Risk Factors Associated With Atrial Fibrillation in Elderly Patients.

Background: Atrial fibrillation (AF) is the most common arrhythmia with a growing prevalence worldwide, especially in the elderly population. Patients with AF are at higher risk of serious life-threatening events and complications that may lead to long-term sequelae and reduce quality of life. The aim of our study was to examine the association of additional risk factors and comorbid medical conditions with AF in patients 65 years, or older. Methods: We performed a retrospective electronic medical record review of patients aged 65 years and older, who visited our internal medicine office between July 1, 2020 and June 30, 2021. Results: Among 2,433 patients, 418 patients (17.2%) had AF. Our analysis showed that for each unit increased in age, there was a 4.5% increase in the odds of AF (95% confidence interval (CI) 2.2-6.9%; P < 0.001). Compared to patients of Caucasian descent, African-American patients had significantly decreased odds of AF (odds ratio (OR) 0.274, 95% CI 0.141 - 0.531; P < 0.001). Patients with hypertension had 2.241 greater odds of AF (95% CI 1.421 - 3.534; P = 0.001). Additional comorbidities with significantly greater odds of AF included other cardiac arrhythmias (OR 2.523, 95% CI 1.720 - 3.720; P < 0.001), congestive heart failure (OR 3.111, 95% CI 1.674 - 5.784; P < 0.001), osteoarthritis (OR 3.014, 95% CI 2.138 - 4.247; P < 0.001), liver disease (OR 2.129, 95% CI 1.164 - 3.893; P = 0.014), and colorectal disease (OR 1.500 95% CI 1.003 - 2.243; P = 0.048). Comorbidities with significantly decreased odds of AF included other rheumatological disorder (OR 0.144, 95% CI 0.086 - 0.243; P < 0.001), non-steroidal anti-inflammatory drugs (NSAIDs) use (OR 0.206, 95% CI 0.125 - 0.338; P < 0.001), and corticosteroid use (OR 0.553, 95% CI 0.374 - 0.819; P = 0.003). Conclusions: Increasing age, hypertension, presence of other cardiac arrhythmias, congestive heart failure, osteoarthritis, liver disease, and colorectal disease are associated with increased odds of having AF.

Resonance Raman Characterization of O2-Binding Heme Proteins.

A vast array of critical in vivo processes and pathways are dependent on a multitude of O2-binding heme proteins which contain a diverse range of functions. Resonance Raman (rR) spectroscopy is an ideal technique for structural investigation of these proteins, providing information about the geometry of the Fe-O-O fragment and its electrostatic interactions with the distal active site. Characterization of these oxy adducts is an endeavor that is complicated by their instability for many heme proteins in solution, an obstacle which can be overcome by applying the rR technique to cryogenically frozen samples. We describe here how to measure rR spectra of heme proteins with stable oxy forms, as well as the technical adaptations required to measure unstable samples at 77 K.

Structure-function characterization of the mono- and diheme forms of MhuD, a noncanonical heme oxygenase from Mycobacterium tuberculosis.

MhuD is a noncanonical heme oxygenase (HO) from Mycobacterium tuberculosis (Mtb) that catalyzes unique heme degradation chemistry distinct from canonical HOs, generating mycobilin products without releasing carbon monoxide. Its crucial role in the Mtb heme uptake pathway has identified MhuD as an auspicious drug target. MhuD is capable of binding either one or two hemes within a single active site, but only the monoheme form was previously reported to be enzymatically active. Here we employed resonance Raman (rR) spectroscopy to examine several factors proposed to impact the reactivity of mono- and diheme MhuD, including heme ruffling, heme pocket hydrophobicity, and amino acid-heme interactions. We determined that the distal heme in the diheme MhuD active site has negligible effects on both the planarity of the His-coordinated heme macrocycle and the strength of the Fe-NHis linkage relative to the monoheme form. Our rR studies using isotopically labeled hemes unveiled unexpected biomolecular dynamics for the process of heme binding that converts MhuD from mono- to diheme form, where the second incoming heme replaces the first as the His75-coordinated heme. Ferrous CO-ligated diheme MhuD was found to exhibit multiple Fe-C-O conformers, one of which contains catalytically predisposed H-bonding interactions with the distal Asn7 residue identical to those in the monoheme form, implying that it is also enzymatically active. This was substantiated by activity assays and MS product analysis that confirmed the diheme form also degrades heme to mycobilins, redefining MhuD's functional paradigm and further expanding our understanding of its role in Mtb physiology.

The key to simplified management of an undescended parathyroid adenoma.

Undescended parathyroid adenoma is a rare cause of primary hyperparathyroidism that happens < 1% of cases. If not suspected, it can lead to a negative bilateral parathyroid exploration and extensive iatrogenic trauma. We propose that with proper imaging the correct diagnosis can be established to simplify surgical management. We describe two cases of patients who underwent a targeted neck exploration due to an undescended parathyroid adenoma diagnosed with an appropriate preoperative imaging protocol. With an appropriate imaging protocol for primary hyperparathyroidism and parathyroid hormone aspirates, an undescended parathyroid adenoma can be primarily diagnosed to guide a focused parathyroidectomy.

El adenoma paratiroideo no descendido ocasiona hiperparatiroidismo primario en <1% de los casos. Si no se sospecha, puede llevar a exploraciones negativas y trauma iatrogénico extenso. Proponemos que, con un protocolo imagenológico adecuado, se puede realizar un diagnóstico correcto, simplificando el abordaje quirúrgico. Describimos dos casos en que se realizó una exploración de cuello dirigida debido a un adenoma paratiroideo no descendido diagnosticado con un protocolo de imagen preoperatorio apropiado. Un protocolo de imagen apropiado para hiperparatiroidismo primario y aspirados de PTH pueden diagnosticar de manera inicial un adenoma paratiroideo no descendido para guiar una paratiroidectomía dirigida.

Comparison of Dosing Schemes for Thyroid Hormone Replacement Therapy After Thyroidectomy.

BACKGROUND: Current thyroid hormone replacement therapy (THRT) is built on weight-based standard calculation of dose. A novel Poisson regression model, which accounts for seven clinical variables, was recently proposed to improve accuracy of THRT. We aimed to compare the accuracy of estimated THRT dose to reach euthyroid and the difference in predicted dose between the Poisson (scheme A) and the weight-based standard (scheme B) in patients following total thyroidectomy for benign disease. METHODS: We retrospectively reviewed medical record of patients who underwent total or completion thyroidectomy for benign disease at a single institution between 2011 and 2019. The THRT dose was calculated using both schemes. We compared the difference between calculated THRT and prediction rates for optimal THRT dosing needed to achieve a euthyroid state between dosing schemes. Patients were evaluated for achieving euthyroid state, defined as TSH 0.45-4.5 mIU/L. We also compared dosing error rates (> 25 mcg over- and underdosing) between schemes. Prediction rates were compared by BMI tertiles to account for the effect of BMI extremes in achieving euthyroid state. The difference in predicted dose between schemes was calculated in both the total sample size and patients that met euthyroid. A measure of agreement, Kappa, was used to estimate agreement between dosing schemes. RESULTS: A total of 406 patients underwent total thyroidectomy for benign disease, with 184 having sufficient follow up data confirming euthyroid state. Of the 184 patients, 85.9% (n = 158) were women, 81% (n = 149) were Hispanic, and 56.5% (n = 104) were obese with a median BMI of 30.8 kg/m2. Scheme A resulted in a higher, but not statistically significant, accuracy rate (A: 60.3%, n = 111 versus B: 53.8%, n = 99; P = 0.21). Overdosing errors were lower with Scheme A (A:17.9% versus B: 32.1%; P = 0.0025) and less extreme > 25 µg (A: 17.9% versus B: 26.1%; P = 0.08). A trend in improved accuracy in patients with a BMI > 35 kg/m2 was noted (A: 46.9% versus B: 34.4%; P = 0.20). Scheme A also resulted in less overdosing errors in obese patients compared to Scheme B (A: 19.2% versus 45.2%; P = 0.0006). The average difference in predicted dose between schemes was an entire dose difference, mean of 16.0 µg and 15.8 µg for the total and euthyroid samples respectively. Furthermore, for the majority of patients the predicted dose did not match between the two dosing schemes for total and euthyroid samples, 76% (n = 311) and 76% (n = 141) respectively. In patients that achieved euthyroid, agreement between dosing schemes was low to moderate (Kappa = 0.360). CONCLUSIONS: Lower rates of overdosing were found for scheme A, particularly with obese patients. No statistically significant differences in predicted THRT dose was observed between schemes. The difference in predicted dose between schemes was on average 15 ug, correlating with an entire dose. The consideration of clinical variables other than weight (scheme A) when determining optimal THRT dosing may be of importance to prevent overdoses, with particular clinical relevance in patients with higher BMIs.

Multimodal analgesia after thyroid or parathyroid surgery: A randomized controlled trial.

BACKGROUND: The opioid epidemic prompted reevaluation of surgeons' opioid prescribing practices. This study aimed to demonstrate noninferiority of a staged analgesic regimen after endocrine surgery. METHODS: We conducted a randomized controlled trial comparing analgesic regimens after thyroidectomy and/or parathyroidectomy. Adult patients (≥18 years) were randomized to study arm (A) as-needed acetaminophen + codeine or (B) scheduled acetaminophen/as-needed tramadol. Patients recorded pain scores and analgesics consumed in a study log. Clinical variables were collected from the medical record. RESULTS: Target enrollment was achieved (n = 126), and randomization was even (A: 44.5%, B: 55.6%). There was no difference between enrolled patients and those who returned the study log (52.4%) by sex (P = .667), age (P = .513), final pathology (P = .137), procedure (P = .667), or randomization arm (P = .795). Most patients (50.8%) reported moderate pain scores (4-6) with no difference between study arms (P = .451). There was no difference in average consumption by morphine milligram equivalents (A: 11.5 ± 12.1 vs B: 12.49 ± 18.07; P = .792) nor total analgesic doses (A: 7.29 ± 7.48 vs B: 8.5 ± 5.36; P = .445). However, a significant difference in average percentage of opioid doses was noted (A: 79.71 ± 33.31 vs B: 27.38 ± 31.88; P < .001). CONCLUSION: Patients reported moderate pain scores with low requirements for analgesics after endocrine surgery. The staged analgesic regimen is noninferior to combination opioids and led to reduced overall consumption.

Racial inequality in the trauma of women: A disproportionate decade.

BACKGROUND: Historically, women have been largely underrepresented in the body of medical research. Given the paucity of data regarding race and trauma in women, we aimed to evaluate the most common types of traumas incurred by women and analyze temporal racial differences. METHODS: A 10-year review (2007-2016) of the National Trauma Data Bank was conducted to identify common mechanisms of injuries among women. Trends of race, intent of injury, and firearm-related assaults were assessed using the Cochran-Armitage Trend test. Multivariable multinomial logistic regressions were utilized to examine the association between race and trauma subtypes. RESULTS: Of the 2,082,768 women identified as a trauma during this study period, the majority presented due to an unintentional intent (94.5%), whereas fewer presented secondary to an assault (4.4%) or self-inflicted injury (1.1%). While racioethnic minority women encompassed a small percentage of total traumas (19%), they accounted for roughly three fifths of assault-related traumas (p < 0.001). Though total assaults decreased by 20.8% during the study period, black and Hispanic women saw a disproportionately smaller decrease of 15.1% and 15.8%, respectively. On regression analysis, compared with white women, black women had more than four times the odds of being an assault-related trauma compared with unintentional trauma (odds ratio, 4.48; 95% confidence interval, 4.41-4.55). On subset analysis, firearm-related assault was 17.3 times more prevalent among black women (white, 0.3% vs. black: 5.2%; p < 0.001). In fact, history of alcohol abuse was found to be an effect modifier of the association of race/ethnicity and firearm-related trauma. CONCLUSION: Compelling data highlight a disproportionate trend in the assault-related trauma of minority women. Specifically, minority women, especially those with a history of alcohol abuse, were at increased risk of being involved in a firearm assault. Further studies are essential to help mitigate disparities and subsequently develop preventative services for this diverse population. LEVEL OF EVIDENCE: Epidemiological, Level III.

Late Bacterial Endocarditis in an Intravenous Drug User With an Amplatzer Septal Occluder.

Infective endocarditis of a fully endothelialized cardiac prosthesis, and especially the late presentation of endocarditis, challenges our current understanding of device-related complications. Late bacterial endocarditis associated with the Amplatzer Septal Occluder, a device frequently used to close atrial septal defects, has been documented only rarely. We report the case of an intravenous drug user who had late infective endocarditis associated with his Amplatzer Septal Occluder, secondary to methicillin-sensitive Staphylococcus aureus bacteremia nearly 14 years after device insertion. The patient recovered after surgical excision and débridement of the vegetative mass, which may be the first time that a surgical approach has been taken to treat this condition. This report corroborates the need for late screening of high-risk patients who have septal occluder devices.

Influence of Adrenal Venous Sampling on Management in Patients with Primary Aldosteronism Independent of Lateralization on Cross-Sectional Imaging.

BACKGROUND: Patients with primary aldosteronism undergo imaging of the adrenal glands after confirmation of the disease. Adrenal venous sampling (AVS) is a useful adjunct to imaging, and advocates believe that AVS should be performed before surgical management. Others argue that patients with unilateral lesions on imaging do not require AVS. Although AVS accuracy has been established, few studies have evaluated how AVS alters management. Our study aimed to determine how AVS affected management of these patients. STUDY DESIGN: Patient data were collected retrospectively from the electronic medical records at a single institution. Patients aged 18 years or older who underwent AVS with successful adrenal vein cannulation from 2007 to 2016 were included. The laterality of AVS was compared with laterality of preprocedural imaging for each patient. The management plan before AVS was determined by laterality on preprocedural imaging. The primary outcomes were management of primary aldosteronism, change in management compared with the plan before AVS, and antihypertensive medication use after therapy. RESULTS: Seventy-four patients had successful adrenal venous cannulation. Thirty-three (44.6%) patients had AVS lateralization that was concordant with preprocedural imaging. Forty-one (55.4%) patients had AVS lateralization that was non-concordant with preprocedural imaging. There was a change in management in 29 (39.2%) patients. CONCLUSIONS: Adrenal venous sampling can delineate the source of aldosterone hypersecretion, and often this is not concordant with cross-sectional imaging. We found that many patients avoided a potentially non-curative operation due to AVS. Adrenal venous sampling frequently alters the management of aldosteronomas and should be highly considered in patients before surgical intervention.

A Review of Postoperative Pain Management for Thyroid and Parathyroid Surgery.

BACKGROUND: Perioperative opioid use has been linked to abuse potential by patients, leading surgeons to scrutinize their postoperative prescribing practices. The goal of the study was to review analgesic regimens for patients undergoing thyroidectomy and parathyroidectomy and extrapolate changes that could be made to decrease opioid use while maintaining adequate pain control. MATERIALS AND METHODS: A literature review was performed. Inclusion criteria were studies 1) written in English, 2) published within the last 20 years, and 3) that included human subjects. Exclusion criteria were studies that 1) evaluated anesthesia regimens exclusively, 2) compared surgical approaches and their effects on pain (e.g., open neck exposure vs. transoral route for thyroidectomy), or 3) included patients undergoing concurrent lateral neck dissection. Of 951 studies originally identified, 10 studies met the criteria. RESULTS: Ten studies were identified, and each evaluated a different analgesic regimen. Five of the studies found a decrease in pain with multimodal regimens. Of the remaining studies, three found no difference in pain control, one found an increase in pain when only an opioid patient-controlled analgesia was used, and one found that 93% of patients required less than 20 oral morphine equivalents postoperatively. CONCLUSIONS: There is no postoperative analgesic regimen that has been established as optimal for patients undergoing parathyroidectomy and thyroidectomy in the current medical literature. However, half of the studies included in this review found that nonopioid adjuncts decreased patients' need for postoperative opioids.

International neuromonitoring study group guidelines 2018: Part II: Optimal recurrent laryngeal nerve management for invasive thyroid cancer-incorporation of surgical, laryngeal, and neural electrophysiologic data.

The purpose of this publication was to inform surgeons as to the modern state-of-the-art evidence-based guidelines for management of the recurrent laryngeal nerve invaded by malignancy through blending the domains of 1) surgical intraoperative information, 2) preoperative glottic function, and 3) intraoperative real-time electrophysiologic information. These guidelines generated by the International Neural Monitoring Study Group (INMSG) are envisioned to assist the clinical decision-making process involved in recurrent laryngeal nerve management during thyroid surgery by incorporating the important information domains of not only gross surgical findings but also intraoperative recurrent laryngeal nerve functional status and preoperative laryngoscopy findings. These guidelines are presented mainly through algorithmic workflow diagrams for convenience and the ease of application. These guidelines are published in conjunction with the INMSG Guidelines Part I: Staging Bilateral Thyroid Surgery With Monitoring Loss of Signal. Level of Evidence: 5 Laryngoscope, 128:S18-S27, 2018.

International neural monitoring study group guideline 2018 part I: Staging bilateral thyroid surgery with monitoring loss of signal.

This publication offers modern, state-of-the-art International Neural Monitoring Study Group (INMSG) guidelines based on a detailed review of the recent monitoring literature. The guidelines outline evidence-based definitions of adverse electrophysiologic events, especially loss of signal, and their incorporation in surgical strategy. These recommendations are designed to reduce technique variations, enhance the quality of neural monitoring, and assist surgeons in the clinical decision-making process involved in surgical management of recurrent laryngeal nerve. The guidelines are published in conjunction with the INMSG Guidelines Part II, Optimal Recurrent Laryngeal Nerve Management for Invasive Thyroid Cancer-Incorporation of Surgical, Laryngeal, and Neural Electrophysiologic Data. Laryngoscope, 128:S1-S17, 2018.

Same day discharge after thyroidectomy is safe and effective.

Historically, thyroidectomies have been performed as inpatient operations due to concerns of postoperative bleeding and symptomatic hypocalcemia. We aim to demonstrate that outpatient thyroidectomy can be performed safely. METHODS: This report outlines a 7-year retrospective analysis (2009-2016) of outpatient vs inpatient thyroidectomies, with outcomes including hematoma, blood loss, recurrent laryngeal nerve injury, symptomatic hypocalcemia, and postoperative emergency room (ER) visits. RESULTS: A total of 1460 thyroidectomies were performed: 1272 (87%) outpatient and 188 (13%) inpatient. Five outpatients: 4 total thyroidectomies (TT), 1 TT with a central lymph node dissection (CLND), and 1 partial thyroidectomy (PT) developed postoperative hematomas (0.34%) at post-discharge hour 3, 9, 10, 13, and 42. Average time to discharge was 2 hours and 37 minutes. Hematomas were evacuated successfully in the operating room under local anesthesia with a 2-day average hospital stay. There were no differences between TT, thyroid lobectomy (TL), and PT procedures for postoperative hematoma (p=0.17). Outpatient compared to inpatient thyroidectomy was more likely to have been performed in patients with lower American Society of Anesthesia scores (2.3 vs 2.9, p<0.0001), less mean blood loss (74 vs 227 ml, p<0.0001), lesser age (52 vs 56 years, p=0.0012), less extensive dissection (p<0.0001), and fewer RLN injuries (2.4% vs 8.5%, p<0.0001). There was no difference between outpatient and inpatient symptomatic hypocalcemia (6.3% vs 9.6%, p=0.09), 30-day postoperative ER visits (8.8% vs 9.6%, p=0.73), and postoperative hematoma (0.39% vs 0%, p=0.39). There was one inpatient mortality from stroke. CONCLUSION: Postoperative hematomas can be managed safely without life-threatening complications suggesting outpatient thyroidectomy can be performed safely by an experienced surgeon, and adverse sequelae dealt with in a safe and effective manner.

American Thyroid Association Statement on Postoperative Hypoparathyroidism: Diagnosis, Prevention, and Management in Adults.

BACKGROUND: Hypoparathyroidism (hypoPT) is the most common complication following bilateral thyroid operations. Thyroid surgeons must employ strategies for minimizing and preventing post-thyroidectomy hypoPT. The objective of this American Thyroid Association Surgical Affairs Committee Statement is to provide an overview of its diagnosis, prevention, and treatment. SUMMARY: HypoPT occurs when a low intact parathyroid hormone (PTH) level is accompanied by hypocalcemia. Risk factors for post-thyroidectomy hypoPT include bilateral thyroid operations, autoimmune thyroid disease, central neck dissection, substernal goiter, surgeon inexperience, and malabsorptive conditions. Medical and surgical strategies to minimize perioperative hypoPT include optimizing vitamin D levels, preserving parathyroid blood supply, and autotransplanting ischemic parathyroid glands. Measurement of intraoperative or early postoperative intact PTH levels following thyroidectomy can help guide patient management. In general, a postoperative PTH level <15 pg/mL indicates increased risk for acute hypoPT. Effective management of mild to moderate potential or actual postoperative hypoPT can be achieved by administering either empiric/prophylactic oral calcium and vitamin D, selective oral calcium, and vitamin D based on rapid postoperative PTH level(s), or serial serum calcium levels as a guide. Monitoring for rebound hypercalcemia is necessary to avoid metabolic and renal complications. For more severe hypocalcemia, inpatient management may be necessary. Permanent hypoPT has long-term consequences for both objective and subjective well-being, and should be prevented whenever possible.

Reoperative central lymph node dissection for incidental papillary thyroid cancer can be performed safely: A retrospective review.

BACKGROUND: This study compares the pathological outcomes and operative morbidity for papillary thyroid cancer (PTC) patients undergoing a primary total thyroidectomy (TT) with central lymph node dissection (CLND), to those undergoing an interval CLND following a previous thyroid operation, or for the unsuspected diagnosis of PTC. METHODS: Single-institution, retrospective review of PTC patients from 2000 to 2015 was performed. Three treatment groups were identified: primary TT/CLND, interval prophylactic CLND, and interval therapeutic CLND. Primary outcome measures were number of lymph nodes removed, hypoparathyroidism and recurrent laryngeal nerve (RLN) injury. RESULTS: Results for 30 prophylactic and 35 therapeutic interval CLND were compared with 218 patients undergoing primary TT/CLND. Interval CLND was associated with similar rates of cervical metastases, complications, and a trend towards decreased lymph node recovery. CONCLUSION: Reoperative CLND for incidental PTC frequently identifies cervical lymph node metastases, potentially reduces recurrence, and can be performed with similar morbidity to a primary lymphadenectomy.

Central Lymph Node Dissection Improves Lymph Node Clearance in Papillary Thyroid Cancer Patients with Lateral Neck Metastases, Even after Prior Total Thyroidectomy.

The oncologic benefit of a central lymph node dissection (CLND) at the time of modified radical neck dissection (MRND) in patients with papillary thyroid cancer who have previously undergone a total thyroidectomy (TT) has not been studied. Patients with lateral cervical metastases were divided into two treatment groups: the concurrent cohort (TT with CLND and MRND), and the interval cohort (CLND and MRND after prior TT). Primary outcomes were lymph node metastases, skip metastases, level VI cancer recurrence, hypoparathyroidism and recurrent laryngeal nerve injury. Treatment groups consisted of 63 and 16 patients in the concurrent and interval groups, respectively. More central lymph nodes were removed (15.4 ± 8.4 to 10.1 ± 5.2 (P = 0.02)), but similar level VI lymph node metastasis occurred (92.0-93.8% (P = 0.99)) in the concurrent group compared with the interval group, respectively. Skip metastases were identified in only 7.6 per cent of patients. The incidence of level VI recurrence and recurrent laryngeal nerve injury was 1.2 per cent. Three patients developed hypoparathyroidism (3.7%). All permanent morbidities occurred in the concurrent group. CLND at the time of MRND for metastatic papillary thyroid cancer frequently identifies level VI metastases and can be done with low operative morbidity by experienced endocrine surgeons, even in patients who have undergone a prior TT.

Surgical management of the recurrent laryngeal nerve in thyroidectomy: American Head and Neck Society Consensus Statement.

"I have noticed in operations of this kind, which I have seen performed by others upon the living, and in a number of excisions, which I have myself performed on the dead body, that most of the difficulty in the separation of the tumor has occurred in the region of these ligaments…. This difficulty, I believe, to be a very frequent source of that accident, which so commonly occurs in removal of goiter, I mean division of the recurrent laryngeal nerve." Sir James Berry (1887).

Routine central lymph node dissection with total thyroidectomy for papillary thyroid cancer potentially minimizes level VI recurrence.

BACKGROUND: Treatment strategies for papillary thyroid cancer remain controversial due to the lack of large, randomized controlled trials. The purpose of this study was to review the benefit of routine bilateral central lymph node dissection (CLND) by analyzing local recurrence and complication rates from a single institution over a 15-year period. METHODS: A retrospective, institutional review board-approved review of the Baylor Scott & White Tumor Registry was performed on all patients who underwent operation for papillary thyroid cancer between 2000 and 2015. Patients were evaluated by age, sex, tumor size, operation performed, pathologic findings, adjuvant therapy, and date of recurrence. Primary outcomes were cancer recurrence, recurrent laryngeal nerve injury, and hypoparathyroidism. RESULTS: Total thyroidectomy with CLND was performed in 266 patients. Metastases to level VI lymph nodes were present in 106/266 (39.8%) patients. Average follow-up after thyroidectomy was 46 months (range 1-125 months). Papillary thyroid cancer recurred in 4 patients after thyroidectomy with CLND for primary tumors with mean size of 1.6 cm (range 1.0-2.0 cm). Two patients with T4 tumors had local recurrence in the paratracheal soft tissues, and 2 patients presented with recurrence in the lateral neck. Temporary nerve injuries occurred in 9/266 (3.4%) and permanent nerve injuries in 1/266 (0.4%) of CLND. Permanent hypoparathyroidism occurred in 4/266 (1.5%) patients. CONCLUSION: Total thyroidectomy with CLND can safely be performed routinely for treatment of papillary thyroid cancer in the hands of experienced endocrine surgeons. Dissection of level VI lymph nodes does not increase the risk of recurrent laryngeal nerve injury when performed routinely. Bilateral CLND with total thyroidectomy for papillary thyroid cancer potentially minimizes recurrence in the level VI compartment.

Improving Minimally Invasive Adrenalectomy: Selection of Optimal Approach and Comparison of Outcomes.

INTRODUCTION: Minimally invasive adrenalectomy is commonly performed by either a transperitoneal laparoscopic (TLA) or posterior retroperitoneoscopic (PRA) approach. Our group described the technique for robot-assisted PRA (RAPRA) in 2010. Few studies are available that directly compare outcomes between the available operative approaches. We reviewed our results for minimally invasive adrenalectomy using the three different approaches over a 10-year period. METHODS: Between January 2005 and April 2015, 160 minimally invasive adrenalectomies were performed. Clinicopathologic data were prospectively collected and retrospectively analyzed. The primary endpoints evaluated were operative time, blood loss, length of stay (LOS), and morbidity. RESULTS: The study included 67 TLA, 76 PRA, and 17 RAPRA procedures. Tumor size for PRA/RAPRA was smaller than for patients undergoing TLA (2.38 vs 3.6 cm, p ≤ 0.0001). Procedure time was shorter for PRA versus TLA (133.3 vs 152.8 min, p = 0.0381), as was LOS (1.85 vs 2.82 days, p = 0.0145). Procedure time was longer in RAPRA versus TLA/PRA (177 vs 153/133 min, p = 0.008), but LOS was significantly decreased (1.53 vs 2.82/1.85 days, p = 0.004). CONCLUSIONS: Minimally invasive adrenalectomy is associated with expected excellent outcomes regardless of approach. In our series, the posterior approach is associated with decreased operative time and LOS. Robotic technology provides potential advantages for the surgeon at the expense of more complex setup requirements and costs. Further study is required to demonstrate clear benefit of one surgical approach. Utilization of the entire spectrum of available operative techniques can allow for selection of the optimal approach based on individual patient factors.