World Journal of Surgery最新文献

Background: Up to 45% of patients may have persistently elevated parathyroid hormone (PTH) levels after curative parathyroidectomy for primary hyperparathyroidism (PHPT), although the clinical significance is unclear. We aimed to assess the long-term clinical significance of persistently elevated PTH early after parathyroidectomy.

Methods: A prospectively collected institutional database was queried for patients who underwent parathyroidectomy for sporadic PHPT between 12/99 and 6/22 and had normal serum calcium levels at 6 months postoperatively. Demographic and clinical data were collected, including diagnoses associated with secondary HPT (gastrointestinal malabsorptive diseases, kidney disease, and vitamin D deficiency). Patients were divided into two groups: normal PTH or elevated PTH at 6 months postoperatively. The rate of persistently elevated PTH, average time to PTH normalization, and time to recurrence were determined.

Results: The final cohort included 1146 patients; 849 (91%) had normal PTH levels and 194 (17%) had early postoperative normocalcemia with elevated PTH at 6 months postoperatively. Among 194 patients (mean follow-up: 50 ± 53 months), 14 (7.2%) developed recurrent pHPT and 86 (44.3%) had normalization of PTH levels (median time to normalization: 12 months) (IQR: 9 and 15). There was no difference in the presence of diagnoses associated with secondary HPT between patients who had recurrent PHPT, normalization of PTH levels, or remained normocalcemic with persistently elevated PTH levels. The median time to recurrence was 22 months (IQR: 11 and 48) for the 7.2% of patients who developed recurrent PHPT compared to 2.4% in the 849 patients with normal calcium and PTH levels at 6 months (p < 0.001).

Conclusions: Following curative parathyroidectomy, persistent elevation of PTH levels is not uncommon. Although most patients have a durable cure, it may be an early sign of persistent/recurrent PHPT. Long-term surveillance for recurrence is necessary.

Background: For small papillary thyroid cancers (PTCs) with no lateral nodal involvement, American Thyroid Association guidelines recommend performing prophylactic central lymph node dissection (pCLND) if it influences further management. Our cohort study explored to what extent performing pCLND for small PTCs can de-escalate subsequent therapy including completion thyroidectomy and adjuvant radioactive iodine (RAI) ablation.

Methods: Adults with T1, T2, and cN0 PTCs were identified from 42 centers across the prospectively maintained Australian and New Zealand Thyroid Cancer Registry (ANZTCR) between 2017 and 2023. Patients were excluded if they had clinical nodal involvement or distant metastases. Subsequent therapy and complication rates were compared between patients with and without pCLND.

Results: Out of 1290 patients with T1, T2, and cN0 PTCs (78% female and median age 53 years), 660 (51%) received a total thyroidectomy and 630 (49%) received a hemithyroidectomy. Prophylactic CLND was performed for 477 patients (37%) and 36% uncovered occult lymph node metastases. After adjusting for differences in age, sex, and tumor characteristics, absence of lymph node metastasis after pCLND was independently associated with fewer completion thyroidectomies (adjusted relative risk [aRR] = 0.65 and p = 0.008) and reduced RAI ablation (aRR 0.55 and p < 0.001). Additionally, pCLND was not associated with higher risks of recurrent laryngeal nerve injury (p = 0.33), temporary hypocalcemia (p = 0.21), or permanent hypoparathyroidism (p = 0.48).

Conclusions: In specialized settings across Australia and New Zealand, identifying negative lymph nodes from pCLND is associated with reduced completion thyroidectomies and RAI ablation amongst low risk cN0 PTCs. There were no additional complications rates when performed by experienced thyroid surgeons.

Background: Despite widespread use of standardized classification systems, risk stratification of thyroid nodules is nuanced and often requires diagnostic surgery. Genomic sequencing is available for this dilemma however, costs and access restricts global applicability. Artificial intelligence (AI) has the potential to overcome this issue nevertheless, the need for black-box interpretability is pertinent. We aimed to create an ultrasonographic segmentation and classification model that offers explainability and risk accountability.

Methodology: Four hundred and fourteen ultrasonography images were collected from 105 patients undergoing thyroidectomy, divided into training and testing groups. Classification ground truth used is exclusively surgical histopathology. Relevant nodules were manually annotated by a dedicated study radiologist and surgeon. Three AI architectures with and without block attention modules were trained to identify the relevant nodule and the best performing was selected for the subsequent task in classifying identified nodules into benign or malignant. Gradient-Weighted Class Activation Map is used to provide saliency mapping for visual interpretability.

Findings: Superior performance was recorded by the block attention model which stratified thyroid nodules into benign versus malignant with an accuracy of 93% versus 90%, F-score 90% versus 89%, sensitivity 93% versus 91% and specificity 92% versus 91% on a training dataset versus a testing dataset respectively.

Gradcam: Visual interpretability maps demonstrate salient areas for a benign nodule diagnosis overlaps spongiform areas and malignant diagnosis salient areas overlap solid components of a partially cystic-solid nodule and microcalcifications within nodules. These findings are consistent with established diagnostic criteria for benign and malignant nodules.

Conclusion: We developed an image segmentation and classification model for the risk stratification of thyroid nodules benchmarking surgical histopathology as ground truth and providing visual interpretability.

Background: Trauma and pregnancy are both risk factors for venous thromboembolism (VTE). We hypothesized that pregnant blunt trauma patients would have a higher incidence of VTE complications compared with matched nonpregnant females.

Methods: We conducted a retrospective cohort study using National Trauma Data Bank data from 2017 to 2022. Female patients with blunt mechanism, age between 15 and 50 years old, were eligible for inclusion. Patients who presented as transfers, hospitalized for less than 72 h, discharged against medical advice, injury severity score <9, or abbreviated injury scale = 6 of any region were excluded. Pregnant patients were matched 1:2 with nonpregnant female patients by age, injury characteristics, comorbidities, and type and timing of chemical VTE prophylaxis. The primary outcomes were the incidences of VTE, deep vein thrombosis (DVT), and pulmonary embolism (PE). Secondary outcomes included other complications and length of stay.

Results: We included 735 pregnant and 1470 matched nonpregnant controls. The median time to initiate chemical VTE prophylaxis was 33 h in pregnant and 34 h in nonpregnant patients (p = 0.42). The incidence of VTE in pregnant blunt trauma patients was 27 (3.7%) versus 45 (3.1%) in matched controls (p = 0.446). There were no significant differences in DVT, PE, or any other complication or mortality or in ICU or hospital length of stay. Unplanned admissions to the ICU were significantly more frequent in pregnant patients (3.8% vs. 2.2% and p = 0.026).

Conclusion: The incidence of VTE complications was similar in pregnant and matched nonpregnant female blunt trauma patients in this retrospective cohort study, supporting the safety of current VTE prophylaxis practices in pregnant patients.

Objective: To identify and address areas for improvement within the current surgical training model in Australia and New Zealand relating to family planning and inflexible training as top barriers to gender equity in surgery.

Methods: A cross-sectional study of accredited surgical trainees and early career surgeons in Australia and New Zealand was conducted between September and October 2023. Participants were recruited by the RACS Fax Mentis, the Urological Society of Australia and New Zealand (USANZ) e-newsletter, and medical social media networks. Qualitative and quantitative data were collated by the electronic survey and thematically analyzed.

Results: There was a total of 146 participants. Approximately two-thirds of respondents identified as mothers and one-third as fathers, with representation from all surgical specialties. We identified four key themes including the disruptive impact of poor work-life balance on family planning, an absence of workplace systemic supports, a need for structured support program upon return-to-work from parental leave, and challenges in balancing professional and parental identities and responsibilities.

Conclusion: To promote a culture of equity, inclusivity, and acceptance, restructuring of surgical training programs are necessary to support trainees as they navigate family planning and parenthood. Promotion of flexible training options and recruitment of additional clinical supports around parental leave period may reduce negative biases toward trainees simultaneously balancing family and work. Systemic change is required to lower barriers to entry and achieve gender equality in surgery.

Introduction: The 2015 American Thyroid Association guidelines recommend de-escalating surgical treatment for papillary thyroid cancer (PTC). We hypothesize that the Dutch PTC population might differ due to a restrictive diagnostic policy that mainly selects symptomatic and palpable thyroid nodules for further diagnostics, potentially selecting relatively more aggressive tumors. We aimed to describe the Dutch PTC population because differences in populations can have consequences for the adoption of foreign guidelines.

Methods: From the Dutch national cancer registry, patients diagnosed with pT1-T3 PTC between 2005 and 2015 were included. Baseline characteristics, disease-free interval, and overall survival were compared between low-risk and non-low risk PTC. Furthermore, the TNM stage of the Dutch and U.S. cohorts were compared via literature search.

Results: Of the 3368 pT1-T3 patients included, 1813 (53.8%) had a low-risk PTC, and 1555 (46.2%) had a non-low-risk PTC. In the Dutch PTC population, pT1 tumors occurred in 45.8%, pT2 and pT3 tumors occurred in 34.9% and 19.3% of the patients, respectively. Of all patients, 10.2% had central lymph node metastases and 16.6% had lateral lymph node metastasis. Distant metastasis only occurred in 18 (0.5%) of the patients. The 10-year overall survival was 89.6%, with rates of 91.6% for low-risk and 87.3% for non-low-risk patients (p = < 0.001). During the follow-up period, 257 patients (7.6%) had a recurrence.

Discussion: The higher frequency of advanced tumors among the Dutch PTC population in contrast to the U.S. emphasizes the need for careful national data analyses before the adoption of surgical intervention de-escalation protocols from other countries.

Background: American Thyroid Association guidelines support active surveillance (AS) for low-risk papillary thyroid cancer (PTC). We developed a calculator to aid patient selection.

Methods: From 2004 to 2020, 148,904 PTC patients were selected from the surveillance, epidemiology, and end results (SEER) database. Univariable and multivariable analysis evaluated patient and treatment characteristics. Patients were randomly allocated into training (80%) or validation sets (20%). Coefficients generated a mathematical model to predict 5- and 10-year disease-specific survival (DSS).

Results: The mean DSS was 15.5 years with a 5- and 10-year DSS of 99.3% and 98.6%, respectively. Age, sex, race, median household income (MHI), tumor size, and nodal status were significant on multivariable analysis (p ≤ 0.05) and included variables in our calculator. 2404 patients underwent non-operative management (NOM) and were more likely older, male, higher MHI, larger tumor size, and less nodal positivity. Area under the curve (AUC) for 5- and 10-year DSS were 0.83 and 0.81, respectively, for the training set and 0.81 and 0.79, respectively, for the validation set.

Example: 65-year-old White female with a 0.8 cm PTC, cN0 with a MHI ≥ $75,000, had a 10-year predicted DSS was 95.6% with NOM and 99.3% with surgery. Alternatively, changing the patient's race to Hispanic, the 10-year predicted DSS was 94.1% with NOM and 99.0% with surgery.

Conclusions: As awareness of AS for PTC expands, it is important to consider objective data to guide informed decision making. This validated calculator is a useful tool to predict DSS for patients considering AS for PTC.