The long-term outcomes of thyroid function after subtotal thyroidectomy for Graves' hyperthyroidism.

BACKGROUND: Surgical management of Graves' disease (GD) is changing from subtotal to total thyroidectomy because the latter eliminates the risk of recurrence. However, to preserve thyroid function in a euthyroid state, subtotal thyroidectomy is still performed for GD in non-Western countries. Therefore, we designed a study to investigate the long-term outcomes in GD patients after subtotal thyroidectomy and the correlation between remnant weight and postoperative thyroid function. MATERIALS AND METHODS: This was a retrospective cohort observation study. Between January 2005 and December 2011, 415 consecutive GD patients treated by subtotal thyroidectomy were enrolled. All data were collected from 385 patients who underwent bilateral subtotal thyroidectomy and 57 patients who underwent the Hartley-Dunhill operation. The median postoperative follow-up time was 72 months (range 12-144 months). RESULTS: The mean weight of the preserved thyroid remnant was 5.1 g. Persistent or recurrent hyperthyroidism was observed in 119 (28.7%) patients. The median time of recurrence was 36 months (range 12-120 months). Hypothyroidism developed in over 50% of patients. A euthyroid state was achieved in only 19.3% of patients, and the rate did not increase significantly as remnant weight increased. Based on a Cox regression analysis, the remnant weight is an independent risk factor for persistent or recurrent hyperthyroidism (hazard ratio: 1.323, 95% confidence interval: 1.198-1.461, P < 0.001). CONCLUSIONS: Subtotal thyroidectomy with the intent to maintain a euthyroid state is not an optimal surgical strategy for the definitive treatment of GD because the persistence or recurrence rate is high and the euthyroid rate is lower than expected.

Intrahepatic biliary mucinous cystic neoplasms: clinicoradiological characteristics and surgical results.

BACKGROUND: Intrahepatic biliary mucinous cystic neoplasms are rare hepatic tumors and account for less than 5% of intrahepatic cystic lesions. Accurate preoperative diagnosis is difficult and the outcome differs among various treatment modalities.The aim of this study is to investigate the clinico-radiological characteristics of intrahepatic biliary mucinous cystic neoplasms and to establish eligible diagnostic and treatment suggestions. METHODS: Nineteen patients with intrahepatic biliary cystadenomas and two patients with biliary cystadenocarcinomas were retrospectively reviewed. Their clinico-radiological variables and survival outcome were analyzed. RESULTS: Of the 19 patients with biliary cystadenoma, 16 (84.2 %) were female. 11 (57.9 %) patients had symptoms before operation with the most common presenting symptom being abdominal pain. Among the patients with available data, serum and cystic fluid CA 19-9 levels were invariably elevated and the CA 19-9 level in the cystic fluid was significantly higher than that in the serum. Loculations (84.2 %) and septations (63.2 %) were the most common radiologic findings. For treatment, 11 (57.9 %) patients received radical resection by either enucleation or hepatic resection, while the remaining 8 (42.1 %) patients underwent only fenestration of liver cysts. Radical resection provided a significantly better clinical outcome than fenestration in terms of tumor recurrence (p = 0.018). The only two male patients with biliary cystadenocarcinoma received radical hepatic resection and achieved a disease-free survival of 16.5 months and 33 months, respectively. CONCLUSION: Intrahepatic biliary mucinous cystic neoplasms are rare and preoperative diagnosis is difficult. Internal septations and loculations on radiologic examinations should raise some suspicion of this diagnosis. Complete tumor excision is the standard treatment that may provide patients with better long term results after the operation.

Long-term therapeutic outcomes of papillary thyroid carcinoma with concomitant hyperparathyroidism: A single center case-control study.

BACKGROUND: Papillary thyroid carcinoma occasionally presents with concomitant hyperparathyroidism; however, the clinical significance has not been well established. This study aimed to evaluate the long-term cancer prognosis following a multimodality therapy. METHODS: We conducted a case-control study using prospectively maintained data from a medical center thyroid cancer database between 1980 and 2013. The study cohort comprised patients with concomitant papillary thyroid carcinoma and hyperparathyroidism. Patients with papillary thyroid carcinoma only were matched using the propensity score method. Therapeutic outcomes, including the non-remission rate of papillary thyroid carcinoma and patient mortality, were compared. RESULTS: We identified 27 study participants from 2537 patients with papillary thyroid carcinoma, with 10 patients having primary hyperparathyroidism and 17 having renal hyperparathyroidism. Eighty-five percent of the cohort was found to have tumor-node-metastasis stage I disease. During a mean follow-up of 7.7 years, we identified 3 disease non-remission and 4 mortality events. The non-remission risk did not increase (hazard ratio [HR], 1.66; 95% confidence interval [CI], 0.43-6.40; p = 0.47); however, the overall mortality risk significantly increased (HR, 4.43; 95% CI, 1.11-17.75; p = 0.04). All mortality events were not thyroid cancer related, including two identified cardiovascular diseases. CONCLUSIONS: Patients with papillary thyroid carcinoma who present with concomitant hyperparathyroidism are usually diagnosed at an early cancer stage with compatible therapeutic outcomes. However, hyperparathyroidism-related comorbidity may decrease long-term survival.

Tumor spectrum of adult intussusception.

INTRODUCTION: Adult intussusception is rare. Most general and colorectal surgeons are unfamiliar with its etiology and optimal management. PATIENTS AND METHODS: Patients older than 16 years and diagnosed with intestinal intussusception between January 1990 and June 2006 were retrospectively reviewed. Data related to presentation, diagnosis, treatment, and pathology were analyzed. RESULTS: Seventy-two patients underwent surgery for intestinal intussusception. Neoplasm was identified as the cause of intussusception in 66 (92%) cases, and 6 (8%) were idiopathic. The incidence of malignant colonic intussusception (63%) was significantly higher than that of enteric intussusception (20%), P = 0.001. Primary colon adenocarcinoma (8 of 10 patients, 80%) and malignant lymphoma (2 of 10 patients, 20%) were the two most common underlying malignant lesions in the colon. Lipoma (15 of 40 patients, 38%) and Peutz-Jegher adenoma (10 of 40 patients, 25%) were the two most common lesions of benign small bowel neoplasms while 27% (3 of 11) of malignant enteric intussusception cases were malignant lymphoma and metastatic respectively. CONCLUSION: Lipoma is the most common benign tumor in both small and large bowel intussusception. Whereas 80% of tumors associated with small bowel intussusception were benign, two-thirds of colonic intussusceptions had resulted from primary adenocarcinoma.

Serial evaluation of the SOFA score is reliable for predicting mortality in acute severe pancreatitis.

Acute severe pancreatitis caused high mortality, and several scoring systems for predicting mortality are available. We evaluated the effectiveness of serial measurement of several scoring systems in patients with acute severe pancreatitis.We retrospectively obtained serial measurements of Ranson, Acute Physiology and Chronic Health Assessment (APACHE) II, and Sequential Organ Failure Assessment (SOFA) scores of 159 patients with acute severe pancreatitis.The overall mortality rate was 20%, and early mortality (in the first 2 weeks) occurred in 10 (7.4%) patients, while late mortality occurred in 17 (12.6%).All scoring systems were reliable for predicting overall and intensive care unit mortality, while the SOFA score on day 7 presented the largest area under the receiver operator characteristic (ROC) curve (0.858, SE 0.055). Changes in scores over time were evaluated for predicting the progression of organ failure, and the change in SOFA score on hospital day 7 or no interval change in SOFA score was associated with higher mortality rates.APACHE II and SOFA scores are both sensitive for predicting mortality in acute pancreatitis. The serial SOFA scores showed reliable for predicting mortality. Hospital day 7 is a reasonable time for SOFA score reassessment to predict late mortality in acute severe pancreatitis.

Outcomes and prognostic factors in thyroid cancer patients with cranial metastases: A retrospective cohort study of 4,683 patients.

BACKGROUND: Cranial metastasis of thyroid cancer is rare. The aim of this study was to analyse the clinical characteristics, treatments and outcomes of thyroid cancer patients with cranial metastasis and to identify the associated prognostic factors. MATERIALS AND METHODS: Between January 1977 and August 2017, a total of 4683 patients were histologically confirmed to have thyroid cancer. Among them, 25 patients (0.53%) were identified as having cranial metastases, and their medical records were reviewed. The Kaplan-Meier method with a log-rank test was performed with cancer-specific survival as the main outcome. Cox regression analysis was used to examine the potential prognostic factors influencing patient survival. RESULTS: Of the 25 patients, 21 were female, and 4 were male. The median age at the time of diagnosis of cranial metastasis was 63 years. Sixteen patients had metastases to the brain, and nine patients had metastases involving the skull only. Papillary carcinoma and follicular carcinoma accounted for 84.0% of cases. Twenty-four cases (96.0%) had extracranial metastases at the time of diagnosis of cranial metastases. Twenty patients received surgery, and 4 patients received palliative radiotherapy. One patient received supportive care only. The median cancer-specific survival after the diagnosis of cranial metastases was 27 months. According to the Kaplan-Meier test, 3 factors had a significant impact on survival, the metastatic site, histological types and surgical resection. According to the Cox regression analysis, skull metastases (HR: 0.274, 95% CI: 0.083-0.904, p = 0.033) and surgical resection (HR: 0.134, 95% CI: 0.019-0.929, p = 0.042) were identified as independent prognostic factors for a better outcome. CONCLUSIONS: Surgical resection is the mainstay therapy for thyroid cancer patients with cranial metastasis. Cranial metastases involving the skull only are associated with a better outcome.

Incidental parathyroidectomy during thyroidectomy increases the risk of postoperative hypocalcemia.

OBJECTIVES/HYPOTHESIS: The correlation between incidental parathyroidectomy (IP) during thyroidectomy and postoperative hypocalcemia remains controversial. Our aim was to investigate the incidence of IP, risk factors, and impact on patient outcomes. STUDY DESIGN: Retrospective cohort study. METHODS: This was a retrospective observational study including 3,186 consecutive patients who underwent thyroidectomy between January 2007 and December 2014. The patients were divided into two groups: the IP group and the non-IP. Numerous clinical parameters were collected and analyzed. RESULTS: The overall incidence of incidentally excised parathyroid glands during thyroidectomy was 6.4%. Patients with IP had significantly higher incidences of postoperative hypocalcemia and hypoparathyroidism than those without IP (P < 0.001). Intrathyroidal parathyroid glands presented only 2.2% of all removed parathyroid glands. Total thyroidectomy, central compartment lymph node dissection, and reoperation were independent risk factors for IP. CONCLUSION: Incidental parathyroidectomy during thyroidectomy is associated with the increased likelihood of postoperative hypocalcemia. All independent risk factors examined in the study for IP are surgery-related. Surgeons should perform meticulous dissection with the intention of avoiding IP and resultant hypocalcemia. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:2194-2200, 2017.

Patient outcomes following surgical management of multinodular goiter: Does multinodularity increase the risk of thyroid malignancy?

BACKGROUND: the difference in the risk of thyroid malignancy for patients with multinodular goiter (MNG) and solitary nodular goiter (SNG) remains controversial. Although total thyroidectomy (TT) is the current preferred surgical option for MNG, permanent hypothyroidism in these patients may be a concern. Therefore, we discuss whether nontotal thyroidectomy is a reasonable alternative surgical option. METHODS: A retrospective cohort study was performed for 1598 consecutive patients who underwent thyroid surgery for nodular goiter between January 2007 and December 2012. Numerous clinical parameters were collected and analyzed. RESULTS: We reviewed 795 patients with MNG and 803 patients with SNG. The prevalence of malignancy on final pathology was significantly higher in the patients with MNG than in the patients with SNG (15.6% vs 10.1%, P = 0.001). However, a multivariate analysis revealed that this difference was insignificant (P = 0.50). Papillary carcinoma was the predominant type in both groups, but papillary microcarcinoma was more frequently found (41.1%) in the patients with MNG. The only multifocal cancers were of the papillary carcinoma histologic type, and the incidence of multifocal papillary carcinoma was significantly higher in the patients with MNG (23.4% vs 7.4%, P = 0.005). Reoperation was not required for the patients who underwent TT for goiter recurrence or incidental carcinoma. The overall rate of recurrence following nontotal thyroidectomy was 12.2%. Among the patients who underwent reoperation for goiter recurrence, 2 (20.0%) were complicated with permanent hypoparathyroidism. Among the patients who underwent a nontotal bilateral thyroidectomy, an average of 56.5% had permanent hypothyroidism. CONCLUSIONS: Multinodularity does not increase the risk of thyroid malignancy. However, patients with MNG who develop papillary carcinoma are at an increased risk of cancer multifocality. If a patient can tolerate lifelong thyroid hormone replacement, TT is the preferred surgical option because it helps avoid reoperation and the associated complications. Nontotal bilateral thyroidectomy does not ensure the preservation of thyroid hormone function.

Surgical management of substernal goitres at a tertiary referral centre: A retrospective cohort study of 2,104 patients.

BACKGROUND: When to use a thoracic approach to treat substernal goitres has often been discussed in the literature. But there are few published reports describing surgical outcomes and associated complications for patients with right-sided vs. left-sided substernal goitres. OBJECTIVE: This study evaluated the characteristics and clinical outcomes of patients who underwent surgical management of substernal goitres, presenting factors indicating the use of a thoracic approach and differences between right- and left-sided goitre extensions. DESIGN: Retrospective cohort study. SETTING: Tertiary referral centre. METHODS: Between January 2007 and December 2012, 2104 patients underwent thyroidectomy at Chang Gung Memorial Hospital and 140 (6.7%) were diagnosed with substernal goitres. Patient medical records were retrospectively reviewed, and data were analysed to assess surgical outcomes. RESULTS: Seven (5.0%) patients required a thoracic approach for goitre removal. Goitre malignancy was verified in 17 (12.1%) patients. The most common postoperative complication was transient hypoparathyroidism (15.0%). Permanent RLN injury occurred in 4.3% of patients and was significantly more frequent using the thoracic approach. Unilateral extension of a substernal goitre was more common than bilateral extension. Right- and left-sided extensions occurred with equal frequency. The rate of postoperative complications was similar between groups and there were no patient deaths. CONCLUSION: Chest radiography and thyroid sonography may provide initial radiologic evidence of goitre extension into the superior mediastinum. Computed tomography evaluation of the depth of goitre extension to the tracheal bifurcation was the strongest predictor of the need to use a thoracic approach. There were no significant differences in the clinical features and outcomes of patients with right- and left-sided substernal goitres. The right recurrent laryngeal nerve shows increased susceptibility to damage during thyroid surgery for substernal goitres. The incidence of malignant substernal goitres is similar to that of malignant cervical goitres.

Disrupted hepatic adiponectin signaling impairs liver regeneration of steatotic rats.

BACKGROUND: Individuals with non-alcohol fatty liver disease (NAFLD) exhibit impaired liver regeneration in a clinical setting and animal experiments. Adiponectin signaling is recognized as an important pathway of lipid metabolism, energy expenditure, anti-inflammation, and cellular proliferation. We herein investigate hepatic adiponectin signaling in dietary steatotic murine models undergoing hepatectomy, which has never been explored. METHODS: Sprague-Dawley rats fed with a normal diet (normal), high fat diet (HF), and a methionine-choline deficiency diet for 1 week (MCD 1W) and 5 weeks (MCD 5W), were used. The animals underwent 70% hepatectomy and were thereafter sacrificed at indicated time points. RESULTS: MCD 5W and HF displayed decreased Ki-67 labeling index and restituted liver mass compared to normal. Hepatic adiponectin, as well as TNF-α, of MCD5W and HF were increased compared to normal; whereas adiponectin receptor type 1 (AdipoR1) and adiponectin receptor type 2 (AdpoR2) were reciprocally decreased when compared to normal. PPARα, a downstream molecule of AdipoR2 axis, was decreased in MCD 5W compared to normal. Adenosine monophosphate- activated protein kinase (AMPK), a downstream molecule of AdipoR1 axis, was inactivated soon after hepatectomy in normal; whereas activation of AMPK persisted until day 3 after hepatectomy in MCD 5W and HF. CONCLUSIONS: Reciprocal expression of adiponectin and its receptors in steatotic rats represents a unique form of adiponectin signaling disruption, which might be associated with impaired liver regeneration.

Clinical analysis and strategy for liver transplantation in patients with pre-existing portal vein thrombosis.

BACKGROUND: Liver transplantation (LT) in patients with portal vein thrombosis (PVT) remains a challenge for transplant surgeons. In this study, we included a group of patients with PVT who underwent LT, and analyzed patient outcomes. METHODS: A total of 356 patients who underwent LT consisting of 167 cases of deceased donor LT and 189 cases of live donor LT at Chang Gung Memorial Hospital Linkou Medical Center between September 1996 and June 2009 were retrospectively reviewed; 24 (6.7%) of these patients had PVT at transplantation. Their clinical features, surgical management, and outcomes were analyzed. RESULTS: Surgical management of patients with PVT included a thrombectomy followed by direct anastomosis between the recipient's and the liver graft portal vein (PV) (n = 13), interposition vein graft between the recipient's coronary vein (CV) and the liver graft PV (n = 3), direct anastomosis of the recipient's CV and the liver graft PV (n = 1), interposition jump graft from the recipient's superior mesenteric vein to the liver graft PV (n = 4), and transection of the thrombotic PV followed by interposition of a venous graft between the recipient's PV and the liver graft PV (n = 3). There were 7 hospital mortalities. The mean follow-up for the 17 surviving patients was 36.3 months (range, 3.4-105.1 months), and 14 patients were still alive at the end of the study. Four patients (16.7%) had rethrombosis of portal inflow after LT. Patients with PVT undergoing LT had a significantly higher mortality rate (p = 0.033) than patients without PVT undergoing LT. However, there was no significant difference in the cumulative survival rates (p = 0.0696). Further analysis of patient survival according to PVT grade, venous graft application, and reconstructed portal flow routes also exhibited no significant differences. CONCLUSIONS: LT for patients with PVT is clinically feasible and should not be considered a contraindication. However, a favorable outcome is achievable only with ideal surgical management to overcome PVT during LT.