Prospective assessment of postoperative complications and associated costs following inguinal lymph node dissection (ILND) in melanoma patients.

BACKGROUND: We prospectively assessed the incidence, risk factors, and costs associated with wound complications and lymphedema in melanoma patients undergoing inguinal lymph node dissection (ILND). MATERIALS AND METHODS: A total of 53 melanoma patients were accrued to 2 trials (June 2005 to July 2008) that included prospective evaluations of postoperative complications; 30-day wound complications included infection, seroma, and/or dehiscence. There were 20 patients who underwent limb volume measurement and completed a 19-item lymphedema symptom assessment questionnaire preoperatively and 3 months postoperatively. A multivariate analysis was performed to evaluate potential risk factors for complications. A microcosting analysis was also performed to evaluate the direct costs associated with wound complications. RESULTS: The 30-day wound complications were noted in 77.4% of patients. A BMI ≥ 30 (n = 28) increased the risk for wound complications (odds ratio [OR] = 11.4, 95% confidence interval [95%CI] 1.6-78.5, P = .01), while advanced nodal disease approached significance (OR = 9.0, 95%CI: 0.79-103.1, P = .08). Other risk factors, including diabetes, smoking, and the addition of a deep pelvic (iliac/obturator) dissection to ILND, were not significant. Of 20 patients, 9 (45%) developed limb volume change (LVC) ≥5% at 3 months, with associated mean symptom scores of 6.1 versus 4.6 for those without LVC. Costs for patients with wound complications were significantly higher than for those without wound complications. CONCLUSIONS: Postoperative wound complications and early onset lymphedema occur frequently following ILND for melanoma. Obesity is an adverse risk factor for 30-day wound complications that can significantly increase postoperative costs, as is likely the case for advanced disease. Risk reduction practices and novel treatment approaches are needed to reduce postoperative morbidity.

Prospective, randomized, controlled trial of parathyroidectomy versus observation in patients with "asymptomatic" primary hyperparathyroidism.

BACKGROUND: Disruptions in cognitive function have been described in the constellation of symptoms associated with "asymptomatic" primary hyperparathyroidism (PHPT). The aim of this study was to determine the impact of parathyroidectomy (PTX) on brain function and sleep in "asymptomatic" PHPT patients. METHODS: We conducted a prospective, randomized trial comparing immediate PTX with observation in patients with asymptomatic PHPT. We performed functional magnetic resonance imaging (fMRI) of the brain, sleep assessment, and validated neuropsychological battery at baseline, 6 weeks, and 6 months. Wilcoxon rank-sum and Pearson and Spearman correlations were used. RESULTS: A total of 18 patients were randomized. Subjective sleepiness correlated with worse performance on executive function tests during fMRI at 6 weeks (Pearson, -0.473; P = .047) and 6 months (Pearson, -0.673; P = .002). Total sleep time correlated with PTH levels at both 6 weeks (Pearson, 0.518; P = .048) and 6 months (Pearson, 0.567; P = .018). At 6 weeks, hypersomnolence as measured subjectively was decreased in the PTX group, but increased in those observed (-2.56 vs 2.22; P = .03) CONCLUSION: This prospective, randomized trial for asymptomatic PHPT patients demonstrated an association of sleep with brain function. Sleep seemed to be an indicator of brain activation in the anterior cingulate gyrus and precentral cortex. Subjective sleepiness was associated with executive function. The results of this pilot study suggest that decreased serum PTH levels correlate with improved sleep and that PTX decreases sleepiness in patients with asymptomatic PHPT.

Peer-reviewed, evidence-based analysis of vitamin D and primary hyperparathyroidism.

BACKGROUND: Research into the actions of vitamin D on the human body has been increasing at an exponential rate, as has understanding of the impact of vitamin D on various aspects of the endocrine system. Primary hyperparathyroidism (PHPT) is a disease of the endocrine system that can result in debility if not diagnosed. New understanding about the effect of vitamin D on parathyroid hormone regulation may provide an opportunity to better understand the coexistence of PHPT and vitamin D deficiency. METHODS: An evidence-based literature review was based on a PubMed search for research involving vitamin D and primary hyperparathyroidism, and evaluating existing research on vitamin D. The PubMed search included English-language articles published between 1977 and 2008, with a focus on research and analysis completed between 2005 and the present. This study examined recent developments in understanding the relationship between vitamin D and PHPT. This review of existing literature examined the impact of vitamin D insufficiency and deficiency, including the impact on diagnosis of vitamin D insufficiency/deficiency, diagnosis and management of PHPT, and the impact on overall health. The level of evidence was determined according to criteria proposed by Sackett et al. and the grade of recommendation according to the criteria proposed by Heinrich et al. RESULTS: Level III and level IV evidence predominates the vitamin D/PHPT based literature, with several notable Heinrich grade A, B, and C studies available. Additional evaluation of studies' review is provided by reference and by section. CONCLUSIONS: Vitamin D metabolism plays an important role in PHPT etiology, diagnosis, and management. Care of both conditions may have an important impact on overall health in humans.

Fibrin sealant does not decrease seroma output or time to drain removal following inguino-femoral lymph node dissection in melanoma patients: a randomized controlled trial (NCT00506311).

BACKGROUND: This study assessed the impact of closed suction drains and evaluated whether the intraoperative use of a fibrin sealant decreased time to drain removal and wound complications in melanoma patients undergoing inguino-femoral lymph node dissection. METHODS: A pilot study (n = 18) assessed the impact of a closed suction drain following inguino-femoral lymph node dissection. A single-institution, prospective trial was then performed in which patients were randomized to a group that received intraoperative application of a fibrin sealant following inguino-femoral lymph node dissection or to a control group that did not receive sealant. RESULTS: The majority of the patients enrolled felt the drains caused moderate or severe discomfort and difficulties with activities of daily living. Thirty patients were then randomized; the median time to drain removal in the control group (n = 14) was 30 days (range, 13-74) compared to 29 days (range, 11-45) in the fibrin sealant group (n = 16; P = 0.6). Major and minor complications were similar in the two groups. CONCLUSION: Postoperative closed suction drains were associated with major patient inconvenience. Applying a fibrin sealant at the time of inguino-femoral lymph node dissection in melanoma patients did not reduce the time to drain removal or postoperative morbidity. Alternative strategies are needed.