A Long, Unnerving Road: Malpractice Claims Involving the Surgical Management of Thyroid and Parathyroid Disease.

BACKGROUND: Given their profound emotional, physical, and financial toll on patients and surgeons, we studied the characteristics, costs, and contributing factors of thyroid and parathyroid surgical malpractice claims. METHODS: Using the Controlled Risk Insurance Company Strategies' Comparative Benchmarking System database, representing ~30% of all US paid and unpaid malpractice claims, 5384 claims filed against general surgeons and otolaryngologists from 1995-2015 were reviewed to isolate claims involving the surgical management of thyroid and parathyroid disease. These claims were studied, and multivariable regression analysis was performed to identify factors associated with plaintiff payout. RESULTS: One hundred twenty-eight thyroid and parathyroid surgical malpractice claims were isolated. The median time from alleged harm event to closure of a malpractice case was 39 months. The most common associated complications were bilateral recurrent laryngeal nerve (RLN) injury (n = 23) and hematoma (n = 18). Complications led to death in 18 cases. Patient payout occurred in 33% of claims (n = 42), and the median cost per claim was $277,913 (IQR $87,343-$783,663). On multivariable analysis, bilateral RLN injury was predictive of patient payout (OR 3.58, p = 0.03), while procedure, death, and surgeon specialty were not. CONCLUSION: Though rare, malpractice claims related to thyroid and parathyroid surgery are costly, time-consuming, and reveal opportunities for early surgeon-patient resolution after poor outcomes.

Putting residents in the office: an effective method to teach the systems-based practice competency.

OBJECTIVES: Systems-based practice (SBP) was 1 of 6 core competencies established by the Accreditation Council for Graduate Medical Education and has proven to be one of the most difficult to effectively implement. This pilot study presents an immersion workshop as an effective tool to teach the SBP competency in a way that could easily be integrated into a residency curriculum. DESIGN: In 2006, 16 surgical residents rotated through 3 stations for 30 minutes each: coding and billing, scheduling operations and return appointments, and patient check-in. Participants were administered a pretest and posttest questionnaire evaluating their knowledge of SBP, and were asked to evaluate the workshop. SETTING: Outpatient clinic at MedStar Georgetown University Hospital, Washington, DC. PARTICIPANTS: Residents in the general surgery residency training program at MedStar Georgetown University Hospital. RESULTS: Most residents (62.5%) improved their score after the workshop, whereas 31.25% showed no change and 6.25% demonstrated a decrease in score. Overall within their training levels, all groups demonstrated an increase in mean test score. Postgraduate year-2 residents demonstrated the greatest change in mean score (20%), whereas postgraduate year-4 residents demonstrated the smallest change in mean score (3.3%). CONCLUSIONS: An immersion workshop where general surgery residents gained direct exposure to SBP concepts in situ was an effective and practical method of integrating this core competency into the residency curriculum. Such a workshop could complement more formal didactic teaching and be easily incorporated into the curriculum. For example, this workshop could be integrated into the ambulatory care requirement that each resident must fulfill as part of their clinical training.

DNA methylation in thyroid tumorigenesis.

Thyroid cancer is the most common endocrine cancer with 1,690 deaths each year. There are four main types of which the papillary and follicular types together account for >90% followed by medullary cancers with 3% to 5% and anaplastic carcinomas making up <3%. Epigenetic events of DNA hypermethylation are emerging as promising molecular targets for cancer detection. Our immediate and long term goal is to identify DNA methylation markers for early detection of thyroid cancer. This pilot study comprised of 21 patients to include 11 papillary thyroid cancers (PTC), 2 follicular thyroid cancers (FTC), 5 normal thyroid cases, and 3 hyperthyroid cases. Aberrant promoter methylation was examined in 24 tumor suppressor genes using the methylation specific multiplex ligation-dependent probe amplification (MS-MLPA) assay and in the NIS gene using methylation-specific PCR (MSP). The frequently methylated genes were CASP8 (17/21), RASSF1 (16/21) and NIS (9/21). In the normal samples, CASP8, RASSF1 and NIS were methylated in 5/5, 4/5 and 1/5 respectively. In the hyperthyroid samples, CASP8, RASSF1 and NIS were methylated in 3/3, 2/3 and 1/3 respectively. In the thyroid cancers, CASP8, RASSF1, and NIS were methylated in 9/13, 10/13, and 7/13 respectively. CASP8, RASSF1 and NIS were also methylated in concurrently present normal thyroid tissue in 3/11, 4/11 and 3/11 matched thyroid cancer cases (matched for presence of both normal thyroid tissue and thyroid cancer), respectively. Our data suggests that aberrant methylation of CASP8, RASSF1, and NIS maybe an early change in thyroid tumorigenesis regardless of cell type.

Synchronous bilateral adrenalectomy for adrenocorticotropic-dependent Cushing's syndrome.

Select patients with ACTH-dependent Cushing's syndrome, such as patients with persistent Cushing's disease after failed hypophysectomy or patients with ectopic ACTH production, may require bilateral adrenalectomy. Laparoscopic bilateral adrenalectomy has been described, offering definitive treatment with reduced morbidity compared with open techniques. We report on the performance of synchronous bilateral adrenalectomy treated using the da Vinci robot (Intuitive Surgical, Sunnyvale, CA). To our knowledge, the usage of this minimally invasive approach for this operation has yet to be reported in literature. The details of the case and a brief review of the literature are described herein.

A four-step technique of robotic right adrenalectomy: initial experience.

OBJECTIVE: To report a safe, quick and reproducible technique of robotically assisted right adrenalectomy (RRA), developed by assessing the surgical anatomy of the right adrenal gland, its vascularity, and the surrounding structures, through a high definition, magnified three-dimensional view of the operating field provided by the da Vinci surgical system (Intuitive Surgical, Sunnyville CA, USA). PATIENTS AND METHODS: Four patients had RRA between January and July 2007 at the Vattikuti Urology Institute, for varied indications. We extensively reviewed published anatomical and surgical reports of the anatomy of the region to plan the surgical steps for RRA, careful reconfirming recognized anatomical facts and their probable significance. The surgical steps involved: (i) complete division of the hepatocolic ligament; (ii) definition of the right adreno-caval junction (ACJ); (iii) division of the right adrenal vein; (iv) dissection and removal of the adrenal gland circumferentially. The surgery was digitally recorded and reviewed. RESULTS: All the adrenalectomies were done transperitoneally through five ports, replicating predetermined surgical steps. There were no anaesthesia or surgery related events and no patient required conversion to open surgery. All the patients had an uneventful recovery and were discharged home 0-3 days after RRA. With increasing experience it was possible to reach the ACJ with minimal peripheral dissection. From a lateral approach, we visualized the adrenal vein travelling along the anterior portion of the gland before terminating at the inferior vena cava and the retrocaval location of the medial edge of the adrenal gland. The right adrenal vein (singular or duplicate) was the only surgically significant vessel, as the other vessels encountered were controlled with bipolar diathermy. CONCLUSIONS: Robotic assistance facilitated microdissection of fine anatomical planes around the right adrenal gland and provided direct access to the crucial ACJ. This technique permits ligation of the adrenal vein as an initial step, with no need to handle the adrenal gland. In the initial experience with four patients this technique was reproducible, regardless of indication or anatomical variance.

Replication-competent adenovirus-mediated suicide gene therapy with radiation in a preclinical model of pancreatic cancer.

In preparation for a Phase I trial, we evaluated the efficacy and toxicity of replication-competent adenovirus-mediated suicide gene therapy in combination with radiation in a preclinical model of pancreatic cancer. Human MiaPaCa-2 and PANC-1 pancreatic adenocarcinoma cells were found to be sensitive to the oncolytic effects of the Ad5-yCD/mutTK(SR39)rep-ADP adenovirus and also to the cytotoxic effects of the yeast cytosine deaminase (yCD) and herpes simplex virus thymidine kinase (HSV-1 TK(SR39)) genes in vitro. Combining Ad5-yCD/mutTK(SR39)rep-ADP-mediated suicide gene therapy with radiation significantly increased tumor control beyond that of either modality alone. Injection of Ad5-yCD/mutTK(SR39)rep-ADP in the dog pancreas at doses (10(12) virus particle (vp)) to be used in humans resulted in mild pancreatitis but not peritonitis or hepatotoxicity. Following administration of 9-(4-[(18)F]-fluoro-3-hydroxymethylbutyl)guanine ([(18)F]-FHBG), a positron-emitting substrate of HSV-1 TK, Ad5-yCD/mutTK(SR39)rep-ADP activity could be monitored non-invasively by positron emission tomography (PET). [(18)F]-FHBG uptake was readily detected in the pancreas but not in other major abdominal organs, indicating that little of the injected adenovirus disseminates to collateral tissues. These results demonstrate that Ad5-yCD/mutTK(SR39)rep-ADP-mediated suicide gene therapy has the potential to augment the effectiveness of pancreatic radiotherapy without resulting in excessive toxicity. Hence they provide the scientific basis for an ongoing Phase I trial in pancreatic cancer.

Survivin expression is up-regulated in vascular injury and identifies a distinct cellular phenotype.

OBJECTIVES: The healing response to vascular injury is characterized by neointimal thickening. Proliferation and phenotypic transformation of vascular smooth muscle cells (SMCs) have been implicated in this process. We sought to investigate the role of survivin, a dual regulator of cell proliferation and apoptosis, in lesion formation after diverse forms of vascular injury. METHODS: Rabbits underwent either carotid interposition vein grafting (n = 17) or bilateral femoral balloon injury (BI; n = 29); some in the BI group were placed on a high-cholesterol diet. A subset of BI arteries were treated with local adenoviral gene delivery of a survivin dominant negative-mutant (AdT34A) versus vector or saline controls. Survivin expression in vessels was analyzed by quantitative reverse transcriptase polymerase chain reaction (RT-PCR) and by immunohistochemistry (IHC), which also included markers of SMC differentiation. Specimens of human tissue including failed lower extremity bypass grafts and carotid plaque were also examined. RESULTS: RT-PCR and IHC demonstrated increased survivin expression in all experimental models, colocalizing at early times with proliferating and alpha-actin-expressing cells but was largely absent in mature, contractile SMCs. Delivery of AdT34A after BI attenuated neointimal hyperplasia. CONCLUSION: These studies provide strong evidence supporting a role for survivin in the cellular response to vascular injury. CLINICAL RELEVANCE: The regulation of cell proliferation, death, and phenotype after vascular interventions remains incompletely understood. We investigated the role of the inhibitor of apoptosis protein survivin in diverse models of vascular injury. The results suggest that survivin is an important modulator of the generalized vascular injury response and may represent a relevant target for therapies targeting intimal hyperplasia.