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Baugh KA, Yip L, Ramonell KM, Carty SE, McCoy KL. Outcomes of subtotal parathyroidectomy for renal hyperparathyroidism. Surgery 2024; 175:788-793. [PMID: 37945480 DOI: 10.1016/j.surg.2023.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 08/27/2023] [Accepted: 09/05/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Renal hyperparathyroidism due to end-stage kidney disease is associated with considerable morbidity, and when refractory is treated with parathyroidectomy. Recurrent renal hyperparathyroidism is a major surgical complication, yet initial target parathyroid remnant size and outcomes, including rates of recurrence are not well elucidated. METHODS This is a single-institution retrospective cohort study of patients who underwent initial subtotal parathyroidectomy for renal hyperparathyroidism on dialysis, from 1990-2022. The subtotal parathyroidectomy was defined as resection of 3 parathyroid glands ± partial resection of the fourth gland leaving a remnant of ∼75-100 mg, and postresection intraoperative parathyroid hormone goal was 150-250 pg/mL. Clinical data were examined for outcomes. RESULTS Among 204 patients who met inclusion criteria, 139 (68%) had follow-up data; 58% (80/139) were women and median age was 45 years. Surgical complications included 2 hematomas (1.4%), 1 recurrent laryngeal nerve injury (<1%), and no patient required readmission for intravenous calcium. Using a target remnant size of 75-100 mg, recurrent renal hyperparathyroidism was uncommon (14/139, 10%) and arose at a median interval of 58.6 months (range, 8-180). In cases of recurrence, the postresection intraoperative parathyroid hormone level was less likely to drop <250 pg/mL (40%, 4/10 vs nonrecurrence 65%, 80/123; P = .11) with a slightly lower median decrease (70% vs 81% in nonrecurrence, P = .8); however, neither were significant. Recurrence did not occur in the 19 patients who later received kidney transplantation (P = .2). CONCLUSION In subtotal parathyroidectomy for renal hyperparathyroidism, use of a target 75-100 mg remnant size results in low complication rates. Durable cure appears to be more likely with renal transplantation.
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Affiliation(s)
| | - Linwah Yip
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | | | - Sally E Carty
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Kelly L McCoy
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
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2
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Baugh KA, Liu JB, Yip L, McCoy KL, Carty SE, Ramonell KM. Sex differences in patients with primary hyperparathyroidism. Surgery 2024; 175:65-72. [PMID: 37980200 DOI: 10.1016/j.surg.2023.07.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 06/27/2023] [Accepted: 07/18/2023] [Indexed: 11/20/2023]
Abstract
BACKGROUND Differences in presenting symptoms of primary hyperparathyroidism and outcomes of parathyroidectomy between sexes have been described, but whether these can be assessed by perioperative use of a validated tool, such as the Pasieka Parathyroidectomy Assessment Score, is unknown. METHOD All patients with primary hyperparathyroidism were asked to complete symptom assessment at the preoperative and postoperative visits. The assessment included a query for 13 Pasieka Parathyroidectomy Assessment Score parameters evaluated using a visual analog scale as described by Pasieka (summative score 0-1,300), and general quality of life and wellness. A review of a prospectively maintained database of primary hyperparathyroidism patients (January 2016-December 2019) was performed, and those who had a 6-month cure after initial parathyroidectomy were included. RESULTS The study cohort was mostly women (77%, 541/701). The median preoperative Pasieka Parathyroidectomy Assessment Score was higher in women (155, 0-1,190) than in men (80.5, 0-855, P < .001), although there were similar rates of asymptomatic primary hyperparathyroidism (Pasieka Parathyroidectomy Assessment Score = 0, 12.5% vs 7%, P = .042). After curative parathyroidectomy, women reported a substantial reduction in symptomatology, with Pasieka Parathyroidectomy Assessment Score declining by 35% at initial postoperative visit (median, 155 vs 100, P < .001), further decreasing to 48% by 6 months (155 vs 80, P < .001). The Pasieka Parathyroidectomy Assessment Score in men did change but to a much smaller degree at both the initial postoperative visit (80.5 vs 70; P = .036) and at 6 months (80.5 vs 57.5; P = .048). CONCLUSION When assessed with the Pasieka Parathyroidectomy Assessment Score, improvement in symptoms was clearly demonstrated for women after curative parathyroidectomy. Whether symptom improvement also occurs in men is less apparent but may be due to disparities in the development and validation of outcomes tools in general.
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Affiliation(s)
| | - Jason B Liu
- Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Linwah Yip
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Kelly L McCoy
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Sally E Carty
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
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3
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Baugh KA, McCoy KL, Leung JH, Carty SE, Ramonell KM, Yip L. Normocalcemic hyperparathyroidism: Intervention to differentiate primary from secondary hyperparathyroidism. Surgery 2024; 175:166-171. [PMID: 37981554 DOI: 10.1016/j.surg.2023.06.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 05/05/2023] [Accepted: 06/20/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Normocalcemic hyperparathyroidism can occur, but surgery should not be considered until common etiologies for secondary hyperparathyroidism are comprehensively excluded. Calcium deficiency is an underrecognized cause of normocalcemic parathyroid hormone elevation, and we aim to determine if the implementation of a preoperative calcium challenge can be used to reduce unnecessary parathyroidectomy. METHODS Consecutive patients referred for parathyroidectomy (1/21-6/22) with normocalcemia (serum calcium <10 mg/dL) and concurrently elevated parathyroid hormone levels were routinely treated with supplemental calcium and vitamin D3, and follow-up laboratory studies were assessed. RESULTS A total of 29/314 (9%) patients had normocalcemic parathyroid hormone elevation with mean calcium, parathyroid hormone, and vitamin D 25OH levels of 9.5 ± 0.3 mg/dL, 109.9 ± 34.9 pg/mL, and 42.7 ± 23.8 ng/mL respectively. Confounding factors included estimated glomerular filtration rate <60 in 2, loop diuretic use in 4, and prior gastric bypass or gastric sleeve surgery in 4. Follow-up biochemical evaluation was available in 27 (92%); results were unchanged in 7 patients (26%); normalization of parathyroid hormone levels with persistently normal calcium levels occurred in 15 (55%), thus confirming secondary hyperparathyroidism and hypercalcemia with elevated parathyroid hormone levels (classic primary hyperparathyroidism) was diagnosed in 5 (19%). Parathyroid exploration has been completed for 3 of 5 patients with classic primary hyperparathyroidism to date. CONCLUSION A preoperative calcium challenge was prospectively initiated in normocalcemic patients with parathyroid hormone elevation, and there was high compliance (92%). Short-interval calcium supplementation revealed ∼50% to have resolved secondary hyperparathyroidism due to insufficient calcium intake, which avoided unnecessary surgery. In contrast, classic patients were unveiled in 20%, allowing for prompt and correct surgical intervention.
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Affiliation(s)
| | - Kelly L McCoy
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Janet H Leung
- Department of Endocrinology, University of Pittsburgh, Pittsburgh, PA
| | - Sally E Carty
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | | | - Linwah Yip
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
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4
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Liu JB, Baugh KA, Ramonell K, McCoy KL, Karslioglu-French E, Morariu EM, Ohori NP, Nikiforova MN, Nikiforov YE, Carty SE, Yip L. Molecular Testing Predicts Incomplete Response to Initial Therapy in Differentiated Thyroid Carcinoma without Lateral Neck or Distant Metastasis at Presentation: Retrospective Cohort Study. Thyroid 2023. [PMID: 36974361 DOI: 10.1089/thy.2023.0060] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
BACKGROUND Molecular testing (MT) is emerging as a potential prognostic factor that can be available before treatment of differentiated thyroid carcinoma begins. Among patients eligible for either lobectomy or total thyroidectomy as their initial therapy, our study aim was to assess (1) if conventionally available preoperative factors are associated with incomplete response to initial therapy, and (2) if molecular testing (MT) results can be a surrogate for the ATA Risk Stratification System (RSS) to estimate risk of recurrence. METHODS The data of consecutive thyroid cancer patients without preoperative lateral neck disease or distant metastasis who underwent index thyroidectomy between November 1, 2017 and October 31, 2021 were reviewed. Logistic regression models including preoperative variables such as MT and/or the postoperatively available RSS were constructed to predict disease recurrence, either structural or biochemical. Model discrimination using the c-statistic and goodness-of-fit were compared. RESULTS Among 945 patients studied, 50 (5.2%) recurred with 18-month median follow up. Recurrences were detected in 17 (2.9%), 20 (6.7%), and 13 (22.8%) patients with RSS-Low, -Intermediate, and -High cancers, respectively (p<0.001). In multivariable analysis, only tumor size was associated with recurrence (OR 1.3, 95% CI 1.1-1.5). In a different model analyzing 440 (46.6%) patients with available MT results, recurrence was associated with both larger tumor size (OR 1.4, 95% CI 1.1-1.8) and MT results (p<0.001). Including MT improved the c-statistic by 27%, which was statistically no different than the model incorporating only the RSS (p=0.15). CONCLUSIONS Disease recurrence was observed across all ATA RSS categories in short-term follow-up, and tumor size was the only conventional preoperative factor associated with recurrence. When MT results were incorporated, they not only improved predictive ability beyond tumor size alone, but also yielded similar ability as the gold standard ATA RSS. Thus, MT results might aid the development of novel preoperative risk stratification algorithms.
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Affiliation(s)
- Jason B Liu
- Brigham and Women's Hospital, 1861, Surgery , 75 Francis St. CA-3, Boston, Massachusetts, United States, 02115-6195;
| | - Katherine A Baugh
- University of Pittsburgh, 6614, Surgery, Pittsburgh, Pennsylvania, United States;
| | - Kimberly Ramonell
- University of Pittsburgh, 6614, Pittsburgh, Pennsylvania, United States;
| | - Kelly L McCoy
- University of Pittsburgh, 6614, Surgery, Pittsburgh, Pennsylvania, United States;
| | - Esra Karslioglu-French
- University of Pittsburgh School of Medicine, 12317, Medicine, Falk Medical Building, 3601 5th Ave, Pittsburgh, Pennsylvania, United States, 15213;
| | - Elena Madalina Morariu
- University of Pittsburgh Medical Center, 6595, Endocrinology, 3601 Fifth Ave, Ste 300, Pittsburgh, Pittsburgh, Pennsylvania, United States, 15213;
| | - N Paul Ohori
- University of Pittsburgh, 6614, Pathology, Pittsburgh, Pennsylvania, United States;
| | - Marina N Nikiforova
- University of Pittsburg Medical Center, Pathology, 200 Lothrop Street, Pittsburgh, United States, 15213;
| | - Yuri E Nikiforov
- University of Pittsburgh School of Medicine, 12317, Department of Pathology, 3477 Euler Way, CLB Room 8031, Pittsburgh, Pennsylvania, United States, 15261;
| | - Sally E Carty
- University of Pittsburgh, Surgery, Division of Endocrine Surgery, 101 Kaufmann, 3471 Fifth Avenue, Pittsburgh, United States, 15213
- United States;
| | - Linwah Yip
- University of Pittsburgh, Surgery, 3471 Fifth Ave, Kaufmann Building, Suite 101, Pittsburgh, Pennsylvania, United States, 15213;
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Brubaker LS, Casciani F, Fisher WE, Wood AL, Cagigas MN, Trudeau MT, Parikh VJ, Baugh KA, Asbun HJ, Ball CG, Behrman SW, Berger AC, Bloomston MP, Callery MP, Christein JD, Fernandez-Del Castillo C, Dillhoff ME, Dixon E, House MG, Hughes SJ, Kent TS, Kunstman JW, Wolfgang CL, Zureikat AH, Vollmer CM, Van Buren G. A risk-adjusted analysis of drain use in pancreaticoduodenectomy: Some is good, but more may not be better. Surgery 2021; 171:1058-1066. [PMID: 34433515 DOI: 10.1016/j.surg.2021.07.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 06/16/2021] [Accepted: 07/16/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Intraperitoneal drain placement decreases morbidity and mortality in patients who develop a clinically relevant postoperative pancreatic fistula (CR-POPF) following pancreaticoduodenectomy (PD). It is unknown whether multiple drains mitigate CR-POPF better than a single drain. We hypothesize that multiple drains decrease the complication burden more than a single drain in cases at greater risk for CR-POPF. METHODS The Fistula Risk Score (FRS), mitigation strategies (including number of drains placed), and clinical outcomes were obtained from a multi-institutional database of PDs performed from 2003 to 2020. Outcomes were compared between cases utilizing 0, 1, or 2 intraperitoneal drains. Multivariable regression analysis was used to evaluate the optimal drainage approach. RESULTS A total of 4,292 PDs used 0 (7.3%), 1 (45.2%), or 2 (47.5%) drains with an observed CR-POPF rate of 9.6%, which was higher in intermediate/high FRS zone cases compared with negligible/low FRS zone cases (13% vs 2.4%, P < .001). The number of drains placed also correlated with FRS zone (median of 2 in intermediate/high vs 1 in negligible/low risk cases). In intermediate/high risk cases, the use of 2 drains instead of 1 was not associated with a reduced rate of CR-POPF, average complication burden attributed to a CR-POPF, reoperations, or mortality. Obviation of drains was associated with significant increases in complication burden and mortality - regardless of the FRS zone. CONCLUSION In intermediate/high risk zone cases, placement of a single drain or multiple drains appears to mitigate the complication burden while use of no drains is associated with inferior outcomes.
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Affiliation(s)
- Lisa S Brubaker
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Fabio Casciani
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Verona, Italy
| | - William E Fisher
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX; Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX
| | - Amy L Wood
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX; Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX
| | - Martha Navarro Cagigas
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX; Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX
| | - Maxwell T Trudeau
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Viraj J Parikh
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Katherine A Baugh
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | | | | | | | | | | | - Mark P Callery
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - John D Christein
- University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | | | - Mary E Dillhoff
- The Ohio State University Wexner Medical Center, Columbus, OH
| | | | | | | | - Tara S Kent
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | | | | | | | - Charles M Vollmer
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - George Van Buren
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX; Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX. https://twitter.com/GeorgeVanBuren
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6
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Baugh KA, Desai S, Van Buren Nd G, Fisher WE, Farinas CA, Dhingra S. Lactoferrin amyloid presenting as a mural nodule in a pancreatic cystic lesion prompting pancreatoduodenectomy: a case report. BMC Gastroenterol 2021; 21:66. [PMID: 33579198 PMCID: PMC7881451 DOI: 10.1186/s12876-021-01641-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 02/03/2021] [Indexed: 12/03/2022] Open
Abstract
Background Amyloid deposition in pancreas is rare. Lactoferrin amyloid deposition has not been reported in pancreas, till date. Presence of enhancing mural nodule in a cyst on imaging is a worrisome feature for malignancy, and warrants surgical resection in a surgically fit candidate, as per Fukuoka guidelines for management of cystic lesions in pancreas. Case report We report a case of localized amyloidosis presenting as a mural nodule in a 1.6 cm cyst located in the head of pancreas, which led to pancreatoduodenectomy in a 69 year old woman. Histological evaluation revealed a simple mucinous cyst with localized lactoferrin amyloid deposition corresponding to the mural nodule identified on imaging. Conclusions We report the first case of localized lactoferrin amyloid deposition in pancreas that presented as a mural nodule in a cystic lesion and prompted pancreatoduodenectomy. This unique case illustrates that on rare occasion mural nodule in a cyst can be benign. It adds amyloid deposition to the differential diagnosis of mural nodules in pancreatic cystic lesions seen on imaging.
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Affiliation(s)
| | | | | | - William E Fisher
- Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Carlos A Farinas
- Department of Radiology, Baylor College of Medicine, Houston, TX, USA
| | - Sadhna Dhingra
- Department of Pathology and Immunology, Baylor College of Medicine, 1 Baylor Plaza, MS BCM315, Houston, TX, 77030, USA.
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7
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Shah KP, Baugh KA, Brubaker LS, Van Buren G, Villafane-Ferriol N, McElhany AL, Mohamed S, Silberfein EJ, Hsu C, Massarweh NN, Tran Cao HS, Mendez-Reyes JE, Fisher WE. Long-Term Assessment of Pancreatic Function After Pancreatectomy for Cystic Neoplasms. J Surg Res 2019; 247:547-555. [PMID: 31740011 DOI: 10.1016/j.jss.2019.09.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 08/20/2019] [Accepted: 09/19/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND With advances in cross-sectional imaging, pancreatic cysts are more frequently diagnosed and have become a common indication for pancreatectomy. The impact of pancreatectomy in these patients is important. The purpose of this study was to assess short-term outcomes, long-term nutritional status, quality of life (QOL), and pancreas function after pancreatectomy for cystic neoplasms. MATERIALS AND METHODS At a single institution, patients at least 3 y post-pancreatectomy for benign cystic neoplasms were identified. Using a validated questionnaire, short-term outcomes, long-term outcomes including endocrine and exocrine insufficiency, long-term nutritional status, and preoperative and postoperative QOL were compared based on operation and indication for resection. RESULTS Among 102 eligible patients, 70 had valid contact information and 51 (72.9%) agreed to participate. Median follow-up was 6 (4-8) y. Patients undergoing pancreatoduodenectomy for benign cysts had higher morbidity than a similar cohort resected for pancreatic adenocarcinoma (patients with at least 1 ≥ grade 2 complication [49.0% versus 31.6%, P = 0.038]). After long-term follow-up, pancreatectomy did not significantly affect perceived QOL. Half of patients had mild-moderate or severe malnourishment, but pancreatic enzyme replacement was reported by only 4 (7.8%) patients. New-onset diabetes was present in 15 (29.4%) patients with median time-to-diagnosis of 6 (1-12) mo after resection. CONCLUSIONS Pancreatectomy for benign cysts did not negatively impact patients' perceived QOL. However, after long-term follow-up, malnutrition and pancreatic insufficiency occurred in a significant percentage and may be greater than previously estimated. Consideration of short- and long-term outcomes should factor into preoperative counseling, especially in cysts with minimal risk of progression to malignancy.
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Affiliation(s)
- Kevin P Shah
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Katherine A Baugh
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Lisa S Brubaker
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - George Van Buren
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | | | - Amy L McElhany
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Sadde Mohamed
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Eric J Silberfein
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Cary Hsu
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Nader N Massarweh
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Hop S Tran Cao
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Jose E Mendez-Reyes
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - William E Fisher
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.
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Baugh KA, Villafane N, Farinas C, Dhingra S, Silberfein EJ, Massarweh NN, Cao HT, Fisher WE, Van Buren G. Pancreatic Incidentalomas: A Management Algorithm for Identifying Ectopic Spleens. J Surg Res 2019; 236:144-152. [DOI: 10.1016/j.jss.2018.11.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 10/01/2018] [Accepted: 11/19/2018] [Indexed: 12/21/2022]
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9
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Villafane-Ferriol N, Baugh KA, McElhany AL, Van Buren G, Fang A, Tashakori EK, Reyes JEM, Cao HST, Silberfein EJ, Massarweh N, Hsu C, Barakat O, Schmidt C, Zyromski NJ, Dillhoff M, Villarreal JA, Fisher WE. Evidence Versus Practice in Early Drain Removal After Pancreatectomy. J Surg Res 2019; 236:332-339. [PMID: 30694774 DOI: 10.1016/j.jss.2018.11.048] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 10/19/2018] [Accepted: 11/21/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND Early drain removal when postoperative day (POD) one drain fluid amylase (DFA) was ≤5000 U/L reduced complications in a previous randomized controlled trial. We hypothesized that most surgeons continue to remove drains late and this is associated with inferior outcomes. METHODS We assessed the practice of surgeons in a prospectively maintained pancreas surgery registry to determine the association between timing of drain removal with demographics, comorbidities, and complications. We selected patients with POD1 DFA ≤5000 U/L and excluded those without drains, and subjects without data on POD1 DFA or timing of drain removal. Early drain removal was defined as ≤ POD5. RESULTS Two hundred and forty four patients met inclusion criteria. Only 90 (37%) had drains removed early. Estimated blood loss was greater in the late removal group (190 mL versus 100 mL, P = 0.005) and pathological findings associated with soft gland texture were more frequent (97 [63%] versus 35 [39%], P < 0.0001). Patients in the late drain removal group had more complications (84 [55%] versus 30 [33%], P = 0.001) including pancreatic fistula (55 [36%] versus 4 [4%], P < 0.0001), delayed gastric emptying (27 [18%] versus 3 [3%], P = 0.002), and longer length of stay (7 d versus 5 d, P < 0.0001). In subset analysis for procedure type, complications and pancreatic fistula remained significant for both pancreatoduodenectomy and distal pancreatectomy. CONCLUSIONS Despite level one data suggesting improved outcomes with early removal when POD1 DFA is ≤ 5000 U/L, experienced pancreas surgeons more frequently removed drains late. This practice was associated with known risk factors (estimated blood loss, soft pancreas) and may be associated with inferior outcomes suggesting potential for improvement.
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Affiliation(s)
| | - Katherine A Baugh
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, Houston, TX
| | - Amy L McElhany
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, Houston, TX
| | - George Van Buren
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, Houston, TX
| | - Andrew Fang
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, Houston, TX
| | - Erisha K Tashakori
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, Houston, TX
| | - Jose E Mendez Reyes
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, Houston, TX
| | - Hop S Tran Cao
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, Houston, TX
| | - Eric J Silberfein
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, Houston, TX
| | - Nader Massarweh
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, Houston, TX
| | - Cary Hsu
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, Houston, TX
| | - Omar Barakat
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, Houston, TX
| | - Carl Schmidt
- Department of Surgery, Ohio State University, Columbus, Ohio
| | - Nicholas J Zyromski
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Mary Dillhoff
- Department of Surgery, Ohio State University, Columbus, Ohio
| | - Joshua A Villarreal
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, Houston, TX
| | - William E Fisher
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, Houston, TX.
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10
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Baugh KA, Tran Cao HS, van Buren G, Silberfein EJ, Hsu C, Chai C, Barakat O, Fisher WE, Massarweh NN. Understaging of clinical stage I pancreatic cancer and the impact of multimodality therapy. Surgery 2018; 165:307-314. [PMID: 30243481 DOI: 10.1016/j.surg.2018.08.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 08/03/2018] [Accepted: 08/06/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Although current guidelines recommend multimodal therapy for all patients with pancreatic ductal adenocarcinoma, it is unclear the extent to which clinical stage I patients are accurately staged and how this may affect management. METHODS In this retrospective cohort study of 4,404 patients aged 18-79 years with clinical stage 1 (ie, T1N0 or T2N0) pancreatic ductal adenocarcinoma treated with upfront resection in the National Cancer Database (2004-2014), understaging was ascertained by comparing pretreatment clinical stage with pathologic stage. The association between adjuvant treatment and overall risk of death among true stage I and understaged patients was evaluated using multivariable Cox regression. RESULTS Upstaging was identified in 72.6% of patients (62.8% T3/4, 53.9% N1) of whom 69.7% received adjuvant therapy compared with 47.0% with true stage I disease. Overall survival at 5 years among those with true stage I disease was significantly higher than those who had been clinically understaged (42.9% vs 16.6%; log-rank, p < 0.001). For true stage I patients, adjuvant therapy was not associated with risk of death (hazard ratio: 1.07, 95% confidence interval: 0.89-1.29). For understaged patients, adjuvant therapy significantly decreased risk of death (hazard ratio: 0.64, 95% confidence interval: 0.55-0.74). CONCLUSION The majority of clinical stage I pancreatic ductal adenocarcinoma patients actually have higher-stage disease and benefit from multimodal therapy; however, one third of understaged patients do not receive any adjuvant treatment. Clinicians should discuss all potential treatment strategies with patients (in the context of the acknowledged risks and benefits), including the utilization of neoadjuvant approaches in those presenting with potentially resectable disease.
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Affiliation(s)
- Katherine A Baugh
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Hop S Tran Cao
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - George van Buren
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Eric J Silberfein
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Cary Hsu
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Christy Chai
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Omar Barakat
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - William E Fisher
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Nader N Massarweh
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX; Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX.
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Baugh KA, Weireter LJ, Collins JN. The trauma pan scan: what else do you find? Am Surg 2014; 80:855-859. [PMID: 25197870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The objective of this study was to investigate the prevalence of incidental findings in pan-computed tomography (CT) scans of trauma patients and the communication of significant findings requiring follow-up to the patient. A retrospective chart review of adult trauma patients was performed during the period of January 1, 2011, to August 31, 2011. During that period, 990 patient charts were examined and 555 charts were selected based on the inclusion criteria of a pan-CT scan including the head, neck, abdomen/pelvis, and chest. Patient demographics such as age, gender, mechanism of injury, and Injury Severity Score were collected. Nontraumatic incidental findings were analyzed to establish the prevalence of incidental findings among trauma patients. Discharge summaries were also examined for follow-up instructions to determine the effectiveness of communication of the significant findings. Between the 555 pan-CT scans (1759 total scans), 1706 incidental findings were identified with an incidence of 3.1 incidental findings per patient and with the highest concentration of findings occurring in the abdomen/pelvis. The majority of findings were benign including simple renal cysts with a prevalence of 7.7 per cent. However, 282 significant findings were identified that were concerning for possible malignancy or those requiring further evaluation, the most common of which were lung nodules, which accounted for 21.6 per cent of significant findings. However, only 32.6 per cent of significant findings were documented as reported to the patient. With the use of pan scans on trauma patients, many incidental findings have been identified to the benefit of the patient. The majority of these are clinically insignificant; however, only 32.6 per cent of potentially significant findings were communicated to the patient. The advantage of early detection comes from proper communication and this study demonstrates that there could be improvement in conveying findings to the patient.
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Abstract
The objective of this study was to investigate the prevalence of incidental findings in pan-computed tomography (CT) scans of trauma patients and the communication of significant findings requiring follow-up to the patient. A retrospective chart review of adult trauma patients was performed during the period of January 1, 2011, to August 31, 2011. During that period, 990 patient charts were examined and 555 charts were selected based on the inclusion criteria of a pan-CT scan including the head, neck, abdomen/pelvis, and chest. Patient demographics such as age, gender, mechanism of injury, and Injury Severity Score were collected. Nontraumatic incidental findings were analyzed to establish the prevalence of incidental findings among trauma patients. Discharge summaries were also examined for follow-up instructions to determine the effectiveness of communication of the significant findings. Between the 555 pan-CT scans (1759 total scans), 1706 incidental findings were identified with an incidence of 3.1 incidental findings per patient and with the highest concentration of findings occurring in the abdomen/pelvis. The majority of findings were benign including simple renal cysts with a prevalence of 7.7 per cent. However, 282 significant findings were identified that were concerning for possible malignancy or those requiring further evaluation, the most common of which were lung nodules, which accounted for 21.6 per cent of significant findings. However, only 32.6 per cent of significant findings were documented as reported to the patient. With the use of pan scans on trauma patients, many incidental findings have been identified to the benefit of the patient. The majority of these are clinically insignificant; however, only 32.6 per cent of potentially significant findings were communicated to the patient. The advantage of early detection comes from proper communication and this study demonstrates that there could be improvement in conveying findings to the patient.
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