Are we producing general surgeons who are ready for community or rural practice?

Summary: General surgery remains a broad and unclearly defined specialty in small and medium-sized communities, where general surgeons perform more subspecialty and non-core procedures than their urban counterparts. It is unclear what specific procedures are being performed or whether today's residents are being trained to meet community needs. We surveyed the members of the British Columbia (BC) Surgical Society and found that only 3% of BC's surgeons believe today's graduates are "definitely prepared" for a broad-based community practice. We also identified several non-core procedures performed more frequently by general surgeons in small and medium-sized communities. General surgery residency is narrowing its focus despite the fact that community general surgeons are maintaining a broad-based practice. To meet the needs of smaller communities, residency programs need to address the discrepancies that exist between the emphasis within the current training structure and the practice of our community surgeons.

Intraoperative parathyroid hormone measurement during parathyroidectomy for treatment of primary hyperparathyroidism: When should you end the operation?

INTRODUCTION: The study objective was to evaluate the intraoperative 50% decrease in PTH level ± PTH normalization for its accuracy and efficiency in predicting cure during parathyroidectomy (PTx) for the treatment of primary hyperparathyroidism (PHP). METHODS: A retrospective review of patients undergoing PTx was conducted. The timepoints at which the 50% PTH decrease was reached were recorded. The accuracy of intraoperative PTH for predicting cure, defined as normocalcemia at 6 months postoperatively, was evaluated. RESULTS: The study population was made up of 248 PHP patients, with 247 patients achieving normocalcemia at 6 months postoperatively. If a 50% PTH decrease was used to indicate operation conclusion, 1 patient would not be cured. Persistent PTH elevation above normal range at T10 had a PPV of 77%, NPV of 99.5%, sensitivity of 95.2% and specificity of 97.3% for predicting the presence of a contralateral pathological parathyroid gland. For the study cohort, 24.5 h of cumulative operating time would be saved if the 50% PTH decrease triggered operation conclusion. DISCUSSION: A decrease in the pre-excision PTH level to 50% of the baseline level, or a decrease in the higher of the baseline or pre-excision PTH levels by 50% at 5 or 10 min post pathological parathyroid gland removal, regardless of whether the PTH level normalizes, reliably predicts cure from PHP and should be used to guide the surgeon during parathyroidectomy.

Limited clinical utility of intraoperative frozen section during parathyroidectomy for treatment of primary hyperparathyroidism.

BACKGROUND: This study's objective was to evaluate the utility of intraoperative frozen section (IFS) performed during parathyroidectomy for treatment of primary hyperparathyroidism (PHP), and to identify patients for whom it is most helpful. METHODS: A retrospective chart review was carried out for all patients who underwent parathyroidectomy for treatment of PHP between January 2013 and June 2018. RESULTS: 262 patients made up the final study population. Overall, IFS provided information that influenced the operative plan in 46 patients (17.6%). IFS altered the operative plan in 10.2% of cases that were correctly preoperatively localized, and in 41.5% of cases that were either incorrectly or not preoperatively localized. CONCLUSIONS: IFS did not provide information that influenced the operative plan during parathyroidectomy for treatment of PHP for the majority of patients. Patients that present with normal PTH and hypercalcemia, or those who do not localize preoperatively, are most likely to benefit from IFS.

Dual energy computed tomography should be a first line preoperative localization imaging test for primary hyperparathyroidism patients.

BACKGROUND: The objective of this study was to evaluate the performance of dual-energy computed tomography (DECT) for preoperative parathyroid tumor (PT) localization in primary hyperparathyroid (PHP) patients. METHODS: A retrospective review was carried out of the medical records of all PHP patients who underwent ultrasound (US), Tc-99m sestamibi noncontrast single photon emission computed tomography (CT-MIBI), DECT and parathyroidectomy at a single center. RESULTS: The sensitivities and accuracies for preoperative PT localization in the 97 patient study population were: US 40% and 93%, CT-MIBI 64.0% and 97%, and DECT 84% and 96%, respectively. In the one third of the study population that did not localize preoperatively with CT-MIBI and US, DECT correctly localized a PT in 21 cases (66%). DE-CT and US correctly localized a PT in 86% of cases, and only 5 (8%) of the cases that were accurately localized by a combination of CT-MIBI and US were not identified by DE-CT. CONCLUSIONS: DECT should be utilized as a first line preoperative PT localization study in PHP patients, and is also a sensitive salvage localization test.

Infant repair of massive aortic aneurysm with prosthetic valved conduit.

A 4-month-old child with severe infantile Marfan syndrome underwent successful repair of an extremely dilated aortic root and severe aortic valve insufficiency using a prosthetic valved conduit.