The Utility of Flap Coverage for Limb Salvage in Patients With Severe Prosthetic Joint Infections of the Knee Requiring Implant Exchange

BACKGROUND

Prosthetic joint infection (PJI) is a challenging complication of knee arthroplasty, which can require amputation in severe cases. This study analyzes the utility of flap reconstruction in PJIs requiring hardware removal and extensive soft tissue debridement.

METHODS

This was a retrospective analysis of patients who were treated according to a multistage extremity salvage protocol between 2018 and 2022. The protocol involved at least 3 planned surgeries including (1) hardware removal with antibiotic spacer placement and soft tissue debridement, (2) spacer exchange with flap coverage, and (3) hardware reimplantation with simultaneous or delayed extensor mechanism reconstruction. All patients had large periprosthetic tissue defects that would necessitate an amputation if not reconstructed. Primary outcomes were extremity salvage and successful defect coverage.

RESULTS

Fifty-two patients (25 female) underwent 62 reconstructions (52 primary, 10 salvage). Flap techniques included pedicled muscular (n = 32), fasciocutaneous (n = 4), combined muscular and fasciocutaneous (n = 2), and free flaps (n = 24). Overall rate of successful defect coverage was 95% (98% in primary and 80% in salvage reconstructions). At a median follow-up of 11 months, 41 patients completed the treatment protocol with a 68% (n = 28) extremity salvage rate (reimplantation arthroplasty, n = 15; permanent knee fusion, n = 13). On the multivariate model including demographic factors, defect size, and flap type, no single factor independently predicted limb salvage.

CONCLUSIONS

Alongside intensive orthopedic surgical treatment, flap coverage may aid in extremity salvage in severe knee PJIs by reestablishing healthy soft tissue coverage and allowing reimplantation arthroplasty. We recommend a multispecialty approach including plastic surgeons for this challenging condition.

Assessing the development status of intraoperative fluorescence imaging for anatomy visualisation, using the IDEAL framework

Objectives

Intraoperative fluorescence imaging is currently used in a variety of surgical fields for four main purposes: visualising anatomy, assessing tissue perfusion, identifying/localising cancer and mapping lymphatic systems. To establish evidence-based guidance for research and practice, understanding the state of research on fluorescence imaging in different surgical fields is needed. We evaluated the evidence on fluorescence imaging used to visualise anatomical structures using the IDEAL framework, a framework designed to describe the stages of innovation in surgery and other interventional procedures.

Design

IDEAL staging based on a thorough literature review.

Setting

All publications on intraoperative fluorescence imaging for visualising anatomical structures reported in PubMed through 2020 were identified for five surgical procedures: cholangiography, hepatic segmentation, lung segmentation, ureterography and parathyroid identification.

Main outcome measures

The IDEAL stage of research evidence was determined for each of the five procedures using a previously described approach.

Results

225 articles (8427 cases) were selected for analysis. Current status of research evidence on fluorescence imaging was rated IDEAL stage 2a for ureterography and lung segmentation, IDEAL 2b for hepatic segmentation and IDEAL stage 3 for cholangiography and parathyroid identification. Enhanced tissue identification rates using fluorescence imaging relative to conventional white-light imaging have been documented for all five procedures by comparative studies including randomised controlled trials for cholangiography and parathyroid identification. Advantages of anatomy visualisation with fluorescence imaging for improving short-term and long-term postoperative outcomes also were demonstrated, especially for hepatobiliary surgery and (para)thyroidectomy. No adverse reactions associated with fluorescent agents were reported.

Conclusions

Intraoperative fluorescence imaging can be used safely to enhance the identification of anatomical structures, which may lead to improved postoperative outcomes. Overviewing current research knowledge using the IDEAL framework aids in designing further studies to develop fluorescence imaging techniques into an essential intraoperative navigation tool in each surgical field.

Biochemical assessment of adrenal insufficiency after adrenalectomy for non-cortisol secreting tumors: clinical correlation and recommendations

BACKGROUND

Data regarding changes in cortisol axis after adrenalectomy for non-cortisol secreting tumors and their correlation with adrenal insufficiency are limited. Our aim was to analyze these changes and their clinical correlations to guide management after adrenalectomy for non-Cushing's tumors.

METHODS

Following IRB approval, postoperative cortisol axis changes were analyzed in patients who underwent unilateral adrenalectomy for non-Cushing's tumors. A morning serum cortisol of ≥ 10 μg/dl was accepted as a sufficient adrenal response.

RESULTS

223 adrenalectomies were analyzed. In 63% of patients, POD1 serum cortisol was ≥ 10 μg/dl and in 37% < 10 μg/dl. No patient with a POD1 cortisol ≥ 10 μg/dl developed AI symptoms, whereas symptoms of AI were observed in 4% of those with < 10 μg/dl. In patients with a POD1 cortisol of < 10 μg/dl, the rate of steroid replacement therapy initiation was 100%, 8%, and 25% when the decision was based on serum cortisol, clinical symptoms, and serum cortisol plus ACTH stimulation test results, respectively. In 90% of asymptomatic patients, hypocortisolemia resolved uneventfully within a week on repeat morning cortisol testing. 75% of patients with hypocortisolemia on POD1 demonstrated an adequate cortisol response to ACTH stimulation test.

CONCLUSION

Although postoperative hypocortisolemia was observed in 37% of patients undergoing unilateral adrenalectomy for non-cortisol secreting tumors, majority did not develop symptoms of adrenal insufficiency. All three steroid initiation approaches appeared safe, with management based on clinical symptoms or selective ACTH stimulation testing sparing more patients from steroids compared to steroid initiation based on POD 1 cortisol levels alone.

Flap survival and functional outcomes in elbow soft tissue reconstruction: A 25-year systematic review

INTRODUCTION

Different elbow flap reconstructions have been described in the literature. We aim to define the optimal flap technique based on defect size and etiology.

METHODS

A systematic review was undertaken using the terms "(Elbow reconstruction) AND ((Soft tissue) OR (flap))". Flaps were grouped under fasciocutaneous (FCF), muscular (MF), distant pedicled (DPF), and free flaps (FF). The primary outcome was flap survival. The secondary outcomes were postoperative complications and range of motion (pROM).

RESULTS

Twenty articles with 224 patients were included. Defect sizes were small (<10 cm²) (18%), medium (10-30 cm²) (23%), large (30-100 cm²) (43%), and massive (>100 cm²) (16%). Etiologies included trauma (26%), burn contractures (26%), infection (26%), hardware coverage (16%), and others (6%). FCF (54%) was the preferred flap followed by MF (28%), DPF (13%), and FF (5%). The rate of flap necrosis was 4% and that of other complications was 10%. The postoperative range of motion (pROM) (reported in 154 patients) was >100°, 50-100°, and <50° in 82%, 17%, and 1% of the cases, respectively. Small defects were most commonly reconstructed with MFs (83%), medium defects were reconstructed with MFs (52%) or FCFs (46%), and large defects were reconstructed with FCFs (91%). Massive defects predominantly required DPFs (60%) and FFs (26%). FCFs were the most common reconstruction method for burn contractures (84%), infections (55%), and traumatic defects (51%). Hardware coverage was predominantly performed using MFs (86%). No difference in complications and pROM was found between flap techniques.

CONCLUSION

Elbow flap reconstruction can be performed using different techniques. FCFs are the most commonly used reconstruction method. MFs are useful for smaller defects and hardware coverage. DPFs and FFs are needed for massive injuries.

The utility of laparoscopic ultrasound during minimally invasive liver procedures in patients with malignant liver tumors who have undergone preoperative magnetic resonance imaging

BACKGROUND

The aim of this study was to assess the utility of laparoscopic ultrasound (LUS) during minimally invasive liver procedures in patients with malignant liver tumors who underwent preoperative magnetic resonance imaging (MRI).

METHODS

Medical records of patients with malignant liver lesions who underwent laparoscopic liver surgery between October 2005 and January 2018 and who underwent an MRI examination at our institution within a month before surgery were collected from a prospectively maintained database. The size and location of tumors detected on LUS, as well as whether they were seen on preoperative imaging, were recorded. Univariate and multivariate regression analyses were performed to identify factors that were associated with the detection of liver lesions on LUS that were not seen on preoperative MRI.

RESULTS

A total of 467 lesions were identified in 147 patients. Tumor types included colorectal cancer metastasis (n = 53), hepatocellular cancer (n = 38), neuroendocrine metastasis (n = 23), and others (n = 33). Procedures included ablation (67%), resection (23%), combined resection and ablation (6%), and diagnostic laparoscopy with biopsy (4%). LUS identified 39 additional lesions (8.4%) that were not seen on preoperative MRI in 14 patients (10%). These were colorectal cancer (n = 20, 51%), neuroendocrine (n = 11, 28%) and other metastases (n = 8, 21%). These additional findings on LUS changed the treatment plan in 13 patients (8.8%). Factors predicting tumor detection on LUS but not on MRI included obesity (p = 0.02), previous exposure to chemotherapy (p < 0.001), and lesion size < 1 cm (p < 0.001).

CONCLUSION

This study demonstrates that, despite advances in MRI, LUS performed during minimally invasive liver procedures may detect additional tumors in 10% of patients with liver malignancies, with the highest yield seen in obese patients with previous exposure to chemotherapy. These results support the routine use of LUS by hepatic surgeons.

Perineal reconstruction after extralevator abdominoperineal resection: Differences among minimally invasive, open, or open with a vertical rectus abdominis myocutaneous flap approaches

BACKGROUND

Perineal wound complications after extralevator abdominoperineal resection for cancer are common with no consensus on optimal reconstructive technique. We compared short- and long-term results of laparoscopic abdominoperineal resection with open surgery ± vertical rectus abdominis myocutaneous flap.

METHODS

This is a single-institution retrospective observational study of 204 consecutive patients with advanced low rectal cancer who underwent extralevator abdominoperineal resection from January 2010 to August 2020. Main outcome measures were short-term results, wound complications, and incisional, parastomal, and perineal hernia rates.

RESULTS

Fifty-five (27%) patients had a laparoscopic approach, 80 (39%) open, and 69 (33%) open + vertical rectus abdominis myocutaneous flap. The groups had similar median length of follow up (P = .75). Patients' age and radiation, intraoperative and postoperative complications, mortality, and readmission rates were similar among the 3 groups. Perineal wound infection and dehiscence rates were not influenced by surgical approach. Laparoscopy resulted in higher perineal (7.3 vs 2.5 vs 0%; P = .047) and parastomal (23.6 vs 13.8 vs 5.8%; P = .016) hernia rates than did open or open + vertical rectus abdominis myocutaneous flap. Patients who underwent an open approach had a higher body mass index and rate of prior surgeries and preoperative ostomies. Laparoscopic and open approaches had significantly shorter operative times (300 vs 303 vs 404 minutes, respectively; P < .001) and shorter length of stay (7.6 vs 10.8 vs 11.12, respectively; P = .006) compared to open with a flap approach.

CONCLUSION

Open and open + vertical rectus abdominis myocutaneous flap approaches for reconstruction after abdominoperineal resection had lower parastomal and perineal hernias rates but similar postoperative morbidity as did the laparoscopic approach.

Robotic Posterior Retroperitoneal Adrenalectomy: Patient Selection and Long-Term Outcomes

BACKGROUND

Recently, efficacy of laparoscopic posterior retroperitoneal adrenalectomy (PRA) for pheochromocytoma and malignancy has been questioned. Although robotic technique using wristed instruments may improve limitations of laparoscopic PRA, the worldwide experience with robotic PRA is limited. This study aimed to describe patient characteristics, surgical technique, and long-term outcomes of robotic PRA from a 12-year single-center experience.

METHODS

This analysis was an institutional review board-approved retrospective study. In this study, PRA was performed robotically, with intraoperative ultrasound and indocyanine green imaging guidance. Long-term outcomes and predictors of operative time (OT) were assessed using descriptive and regression analyses. Using OT as a surrogate for difficulty of procedure, receiver operating characteristic curve analysis was performed to quantify anthropometric thresholds that would predict a more challenging procedure.

RESULTS

Altogether, 112 robotic PRA procedures were performed. Three cases (3%) were converted to a lateral approach, and one case (1%) was converted to open surgery. The morbidity rate was 2%. Microscopic capsular disruption occurred for one patient. No patient experienced persistent disease or local recurrence from pheochromocytoma or malignant adrenal tumors during the follow-up period (median, 48 months). Operating time was independently predicted by perirenal fat thickness, with 18.5 mm as the critical threshold.

CONCLUSION

In this study, favorable PRA outcomes were achieved with careful patient selection and meticulous surgical technique that used robotic articulation guided by intraoperative imaging.

Standardization of thyroid fine needle aspiration procedure and outcomes within an endocrine surgery department

Background

Fine needle aspiration (FNA) biopsy is an essential procedure for thyroid nodules. Although, the efficacy of surgeon-performed thyroid FNA biopsies has been demonstrated in the literature, there are insufficient data regarding how to establish an efficient program with a low insufficiency rate within a group practice.

Methods

An endocrine surgery thyroid FNA biopsy program was established in 2000 by one surgeon, with training of additional partners during fellowship and upon recruitment. The results within 18 years were analyzed. The FNA biopsies were performed by endocrine surgeons under ultrasound guidance without on-site pathologist review.

Results

A total of 5,469 FNA biopsies were performed by 7 surgeons. The total number of FNA biopsies performed by each surgeon varied between 291-1,378. FNA biopsies were performed in 2 passes using 22-gauge needles under constant suction. The overall insufficiency rate was 4.3%, with individual surgeon rates ranging between 2.7% and 7.2%. The insufficiency rate for the whole team ranged between 3.3% and 5% when examined in 5-year blocks.

Conclusions

This study shows that an establishment of a highly efficient thyroid FNA biopsy program within a group practice is possible with a structured endocrine surgical training and adoption of a standard technique.

A visual quantification of tissue distinction in robotic transabdominal lateral adrenalectomy: comparison of indocyanine green and conventional views

BACKGROUND

Recent studies have reported the feasibility of indocyanine green fluorescence imaging of adrenal tumors to guide dissection. Although the adrenal has been reported to concentrate the dye more than surrounding tissues, the amount of tissue distinction and how this compares with conventional vision has not been quantified before. The aim of this study is to quantify this distinction using color analysis.

METHODS

This was an institutional review board-approved retrospective study. By excluding adrenal cortical carcinoma, metastasis and pheochromocytoma, video recordings of 50 patients who underwent robotic transabdominal lateral adrenalectomy with indocyanine green (ICG) imaging for adrenocortical tumors between August 2015 and May 2018 were reviewed. Using a color analysis software, the pixel intensity of adrenal tumors versus adjacent retroperitoneal tissues was calculated for conventional red, green and blue, as well as indocyanine green (ICG) scales. Statistical analysis was performed using ANOVA.

RESULTS

A total of 50 patients underwent unilateral robotic transabdominal lateral adrenalectomy. All procedures were completed robotically without a conversion to laparoscopy or open. Morbidity was 4%. Measured pixel intensity of adrenal tumors was higher than adjacent retroperitoneal tissues for all conventional color and ICG modes (p < 0.0001), with the gradient being more pronounced for ICG green versus conventional red, green and blue modes.

CONCLUSIONS

To our knowledge this is the first study attempting to encode tissue planes in robotic adrenalectomy. The results show that the visual contrast distinction observed between adrenal and adjacent retroperitoneal tissues can be quantified using pixel intensity. ICG enabled the distinction of tissue planes with a wider gradient compared to conventional RGB view, quantifying its subjective benefits reported in prior studies.

A Critical Analysis of Computed Tomography Washout in Lipid-Poor Adrenal Incidentalomas

BACKGROUND

Contrast-enhanced computed tomography (CT) with washout has emerged as an option to distinguish lipid-poor adenomas from non-adenomas.

OBJECTIVE

The aim of this study was to assess the utility of CT washout in characterizing indeterminate lipid-poor adrenal incidentalomas.

METHODS

From an Institutional Review Board-approved database, patients with adrenal incidentalomas who had adrenal protocol CT scans with a 15-min washout between 2003 and 2019 were identified. Non-contrast CT attenuation and washout patterns of different tumor types were compared.

RESULTS

Overall, 156 patients with 175 adrenal lesions were included. Average tumor size was 3.0 cm, non-contrast CT density was 24.7 Hounsfield units (HU), and absolute washout was 52.6%. In 102 lesions (58.3%), CT washout was ≥ 60%; 94 (92.2%) of these were benign adrenocortical adenomas, 7 (6.9%) were pheochromocytomas, and 1 (0.9%) was an adrenal hematoma. Furthermore, in 73 tumors (41.7%), CT washout was < 60%; diagnosis was benign adrenocortical adenoma in 45 (61.6%) lesions, pheochromocytoma in 8 (11%) lesions, metastasis in 9 (12.3%) lesions, adrenocortical cancer in 6 (8.2%) lesions, and 'others' in 5 (6.9%) lesions. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of  > 60% absolute CT washout for detecting an adrenal adenoma was 67.6%, 77.8%, 92.2%, 38.4%, and 69.7%, respectively.

CONCLUSION

CT washout should be incorporated into the management algorithm of indeterminate adrenal incidentalomas with a high non-contrast CT attenuation to 'rule-in' benign tumors. For small tumors with mild elevation of plasma metanephrines, it should be kept in mind that adenomas and pheochromocytomas may have similar imaging and washout characteristics.

An intra-operative video comparison of laparoscopic versus robotic transabdominal lateral adrenalectomy

BACKGROUND

The aim was to compare intraoperative conduct of adrenalectomy between laparoscopic and robotic approaches.

METHODS

Intraoperative video-recordings of patients who underwent robotic (n = 30) and laparoscopic adrenalectomy (n = 30) were analysed using Mann-Whitney U, chi-square and multivariate regression analyses.

RESULTS

Demographics, indications and outcomes were similar between groups. For all tumour sizes, camera was more engaged to surgical task and exhibited less vision problems in robotic versus laparoscopic group. There was less instrument exchange and restriction of exposure with robotic approach. For dissection, robotic approach allowed for a wider range of instrument reach around adrenal. Robotically, there was an increased ability to do fine dissection, rather than en bloc division with rigid laparoscopic vessel sealers. Bleeding problems were less robotically.

CONCLUSION

Despite similarities in post-operative morbidity and hospital stay, there was a superiority in quality of procedure performed with robotic versus laparoscopic adrenalectomy for both small and large adrenal tumours.

The impact of near infrared fluorescence imaging on parathyroid function after total thyroidectomy

BACKGROUND

Compared with conventional thyroidectomy, hypocalcemia rate was reported to be lower after total thyroidectomy (TT) utilizing near infrared fluorescence imaging (NIFI). The aim of this study is to evaluate the impact of NIFI on postoperative parathyroid function after TT.

METHODS

This was a retrospective institutional review board-approved study comparing 100 patients who underwent TT with NIFI guidance and 200 patients without, by the same surgeon. Clinical parameters were compared using χ² and t test.

RESULTS

Average number of parathyroid glands identified intraoperatively was similar between two groups. However, rate of incidental parathyroidectomy was higher in conventional (14%) versus NIFI group (6%) (P = .039), despite similar (4% vs 6%, respectively) autotransplantation rates (P = .562). Incidences of transient (6.5% vs 5.0%) and permanent (0.5% vs 0%) hypocalcemia were not statistically different between conventional and NIFI groups (P = NS).

CONCLUSION

The use of NIFI during thyroidectomy may decrease the rate of incidental parathyroidectomy by increasing the ability of the surgeon to recognize parathyroid glands with fluorescent contrast distinction. Nevertheless, in contrary to recent reports in literature, postoperative hypocalcemia rate was not altered compared with conventional technique, suggesting that preservation of parathyroid vasculature, rather than an augmented ability to detect the glands, may dominantly affect postoperative function.

A comparison of indocyanine green fluorescence and laparoscopic ultrasound for detection of liver tumors

BACKGROUND

Indocyanine green (ICG) fluorescence imaging (ICG-FI) has been suggested for intraoperative identification of liver tumors. We aim to compare the intraoperative diagnostic utility of this imaging modality with laparoscopic ultrasound (LUS).

METHODS

This is an IRB-approved prospective study. ICG was administered intravenously 1-2 days before surgery. The findings on ICG-FI were compared to those on preoperative cross-sectional imaging (POCSI), LUS, diagnostic laparoscopy (DL).

RESULTS

A total of 144 lesions (62 superficial [visible on DL] and 82 deep) were detected in the study patients. POCSI identified 74%, LUS identified 92%, and ICG-FI identified 43%. ICG-FI detection rate was higher for superficial (95%) versus deep lesions (4%). 3% (4/144) of all lesions were seen only on ICG-FI. However, all of these lesions were small and superficial lesions that were apparent on DL.

CONCLUSION

Although ICG-FI allowed detection of small superficial lesions that were not identifiable by POCSI or LUS, these lesions were apparent on DL even before ICG-FI. Therefore, its utility as an intraoperative diagnostic modality is limited at the dosage and timing used in the study. We believe that rather than a diagnostic tool, it has more potential for a dynamic use in guiding the resection of superficial lesions and delineating segmental/lobar anatomy.

Autofluorescence imaging of parathyroid glands: An assessment of potential indications

BACKGROUND

The aim of this study was to determine both the accuracy of near infrared fluorescence imaging to detect parathyroid glands and the potential indications of near infrared fluorescence imaging in thyroid and parathyroid surgery by correlating the autofluorescence signature with the pathologic specimen.

METHODS

This was an institutional review board-approved, prospective study of patients undergoing thyroidectomy and parathyroidectomy with near infrared fluorescence imaging. Each specimen sent to pathology was inspected with near infrared fluorescence imaging and predicted to be either parathyroid or non-parathyroid tissue by its autofluorescence signature and then correlated with the pathologic findings.

RESULTS

Autofluorescence was demonstrated to be present in 98% of the parathyroid glands, with 23% identified correctly with infrared based on the autofluorescence signature before visual identification by the surgeon. There were 550 specimens that were imaged with autofluorescence and then sent to pathology. For these samples, sensitivity, specificity, and positive and negative predictive values to predict parathyroid tissue were 98.5%, 97.2%, 95.1%, and 99.1%. In 5% of the total thyroidectomy specimens, incidentally resected parathyroid glands were identified with autofluorescence, leading to their subsequent reimplantation. In patients with parathyroid disease and negative preoperative localization, 21% of abnormal glands were recognized with autofluorescence before visual identification by the surgeon.

CONCLUSION

Although the ability of infrared autofluorescence to confirm the presence of parathyroid tissue within surgical specimens was high, its power to find parathyroid glands in situ before visual recognition by surgeons was low. These advantages and limitations should be kept in mind when incorporating this technology into an endocrine surgical practice. Once a parathyroid seems to have been identified by the surgeon or tissue that looks like a parathyroid gland is identified, the autofluorescence signature is a very accurate assurance of parathyroid tissue.

Thyroglobulin washout from cervical lymph node fine needle aspiration biopsies in patients with differentiated thyroid cancer: an analysis of different expressions to use in post-total thyroidectomy follow-up

INTRODUCTION

Although frequently used as an adjunct to cytology in patients with differentiated thyroid cancers, interpretation of thyroglobulin washout remains unclear. We aim to compare the utility of different analytic tools to develop recommendations for use in post-total thyroidectomy follow-up.

METHODS

This is an institutional review board-approved retrospective study of patients who underwent lymph node fine needle aspiration biopsy with thyroglobulin washout between 2012 and 2018, during the post-total thyroidectomy follow-up of differentiated thyroid cancer. The utilities of thyroglobulin washout concentration, thyroglobulin washout/serum thyroglobulin ratio, and absolute thyroglobulin content were compared.

RESULTS

Sixty-four patients underwent 79 fine needle aspirations with thyroglobulin washout of cervical lymph nodes. Fifty-two lymph nodes were found to be metastatic and 27 benign. One patient had a pathologically confirmed lymph node metastasis despite a thyroglobulin washout of 0. The optimal cutoffs of thyroglobulin washout, thyroglobulin washout/serum thyroglobulin ratio, and absolute thyroglobulin content to predict metastatic involvement were 2.5 ng/ml (94% sensitive, 100% specific), 0.1 (100% sensitive and specific), and 12.5 (94% sensitive, 100% specific), respectively. The second measure lacked utility in patients with undetectable serum thyroglobulin.

CONCLUSION

The use of thyroglobulin washout concentration or thyroglobulin washout/serum thyroglobulin ratio has drawbacks based on variations in technique and clinical scenario. Absolute thyroglobulin content is an alternative that may be a more objective expression of thyroglobulin washout.

Minimally invasive resection of posterosuperior liver tumors in the supine position using intra-abdominal trocars

BACKGROUND

Laparoscopic liver resection (LLR) of posterosuperior (PS) segment liver tumors is technically challenging with confusion about optimal patient positioning and trocar placement (i.e., transabdominal vs. transcostal). The aim of this study is to describe our technique and outcomes with LLR of these tumors.

METHODS

This is an IRB-approved retrospective review of a prospective database. Between 2005 and 2017, patients with benign and malignant lesions underwent LLR. Perioperative outcomes of PS (segments 4A, 7, and 8) and anterolateral (AL) resections were compared. All patients were operated through intra-abdominal trocars in the supine position.

RESULTS

304 patients underwent LLR for AL (n = 217) and PS (n = 87) segmental lesions. Minor liver resections were performed in 274 patients and major resections in 30. Groups were comparable for age, sex, pathology, and tumor size (mean 4.2 and 3.7 cm for AL and PS). Inflow occlusion was more frequently performed for PS resections, but precoagulation rates were similar. PS resections more frequently required hand assistance (50% vs. 20%, p < 0.001) and conversion to open (18% vs. 7%, p = 0.04). For PS versus AL resections, operative time (253 vs. 205 min, p ≤ 0.001) was longer and associated with more blood loss (307 vs. 211 mL, p < 0.001) and more frequent need for blood transfusion (15% vs. 7%, p = 0.04). However, the rate of negative resection margin, 90-day complication rates, and length of stay were similar between the two groups.

CONCLUSION

This study shows that LLR of PS located liver tumors is more challenging compared to AL lesions. Nevertheless, it can be performed successfully in the majority of patients with supine positioning and intra-abdominal trocar placement, without compromising oncologic principles. Liberal uses of hand assistance and inflow occlusion were the technical tips helping us to successfully resect these tumors laparoscopically.

Outcomes of laparoscopic tumor ablation for neuroendocrine liver metastases: a 20-year experience

BACKGROUND

Since neuroendocrine tumors have an indolent behavior, studies looking at oncologic outcomes should report a long-term follow-up. Over the years, we have been treating selected patients with neuroendocrine liver metastases (NELM) with laparoscopic ablation (LA) and reported favorable local tumor control. The aim of this study is to see whether this local efficacy translates into long-term oncologic outcomes.

METHODS

This was an IRB-approved study of patients who underwent LA for NELM at a single center. Overall and progression-free survivals were analyzed using Kaplan-Meier and Cox proportional hazards model.

RESULTS

Study included 58 women and 71 men with a median age of 58 (IQR 47-67) years. Tumor type included carcinoid (n = 92), pancreatic islet cell (n = 28), and medullary thyroid cancer (n = 9). There was a median of 6 (IQR 3-8) tumors, measuring 1.6 (IQR 1.1-2.4) cm. At a median follow-up of 73 (IQR 34-135) months, local liver recurrence per patient, new liver recurrence, and new extrahepatic recurrence rates were 22, 68, and 33%, respectively. Local tumor recurrence per lesion was 5% (n = 42/770). Median overall survival was 125 months, with 5-year, and 10-year overall survivals being, 76%, and 59%, respectively; and median disease-free survival was 13 months, with 5-year, and 10-year progression-free survivals being 26%, and 6%, respectively. On Cox proportional hazards model, overall survival was independently predicted by tumor size, grade, and resection status of primary.

CONCLUSION

To our knowledge, this is the largest single-center experience with the longest follow-up regarding the utilization of LA for NELM. Our results demonstrate that in selected patients, LA achieves a 95% local tumor control and 59% 10-year overall survival.

A comparison of microwave thermosphere versus radiofrequency thermal ablation in the treatment of colorectal liver metastases

BACKGROUND

Microwave thermosphere ablation (MTA) is a new generation technology. The aim of this study was to compare the efficacy of MTA and radiofrequency ablation (RFA) in achieving local tumor control in patients with colorectal liver metastasis (CRLM).

METHODS

This was a retrospective study of a prospective ablation database. Fifty-four patients with 155 CRLM lesions underwent RFA and 51 patients with 121 lesions underwent MTA. Patients were managed by a multidisciplinary team. Clinical and oncologic data were analyzed. Kaplan-Meier and Cox Proportional Hazards model were used for statistical analysis.

RESULTS

Demographics were similar between the two groups. Total ablation and operative times were significantly shorter in MTA group (19 vs. 37 mins, p < 0.001, 154 vs. 202 mins, p = 0.009). With a similar hospital stay (median 1), 90-day morbidity was similar (8 vs. 10%, p = 0.848), without mortality. Local recurrence (LR) rate per lesion was 20% in RFA and 10% in MTA group (p = 0.020). On Cox Proportion Hazards model, ablation modality and tumor size were independent predictors of LR.

CONCLUSIONS

This is the first study comparing the efficacy of RFA and MTA on CRLM. The results suggest that compared to RFA, MTA improves local tumor control, while significantly shortening operative time.

Characterization of fluorescence patterns exhibited by different adrenal tumors: Determining the indications for indocyanine green use in adrenalectomy

BACKGROUND

A number of small studies have reported the use of indocyanine green imaging during adrenalectomy. Nevertheless, imaging properties of different tumors and the indications for indocyanine green imaging use in adrenalectomy have not been defined.

METHODS

This is an Institutional Review Board-approved retrospective review of a prospectively maintained database. Consenting patients underwent indocyanine green imaging fluorescence-guided robotic adrenalectomy. Fluorescence patterns of adrenal tumors were assessed. Multivariate logistic regression was performed to determine the best clinical applications.

RESULTS

One hundred patients with Cushing syndrome (n = 29), pheochromocytoma (n = 24), primary hyperaldosteronism (n = 23), nonsecreting adrenocortical adenoma (n = 9), and other tumors (n = 15) underwent robotic adrenalectomy through lateral transabdominal (n = 77) and posterior retroperitoneal (n = 23) approaches. Mean tumor size was 3.6 cm and mean body mass index 33. A total of 74% of the tumors were hyperfluorescent compared with the surrounding retroperitoneal tissues, whereas the remaining 26% were nonfluorescent. Hyperfluorescence was predicted by adrenocortical tissue origin but not by demographic characteristics or tumor size. The contrast distinction between the tumor and the retroperitoneum was better, similar, or inferior on indocyanine green fluoresced compared with the nonfluoresced view in 41%, 27%, and 32% of patients, respectively. The utility was best for adrenocortical adenomas removed through a lateral transabdominal approach. Indocyanine green fluorescence imaging was used to confirm remnant viability in all 4 patients undergoing cortical-sparing adrenalectomy for pheochromocytoma (n = 2), adrenal cyst (n = 1), and lymphatic malformation (n = 1).

CONCLUSION

Adrenal tumors have different patterns of indocyanine green fluorescence based on histologic origin. Indocyanine green confers the highest utility for adrenocortical tumors removed through a lateral transabdominal approach and cortical-sparing adrenalectomy.

Efficacy of surgeon-performed, ultrasound-guided lymph node fine needle aspiration in patients with thyroid pathologic conditions

BACKGROUND

Although the concept of surgeon-performed fine needle aspiration of thyroid nodules is established, experience with surgeon-performed lymph node fine needle aspiration is scant. We aimed to study the efficacy of surgeon-performed lymph node fine needle aspiration in patients with thyroid pathologic conditions.

METHODS

This is an institutional review board-approved study of patients with thyroid pathologic conditions who underwent surgeon-performed lymph node fine needle aspiration between 2002 and 2017. Efficacy and utility were analyzed.

RESULTS

A total of 201 patients with benign nodular goiter (n = 30) and thyroid cancer (n = 200) underwent 230 lymph node fine needle aspirations (89 during preoperative workup, 141 at postoperative follow-up). Insufficient aspiration rate was 6% and indeterminate cytologic results 3%. In 91% of patients with suspicious lymph nodes, definite diagnosis could be obtained by fine needle aspiration; 51% (n = 118) of fine needle aspirations indicated metastasis from thyroid cancer and 40% (n = 91) benign findings. Sensitivity and specificity of lymph node fine needle aspiration in diagnosing nodal metastasis were 92% and 89%, respectively. Cytologic testing and thyroglobulin washout indicated 95% concordance. On logistic regression, spherical shape, microcalcifications, cystic appearance, and loss of hilum on ultrasound independently predicted lymph node metastasis.

CONCLUSION

Our data indicate that an adequate surgeon-performed lymph node fine needle aspiration is highly accurate in diagnosing nodal status in thyroid pathologic conditions. We recommend adoption of this technique, when feasible, to develop an efficient, comprehensive thyroid practice.

Long-Term Oncologic Outcomes Following Robotic Liver Resections for Primary Hepatobiliary Malignancies: A Multicenter Study

OBJECTIVE

Robotic liver surgery (RLS) has emerged as a feasible alternative to laparoscopic or open resections with comparable perioperative outcomes. Little is known about the oncologic adequacy of RLS. The purpose of this study was to investigate the long-term oncologic outcomes for patients undergoing RLS for primary hepatobiliary malignancies.

METHODS

We performed an international, multicenter, retrospective study of patients who underwent RLS for hepatocellular carcinoma (HCC), cholangiocarcinoma (CC), or gallbladder cancer (GBC) between 2006 and 2016. Age, gender, histology, resection margin status, extent of surgical resection, disease-free survival (DFS), and overall survival (OS) were retrospectively collected and analyzed.

RESULTS

Of the 61 included patients, 34 (56%) had RLS performed for HCC, 16 (26%) for CC, and 11 (18%) for GBC. The majority of resections were nonanatomical or segmental resections (39.3%), followed by central hepatectomy (18%), left-lateral sectionectomy (14.8%), left hepatectomy (13.1%), right hepatectomy (13.1%), and right posterior segmentectomy (1.6%). R0 resection was achieved in 94% of HCC, 68% of CC, and 81.8% of GBC patients. Median hospital stay was 5 days, and conversion to open surgery was needed in seven patients (11.5%). Grade III-IV Dindo-Clavien complications occurred in seven patients with no perioperative mortality. Median follow-up was 75 months (95% confidence interval 36-113), and 5-year OS and DFS were 56 and 38%, respectively. When stratified by tumor type, 3-year OS was 90% for HCC, 65% for GBC, and 49% for CC (p = 0.01).

CONCLUSIONS

RLS can be performed for primary hepatobiliary malignancies with long-term oncologic outcomes comparable to published open and laparoscopic data.

Detection of Parathyroid Autofluorescence Using Near-Infrared Imaging: A Multicenter Analysis of Concordance Between Different Surgeons

BACKGROUND

Parathyroid glands (PGs) exhibit autofluorescence (AF) when excited by near-infrared laser. This multicenter study aims to analyze how this imaging could facilitate the detection of PGs during thyroidectomy and parathyroidectomy procedures.

METHODS

This was a retrospective Institutional Review Board-approved analysis of prospectively collected data at three centers. Near-infrared fluorescence imaging (NIFI) was used to detect AF from PGs during thyroidectomy and parathyroidectomy procedures. Logistic regression analysis was performed to assess the utility of NIFI to identify PGs and concordance at these centers.

RESULTS

Overall, 210 patients underwent total thyroidectomy (n = 95), thyroid lobectomy (n = 41), and parathyroidectomy (n = 74) (n = 70 per center). Using NIFI, AF was detected from 98% of visually identified PGs. Upon initial exploration, 46% of PGs were not visible to the naked eye due to coverage by soft tissue, but AF from these glands could be detected by NIFI without any further dissection. Overall, a median of one PG per patient was detected by NIFI in this fashion before being identified visually (p = nonsignificant between centers). On logistic regression, smaller PGs were more likely to be missed visually, but localized by AF on NIFI (odds ratio with increasing size, 0.91; p = 0.02).

CONCLUSIONS

In our experience, NIFI facilitated PG identification by detecting their AF, before conventional recognition by the surgeon, in 37-67% of the time. Despite the variability in this rate across centers, there was a concordance in detecting AF from 97 to 99% of the PGs using NIFI. We suggest the incorporation of AF on NIFI alongside conventional visual cues to aid identification of PGs during neck operations.

Robotic and endoscopic transoral thyroidectomy: feasibility and description of the technique in the cadaveric model

Background

Numerous new approaches have been described over the years to improve the cosmetic outcomes of thyroid surgery. Transoral approach is a new technique that aims to achieve superior cosmetic outcomes by concealing the incision in the oral cavity.

Methods

Transoral thyroidectomy through vestibular approach was performed in two institutions on cadaveric models. Procedure was performed endoscopically in one institution, while the robotic technique was utilized at the other.

Results

Transoral thyroidectomy was successfully performed at both institutions with robotic and endoscopic techniques. All vital structures were identified and preserved.

Conclusions

Transoral thyroidectomy has been performed in animal and cadaveric models, as well as in some clinical studies. Our initial experience indicates the feasibility of this approach. More clinical studies are required to elucidate its full utility.

Local recurrence after microwave thermosphere ablation of malignant liver tumors: results of a surgical series

BACKGROUND

Microwave thermosphere ablation is a new treatment modality that creates spherical ablation zones using a single antenna. This study aims to analyze local recurrence associated with this new treatment modality in patients with malignant liver tumors.

METHODS

This is a prospective clinical study of patients who underwent microwave thermosphere ablation of malignant liver tumors between September 2014 and March 2017. Clinical, operative, and oncologic parameters were analyzed using Kaplan-Meier survival and Cox proportional hazards model.

RESULTS

One hundred patients underwent 301 ablations. Ablations were performed laparoscopically in 87 and open in 13 patients. Pathology included neuroendocrine liver metastasis (n = 115), colorectal liver metastasis (n = 100), hepatocellular cancer (n = 21), and other tumor types (n = 65). Ninety-day morbidity was 7% with one not procedure-related mortality. Median follow-up was 16 months with 65% of patients completing at least 12 months of follow-up. The rate of local tumor recurrence rate per lesion was 6.6% (20/301). Local tumor, new hepatic, and extrahepatic recurrences were detected in 15%, 40%, and 40% of patients, respectively. Local recurrence rate per pathology was 12% for both colorectal liver metastasis (12/100) and other metastatic tumors (8/65). No local recurrence was observed to date in the neuroendocrine liver metastasis and in the limited number of patients with hepatocellular cancers. Tumor size >3 cm and tumor type were independent predictors of local recurrence.

CONCLUSION

This is the first study to analyze local recurrence after microwave thermosphere ablation of malignant liver tumors. Short-term local tumor control rate compares favorably with that reported for radiofrequency and other microwave technologies in the literature.

Analysis of postoperative biochemical values and clinical outcomes after adrenalectomy for primary aldosteronism

BACKGROUND

Primary aldosteronism causes hypertension and hypokalemia and is often surgically treatable. Diagnosis includes elevated plasma aldosterone, suppressed plasma renin activity, and elevated aldosterone renin ratio. Adrenalectomy improves hypertension and hypokalemia. Postoperative plasma aldosterone and plasma renin activity may be useful in documenting cure or failure.

METHOD

A retrospective analysis of patients who underwent adrenalectomy for primary aldosteronism from 2010 to 2016 was performed, analyzing preoperative and postoperative plasma aldosterone, plasma renin activity, hypertension, and hypokalemia. The utility of postoperative testing was assessed. Clinical cure was defined as improved hypertension control and resolution of potassium loss. Biochemical cure was defined as aldosterone renin ratio reduction to <23.6.

RESULTS

Forty-four patients were included; 20 had plasma aldosterone and plasma renin activity checked on postoperative day 1. In the study, 40/44 (91%) were clinically cured. All clinical failures had of biochemical failure at follow-up. Postoperative day 1aldosterone renin ratio <23.6 had PPV of 95% for clinical cure. Cured patients had mean plasma aldosterone drop of 33.1 ng/dL on postoperative day 1; noncured patient experienced 3.9 ng/dL increase. A cutoff of plasma aldosterone decrease of 10 ng/dL had high positive predictive value for clinical cure.

CONCLUSION

Changes in plasma aldosterone and plasma renin activity after adrenalectomy correlate with improved hypertension and hypokalemia. The biochemical impact of adrenalectomy manifests as early as postoperative day 1. We propose a plasma aldosterone decrease of 10 ng/dL as a criterion to predict clinical cure.

Comparison of indocyanine green fluorescence and parathyroid autofluorescence imaging in the identification of parathyroid glands during thyroidectomy

Background

Indocyanine green fluorescence (ICGF) and parathyroid autofluorescence (AF) are two new techniques that aid in the identification of parathyroid glands (PG) intraoperatively during thyroidectomy. There is no study comparing the efficacy of these techniques.

Methods

This was an IRB-approved clinical study comparing the utility of ICGF and AF for identification of PGs during thyroidectomy. Data were collected prospectively. Both techniques were compared to naked eye (NE) for PG detection. Standard statistical methods were used for data analysis.

Results

Twenty-two patients in each group underwent a total of 39 total thyroidectomies and 5 thyroid lobectomies. AF and ICGF had similar detection rates for PGs [98% (61 of 62) and 95% (60 of 63) of PGs, respectively; P=0.31]. The location of PGs was suggested before detection with NE more frequently by AF than ICGF [52% (32 of 62) vs. 6% (4 of 63) of PGs; P<0.001]. In 82% (18 of 22) of patients at least one PG was detected by AF before NE, as opposed to 14% (3 of 22) by ICGF (P<0.001). The median (range) number of PGs detected before NE per patient was greater with AF than ICGF [2 (0-3) vs. 0 (0-2)];. Upper PGs were more likely to be detected by AF before recognition with NE than the lower ones (P=0.03). There was no predictive factor for ICGF detection. Postoperative hypocalcemia rates were similar [9% (2 of 22) and 5% (1 of 22) for AF and ICGF, respectively; P>0.99].

Conclusions

To the best of our knowledge, this is the first comparative study between parathyroid AF and ICGF in detection of PGs during thyroidectomy. Our data suggest both techniques have similarly high detection rates and that the main difference lies in the timing of detection. AF more frequently detects PGs before recognition with NE compared to ICGF.

Laparoscopic versus open 1-stage resection of synchronous liver metastases and primary colorectal cancer

BACKGROUND

The aim of this study is to compare the perioperative and oncologic outcomes of open and laparoscopic approaches for concomitant resection of synchronous colorectal cancer and liver metastases.

METHODS

Between 2006 and 2015, all patients undergoing combined resection of primary colorectal cancer and liver metastases were included in the study (n=43). Laparoscopic and open groups were compared regarding clinical, perioperative and oncologic outcomes.

RESULTS

There were 29 patients in the open group and 14 patients in the laparoscopic group. The groups were similar regarding demographics, comorbidities, histopathological characteristics of the primary tumor and liver metastases. Postoperative complication rate (44.8% vs. 7.1%, P=0.016) was higher, and hospital stay (10 vs. 6.4 days, P=0.001) longer in the open compared to the laparoscopic group. Overall survival (OS) was comparable between the groups (P=0.10); whereas, disease-free survival (DFS) was longer in laparoscopic group (P=0.02).

CONCLUSIONS

According to the results, in patients, whose primary colorectal cancer and metastatic liver disease was amenable to a minimally invasive resection, a concomitant laparoscopic approach resulted in less morbidity without compromising oncologic outcomes. This suggests that a laparoscopic approach may be considered in appropriate patients by surgeons with experience in both advanced laparoscopic liver and colorectal techniques.

The use of near-infrared fluorescence imaging in endocrine surgical procedures

Near-infrared fluorescence imaging in endocrine surgery is a new, yet highly investigated area. It involves indocyanine green use as well as parathyroid autofluorescence. Several groups have described their technique and reported on the observed utility. However, there is no consensus on technical details. Furthermore, the correlation between intraoperative findings and postoperative outcomes is unclear. With this study, we aim to review the current literature on fluorescence imaging and share our insights on technical details.

MicroRNA-584 and the protein phosphatase and actin regulator 1 (PHACTR1), a new signaling route through which transforming growth factor-β Mediates the migration and actin dynamics of breast cancer cells

TGF-β plays an important role in breast cancer progression as a prometastatic factor, notably through enhancement of cell migration. It is becoming clear that microRNAs, a new class of small regulatory molecules, also play crucial roles in mediating tumor formation and progression. We found TGF-β to down-regulate the expression of the microRNA miR-584 in breast cancer cells. Furthermore, we identified PHACTR1, an actin-binding protein, to be positively regulated by TGF-β in a miR-584-dependent manner. Moreover, we found TGF-β-mediated down-regulation of miR-584 and increased expression of PHACTR1 to be required for TGF-β-induced cell migration of breast cancer cells. Indeed, both overexpression of miR-584 and knockdown of PHACTR1 resulted in a drastic reorganization of the actin cytoskeleton and reduced TGF-β-induced cell migration. Our data highlight a novel signaling route whereby TGF-β silences the expression of miR-584, resulting in enhanced PHACTR1 expression, and further leading to actin rearrangement and breast cancer cell migration.