Ectopic and supernumerary parathyroid glands in patients with refractory renal hyperparathyroidism.

BACKGROUND: The aims of this study were to determine the rate of ectopic and supernumerary parathyroid glands and the outcome of surgical therapy in patients with refractory renal hyperparathyroidism. MATERIALS AND METHODS: A retrospective review of all patients who underwent parathyroidectomy for refractory renal hyperparathyroidism was completed. Operative and pathology reports were reviewed, and the number and location of resected parathyroid glands, patient outcomes, and follow-up were determined. RESULTS: During the period 1993-2019, a total of 68 patients underwent subtotal or total parathyroidectomy for renal hyperparathyroidism. Of those, 59 patients (87%) were on dialysis for an average of 6.7 years. We determined that 18 patients (26%) had 24 ectopic parathyroid glands, including 9 (13%) patients with 11 supernumerary glands. A total of 2 patients had a supernumerary gland in a normal anatomic location. Of the 24 ectopic glands, 14 (58%) were in the thymus. After parathyroidectomy, 4 patients (5.9%) had persistent hyperparathyroidism, 6 patients (8.8%) developed recurrent hyperparathyroidism, and 2 patients (3%) had permanent hypoparathyroidism. CONCLUSION: Ectopic and supernumerary parathyroid glands occurred in 26% and 16% of patients with renal hyperparathyroidism, respectively, and the thymus was the most common location. Thorough neck exploration and transcervical thymectomy are important to help reduce persistent and recurrent hyperparathyroidism after parathyroidectomy for renal hyperparathyroidism.

Desaturation during Six-Minute Walk Testing Predicts Major Morbidity Following Anatomic Lung Resection among Patients with COPD.

BACKGROUND: Pulmonary function testing (PFT) is commonly used to risk-stratify patients prior to lung resection. Guidelines recommend that patients with reduced lung function, due to chronic lung conditions such as Chronic Obstructive Pulmonary Disease (COPD), should receive additional physiologic testing to determine fitness for resection. We reviewed our experience with six-minute walk testing (SMWT) to determine the association of test results and post-operative complications. METHODS: Consecutive adult patients undergoing segmentectomy, lobectomy, bilobectomy or pneumonectomy between 1 January, 2007 and 1 January, 2017 were identified in a prospectively maintained database. Patients with poor lung function, as defined by percent predicted forced expiratory volume in 1 s (FEV1) or diffusion capacity of carbon monoxide (DLCO) ≤60%, had results of SMWT extracted from their chart. Association of test result to post-operative events was performed. RESULTS: 581 patients had anatomic lung resections with predicted post-operative FEV1 or DLCO values ≤60%, consistent with a diagnosis of COPD. Among them, 50 (8.6%) had preoperative SMWT performed. Patients who received SMWT were more likely to have a FEV1 or DLCO less than 40 percent predicted (24/50 (48.0%) vs 166/531 (31.3%), p = 0.016). Post-operatively, patients who had SMWT performed had higher rates of pneumonia, but similar rates of major morbidity. The post-exercise oxygen saturation and the amount of desaturation correlated with the occurrence of major morbidity. In multivariable regression, oxygen desaturation was an independent risk factor for the occurrence of major morbidity, and desaturation was an excellent predictor of major morbidity by receiver operating characteristic curves analsysis. CONCLUSIONS: Among patients with elevated risk, oxygen desaturation during SMWT was independently associated with the occurence of major morbidity in multivariable analysis, while pulmonary function testing was not. SMWT is an important tool for risk-stratification, and may be underutilized.

Early discharge after lung resection is safe: 10-year experience.

BACKGROUND: The average hospitalization after lung resection is 6 days, but some patients are discharged early in the post-operative period. The patient factors associated with early discharge (ED) and the safety of this approach are unknown. We hypothesized that specific patient populations are associated with ED, and that complications in this practice are low. METHODS: A prospective database of lung resections performed at an academic medical center between Jan 1, 2007 and Jan 1, 2017 was queried. Demographic and outcome variables were assessed using standard techniques. ED was defined as the length of stay (LOS) for the quintile with the lowest LOS for patients with anatomic resection (AR) or patients with wedge resection (WR). We then compared clinical factors between patients with ED to those patients discharged by day 7, to determine factors associated with ED (relative to "average" discharge). RESULTS: During the study period, there were 922 AR and 1,150 WR performed. A total of 448 (39.0%) patients had WRED and 211 patients (22.9%) had ARED. The rate of WRED varied by surgeon, but ARED did not. ARED and WRED patients was associated with several factors, including younger age, better lung function, and were less likely to have elevated American Society of Anesthesiologist (ASA) class. Multivariable analysis suggested that patient factors and primary surgeon influence ED. WRED was associated with 30-day mortality of 0.22% vs. 1.14% for longer LOS (P=0.08). After AR, there were no post-operative deaths within 30 days among 211 patients discharged on postoperative day 1 or 2 [(vs. 2/541, 0.4%, P=0.376) with longer LOS, P=0.048]. CONCLUSIONS: ED after lung resection is multifactorial but is safe among selected patients. Age, lung function, procedure duration, and surgeon all influence ED. Complications after ED were rare. Individual surgeon comfort with ED likely impacts LOS, and education or enhanced recovery protocols may help overcome this barrier. Standardized pathways would likely help identify low-risk patients for expeditious discharge.