Roy Phitayakorn

Standardized Algorithms for Management of Anastomotic Leaks and Related Abdominal and Pelvic Abscesses After Colorectal Surgery

BackgroundThe risk factors and incidence of anastomotic leak following colorectal surgery are well reported in the literature. However, the management of the multiple clinical scenarios that may be encountered has not been standardized.MethodsThe medical literature from 1973 to 2007 was reviewed using PubMed for papers relating to anastomotic leaks and abdominal abscess, with a specific emphasis on predisposing factors, prevention strategies, and treatment approaches. A six-round modified Delphi research method was utilized to find consensus among a group of expert colorectal surgeons and interventional radiologists regarding standardized management algorithms for anastomotic leaks.ResultsManagement scenarios were divided into those for intraperitoneal anastomoses, extraperitoneal (low pelvic) anastomoses, and anastomoses with proximal diverting stomas. Management options were then based on the clinical presentation and radiographic findings and organized into three interconnected algorithms.ConclusionsThis process was a useful first step toward establishing guidelines for the management of anastomotic leak.

Hyperparathyroid crisis: use of bisphosphonates as a bridge to parathyroidectomy.

BACKGROUND Hyperparathyroid crisis is an uncommon, potentially lethal condition for which emergent parathyroidectomy has been advocated. STUDY DESIGN The manifestations of hyperparathyroid crisis and outcomes of bisphosphonate-based therapy and delayed parathyroidectomy were determined and compared with cases from a review of the literature. Laboratory indices and gland weights were compared with those from patients with primary hyperparathyroidism without crisis. RESULTS Of the 292 patients operated on for hyperparathyroidism, 8 (2.8%) had hyperparathyroid crisis, consistent with rates of 1.6% to 6% reported in the literature. Hyperparathyroid crisis was manifested by vomiting, nausea, or both (n=6); abdominal pain (n=3); mental status changes (n=3); pancreatitis (n=2); bone pain, osteolytic lesions, or both (n=2); electrocardiogram changes (n=1); and an acute conversion disorder (n=1). Isotonic sodium chloride and furosemide, in combination with a bisphosphonate drug in 7 of 8 patients, resulted in a calcium decline from 16.2+/-1.6 mg/dL to 11.8+/-1.6 mg/dL, with resolution of electrocardiogram and mental status changes, and pancreatitis before resection of an adenoma (n=7) or carcinoma (n=1). Patients with hyperparathyroid crisis had higher parathyroid hormone levels (691.7 +/-662.4 pg/mL versus 172.6 +/-147.5 pg/mL; p=0.062), larger tumor weights (7.5 +/-8.4 g versus 1.6 +/-2.1 g; p=0.085), and lower postoperative calcium levels (7.3 +/-1.6 mg/dL versus 8.7+/-0.9 mg/dL; p=0.035) than patients without crisis. Four (50%) of the 8 tumors were found in ectopic locations. There was no mortality from hyperparathyroid crisis, compared with a 7% mortality rate for cases reported in the literature since 1978. CONCLUSIONS Rehydration, calciuresis, and bisphosphonate therapy are effective in correcting life-threatening manifestations of hyperparathyroid crisis, providing an effective bridge to parathyroidectomy.

Diagnosis and management of pheochromocytoma

Tumors that that secrete excessive levels of catecholamines, commonly termed “pheochromocytomas,” can arise from the adrenal gland (pheochromocytomas [PCCs]) or from the sympathetic ganglia (paragangliomas [PGLs] or extra-adrenal PCCs). The adrenal glands, also known as the suprarenal glands, are located in the retroperitoneum, superomedial to the kidneys and high up under the costal margin adjacent to the diaphragm. Histologically, the adrenal glands consist of an outer cortex and inner medulla and secrete hormones essential for normal human physiologic function. Each of the adrenal glands, in their normal size and configuration, measure approximately 3-5 cm in length, 4-6 mm in thickness, and weigh approximately 4-5 g. They are closely approximated to the superomedial aspect of the kidneys and are surrounded by a fibrous capsule of connective tissue (Gerota fascia of the kidney) outside of which is loose connective tissue and abundant perinephric and retroperitoneal fat. The adrenal glands are clearly distinguished from the surrounding fat by their bright yellow color and more nodular and fibrous consistency. The bright yellow color is the adrenal cortical tissue. The inner medulla, only apparent with adrenal sectioning after removal, is gray-brown in color. Despite the distinct color and appearance of the adrenal cortex, the retroperitoneal location and covering of fat and connective tissue can obscure the gland. A significant amount of dissection in the retroperitoneal and perirenal fat is often required to locate the adrenal glands during surgery. The adrenal glands are composed of 2 discrete and separate anatomical, embryologic, and functional regions: the adrenal cortex and the adrenal medulla. The outer layer, or the adrenal cortex, arises from the mesoderm during embryologic development and accounts for the majority of the gland substance. The cortex has 3 separate layers or zones, and each secretes a different set of hormones. The outermost layer is the zona glomerulosa and secretes the mineralocorticoid known as aldosterone. The primary function of aldosterone is to increase renal sodium reabsorption and potassium excretion. Tumors from this adrenal cortical layer that overproduce aldosterone cause a clinical syndrome termed “Conn syndrome,” and patients frequently present with hypertension and hypokalemia. The middle layer and inner regions of the cortex, the zona fasciculata and the zona reticularis, secrete glucocorticoids (cortisol) and androgens, respectively. Hormonally active tumors from these regions can cause Cushing syndrome (excess cortisol) or a virilizing syndrome (excess androgens). The innermost region of the adrenal gland is the medulla, which is derived from the same neural crest cells that comprise the sympathetic ganglia. The adrenal medulla is innervated by preganglionic fibers of the

Thyroid-associated paragangliomas.

BACKGROUND Paragangliomas in the region of the thyroid gland are rare tumors that can present a diagnostic challenge by mimicking follicular and c-cell derived thyroid tumors. SUMMARY Thyroid-associated paragangliomas are likely a subset of laryngeal paragangliomas and, although quite rare, should be considered in the differential diagnosis of a hypervascular thyroid nodule. The preoperative diagnosis of thyroid-associated paragangliomas can be challenging since the cytologic and histologic features overlap with more common primary thyroid neoplasms, in particular medullary carcinoma. Differential expression of a panel of immunohistochemical markers, including neuro-specific enolase, chromogranin A, synaptophysin, keratin, and S100, can be used to distinguish thyroid-associated paragangliomas from primary thyroid tumors. Intraoperatively, thyroid-associated paragangliomas may be associated with significant intraoperative bleeding and are often densely adherent to surrounding tissues, including the recurrent laryngeal nerve. Interestingly, the aggressive local behavior of these tumors does not correspond to potential for malignancy, as there are no patients with malignant thyroid-associated paragangliomas reported in the medical literature. Therefore, these tumors may be treated with limited resection. Postoperatively, patients with paragangliomas should receive hormonal evaluation for functional disease, imaging evaluation for multicentric and metastatic disease, and genetic counseling. CONCLUSION Thyroid-associated paragangliomas are an important part of the differential diagnosis of a hypervascular thyroid nodule, especially in a patient with a fine-needle aspiration biopsy suggestive of medullary thyroid carcinoma, but with unremarkable serum calcitonin levels. Consideration of a thyroid-associated paraganglioma also has important operative and postoperative implications for determining the extent of thyroid resection as well as follow-up testing.

Follow-Up After Surgery for Benign Nodular Thyroid Disease: Evidence-Based Approach

BackgroundThere is no consensus on what constitutes appropriate methodology and timing for follow-up of patients after surgery for benign nodular disease.MethodsA systematic review of the medical literature using evidence-based criteria was used to address the following four issues: (1) How often should patients who have undergone thyroidectomy for the treatment of benign nodular goiter be followed, and what constitutes appropriate follow-up? (2) What is the most appropriate method for detecting recurrent nodular thyroid disease? (3) Does thyroid hormone administration prevent recurrent nodular thyroid disease? (4) Does iodine administration prevent recurrent nodular thyroid disease?ResultsAltogether, 742 articles were found in MEDLINE using a keyword search strategy; we then narrowed them to 23 articles. There were a total of four articles with Level I data, five articles with Level II data, one article with Level III data, and 13 articles with Level IV or retrospective data.ConclusionsBased on the available data, it is our recommendation that patients undergoing thyroid lobectomy for benign nodular thyroid disease should be followed with an annual physical examination, neck ultrasonography, and serum thyroid-stimulating hormone (TSH) measurement. Patients undergoing total thyroidectomy should be followed with an annual physical examination and a serum TSH measurement. Routine thyroxine and/or iodine supplementation may be useful for preventing recurrence in patients from iodine-deficient regions.

A multi-institutional study of the emotional intelligence of resident physicians

BACKGROUND Although emotional intelligence (EI) may have a role in the development of Accreditation Council for Graduate Medical Education core competencies, few studies have measured resident EI across specialties. This study aimed to describe the EI of resident physicians across multiple specialties. METHODS Three hundred twenty five surgery, pediatric, and pathology residents at 3 large academic institutions were invited to complete the psychometrically validated Trait Emotional Intelligence Questionnaire. RESULTS The response rate was 42.8% (n = 139). Global EI of all residents (101.0 ± 8.1) was comparable with, but less variable than, the general population sample and was not statistically different between specialties. Compared with the norm sample, residents in the 3 specialty groups demonstrated unique combinations of areas of relative high and low development. CONCLUSIONS There exist distinct strengths and opportunities for the development for surgery, pediatrics, and pathology residents. Future investigations could use EI profiling to create educational interventions to develop specific areas of EI and assess correlation with resident performance.

WISE-MD usage among millennial medical students

BACKGROUND E-learning is increasingly common in undergraduate medical education. Internet-based multimedia materials should be designed with millennial learner utilization preferences in mind for maximal impact. METHODS Medical students used all 20 Web Initiative for Surgical Education of Medical Doctors modules from July 1, 2013 to October 1, 2013. Data were analyzed for topic frequency, time and week day, and access to questions. RESULTS Three thousand five hundred eighty-seven students completed 35,848 modules. Students accessed modules for average of 51 minutes. Most frequent use occurred on Sunday (23.1%), Saturday (15.4%), and Monday (14.3%). Friday had the least use (8.2%). A predominance of students accessed the modules between 7 and 10 PM (34.4%). About 80.4% of students accessed questions for at least one module. They completed an average of 40 ± 30 of the questions. Only 827 students (2.3%) repeated the questions. CONCLUSIONS Web Initiative for Surgical Education of Medical Doctors has peak usage during the weekend and evenings. Most frequently used modules reflect core surgical problems. Multiple factors influence the manner module questions are accessed.

Are There Gender Differences in the Emotional Intelligence of Resident Physicians

BACKGROUND Because academic literature indicates that emotional intelligence (EI) is tied to work performance, job satisfaction, burnout, and client satisfaction, there is great interest in understanding physician EI. OBJECTIVE To determine whether gender differences in resident EI profiles mirror EI gender differences in the general population. STUDY DESIGN (INCLUDE PARTICIPANTS AND SETTING) A total of 325 residents in 3 types of residency programs (pathology, pediatrics, and general surgery) at 3 large academic institutions were invited electronically to complete the validated Trait Emotional Intelligence Questionnaire (TEIQue), a tool consisting of 153 items that cluster to 15 independent facets, 4 composite factors, and 1 global EI score. RESULTS The response rate was 42.8% (n = 139, women = 84). Global EI was not significantly different between men and women resident physicians (p = 0.74). Women scored higher than men in the TEIQue facets impulse control (p = 0.004) and relationships (p = 0.004). Men scored higher than women in 2 facets, stress management (p = 0.008) and emotion management (p = 0.023). Within surgery (n = 85, women = 46), women scored higher than men in impulse control (p = 0.006), whereas men scored higher in stress management (p = 0.008). CONCLUSIONS Men and women residents across 3 specialties demonstrated near-identical global EI scores. However, gender differences in specific TEIQue facets suggest that similar to the general population, men and women residents may benefit from specific training of different EI domains to enhance well-rounded development. The lack of significant gender differences within surgery may indicate that surgery attracts individuals with particular EI profiles regardless of gender. Future research should focus on the functional relationship between educational interventions that promote targeted EI development and enhanced clinical performance.

What Constitutes Adequate Surgical Therapy For Benign Nodular Goiter

BACKGROUND It is our hypothesis that the extent of thyroid resection for benign nodular thyroid disease (NTD) should be based on the extent of disease. METHODS Patients operated on for benign NTD from 1990 through 2007 were divided into 3 groups: those who underwent lobectomy for unilateral NTD (Group 1); near-total or total thyroidectomy for bilateral NTD (Group 2); and reoperation for NTD initially treated at other institutions (Group 3). The incidence of recurrence was determined for Groups 1 and 2 and the timing of diagnosis was compared to Group 3. Potential risk factors for recurrent disease were examined. RESULTS Five hundred forty-five patients were operated on for benign NTD. Contralateral disease was excluded in Group 1 patients using ultrasound (47.7%) and/or intraoperative palpation (100%). Five (1.9%) of 260 patients in Group 1 and 1 (0.4%) of 248 patients in Group 2 developed recurrent NTD after 7 +/- 4 (median = 8) and 4 y compared to a mean 19 +/- 11 (median = 20) y for the 37 patients in Group 3 following 1 to 3 previous thyroidectomies. Recurrent disease was diagnosed by physical exam in 24 (55.8%) and imaging in 19 (44.2%) patients. Thyroid hormone was required for postsurgical hypothyroidism in 70 (26.9%) patients in Group 1. CONCLUSION Thyroid lobectomy is optimal therapy when benign NTD is limited to 1 lobe, as evidenced by a 2% recurrence rate and maintenance of euthyroidism in 73% of patients. When NTD is bilateral, total thyroidectomy is indicated to eliminate recurrence, underscoring the importance of routine preoperative ultrasound.

Research priorities for multi-institutional collaborative research in surgical education

BACKGROUND Research in surgical education has seen unprecedented growth but originates from single institutions and remains uncoordinated; this study aimed to generate a list of research priorities in surgical educational topics. METHODS The membership of the Association for Surgical Education was asked to submit up to 5 research questions concerned with multi-institutional collaborative surgical education research and to identify challenges faced by surgical education researchers. A modified Delphi methodology was used to create the research agenda based on these responses. RESULTS Surgical educators responded to 3 survey rounds. Categories of submitted questions included teaching methods and curriculum development; assessment and competency; simulation; medical student preparation and selection; impact of work hour restrictions; and faculty development. Participants cited institutional culture and practice variability and lack of institutional review board coordination as common barriers to collaborative research, while identifying extensive planning, frequent communication, and availability of dedicated research coordinators as the most important facilitators. CONCLUSIONS Using a Delphi methodology, a prioritized agenda for multi-institutional surgical education research was developed that may help advance surgeon education.