Point-of-Care Ultrasound in General Surgery Residency Training: A Proposal for Milestones in Graduate Medical Education Ultrasound.

The use of point-of-care ultrasound (US) in the clinical setting has undergone massive growth, although its incorporation into training and practice is variable. Surgeons are interested in using point-of-care US and can incorporate it effectively into clinical practice. However, the current state of point-of-care US training in general surgery is inadequate. The Accreditation Council for Graduate Medical Education introduced the Milestones Project to evaluate resident and fellow performance. Emergency medicine is the only specialty with a point-of-care US milestone. We have successfully implemented a US training program into our general surgery residency curriculum and now propose milestones in point-of-care US for all general surgery residents.

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 randomized, prospective trial of operative treatments for hyperparathyroidism in patients with multiple endocrine neoplasia type 1.

BACKGROUND: Hyperparathyroidism (HPT) in multiple endocrine neoplasia (MEN) type 1 is associated with multiglandular parathyroid disease. Previous retrospective studies comparing subtotal parathyroidectomy (SP) and total parathyroidectomy with autotransplantation (TP/AT) have not established clearly better outcomes with either procedure. METHODS: Patients were assigned randomly to either SP or TP/AT and data were collected prospectively. The rates of persistent HPT, recurrent HPT, and postoperative hypoparathyroidism were compared. RESULTS: The study cohort included 32 patients randomized to receive either SP or TP/AT (mean follow-up, 7.5 ± 5.7 years). The overall rate of recurrent HPT was 19% (6/32). Recurrent HPT occurred in 4 of 17 patients (24%) treated with SP and 2 of 15 patients (13%) treated with TP/AT (P = .66). Permanent hypoparathyroidism occurred in 3 of 32 patients (9%) overall. The rate of permanent hypoparathyroidism was 12% in the SP group (2/17) and 7% in the TP/AT group (1/15). A second operation was performed in 4 of 17 patients initially treated with SP (24%), compared with 1 of 15 patients undergoing TP/AT (7%; P = .34). CONCLUSION: This randomized trial of SP and TP/AT in patients with MEN 1 failed to show any difference in outcomes when comparing results of SP versus TP/AT. Both procedures are associated with acceptable results, but SP may have advantages in that is involves only 1 surgical incision and avoids an obligate period of transient postoperative hypoparathyroidism.

The long-term impact of routine intraoperative nerve monitoring during thyroid and parathyroid surgery.

BACKGROUND: Despite widespread use of intraoperative nerve monitoring (IONM) as an adjunct to visual identification of the recurrent laryngeal nerve (RLN), published studies have shown little or no benefit. No long-term studies exist detailing the effect of experience gained from IONM on the rate of RLN injury. The aim of this study was to evaluate the impact of IONM feedback on surgical outcomes over time at a single institution. METHODS: We conducted retrospective analysis of prospectively gathered data for 1,936 patients including 3,435 nerves at risk between March 2004 and September 2011. Each RLN was analyzed for the specific, unilateral operative procedure that placed the nerve at risk of injury. The primary outcome measures included temporary vocal cord palsy and permanent vocal cord paralysis or paresis as determined by intraoperative loss of RLN function and postoperative laryngoscopy. Additional measures included instances where IONM assisted the surgeon's localization of the RLN. RESULTS: Of the 3,435 nerves at risk, 105 (3.06%) were injured, 4 had permanent paralysis (0.12%), and 7 had paresis (0.20%). Over time, a decrease in RLN injury was seen per successive operative year for thyroid lobectomy with paratracheal lymph node dissection with or without parathyroidectomy (odds ratio, 0.98; 95% confidence interval, 0.97-1.00; P = .04); the rate of nerve injury stabilized after 20 months of continued use of nerve monitoring. IONM particularly assisted the surgeon with identification of 108 nerves at risk (3.14%) with aberrant anatomy, and with identification of 236 nerves at risk (6.87%) during difficult dissections. CONCLUSION: With experience, routine use of IONM during thyroid and parathyroid operations significantly decreased the incidence of injury to the RLN for thyroid lobectomy with paratracheal lymph node dissection and provided useful assistance with RLN identification for 10% of nerves at risk.