Rapid intraoperative perfusion assessment of parathyroid adenomas with ICG using a wide-field portable hand-held fluorescence imaging system.

BACKGROUND: Fluorescence angiography (FA) using indocyanine green dye (ICG) has recently been introduced for real-time identification of parathyroid adenomas. However, time to peak fluorescence has not yet been critically evaluated. METHODS: This was a retrospective review of parathyroidectomies with ICG FA over a one-year period. RESULTS: There were 66 patients with average age of 64 years. The average time to initial fluorescence was 26.7 s and to peak fluorescence was 38.0 s. The time to saline flush administration significantly correlated with times to initial and peak fluorescence (p < .0001). The rate of in-situ fluorescence was 97%. The rates of suspected adenoma detection were 69% for sestamibi scan, 71% for ultrasound, and 96% for CT scan. Imaging was discordant in 13 cases (20%), with the adenoma located on the opposite side of the neck in 4 cases. CONCLUSIONS: ICG FA is a rapid and effective adjunct for the intraoperative identification of parathyroid adenomas.

The price is right: Routine fluorescent cholangiography during laparoscopic cholecystectomy.

BACKGROUND: Early experience with indocyanine green-based fluorescent cholangiography during laparoscopic cholecystectomy suggests the potential to improve outcomes. However, the cost-effectiveness of routine use has not been studied. Our objective was to evaluate the cost-effectiveness of fluorescent cholangiography versus standard bright light laparoscopic cholecystectomy for noncancerous gallbladder disease. METHODS: A Markov model decision analysis was performed comparing fluorescent cholangiography versus standard bright light laparoscopic cholecystectomy alone. Probabilities of outcomes, survival, toxicities, quality-adjusted life-years, and associated costs were determined from literature review and pooled analysis of currently available studies on fluorescent cholangiography (n = 37). Uncertainty in the model parameters was evaluated with 1-way and probabilistic sensitivity analyses, varying parameters up to 40% of their means. Cost-effectiveness was measured with an incremental cost-effectiveness ratio expressed as the dollar amount per quality-adjusted life-year. RESULTS: The model predicted that fluorescent cholangiography reduces lifetime costs by $1,235 per patient and improves effectiveness by 0.09 quality-adjusted life-years compared to standard bright light laparoscopic cholecystectomy. Reduced costs were due to a decreased operative duration (21.20 minutes, P < .0001) and rate of conversion to open (1.62% vs 6.70%, P < .0001) associated with fluorescent cholangiography. The model was not influenced by the rate of bile duct injury. Probabilistic sensitivity analysis found that fluorescent cholangiography was both more effective and less costly in 98.83% of model iterations at a willingness-to-pay threshold of $100,000/quality-adjusted life year. CONCLUSION: The current evidence favors routine use of fluorescent cholangiography during laparoscopic cholecystectomy as a cost-effective surgical strategy. Our model predicts that fluorescent cholangiography reduces costs while improving health outcomes, suggesting fluorescence imaging may be considered standard surgical management for noncancerous gallbladder disease. Further study with prospective trials should be considered to verify findings of this predictive model.

Improved perioperative outcomes with minimally invasive distal pancreatectomy: results from a population-based analysis.

IMPORTANCE: Interest in minimally invasive distal pancreatectomy (MIDP) has grown in recent years, but currently available data are limited. Greater insight into application patterns and outcomes may be gained from a national database inquiry. OBJECTIVES: To study trends in the use of MIDP and compare the short-term outcomes of MIDP with those of open distal pancreatectomy. DESIGN, SETTING, AND PARTICIPANTS: Population-based retrospective cohort study evaluating perioperative outcomes and hospital charge measures for distal pancreatectomy, comparing the surgical approaches and adjusting for patient- and hospital-level factors, among patients undergoing elective distal pancreatectomy from 1998 to 2009 in the Nationwide Inpatient Sample in a 20% stratified sample of all US hospitals. MAIN OUTCOMES AND MEASURES: In-hospital mortality, rates of perioperative complications and splenectomy, total charges, and length of stay. RESULTS: A total of 8957 distal pancreatectomies were included in this analysis, of which 382 (4.3%) were MIDPs. On a national level, this projected to 42,320 open distal pancreatectomies and 1908 MIDPs. The proportion of distal pancreatectomies performed via minimally invasive approaches tripled between 1998 and 2009, from 2.4% to 7.3%. The groups were comparable for sex and comorbidity profiles, while patients who underwent MIDP were 1.5 years older. On multivariate analysis, MIDP was associated with lower rates of overall predischarge complications, including lower incidences of postoperative infections and bleeding complications, as well as a shorter length of stay by 1.22 days. There were no differences in rates of in-hospital mortality, concomitant splenectomy, or total charges. CONCLUSIONS AND RELEVANCE: This population-based study of MIDP reveals that the application of this approach has tripled in practice and provides strong evidence that MIDP has evolved into a safe option in the treatment of benign and malignant pancreatic diseases.

Writing a successful NIH Mentored Career Development Grant (K award): hints for the junior faculty surgeon.

Surgery is a labor-intensive, time-consuming profession. Young faculty members in surgery are saddled with many clinical time constraints that often allow precious few moments for academic pursuits. Consequently, K award submissions from surgeons trail nonsurgeons. The National Institutes of Health (NIH), however, is actively trying to encourage participation of surgeons in basic science research, translational research, clinical outcomes research, and even in prevention/control research. But, at the same time, the NIH has newly implemented a policy that has made the grant review process more restrictive by only allowing 2 submissions of any grant application. It is imperative, therefore, for junior faculty surgeons to learn "grantsmanship" and have the ability to construct succinct, competitive K award grants. Although most of this information is public knowledge and made available by the NIH itself, many of the practical points presented here are tailored to the special needs of clinically active surgical researchers. Often, these "hints" are buried on expansive websites that require considerable time to read and navigate. The authors have a long combined experience on a study section dedicated to adjudicating K awards. The goal of this review is to present concise, useful information about common errors, research plan dos and don'ts, template examples of superior mentored letters, and many other suggestions that may assist any first-time candidate for these awards.