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Background Finding and preserving normal parathyroid glands or localizing and removing diseased parathyroid glands are crucial steps to successful thyroid and parathyroid operations. Using near-infrared fluorescence detection to identify parathyroid glands during thyroid and parathyroid operations has lately gained widespread recognition, with 2 Food and Drug Administration–cleared devices currently in the market. We aim to update the endocrine surgery community on how near-infrared fluorescence detection can be most optimally used for rapid intraoperative parathyroid gland identification or preservation. Methods A literature review was performed using the key terms: “parathyroid,” “near infrared,” and “fluorescence” in relevant search engines. Based on the reviewed literature and expert surgeons’ opinions, recommendations were formulated for applying near-infrared fluorescence detection to identify or preserve parathyroid glands during cervical endocrine surgery. Results The scope of near-infrared fluorescence detection can be broadly categorized into (1) using near-infrared auto-fluorescence to identify or locate both healthy and diseased parathyroid glands, and (2) using contrast-enhanced near-infrared fluorescence to evaluate parathyroid gland perfusion. The benefits and pitfalls for both near-infrared–based approaches are described herein. Conclusion Near-infrared fluorescence detection appears helpful for identification and likely preservation of parathyroid glands. We hope these recommendations will be valuable to the practicing endocrine surgeon as they consider incorporating these intraoperative adjuncts in their surgical practice.

Background Adrenocortical carcinoma is a rare, aggressive cancer. We compared features of patients who underwent synchronous versus metachronous metastasectomy. Methods Adult patients who underwent resection for metastatic adrenocortical carcinoma from 1993 to 2014 at 13 institutions of the US adrenocortical carcinoma group were analyzed retrospectively. Patients were categorized as synchronous if they underwent metastasectomy at the index adrenalectomy or metachronous if they underwent resection after recurrence of the disease. Factors associated with overall survival were assessed by univariate analysis. Results In the study, 84 patients with adrenocortical carcinoma underwent metastasectomy; 26 (31%) were synchronous and 58 (69%) were metachronous. Demographics were similar between groups. The synchronous group had more T4 tumors at the index resection (42 vs 3%, P 001). The metachronous group had prolonged median survival after the index resection (86.3 vs 17.3 months, P 001) and metastasectomy (36.9 vs 17.3 months, P = .007). Synchronous patients with R0 resections had improved survival compared to patients with R1/2 resections ( P = .008). Margin status at metachronous metastasectomy was not associated with survival ( P = . 452). Conclusion Select patients with metastatic adrenocortical carcinoma may benefit from metastasectomy. Patients with metachronous metastasectomy have a more durable survival benefit than those undergoing synchronous metastasectomy. This study highlights need for future studies examining differences in tumor biology that could explain outcome disparities in these distinct patient populations.

Background Difficulty in identifying the parathyroid gland during neck operations can lead to accidental parathyroid gland excisions and postsurgical hypocalcemia. A clinical prototype called as PTeye was developed to guide parathyroid gland identification using a fiber-optic probe that detects near-infrared autofluorescence from parathyroid glands as operating room lights remain on. An Overlay Tissue Imaging System was designed concurrently to detect near-infrared autofluorescence and project visible light precisely onto parathyroid gland location. Methods The PTeye and the Overlay Tissue Imaging System were tested in 20 and 15 patients, respectively, and a modified near-infrared imaging system was investigated in 6 patients. All 41 patients underwent thyroidectomy or parathyroidectomy. System accuracy was ascertained with surgeon's visual confirmation for in situ parathyroid glands and histology for excised parathyroid glands. Results There was no observable difference between near-infrared autofluorescence of healthy and diseased parathyroid glands. The PTeye identified 98% of the parathyroid gland, whereas the near-infrared imaging system and the Overlay Tissue Imaging System identified 100% and 97% of the parathyroid glands, respectively. Conclusion The PTeye can guide in real-time parathyroid gland identification even with ambient operating room lights. The near-infrared imaging system performs parathyroid gland imaging with high sensitivity, whereas the Overlay Tissue Imaging System enhances parathyroid gland visualization directly within the surgical field without requiring display monitors. These label-free technologies can be valuable adjuncts for identifying parathyroid glands intraoperatively.

It is common practice to perform flexible laryngoscopy (FL) to ensure true vocal cord (TVC) mobility in patients with previous neck operations or patients with suspected VC dysfunction. Vocal cord ultrasonography (VCUS) is accurate in identifying TVC paralysis. The goal of this study is to evaluate the impact of VCUS as the initial study to confirm TVC mobility in patients requiring preoperative FL.A total of 194 consecutive patients with indications for preoperative FL underwent VCUS. In group 1, 52 patients had FL regardless of the results of VCUS, whereas in group 2, 142 patients had VCUS followed by FL only when VCUS was unsatisfactory.VCUS visualized TVC/arytenoids in 164 of 194 (85%) patients. TVC visualization was more common in women (95%) and in patients without thyroid cartilage calcification (92%) (P.0005). VCUS predicted all paralyzed TVC. In group 2, 76% of patients had adequate VCUS and avoided preoperative FL. Among 24% of patients in whom VCUS was inadequate, 16 had preoperative FL attributable to a lack of TVC visualization, 6 had abnormal TVC mobility, 11 needed additional confirmations, and 2 had previous FL for another reason.VCUS changed surgeon practices by avoiding the need for preoperative FL in the majority of patients. This noninvasive and sensitive method demonstrates TVC mobility and safely precludes preoperative FL in most patients.

Background Subjective symptoms such as decreased energy, chronic fatigue, and depression are associated with hyperparathyroidism. Studies have shown that these symptoms are improved during short-term follow-up after parathyroidectomy. This study evaluates the durability of this subjective improvement in quality-of-life symptoms in a large population of patients with follow-up greater than 1 year after operation. Methods Between 2002 and 2005, 258 patients underwent parathyroidectomy, 100 (81 females and 19 males) of whom were available for this study. The patients were evaluated with a survey based on the Health Outcomes Institute Health Status Questionnaire. Some answers were quantified on a 1 to 6 scale, while others consisted of “yes” or “no” responses. Patients completed a questionnaire prior to parathyroidectomy and postoperatively at 1 month, 3 to 6 months, and 1 to 2 years or greater intervals. Statistical analysis was used to detect changes attributable to parathyroidectomy. A P value Results At 1-month follow-up, patients’ perceptions of their overall health, energy level, and mood significantly improved. At 6-month follow-up, significant improvements in muscle strength, health, endurance, and relief of anxiety were documented. At the interval of 1 to 2 years, overall health, energy level, endurance, and relief of anxiety were improved. There was no significant decrement in the quality of life in these patients after parathyroidectomy. Conclusions Parathyroidectomy for hyperparathyroidism is associated with significant lasting improvement in subjective symptoms. The potential durable improvement in these quality-of-life symptoms is a valid indication for parathyroidectomy.

Transcutaneous vocal cord ultrasonography (TVCUS) is a noninvasive study used to identify true vocal cord (TVC) mobility. Its sensitivity in predicting TVC paralysis when compared with indirect flexible laryngoscopy (IFL) ranges from 62 to 93%. This study aimed to evaluate the feasibility of surgeon-performed TVCUS in assessing TVC mobility in the outpatient setting.At 5 institutions, 510 consecutive patients underwent 887 TVCUS performed by 8 surgeons during initial surgical evaluation. IFL was obtained in selected patients. TVCUS was repeated during the first postoperative visit, and IFL was obtained only when judged necessary. Clinical parameters were collected and later correlated with TVC visualization.TVC visualization was possible in 688 of 887 TVCUS (77%); visibility ranged from 41 to 86% among performing surgeons. IFL was done in 81 patients (16%) and TVCUS predicted TVC paralysis in all cases when TVC were seen. TVC visualization was possible more often in females than males (83% vs 17%; P.0005) and in patients without thyroid cartilage calcification than those with calcification (83% vs 42%; P.0005).Experienced surgeon-ultrasonographers can use TVCUS to visualize TVC in most female patients and less so in males. TVCUS is highly sensitive, but operator dependent. This study demonstrates the feasibility of TVCUS and directs further attention to defining its optimal role in assessment of TVC mobility.

Surgeon-performed ultrasound (SUS) has become an extension of the physical examination in the evaluation of patients with thyroid nodules. Amid concerns that too many "diagnostic" thyroidectomies are performed, this study examines the usefulness of SUS in predicting benign thyroid nodules.A retrospective review of 624 patients with solitary or dominant thyroid nodules and prospectively collected data of SUS nodule features before thyroidectomy (benign = 407; malignant = 217) was performed. A specific model for statistical analysis was created to predict benignity.Significant predictors of benignity by SUS after logistic regression included isoechogenicity, cystic component, no microcalcifications, regular borders, and size1 cm. The resultant specificity of this reduced model was 97.6% with a 10.6% sensitivity for predicting benign pathology. After excluding patients with lesions4 cm or a history of thyroid cancer, thyroid nodules measuring 1-4 cm with the presence of the 4 other criteria by SUS was 98.5% specific for the detection of benign pathology (1.5% false-negative rate).Approximately 10% of thyroidectomy patients had benign nodules that were 1-4 cm, isoechoic, with regular borders, had a cystic component, and no microcalcifications by SUS. Patients without clinical risk factors and these SUS features may safely forego further fine needle aspiration and thyroid lobectomy, and can be monitored with serial ultrasound examinations.

Disparities may exist in the care of patients with primary hyperparathyroidism (HPT). This study examines the presentation and outcomes of underinsured patients undergoing parathyroidectomy.We divided 493 HPT patients who underwent initial parathyroidectomy from 2000 to 2008 at a single institution into 2 groups: underinsured patients (group 1; n = 94) evaluated and treated at a county hospital, and patients with insurance (group 2; n = 399). Univariate and multivariate analysis adjusting for race and ethnicity were conducted to determine the association of being underinsured with several clinical variables.More patients in group 1 compared with group 2 were of black or Hispanic background (92% vs. 44%; P.0001). Group 1 patients had higher mean preoperative serum calcium and PTH levels: 12.1 vs. 11.8 mg/dL (P = .009) and 263 vs. 198 pg/mL (P = .03), respectively. Seven group 1 (7.4%) and 7 group 2 (1.8%) patients presented with hypercalcemic crisis (P = .003). On multivariate analysis, underinsurance was associated with higher serum calcium levels (P = .011) and hypercalcemic crisis at presentation (odds ratio, 5.59; 95% confidence interval, 1.45-21.51; P = .012). Follow-up was shorter in group 1 patients (15 vs. 24 months; P.001) and postoperative PTH levels were higher (76 vs. 48 pg/mL; P.001). Other perioperative data were not different between the groups.Underinsured patients with HPT may present with higher serum calcium and PTH levels, are more likely to have hypercalcemic crisis, and less likely to return for follow-up. Underfunded health insurance coverage may account for differences seen in this study.

Two important changes in the past decade have altered the landscape of graduate medical education (GME) in the U.S. The national restrictions on trainee duty hours mandated by the Accreditation Council for Graduate Medical Education (ACGME) were the most visible and generated much controversy. Equally important is the ACGME Outcome Project, which mandates competency-based training. Both of these changes have unique implications for surgery trainees, who traditionally spent long hours caring for patients in the hospital, and who must be assessed in 2 broad domains: their medical care of pre- and postoperative patients, and their technical skill with procedures in and out of the operating room. This article summarizes 3 key challenges that lie ahead for surgical educators. First, the changes in duty hours in the past 7 years are summarized, and the conversation about added restrictions planned for July 2011 is reviewed. Next, the current state of the assessment of competency among surgical trainees is reviewed, with an outline of the challenges that need to be overcome to achieve widespread, competency-based training in surgery. Finally, the article summarizes the problems caused by increased reliance on handoffs among trainees as they compensate for decreased time in the hospital, and suggests changes that need to be made to improve safety and efficiency, including how to use handoffs as part of our educational evaluation of residents.

Background Hypercalcemic crisis is a serious and potentially life-threatening complication of markedly increased serum calcium concentrations most commonly due to severe primary sporadic hyperparathyroidism (HPT). Methods A review of 1,310 consecutive patients with severe sporadic HPT who underwent parathyroidectomy at a single institution from April 1970 through July 2009 was performed. Of this series, 88 patients were treated operatively for hypercalcemic crisis associated with signs and symptoms of acute calcium intoxication and/or serum calcium concentrations ≥14 mg/dL (3.5 mmol/L). Clinical presentation, laboratory values, operative success, operative failure, and disease recurrence were compared to noncrisis patients. Results Preoperative calcium and parathyroid hormone (PTH) concentrations were significantly greater among patients with hypercalcemic crisis. Crisis patients had a greater incidence of mental status changes, fatigue, ectopic glands, and pancreatitis. Postoperatively, calcium and PTH levels were similar. Overall, crisis patients had a lesser rate of operative success compared to noncrisis patients (92% vs 97%). With the advent of intraoperative PTH monitoring–guided focused parathyroidectomy in 1993, success rates equalized (95% vs 97%). There was no difference in disease recurrence. Overall follow-up was 59 months. Conclusion Hypercalcemic crisis patients are appropriately treated by expeditious parathyroidectomy, but overall have slightly lesser rates of initial operative success than noncrisis patients. Long-term results reveal similar serum calcium, PTH concentrations, and recurrence rates at a mean follow-up of nearly 5 years.

Background Sample collection site may affect the dynamics of intraoperative parathyroid hormone monitoring (IPM) and influence surgical decisions. Methods We prospectively studied 45 patients undergoing parathyroidectomy for primary hyperparathyroidism. The IPM cure criterion was a decrease in peripheral vein (PV) parathyroid hormone (PTH) of >50% at 10 minutes after gland excision. PTH samples were collected simultaneously from PV and central vein (CV) and compared for PTH decay, the incidence of >50% PTH decay, and the incidence of normal PTH values after gland excision. Results Mean PTH levels were significantly higher from the CV before and after gland excision. Mean PTH decay 10 minutes after gland excision was 89% PV versus 88% CV, resulting in mean PTH levels of 27 ± 23 and 39 ± 35 pg/mL, respectively ( P 50% decay in PTH was present in 98% PV versus 88% CV samples. By 10 minutes, the incidence of >50% PTH decay was equivalent (98%). This yielded normal range PTH levels from the PV versus CV in 90% versus76% of patients at 5 minutes, 96% versus 89% at 10 minutes, and 95% versus 81% at 20 minutes. Of 45 patients, 44 (98%) are normocalcemic at a mean follow-up of 6.3 months. IPM predicted the single operative failure. Conclusions CV sampling produces significantly higher PTH levels. Surgeons sampling from a PV may observe a >50% decrease in PTH and normal range PTH values starting 5 minutes after gland excision. Surgeons who sample from the CV and require normalization of PTH levels may have to wait longer and/or continue potentially unnecessary neck exploration.

Background Many patients with sporadic primary hyperparathyroidism (SPHPT) have discordant preoperative Tc-99m-sestamibi (MIBI) and ultrasonography studies prior to focused parathyroidectomy (PTX). This study examines the usefulness of intraoperative parathormone monitoring (IPM) during PTX in patients with discordant preoperative localization studies. Methods A retrospective series of 225 consecutive SPHPT patients with MIBI scans and surgeon performed ultrasonography (SUS) prior to focused parathyroidectomy were studied. All patient operations were reviewed, and how IPM changed operative management was determined. Correct gland localization, presence of multigland disease (MGD), and operative outcome were also examined. Results In 225 patients, overall operative success was 97%, and IPM changed operative management in 29% of patients. In 85 patients (38%) with discordant studies, operative success was 93%; IPM changed operative management in 74% of these patients. IPM allowed for 66% (56/85) of these operations to be performed as unilateral neck exploration and confirmed removal of abnormal glands in 7 patients with MGD. In 140 patients (62%) with concordant localization, in which operative success was 99%, IPM changed operative management in only 2% (3/140) of these patients with MGD. Conclusion Although of marginal benefit in patients with concordant imaging studies, IPM remains essential for performing successful PTX with discordant or incorrect concordant localization.

Background Parathyroid histopathology has been used to predict single or multiglandular disease (MGD). “Hyperplasia” implies MGD, whereas “adenoma” suggests single gland involvement. Intraoperative parathyroid hormone (PTH) monitoring (IPM) guides parathyroidectomy based on function. We sought to evaluate the accuracy of histopathology in the diagnosis of single or MGD and in predicting operative success. Methods We reexamined the parathyroid glands from 402 patients with sporadic primary hyperparathyroidism (SPHPT) who underwent initial IPM-guided parathyroidectomies. Operative findings and outcome were correlated with histopathology of excised glands. Operative success was eucalcemia for ≥6 months and recurrence of hypercalcemia/high PTH after successful parathyroidectomy. Results Of 402 patients, 384 had 1 gland excised resulting in operative success; hyperplasia was diagnosed in 244 of the 384 (64%), with only 2 developing recurrence. Of the 384 patients, 140 (37%) had adenomas with 1 late recurrence. There were 18 patients with MGD (14 hyperplasias, 4 adenomas). There were 5 failures with hyperplasia predicting MGD. Histopathology was incorrect in predicting the number of glands involved in 249 of 402 (62%) patients, and IPM was incorrect in only 13 (3%). Conclusion Histopathology of excised abnormal parathyroid glands does not predict the secretory function of the remaining parathyroid glands left in situ. IPM guided parathyroidectomy accurately based on function alone; however, histopathology was inaccurate in predicting MGD and should not be used to guide parathyroidectomy in patients with SPHPT.

Background As many as 43% of patients will have normocalcemic intact parathyroid hormone (PTH) elevation after undergoing curative parathyroidectomy for primary hyperparathyroidism. This phenomenon may be due in part to an absolute or relative deficiency of vitamin D, which is under-recognized in patients with primary hyperparathyroidism. Methods From September 1, 2004, to September 30, 2005, 86 consecutive patients underwent parathyroidectomy for primary sporadic hyperparathyroidism (psHPT). The patients were segregated into 2 groups based on postoperative management. Group 1 was composed of 26 patients who received routine oral calcitriol and calcium carbonate postoperatively. The 60 patients in the second group (group 2) received calcium carbonate postoperatively at the discretion of the primary surgeon. Results A total of 85 patients (99%) achieved postoperative cure with sustained reduction in serum calcium. Within 30 days postoperatively, mean serum PTH levels normalized in both groups (41 ± 31 vs 39 ± 31 pg/ml; P = .91). However, at 1 to 3 months postoperatively, mean serum calcium levels remained similar (9.5 ± 0.7 vs 9.3 ± 0.5 mg/dl; P = .39) whereas mean serum PTH levels in groups 1 and 2 were 43 ± 25 pg/ml and 67 ± 45 pg/ml ( P = .02), respectively. At 4 to 6 months postoperatively, mean PTH was again higher in group 2 (36 ± 22 vs 67 ± 35; P = .03), whereas mean serum calcium levels were normal (9.2 ± 0.8 vs 9.6 ± 0.4 mg/dl; P = .18). The incidence of postoperative normocalcemic PTH elevation was significantly higher in group 2 at 1 to 3 months (14% vs 39%; P = .04) and at 7 to 12 months (22% vs 83%; P = .04). Conclusions Vitamin D supplementation following parathyroidectomy for primary hyperparathyroidism reduces the incidence of postoperative eucalcemic PTH elevation.

Background. Laparoscopic adrenalectomy for small pheochromocytomas, although challenging, is widely accepted. However, its application to pheochromocytomas larger than 6 cm is questioned due to concerns of malignancy and case complexity. Our aim was to examine the impact of pheochromocytoma tumor size (≥6 cm vs

Background. The natural history of nonfunctioning islet cell carcinoma of the pancreas is poorly defined. We therefore reviewed our institutional experience during a period of 12 years to define more clearly the natural history of this disease as a basis for individual therapeutic recommendations. Methods. The records of all patients who had histologically or cytologically confirmed nonfunctioning islet cell carcinoma of the pancreas were retrospectively reviewed. Patients were grouped by extent of disease at diagnosis and by initial treatment. Survival distributions were estimated by Kaplan-Meier analysis. Results. One hundred sixty-three patients with nonfunctioning islet cell carcinoma of the pancreas were identified. The overall median survival duration was 3.2 years. The median survival was 7.1 years in patients with localized disease who underwent a potentially curative resection and 5.2 years in those with locally advanced, unresectable, nonmetastatic disease (P =.04). Patients with metastatic disease that could not be resected had a median survival of 2.1 years. Conclusions. Patients with completely resected localized disease had a long median survival. Patients with nonmetastatic but unresectable locally advanced disease also had a surprisingly long median survival; major treatment-related morbidity may be hard to justify in this subgroup. The short median survival in patients with metastatic disease suggests that the frequent practice of observation in this patient subgroup needs to be reexamined and that continued investigation of regional and systemic therapies with novel agents is warranted. (Surgery 2001;130:1078-85.)