Search

The history of the Connell Stitch begins at the Milwaukee County Hospital in 1887 and continues across two generations of surgeons, Dr. M.E. Connell and Dr. F Gregory Connell. With this historical article, we review the evolution of the Connell stitch in context of the surgeons responsible for the stitch's development and evolution. Understanding the history of the Connell stitch facilitates a better appreciation for the Connell Stitch that we know and use today. [ABSTRACT FROM AUTHOR]

Pancreatic neuroendocrine tumors rarely undergo cystic degeneration leading to a radiologic appearance, which is often interpreted as a pancreatic mucinous cystadenoma or pseudocyst. We reviewed our experience with 38 neuroendocrine tumors, four of which were cystic, and 24 other cystic pancreatic tumors (mucinous cystadenoma [n = 5], cystadenocarcinoma [n = 6], serous cystadenoma [n = 3], solid/cystic papillary neoplasm [n = 3], intraductal papillary mucinous tumor [n = 6], and mucinous adenocarcinoma [n = 1]) managed operatively between 1990 and 2000. This review was undertaken to identify clinical and pathologic features useful for preoperative diagnosis of cystic neuroendocrine tumors. Two of the four patients with cystic neuroendocrine tumors presented with abdominal pain, one patient was asymptomatic, and one patient had hypoglycemia. Three of the four cystic neuroendocrine tumors were identified by CT scan, and none were biopsied preoperatively. Preoperative diagnoses included mucinous cystadenoma in two patients (n = 2), pancreatic cystic neoplasm in one patient, (n = 1) and insulinoma in one patient (n = 1). All four cystic neuroendocrine tumors were benign and were completely resected (distal pancreatectomy [n = 2], enucleation [n = 2]). Cystic neuroendocrine tumors are difficult to diagnose preoperatively because the majority of these tumors are nonfunctional, and CT does not differentiate these tumors from other cystic neoplasms. Cystic neuroendocrine tumors represent a subgroup of pancreatic cystic and neuroendocrine tumors with malignant potential. Their high resectability rate further supports the role of surgical exploration and resection in the treatment of pancreatic cystic neoplasms. ( J Gastrointest Surg 2002;6:66-74.) [Copyright &y& Elsevier]

Background Intraoperative parathyroid hormone (IOPTH) level monitoring is a useful adjunct to parathyroidectomy for primary hyperparathyroidism (pHPT). Occasionally, increases (“spikes”) in IOPTH levels from the preoperative baseline parathyroid hormone may occur, which may lead to longer operative times or more extensive neck exploration or both. The aim of this study was to determine if the extent of IOPTH level increase predicts single gland disease (SGD). Methods This is a retrospective review of a prospective parathyroid database of patients undergoing parathyroidectomy for sporadic pHPT from 1999-2013. Extent of parathyroid hormone spike was calculated by the difference in IOPTH level at the time of gland excision and baseline: group 1 had a decrease in IOPTH level, group 2 had IOPTH level increase one to three times above the baseline, and group 3 had IOPTH level increase greater than three times above the baseline. Results Of the 900 patients in the cohort, there were 634 patients (70%) in group 1, 234 (26%) in group 2, and 32 (4%) in group 3. SGD was identified in 88%, 78%, and 100% of patients in groups 1, 2, and 3, respectively. The median gland weight in group 3 (920 mg) was significantly larger than those in groups 1 and 2 (440 and 460 mg, respectively; P < 0.001). Conclusions IOPTH level spikes occur in nearly one-third of patients undergoing parathyroidectomy for sporadic pHPT. Patients with extensive IOPTH level increase are more likely to have larger SGD, whereas patients with moderate IOPTH level increases have increased incidence of multigland disease. In patients with a significant increase in IOPTH levels and larger glands, no further surgical exploration may be indicated. [ABSTRACT FROM AUTHOR]

Inroduction The number of endocrine procedures, specifically parathyroidectomy, thyroidectomy, and adrenalectomy, being performed is increasing. There is a paucity of literature on the feasibility of combining these procedures with other surgical procedures. Therefore, the aim of this study was to determine the effect of performing concurrent surgical procedures on postoperative outcomes. Methods This is a single institution retrospective review of multiple prospectively maintained databases of patients who underwent elective thyroidectomy, parathyroidectomy, and/or adrenalectomy in combination with another procedure. The other procedures included soft tissue, breast or hernia, abdominal major, abdominal minor, cervical, and “other”. Demographics, operative details, length-of-stay, and 30-d outcomes were reviewed. “Endocrine-specific” complications included recurrent laryngeal nerve injury, hypoparathyroidism, cervical wound infection, hematoma, and other. Results The cohort comprised 104 patients. Overall, 19 (18%) patients had 21 complications, including endocrine-specific complications in eleven (11%) patients. These eleven complications included recurrent laryngeal nerve injury ( n = 3; 3%), hematoma ( n = 2; 2%), wound infection ( n = 1; 1%), transient hypoparathyroidism ( n = 2; 2%), and other ( n = 3; 3%). The remaining complications included three (3%) general complications, six (6%) patients with complications related to the concurrent procedure, and one patient who underwent an open adrenalectomy and hysterectomy and developed a midline wound dehiscence, which could not be specifically attributed to either procedure. Conclusions Less than 5% of patients undergoing a surgical endocrine procedure underwent a concurrent procedure, ranging from soft tissue to major abdominal. Short-term endocrine-specific complications were managed safely, suggesting that concurrent procedures can be considered, with minimal effect on patient outcomes. [ABSTRACT FROM AUTHOR]

Background: Low 24-hour urine calcium (uCa) levels in patients with primary hyperparathyroidism (pHPT) raise concern for familial hypocalciuric hypercalcemia. This study evaluated patients with a low 24-hour uCa level for potential differences that may guide the extent of preoperative evaluation needed. Methods: A retrospective review was conducted of 1,139 sporadic pHPT patients who underwent parathyroidectomy between December 1999 and May 2011. Results: Of the 54 (5%) patients with greater than or equal to one low 24-hour uCa (<100 mg), 28 (52%) patients had only one low level, 9 (17%) had multiple low levels, and 17 (31%) had a repeat 24-hour uCa greater than 100. In the latter group, 4 of the 9 (53%) patients were on a thiazide and had normalization after cessation. Among the groups, differences existed only in serum creatinine (P = .0011) and glomerular filtration rate (P = .0007). Conclusion: This study suggests that sporadic pHPT patients with low 24-hour uCa levels may not require further evaluation with genetic testing for familial hypocalciuric hypercalcemia, especially if previous eucalcemia is documented. [ABSTRACT FROM AUTHOR]

Objective: To determine whether surgical volume influences the cause of operative failures after parathyroidectomy for hyperparathyroidism., Summary and Background Data: The surgical success rate for hyperparathyroidism from high-volume centers exceeds 95%, but some patients have unsuccessful parathyroidectomies. Although operative failure can be due to hyperfunctioning parathyroid glands in ectopic locations, less experienced surgeons may be more likely to miss an abnormal parathyroid in normal anatomic locations, which we describe as "preventable operative failure.", Methods: We used 2 prospective databases containing over 2000 consecutive patients who underwent parathyroidectomy. We identified 159 patients with persistent/recurrent hyperparathyroidism subsequently cured with additional surgery. The initially failed operations were classified as being performed at high- (>50 cases/yr) or low-volume (<50 cases/yr) hospitals. Hospital volume was obtained from a Wisconsin state database of 89 hospitals, which reported 6336 parathyroid operations during the same decade., Results: Patients who initially failed their operation performed at the high- or low-volume centers were similar with regard to age, laboratory values, gender, and parathyroid weights. Despite a higher incidence of multigland disease (which increases the likelihood of operative failure) in the high-volume group, patients in the low-volume group were more likely to have a missed parathyroid gland in a normal anatomic location (89% vs. 13%, P < 0.0001), and thus a higher proportion of preventable operative failures., Conclusions: Surgical volume influences the failure pattern after parathyroidectomy for hyperparathyroidism. Preventable operative failures are more common in low-volume centers.

Objective: The aim of this study was to determine whether aggressive management of neuroendocrine hepatic metastases improves survival., Summary Background Data: Survival in patients with carcinoid and pancreatic neuroendocrine tumors is significantly better than adenocarcinomas arising from the same organs. However, survival and quality of life are diminished in patients with neuroendocrine hepatic metastases. In recent years, aggressive treatment of hepatic neuroendocrine tumors has been shown to relieve symptoms. Minimal data are available, however, to document improved survival with this approach., Methods: The records of patients with carcinoid (n = 84) and pancreatic neuroendocrine tumors (n = 69) managed at our institution from January 1990 through July 2004 were reviewed. Eighty-four patients had malignant tumors, and hepatic metastases were present in 60 of these patients. Of these 60 patients, 23 received no aggressive treatment of their liver metastases, 19 were treated with hepatic resection and/or ablation, and 18 were managed with transarterial chemoembolization (TACE) frequently (n = 11) in addition to resection and/or ablation. These groups did not differ with respect to age, gender, tumor type, or extent of liver involvement., Results: Median and 5-year survival were 20 months and 25% for the Nonaggressive group, >96 months and 72% for the Resection/Ablation group, and 50 months and 50% for the TACE group. The survival for the Resection/Ablation and the TACE groups was significantly better (P < 0.05) when compared with the Nonaggressive group. Patients with more than 50% liver involvement had a poor outcome (P < 0.001)., Conclusions: These data suggest that aggressive management of neuroendocrine hepatic metastases does improve survival, that chemoembolization increases the patient population eligible for this strategy, and that patients with more than 50% liver involvement may not benefit from an aggressive approach.

Objective: The objectives of this analysis were to define the incidence, natural history, and predictors of neoplasia in pancreatic cysts to determine which patients can safely be observed and which should undergo an operation., Summary Background Data: With advancements in imaging technology, cystic lesions of the pancreas are being detected with increased frequency. Many of these lesions are small and asymptomatic, but they may be associated with pancreatitis or have malignant potential. Therefore, the management of these patients is complex, and knowledge of pancreatic cyst natural history and predictors of neoplasia are important., Methods: From January 1995 through December 2002, all radiologic, surgical, and pathology records were reviewed for the presence of pancreatic cysts. In determining natural history, only patients with 2 scans more than 1 month apart at our institution were included. Patients with a clinical history and laboratory evidence of pancreatitis and/or pathologic confirmation of a pseudocyst were excluded. Factors analyzed as potential predictors of neoplasia included age, gender, cyst size, and symptoms. Serous cystadenomas, solid and cystic papillary (Hamoudi) tumors, lymphoepithelial cysts and simple cysts were all benign, whereas mucinous cystic neoplasms, intraductal papillary mucinous neoplasm, cystic neuroendocrine tumors, and cystadenocarcinomas were considered to be premalignant or malignant., Results: Among 24,039 CT or MR scans, 290 patients (1.2%) had pancreatic cysts, and 168 of these patients (0.7%) had no documentation of pancreatitis. Seventy-nine of these patients with 103 cysts had more than 1 scan with an average interval of 16 months. These cysts increased in size in 19%, did not change in 59% and decreased in 22% of patients. Forty-nine patients underwent surgery for 14 benign (serous cystadenomas = 10, Hamoudi = 2, lymphoepithelial = 1, simple = 1) 25 premalignant (mucinous cystic neoplasm =16, intraductal papillary mucinous neoplasm = 5, neuroendocrine tumors = 4), or 10 malignant (intraductal papillary mucinous neoplasm = 7, cystadenocarcinomas = 3) lesions. Gender and cyst size did not predict neoplasia. However, presence of symptoms predicted premalignant or malignant pathology (60% vs. 23%, P < 0.05), and age over 70 years was associated with malignancy (60% vs. 21%, P < 0.02)., Conclusions: These data suggest that cystic pancreatic neoplasms 1) occur in 0.7% of patients, 2) increase in 19% over 16 months, and 3) are likely (60%) to be malignant in patients older than 70 years. Therefore, we recommend surgical excision for pancreatic cysts that are increasing under observation, symptomatic, or detected radiologically in fit older patients.