Diagnostic Test Accuracy of Ultrasonography vs Computed Tomography for Papillary Thyroid Cancer Cervical Lymph Node Metastasis: A Systematic Review and Meta-analysis.

Importance: The use of ultrasonography (US) vs cross-sectional imaging for preoperative evaluation of papillary thyroid cancer is debated. Objective: To compare thyroid US and computed tomography (CT) in the preoperative evaluation of papillary thyroid cancer for cervical lymph node metastasis (CLNM), as well as extrathyroidal disease extension. Data Sources: MEDLINE and Embase were searched from January 1, 2000, to July 18, 2020. Study Selection: Studies reporting on the diagnostic accuracy of US and/or CT in individuals with treatment-naive papillary thyroid cancer for CLNM and/or extrathyroidal disease extension were included. The reference standard was defined as histopathology/cytology or imaging follow-up. Independent title and abstract review (2515 studies) followed by full-text review (145 studies) was completed by multiple investigators. Data Extraction and Synthesis: PRISMA guidelines were followed. Methodologic and diagnostic accuracy data were abstracted independently by multiple investigators. Risk of bias assessment was conducted using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool independently and in duplicate. Bivariate random-effects model meta-analysis and multivariable meta-regression modeling was used. Main Outcomes and Measures: Diagnostic test accuracy of US and CT of the neck for lateral and central compartment CLNM, as well as for extrathyroidal disease extension, determined prior to study commencement. Results: A total of 47 studies encompassing 31 942 observations for thyroid cancer (12 771 with CLNM; 1747 with extrathyroidal thyroid extension) were included; 21 and 26 studies were at low and high risk for bias, respectively. Based on comparative design studies, US and CT demonstrated no significant difference in sensitivity (73% [95% CI, 64%-80%] and 77% [95% CI, 67%-85%], respectively; P = .11) or specificity (89% [95% CI, 80%-94%] and 88% [95% CI, 79%-94%], respectively; P = .79) for lateral compartment CLNM. For central compartment metastasis, sensitivity was higher in CT (39% [95% CI, 27%-52%]) vs US (28% [95% CI, 21%-36%]; P = .004), while specificity was higher in US (95% [95% CI, 92%-98%]) vs CT (87% [95% CI, 77%-93%]; P < .001). Ultrasonography demonstrated a sensitivity of 91% (95% CI, 81%-96%) and specificity of 47% (95% CI, 35%-60%) for extrathyroidal extension. Conclusions and Relevance: The findings of this systematic review and meta-analysis suggest that further study is warranted of the role of CT for papillary thyroid cancer staging, possibly as an adjunct to US.

Preoperative and intraoperative factors predictive of length of hospital stay after pulmonary lobectomy.

BACKGROUND: Length of hospital stay is an important determinant of overall surgical costs. Health care resources are finite, so reductions in length of stay are desirable. We reviewed our experience with pulmonary lobectomy to identify preoperative and intraoperative factors that predicted the length of postoperative hospital stay. By identifying these factors, we hoped to favorably influence future patient management. METHODS: Records of patients undergoing pulmonary lobectomy for benign or malignant disease over a four-year period (1998-2001) were reviewed. Data was collected on age, sex, pulmonary function, pulmonary pathology, cigarette smoking, type of thoracotomy incision, use of surgical sealants, surgeon, and length of hospital stay. RESULTS: Three hundred and sixty patients underwent lobectomy. Forward stepwise regression identified age (p=0.022), FEV1 (forced expiratory volume in one second) (p=0.047), diffusion capacity (p=0.020), and surgeon (p<0.001) as independent factors predictive of hospital length of stay. When these four factors were analyzed in a multiple linear regression model, the surgeon variable emerged as the strongest predictor of length of stay (p<0.001). CONCLUSIONS: Although patient factors were influential, the individual surgeon was the most important determinant of hospital length of stay after pulmonary lobectomy. It may be possible to reduce length of hospital stay by identifying variations in practice within the surgical group, and encouraging widespread adoption of "best practice" surgical techniques.

Pyloric drainage (pyloroplasty) or no drainage in gastric reconstruction after esophagectomy: a meta-analysis of randomized controlled trials.

BACKGROUND/AIM: A gastric conduit is usually used to reconstruct the foregut after esophagectomy for cancer. The gastric emptying may be impaired after this operation, so some esophageal surgeons routinely add a pyloric drainage procedure (pyloroplasty or pyloromyotomy). We performed a meta-analysis of randomized controlled trials (RCTs) to determine the effect of pyloric drainage on patient outcomes. METHODS: Medline and manual searches were done (completed independently and in duplicate) to identify all published RCTs that addressed the issue of pyloric drainage procedures during gastric conduit reconstruction of the esophagus. The selection process was inclusive; no trials were excluded. Trial validity assessment was done, and a trial quality score was assigned. Early outcomes assessed by meta-analysis included operative mortality, esophagogastric anastomotic leaks, pulmonary morbidity, pyloric drainage complications, fatal pulmonary aspiration, and gastric outlet obstruction. A random-effects model was used, and the relative risk was the principal measure of effect. Systematic semiquantitative review was used for late outcomes such as gastric emptying, bile reflux, nutritional status, and obstructive foregut symptoms. RESULTS: Nine RCTs, that included a total of 553 patients, were selected, with quality scores ranging from 1 to 4 (5-point Jadad scale). Selection and validity agreement was strong. The relative risk (95% CI; p value), expressed as pyloric drainage versus no drainage (treatment vs. control), was 0.92 (0.34, 2.44; p = 0.86) for operative mortality, 0.90 (0.47, 1.76; p = 0.77) for esophagogastric anastomotic leaks, 0.69 (0.42, 1.14; p = 0.15) for pulmonary morbidity, 2.55 (0.34, 18.98; p = 0.36) for pyloric drainage complications, 0.25 (0.04, 1.60; p = 0.14) for fatal pulmonary aspiration, and 0.18 (0.03, 0.97; p = 0.046) for gastric outlet obstruction. Systematic semiquantitative review showed a nonsignificant trend favoring pyloric drainage for the late outcomes of gastric emptying, nutritional status, and obstructive foregut symptoms. For the late outcome of bile reflux, there was a nonsignificant trend favoring the no-drainage group. The scintographic gastric emptying time, expressed as a ratio (pyloric drainage/no drainage), was 0.53. CONCLUSIONS: Data synthesized from existing RCTs show that pyloric drainage procedures reduce the occurrence of early postoperative gastric outlet obstruction after esophagectomy with gastric reconstruction, but they have little effect on other early and late patient outcomes.