Central venous parathyroid hormone monitoring using a novel, specific anatomic method accurately predicts cure during minimally invasive parathyroidectomy.

BACKGROUND: Measurement of intraoperative parathyroid hormone (PTH) levels is an important adjunct to confirm biochemical cure during parathyroidectomy. The purpose of this study was to evaluate a simplified anatomic technique for PTH sampling from the central veins through the minimally invasive neck incision, and to compare the predictive accuracy of central and peripheral PTH values. METHODS: A specific anatomic method for central PTH sampling was employed in 48 patients. Samples were drawn simultaneously from peripheral and central veins at baseline and 10 minutes postexcision of all hyperfunctioning parathyroid glands. RESULTS: The central venous PTH levels independently predicted biochemical cure according to the Miami criterion in all the patients. There was no significant difference in the postexcision central and peripheral values, which were 24.40 + 1.86 and 21.69 + 1.74, respectively (P = .877, ANOVA test). CONCLUSIONS: This study provides the original description of a simplified technique for measurement of intraoperative PTH levels in the central veins with direct comparison to peripheral venous levels, and confirmation of accuracy in predicting biochemical cure when relying on centrally obtained values alone.

A novel method for the management of post-thyroidectomy or parathyroidectomy hematoma: a single-institution experience after over 4,000 central neck operations.

BACKGROUND: Cervical hematoma is a rare but serious complication of thyroid and parathyroid surgery that has historically required inpatient monitoring. With improved surgical technique and experience, operations are being performed increasingly as outpatient procedures. Therefore, a safe and systematic approach to cervical exploration of a postoperative hematoma needs to be defined. METHODS: From 1996 to 2013, a retrospective review was performed of 4,140 thyroid and parathyroid operations. Surgical outcomes data were recorded, specifically including the occurrence of a cervical hematoma, time interval to presentation, and methods of management. RESULTS: A total of 18 patients (0.43 %) developed a postoperative cervical hematoma that required surgical intervention. The occurrence of hematoma was 0.66 % (n = 11) for bilateral thyroid procedures, 0.21 % (n = 3) for unilateral thyroid procedures, and 0.13 % (n = 1) for parathyroid procedures. There were 3 (1.69 %) patients who had combined unilateral thyroid and parathyroid procedures and developed hematomas. Emergent bedside decompression was required for only two patients, both of whom suffered respiratory arrest in the postoperative anesthesia recovery unit. The remaining 16 patients were explored in the operating room, utilizing initial local anesthesia in the semi-upright position in 11 patients (69 %). CONCLUSIONS: From our experience, hematomas that caused significant airway compromise leading to respiratory arrest occurred in the postoperative anesthesia recovery room, and hematoma presentation after this time did not require emergent bedside decompression. Hematoma, when it occurs, can otherwise be managed safely in the operating room after inpatient or outpatient procedures using initial local anesthesia with the patient in the semi-upright position for hematoma evacuation.

Outpatient laparoscopic appendectomy should be the standard of care for uncomplicated appendicitis.

BACKGROUND: In 2012, a protocol for routine outpatient laparoscopic appendectomy for uncomplicated appendicitis was published reflecting high success, low morbidity, and significant cost savings. Despite this, national data reflect that the majority of laparoscopic appendectomies are performed with overnight admission. This study updates our experience with outpatient appendectomy since our initial report, confirming the efficacy of this approach. METHODS: In July 2010, a prospective protocol for outpatient laparoscopic appendectomy was adopted at our institution. Patients were dismissed from the postanesthesia recovery room or day surgery if they met predefined criteria for dismissal. Patients admitted to a hospital room as either full admission or observation status were considered failures of outpatient management. An institutional review board-approved retrospective review of patients undergoing laparoscopic appendectomy for uncomplicated appendicitis from July 2010 through December 2012 was performed to analyze success of outpatient management, postoperative morbidity and mortality, as well as readmission rates. RESULTS: Three hundred forty-five patients underwent laparoscopic appendectomy for uncomplicated appendicitis during this time frame. There were 166 men and 179 women, with a mean age of 35 years. Three hundred five patients were managed as outpatients, with a success rate of 88%. Forty patients (12%) were admitted for preexisting comorbidities (15 patients), postoperative morbidity (6 patients), or lack of transportation or home support (19 patients). Twenty-three patients (6.6%) experienced postoperative morbidity. There were no mortalities. Four patients (1%) were readmitted for transient fever, nausea/vomiting, partial small bowel obstruction, and deep venous thrombosis. CONCLUSION: Outpatient laparoscopic appendectomy can be performed with a high rate of success, a low morbidity, and a low readmission rate. This study reaffirms our original pilot study and should serve as the basis for a change in the standard of care for appendicitis. LEVEL OF EVIDENCE: Therapeutic study, level V.

Are commercial negative pressure systems worth the cost in open abdomen management?

BACKGROUND: A commercial negative pressure product is compared with the Barker technique (sterile x-ray cassette cover, lap pads, adhesive drape with negative pressure) for temporary abdominal closure in open abdomen management. STUDY DESIGN: We performed a retrospective review of 37 open abdomen patients who had temporary abdominal closure with a commercial negative pressure device (ABThera, KCI) from 2010 to 2011. These patients were compared with the most recent 37 patients having open abdomen management using the Barker technique from 2009 to 2010. Patient demographics, body mass index (BMI), preoperative albumin, indication for open abdomen management, number of operations, use of sequential closure, and success with closure were analyzed. Patients were compared using chi square, t-test, and logistic regression analysis with significance of p < 0.05. RESULTS: Mean age and BMI were significantly higher in the ABThera patients. No statistically significant differences were seen in male:female ratio, indication for open abdomen management, preoperative albumin, number of operations, and use of sequential closure. In 33 patients (89%) ultimate midline fascial closure was achieved with the ABThera vs in 22 patients (59%) using the Barker technique (p < 0.05). Logistic regression analysis was performed on the 3 significant variables identified on bivariate analysis. Only the type of temporary abdominal closure proved significant, with an odds ratio of 7.97 favoring ABThera (95% CI 1.98 to 32.00). CONCLUSIONS: A commercially available negative pressure device for temporary abdominal closure had significantly greater success with ultimate closure after open abdomen management compared with the Barker technique. The added cost of the device is offset by improved patient results and savings from successful closure.

A prospective treatment protocol for outpatient laparoscopic appendectomy for acute appendicitis.

BACKGROUND: Many laparoscopic procedures are currently performed on an outpatient basis. Laparoscopic appendectomy, however, continues to require postoperative hospitalization at most institutions. A treatment protocol for outpatient laparoscopic appendectomy was developed to determine if this could be successfully performed without increasing postoperative complications. We hypothesized that adopting an outpatient protocol for laparoscopic appendectomy will significantly increase the rate of outpatient management for uncomplicated appendicitis, without an increase in morbidity or mortality. STUDY DESIGN: We initiated a prospective outpatient protocol for laparoscopic appendectomy in July 2010 at our institution. All patients having laparoscopic appendectomy from July 2010 to March 2011 were included as protocol patients and were retrospectively reviewed. A separate group of patients having laparoscopic appendectomy from January to September 2009 were analyzed as historical controls. These 2 groups were compared for demographics, preoperative comorbidities, outpatient management, and postoperative morbidity by chi-square analysis, with a 0.95 confidence level for statistical significance. RESULTS: A total of 116 protocol patients were compared with 119 historical control patients. There were no significant differences in patient demographics, preoperative comorbidities, and pathologic findings between protocol patients and historical controls. Ninety-nine protocol patients (85.3%) had procedures as outpatients compared with 42 historical control patients (35.3%; p < 0.05). Postoperative morbidity occurred in 6 protocol patients (5.2%) and 10 historical controls (8.4%; p = NS). There were no readmissions or mortalities in the protocol group. CONCLUSIONS: An outpatient protocol for laparoscopic appendectomy significantly increased the rate of outpatient management with no increase in morbidity or mortality. This practice has now become standard of care at our institution.

Outpatient laparoscopic appendectomy for acute appendicitis.

Laparoscopic appendectomy is the widely accepted treatment for acute appendicitis. This approach offers the potential of less pain, shorter hospital stay, and quicker return to activities. Traditionally, patients are hospitalized for 24 hours after laparoscopic appendectomy. This practice can be questioned due to the good results of other outpatient laparoscopic surgery. A retrospective review of 119 patients undergoing laparoscopic appendectomy for uncomplicated acute appendicitis was undertaken from January through September 2009; outpatient and inpatient laparoscopic appendectomies were compared. Patients were selected for outpatient management based upon physician discretion and their clinical course in operation and recovery rooms. Forty-two patients were dismissed on the day of surgery and 77 were admitted for 1 to 5 days postoperatively. No significant differences in age, gender, and preoperative comorbidities between outpatient and inpatient groups were found. Postoperative complications occurred in 2.4 per cent of outpatients and 11.7 per cent of inpatients (P = 0.16). Complications included superficial wound infections, urinary retention, urinary tract infection, intra-abdominal bleeding, pneumonia, and infected hematoma. Based upon this study, outpatient laparoscopic appendectomy can be performed safely in selected patients. This study provides the background for the present prospective protocol for routine outpatient laparoscopic appendectomy at our institution.

Elucidating mechanisms of recurrent laryngeal nerve injury during thyroidectomy and parathyroidectomy.

BACKGROUND: Intraoperative nerve monitoring during thyroidectomy, parathyroidectomy, or related central neck procedures can elucidate actual or potential mechanisms of recurrent laryngeal nerve (RLN) injury, especially visually intact nerves, which were previously unknown to the endocrine surgeon. STUDY DESIGN: In this prospective evaluation study, 373 patients underwent 380 consecutive thyroidectomy- or parathyroidectomy-related operations using intraoperative nerve monitoring, with 666 RLNs at risk. The success of visual and functional identification of the RLN, persistent loss of RLN function to nerve stimulation, the mechanism and location of RLN injury, and anatomy of the RLN or technical difficulties that appeared potentially risky for RLN injury were recorded. RESULTS: RLN was identified visually or functionally in 98.2% of nerves at risk. Initial intraoperative injury to the RLN occurred in 25 nerves at risk (3.75%). It was significantly more likely to be a visually intact RLN (n = 22; 3.3%) than a transected RLN (n = 3; 0.45%), p < 0.001. Paralysis persisted in 2 RLNs (0.3%). Visual misidentification accounted for only 1 RLN injury; the most common cause of injury resulted from traction to the anterior motor branch of a bifurcated RLN near the ligament of Berry (n = 7; 28%), then paratracheal lymph node dissection (n = 6; 24%), incorporating ligature (n = 4; 16%), and adherent cancer (n = 4; 16%). Fifty nerves at risk (7.5%) were identified as particularly at risk for injury, most notably those with anatomic variants (n = 26; 52%) and large or vascular thyroid lobes (n = 19; 38%). CONCLUSIONS: RLN injury during thyroidectomy or parathyroidectomy occurs intraoperatively significantly more often to a visually intact RLN than to a transected nerve. The anterior motor branch of an RLN bifurcating near the ligament of Berry is particularly at risk of traction injury.

Intraoperative neurophysiology testing of the recurrent laryngeal nerve: plaudits and pitfalls.

BACKGROUND: Electrode-imbedded endotracheal tubes allow continuous intraoperative assessment of vocal cord function when connected to an electromyographic (EMG) response monitor. Whether this device enhances or hinders the identification and preservation of the recurrent laryngeal nerve (RLN) is unclear. METHODS: The utility of continuous intraoperative neurophysiology testing (INT) of RLNs was evaluated prospectively in 100 patients undergoing 103 thyroid or parathyroid operations, involving 185 RLNs. The initial experience with 93 RLNs was compared with the subsequent 92 RLNs. RESULTS: Overall, 97.8% of RLNs were identified intraoperatively: 1.6% visually only, 2.2% nerve stimulator only, and 94% both. There was 1 transected RLN (1.1%) in each study group. The EMG monitor could not alert the surgeon to prevent these injuries. Overall, there were 14 instances of nonfunction of visually intact RLNs (7.6%), at some point during the operation and 4 resulting in temporary paralysis (2.2%). There were 8 instances of altered RLN function (4.3%) with no altered vocal cord function postoperatively. The nerve stimulator aided dissection of the RLN in 17 instances (9.2%). There were 7 episodes (3.8%) of equipment dysfunction that hampered surgical dissection. Between study groups there was significantly increased use of the nerve stimulator to first identify the location of the RLN before visual confirmation: 4 of 93, initial group versus 25 of 92, latter group (P < .001). CONCLUSIONS: INT aids the anatomic identification of the RLN only when a positive EMG response occurs. A negative EMG response can indicate a non-nerve structure, altered function of the RLN, or equipment setup malfunction. INT cannot necessarily prevent RLN transection.