for return to the operating room (9.8% vs. 6.5%, p=0.75) Conclusions: Restrictive perioperative management after colorectal surgery is safe and does not result in a clinically or statistically increased rate of post-operative acute kidney injury.