The COVID-19 Tracheostomy Experience at a Large Academic Medical Center in New York during the First Year.

Background: New York City was the epicenter of the initial surge of the COVID-19 pandemic in the United States. Tracheostomy is a critical procedure in the care of patients with COVID-19. We hypothesized that early tracheostomy would decrease the length of time on sedation, time on mechanical ventilation, intensive care unit length of stay, and mortality. Methods: A retrospective analysis of outcomes for all patients with COVID-19 who underwent tracheostomy during the first year of the COVID-19 pandemic at the Mount Sinai Hospital in New York City, New York. All adult intensive care units at the Mount Sinai Hospital, New York. Patients/subjects: 888 patients admitted to intensive care with COVID-19. Results: All patients admitted to the intensive care unit with COVID-19 (888) from 1 March 2020 to 1 March 2021 were analyzed and separated further into those intubated (544) and those requiring tracheostomy (177). Of those receiving tracheostomy, outcomes were analyzed for early (≤12 days) or late (>12 days) tracheostomy. Demographics, medical history, laboratory values, type of oxygen and ventilatory support, and clinical outcomes were recorded and analyzed. Conclusions: Early tracheostomy resulted in reduced duration of mechanical ventilation, reduced hospital length of stay, and reduced intensive care unit length of stay in patients admitted to the intensive care unit with COVID-19. There was no effect on overall mortality.

Tiroidectomía endoscópica transoral por vía vestibular: resultados de los 53 primeros casos / Transoral endoscopic thyroidectomy vestibular approach: Results after 53 first cases

Introducción: La tiroidectomía endoscópica transoral por vía vestibular permite el acceso al tiroides sin cicatrices visibles y con el mejor resultado cosmético posible. Métodos: Estudio observacional prospectivo de 53 pacientes sometidos a tiroidectomía endoscópica transoral desde julio de 2017 hasta junio de 2021. Resultados: Cincuenta y dos casos (98,1%) fueron mujeres con una mediana de edad de 44 años. El nódulo tiroideo fue la indicación quirúrgica más frecuente (73,6%). Se realizaron 42 lobectomías,11 tiroidectomías totales y en 4 casos se asoció vaciamiento ganglionar del compartimento central izquierdo. La mediana de tiempo para la colocación de trócares fue de 14min, y para la lobectomía, la tiroidectomía total y el vaciamiento ganglionar del compartimento central izquierdo, de 80, 140 y 30min, respectivamente. La mediana de estancia hospitalaria fue de 2 días. Cuatro pacientes presentaron disfonía (7,5%), pero la laringoscopia solo confirmó lesión del recurrente en 2 casos, una de ellas permanente (1,6%). En los pacientes con tiroidectomía total la frecuencia de hipoparatiroidismo transitorio fue del 18,2% y el permanente de 0%. Dentro de las complicaciones asociadas al abordaje, en todos los pacientes se presentó anestesia de la región mentoniana transitoria y de intensidad variable. Conclusiones: La cirugía transoral es un abordaje de aplicación reciente en nuestra unidad. Los resultados en nuestros primeros pacientes muestran que es un abordaje eficaz y seguro cuando se realiza en pacientes bien seleccionados, con el mejor resultado cosmético y con complicaciones nuevas, asociadas al abordaje, transitorias en nuestra serie. (AU)

Introduction: Transoral endoscopic thyroidectomy through vestibular approach allows access to the thyroid with the best cosmetic results as there are no visible scars. Methods: Here we present a prospective observational study of 53 patients which underwent transoral endoscopic thyroidectomy from July 2017 to June 2021. Results: Fifty-two cases (98.1%) were women (median age 44 years old). Thyroid nodule was the main surgical indication accounting 73.6% of cases. We performed 42 lobectomies and 11 total thyroidectomies; 4 left central neck dissection were also associated. The median surgical time for port placement was 14min, and for lobectomy, total thyroidectomy and left central neck dissection were 80, 140 and 30min, respectively. The median of hospital stay was 2 days. Dysphonia was present in 4 patients (7.5%); however, laryngoscopy only confirmed laryngeal nerve impairment in 2 cases, one of them classified as permanent (1.6%). In those patients that underwent total thyroidectomy, the rate of transient hypoparathyroidism was 18.2% whereas permanent was 0%. Regarding complications associated to the new approach, transient chin numbness appeared in all patients with a variable degree of intensity. Conclusions: Transoral surgery is a recent approach in our unit. Our results, based on the first 53 patients, show that it is a safe and effective approach when performed in appropriately selected patients offering the best cosmetic result. Besides, new complications associated to the approach has been shown to be transient. (AU)

Tiroidectomía endoscópica transoral por vía vestibular: resultados de los 53 primeros casos / Transoral endoscopic thyroidectomy vestibular approach: Results after 53 first cases

Introducción: La tiroidectomía endoscópica transoral por vía vestibular permite el acceso al tiroides sin cicatrices visibles y con el mejor resultado cosmético posible. Métodos: Estudio observacional prospectivo de 53 pacientes sometidos a tiroidectomía endoscópica transoral desde julio de 2017 hasta junio de 2021. Resultados: Cincuenta y dos casos (98,1%) fueron mujeres con una mediana de edad de 44 años. El nódulo tiroideo fue la indicación quirúrgica más frecuente (73,6%). Se realizaron 42 lobectomías,11 tiroidectomías totales y en 4 casos se asoció vaciamiento ganglionar del compartimento central izquierdo. La mediana de tiempo para la colocación de trócares fue de 14min, y para la lobectomía, la tiroidectomía total y el vaciamiento ganglionar del compartimento central izquierdo, de 80, 140 y 30min, respectivamente. La mediana de estancia hospitalaria fue de 2 días. Cuatro pacientes presentaron disfonía (7,5%), pero la laringoscopia solo confirmó lesión del recurrente en 2 casos, una de ellas permanente (1,6%). En los pacientes con tiroidectomía total la frecuencia de hipoparatiroidismo transitorio fue del 18,2% y el permanente de 0%. Dentro de las complicaciones asociadas al abordaje, en todos los pacientes se presentó anestesia de la región mentoniana transitoria y de intensidad variable. Conclusiones: La cirugía transoral es un abordaje de aplicación reciente en nuestra unidad. Los resultados en nuestros primeros pacientes muestran que es un abordaje eficaz y seguro cuando se realiza en pacientes bien seleccionados, con el mejor resultado cosmético y con complicaciones nuevas, asociadas al abordaje, transitorias en nuestra serie. (AU)

Introduction: Transoral endoscopic thyroidectomy through vestibular approach allows access to the thyroid with the best cosmetic results as there are no visible scars. Methods: Here we present a prospective observational study of 53 patients which underwent transoral endoscopic thyroidectomy from July 2017 to June 2021. Results: Fifty-two cases (98.1%) were women (median age 44 years old). Thyroid nodule was the main surgical indication accounting 73.6% of cases. We performed 42 lobectomies and 11 total thyroidectomies; 4 left central neck dissection were also associated. The median surgical time for port placement was 14min, and for lobectomy, total thyroidectomy and left central neck dissection were 80, 140 and 30min, respectively. The median of hospital stay was 2 days. Dysphonia was present in 4 patients (7.5%); however, laryngoscopy only confirmed laryngeal nerve impairment in 2 cases, one of them classified as permanent (1.6%). In those patients that underwent total thyroidectomy, the rate of transient hypoparathyroidism was 18.2% whereas permanent was 0%. Regarding complications associated to the new approach, transient chin numbness appeared in all patients with a variable degree of intensity. Conclusions: Transoral surgery is a recent approach in our unit. Our results, based on the first 53 patients, show that it is a safe and effective approach when performed in appropriately selected patients offering the best cosmetic result. Besides, new complications associated to the approach has been shown to be transient. (AU)

Transoral endoscopic thyroidectomy vestibular approach: Results after 53 first cases.

INTRODUCTION: Trans Oral Endoscopic Thyroidectomy through Vestibular Approach (TOETVA) allows access to the thyroid with the best cosmetic results as there are no visible scars. METHODS: Here we present a prospective observational study of 53 patients which underwent TOETVA from July 2017 to June 2021. RESULTS: Fifty-two cases (98.1%) cases were women (median age 44 years old). Thyroid nodule was the main surgical indication accounting 73.6% of cases. We performed 42 lobectomies and 11 total thyroidectomies; 4 left Central Neck Dissection (CND) were also associated. The median surgical time for port placement was 14 min and for lobectomy, total thyroidectomy and left CND were 80, 140 and 30 min, respectively. The median of hospital stay was 2 days. Dysphonia was present in 4 patients; however, laryngoscopy only confirmed laryngeal nerve impairment in 2 cases, one of them classified as permanent (1.6%). In those patients that underwent total thyroidectomy, the rate of transient hypoparathyroidism was 18.2% whereas permanent was 0%. Regarding complications associated to the new approach, transient chin numbness appeared in all patients with a variable degree of intensity. CONCLUSTIONS: Transoral surgery is a recent approach in our Unit. Our results, based on the first 53 patients, show that it is a safe and effective approach when performed in appropriately selected patients offering the best cosmetic result. Besides, new complications associated to the approach has been shown to be transient.

How Effective is the Use of Molecular Testing in Preoperative Decision Making for Management of Indeterminate Thyroid Nodules?

INTRODUCTION: We performed Thyroseq v2 molecular testing on indeterminate thyroid nodules and evaluated whether they underwent a management change from the standard of thyroid lobectomy. METHODS: We conducted a retrospective analysis of all indeterminate thyroid nodules that underwent Thyroseq v2 molecular testing from 2014 to 2019 at a large academic center. Pathology was reviewed by thyroid cytopathologists. Thyroseq results were reported benign (malignancy probability less than 10%) or suspicious (malignancy probability greater than 30%). The primary endpoint was a management change from a diagnostic lobectomy. RESULTS: A total of 142 nodules were included: 113 (80%) Bethesda III and 29 (20%) Bethesda IV. Seventy-three nodules underwent surgical management and 69 did not. We noted a change in management in 64% (91/142) of nodules. Patients who underwent a change in management to no surgery had a significantly higher rate of benign Thyroseq result than those without a change (75.8% vs. 49.0%, p = 0.001). On logistic regression analysis, a benign Thyroseq result was a positive independent predictor of a change to no surgery (OR 3.87, 95% CI 1.69-8.89). Nodule size, multiple nodules, compressive symptoms, and history of hypothyroidism were not significant. Of the 91 patients who underwent a management change, 71% (65/91) did not undergo surgery. On follow-up (average 985 ± 615 days), 12% (8/65) of those nodules were growing or developed suspicious features requiring surgery. CONCLUSIONS: Molecular testing helped avoid surgery in almost half our population with indeterminate thyroid nodules, and benign results may help avoid surgery in asymptomatic patients with indeterminate thyroid nodules.

The Mount Sinai Clinical Pathway for the Diagnosis and Management of Hypercortisolism due to Ectopic ACTH Syndrome.

Neoplasms that secrete ectopic adrenocorticotropin (ACTH) may cause severe, life-threatening hypercortisolism. These tumors are often difficult to localize and treat, requiring a comprehensive and systematic management plan orchestrated by a multidisciplinary team. The Mount Sinai Adrenal Center hosted an interdisciplinary retreat of experts in adrenal disorders and neuroendocrine tumors (NETs) with the aim of developing a clinical pathway for the management of Cushing syndrome due to ectopic ACTH production. The result was institutional recommendations for the diagnosis, localization, surgical approaches to intrathoracic tumors and bilateral adrenalectomy, and perioperative and postoperative medical management of hypercortisolism and its sequelae. Specific recommendations were made regarding the timing and selection of therapies based on the considerations of our team as well as a review of the current literature. Our clinical pathway can be applied by other institutions directly or serve as a guide for institution-specific management.

The Role of Surgeon-Performed Office and Preincision Ultrasounds in Localization of Parathyroid Adenomas in Primary Hyperparathyroidism.

OBJECTIVE: We studied the use of surgeon-performed office ultrasound (OU) and preincision ultrasound (PIU) in preoperatively localizing parathyroid adenomas in primary hyperparathyroidism (PHPT). METHODS: A retrospective chart review was performed for patients with PHPT who underwent parathyroidectomy between 2013 and 2015. The results of OU and PIU were recorded and compared with the final surgical pathology. RESULTS: Of 348 patients with PHPT, 285 (81.9%) had single-lesion disease, 49 (14.1%) had double-lesion disease, and 14 (4.0%) had multigland disease with 3 or more lesions. For single-lesion disease, the overall sensitivity and specificity of OU to correctly lateralize the lesion were 64.2% and 91.2%, while those of PIU were 89.4% and 93.6%, respectively. The sensitivity and specificity of PIU were comparable to those of 4-dimensional computed tomography (87.1% and 90.7%, respectively) and 99mTc-sestamibi scintigraphy (70.4% and 95.9%, respectively). While the majority of PIU cases were preceded by other imaging studies, the accuracy in localizing lesions was not largely affected by the presence of prior computed tomography and/or 99mTc-sestamibi scintigraphy, as opposed to ultrasounds only. For detecting the presence of multigland disease, the sensitivity and specificity of OU were 26% and 92.2%, while those of PIU were 64.3% and 94.7%, respectively. CONCLUSION: Surgeon-performed OU and PIU are valuable tools in preoperatively localizing the parathyroid adenoma in single-lesion disease, while their utility may be limited for double-lesion or multigland disease. PIU in particular yields high accuracy in detecting parathyroid lesions in combination with other imaging modalities.

Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) learning curve: a regression analysis of complication rates and severity.

BACKGROUND: Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) is a natural orifice transluminal endoscopic surgery that offers a truly scarless approach to thyroidectomy. Introduced in 2008, there is a growing body of literature establishing it as a safe endoscopic approach for thyroid procedures. While it is not yet widely practiced, it is quickly growing in popularity. As more surgeons begin to add this technique to their repertoire the question of the learning curve has to be examined. METHODS: Case series from the initial TOETVA operations of four surgeons at three different hospitals were examined. Binomial and ordinal logistic regression were used to characterize the changes in complication rate and severity as they related to case number in the series. Statistics were performed in Minitab and SAS. RESULTS: Each surgeon performed between 23 and 40 TOETVA operations for a total of 130 cases. Binary logistic regression shows a negative relationship between case number and complication rate (P < 0.001, Odds Ratio: 0.91). Ordinal logistic regression shows a negative relationship between case number and complication severity (P < 0.001, Odds Ratio: 1.07). The maximum slope of improvement of complication rate occurred at case number 12. CONCLUSION: The most significant decrease in complications for TOETVA occurs at case 12. As case number progresses, there is a significant decrease in both the risk of a complication occurring and of the severity of that complication. These results support the previously published data on TOETVA learning curve based on operative time.

Aberrant methylation underlies insulin gene expression in human insulinoma.

Human insulinomas are rare, benign, slowly proliferating, insulin-producing beta cell tumors that provide a molecular "recipe" or "roadmap" for pathways that control human beta cell regeneration. An earlier study revealed abnormal methylation in the imprinted p15.5-p15.4 region of chromosome 11, known to be abnormally methylated in another disorder of expanded beta cell mass and function: the focal variant of congenital hyperinsulinism. Here, we compare deep DNA methylome sequencing on 19 human insulinomas, and five sets of normal beta cells. We find a remarkably consistent, abnormal methylation pattern in insulinomas. The findings suggest that abnormal insulin (INS) promoter methylation and altered transcription factor expression create alternative drivers of INS expression, replacing canonical PDX1-driven beta cell specification with a pathological, looping, distal enhancer-based form of transcriptional regulation. Finally, NFaT transcription factors, rather than the canonical PDX1 enhancer complex, are predicted to drive INS transactivation.

Intrathoracic Sleeve Migrations After Sleeve Gastrectomy: A Compilation of Case Reports.

Background: Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric procedure in the United States. Postoperative migration of the stomach into the chest is a rare complication of this procedure. In this study, we present a compilation of acute and chronic intrathoracic sleeve migrations (ITSMs) after LSG and present possible underlying mechanisms of this complication, as described in the literature. Methods: We retrospectively reviewed the preoperative, intraoperative, and postoperative course of patients who had an ITSM after LSG between 2011 and 2019. Results: Two patients presented with this complication in the acute setting, whereas 3 patients developed ITSM as a chronic issue years after the primary procedure. All 5 were female patients, with a mean age and body mass index of 55.6 ± 9.5 (years) and 37.8 ± 2.9 kg/m2, respectively. None of the cases had a hiatal hernia repair during the initial operation. All cases were completed laparoscopically with reduction of the migrated sleeve into the abdomen and primary hiatal hernia repair. One case required a return to the operating room for an acute reherniation. Conclusion: In this article, we report a compilation of cases of ITSMs after LSG with distinct clinical features that highlight the diversity of possible reasons and risk factors for its development.

Transoral Endoscopic Thyroidectomy Vestibular Approach: A Single-institution Experience of the First 50 Cases.

Background. Transoral endoscopic thyroidectomy vestibular approach (TOETVA) has evolved from a novel procedure to a cosmetically appealing alternative to the traditional open thyroidectomy. TOETVA is limited to only high-volume centers with the hope to expand and demonstrate the safety, reproducibility, and application for the correct patient with thyroid disease. We present our experience with the first 50 TOETVA procedures performed at our institution. Methods. From September 2016 to June 2018, we performed 50 transoral endoscopic thyroidectomies via the vestibular approach for a variety of thyroid pathologies. Outcomes were analyzed from a prospectively maintained database. Patients were treated for a different range of thyroid pathologies. Results. A total of 12 (24%) patients underwent total thyroidectomy, whereas 38 (76%) patients underwent a subtotal thyroidectomy or thyroid lobectomy. The mean surgical time was 149 ± 40.0 (90-256) minutes for lobectomy and 217.6 ± 33.3 (175-276) minutes for total thyroidectomy. Of our 50 patients, 16 (32%) had postoperative transient lower lip numbness with an average time to recovery of 23.8 (.43-48) weeks, with 1 (2%) patient having persistent, but improving, lower lip numbness beyond the 6-month follow-up. There were 13 (26%) patients with transient chin numbness with an average time to recovery of 15.7 (2-48) weeks. Two (4%) patients had transient recurrent laryngeal nerve (RLN) injury with hoarseness, whereas 1 (2%) patient had permanent injury. Conclusion. The TOETVA is a safe and reproducible procedure. For selected patients, this technique is a viable alternative to conventional thyroidectomy.

International Multi-institutional Experience with the Transoral Endoscopic Thyroidectomy Vestibular Approach.

Background: Surgical approaches to thyroidectomies have undergone a rapid evolution over the past three decades. Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is currently the latest remote access procedure for the treatment of benign and malignant thyroid disease. The purpose of this article is to present the results of TOETVA from five different international institutions. Materials and Methods: From 2016 to 2019, 152 TOETVA procedures were performed on 149 patients at five separate international institutions. Outcomes were analyzed from a prospectively maintained database. There were 12 (8%) men and 137 (92%) women with mean ages of 41.5 ± 10.3 (27-69) and 46.9 ± 1.8 (17-78), respectively. Results: There were 3 (2%) cases that required conversion from the endoscopic approach to an open procedure. A thyroid lobectomy was performed in 111 (73.0%) cases, total thyroidectomy in 38 (25.0%) cases whereas a completion thyroidectomy in 3 (2.0%) cases. Mean operative times were 161.8 ± 42.4 (83-304) minutes for the lobectomy, 213.4 ± 71.7 (120-430) minutes for the total thyroidectomy, and 136.7 ± 109.8 (64-263) minutes for the completion thyroidectomy. The final pathology report revealed 107 (70.4%) benign nodules, 44 (28.9%) nodules with underlying papillary thyroid carcinoma, and 1 (0.7%) case with Hurthle cell carcinoma. Of the 152 cases, 7 (4.7%) patients developed temporary hypoparathyroidism. There were 5 (3.3%) patients who developed transient recurrent laryngeal nerve (RLN) injury and 3 (2.0%) with persistent injury of the RLN. Temporary lower lip numbness was noted in 51 (33.6%) patients whereas 1 (0.7%) patient was noted to have persistent numbness. We reported 57 (38.5%) patients with temporary chin numbness, 9 (5.9%) patients with skin injuries, and 2 (1.3%) with tracheal perforation. Conclusion: To date, the literature and the outcomes from these 5 international institutions have determined that, in select patients, TOETVA can be as safe and efficacious as the traditional trans-cervical technique for the treatment of specific thyroid pathologies.

Primera tiroidectomía transoral vestibular endoscópica (TOETVA) en la Argentina / First transoral endoscopic thyroidectomy vestibular approach in Argentina

Se realizó una lobectomía transoral vestibular endoscópica (TOETVA) en una paciente femenina de 53 años interesada particularmente en su resultado cosmético, que presentaba un nódulo de 40 mm en el lóbulo tiroideo izquierdo. Mostró una excelente evolución posoperatoria. Se realizó la revisión de la bibliografía acerca de este abordaje y se informa el primer caso del país.

A 53-year-old female patient with a 40-mm nodule in the left thyroid lobe underwent surgery using the transoral endoscopic thyroidectomy vestibular approach (TOETVA) because she was particularly interested in the cosmetic results. She evolved with excellent postoperative outcome. We review the literature dealing with this approach and report the first case in our country.

Transoral Endoscopic Thyroidectomy Vestibular Approach.

BACKGROUND: Remote-access thyroid surgery has gained popularity and has advanced significantly over the past two decades, given the patient desire to avoid cosmetically displeasing scarring. It has only been recently that natural-orifice transluminal endoscopic surgery (NOTES) techniques have been geared for thyroidectomies. The transoral endoscopic thyroidectomy vestibular approach has been categorized as a NOTES procedure-given the approach to the thyroid gland via incisions in the oral cavity. Our aim is to provide a review of the current literature on the transoral endoscopic thyroidectomy vestibular approach (TOETVA), to present the worldwide experience of this novel procedure, and to outline whether individual patients have characteristics that would make the procedure feasible for this technique. METHODS: A literature review was done to compile articles detailing the international experience with TOETVA. Our experience combined with what has been published in the literature was used to establish which pathological and patient characteristics make this particular technique feasible for a thyroidectomy. RESULTS: We detail in the provided tables both feasibility for this surgical technique and the international experience. CONCLUSION: TOETVA represents the latest remote-access endoscopic technique for the excision of the thyroid gland. TOETVA is being performed at various international institutions and multiple hospitals in the United States.

Ketorolac Use Shortens Hospital Length of Stay After Bariatric Surgery: a Single-Center 5-Year Experience.

INTRODUCTION: There has been a recent increased interest in the use of non-steroidal anti-inflammatory drugs (NSAIDs) such as ketorolac for post-operative pain management to minimize opioid use and decrease hospital length of stay (LOS). Although NSAID use has been controversial following bariatric surgery due to anecdotal concerns for increased gastric bleeding, the impact of ketorolac as an adjunct to opioids needs further investigation on LOS and post-operative complications like bleeding. OBJECTIVE: This study aims to evaluate the impact of post-operative ketorolac use on opioid consumption, LOS, and bleeding risk after bariatric surgery. METHODS: We retrospectively analyzed a prospectively maintained database of all bariatric surgery patients who either underwent sleeve gastrectomy (SG) or Roux-en-Y gastric bypass surgery (RYGB) at a tertiary center between 2011 and 2015. Patients were stratified into 2 groups based on post-operative pain control regimen as follows: (1) ketorolac and opioids and (2) opioids alone. RESULTS: A total of 1555 patients were identified who underwent either SG (n = 1255) or RYGB (n = 300). The overall LOS was 1.81 ± .059 days for ketorolac-opioid patients vs. 2.09 ± .065 days for opioid-only patients (P < 0.001). Furthermore, the risk of post-operative bleeding was similar between the two groups (P = 0.097). CONCLUSION: Patients who received ketorolac as an adjunct to opioids had a significantly shorter LOS compared to opioid-only patients. Additionally, ketorolac use was not associated with increased risk of post-operative bleeding complications. Therefore, if not contraindicated, ketorolac should be considered routinely for post-operative pain control among bariatric surgery patients.

Is bariatric surgery effective for co-morbidity resolution in the super-obese patients?

BACKGROUND: Type 2 diabetes (T2D), obstructive sleep apnea (OSA), hypertension (HTN), and hyperlipidemia (HLD) are common co-morbidities that are strongly associated with obesity. OBJECTIVE: The purpose of this study was to compare the rate of obesity-related co-morbidity remission and percent total body weight loss of super-obese patients with a body mass index (BMI) ≥50 kg/m2 with bariatric patients who have a BMI of 30 to 49.9 kg/m2. SETTING: Academic hospital, United States. METHODS: A retrospective analysis of outcomes of a prospectively maintained database was done on obese patients with a diagnosis of ≥1 co-morbidity (T2D, OSA, HTN, or HLD) who at the time of initial visit had undergone either a sleeve gastrectomy or a Roux-en-Y gastric bypass at our hospital between 2011 and 2015. The patients were stratified based on their preoperative BMI class, BMI of 30 to 49.9 kg/m2 versus BMI ≥50 kg/m2. RESULTS: Of the 930 patients, 732 underwent sleeve gastrectomy and 198 underwent Roux-en-Y gastric bypass. The 6-month follow-up co-morbidity remission rates for patients with a BMI of 30 to 49.9 kg/m2 (n = 759) versus super-obese patients (n = 171) were 46.0% and 36.7% (P = .348) for T2D; 75.0% and 73.2% (P = .772) for OSA; 35.0% and 22.0% (P = .142) for HTN; and 37.0% and 21.0% (P = .081) for HLD, respectively. The 1-year follow-up co-morbidity remission rates for patients with a BMI of 30 to 49.9 kg/m2 versus super-obese patients were 54.2% and 45.5% (P = .460) for T2D; 87.0% and 89.7% (P = .649) for OSA; 37.4% and 23.9% (P = .081) for HTN; and 43.2% and 34.6% (P = .422) for HLD, respectively. Furthermore, there was no difference in the mean percent total weight loss for patients with a preoperative BMI of 30 to 49.9 kg/m2 versus the super-obese at the 6-month (21.4%, 20.9%, P = .612) and 1-year (28.0%, 30.7%, P = .107) follow-ups. CONCLUSION: In our study, preoperative BMI did not have an impact on postoperative co-morbidity remission rates or percent total body weight loss. Future studies should investigate the effect of other factors, such as disease severity and duration.

Minimally invasive adrenal surgery: virtue or vice?

Adrenocortical carcinoma (ACC) is a rare malignancy associated with poor prognosis despite available treatments. In patients with localized or locally advanced disease, complete resection with negative margins offers the only potential for cure. Unfortunately, most patients develop local and distant recurrence following initial resection highlighting the importance of meticulous surgical technique in the hands of an experienced surgeon. While minimally invasive surgery (MIS) has supplanted open surgery for small to medium-sized benign adrenal tumors, controversy surrounds the use of MIS for resection of ACC. We sought to provide an overview of the key oncological principles in the surgical management of ACC and to critically review the literature comparing outcomes between the open and MIS approaches.

Preoperative insulin therapy as a marker for type 2 diabetes remission in obese patients after bariatric surgery.

BACKGROUND: Obesity not only increases the chances of developing diabetes-one of the top causes of death in the United States-but it also results in further medical complications. OBJECTIVE: To compare the 6-month and 1-year postoperative remission rates of type 2 diabetic (T2D) patients after bariatric surgery based on preoperative glycosylated hemoglobin (A1C) stratification and pharmacologic therapy: insulin-dependent diabetic (IDD) versus noninsulin-dependent diabetic (NIDD). SETTING: Academic hospital, United States. METHODS: We retrospectively analyzed a prospectively maintained database of 186 obese patients with a diagnosis T2D who had undergone either a sleeve gastrectomy or a Roux-en-Y gastric bypass surgery at our hospital. RESULTS: At 6 months (n = 180), patients who were stratified by preoperative A1C levels (<6.5; ≥6.5 to<8; ≥8) had 70.5%, 51.7%, and 30.0% remission rates (P<.001) and at 1 year (n = 118) patients had 72.0%, 54.0%, and 42.8% remission rates (P = .053), respectively. When patients were substratified by preoperative pharmacologic therapy, IDD and NIDD patients had different remission rates within the same A1C level. At 6-months follow-up within A1C ≥6.5 to<8 (IDD versus NIDD), the remission rate was 23.5% versus 64.1% (odds ratio [OR]: .173, confidence interval [CI]: .0471, .6308, P = .0079), and within A1C ≥8 the remission was 24.0% versus 37.5% (OR: .5263, CI: .2115, 1.3096, P = .1676), respectively. At 1-year follow-up within A1C ≥6.5 to<8, the remission rate was 30.0% versus 62.9% (OR: .2521, CI: .0529, 1.2019, P = .0838), and within A1C ≥8 the remission was 31.4% versus 61.9% (OR: .2821, CI: .0908, .8762, P = .0286), respectively. Furthermore, when IDD patients were compared between A1C ≥6.5 to<8 and A1C ≥8 the remission rates were nearly identical, and for NIDD patients A1C was not significantly associated with remission regardless of the level, except at 6 months. CONCLUSION: While a difference was observed between overall A1C levels-the lower the A1C level, the higher the remission rate-IDD patients had lower remission rates than NIDD patients irrespective of A1C levels; further, IDD patients performed similarly across A1C levels.