F18-Choline PET/CT or MIBI SPECT/CT in the Surgical Management of Primary Hyperparathyroidism: A Diagnostic Randomized Clinical Trial.

Importance: Whether F18-choline (FCH) positron emission tomographic (PET)/computed tomographic (CT) scan can replace Tc99m-sestaMIBI (MIBI) single-photon emission (SPE)CT/CT as a first-line imaging technique for preoperative localization of parathyroid adenomas (PTA) in patients with primary hyperparathyroidism (PHPT) is unclear. Objective: To compare first-line FCH PET/CT vs MIBI SPECT/CT for optimal care in patients with PHPT needing parathyroidectomy and to compare the proportions of patients in whom the first-line imaging method resulted in successful minimally invasive parathyroidectomy (MIP) and normalization of calcemia 1 month after surgery. Design, Setting, and Participants: A French multicenter randomized open diagnostic intervention phase 3 trial was conducted. Patients were enrolled from November 2019 to May 2022 and participated up to 6 months after surgery. The study included adults with PHPT and an indication for surgical treatment. Patients with previous parathyroid surgery or multiple endocrine neoplasia type 1 (MEN1) were ineligible. Interventions: Patients were assigned in a 1:1 ratio to receive first-line FCH PET/CT (FCH1) or MIBI SPECT/CT (MIBI1). In the event of negative or inconclusive first-line imaging, they received second-line FCH PET/CT (FCH2) after MIBI1 or MIBI SPECT/CT (MIBI2) after FCH1. All patients underwent surgery under general anesthesia within 12 weeks following the last imaging. Clinical and biologic (serum calcemia and parathyroid hormone levels) assessments were performed 1 and 6 months after surgery. Main Outcomes and Measures: The primary outcome was a true-positive first-line imaging-guided MIP combined with uncorrected serum calcium levels of 2.55 mmol/l or less 1 month after surgery, corresponding to the local upper limit of normality. Results: Overall, 57 patients received FCH1 (n = 29) or MIBI1 (n = 28). The mean (SD) age of patients was 62.8 (12.5) years with 15 male (26%) and 42 female (74%) patients. Baseline patient characteristics were similar between groups. Normocalcemia at 1 month after positive first-line imaging-guided MIP was observed in 23 of 27 patients (85%) in the FCH1 group and 14 of 25 patients (56%) in the MIBI1 group. Sensitivity was 82% (95% CI, 62%-93%) and 63% (95% CI, 42%-80%) for FCH1 and MIBI1, respectively. Follow-up at 6 months with biochemical measures was available in 43 patients, confirming that all patients with normocalcemia at 1 month after surgery still had it at 6 months. No adverse events related to imaging and 4 adverse events related to surgery were reported. Conclusions: This randomized clinical trial found that first-line FCH PET/CT is a suitable and safe replacement for MIBI SPECT/CT. FCH PET/CT leads more patients with PHPT to correct imaging-guided MIP and normocalcemia than MIBI SPECT/CT thanks to its superior sensitivity. Trial Registration: ClinicalTrials.gov Identifier: NCT04040946.

Risk factors associated with early and late free flap complications in head and neck osseous reconstruction.

PURPOSE: This study was designed to identify risk factors for post-operative complications in micro-anastomosed osteomyocutaneous free flaps (MOFF) and analyzed their consequences in long term. METHODS: A retrospective review of 100 MOFF realized between May 2007 and October 2019 was performed. Demographic data, perioperative management and postoperative complications were enrolled and analyzed in a multivariate model. Patients were followed for ≥ 6 months. RESULTS: Major surgical complication rate was 20% with 5% of overall free flap failure rate and 6% of anastomosis salvage surgery. Risk identified for major surgical complication was alcohol consumption (p = 0.0054). Minor surgical complications occurred in 26% of patients mostly due to infections (19%). No significant risk factor was associated to minor surgical complications. Major and minor medical complication rates were, respectively, 10% and 10%. Risk identified for major medical complication were age over 70 (p = 0.0253) and history of chemotherapy (p = 0.0277). Risk identified for minor medical complication were alcohol consumption p = 0.0232) and a history of radiotherapy (p = 0.0329). CONCLUSIONS: Alcoholism is an independent risk factor for the surgical complication of MOFF that must be taken into account before surgery. Patients with a history of chemotherapy, radiotherapy or who are over 70 years of age are at greater risk of postoperative medical complications and require special attention.

Surgical management of MILD hyperparathyroidism.

INTRODUCTION: There is no consensus for management of Mild primary hyperparathyroidism (MILD-pHP). Specific management has been suggested by some authors. We have compared the surgical management of the patients with MILD-pHP to those with Classic primary hyperparathyroidism (C-pHP) treated by surgery according to The Fourth International Workshop on pHP. MATERIALS AND METHODS: Data of 173 patients who underwent a parathyroidectomy were reviewed and retrospectively analysed. Management of 32 patients with MILD-pHPT (18.5%) patients were compared to that of 141 (81.5%) patients with C-pHPT. RESULTS: MILD-pHP group was more often discovered after non-fractured osteoporosis (21.9% vs 7.1%, p = 0.02) and surgery for chondrocalcinosis was more often carried out (6.3% vs 0%, p = 0.03) in the MILD-pHP group. A Mini-Invasive Parathyroidectomy (MIP) was carried out in 81.3% of cases, and 87.5% of patients had a single adenoma. The rate of multiglandular pathology was not different. Same day discharge was significantly higher in MILD-pHP group (37.5% vs 17.7%, p = 0.01). Success was obtained in 87.5% in the MILD-pHP group, there was no significant difference with the C-pHP group (92.9%, p = 0.48). There was no significant difference in the imaging performances. Imaging discordance was observed in 18.8% of cases in MILD-pHP and 33.6% in C-pHP (p = 0.38) without correlation with surgical failure. CONCLUSION: This study suggests that, by selecting patients on the basis of concordant imaging and international recommendations, there is no difference in outcome between MILD-pHP and C-pHP treated surgically.

Neck Surgery with Hypnosis: An Evaluation Based Upon Patient's Self Assessment.

BACKGROUND: Surgery with hypnosis avoids the use of general anesthesia (GA). It also shortens hospitalization and promotes outpatient surgery. The objective of this study has been to assess the satisfaction of operated patients. No previous study has focused on patient satisfaction in a prospective design. METHODS: In this prospective, non-randomized, observational study, all patients operated with hypnosis between 2009 and 2017 in the Ear, Nose, and Throat department of a tertiary care hospital were selected. All patients were asked to fill a questionnaire based on a previously validated questionnaire incremented with complementary questions. Questionnaires were completed immediately after surgery for 31 patients and after 6 months for 20 patients. Global Satisfaction Index (GSI) was self-assessed on a scale ranging from 1 to 10. Patients were asked; whether they felt comfortable during the operation, whether hypnosis helped them, whether the experience matched their expectations, whether they would revisit or recommend it to someone else and whether they considered to have been sufficiently informed before the procedure. The data was analyzed using a linear regression model with P < .05 considered as statistically significant. RESULTS: During the inclusion period, no patient required conversion to GA. A total of 48 questionnaires were evaluated. The median of the GSI was 8/10. GSI significantly correlated with patient comfort (P < 0.0001) and quality of preoperative information (P = .002). The percentage of patients who found hypnosis helpful correlated with the duration of surgery (P = .04). The probability for a patient to consider hypnosis as an experience matching their expectation increased with surgical team experience OR 0.55 (0.3-0.9). CONCLUSION: This study reveals that patients' global satisfaction after hypnosis is high. This is significantly related to the quality of preoperative information and to the experience of the surgical team. It also suggests that patients are more likely to benefit from hypnosis if the surgery is longer.

Fascia Temporalis Free Flap for Cricotracheal Reconstruction: A Novel Approach.

BACKGROUND: The aim of tracheal reconstruction is to provide an airtight and noncollapsible airway covered with a suitable epithelial lining. To date, no ideal treatment is available for large tracheal defects. METHODS: We report 4 patients who underwent one-stage reconstruction for a cricotracheal stenosis with a free temporoparietal fascia flap and costal cartilage grafts. RESULTS: Closure of tracheostoma was achieved for all patients. The main advantage of this flap compared with the free radial forearm flap is that it supplies a more suitable lining allowing the reepithelialization process with respiratory epithelium. CONCLUSIONS: This one-stage procedure provides a reliable construct to substitute for large tracheal defects, even in areas previously exposed to an operation or radiotherapy.

[Epidemiology and anatomy of head and neck cancers]. / Épidémiologie et anatomie des cancers ORL.

Oral cavity and pharyngeal cancers account for 75% of head and neck cancers and are the fourth most spread cancer in men. Their incidence has decreased since 1980 in men (incidence from 2011 gives 13,930 for lip, oral cavity, pharyngeal and laryngeal carcinomas) but has increased in women, linked to the more recent smoking or alcohol intoxication in women. In addition to the smoking or alcohol consumption risk factors, the EBV role in nasopharyngeal carcinomas, HPV in the oropharyngeal carcinomas and professional exposures in paranasal sinuses cancers are recognized. Head and neck cancers are the fifth most common cancer in men mortality in France. Extended anatomical sites reflect the diagnostic's complexity specific to some locations (sinuses, nasopharynx), possible therapies and prognosis depending on the affected site.