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Concurrent endocrine and other surgical procedures: an institutional experience
j o u r n a l o f s u r g i c a l r e s e a r c h 0 1 m a y 2 0 1 7 ( 2 1 1 ) 1 0 7 e1 1 3
Available online at www.sciencedirect.com
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Concurrent endocrine and other surgical procedures: an institutional experience Rachel Morris, MD, Tina W.F. Yen, MD, MS, Kara Doffek, BS, Azadeh A. Carr, MD, Stuart D. Wilson, MD, Douglas B. Evans, MD, and Tracy S. Wang, MD, MPH* Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin Milwaukee, WI
article info
abstract
Article history:
Inroduction: The number of endocrine procedures, specifically parathyroidectomy, thy-
Received 14 September 2016
roidectomy, and adrenalectomy, being performed is increasing. There is a paucity of
Received in revised form
literature on the feasibility of combining these procedures with other surgical pro-
28 November 2016
cedures. Therefore, the aim of this study was to determine the effect of performing
Accepted 9 December 2016
concurrent surgical procedures on postoperative outcomes.
Available online 22 December 2016
Methods: This is a single institution retrospective review of multiple prospectively maintained databases of patients who underwent elective thyroidectomy, para-
Keywords:
thyroidectomy, and/or adrenalectomy in combination with another procedure. The
Thyroidectomy
other procedures included soft tissue, breast or hernia, abdominal major, abdominal
Adrenalectomy
minor, cervical, and “other”. Demographics, operative details, length-of-stay, and 30-d
Parathyroidectomy
outcomes were reviewed. “Endocrine-specific” complications included recurrent
Surgical outcomes
laryngeal nerve injury, hypoparathyroidism, cervical wound infection, hematoma, and
Concurrent procedures
other. Results: The cohort comprised 104 patients. Overall, 19 (18%) patients had 21 complications, including endocrine-specific complications in eleven (11%) patients. These eleven complications included recurrent laryngeal nerve injury (n ¼ 3; 3%), hematoma (n ¼ 2; 2%), wound infection (n ¼ 1; 1%), transient hypoparathyroidism (n ¼ 2; 2%), and other (n ¼ 3; 3%). The remaining complications included three (3%) general complications, six (6%) patients with complications related to the concurrent procedure, and one patient who underwent an open adrenalectomy and hysterectomy and developed a midline wound dehiscence, which could not be specifically attributed to either procedure. Conclusions: Less than 5% of patients undergoing a surgical endocrine procedure underwent a concurrent procedure, ranging from soft tissue to major abdominal. Short-term
endocrine-specific
complications
were
managed
safely,
suggesting
that concurrent procedures can be considered, with minimal effect on patient outcomes. ª 2016 Elsevier Inc. All rights reserved.
This manuscript was presented at the 11th Annual Academic Surgical Congress, February 2016, Jacksonville, Florida. * Corresponding author. Division of Surgical Oncology, Department of Surgery, Section of Endocrine Surgery, Medical College of Wisconsin, 9200 W. Wisconsin Avenue, Milwaukee, WI 53226. Tel.: þ1 414 805 5755; fax: þ1 414 805 5771. E-mail address: [email protected] (T.S. Wang). 0022-4804/$ e see front matter ª 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2016.12.013
108
j o u r n a l o f s u r g i c a l r e s e a r c h 0 1 m a y 2 0 1 7 ( 2 1 1 ) 1 0 7 e1 1 3
Introduction An increasing number of surgical endocrine operations (thyroidectomy, parathyroidectomy, and adrenalectomy) are being performed in the United States each year; approximately, 80,000 were performed in 2004, and age-adjusted population projections have predicted that over 100,000 surgical endocrine procedures will be performed by 2020.1 In general, cervical endocrine procedures have a low risk of morbidity and mortality, with reported rates of permanent recurrent laryngeal nerve (RLN) injury ranging from 1%-3% and of permanent hypoparathyroidism from 2%-3%.2,3 Adrenalectomy, for which the laparoscopic approach is now the standard of care, is also associated with low rates of morbidity, with reported complication rates of 5.6%-14% at high-volume centers.4,5 In patients who have indications for a surgical procedure for an unrelated disease process, there may be benefit to performing the endocrine procedure at the same time. Currently, over 900,000 laparoscopic cholecystectomies, 1.4 million integumentary system, and nearly one million abdominal wall hernia repairs are performed annually in the United States.6-8 Combining elective operations may save patients from additional cost and exposure to anesthetic.9 Furthermore, patients with inherited endocrine diseases, such multiple endocrine neoplasia (MEN) 1 or 2, represent an additional population that is likely to have indications for multiple surgical interventions and may benefit from concurrent cervical and abdominal endocrine procedures. It is important that both patients and providers should be aware of the risks and benefits of undergoing concurrent endocrine and other surgical interventions. To our knowledge, no studies have compared rates of complications in patients undergoing endocrine procedures alone versus concurrent endocrine and other surgical procedures. We hypothesized that complication rates would be no different in patients undergoing concurrent endocrine and other operations. The purpose of this study was to examine the postoperative complication rates in patients who underwent concurrent procedures and to compare these rates with patients who underwent endocrine procedures alone.
Methods This is a retrospective review of multiple prospective databases of 2930 patients who underwent thyroidectomy, parathyroidectomy, or adrenalectomy at a single academic institution. The databases spanned the years of 1999-2015 (parathyroid), 2009-2015 (thyroid), and 2002-2015 (adrenal). Study approval, which included a waiver of informed consent, was obtained from the Medical College of Wisconsin Institutional Review Board. All adult patients (>18 y) who underwent thyroidectomy, parathyroidectomy, and adrenalectomy who also underwent a concurrent surgical procedure were included; patients who underwent concurrent parathyroidectomy and thyroidectomy were excluded. Patient demographic and clinical data were collected; this included indications for surgery, operative findings,
length-of-stay, rates of readmission, and final pathology. The concurrent procedures performed included skin, soft tissue, breast or hernia, abdominal major, abdominal minor, cervical, and “other” (Table 1). The “other” group comprised orthopedic and cardiothoracic interventions. Patients who had thyroidectomy or parathyroidectomy in combination with adrenalectomy (combined endocrine group) also were included. Thirty-day outcomes were examined; the time frame of 30-d was chosen, as it is the standard for Medicare, Medicaid, and other agencies. Complications were divided into “cervical endocrine-specific” (RLN injury, hypoparathyroidism, hematoma requiring reoperation, wound infection, and other
Table 1 e Concurrent endocrine and other surgical procedures (excluding seven combined endocrine procedures). Procedure, total# (n ¼ 97)
Parathyroid, n ¼ 30 (29%)
Thyroid, n ¼ 40 (38%)
Adrenal, n ¼ 27 (26%)
12 (40%)
19 (48%)
8 (30%)
Soft tissue
6
9
1
Hernia
6
4
6
Breast
0
4
1
Port removal
0
2
0
Abdominal minor
7 (23%)
7 (18%)
4 (15%)
5
3
4
SSB/Hernia
Laparoscopic cholecystectomy Ileostomy closure
1
0
0
Diagnostic laparoscopy
1
1
0
Salpinopherectomy
0
2
0
Baclofen pump
0
1
0
Abdominal major
6 (20%)
4 (10%)
14 (52%)
Nephrectomy
1
2
0
Pancreatectomy
3
2
4
Gastrectomy
0
0
2
Open cholecystectomy
0
0
4
Other laparotomy
2
0
4
1 (3%)
3 (8%)
1 (4%)
Orthopedic
1
1
0
Cardiothoracic
0
2
1
4 (13%)
7 (18%)
0 (0%)
Other
Neck Parotidectomy
1
2
0
Tonsillectomy
1
1
0
Laryngoscopy
1
1
0
Excision of soft palate
1
0
0
Disc fusion
0
2
0
VATS thymectomy
0
1
0
SSB ¼ skin, soft tissue, breast, hernia; VATS ¼ video-assisted thoracoscopic surgery.
109
morris et al concurrent endocrine and other surgical procedures
complications associated with thyroidectomy or parathyroidectomy), “general” (infectious, pulmonary, arrhythmia, and other), and complications “related to the other procedure”. RLN injury was defined as any known nerve palsy identified on postoperative laryngoscopy, and hypoparathyroidism was defined as the need for calcium and calcitriol supplementation at the 30-d time point. Preoperative vocal cord evaluation via direct laryngoscopy is performed for all patients with subjective changes in voice quality and for those with a previous history of a cervical procedure; postoperative laryngoscopy was performed for patients with subjective changes in voice quality. Following parathyroidectomy, routine calcium supplementation is initiated; our institutional protocol for calcium and calcitriol supplementation after total thyroidectomy has previously been described.10 Both RLN injury and hypoparathyroidism were considered transient, given the time frame of the study. Thirty-day rates of complications were compared between the parathyroid, thyroid, and adrenal groups who had undergone concurrent procedures. The cervical endocrineespecific complication rates for patients who underwent endocrine procedures concurrently with other procedures were also compared to cervical endocrine complication rates for patients who underwent endocrine procedures alone. Continuous variables were evaluated using t-tests, and categorical variables were analyzed with chi-squared tests. P value of less than 0.05 was considered statistically significant.
For the concurrent procedures, 30 (29%) were performed at the time of parathyroidectomy, 40 (38%) at the time of thyroidectomy, and 27 (26%) at the time of adrenalectomy (Table 2). An additional 7 (7%) patients underwent a cervical endocrine procedure (thyroidectomy, parathyroidectomy, or lateral neck dissection) at the time of adrenalectomy. Six of the seven (86%) patients who underwent combined adrenal and cervical endocrine procedures had a known genetic mutation consistent with MEN1 or MEN2A. Five patients had MEN2A, and one patient had MEN1. The remaining patient had a clinical diagnosis of MEN1; however, genetic testing was negative. All patients underwent adrenalectomy in combination with parathyroidectomy (3), thyroidectomy (2), both parathyroidectomy and thyroidectomy (1), or lateral neck dissection (1). Of the 104 patients, 57 (55%) patients had procedures performed by > 1 surgeon. Of these, 32 (66%) patients had >1 surgeon from a specialty within general surgery, and 25 (44%) patients had surgeons from >1 surgical subspecialty (general surgery and an additional specialty, such as orthopedic surgery, neurosurgery, or otolaryngology). The remaining 47 patients had all procedures performed by the same surgeon, including five of seven combined endocrine procedures. There was no difference in the rate of complications between the 32 patients who had >1 surgeon from a specialty within general surgery and the 47 patients who had all procedures performed by the same surgeon (25% versus 19%, P ¼ 0.55).
Length-of-stay and readmission
Results Demographics Of the 2979 patients who underwent thyroidectomy, parathyroidectomy, and/or adrenalectomy during the study period, 104 (3.5%) patients underwent a concurrent procedure and were included in the final cohort. The median age was 53 y (range, 24-87), and the majority of patients were female (n ¼ 59; 57%) and white (n ¼ 69; 66%). Parathyroidectomy patients were older (median age, 60; range, 34-87) than thyroidectomy (median, 50; range, 21-82) or adrenal (median, 53; range, 24-71) patients (P ¼ 0.03). There were no differences by race or body mass index between the groups (Table 2).
Overall median length-of-stay for the cohort was 2 d (range, 0-20). Median length-of-stay was 1 d for parathyroid (range, 0-16) and thyroid (range, 1-8) patients. The median length-of stay for adrenal patients was 4 d (range, 1-20), including patients undergoing adrenalectomy at the time of thyroidectomy or parathyroidectomy. In each group, patients with a longer length-of-stay had a more complex concurrent procedure, specifically abdominal major. The longer length-ofstay for these patients was related to the abdominal major procedure, including management of postoperative ileus, pain, and wound care. Overall, three (3%) patients were readmitted within the 30-d period. One patient, who underwent thyroidectomy
Table 2 e Demographics of the 104 patients who underwent concurrent endocrine and other surgical procedures. Total, n ¼ 104
Parathyroid, n ¼ 30
Thyroid, n ¼ 40
Adrenal, n ¼ 27
Cervical endocrine and adrenalectomy, n ¼ 7 49 (28-59)
Median age, years (range)
53 (24-87)
60 (34-87)
50 (21-82)
53 (24-71)
Female patients (%)
59 (57)
16 (52)
30 (73%)
10 (66)
3 (60)
White
69 (66)
27 (90)
30 (75)
9 (33)
3 (43)
Black
17 (16)
4 (13)
8 (20)
3 (11)
2 (29)
Other
3 (3)
0 (0)
2 (5)
1 (4)
Race (%)
Median body mass index, kg/m2 (range)
P value 0.03 0.26 0.50
29 (17-59)
27.3 (20-59)
28.8 (17-43)
30 (20-48)
0 (0) 29 (25-47)
1.0
110
j o u r n a l o f s u r g i c a l r e s e a r c h 0 1 m a y 2 0 1 7 ( 2 1 1 ) 1 0 7 e1 1 3
complicated by RLN injury and partial nephrectomy, was admitted on postoperative day 3 for a hospital-acquired pneumonia. The patient was brought to the emergency department by her family due to fever and confusion without any documented contact with either surgical team. Two additional patients required readmission and were directly admitted from clinic during their postoperative clinic visit or transferred from another hospital. This included one patient who underwent adrenalectomy with concurrent umbilical hernia repair and who had an intraabdominal fluid collection on postoperative day 15 that did not require drainage. The other patient, who underwent adrenalectomy with concurrent laparoscopic cholecystectomy, was admitted for a fever workup on postoperative day 17 and was subsequently treated for a urinary tract infection. One additional patient, who underwent adrenalectomy and colectomy, was seen in the emergency department for shortness of breath but was discharged home. No other patients were seen postoperatively in the emergency department.
Complications Overall, 19 (18%) patients had 21 complications (Table 3). These included 11 endocrine-specific complications in 11 (11%) patients: 3 (3%) with an RLN injury, 2 (2%) with a cervical hematoma, 2 (2%) with hypoparathyroidism, 1 (1%) with a wound infection (n ¼ 1; 1%), and 3 (3%) patients with other complications. The other complications were a tear in the trachea after thyroidectomy, splenectomy after adrenalectomy, and intraabdominal abscess after adrenalectomy. Of the two patients with hypoparathyroidism, one patient with MEN1 had concurrent subtotal parathyroidectomy and pancreatic surgery and was not given oral medications until there was return of bowel function; therefore, initial
intermittent intravenous-scheduled calcium supplementation was given for the first three postoperative 3 d. Clear liquid diet and tube feeds via surgical jejunostomy tube were started on postoperative day 3, and routine oral calcium supplementation was started on postoperative day 4. The patient was asymptomatic for symptoms of hypocalcemia throughout her postoperative course and was able to tolerate oral calcium and calcitriol during the hospitalization; the patient’s hospital length-of-stay (15 d) was related to prolonged recovery of gastrointestinal function and not management of postoperative hypoparathyroidism. Of the remaining 10 complications in eight patients, three patients (2.8%) had a general complication, which included pneumonia, postoperative arrhythmia, and an infectious complication (Table 3). Six patients (6%) had a complication specifically related to the other procedure: pneumothorax after video-assisted thoracoscopic surgery, wound infection after nephrectomy, hematoma after mastectomy, chyle leak after pancreaticoduodenectomy, pancreatic leak after distal pancreatectomy, and conduit ischemia after esophagectomy. Two of these patients required reoperation for evacuation of breast hematoma and revision of esophageal conduit. Two patients had more than one complication. These were intraabdominal infection and postoperative arrhythmia after parathyroidectomy and nephrectomy and RLN injury and presumed pneumonia after thyroidectomy and nephrectomy. She presented to the emergency department with confusion and fever and was treated with empiric antibiotics for a presumed pneumonia, based on findings on chest x-ray, although all sputum cultures were negative. One patient undergoing an open adrenalectomy and total abdominal hysterectomy with bilateral salpingo-oophorectomy developed a midline wound dehiscence, which could not be attributed to either specific procedure.
Table 3 e 30-d complications after combined endocrine and other surgical procedure. Parathyroid, n ¼ 30
Thyroid, n ¼ 40
Adrenal, n ¼ 27
Cervical endocrine and adrenalectomy, n ¼ 7
P value
4 (13%)
10 (25%)
4 (15%)
1 (14%)
0.53
5
11
4
1
0.53
Infectious
1
0
1
0
0.48
Pulmonary
0
1
0
0
0.66
Arrhythmia
1
0
0
0
0.48
Nerve injury
0
3
0
0
0.18
Hematoma
1
1
0
0
0.79
Infectious
0
1
0
0
0.74
Other
1
1
1
0
0.96
Hypoparathyroidism
1
0
0
1
0.06
Other n ¼ 6
1
4
1
0
0.52
Unknown n ¼ 1
0
0
1
0
0.41
Total number of patients with a complication (%) Total events General n ¼ 3
Endocrine n ¼ 11
morris et al concurrent endocrine and other surgical procedures
The complication rates of the 97 patients undergoing concurrent procedures at the time of their endocrine procedure (excluding the combined endocrine group) were then compared to the 2930 patients in our institutional database who underwent endocrine procedures alone (Table 4). There was no significant difference in 30-d complications in the patients undergoing parathyroidectomy, thyroidectomy, or adrenalectomy for any complication. Complication rates in both groups were low; however the group with concurrent procedures tended to have higher rates of hypoparathyroidism after parathyroidectomy, neck hematoma after parathyroidectomy, RLN injury after thyroidectomy, and deep space infection after adrenalectomy (Table 4), but these differences were not statistically significant.
Discussion Surgical endocrine procedures (parathyroidectomy, thyroidectomy, and adrenalectomy) are typically associated with low
Table 4 e Comparison of complication rates in patients undergoing endocrine procedures versus combined endocrine and other procedure. Complication
Single procedure
Combined
P value
n ¼ 1489
n ¼ 30
Hypoparathyroidism
67 (4.5%)
2 (6.6%)
0.64
Hematoma
10 (0.7%)
1 (3.3%)
0.43
RLN injury
34 (2.3%)
0
Parathyroid
Wound infection
1 (0.07%)
Cardiac
5 (0.3%)
Pulmonary
0 1 (3.3)
11 (0.7%)
0
Other
7 (0.5%)
1 (3.3%)
Thyroid
n ¼ 1094
n ¼ 40
0.38
0.40
Hypoparathyroidism
33 (3%)
Hematoma
17 (1.6%)
1 (2.4%)
0.71
RLN injury
19 (1.7%)
3 (7.5%)
0.18
6 (0.5%)
0
Superior laryngeal nerve injury Wound infection
0
13 (1.2%)
1 (2.4%)
Chyle leak
7 (0.6%)
0
Cardiac
2 (0.2%)
0
Pulmonary
2 (0.2%)
2 (5.0%)
0.18
Other
1 (0.09%)
1 (2.6%)
0.34
Death
1 (0.09%)
0
n ¼ 237
n ¼ 27
Return to OR for hemorrhage
1 (0.4%)
0
Wound infection
4 (1.7%)
0
Deep space infection
3 (1.3%)
1 (3.7%)
Pulmonary
8 (3.4%)
0
Clostridium difficile
3 (1.3%)
0
Other
3 (1.3%)
1 (3.7%)
0
1 (3.7%)
Adrenal
Unknown
0.60
0.52
0.52
111
rates of morbidity and minimal hospital length-of-stay.11-13 Concurrent procedures with endocrine operations are not well described in the surgical endocrine literature, although it has been described in the literature for procedures in other surgical specialties.14-16 This study examined the safety of undergoing combined surgical endocrine and other procedures. Of the 2930 patients in the cohort, concurrent procedures were performed in 104 (3.5%) patients. There was no difference in 30-d outcomes between patients who underwent endocrine procedures alone or concurrently with other procedures. To our knowledge, this is the first study to document outcomes after concurrent endocrine and other surgical procedures. Concurrent procedures may either be performed for a single disease involving multiple locations or for distinct disease processes. Combined colon and minor liver resections for metastatic disease can be performed with similar morbidity and mortality to colectomy alone as shown in several studies of over 360,000 patients.9,17 Other studies have addressed concurrent procedures for distinct disease processes. A literature review of combined varied elective gynecological and plastics procedures, mainly abdominoplasty for excess abdominal skin, has also been found to be safe and associated with low rates of complications. Operative times were expectedly slightly increased and, there was an excellent satisfaction rate.18 However, time under general anesthesia has been shown to be related to increased complications and length-of-stay in patients undergoing major head and neck surgery.19 It is possible that the longer general anesthetic and operating times may have contributed to the trend toward higher rates of neck hematoma in the concurrent group, due to coagulopathy and/or blood loss, although the differences were not statistically significant. Other studies of over 400 patients have found that combining other procedures such as hysterectomy, appendectomy, or hernia repair with laparoscopic cholecystectomy results in the following advantages: single anesthesia exposure, single hospital stay, and greater convenience for the patient.14 We would expect that these results would be generalizable to other surgical populations. Hyperparathyroidism is the most common endocrinopathy in MEN1 and often involves multigland disease. As a result of the extent of surgical resection required, reported rates of postoperative hypoparathyroidism range from 3%-25% for subtotal and total parathyroidectomy, respectively.20-22 Treatment of hypoparathyroidism usually involves oral calcium with or without calcitriol supplementation. In our series, two patients with MEN developed hypoparathyroidism following parathyroidectomy. One patient with MEN1 underwent concomitant pancreatectomy and required intravenous calcium supplementation due to nil per os (NPO) status. NPO status was a unique consideration requiring alteration of the typical oral calcium supplementation for hypoparathyroidism. The other patient had MEN2A and underwent concomitant parathyroidectomy and adrenalectomy. This patient was treated with oral calcium, and the concurrent procedure did not alter postoperative management. Neither patient developed any further sequela of acute hypocalcemia. However, postoperative requirement of NPO status should be considered when deciding to perform concurrent procedures, as hypocalcemia requiring calcium
112
j o u r n a l o f s u r g i c a l r e s e a r c h 0 1 m a y 2 0 1 7 ( 2 1 1 ) 1 0 7 e1 1 3
supplementation is a known possible consequence of thyroid and parathyroid surgery, and particularly in patients who may require resection of >1 abnormal parathyroid gland. This potential complication can be more difficult to manage after combined abdominal procedures, although no additional complications were noted in our study. Patients with MEN1 or MEN2 are likely to have indications for multiple surgical endocrine procedures and were safely managed after combined endocrine procedures in our series. This study has several limitations, including those specific to a retrospective observational series, such as missing data points. Analysis of complication rates for the nonendocrine procedure when performed alone was not included in the study, although complication rates in our combined group were low. We did not perform cost analysis on this cohort. In addition, we did not examine long-term complication rates (>30 d) in this study. Furthermore, patient selection was likely influenced by both patient and surgeon bias. It is unclear if healthier patients were more likely to be selected due to their ability to tolerate a more extensive procedure, or if patients with multiple comorbidities were selected in an attempt to limit their anesthetic exposure. Patient and surgeon preference likely had a significant impact on preoperative decision-making.
Conclusion In summary, in this study of 104 patients, the first to describe performance of endocrine operations with other surgical operations, there were no detectable differences in complication rates for the endocrine procedures between patients undergoing concurrent and other surgical procedures versus endocrine procedures alone. We acknowledge that performing concurrent procedures may involve additional logistical challenges, including coordination of multiple surgeons, longer anesthetic times, additional positioning in the operating room, and setup of equipment. The postoperative management of patients who may require oral calcium and/or calcium supplementation may also be more complex in patients who are undergoing concurrent abdominal procedures. However, concurrent procedures could be considered in selective patients as there appears to be minimal impact on patient outcomes, and there are potential advantages, including single anesthetic and patient convenience.
Acknowledgment Authors’ contributions: R.M. contributed to study concept and design; acquisition, analysis, and interpretation of data; and drafting and critical revision of the manuscript. T.W.F.N. contributed to interpretation of data; and drafting and critical revision of the manuscript. K.D. contributed to study concept, acquisition, and interpretation of data; and critical revision of the manuscript. A.A.D. contributed to the critical revision of the manuscript. S.D.W. contributed to study concept and interpretation of data. D.B.E. contributed to the critical revision of the manuscript. T.S.W. contributed to study concept
and design; acquisition, analysis, and interpretation of data; drafting of the manuscript; critical revision of the manuscript; and study supervision.
Disclosure The authors have no financial affiliations or personal relationships to disclose with respect to this manuscript.
references
1. Sosa JA, Wang TS, Yeo HL, et al. The maturation of a specialty: workforce projections for endocrine surgery. Surgery. 2007;142:876e883. 2. The American Association of Endocrine Surgeons, Patient Education Site. 3. Ayala MA, Yencha MW. Outpatient Thyroid Surgery in a LowSurgical Volume Hospital. World J Surg. 2015;39:2253e2258. 4. Dickson PV, Jimenez C, Chisholm GB, et al. Posterior retroperitoneoscopic adrenalectomy: a contemporary American experience. J Am Coll Surg. 2011;212:659, 665-667. 5. Epelboym I, Digesu CS, Johnston MG, et al. Expanding the indications for laparoscopic retroperitoneal adrenalectomy: experience with 81 resections. J Surg Res. 2014;187:496e501. 6. Rutkow IM. Demographic and socioeconomic aspects of hernia repair in the United States in 2003. Surg Clin North Am. 2003;83:1045e1051. vevi. 7. Ingraham AM, Cohen ME, Ko CY, Hall BL. A current profile and assessment of North American cholecystectomy: results from the american college of surgeons national surgical quality improvement program. J Am Coll Surg. 2010;211:176e186. 8. Centers for Disease Control and Prevention, National Center for Health Statistics. Inpatient surgery. 2010. 9. Abbott AM, Parsons HM, Tuttle TM, Jensen EH. Short-term outcomes after combined colon and liver resection for synchronous colon cancer liver metastases: a population study. Ann Surg Oncol. 2013;20:139e147. 10. Cayo AK, Yen TW, Misustin SM, et al. Predicting the need for calcium and calcitriol supplementation after total thyroidectomy: results of a prospective, randomized study. Surgery. 2012;152:1059e1067. 11. Norle´n O, Wang KC, Tay YK, et al. No need to abandon focused parathyroidectomy: a multicenter study of long-term outcome after surgery for primary hyperparathyroidism. Ann Surg. 2015;261:991e996. 12. Khavinin N, Mlodinow A, Kim JY, Ver Halen JP, Antony AK, Samant S. Assessing safety and outcomes in outpatient versus inpatient thyroidectomy using the NSQIP: a propensity score matched analysis of 16,370 patients. Ann Surg Oncol. 2015;22:429e436. 13. Dickson PV, Alex GC, Grubbs EG, et al. Posterior retroperitoneoscopic adrenalectomy is a safe and effective alternative to transabdominal laparoscopic adrenalectomy for pheochromocytoma. Surgery. 2011;150:452e458. 14. Savita K, Khedkar I, Bhartia VK. Combined procedures with laparoscopic cholecystectomy. Indian J Surg. 2010;72:377e380. 15. Kim HJ, Choi G-S, Park JS, Park SY, Jun SH. Simultaneous laparoscopic multi-organ resection combined with colorectal cancer: comparison with non-combined surgery. World J Gastroenterol. 2012;18:806e813. 16. Hensel JM, Lehman JA, Tantri MP, Parker MG, Wagner DS, Topham NS. An outcomes analysis and satisfaction survey of 199 consecutive abdominoplasties. Ann Plast Surg. 2001;46:357e363.
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17. Reddy SK, Pawlik TM, Zorzi D, et al. Simultaneous resections of colorectal cancer and synchronous liver metastases: a multi-institutional analysis. Ann Surg Oncol. 2007;14:3481e3491. 18. Kryger ZB, Dumanian GA, Howard MA. Safety issues in combined gynecologic and plastic surgical procedures. Int J Gynaecol Obstet. 2007;99:257e263. Epub 2007 Jul 30. 19. Boruk M, Chernobilsky B, Rosenfeld RM, Har-El G. Age as a prognostic factor for complications of major head and neck surgery. Arch Otolaryngol Head Neck Surg. 2005;131:605e609.
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20. Fyrsten E, Norle´n O, Hessman O, Sta˚lberg P, Hellman P. Long-term surveillance of treated hyperparathyroidism for multiple endocrine neoplasia type 1: recurrence or hypoparathyroidism? World J Surg. 2016;40:615e621. 21. Lambert LA, Shapiro SE, Lee JE, et al. Surgical treatment of hyperparathyroidism in patients with multiple endocrine neoplasia type 1. Arch Surg Chic Ill. 2005;140:374e382. 22. Tonelli F, Marcucci T, Fratini G, Tommasi MS, Falchetti A, Brandi ML. Is total parathyroidectomy the treatment of choice for hyperparathyroidism in multiple endocrine neoplasia type 1? Ann Surg. 2007;246:1075e1082.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Concurrent endocrine and other surgical procedures: an institutional experience Rachel Morris, MD, Tina W.F. Yen, MD, MS, Kara Doffek, BS, Azadeh A. Carr, MD, Stuart D. Wilson, MD, Douglas B. Evans, MD, and Tracy S. Wang, MD, MPH* Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin Milwaukee, WI
article info
abstract
Article history:
Inroduction: The number of endocrine procedures, specifically parathyroidectomy, thy-
Received 14 September 2016
roidectomy, and adrenalectomy, being performed is increasing. There is a paucity of
Received in revised form
literature on the feasibility of combining these procedures with other surgical pro-
28 November 2016
cedures. Therefore, the aim of this study was to determine the effect of performing
Accepted 9 December 2016
concurrent surgical procedures on postoperative outcomes.
Available online 22 December 2016
Methods: This is a single institution retrospective review of multiple prospectively maintained databases of patients who underwent elective thyroidectomy, para-
Keywords:
thyroidectomy, and/or adrenalectomy in combination with another procedure. The
Thyroidectomy
other procedures included soft tissue, breast or hernia, abdominal major, abdominal
Adrenalectomy
minor, cervical, and “other”. Demographics, operative details, length-of-stay, and 30-d
Parathyroidectomy
outcomes were reviewed. “Endocrine-specific” complications included recurrent
Surgical outcomes
laryngeal nerve injury, hypoparathyroidism, cervical wound infection, hematoma, and
Concurrent procedures
other. Results: The cohort comprised 104 patients. Overall, 19 (18%) patients had 21 complications, including endocrine-specific complications in eleven (11%) patients. These eleven complications included recurrent laryngeal nerve injury (n ¼ 3; 3%), hematoma (n ¼ 2; 2%), wound infection (n ¼ 1; 1%), transient hypoparathyroidism (n ¼ 2; 2%), and other (n ¼ 3; 3%). The remaining complications included three (3%) general complications, six (6%) patients with complications related to the concurrent procedure, and one patient who underwent an open adrenalectomy and hysterectomy and developed a midline wound dehiscence, which could not be specifically attributed to either procedure. Conclusions: Less than 5% of patients undergoing a surgical endocrine procedure underwent a concurrent procedure, ranging from soft tissue to major abdominal. Short-term
endocrine-specific
complications
were
managed
safely,
suggesting
that concurrent procedures can be considered, with minimal effect on patient outcomes. ª 2016 Elsevier Inc. All rights reserved.
This manuscript was presented at the 11th Annual Academic Surgical Congress, February 2016, Jacksonville, Florida. * Corresponding author. Division of Surgical Oncology, Department of Surgery, Section of Endocrine Surgery, Medical College of Wisconsin, 9200 W. Wisconsin Avenue, Milwaukee, WI 53226. Tel.: þ1 414 805 5755; fax: þ1 414 805 5771. E-mail address: [email protected] (T.S. Wang). 0022-4804/$ e see front matter ª 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2016.12.013
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Introduction An increasing number of surgical endocrine operations (thyroidectomy, parathyroidectomy, and adrenalectomy) are being performed in the United States each year; approximately, 80,000 were performed in 2004, and age-adjusted population projections have predicted that over 100,000 surgical endocrine procedures will be performed by 2020.1 In general, cervical endocrine procedures have a low risk of morbidity and mortality, with reported rates of permanent recurrent laryngeal nerve (RLN) injury ranging from 1%-3% and of permanent hypoparathyroidism from 2%-3%.2,3 Adrenalectomy, for which the laparoscopic approach is now the standard of care, is also associated with low rates of morbidity, with reported complication rates of 5.6%-14% at high-volume centers.4,5 In patients who have indications for a surgical procedure for an unrelated disease process, there may be benefit to performing the endocrine procedure at the same time. Currently, over 900,000 laparoscopic cholecystectomies, 1.4 million integumentary system, and nearly one million abdominal wall hernia repairs are performed annually in the United States.6-8 Combining elective operations may save patients from additional cost and exposure to anesthetic.9 Furthermore, patients with inherited endocrine diseases, such multiple endocrine neoplasia (MEN) 1 or 2, represent an additional population that is likely to have indications for multiple surgical interventions and may benefit from concurrent cervical and abdominal endocrine procedures. It is important that both patients and providers should be aware of the risks and benefits of undergoing concurrent endocrine and other surgical interventions. To our knowledge, no studies have compared rates of complications in patients undergoing endocrine procedures alone versus concurrent endocrine and other surgical procedures. We hypothesized that complication rates would be no different in patients undergoing concurrent endocrine and other operations. The purpose of this study was to examine the postoperative complication rates in patients who underwent concurrent procedures and to compare these rates with patients who underwent endocrine procedures alone.
Methods This is a retrospective review of multiple prospective databases of 2930 patients who underwent thyroidectomy, parathyroidectomy, or adrenalectomy at a single academic institution. The databases spanned the years of 1999-2015 (parathyroid), 2009-2015 (thyroid), and 2002-2015 (adrenal). Study approval, which included a waiver of informed consent, was obtained from the Medical College of Wisconsin Institutional Review Board. All adult patients (>18 y) who underwent thyroidectomy, parathyroidectomy, and adrenalectomy who also underwent a concurrent surgical procedure were included; patients who underwent concurrent parathyroidectomy and thyroidectomy were excluded. Patient demographic and clinical data were collected; this included indications for surgery, operative findings,
length-of-stay, rates of readmission, and final pathology. The concurrent procedures performed included skin, soft tissue, breast or hernia, abdominal major, abdominal minor, cervical, and “other” (Table 1). The “other” group comprised orthopedic and cardiothoracic interventions. Patients who had thyroidectomy or parathyroidectomy in combination with adrenalectomy (combined endocrine group) also were included. Thirty-day outcomes were examined; the time frame of 30-d was chosen, as it is the standard for Medicare, Medicaid, and other agencies. Complications were divided into “cervical endocrine-specific” (RLN injury, hypoparathyroidism, hematoma requiring reoperation, wound infection, and other
Table 1 e Concurrent endocrine and other surgical procedures (excluding seven combined endocrine procedures). Procedure, total# (n ¼ 97)
Parathyroid, n ¼ 30 (29%)
Thyroid, n ¼ 40 (38%)
Adrenal, n ¼ 27 (26%)
12 (40%)
19 (48%)
8 (30%)
Soft tissue
6
9
1
Hernia
6
4
6
Breast
0
4
1
Port removal
0
2
0
Abdominal minor
7 (23%)
7 (18%)
4 (15%)
5
3
4
SSB/Hernia
Laparoscopic cholecystectomy Ileostomy closure
1
0
0
Diagnostic laparoscopy
1
1
0
Salpinopherectomy
0
2
0
Baclofen pump
0
1
0
Abdominal major
6 (20%)
4 (10%)
14 (52%)
Nephrectomy
1
2
0
Pancreatectomy
3
2
4
Gastrectomy
0
0
2
Open cholecystectomy
0
0
4
Other laparotomy
2
0
4
1 (3%)
3 (8%)
1 (4%)
Orthopedic
1
1
0
Cardiothoracic
0
2
1
4 (13%)
7 (18%)
0 (0%)
Other
Neck Parotidectomy
1
2
0
Tonsillectomy
1
1
0
Laryngoscopy
1
1
0
Excision of soft palate
1
0
0
Disc fusion
0
2
0
VATS thymectomy
0
1
0
SSB ¼ skin, soft tissue, breast, hernia; VATS ¼ video-assisted thoracoscopic surgery.
109
morris et al concurrent endocrine and other surgical procedures
complications associated with thyroidectomy or parathyroidectomy), “general” (infectious, pulmonary, arrhythmia, and other), and complications “related to the other procedure”. RLN injury was defined as any known nerve palsy identified on postoperative laryngoscopy, and hypoparathyroidism was defined as the need for calcium and calcitriol supplementation at the 30-d time point. Preoperative vocal cord evaluation via direct laryngoscopy is performed for all patients with subjective changes in voice quality and for those with a previous history of a cervical procedure; postoperative laryngoscopy was performed for patients with subjective changes in voice quality. Following parathyroidectomy, routine calcium supplementation is initiated; our institutional protocol for calcium and calcitriol supplementation after total thyroidectomy has previously been described.10 Both RLN injury and hypoparathyroidism were considered transient, given the time frame of the study. Thirty-day rates of complications were compared between the parathyroid, thyroid, and adrenal groups who had undergone concurrent procedures. The cervical endocrineespecific complication rates for patients who underwent endocrine procedures concurrently with other procedures were also compared to cervical endocrine complication rates for patients who underwent endocrine procedures alone. Continuous variables were evaluated using t-tests, and categorical variables were analyzed with chi-squared tests. P value of less than 0.05 was considered statistically significant.
For the concurrent procedures, 30 (29%) were performed at the time of parathyroidectomy, 40 (38%) at the time of thyroidectomy, and 27 (26%) at the time of adrenalectomy (Table 2). An additional 7 (7%) patients underwent a cervical endocrine procedure (thyroidectomy, parathyroidectomy, or lateral neck dissection) at the time of adrenalectomy. Six of the seven (86%) patients who underwent combined adrenal and cervical endocrine procedures had a known genetic mutation consistent with MEN1 or MEN2A. Five patients had MEN2A, and one patient had MEN1. The remaining patient had a clinical diagnosis of MEN1; however, genetic testing was negative. All patients underwent adrenalectomy in combination with parathyroidectomy (3), thyroidectomy (2), both parathyroidectomy and thyroidectomy (1), or lateral neck dissection (1). Of the 104 patients, 57 (55%) patients had procedures performed by > 1 surgeon. Of these, 32 (66%) patients had >1 surgeon from a specialty within general surgery, and 25 (44%) patients had surgeons from >1 surgical subspecialty (general surgery and an additional specialty, such as orthopedic surgery, neurosurgery, or otolaryngology). The remaining 47 patients had all procedures performed by the same surgeon, including five of seven combined endocrine procedures. There was no difference in the rate of complications between the 32 patients who had >1 surgeon from a specialty within general surgery and the 47 patients who had all procedures performed by the same surgeon (25% versus 19%, P ¼ 0.55).
Length-of-stay and readmission
Results Demographics Of the 2979 patients who underwent thyroidectomy, parathyroidectomy, and/or adrenalectomy during the study period, 104 (3.5%) patients underwent a concurrent procedure and were included in the final cohort. The median age was 53 y (range, 24-87), and the majority of patients were female (n ¼ 59; 57%) and white (n ¼ 69; 66%). Parathyroidectomy patients were older (median age, 60; range, 34-87) than thyroidectomy (median, 50; range, 21-82) or adrenal (median, 53; range, 24-71) patients (P ¼ 0.03). There were no differences by race or body mass index between the groups (Table 2).
Overall median length-of-stay for the cohort was 2 d (range, 0-20). Median length-of-stay was 1 d for parathyroid (range, 0-16) and thyroid (range, 1-8) patients. The median length-of stay for adrenal patients was 4 d (range, 1-20), including patients undergoing adrenalectomy at the time of thyroidectomy or parathyroidectomy. In each group, patients with a longer length-of-stay had a more complex concurrent procedure, specifically abdominal major. The longer length-ofstay for these patients was related to the abdominal major procedure, including management of postoperative ileus, pain, and wound care. Overall, three (3%) patients were readmitted within the 30-d period. One patient, who underwent thyroidectomy
Table 2 e Demographics of the 104 patients who underwent concurrent endocrine and other surgical procedures. Total, n ¼ 104
Parathyroid, n ¼ 30
Thyroid, n ¼ 40
Adrenal, n ¼ 27
Cervical endocrine and adrenalectomy, n ¼ 7 49 (28-59)
Median age, years (range)
53 (24-87)
60 (34-87)
50 (21-82)
53 (24-71)
Female patients (%)
59 (57)
16 (52)
30 (73%)
10 (66)
3 (60)
White
69 (66)
27 (90)
30 (75)
9 (33)
3 (43)
Black
17 (16)
4 (13)
8 (20)
3 (11)
2 (29)
Other
3 (3)
0 (0)
2 (5)
1 (4)
Race (%)
Median body mass index, kg/m2 (range)
P value 0.03 0.26 0.50
29 (17-59)
27.3 (20-59)
28.8 (17-43)
30 (20-48)
0 (0) 29 (25-47)
1.0
110
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complicated by RLN injury and partial nephrectomy, was admitted on postoperative day 3 for a hospital-acquired pneumonia. The patient was brought to the emergency department by her family due to fever and confusion without any documented contact with either surgical team. Two additional patients required readmission and were directly admitted from clinic during their postoperative clinic visit or transferred from another hospital. This included one patient who underwent adrenalectomy with concurrent umbilical hernia repair and who had an intraabdominal fluid collection on postoperative day 15 that did not require drainage. The other patient, who underwent adrenalectomy with concurrent laparoscopic cholecystectomy, was admitted for a fever workup on postoperative day 17 and was subsequently treated for a urinary tract infection. One additional patient, who underwent adrenalectomy and colectomy, was seen in the emergency department for shortness of breath but was discharged home. No other patients were seen postoperatively in the emergency department.
Complications Overall, 19 (18%) patients had 21 complications (Table 3). These included 11 endocrine-specific complications in 11 (11%) patients: 3 (3%) with an RLN injury, 2 (2%) with a cervical hematoma, 2 (2%) with hypoparathyroidism, 1 (1%) with a wound infection (n ¼ 1; 1%), and 3 (3%) patients with other complications. The other complications were a tear in the trachea after thyroidectomy, splenectomy after adrenalectomy, and intraabdominal abscess after adrenalectomy. Of the two patients with hypoparathyroidism, one patient with MEN1 had concurrent subtotal parathyroidectomy and pancreatic surgery and was not given oral medications until there was return of bowel function; therefore, initial
intermittent intravenous-scheduled calcium supplementation was given for the first three postoperative 3 d. Clear liquid diet and tube feeds via surgical jejunostomy tube were started on postoperative day 3, and routine oral calcium supplementation was started on postoperative day 4. The patient was asymptomatic for symptoms of hypocalcemia throughout her postoperative course and was able to tolerate oral calcium and calcitriol during the hospitalization; the patient’s hospital length-of-stay (15 d) was related to prolonged recovery of gastrointestinal function and not management of postoperative hypoparathyroidism. Of the remaining 10 complications in eight patients, three patients (2.8%) had a general complication, which included pneumonia, postoperative arrhythmia, and an infectious complication (Table 3). Six patients (6%) had a complication specifically related to the other procedure: pneumothorax after video-assisted thoracoscopic surgery, wound infection after nephrectomy, hematoma after mastectomy, chyle leak after pancreaticoduodenectomy, pancreatic leak after distal pancreatectomy, and conduit ischemia after esophagectomy. Two of these patients required reoperation for evacuation of breast hematoma and revision of esophageal conduit. Two patients had more than one complication. These were intraabdominal infection and postoperative arrhythmia after parathyroidectomy and nephrectomy and RLN injury and presumed pneumonia after thyroidectomy and nephrectomy. She presented to the emergency department with confusion and fever and was treated with empiric antibiotics for a presumed pneumonia, based on findings on chest x-ray, although all sputum cultures were negative. One patient undergoing an open adrenalectomy and total abdominal hysterectomy with bilateral salpingo-oophorectomy developed a midline wound dehiscence, which could not be attributed to either specific procedure.
Table 3 e 30-d complications after combined endocrine and other surgical procedure. Parathyroid, n ¼ 30
Thyroid, n ¼ 40
Adrenal, n ¼ 27
Cervical endocrine and adrenalectomy, n ¼ 7
P value
4 (13%)
10 (25%)
4 (15%)
1 (14%)
0.53
5
11
4
1
0.53
Infectious
1
0
1
0
0.48
Pulmonary
0
1
0
0
0.66
Arrhythmia
1
0
0
0
0.48
Nerve injury
0
3
0
0
0.18
Hematoma
1
1
0
0
0.79
Infectious
0
1
0
0
0.74
Other
1
1
1
0
0.96
Hypoparathyroidism
1
0
0
1
0.06
Other n ¼ 6
1
4
1
0
0.52
Unknown n ¼ 1
0
0
1
0
0.41
Total number of patients with a complication (%) Total events General n ¼ 3
Endocrine n ¼ 11
morris et al concurrent endocrine and other surgical procedures
The complication rates of the 97 patients undergoing concurrent procedures at the time of their endocrine procedure (excluding the combined endocrine group) were then compared to the 2930 patients in our institutional database who underwent endocrine procedures alone (Table 4). There was no significant difference in 30-d complications in the patients undergoing parathyroidectomy, thyroidectomy, or adrenalectomy for any complication. Complication rates in both groups were low; however the group with concurrent procedures tended to have higher rates of hypoparathyroidism after parathyroidectomy, neck hematoma after parathyroidectomy, RLN injury after thyroidectomy, and deep space infection after adrenalectomy (Table 4), but these differences were not statistically significant.
Discussion Surgical endocrine procedures (parathyroidectomy, thyroidectomy, and adrenalectomy) are typically associated with low
Table 4 e Comparison of complication rates in patients undergoing endocrine procedures versus combined endocrine and other procedure. Complication
Single procedure
Combined
P value
n ¼ 1489
n ¼ 30
Hypoparathyroidism
67 (4.5%)
2 (6.6%)
0.64
Hematoma
10 (0.7%)
1 (3.3%)
0.43
RLN injury
34 (2.3%)
0
Parathyroid
Wound infection
1 (0.07%)
Cardiac
5 (0.3%)
Pulmonary
0 1 (3.3)
11 (0.7%)
0
Other
7 (0.5%)
1 (3.3%)
Thyroid
n ¼ 1094
n ¼ 40
0.38
0.40
Hypoparathyroidism
33 (3%)
Hematoma
17 (1.6%)
1 (2.4%)
0.71
RLN injury
19 (1.7%)
3 (7.5%)
0.18
6 (0.5%)
0
Superior laryngeal nerve injury Wound infection
0
13 (1.2%)
1 (2.4%)
Chyle leak
7 (0.6%)
0
Cardiac
2 (0.2%)
0
Pulmonary
2 (0.2%)
2 (5.0%)
0.18
Other
1 (0.09%)
1 (2.6%)
0.34
Death
1 (0.09%)
0
n ¼ 237
n ¼ 27
Return to OR for hemorrhage
1 (0.4%)
0
Wound infection
4 (1.7%)
0
Deep space infection
3 (1.3%)
1 (3.7%)
Pulmonary
8 (3.4%)
0
Clostridium difficile
3 (1.3%)
0
Other
3 (1.3%)
1 (3.7%)
0
1 (3.7%)
Adrenal
Unknown
0.60
0.52
0.52
111
rates of morbidity and minimal hospital length-of-stay.11-13 Concurrent procedures with endocrine operations are not well described in the surgical endocrine literature, although it has been described in the literature for procedures in other surgical specialties.14-16 This study examined the safety of undergoing combined surgical endocrine and other procedures. Of the 2930 patients in the cohort, concurrent procedures were performed in 104 (3.5%) patients. There was no difference in 30-d outcomes between patients who underwent endocrine procedures alone or concurrently with other procedures. To our knowledge, this is the first study to document outcomes after concurrent endocrine and other surgical procedures. Concurrent procedures may either be performed for a single disease involving multiple locations or for distinct disease processes. Combined colon and minor liver resections for metastatic disease can be performed with similar morbidity and mortality to colectomy alone as shown in several studies of over 360,000 patients.9,17 Other studies have addressed concurrent procedures for distinct disease processes. A literature review of combined varied elective gynecological and plastics procedures, mainly abdominoplasty for excess abdominal skin, has also been found to be safe and associated with low rates of complications. Operative times were expectedly slightly increased and, there was an excellent satisfaction rate.18 However, time under general anesthesia has been shown to be related to increased complications and length-of-stay in patients undergoing major head and neck surgery.19 It is possible that the longer general anesthetic and operating times may have contributed to the trend toward higher rates of neck hematoma in the concurrent group, due to coagulopathy and/or blood loss, although the differences were not statistically significant. Other studies of over 400 patients have found that combining other procedures such as hysterectomy, appendectomy, or hernia repair with laparoscopic cholecystectomy results in the following advantages: single anesthesia exposure, single hospital stay, and greater convenience for the patient.14 We would expect that these results would be generalizable to other surgical populations. Hyperparathyroidism is the most common endocrinopathy in MEN1 and often involves multigland disease. As a result of the extent of surgical resection required, reported rates of postoperative hypoparathyroidism range from 3%-25% for subtotal and total parathyroidectomy, respectively.20-22 Treatment of hypoparathyroidism usually involves oral calcium with or without calcitriol supplementation. In our series, two patients with MEN developed hypoparathyroidism following parathyroidectomy. One patient with MEN1 underwent concomitant pancreatectomy and required intravenous calcium supplementation due to nil per os (NPO) status. NPO status was a unique consideration requiring alteration of the typical oral calcium supplementation for hypoparathyroidism. The other patient had MEN2A and underwent concomitant parathyroidectomy and adrenalectomy. This patient was treated with oral calcium, and the concurrent procedure did not alter postoperative management. Neither patient developed any further sequela of acute hypocalcemia. However, postoperative requirement of NPO status should be considered when deciding to perform concurrent procedures, as hypocalcemia requiring calcium
112
j o u r n a l o f s u r g i c a l r e s e a r c h 0 1 m a y 2 0 1 7 ( 2 1 1 ) 1 0 7 e1 1 3
supplementation is a known possible consequence of thyroid and parathyroid surgery, and particularly in patients who may require resection of >1 abnormal parathyroid gland. This potential complication can be more difficult to manage after combined abdominal procedures, although no additional complications were noted in our study. Patients with MEN1 or MEN2 are likely to have indications for multiple surgical endocrine procedures and were safely managed after combined endocrine procedures in our series. This study has several limitations, including those specific to a retrospective observational series, such as missing data points. Analysis of complication rates for the nonendocrine procedure when performed alone was not included in the study, although complication rates in our combined group were low. We did not perform cost analysis on this cohort. In addition, we did not examine long-term complication rates (>30 d) in this study. Furthermore, patient selection was likely influenced by both patient and surgeon bias. It is unclear if healthier patients were more likely to be selected due to their ability to tolerate a more extensive procedure, or if patients with multiple comorbidities were selected in an attempt to limit their anesthetic exposure. Patient and surgeon preference likely had a significant impact on preoperative decision-making.
Conclusion In summary, in this study of 104 patients, the first to describe performance of endocrine operations with other surgical operations, there were no detectable differences in complication rates for the endocrine procedures between patients undergoing concurrent and other surgical procedures versus endocrine procedures alone. We acknowledge that performing concurrent procedures may involve additional logistical challenges, including coordination of multiple surgeons, longer anesthetic times, additional positioning in the operating room, and setup of equipment. The postoperative management of patients who may require oral calcium and/or calcium supplementation may also be more complex in patients who are undergoing concurrent abdominal procedures. However, concurrent procedures could be considered in selective patients as there appears to be minimal impact on patient outcomes, and there are potential advantages, including single anesthetic and patient convenience.
Acknowledgment Authors’ contributions: R.M. contributed to study concept and design; acquisition, analysis, and interpretation of data; and drafting and critical revision of the manuscript. T.W.F.N. contributed to interpretation of data; and drafting and critical revision of the manuscript. K.D. contributed to study concept, acquisition, and interpretation of data; and critical revision of the manuscript. A.A.D. contributed to the critical revision of the manuscript. S.D.W. contributed to study concept and interpretation of data. D.B.E. contributed to the critical revision of the manuscript. T.S.W. contributed to study concept
and design; acquisition, analysis, and interpretation of data; drafting of the manuscript; critical revision of the manuscript; and study supervision.
Disclosure The authors have no financial affiliations or personal relationships to disclose with respect to this manuscript.
references
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