The impact of lymph node ratio on disease recurrence in papillary thyroid microcarcinoma.

INTRODUCTION: Lymph node (LN) metastases in papillary thyroid microcarcinomas (microPTCs) are common. The lymph node ratio (LNR) has been proposed as a risk factor for recurrence in papillary thyroid cancer. However, its relevance in microPTC is undetermined. METHODS: Patients who underwent resection of their microPTC with concomitant LN clearance between 2005 and 2018 were identified. The LNR was calculated as the ratio of positive LNs to the total number of LNs. RESULTS: Data on 50 patients (36 female [72%]; median age 47 years [range: 19-84]) who underwent LN clearance (28 central [56%] vs 22 central + lateral [44%]) were analysed. Positive LNs were found in over two-thirds of the patients (n = 34; 68%). After a median follow-up of 61 months, 14 patients (28%) had developed recurrence. Positive LNs were not found to impact recurrence-free survival; extranodal extension and an LNR ≥ 0.26 were found to significantly increase the risk of recurrence on unadjusted analyses (p < 0.05). CONCLUSIONS: LN metastases are frequent among patients with microPTC. A higher LNR seems to be associated with recurrence. Additional studies are needed to further clarify these findings and to assess the possible role of LNR in treatment and surveillance.

Hashimoto's thyroiditis on outcomes in papillary thyroid cancer revisited: experience from South East Asia.

INTRODUCTION: The association between Hashimoto Thyroiditis (HT) and papillary thyroid cancer (PTC) remains uncertain. HT, the most common inflammatory condition of the thyroid, is postulated to increase the risk of PTC and yet confer cancer-retarding effects. In this study, we aim to evaluate the prevalence of HT in patients surgically treated for PTC and evaluate the long-term prognostic implications. METHODS: This is a retrospective study of 521 patients with PTC who underwent hemi- or total thyroidectomy between January 2000 and December 2018 at a tertiary referral centre. Patients were categorised into two group: group A (n=402) consists of patients with PTC without HT, whereas group B (n=119) consists of patients with PTC and HT. Demographic and clinicopathological details, recurrence rates and overall survival were collected. Univariate and multivariate analyses were performed to evaluate for clinical factors associated with HT. RESULTS: A total of 521 patients with a mean age of 46.7 years were evaluated. HT was detected in 22.8% of patients with PTC. On multivariate analysis, presence of HT was associated with a lower incidence of extrathyroidal extension (hazard ratio: 0.59, 95%confidence interval 0.37-0.95). Also, patients with HT tend to have fewer cycles of radioactive iodine and correspondingly have excellent response to treatment. However, no differences in recurrence rates and overall survival were detected. CONCLUSIONS: One-fifth of patients with PTC have coexisting HT. These patients tend to have less-aggressive tumour features such as extrathyroidal extension. However, the effect of HT on recurrence and overall survival appears to be inconsequential clinically.

Role of 18 F-FDG PET/CT in Erdheim-Chester Disease in the Era of Multimodality Imaging.

Erdheim-Chester disease is a rare disease with systemic non-Langerhans cell histiocytosis, the diagnosis of which with conventional imaging modalities is challenging. We describe a case of a 73-year-old woman who was referred with a progressive history of bilateral proptosis. The magnetic resonance imaging (MRI) orbit demonstrated bilateral orbital masses with optic nerve encasement. A subsequent 18F-FDG PET/CT scan showed multi-organ disease with involvement of the orbits, pericardium, aorta, pararenal fascia, and appendicular bones. Metabolically active, easily accessible areas were selected for CT-guided biopsy. The biopsy showed sheets of foamy histiocytes with the expression of CD 68 and CD 163 consistent with a diagnosis of Erdheim-Chester disease. The FDG PET/CT played a pivotal role in establishing the diagnosis with the assessment of disease extent and further guided in the targeted biopsy.

Parathyroid allotransplantation to treat post-thyroidectomy hypoparathyroidism: A review of case studies.

OBJECTIVE: Symptomatic long-term hypoparathyroidism following thyroid surgery requires an alternative and permanent therapy that would effectively restore parathyroid function and eliminate the need for substitution drug therapy. The aim of this study was to systematically review the literature on the efficacy and safety of parathyroid allotransplantation to treat post-operative hypoparathyroidism. METHODS: MEDLINE, Embase, BIOSIS and the Cochrane Library were searched for published articles (from inception of each database to September 30, 2018). A total of 9 studies comprising 146 patients (177 allotransplantations) with post thyroidectomy hypoparathyroidism were identified. RESULTS: Parathyroid tissues used for allotransplant were cultured parathyroid cells, cryopreserved parathyroid cells and encapsulated microspheres. Post-transplant immunosuppression was only reported in three studies, mainly with oral prednisolone for 2 weeks to 6 months. Mean graft survival following allotransplantation was 47% (95% CI 24%-71%) when patients were followed-up to 6 months and 41% (95% CI 2.3%-80%) at 12 months. There was significant unexplained heterogeneity observed between studies in both these groups (I2 > 50%). Parathyroid hormone (PTH) levels, and serum calcium levels post intervention was not reported in all studies, but available evidence suggests the levels remains higher (PTH level around 12 pg/ml; Ca level around 8 mg/dl) post-allotransplantation for up to 24 months. CONCLUSIONS: Long-term benefit and harms of allotransplantation is still unclear due to the clinical and statistical heterogeneity observed among the studies. Therefore, conduct of a well-designed controlled clinical trial in the immediate future on allotransplantation is of paramount importance.

Preoperative scar perception study comparing 'scarless' in the neck endoscopic thyroidectomy with open thyroidectomy: a cross-sectional study.

INTRODUCTION: Open thyroidectomy is the most common approach to thyroid surgery. However, 'scarless' (in the neck) endoscopic thyroidectomy, consisting of endoscopic and robotic surgery, is progressively being adopted for its perceived cosmetic benefits. This study aims to determine the patient's preferred surgical approach and to identify the factors that influence their decision. MATERIALS AND METHODS: A pilot study consisting of 100 patients with a surgical thyroid disorder were prospectively recruited from a single tertiary centre. An interviewer-administered survey was conducted. Demographic, socioeconomic status, scar perception and an adapted body image scale were evaluated to identify factors that shaped the patient's perception of the surgical approach. RESULTS: The mean age of participants was 54.5 ± 13.0 years; 72% were women and 87% Chinese. Of the 100 patients, 75 patients considered scarless endoscopic thyroidectomy as their preferred surgical approach while 25 patients opted for open thyroid surgery. Improvement in scar perception score between scarless endoscopic thyroidectomy and open thyroid surgery is associated with an increased willingness to choose scarless endoscopic thyroidectomy. The mean body image scale score was 6.9 ± 2.8, indicating no statistical difference between the surgical approaches. On multivariate analysis, improvement in scar perception score (odds ratio 3.38, 95% confidence interval 1.11-10.29) and having surgeon recommendation (odds ratio 6.38, 95% confidence interval 1.80-22.63) were independently associated with interest in scarless endoscopic thyroidectomy. CONCLUSION: Patients interest in undergoing scarless endoscopic thyroidectomy is driven by improved scar perception and surgeon's recommendation compared with open thyroid surgery.

Synchronous symptomatic parathyroid carcinoma and parathyroid adenoma with incidental follicular thyroid carcinoma.

We describe the case of an 89-year old Caucasian woman admitted with confusion and severe clinical manifestations of acute hypercalcaemia. There was no history suggestive of any malignancy and initial management included correction of the hypercalcaemia with intravenous fluid therapy. Sestamibi parathyroid scintigraphy and neck ultrasonography demonstrated a 4cm left-sided thyroid lesion and a nearly 2cm right-sided thyroid lesion. The patient underwent a total thyroidectomy and parathyroidectomy. Histology confirmed a concomitant parathyroid adenoma, parathyroid carcinoma and follicular thyroid carcinoma. To our knowledge, this is the first reported case in the literature.

Flatulence After Anti-reflux Treatment (FAART) Study.

BACKGROUND: Flatulence is known to be a common side effect of laparoscopic fundoplication, yet the true incidence is unclear and its impact on patients' quality of life not well understood. This study aimed to assess the long-term incidence of flatulence, and its effect on quality of life, following fundoplication. METHODS: All patients who underwent primary laparoscopic fundoplication between 1999 and 2009 were identified from a prospectively maintained institutional database. A cross-sectional analysis of post-operative gastrointestinal symptoms and quality of life was performed using a symptom-specific questionnaire. Statistical analysis of outcomes stratified by sex and type of fundoplication was performed. RESULTS: 462 eligible patients were identified from the database, with follow-up obtained in 265 (57%). Median age at surgery was 53 (22-78) years. 137 patients (52%) were female. 138 (52%) underwent a 360° fundoplication, the remainder a partial fundoplication. At median follow-up of 11 (8-15) years, excessive flatulence was reported by 85%. Only 12% reported an adverse impact on social life, and 11% an adverse impact on quality of life. Flatulence was worse following a total than partial fundoplication, women reported more gas-related symptoms than men, yet neither sex nor wrap type had a significant impact on social life or quality of life. CONCLUSIONS: The majority of patients report excessive flatulence at long-term follow-up after anti-reflux surgery, yet the impact on social life and quality life was small. There was no evidence to support tailoring of wrap type by sex to avoid gas-related symptoms. The authors advocate that all patients understand the inevitable side effects of fundoplication to help manage expectations from surgery.

Ipsilateral nonrecurrent laryngeal nerve palsy and delayed palsy of the contralateral recurrent laryngeal nerve in a case of third-time reoperative thyroid surgery.

The occurrence of nonrecurrent laryngeal nerve and delayed nerve palsy of the contralateral nerve occurring simultaneously has never been described. A 67-year-old woman underwent reoperative completion thyroidectomy for enlarging thyroid nodules with recurrent hyperthyroidism and obstructive symptoms. Preoperative computed tomography of the neck showed a large compressive goitre with an aberrant right subclavian artery. At surgery, a type 1 nonrecurrent laryngeal nerve was found and inadvertently transected due to dense adhesions. It was repaired with ansa cervicalis graft. A fully preserved and functional recurrent laryngeal nerve was seen on the contralateral side at the end of surgery. However, the patient developed a delayed palsy on day 4 of the recurrent laryngeal nerve requiring a tracheostomy. Following successful speech and swallowing therapy, the patient was decannulated with good phonation and recovery of the left cord. Patients are at risk of bilateral nerve injury and late onset palsy in reoperative thyroid surgery. Management can be challenging and should be recognised to ensure appropriate therapy.

Binding of aberrant glycoproteins recognizable by Helix pomatia agglutinin in adrenal cancers.

BACKGROUND: Aberrant glycosylation is a hallmark of cancer cells and plays an important role in oncogenesis and cancer progression including metastasis. This study aimed to assess alteration in cellular glycosylation, detected by lectin Helix pomatia agglutinin (HPA) binding, in adrenal cancers and to determine whether such altered glycosylation has prognostic significance. METHODS: HPA binding lectin histochemistry was performed on archival paraffin wax-embedded specimens of adrenocortical cancers excised from patients attending two tertiary referral centres. Benign tumours were used as controls. Demographic, histological and survival data were collected and compared between patients with HPA-positive and HPA-negative tumours. RESULTS: Thirty-two patients were treated for adrenal cancer between 2000 and 2016; their median age was 49 (range 23-79) years. Fifteen patients had functioning tumours (14 adrenal Cushing's tumours and 1 Conn's tumour). Mean(s.d.) tumour size was 127·71(49·70) mm. None of 10 control tumours expressed HPA-binding glycoproteins. Invasion was associated with HPA-binding glycoproteins (P = 0·018). Local recurrence or metastatic disease did not significantly differ between HPA-positive and HPA-negative adrenocortical cancers. Overall survival was significantly longer in patients with HPA-negative tumours (median survival not reached versus 22 months in patients with HPA-positive tumours; P = 0·002). CONCLUSION: Altered cellular glycosylation detected by lectin HPA is associated with poor survival in patients with adrenocortical cancer.

Rising incidence of thyroid cancer in Singapore not solely due to micropapillary subtype.

Introduction The annual incidence of thyroid cancer is known to vary with geographic area, age and gender. The increasing incidence of thyroid cancer has been attributed to increase in detection of micropapillary subtype, among other factors. The aim of the study was to investigate time trends in the incidence of thyroid cancer in Singapore, an iodine-sufficient area. Materials and methods Data retrieved from the Singapore National Cancer Registry on all thyroid cancers that were diagnosed from 1974 to 2013 were reviewed. We studied the time trends of thyroid cancer based on gender, race, pathology and treatment modalities where available. Results The age-standardised incidence rate of thyroid cancer increased to 5.6/100,000 in 2013 from 2.5/100,000 in 1974. Thyroid cancer appeared to be more common in women, with a higher incidence in Chinese and Malays compared with Indians. Papillary carcinoma is the most common subtype. The percentage of papillary microcarcinoma has remained relatively stable at around 38% of all papillary cancers between 2007 and 2013. Although the incidence of thyroid cancer has increased since 1974, the mortality rate has remained stable. Conclusion This trend of increase in incidence of thyroid cancer in Singapore compares with other published series; however, the rise seen was not solely due to micropapillary type. Thyroid cancer was also more common in Chinese and Malays compared with Indians for reasons that needs to be studied further.

Comparison of prognostic scoring systems in follicular thyroid cancer.

INTRODUCTION Many studies have addressed the accuracy of prognostic scoring systems in the treatment of differentiated thyroid cancers as a whole but few have addressed this issue in patients with follicular thyroid cancer (FTC) alone. The aim of this study was to establish the accuracy of the various scoring systems in determining the overall and disease free survival of FTC patients in Singapore. METHODS Retrospective review was undertaken of 82 patients with FTC treated at a single tertiary institution between January 2000 and December 2014. Demographic, clinical, pathological and treatment outcomes were analysed. Prognostic scoring systems evaluated for the cohort included TNM (Tumour, Nodes, Metastases), AGES (Age, Grade, Extent, Size), MACIS (Metastases, Age, Completeness of resection, Invasion, Size), AMES (Age, Metastases, Extent, Sex) and EORTC (European Organisation for Research and Treatment of Cancer). Statistical analysis was performed by plotting Kaplan-Meier survival curves and using the Cox proportional hazards model. RESULTS There were 29 male and 53 female patients with a mean age of 48 years. The mean follow-up duration was 88 months and there were 7 deaths (9%). The ten-year overall survival rate was 90%. Factors predictive of survival on univariate analysis were age, size of tumour, invasiveness, completeness of resection, metastasis, external beam radiotherapy, and risk scores using the AGES and MACIS scoring systems (p<0.05). On multivariate analysis, AGES and MACIS provided the best prognostic information. CONCLUSIONS MACIS is the best prognostic scoring system currently available for FTC and it is superior to other scoring systems in term of guiding management. The scoring systems require further development to accommodate variations in clinical practice globally and to improve the prognostic accuracy.

Prevalence of ECG changes during adenosine stress and its association with perfusion defect on myocardial perfusion scintigraphy.

OBJECTIVE: Myocardial perfusion scintigraphy (MPS) is a valuable, noninvasive imaging modality in the evaluation of patients with coronary artery disease. Adenosine stress may occasionally be associated with ECG changes. This study evaluated the strength of association between adenosine stress-related ECG changes and perfusion defects on Tc-MPS. PATIENTS AND METHODS: 117 (mean age: 61.25±9.27 years; sex: men 87, women 30) patients with known/suspected coronary artery disease underwent adenosine stress MPS. ECG was monitored continuously during adenosine stress for ST-depression. On the basis of the summed difference score, reversible perfusion defects were categorized as follows: normal: less than 4, mild: 4-8, moderate: 9-13, and severe: more than 13. RESULTS: ST-depression was observed in 27/117 (23.1%) and reversible perfusion defects were observed in 18/27 (66.66%) patients. 2/27, 6/27, and 10/27 patients had mild, moderate, and severe ischemia, respectively. 9/27 patients had normal perfusion. ECG changes and perfusion defects showed a moderate strength of association (correlation coefficient r=0.35, P=0.006). The sensitivity, specificity, positive predictive value, and negative predictive value of ECG findings for prediction of ischemia were 35.29, 86.36, 67.67, and 63.33%, respectively. CONCLUSION: ECG changes during adenosine stress are not uncommon. It shows a moderate strength of association with reversible perfusion defects. ECG changes during adenosine merit critical evaluation of MPS findings.

Patterns of metastasis in follicular thyroid carcinoma and the difference between early and delayed presentation.

Introduction Follicular thyroid cancer (FTC) has a good prognosis if treated early. The aim of this study was to look at the difference in outcomes in those who presented with metastasis early or late in their disease. Methods A retrospective cohort study was conducted of patients diagnosed with FTC (n=91) treated between 2000 and 2013. Demographic, laboratory, pathological and survival data were collected and analysed. Results Metastatic FTC was diagnosed in 20 cases (22%). The median age at diagnosis was 65 years (range: 17-86 years) and 65% of the patients were female. Twelve patients (60%) were diagnosed with metastatic disease at presentation, with the bones being the most common site (75%). In the remaining eight cases (40%), metastasis developed at a median of 4.5 years (range: 2-8 years) after initial thyroid surgery, lungs being the most common site (50%). Eighteen patients (90%) underwent surgical intervention for the primary disease. Sixteen patients (80%) received adjuvant radioactive iodine and eight (40%) received external beam radiotherapy. Widely invasive follicular cancer was the predominant histological diagnosis (90%). No prognostic association was observed with any of the parameters studied. The overall disease specific mortality rate was 40%. There was no significant difference in mortality between those who presented with metastatic disease and those who developed metastasis during the follow-up period (33% vs 50%, p=0.61). Conclusions The clinical outcome and prognosis for cases with metastatic disease is generally poor. Despite this, almost half of the patients in our study were still alive at a median follow-up of 5.5 years, regardless of whether they were diagnosed with metastatic disease on initial presentation or whether they developed metastasis after initial thyroid surgery.

Autoimmune hemolysis and immune thrombocytopenic purpura after cord blood transplantation may be life-threatening and warrants early therapy with rituximab.

Autoimmune hemolysis (AH) and immune thrombocytopenic purpura (ITP) are recognized complications after cord blood transplantation (CBT). We evaluated the incidence and characteristics of AH/ITP after double-unit CBT in a day 100 landmark analysis of 152 patients (median age 36 years, range 0.9-70 years) transplanted for hematologic malignancies with myeloablative or nonmyeloablative conditioning and calcineurin inhibitor (CNI)/mycophenolate mofetil. With a median 5.2-year (range 1.6-9.7 years) survivor follow-up, 10 patients developed autoimmune cytopenias (8 AH, 1 ITP, 1 both) at a median of 10.4 months (range 5.8-24.5) post CBT for a 7% cumulative incidence 3 years after the day 100 landmark. Six patients presented with severe disease (hemoglobin ⩽6 g/dL and/or platelets <20 × 109/L). All AH patients were direct antiglobulin test positive. All 10 cases developed during immunosuppression taper with 8 having prior acute GVHD. All 10 patients received rituximab 2-18 days after diagnosis, and corticosteroids combined with rituximab within <7 days was the most effective. No patient died of AH/ITP. AH/ITP occurs infrequently after CBT but may be life-threatening requiring emergency therapy. Rituximab combined with corticosteroids at diagnosis is warranted in patients with severe disease.

Mediastinal parathyroid adenomas and their surgical implications.

Primary hyperparathyroidism is a relatively common problem encountered by any endocrine surgical unit. Ectopic parathyroid adenomas have been known to be a common cause of persistent hyperparathyroidism after surgery. A common site of the missed ectopic gland will be that in the mediastinum. However, with the increasing improvement in available imaging, it is likely that this can be diagnosed preoperatively. The surgical approach to the mediastinal parathyroid has also changed vastly over the last decade from maximally invasive to minimally invasive with minimal complications. We provide a review on the entity of mediastinal parathyroid adenomas and their surgical implications.

Intraoperative Frozen Section Evaluation of Sentinel Lymph Nodes in Breast Carcinoma: Single-Institution Indian Experience.

Sentinel lymph node biopsy is an established way of predicting axillary nodal metastasis in early breast cancer. Intraoperative frozen sections (FS) of sentinel lymph nodes (SLNs) can be used to detect metastatic disease, allowing immediate axillary lymph node dissection. The purpose of this study was to evaluate the accuracy of intraoperative frozen sections in evaluation of sentinel lymph nodes in cases of breast cancer. Between March 2006 and August 2010, a total of 164 patients with clinically node-negative operable breast cancer were subjected to sentinel lymph node biopsy of axillary lymph nodes using preoperative peritumoral injection of radioactive colloid and methylene blue. Intraoperative identification of sentinel nodes was done using a handheld gamma probe and identification of blue-stained nodes. The nodes were sent for frozen section examination. The results of frozen section were compared with the final histopathology. Out of the 164 cases, metastases were detected in SLN by frozen section in 38 cases. There were three false-negative cases (all showing micrometastasis on final histopathology). FS had sensitivity of 92.6 %, specificity of 100 %, and overall accuracy of 98.1 %. The positive predictive value was 100 %, and the negative predictive value was 97.6 %. FS for diagnosis of metastasis of SLNs is reliable. Patients with negative SLNs by the FS diagnosis can avoid reoperation for axillary lymph node dissection. However, FS may fail to detect micrometastases, especially in cases with small tumors.

Romiplostim for management of chemotherapy-induced thrombocytopenia.

PURPOSE: Chemotherapy-induced thrombocytopenia (CIT) can cause delay or reduction in subsequent courses of chemotherapy. Here, we report on a series of 20 patients who had protracted CIT and were treated with romiplostim, a thrombopoietin receptor agonist. PATIENTS AND METHODS: We performed a retrospective review of the use of romiplostim for dose-limiting CIT at Memorial Sloan-Kettering Cancer Center from 2010-2012. Romiplostim was initiated at 1-2 mcg/kg weekly, with dose escalation by 1 mcg/kg per week until recovery of platelets (≥ 100 × 10(9)/L). If patients resumed chemotherapy, weekly romiplostim was continued. RESULTS: Romiplostim improved platelet counts in all 20 patients. In 19 of 20 patients, platelet counts of ≥ 100 × 10(9)/L were achieved. The mean dose of romiplostim to achieve adequate platelet recovery was 2.9 mcg/kg (range 1.0-5.1). Sixteen patients achieved platelet recovery by 2 weeks. Fifteen patients resumed cytotoxic chemotherapy with continued romiplostim support and 14 tolerated at least two subsequent cycles of chemotherapy, on schedule, without recurrence of dose-limiting CIT. Sepsis prevented continued chemotherapy in one patient. No resistance to romiplostim was observed. Three deep vein thromboses (DVT) were observed; one of which was a recurrent DVT in a patient who had previously experienced a DVT and was off anticoagulation. Three DVTs within 20 patients is within the anticipated thrombosis rates of patients with active cancer on chemotherapy. CONCLUSION: Romiplostim resulted in improvement in platelet counts, allowing resumption of chemotherapy without recurrence of dose-limiting CIT. No treatment-related toxicity was observed, but this would need to be confirmed in a larger, prospective trial. Our series differs from prior studies in that we selected only those patients who had already demonstrated persistent thrombocytopenia, and we continued weekly romiplostim during chemotherapy. Romiplostim may be a safe and effective treatment for CIT.

Primary hyperparathyroidism with water clear cell content: the impact of histological diagnosis on clinical management and outcome.

Water clear cell hyperplasia (WCCH) and water clear cell adenomas (WCCA) of the parathyroid glands are rare causes of primary hyperparathyroidism. We report in this series one case of WCCH and two cases of WCCA representing 0.3% of patients with primary hyperparathyroidism presenting to our institution. Increased parathyroid cellular water content was responsible for relatively larger parathyroid gland sizes. However, this was not associated with higher biochemical markers or more severe clinical presentations. Histological distinction between WCCH and WCCA is difficult but important since patients with WCCH who have had a parathyroidectomy via a unilateral neck exploration may carry an increased risk of future disease recurrence.

Medical talc increases the incidence of seroma formation following onlay repair of major abdominal wall hernias.

PURPOSE: Seroma is a well established complication of the repair of major abdominal wall hernias, occasionally requiring aspiration and reoperation. Medical talc seromadesis (MTS) has been described in the literature. The aim of this study was to determine the effect of MTS on seroma formation after onlay repair of incisional hernia. METHODS: A retrospective review of a prospective database was conducted for 5 months from April 2011, when 21 consecutive patients received MTS. Outcomes were compared with a published and validated series from the same unit. RESULTS: There were no differences in basic demographics and co-morbidities between the two groups. The mean BMI was 34 for the MTS group. The incidence of recurrent incisional hernia prior to surgery was greater in MTS (9/21 vs. 36/116, p = 0.39). The mean area of fascial defect measured intra-operatively and mesh used to cover the incisional hernia defect was 170 and 309 cm(2) for the MTS group. The mean operating time was 152 min and a mean of 10 g of medical talc was used for seromadesis. The seroma rate increased from 11/116 (9.5 %) to 16/21 (76 %) (p = 0.001) as did the rate of superficial wound infection 10/116 (8.6 %) to 9/21 (43 %) (p = 0.03) in the MTS group. There was no difference in the length of in-hospital stay between the two groups. CONCLUSIONS: The application of medical talc increased the rate of seroma formation and superficial wound infection in patients undergoing open 'onlay' repair of major abdominal wall hernia.

Assessment and comparison of recovery after open and minimally invasive esophagectomy for cancer: an exploratory study in two centers.

BACKGROUND: Minimally invasive esophagectomy (MIE) may lead to early restoration of health-related quality of life, but few prospective comparative studies have been performed. This exploratory study compared recovery between totally minimally invasive esophagectomy (MIE), laparoscopically assisted esophagectomy (LAE) and open surgery (OE). METHODS: A prospective study in 2 specialist centers recruited consecutive patients undergoing OE, LAE, or MIE for high-grade dysplasia or cancer. Patients completed validated questionnaires, the Multi-Dimensional Fatigue Inventory (MFI-20), modified Katz Scale, and modified Lawton and Brody Scale (assessing activities of daily living) before and 6 weeks and 3 and 6 months after surgery. RESULTS: A total of 97 patients (26 women; median age 64 years) were scheduled for surgery that was abandoned in 11 due to occult low-volume metastatic disease. In the remaining 86 (OE = 19, LAE = 31, and MIE = 36), there were 4 in-hospital deaths (4 %), and 54 postoperative complications (OE = 12, LAE = 19, and MIE = 23). Overall questionnaire compliance was high (77 %) and baseline scores similar in all groups, although clinical differences between groups were observed with earlier tumors and more squamous cell cancers selected for MIE. Following surgery fatigue levels increased dramatically and activity levels reduced in all groups. These gradually recovered to baseline following MIE and LAE within 6 months, but the ability to perform activities of daily living and most parameters of fatigue had not returned to baseline levels in the OE group. CONCLUSIONS: This exploratory prospective nonrandomized study of recovery after different types of surgery for esophageal cancer showed possible small benefits to MIE. A much larger study is needed to confirm these findings.