Use of Structured Presentation Formatting and NSQIP Guidelines Improves Quality of Surgical Morbidity and Mortality Conference.

BACKGROUND: Surgical Morbidity and Mortality (M&M) conference lacks a standardized structure across institutions. We compared implementation of structure and National Surgical Quality Improvement Program's (NSQIP) definitions to organize our M&M and identify cases for discussion versus the usually used method at many centers of case identification by an attending surgeon or resident. METHODS AND MATERIALS: A prospective study was performed, over a 10-wk period, to compare the identification of adverse events and the educational value of our M&M conference before and after implementation of structured NSQIP-defined presentations. Chart review was performed by a trained surgical clinical reviewer and trained NSQIP resident of all cases over the study period to identify NSQIP-defined occurrences. All presented M&Ms were evaluated for adequate reporting of adverse events and areas for improvement on a three-point scale. Surveys were administered before and after intervention to assess educational value to resident and faculty on a five-point Likert scale. Survey and presentation data were compared using Student's t-tests. P-values <0.05 were considered significant. RESULTS: Before intervention, 15% of NSQIP-defined occurrences were identified compared with 81% after intervention (P < 0.01). Thirty-three percent of deaths (1 of 3) before intervention were identified versus 100% (4 of 4) identified after intervention. Surveys obtained from faculty, residents, and students of individual presentations found improved clarity and educational content in cases presented (2.6-2.8) and improved identification of etiology (2.5-2.8), learning points (2.1-2.7), and opportunities for prevention of future adverse events (2.1-2.6) (all P < 0.01). Residents and faculty overall found that the postintervention model better identified adverse events (3.0-3.7, P = 0.02), opportunities for prevention (2.8-3.3, P = . 04), and promoted improved transparency (2.9-3.8, P < 0.01). Eighty-five percent of participants supported the changes in M&M conference. CONCLUSIONS: Incorporation of a clearly defined structure using NSQIP definitions for morbidity and identification of every mortality in our M&M conference standardized identification of adverse events thus improving conference quality. Consideration of the use of this structure should be given to other surgical departmental M&Ms.

Minimally elevated preoperative parathyroid hormone level influences the management of primary hyperparathyroidism.

OBJECTIVES/HYPOTHESIS: To determine the effect of preoperative parathyroid hormone (PTH) level on the extent of surgery and the accuracy of parathyroid imaging in primary hyperparathyroidism. STUDY DESIGN: Retrospective cohort. METHODS: Final diagnosis of single-gland adenoma and its location versus multigland disease was established in this retrospective cohort study. Positive predictive value, negative predictive value, and accuracy of imaging were analyzed in relation to preoperative PTH levels. RESULTS: Eighty-seven percent of the 218 patients enrolled in the study underwent unilateral targeted operation and had a 97.9% (95% confidence interval: 95.8%-100%) success rate. However, in patients with PTH <65 pg/mL, 28.6% had bilateral exploration compared to 10.3% in those with PTH ≥65 pg/mL (P = .042). In patients with PTH <65 pg/mL, 7/21 (33.3%) had inaccurate sestamibi findings compared to 24/174 (13.8%) in patients with PTH ≥65 pg/mL (P = .047). CONCLUSIONS: Accuracy of sestamibi drops significantly, by threefold, in patients with mild primary hyperparathyroidism and PTH <65 pg/mL. Patients with PTH < 65 pg/mL have a 2.5-fold higher rate of bilateral operation to identify the hypersecreting gland(s) compared to patients with PTH ≥65 pg/mL. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:1016-1021, 2018.

Utility of Single-Phase Computed Tomography in Identifying Parathyroid Adenomas: A Feasibility Study.

OBJECTIVE: We tested the hypothesis that a single-phase neck computed tomography (CT) is not inferior to multiphase neck CT (MPNCT), ultrasound, or nuclear medicine sestamibi scan in identifying parathyroid adenomas (PAs). METHODS: A total of 29 patients who had an MPNCT for the evaluation of a PA were identified; 11 patients met the inclusion criteria. During the 30-second arterial phase CT (APNCT), a normalized Hounsfield unit of suspected PA was compared to Hounsfield unit of a normal-appearing level I and a level II lymph node. A PA was defined as a lesion with a ratio of greater than 1.4 when compared to the level I and level II lymph node. This cutoff was determined based on the normalized ratios between level II and level I lymph nodes. Results of intraoperative parathyroid hormone assays and surgical pathology were used to validate the accuracy of this technique. RESULTS: The sensitivity of this method in APNCT is 90.9% whereas positive predictive value is 100%. The sensitivity or positive predictive value of ultrasound and nuclear medicine are 60% or 100% and 90% or 100%, respectively. CONCLUSION: The sensitivity of APNCT is equivalent to that of MPNCT in identifying PA.

Metastatic Renal Cell Carcinoma to the Thyroid 23 Years After Nephrectomy.

Thyroid carcinoma is an uncommon form of human cancer, with an outstanding overall cure rate. This excellent prognosis is based on the fact that well over 99% of thyroid cancers are primary tumors. Metastatic cancer to the thyroid remains very rare. We report a case of clear cell renal carcinoma metastatic to the thyroid gland 23 years after nephrectomy.

Targeted parathyroidectomy: effectiveness and intraoperative rapid-parathormone dynamics.

OBJECTIVE: The objective of this study is to assess the effectiveness of selective parathyroid exploration, using preoperative image localization and intraoperative rapid-parathormone (rPTH) assay. The kinetics of intraoperative rPTH in parathyroid adenoma vs. multiglandular disease is assessed. DESIGN: This is a prospective noncontrolled study of a cohort of 100 patients with primary hyperparathyroidism, at a single academic institution. The patients underwent selective parathyroidectomy after preoperative localization, including sestamibi scan and ultrasonography. Intraoperative rPTH assay was used to determine the extent and success of parathyroidectomy. Frozen sections were used as additional confirmation. Follow-up serum calcium levels were used to assess the effectiveness of selective parathyroidedcomy. RESULTS: Mean preoperative serum calcium (Ca) and baseline intact-parathormone were 11.6 mg/dL and 136, respectively. Data were available in 96 cases: 87 single-gland adenoma with two in ectopic mediastinal position, two double adenoma and seven cases of hyperplasia. Ten percent of patients with adenoma needed bilateral exploration for nonlocalizing or false negative imaging, or for intraoperative rPTH failure to decay. All of the patients undergoing unilateral targeted exploration were normocalcemic on follow up. There were only one failed exploration and two cases of recurrent mild hypercalcemia, all three in bilateral exploration cases. Intraoperative rPTH reduction by standard curves was predictive of successful excision of all of the abnormal glands, as confirmed by postoperative serum calcium levels. More than one postexcision rPTH measurement was useful by showing failure of a decaying slope in multiglandular disease. CONCLUSION: Targeted parathyroidectomy, when appropriately selected and carried out, is an effective treatment of primary hyperparathyroidism in most cases. Intraoperative rPTH can correctly guide removal of hyperfunctioning glands. Targeted parathyroidectomy offers the advantage of less invasive surgery with less tissue dissection confined to one side and avoids surgically disturbing the remainder of the neck. This should reduce postoperative complications and allow for easier and safer re-exploration in the few cases with persistent or recurrent disease.

Colon cancer metastatic to the lung and the thyroid gland.

The clinical diagnosis of primary thyroid cancer is uncommon, constituting 1.5% of all cancers in the United States. Clinically diagnosed metastatic cancer to the thyroid gland is rare. Colon cancer is one of the most common cancers in the United States, with a high propensity to metastasize; 30% to 40% of patients have metastatic disease at the initial diagnosis. The most common sites of metastasis from colon cancer are the regional lymph nodes, the liver, the lung, and the peritoneum. Colon cancer metastasis to the thyroid gland is rare, with only a few reported cases, mainly in the pathology literature. These cases describe metastasis from colon cancer to the thyroid gland that became apparent years after the initial diagnosis of colon cancer and were usually associated with dissemination to the liver, the lung, or both. We report a case of colonic adenocarcinoma metastatic to the thyroid gland and lung without involvement of the liver. A review of the literature is also included.