Surgery最新文献

Background: Primary hyperparathyroidism predominately affects women who are postmenopausal and causes complications, including fragility fractures. Its treatment is parathyroidectomy, which is associated with low complication and >95% cure rates. Considering fractures are associated with premature death, we aimed to determine whether the surgical management of individuals with biochemical diagnosis of primary hyperparathyroidism was associated with a reduction in fracture risk.

Methods: In this population-based cohort study, we used administrative health databases to identify adults ≥18 year old who were biochemically diagnosed with primary hyperparathyroidism between 2007 and 2016 in Ontario. Patients were included if their calcium was ≥2.6 mmol/L (≥10.42 mg/dL) with a concurrent parathyroid hormone of ≥2.2 pmol/L (≥20.75 pg/mL). We followed patients and compared the incidence of fractures between those with and without parathyroidectomy. To control for potential confounding, we used inverse probability of treatment weighting to estimate the average treatment effect in the treated. Fine-Gray competing risk regression models were used to determine the association between surgery and time to fracture.

Results: In a cohort of 28,059 with a biochemical diagnosis of primary hyperparathyroidism, the mean age (standard deviation) was 65 years (14.2 years), and 75% (n = 21,139) were female. Only 12.6% (n = 3,523) underwent parathyroidectomy. Weighted fracture cumulative incidence at 12 years postdiagnosis was 10.17% (n = 182) in surgical patients and 14.04% (n = 2,004) in nonsurgical patients. Parathyroidectomy prevented 1 fracture for every 26 surgeries performed (weighted risk difference, 3.87%, 95% confidence interval, 0.96%-6.62%) and reduced the hazard of fracture by 22% (weighted hazard ratio, 0.78; 95% confidence interval, 0.64-0.95).

Conclusion: In a large, publicly funded health system, parathyroidectomy significantly reduced the short- and long-term risk of fragility fractures in patients with primary hyperparathyroidism.

Background: To date, there is no reliable measure for the prevention of postoperative hemorrhage after thyroid surgery. An increase in the postoperative hemorrhage rate at our institution in 2021 prompted us to look for possible causes with a special focus on perioperative systolic blood pressure, the individual surgeon, and surgeon-to-patient gender congruence.

Methods: We drew on our prospectively managed database to review 43,360 consecutive thyroid surgeries. In addition to a risk factor analysis, a subanalysis of perioperative systolic blood pressure values was performed in 26 patients with postoperative hemorrhage and 26 controls, on the basis of the hypothesis that a targeted pharmacologic increase in systolic blood pressure could reveal covert sources of bleeding.

Results: Postoperative hemorrhage developed in 707 of 43,360 cases (1.6%). Risk factors included older age (odds ratio, 1.017), male gender (odds ratio, 1.629), Graves disease (odds ratio, 1.515), and recurrent benign thyroid disease (odds ratio, 1.693). The individual surgeon significantly influenced the rate of postoperative hemorrhage (odds ratio, up to 2.817). Surgeon-to-patient gender (in)congruence did not affect the rate of postoperative hemorrhage. The subanalysis of perioperative blood pressure revealed mostly arterial bleeding sources (17/26 [65.4%]) and significantly lower intraoperative yet greater postoperative systolic blood pressure values (100 mm Hg vs median 120 mm Hg; P = .009; and 150 mm Hg vs 130 mm Hg; P = .005; respectively) in patients who later developed postoperative hemorrhage.

Conclusion: Although our data suggest that increasing intraoperative systolic blood pressure before wound closure may help to detect covert bleeding sources and therefore prevent postoperative hemorrhage, future studies are necessary to substantiate this finding. We recommend close collaboration with anesthesiologists as well as counteracting postoperative blood pressure increases. The individual surgeon was a major factor influencing the rate of postoperative hemorrhage. However, there were no differences between female and male surgeons operating on female or male patients.