Gland surgery最新文献

Background: Hypocalcemia is the most common complication following parathyroidectomy (PTX) in patients with primary hyperparathyroidism (PHPT). With asymptomatic PHPT cases increasingly comprising a larger proportion of clinical presentations, the association between preoperative symptom status and postoperative hypocalcemia risk remains poorly defined. This study aimed to identify risk factors for hypocalcemia after PTX in symptomatic vs. asymptomatic PHPT patients to enable individualized calcium management protocols.

Methods: A retrospective analysis was performed on patients with primary PHPT who underwent PTX between July 2012 and August 2024. A total of 478 patients were included and categorized into two groups based on symptomatic status at admission. Data regarding demographics, surgical details, and laboratory parameters were collected. Univariate and multivariate analyses were performed to identify factors associated with postoperative hypocalcemia in PHPT patients.

Results: Multivariate analysis revealed that the preoperative serum chloride/calcium (Cl/Ca) ratio [odds ratio (OR) =1.104; 95% confidence interval (CI): 1.025-1.190; P=0.009], alkaline phosphatase (OR =1.002; 95% CI: 1.001-1.003; P=0.001) and female gender (OR =0.257; 95% CI: 0.103-0.641; P=0.004) were statistically significant predictors of early postoperative hypocalcemia in the symptomatic group. In the asymptomatic group, age ≤60 years (OR =0.379; 95% CI: 0.161-0.894; P=0.03) and a higher preoperative serum Cl/Ca ratio (OR =1.335; 95% CI: 1.170-1.523; P<0.001) were identified as independent predictors of early postoperative hypocalcemia.

Conclusions: This first stratification analysis of PHPT patients by symptomatic status identified the serum Ca/Cl ratio as a common, independent predictor of post-PTX hypocalcemia in both symptomatic and asymptomatic groups. Additionally, in symptomatic patients, alkaline phosphatase levels and female gender were associated with early hypocalcemia. Conversely, for asymptomatic patients, age ≤60 years emerged as a significant predictor.

Breast cancer is the most common malignancy among women, and as survival continues to improve, increasing attention has been placed on optimizing quality of life after treatment. Breast reconstruction is an important part of this process and remains among the top five reconstructive procedures performed in the United States. Reconstruction of the nipple-areola complex (NAC) is often the final-and in many ways the most rewarding-step in the reconstructive sequence. NAC reconstruction plays a critical role in psychological recovery by helping patients regain a sense of wholeness after mastectomy. The objective of this study was to provide an overarching review on NAC reconstruction techniques, drawing from published literature and current institutional practices. A narrative review was conducted by querying PubMed using the terms ("NAC" OR "nipple-areolar complex") AND ("reconstruction" OR "tattoo") to synthesize contemporary literature on NAC reconstruction techniques including local flaps, grafts, implant devices, and tattooing. Additionally, patients who underwent NAC reconstruction at a single academic institution were reviewed and outcomes included. Local flaps are the foundation of surgical NAC reconstruction, though projection loss can vary from 40-75% depending on flap type. Adjuncts such as acellular dermal matrix (ADM), bioabsorbable scaffolds, and implant devices can improve projection durability. Tattooing techniques have advanced substantially able to deliver three dimensional results with a high patient satisfaction and minimal down time; however, pigment fading is common. NAC reconstruction is an individualized process that can be achieved using a variety of tools including flaps, implant devices, and tattooing. These techniques can be used in combination or on their own depending on patient preference and anatomy with the goal of delivering symmetry, durability, and high satisfaction.

Background: During intraoperative neuromonitoring (IONM), an evoked amplitude below 100 µV is typically regarded as loss of signal (LOS). However, after adjusting the event threshold, previously undetectable electromyographic (EMG) waveforms may become visible. This study aimed to evaluate the diagnostic and clinical significance of such subthreshold EMG waveforms.

Methods: A total of 231 patients (335 nerves at risk, NARs) who underwent thyroidectomy with IONM using either EMG endotracheal tube electrodes or adhesive skin electrodes were retrospectively reviewed. Evoked EMG parameters, including mean amplitude and latency after stimulation of the recurrent laryngeal nerve (RLN) and vagus nerve (VN), were analyzed. Preoperative and postoperative laryngoscopic examinations were performed to assess vocal fold mobility.

Results: Among the 335 NARs, twelve NARs (3.5%) demonstrated evoked EMG amplitudes below 100 µV and were confirmed as true LOS, all of which were classified as Type I (segmental) LOS. After stepwise lowering the event threshold from 100 µV to 80 and subsequently to 50 µV, biphasic EMG waveforms became detectable in 10 of these 12 cases. Although all 12 nerves exhibited immediate postoperative vocal fold paralysis, the 10 nerves with detectable low-amplitude waveforms showed complete recovery of vocal fold mobility within eight months postoperatively.

Conclusions: In cases of Type I LOS during thyroid surgery, the presence of subthreshold biphasic EMG waveforms may reflect residual neural conduction and is strongly associated with postoperative vocal fold recovery. These findings suggest that optimization of threshold settings can improve the sensitivity of IONM interpretation and assist in intraoperative prognostic assessment.

In oncologic breast reconstruction, autologous techniques have been demonstrated to provide patients with improved long-term outcomes and fewer complications than implant-based techniques, especially in the setting of adjunct therapies. While the deep inferior epigastric perforator (DIEP) flap remains the gold standard, not all patients are suitable candidates due to insufficient abdominal tissue or prior abdominal surgeries. Recent advances in microsurgical and imaging techniques, such as computed tomography angiography (CTA) for perforator mapping, have provided reconstructive surgeons with the ability to reliably harvest perforator-based flaps from various areas of the body that minimize donor site morbidity while maximizing reconstructive success. The profunda artery perforator (PAP) flap has emerged as a useful tool in the reconstructive microsurgeon's armamentarium for breast reconstruction in patients where more traditional donor sites are inappropriate or unavailable. Harvested from the posteromedial thigh, this fasciocutaneous flap preserves underlying muscle function and offers distinct advantages, including a reliable vascular pedicle and a discreetly hidden scar. This review article outlines the development of the flap, recent modifications, and relevant surgical anatomy, ultimately synthesizing current clinical outcomes to validate the PAP flap as a robust and aesthetically superior alternative for restoring natural breast contour.

Background: Robot-assisted surgical techniques are increasingly adopted in breast reconstruction, yet the optimal implant placement approach remains debated. Robot-assisted nipple-sparing mastectomy (RANSM) with immediate prosthetic breast reconstruction using the Da Vinci system has shown improved cosmetic outcomes and patient satisfaction. While prepectoral reconstruction offers easier implant placement and fewer complications, subpectoral reconstruction provides better upper pole contours and reduced acellular dermal matrix (ADM) requirements. This study compared surgical and esthetic outcomes between prepectoral and subpectoral approaches in robot-assisted immediate prosthetic reconstruction.

Methods: This single-institute retrospective analysis included patients with breast cancer who underwent RANSM with immediate prosthetic breast reconstruction between October 2021 and May 2024. Seventeen breasts from 10 patients (five prepectoral and five subpectoral cases) were analyzed. Surgical metrics, including operation time, console time, blood loss, hospital stay, and complications, were assessed. Seven independent plastic surgeons graded 1-year postoperative esthetic outcomes using the Harvard/National Surgical Adjuvant Breast and Bowel Project scale.

Results: The prepectoral group demonstrated significantly better esthetic outcomes (mean score, 2.42) than those of the subpectoral group (mean score, 3.65; P=0.04). Complication rates were similar between groups, with animation deformities occurring exclusively in the subpectoral group. Subpectoral reconstruction required additional ADM in patients with curved thoracic contours due to muscle injuries.

Conclusions: In conclusion, prepectoral reconstruction provides superior esthetics outcomes and eliminates animation deformity, while subpectoral reconstruction may offer enhanced upper pole support. Both methods offer distinct benefits, with patient-specific factors being crucial for optimal approach selection. Larger studies are needed to refine patient selection and outcomes in robot-assisted reconstruction.

Background: Although myasthenia gravis (MG) commonly coexists with thymoma, its prognostic role in thymoma recurrence is controversial. Therefore, we aimed to identify clinical and pathological predictors of recurrence after thymectomy in a single-center cohort.

Methods: We retrospectively reviewed adult patients who underwent thymectomy for pathologically confirmed thymoma between January 2000 and December 2023 at a single tertiary center. Patients with at least 12 months of follow-up were included. Clinical, surgical, and pathological features were compared between patients with and without MG. Survival outcomes, including recurrence-free survival (RFS, R0 subgroup), progression-free survival (PFS, overall cohort), and overall survival (OS), were analyzed using Kaplan-Meier methods with log-rank tests. Independent predictors of recurrence were evaluated using Cox proportional hazards regression restricted to patients with R0 resection.

Results: Patients with MG were significantly younger and more likely to undergo transsternal extended thymectomy than those without MG. Although thymoma recurrence was more frequent in the MG group, MG status was not significantly associated with RFS or OS. Kaplan-Meier analysis showed that advanced-stage thymoma (stage III-IV) was associated with significantly shorter RFS, PFS, and OS compared with early-stage disease. In multivariate Cox regression restricted to R0 resections, advanced Masaoka stage remained an independent predictor of recurrence, while tumor size showed only a borderline association.

Conclusions: Advanced Masaoka stage is the strongest independent predictor of thymoma recurrence after complete resection. Tumor size demonstrated a borderline association, suggesting a potential contributory role that requires further validation. MG, although clinically important for peri- and post-operative management, was not independently associated with recurrence.

Background: Pancreatic anastomosis has been developed, and each anastomosis has its pros and cons. This study investigated the prevalence of postoperative complications, particularly pancreatic fistula (POPF), among five types of pancreatoenteric anastomoses to determine the optimal anastomosis for patients undergoing pancreatectomy.

Methods: This study retrospectively and consecutively analyzed the data of 365 patients who underwent pancreatectomy with pancreaticoenteral anastomosis at two academic institutions from 1994 to 2024. Pancreaticogastrostomy via invagination was performed in 24 patients (group PG). For pancreaticojejunal anastomosis, we performed an end-to-end invagination procedure on eight patients (group PJI), two-layer suturing procedure on 96 patients (group PJT), Kakita procedure on 55 patients (group K), and modified Blumgart procedure on 182 patients (group B).

Results: Group B had the shortest hospital stay and fastest resumption of oral intake. Groups PG and PJI exhibited higher grade B/C POPF rates and prolonged ascites. The potential benefits of group B included reduced hospitalization period and enhanced recovery owing to decreased POPF rates. Habitual alcohol consumption and high preoperative creatinine levels increased the risk of POPF, whereas external drainage issues and blood loss contributed to prolonged ascites. In particular, habitual alcohol consumption [relative risk (RR) =2.42], group K anastomosis (RR =2.79), soft pancreatic texture (RR =2.48), delayed oral intake (≥4 days; RR =2.78), and complete external drainage (RR =8.68) were independent predictors of POPF.

Conclusions: Modified Blumgart procedure is an optimal pancreaticoenteral anastomosis technique for avoiding POPF. Early oral intake has emerged as a protective factor, highlighting its role in improving postoperative outcomes. Surgeons should prioritize intraoperative blood conservation, perioperative nutritional support, and appropriate anastomotic selection to enhance surgical success.

Background: Adenoid cystic carcinoma (ACC) of the parotid gland is a rare malignant salivary tumor with aggressive biological behavior, including perineural invasion and delayed metastasis. Despite an 85% 5-year survival rate, long-term prognosis declines to approximately 30%. Preoperative imaging diagnosis remains challenging due to ACC's heterogeneous features on ultrasound, often mimicking benign tumors like pleomorphic adenoma, leading to misdiagnosis. The clinical value of multimodal imaging integration for ACC is underexplored.

Case description: A 46-year-old female presented with a painless left parotid mass persisting for >1 year. Initial ultrasound revealed a well-defined, hypoechoic solid nodule (measuring 2.5 cm × 2.0 cm × 2.0 cm on sonography) with homogeneous echogenicity, posterior acoustic enhancement, and sparse punctate/linear vascular signals, suggestive of pleomorphic adenoma. Enhanced computed tomography (CT) showed a heterogeneously enhancing mass (+45 HU arterial phase) without invasion. Postoperative pathology confirmed ACC (cribriform/trabecular patterns; SOX10/p63-positive; Ki-67 3%; MYB::NFIB fusion-negative). The patient underwent parotidectomy with facial nerve preservation and adjuvant radiotherapy, with no recurrence at 6-month magnetic resonance imaging (MRI) follow-up.

Conclusions: This case highlights ACC's propensity for "benign-mimicking" sonographic features (well-defined margins, posterior enhancement, hypovascularity), contributing to misdiagnosis. It underscores that integrating elastography (for assessing stiffness), contrast-enhanced ultrasound (for evaluating washout patterns), CT/MRI (for detecting suspicious perineural spread), and molecular biomarkers (e.g., low Ki-67) is crucial to improving diagnostic accuracy and optimizing follow-up management for ACC.