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Does frozen section alter surgical management of multinodular thyroid disease?
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ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS—ABSTRACTS which were found to be significantly associated with postoperative complications. Conclusions: Successful resolution of pancreatic pseudocysts can be achieved by transpapillary drainage and surgical treatment. In this study with not entirely congruent study groups ERCP appeared associated with fewer complications than conventional surgical treatment. Patient variables, specifically ASA classification, may guide surgeons towards a choice of treatment. 361. DISTAL PANCREATECTOMY WITH SPLENIC PRESERVATION REVISITED. J. R. Rodriguez1, M. G. Madanat1, B. C. Healy 1, S. P. Thayer1, A. L. Warshaw1, C. Fernandez-del Castillo2; 1Massachusetts General Hospital, Boston, MA, 2Harvard School of Public Health, Boston, MA. Introduction: In 1988 Warshaw described a novel approach to resecting the distal pancreas while preserving the spleen, relying on blood supply from the short gastric vessels. The benefits of conserving the spleen are well documented, but the short-term implications of this operation have not been examined in depth. The purpose of this study is to describe our outcomes with this surgical technique in a large cohort of patients. Methods: The medical records of 259 patients who underwent distal pancreatic resections at Massachusetts General Hospital from 1994 to 2004 were identified. Their clinical course was detailed retrospectively utilizing hospital and clinic charts and our computerized institutional Clinical Application System. Splenectomy (DP) and splenic preservation (SP) groups were compared with respect to baseline characteristics. Univariate logistic regression was utilized to determine if there was an association between the primary outcome (postoperative complications) and the type of surgery (DP vs. SP). Other potentially relevant predictors were also examined using univariate logistic regression to assess for potential confounders and a multiple logistic regression was modeled. Results: SP was performed in 74 (29%) patients. As a group, these patients were more likely to be women (74% vs. 56%, p⬍0.008) and to undergo the distal pancreatectomy for benign disease (93% vs. 54%, p⬍0.0001). Their operative times were shorter (2.5h vs. 3.1h, p⬍0.0001), they had less blood loss (300ml vs. 500ml, p⬍0.0001) and a shorter length of stay [6 days (IQR 5-7) vs. 7 days (IQR 5-8), p⫽0.001]. Overall postoperative morbidity occurred in 152 patients (58.7%). SP was not a significant predictor of perioperative complications in either univariate (p⫽0.445) or adjusted analysis (p⫽0.50). Significant associations with postoperative complications were found with male gender (p⫽0.011), longer operative time (p⫽0.001), locally advanced disease (p⫽0.031), increasing blood loss (p⬍0.001), and additional surgical procedures (p⫽0.006). In the final multiple logistic regression model only blood loss (OR 1.62) and additional procedures (OR 1.90) were significant predictors of postoperative complications. Re-exploration was required in two patients (2.7%) in the SP group for splenic infarction and in two patients (1.1%) in the DP group for abscess and hemorrhage. There were 2 postoperative deaths (0.8%), both in the DP group. Conclusions: Distal pancreatectomy with splenic preservation relying on blood supply from the short gastric vessels is applicable in about 30% of patients, and although associated with a small need for reexploration related to splenic infarct (2.7%), does not have a higher incidence of postoperative complications. This simple approach to splenic preservation is a desirable alternative to conventional distal pancreatectomy with splenectomy and may have an increasing role as laparoscopic distal pancreatectomy becomes more commonplace. 362. WHAT IS THE BIOLOGY AND OPTIMAL TREATMENT FOR PAPILLARY MICROCARCINOMA OF THE THYROID? Cheema Y, Olson S, Elson D, Chen H; University of Wisconsin Introducation: Papillary microcarcinomas of the thyroid, defined as tumors measuring ⬍10mm, are believed to be a less aggressive subset of papillary cancers which behave more like benign lesions
and are often more conservatively treated. However, some groups have reported a high incidence of metastases from papillary microcarcinomas and favor aggressive surgical resection followed by radioiodine therapy. Therefore, to characterize the biology and optimal treatment for papillary microcarcinomas, we reviewed our experience. Methods: From May 1994 to October 2004, 184 patients underwent surgery for papillary thyroid cancer at our institution. Of these patients, 10 were excluded because there was no record of tumor size. Of the remaining 174 patients, 74 (42%) had papillary microcarcinomas. Data from these patients were retrospectively analyzed. Results: The mean age of these patients was 42⫾1.48 year and 57 (77%) were female. The mean tumor size was 5.7⫾0.38 mm. Of the 74 patients, 12 (16%) had lymph node metastases. The majority of patients (65%) underwent a total thyroidectomy and 61% had radioiodine ablation therapy following surgery. With follow-up up to 134 months, the recurrence rate was 8% and only 2 patients currently have active disease. No patients with papillary microcarcinoma have died during this period. Conclusion: Papillary microcarcinomas of the thyroid are quite common, comprising almost half of all papillary cancers. Despite a significant rate of metastatic disease, the prognosis for patients with microcarcinomas has been excellent with 100% survival and a low recurrence rate. These outcomes may be the result of the aggressive surgical therapy utilized at our institution. Thus, papillary microcarcinomas appear to have a similar biology to other low risk papillary thyroid cancers and warrant similar treatment. 363. DOES FROZEN SECTION ALTER SURGICAL MANAGEMENT OF MULTINODULAR THYROID DISEASE? Olson S, Cheema Y, Harter J, Starling J, Chen H; University of Wisconsin Background: Frozen section (FS) evaluation during thyroid surgery is often utilized to guide intraoperative management. For instance, a previously unrecognized thyroid cancer diagnosed by FS analysis allows an initial definitive operation and reduces the need for re-operation. We sought to determine the utility of FS in patients undergoing thyroidectomy for multinodular thyroid disease. Methods: From May 1994 through November 2004, 236 patients with multinodular goiter underwent thyroidectomy at our institution. Patient data were retrospectively analyzed to see if a frozen section was performed during the procedure and whether it affected the outcome. Results: Of the 236 patients, 135 (57%) had intraoperative FS. There were no differences between patients who had FS analysis and those who did not with regard to age, gender, and the incidence of malignancy. Of the patients who had FS, 4/135 (3%) were subsequently diagnosed with thyroid cancer on permanent histology. Three of these FS were misread as benign. Therefore, the sensitivity of FS for the diagnosis of thyroid cancer was only 25%. Importantly, in none of the 135 patients did FS alter the intraoperative management. Conclusion: While FS was commonly utilized in patients undergoing thyroidectomy at our institution, in no patient over the last decade did FS correctly alter the intraoperative management. Given the time required to perform FS and the cost associated with it, we believe that routine FS should not be performed in these patients. N Frozen Section No Frozen Section p-value
135 101
Mean Age(yrs)
Gender (%female)
% Malignancy
50 ⫾ 14 53 ⫾ 16 0.133
85% 80% 0.312
3% 8% 0.086
364. REVISING THE LEAPFROG INITIATIVE: EXPORTING SURGICAL EXCELLENCE FOR WHIPPLE RESECTION. Maa J, Gosnell JE, Harris HW, Gibbs VC; University of California, San Francisco
ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS—ABSTRACTS which were found to be significantly associated with postoperative complications. Conclusions: Successful resolution of pancreatic pseudocysts can be achieved by transpapillary drainage and surgical treatment. In this study with not entirely congruent study groups ERCP appeared associated with fewer complications than conventional surgical treatment. Patient variables, specifically ASA classification, may guide surgeons towards a choice of treatment. 361. DISTAL PANCREATECTOMY WITH SPLENIC PRESERVATION REVISITED. J. R. Rodriguez1, M. G. Madanat1, B. C. Healy 1, S. P. Thayer1, A. L. Warshaw1, C. Fernandez-del Castillo2; 1Massachusetts General Hospital, Boston, MA, 2Harvard School of Public Health, Boston, MA. Introduction: In 1988 Warshaw described a novel approach to resecting the distal pancreas while preserving the spleen, relying on blood supply from the short gastric vessels. The benefits of conserving the spleen are well documented, but the short-term implications of this operation have not been examined in depth. The purpose of this study is to describe our outcomes with this surgical technique in a large cohort of patients. Methods: The medical records of 259 patients who underwent distal pancreatic resections at Massachusetts General Hospital from 1994 to 2004 were identified. Their clinical course was detailed retrospectively utilizing hospital and clinic charts and our computerized institutional Clinical Application System. Splenectomy (DP) and splenic preservation (SP) groups were compared with respect to baseline characteristics. Univariate logistic regression was utilized to determine if there was an association between the primary outcome (postoperative complications) and the type of surgery (DP vs. SP). Other potentially relevant predictors were also examined using univariate logistic regression to assess for potential confounders and a multiple logistic regression was modeled. Results: SP was performed in 74 (29%) patients. As a group, these patients were more likely to be women (74% vs. 56%, p⬍0.008) and to undergo the distal pancreatectomy for benign disease (93% vs. 54%, p⬍0.0001). Their operative times were shorter (2.5h vs. 3.1h, p⬍0.0001), they had less blood loss (300ml vs. 500ml, p⬍0.0001) and a shorter length of stay [6 days (IQR 5-7) vs. 7 days (IQR 5-8), p⫽0.001]. Overall postoperative morbidity occurred in 152 patients (58.7%). SP was not a significant predictor of perioperative complications in either univariate (p⫽0.445) or adjusted analysis (p⫽0.50). Significant associations with postoperative complications were found with male gender (p⫽0.011), longer operative time (p⫽0.001), locally advanced disease (p⫽0.031), increasing blood loss (p⬍0.001), and additional surgical procedures (p⫽0.006). In the final multiple logistic regression model only blood loss (OR 1.62) and additional procedures (OR 1.90) were significant predictors of postoperative complications. Re-exploration was required in two patients (2.7%) in the SP group for splenic infarction and in two patients (1.1%) in the DP group for abscess and hemorrhage. There were 2 postoperative deaths (0.8%), both in the DP group. Conclusions: Distal pancreatectomy with splenic preservation relying on blood supply from the short gastric vessels is applicable in about 30% of patients, and although associated with a small need for reexploration related to splenic infarct (2.7%), does not have a higher incidence of postoperative complications. This simple approach to splenic preservation is a desirable alternative to conventional distal pancreatectomy with splenectomy and may have an increasing role as laparoscopic distal pancreatectomy becomes more commonplace. 362. WHAT IS THE BIOLOGY AND OPTIMAL TREATMENT FOR PAPILLARY MICROCARCINOMA OF THE THYROID? Cheema Y, Olson S, Elson D, Chen H; University of Wisconsin Introducation: Papillary microcarcinomas of the thyroid, defined as tumors measuring ⬍10mm, are believed to be a less aggressive subset of papillary cancers which behave more like benign lesions
and are often more conservatively treated. However, some groups have reported a high incidence of metastases from papillary microcarcinomas and favor aggressive surgical resection followed by radioiodine therapy. Therefore, to characterize the biology and optimal treatment for papillary microcarcinomas, we reviewed our experience. Methods: From May 1994 to October 2004, 184 patients underwent surgery for papillary thyroid cancer at our institution. Of these patients, 10 were excluded because there was no record of tumor size. Of the remaining 174 patients, 74 (42%) had papillary microcarcinomas. Data from these patients were retrospectively analyzed. Results: The mean age of these patients was 42⫾1.48 year and 57 (77%) were female. The mean tumor size was 5.7⫾0.38 mm. Of the 74 patients, 12 (16%) had lymph node metastases. The majority of patients (65%) underwent a total thyroidectomy and 61% had radioiodine ablation therapy following surgery. With follow-up up to 134 months, the recurrence rate was 8% and only 2 patients currently have active disease. No patients with papillary microcarcinoma have died during this period. Conclusion: Papillary microcarcinomas of the thyroid are quite common, comprising almost half of all papillary cancers. Despite a significant rate of metastatic disease, the prognosis for patients with microcarcinomas has been excellent with 100% survival and a low recurrence rate. These outcomes may be the result of the aggressive surgical therapy utilized at our institution. Thus, papillary microcarcinomas appear to have a similar biology to other low risk papillary thyroid cancers and warrant similar treatment. 363. DOES FROZEN SECTION ALTER SURGICAL MANAGEMENT OF MULTINODULAR THYROID DISEASE? Olson S, Cheema Y, Harter J, Starling J, Chen H; University of Wisconsin Background: Frozen section (FS) evaluation during thyroid surgery is often utilized to guide intraoperative management. For instance, a previously unrecognized thyroid cancer diagnosed by FS analysis allows an initial definitive operation and reduces the need for re-operation. We sought to determine the utility of FS in patients undergoing thyroidectomy for multinodular thyroid disease. Methods: From May 1994 through November 2004, 236 patients with multinodular goiter underwent thyroidectomy at our institution. Patient data were retrospectively analyzed to see if a frozen section was performed during the procedure and whether it affected the outcome. Results: Of the 236 patients, 135 (57%) had intraoperative FS. There were no differences between patients who had FS analysis and those who did not with regard to age, gender, and the incidence of malignancy. Of the patients who had FS, 4/135 (3%) were subsequently diagnosed with thyroid cancer on permanent histology. Three of these FS were misread as benign. Therefore, the sensitivity of FS for the diagnosis of thyroid cancer was only 25%. Importantly, in none of the 135 patients did FS alter the intraoperative management. Conclusion: While FS was commonly utilized in patients undergoing thyroidectomy at our institution, in no patient over the last decade did FS correctly alter the intraoperative management. Given the time required to perform FS and the cost associated with it, we believe that routine FS should not be performed in these patients. N Frozen Section No Frozen Section p-value
135 101
Mean Age(yrs)
Gender (%female)
% Malignancy
50 ⫾ 14 53 ⫾ 16 0.133
85% 80% 0.312
3% 8% 0.086
364. REVISING THE LEAPFROG INITIATIVE: EXPORTING SURGICAL EXCELLENCE FOR WHIPPLE RESECTION. Maa J, Gosnell JE, Harris HW, Gibbs VC; University of California, San Francisco