Changes in Tracheal Tube Cuff Pressure and Recurrent Laryngeal Nerve Conductivity During Thyroid Surgery
Author list - James W. Taylor, Kathleen Soeyland, Christine Ball, James C. Lee, Jonathan Serpell
The aetiology of recurrent laryngeal nerve (RLN) neurapraxia is unclear in most RLN palsies post-thyroidectomy. We hypothesised that high intralaryngeal pressures impede RLN conductivity, in turn contributing to RLN palsy. Therefore, we measured tracheal tube (TT) cuff pressure (as a surrogate for intralaryngeal pressure) and RLN conduction during ten standard manoeuvres in thyroidectomy, to assess for correlation between cuff pressure and RLN conductivity.
A prospective cohort study of thyroidectomy during 2018. For each thyroid lobe, TT cuff pressure was continuously measured via an air pressure transducer. RLN conduction (amplitude and latency) was measured using continuous neuromonitoring. Changes in mean TT cuff pressure and median nerve conduction from baseline measurements were analysed using Student’s t test and Wilcoxon signed-rank test.
In a total of 50 RLNs, the mean baseline TT cuff pressure of 19.5 ± 8.9 mmHg increased significantly to 22.0 mmHg during anteromedial rotation of the thyroid (p < 0.05). RLN conduction changed during manipulation of the superior thyroid pole with shortening of latency (−0.49% from baseline, p = 0.05) and reduction in amplitude (−12.0% from baseline, p = 0.02). The timing of these deviations did not correlate with the increased TT cuff pressure. In three cases of temporary RLN palsy, the mean cumulative case TT cuff pressure was significantly higher (24.8 mmHg, p = 0.02).
This study demonstrates that TT cuff pressure and RLN conductivity can change significantly with manipulation of the thyroid and that high TT cuff pressures may be associated with RLN injuries.
URL - https://rdcu.be/bZ7aM
Invited Commentary: Biochemical Profile Affects IoPTH Kinetics and Cure Rate in Primary Hyperparathyroidism
Author list - F. Fausto Palazzo
URL - https://rdcu.be/bZ7bj
Comparative Performance of the 7th and 8th Editions of the American Joint Committee on Cancer Staging Manual for Adrenocortical Carcinoma
Author list - Sarah B. Fisher, Mouhammed A. Habra, Yi-Ju Chiang, Si-Yuan Wu, Paul H. Graham, Elizabeth G. Grubbs, Jeffrey E. Lee, Nancy D. Perrier
The American Joint Committee on Cancer 8th edition staging manual for adrenocortical carcinoma (ACC) redefines T stage to include large vessel invasion (T4, previously undescribed) and restricts stage IV to those with distant metastases. We evaluated the prognostic power of the 8th edition.
Patients with ACC treated between January 1, 2000, and December 31, 2015, were identified. Overall survival (OS) was compared using Kaplan–Meier and Cox proportional hazard models.
Of 290 patients evaluated, the change in T stage nomenclature impacted 13 (4.5%) who were previously categorized as T3; 61 had large vessel involvement but were already T4 based on invasion of adjacent organs. The restriction of stage IV to patients with distant metastases downstaged 41 (14.1%; T4N0M0 or T3–4N1M0) to stage III. In the 7th edition, the hazard ratio (HR) for death was similar between patients with stage II and III disease, with 5-year OS 66.7%, 54.4%, 57.2%, and 14.0% (stages I, II, III, and IV, respectively). In the 8th edition, stages I and II remain unchanged, with 5-year OS for stage III and IV 44.1% and 9.2%, respectively. The c-index for the 7th and 8th editions was similar (83.4 and 82.7, respectively).
While 8th edition changes impact a relatively small proportion of ACC patients, they represent progress toward a common staging system that accurately reflects prognosis. In the 8th edition, the inclusion of patients with T4 tumors or nodal disease as stage III rather than IV results in improved stratification between stages II and III.
URL - https://rdcu.be/bZ7bP
Prognostic Assessment of Non-functioning Neuroendocrine Pancreatic Neoplasms as a Basis for Risk-Adapted Resection Strategies
Author list -F. M. Watzka, F. Meyer, J. I. Staubitz, C. Fottner, A. Schad, H. Lang & T. J. Musholt
In contrast to exocrine pancreatic carcinomas, prognosis and treatment of pancreatic neuroendocrine neoplasms (PNEN) are significantly different. The variable growth pattern and associated clinical situation of functioning and non-functioning PNEN demand an individualized surgical approach. However, due to the scarce evidence associated with the rare disease, guidelines lack detailed recommendations for indication and for the required extent of surgical resection.
In a retrospective single-center study from 1990 to 2018, 239 patients with PNEN were identified. Clinical data were collected in the MaDoc database of the University Medical Center Mainz. A total of 155 non-functional PNEN were selected for further analysis.
According to the classification of NET by the WHO in 2017, 28.8% (n = 40) of the tumors were G1, 61.9% (n = 86) G2, and 9.4% (n = 13) G3. In 73 patients, hepatic metastases were present. Sixty patients had lymph node metastasis. An R0 resection was achieved in 98 cases, an R1 situation in 10 cases. Five times, a tumor debulking was carried out (R2) and 5 times the operation was aborted without any resection because of the advanced tumor stage. A relapse occurred in 29 patients. Different prognostic factors (grade, tumor size, age) were analyzed. Grade-dependent 10-year overall survival rates were 79.5% (grade 1) and 60.1% (grade 2), respectively. The survival rate of grade 3 patients was limited to 66.7% after 13 months.
In our study, patients with non-functioning PNEN had a longer overall survival after successful R0 resection. The risk analysis confirmed a Ki-67 cutoff value of 5%, which divided a high- and low-risk group. Patients with a PNEC G3 (Ki-67 index > 50%) had a very poor prognosis.
URL - https://rdcu.be/bZ7b9
Smartphone-Based Application for Tele-follow-up of Patients with Endocrine Disorders in Context of a LMIC
Author list - Sanjay Kumar Yadav, Chandan Kumar Jha, Saroj Kanta Mishra & Anjali Mishra
Remote video consultations are increasingly used in clinical practice, and a lot of data are emerging on its feasibility and acceptability. This study aims to bring out qualitative and quantitative data which will enhance our understanding of strengths and limitations of this media in the setting of a low- and middle-income country (LMIC).
Materials and methods
This was a prospective study conducted from January 2017 to May 2018, at the Department of Endocrine Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, India. A total of 107 patients were selected who chose remote follow-up care through social media (WhatsApp). Data were analyzed on feasibility, clinical safety, satisfaction and economic burden.
A total of 107 postoperative patients were followed up using a social media tool. A total of 396 tele-sessions were held. The average number of tele-consultations per patient was 3.7 (range 2–6). Reasons for tele-follow-up included: confirmation of histology report (n = 92), medication dosage adjustments (n = 148), wound evaluation (n = 102), reporting of serum TSH and serum calcium levels (n = 296) and medical fitness certificate (n = 13). Wound evaluation through tele-follow-up was on par with the outpatient department (OPD) follow-up as no patient had to report to OPD for wound infection. Satisfaction level was excellent in 55% of patients and very good in 25%. 20% of the patients reported an average satisfaction level. If all of these 107 patients would have come to our OPD follow-up, they would have traveled 613.2 miles (908 km) per patient on an average, apart from losing work hours. Average cost and workdays saved per visit were $78 and 5.4 days, respectively.
Video consultation using social media tools is clinically safe and cost effective. Economic benefits far outweigh the risk of missing an adverse event, especially in the setting of low- and middle-income countries.
URL - https://rdcu.be/bZ7cs
Endocrine Surgery Without the Bells and Whistles: Editorial of the International Association of Endocrine Surgeons Symposium
Author list - Janice L. Pasieka
URL - https://rdcu.be/bZ7de
Proceedings and Insights of the 2019 International Association of Endocrine Surgeons Symposium on Surgeon Well-Being
Author list - Kristina J. Nicholson, James A. Lee, Catharina I. Lundgren, Sally P. Meade, Frédéric Triponez & Sally E. Carty
URL - https://rdcu.be/bZ7cU