Rebecca S Sippel

Publications (97)307.23 Total impact

• Article: Significance of rebounding parathyroid hormone levels during parathyroidectomy.

  David F Schneider, Kristin A Ojomo, Haggi Mazeh, Sarah C Oltmann, Rebecca S Sippel, Herbert Chen
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  ABSTRACT: BACKGROUND: Using minimally invasive parathyroidectomy (MIP), most surgeons require a 50% decline in intraoperative parathyroid hormone (IoPTH) to determine cure, but the significance of IoPTH kinetics occurring after this drop remains unknown. The aim of this study was to determine the impact of IoPTH levels that first meet criteria for cure, but then increase again, or rebound, between 10 and 15 min postexcision. METHODS: We conducted a retrospective review of patients undergoing initial parathyroidectomy for primary hyperparathyroidism at our institution from 2001 to 2011. Rebound IoPTH was defined as an increase in parathyroid hormone ≥5 pg/mL after achieving the 50% drop required for cure. Comparisons were evaluated with the Student t-test, chi-square test, or Fisher exact test where appropriate. RESULTS: Of the 1386 patients who met selection criteria, 86 (6.2%) patients exhibited rebound IoPTH. The mean magnitude of rebound was 13.8 ± 3.6 pg/mL. Compared with those not displaying rebound, more patients with rebound IoPTH were treated with open parathyroidectomy rather than MIP (10.8% versus 4.5%, P < 0.01). The recurrence rate among those with rebound IoPTH was more than double that of the patients without rebound IoPTH (5.8% versus 2.2%, P = 0.03). Magnitude of rebound, however, did not correlate with recurrence. The rate of persistent disease was not different between those with and without rebound IoPTH. Rebound was a much better indicator of recurrence than patients whose final IoPTH levels were not within the normal range. CONCLUSIONS: Rebound IoPTH is more common in patients who develop recurrent hyperparathyroidism. Therefore, surgeons should closely monitor patients with rebound IoPTH for disease recurrence.
  Journal of Surgical Research 05/2013; · 2.25 Impact Factor
• Article: Radioactive iodine scanning is not beneficial but its use persists for euthyroid patients.

  Rajarajan Panneerselvan, David F Schneider, Rebecca S Sippel, Herbert Chen
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  ABSTRACT: BACKGROUND: Radioactive iodine (RAI) scanning is a method of determining the functional status of thyroid nodules. Historically, practitioners thought "cold" or inactive nodules were more likely malignant. However, surgeons no longer find these scans helpful for preoperative management of euthyroid patients. The purpose of this study was to evaluate the utility of RAI scans. METHODS: We retrospectively reviewed cases of euthyroid patients (thyroid-stimulating hormone > 1.0 mIU/L) who underwent RAI scans before thyroid surgery at our institution between 1994 and 2011. We correlated the RAI scan results with final pathology. We considered RAI scans concordant with pathology when we found a malignancy on the same lobe as a cold nodule. We also tabulated the specialty and affiliation of the ordering physicians. RESULTS: A total of 109 euthyroid patients underwent RAI scanning as part of their preoperative workup. Of these, 88 patients (81%) had a cold nodule. A malignancy concordant with the RAI scan findings occurred in only 15 of these patients (17%). Non-surgical specialties ordered 90 scans (95%). Only 11 of these scans (10%) were performed in the past 5 y, and physicians outside the academic institution ordered all 11 (100%) of these. A linear regression of RAI scanning per year yielded a slightly negative slope (m-0.32 per year). CONCLUSIONS: Radioactive iodine scanning is not useful for the surgical management of thyroid disease in euthyroid patients because it poorly predicts malignancy. The overall use of RAI scans is trending downward, but they are still ordered by non-surgical referring physicians.
  Journal of Surgical Research 04/2013; · 2.25 Impact Factor
• Article: Synchronous and Antecedent Nonthyroidal Malignancies in Patients with Papillary Thyroid Carcinoma.

  Sara E Murray, David F Schneider, Philip S Bauer, Rebecca S Sippel, Herbert Chen
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  ABSTRACT: BACKGROUND: There is a known association between the development of papillary thyroid cancer (PTC) after a primary nonthyroidal cancer (NTC). However, the prevalence of synchronous or antecedent NTCs in patients with PTC is undetermined, as are the clinicopathologic characteristics of PTC in these patients. STUDY DESIGN: A review was performed of our prospectively maintained PTC database between January 1995 and December 2010. Information collected included patient and tumor characteristics, medical history, PTC presentation, and treatment modality. RESULTS: Four hundred and thirty-three adult patients underwent thyroid resection and had PTC on final pathology. Sixty-seven cases of synchronous or antecedent NTCs were observed in 60 patients (13.9%). The most commonly associated antecedent NTCs were breast (n = 11), prostate (n = 8), and melanoma (n = 5), whereas renal cell carcinoma (n = 3) and melanoma (n = 3) were the synchronous NTCs most observed. Compared with patients without an NTC, those with an NTC were older (56.4 ± 15.5 years vs 44.9 ± 14.2 years; p < 0.0001), had experienced radiation exposure (35.0% vs 3.5%; p < 0.001), and more commonly presented with a thyroid mass incidentally on imaging (41.7% vs 9.1%; p ≤ 0.001). Papillary thyroid cancer tumor characteristics were similar between groups, except that NTC patients presented at a more advanced stage. However, when analyzed independently, primary tumor size, and nodal and distant metastases were comparable. CONCLUSIONS: The prevalence of synchronous or antecedent NTCs in patients surgically treated for PTC is 13.9%. These patients present with PTC tumor characteristics similar to those without additional NTCs, and should therefore be managed equivalently. In addition, surgeons should be aware of the frequency of synchronous PTC with these types of tumors and consider evaluation of the neck at the time of NTC diagnosis.
  Journal of the American College of Surgeons 03/2013; · 4.55 Impact Factor
• Article: Follicular Variant of Papillary Thyroid Carcinoma is a Unique Clinical Entity: A Population-Based Study of 10,740 Cases.

  Xiao-Min Yu, David F Schneider, Glen Leverson, Herbert Chen, Rebecca S Sippel
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  ABSTRACT: Background: Follicular variant of papillary thyroid carcinoma (FV-PTC) has been increasingly diagnosed in recent years. However, little is known about its clinical behavior. The purpose of this study was to determine the disease characteristics of FV-PTC, and to compare it with classical papillary thyroid carcinoma (C-PTC) and follicular thyroid carcinoma (FTC). Methods: All cases of C-PTC, FV-PTC and FTC larger than 1 cm in the Surveillance, Epidemiology and End Results (SEER) Cancer Database from 1988 to 2007 were identified. Tumor behavior and patient survival were compared among these three groups. Different risk factors for disease-specific mortality in each group were evaluated by multivariate analysis. Results: A total over 36,000 surgical cases were identified including 21,796 C-PTCs, 10,740 FV-PTCs and 3,958 FTCs. Extrathyroidal extension and lymph node metastases were more common in FV-PTC than in FTC, but significantly less common than in C-PTC (p<0.0001). Distant metastasis rate were present in 2% of patients with FV-PTC, 1% in C-PTC and 4% in FTC (p<0.0001). The 10-year disease-specific survival for patients with FV-PTC was 98%, similar to C-PTC (97%), but better than FTC (94%, p<0.0001). Age greater than 45 years remained a strong risk factor for disease-specific mortality in both FV-PTC and C-PTC, while the presence of extrathyroidal extension and distant metastases were stronger predictors of disease-specific mortality in FV-PTC than in C-PTC. Conclusions: FV-PTC is a common variant of PTC. Its clinical behavior is unique and represents an intermediate entity with clinical features that are between C-PTC and FTC. Interestingly, despite the variations in clinical behavior, the long-term outcome of these patients remains excellent and similar to C-PTC.
  Thyroid: official journal of the American Thyroid Association 03/2013; · 2.60 Impact Factor
• Article: Cancer after Thyroidectomy: A Multi-Institutional Experience with 1,523 Patients.

  J Joshua Smith, Xi Chen, David F Schneider, James T Broome, Rebecca S Sippel, Herbert Chen, Carmen C Solórzano
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  ABSTRACT: BACKGROUND: The incidence of thyroid cancer in patients treated operatively for thyroid disease has been historically low (<5%). Previous series have not specifically addressed cancer rates in both euthyroid and hyperthyroid patients. This study examined cancer frequency in patients referred for removal of benign thyroid disease in a multi-institutional series. STUDY DESIGN: A total of 2,551 patients underwent thyroidectomy at 3 high-volume institutions. Indeterminate/malignant fine-needle aspiration diagnosis was excluded (n = 1,028). Cancer cases were compared among 1,523 patients with Graves' disease (n = 264), nodular goiter (n = 1,095), and toxic nodular goiter (n = 164). Fisher's exact test, chi-square test, Wilcoxon rank sum, Kruskal-Wallis nonparametric t-tests, and multivariable logistic regression were used. RESULTS: Overall, 238 (15.6%) cancers were recorded: Graves' disease (6.1%), nodular goiter (17.5%), and toxic nodular goiter (18.3%). Cancer rates were significantly different among these groups (p < 0.01) and significantly higher in nodular goiter and toxic nodular goiter vs Graves' disease (p < 0.01); no significant differences in cancer rates were noted among institutions. Overall, 275 patients had thyroiditis (18%). There was a significant association with younger age, male sex, nodular thyroids, and cancer (p < 0.05). Presence of thyroiditis or performance of preoperative fine-needle aspiration was not associated with cancer. Mean cancer size was 1.1 cm (46% >0.5 cm; 39% >1 cm). Most patients underwent total thyroidectomy (80%). CONCLUSIONS: These data confirm higher than expected incidental thyroid cancer rates (15.6%) in the largest multi-institutional surgical series to date. Nodular thyroids, males, and young patients were more likely to harbor incidental carcinoma. These data support consideration of initial total thyroidectomy as the preferred approach for patients referred to the surgeon with bilateral nodular disease.
  Journal of the American College of Surgeons 02/2013; · 4.55 Impact Factor
• Article: REMNANT UPTAKE AS A POSTOPERATIVE ONCOLOGIC QUALITY INDICATOR.

  David F Schneider, Kristin A Ojomo, Herbert Chen, Rebecca S Sippel
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  ABSTRACT: BACKGROUND: The purpose of this study was to examine the utility of remnant uptake on postoperative radioiodine scans as an oncologic indicator after thyroidectomy for differentiated thyroid cancer (DTC). METHODS: We conducted a retrospective review of patients undergoing total thyroidectomy for DTC and subsequent radioactive iodine (RAI) treatment. Of the eight surgeons included, three were considered high volume, performing at least 20 thyroidectomies per year. Patients with distant metastases at diagnosis or poorly differentiated variants were excluded. To control for the effect of varying RAI doses, the remnant uptake was analyzed as a ratio of the percentage uptake to the dose received (uptake to dose ratio, UDR). Multivariate logistic regression was used to determine the influence of UDR on recurrence. RESULTS: Of the 223 patients who met inclusion criteria, 21 patients (9.42%) experienced a recurrence. Those who recurred had a ten-fold higher UDR compared to those who did not recur (0.030 vs. 0.003, p = 0.001). Similarly, patients with increasing postoperative thyroglobulin measurements (0.339 vs. 0.003, p<0.001) also had significantly greater UDRs compared to those with stable thyroglobulin. The UDRs of high volume surgeons were significantly smaller than low volume surgeons (0.003 vs. 0.025, p = 0.002). When combined with other known predictors for recurrence, UDR (OR 3.71, C.I 1.05 - 13.10, p = 0.041) was significantly associated with recurrence. High volume surgeons maintained a low level of permanent complications across all UDRs whereas low volume surgeons had greater permanent complications associated with higher uptake.
  Thyroid: official journal of the American Thyroid Association 02/2013; · 2.60 Impact Factor
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  Available from: Haggi Mazeh

  Article: Lymph Node Ratio Predicts Recurrence in Papillary Thyroid Cancer.

  David F Schneider, Haggi Mazeh, Herbert Chen, Rebecca S Sippel
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  ABSTRACT: Background. Lymph node metastasis occurs in 20%-50% of patients presenting for initial treatment of papillary thyroid cancer (PTC). The significance of lymph node metastases remains controversial, and the aim of this study is to determine how the lymph node ratio (LNR) may predict the likelihood of disease recurrence.Methods. We conducted a retrospective review of patients undergoing total thyroidectomy for PTC at our institution from 2005 to 2010. A total LNR (positive nodes to total nodes) and central lymph node ratio (cLNR) was calculated. Regression was used to determine a threshold LNR that best predicted recurrence. Multivariate logistic regression then determined the influence of LNR on recurrence while accounting for other known predictors of recurrence. Kaplan-Meier analysis and the log-rank test were used to compare differences in disease-free survival.Results. Of the 217 patients undergoing total thyroidectomy for PTC, 69 patients had concomitant neck dissections. Sixteen (23.2%) patients developed disease recurrence. When disease-free survival functions were compared, we found that patients with a total LNR ≥0.7 (p < .01) or a cLNR ≥0.86 (p = .04) had significantly worse disease-free survival rates than patients6 with ratios below these threshold values. Considering other known predictors of recurrence, we found that LNR was significantly associated with recurrence (odds ratio: 19.5, 95% confidence interval: 4.1-22.9; p < .01).Conclusions. Elevated total LNR and cLNR are strongly associated with recurrence of PTC after initial operation. LNR in PTC is a tool that can be used to determine the likelihood of the patient developing recurrent disease and inform postoperative follow-up.
  The Oncologist 01/2013; · 3.91 Impact Factor
• Article: Early-phase technetium-99m sestamibi scintigraphy can improve preoperative localization in primary hyperparathyroidism.

  Jocelyn F Burke, Kalpana Naraharisetty, David F Schneider, Rebecca S Sippel, Herbert Chen
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  ABSTRACT: BACKGROUND: In hyperparathyroidism, dual-phase technetium-99m sestamibi scintigraphy is important for parathyroid adenoma localization. We hypothesized that reviewing early-phase scans can increase localization in patients with primary hyperparathyroidism (PHPT). METHODS: We reviewed our prospectively maintained database for patients with sestamibi scans before parathyroidectomy for PHPT from 2001 to 2011. Early-phase scans were read and compared with the location of the gland(s) removed at operation. RESULTS: Of 902 patients identified, radiologists read 693 scans as positive. Of 209 negative scans, 141 (67%) were positive in the early phase; 135 (96%) correctly identified the side of the adenoma. Using radiologist reads, 35% of patients with negative scans and 41% of patients with falsely localized glands required bilateral exploration compared with 5% of patients with correctly localized glands. CONCLUSIONS: A review of early scans in patients with negative imaging increases accurate adenoma localization and allows for minimally invasive operations in more patients.
  American journal of surgery 01/2013; · 2.36 Impact Factor
• Article: Using Body Mass Index to Predict Optimal Thyroid Dosing after Thyroidectomy.

  Kristin A Ojomo, David F Schneider, Alexandra E Reiher, Ngan Lai, Sarah Schaefer, Herbert Chen, Rebecca S Sippel
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  ABSTRACT: BACKGROUND: Current postoperative thyroid replacement dosing is weight based, with adjustments made after thyroid-stimulating hormone values. This method can lead to considerable delays in achieving euthyroidism and often fails to accurately dose over- and underweight patients. Our aim was to develop an accurate dosing method that uses patient body mass index (BMI) data. STUDY DESIGN: A retrospective review of a prospectively collected thyroid database was performed. We selected adult patients undergoing thyroidectomy, with benign pathology, who achieved euthyroidism on thyroid hormone supplementation. Body mass index and euthyroid dose were plotted and regression was used to fit curves to the data. Statistical analysis was performed using STATA 10.1 software (Stata Corp). RESULTS: One hundred twenty-two patients met inclusion criteria. At initial follow-up, only 39 patients were euthyroid (32%). Fifty-three percent of patients with BMI >30 kg/m(2) were overdosed, and 46% of patients with BMI <25 kg/m(2) were underdosed. The line of best fit demonstrated an overall quadratic relationship between BMI and euthyroid dose. A linear relationship best described the data up to a BMI of 50. Beyond that, the line approached 1.1 μg/kg. A regression equation was derived for calculating initial levothyroxine dose (μg/kg/d = -0.018 × BMI + 2.13 [F statistic = 52.7, root mean square error of 0.24]). CONCLUSIONS: The current standard of weight-based thyroid replacement fails to appropriately dose underweight and overweight patients. Body mass index can be used to more accurately dose thyroid hormone using a simple formula.
  Journal of the American College of Surgeons 01/2013; · 4.55 Impact Factor
• Article: Impact of Lymph Node Ratio on Survival in Papillary Thyroid Cancer.

  David F Schneider, Herbert Chen, Rebecca S Sippel
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  ABSTRACT: BACKGROUND: In papillary thyroid cancer, the role of lymph node dissection remains controversial, and staging systems consider metastatic lymph nodes as a binary entity. The purpose of this study was to determine a threshold lymph node ratio (LNR) that impacted disease-specific mortality (DSM). METHODS: We utilized the surveillance, epidemiology, and end results (SEER) database to analyze adult patients who underwent thyroidectomy with lymph node dissection. A LNR (metastatic lymph nodes to total lymph nodes) was calculated after eliminating patients with less than three nodes collected. Kaplan-Meier estimates for DSM were plotted for LNRs and compared by the log rank test. The Cox proportional hazards model was used to evaluate LNR with other known clinical and pathologic determinants of prognosis. RESULTS: A total of 10,955 cases contained data on lymph nodes. Median follow-up time was 25 months (range 0-59 months), and the mean LNR was 0.28 ± 0.37. After comparing Kaplan-Meier survival estimates and overall DSM rates, we found that a LNR ≥0.42 best divided those with lymph node metastasis based on DSM (p < 0.01). Those with a LNR ≥0.42 experienced a DSM rate of 1.72 % while those with a LNR <0.42 had a DSM rate of 0.65 % (p < 0.01). In addition, patients with a LNR ≥0.42 experienced a 77 % higher DSM rate compared to those with metastatic lymph nodes as a whole. When considered with other known determinants of prognosis, we found that LNR was strongly associated with DSM (hazard ratio 4.33, 95 % confidence interval 1.68-11.18, p < 0.01). CONCLUSIONS: LNR is a strong determinant of DSM, and a threshold LNR of 0.42 can be used to risk-stratify patients with metastatic lymph nodes.
  Annals of Surgical Oncology 12/2012; · 4.17 Impact Factor
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  Available from: Haggi Mazeh

  Article: Symptoms of gastroesophageal reflux disease improve after parathyroidectomy.

  Alexandra E Reiher, Haggi Mazeh, Sarah Schaefer, Jon Gould, Herbert Chen, Rebecca S Sippel
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  ABSTRACT: Primary hyperparathyroidism can be associated with symptoms related to GERD, but it is unclear which symptoms of GERD improve after parathyroidectomy. Our goal was to assess prospectively for changes in specific GERD symptoms after parathyroidectomy using a validated questionnaire. Using the GERD health-related quality of life (GERD-HRQL) questionnaire, symptoms of heartburn were prospectively assessed before and 6 months after treatment of hyperparathyroidism with parathyroidectomy. This validated questionnaire includes 10 items, with a Likert scale of 0-5. Scores range from 0 to 45, a lesser score indicates fewer/less severe symptoms. Pre- and postoperative surveys were available for 51 patients. Parathyroidectomy improved the overall questionnaire score (12.5 ± 1.3 vs 4.5 ± 0.9, P < .0001). Overall scores for each question improved after parathyroidectomy, including symptoms of dysphagia (P = .001) and overall satisfaction with symptoms (P < .0001). However, the number of patients taking antireflux medication before and after parathyroidectomy was not substantially different (34 vs 28 patients, P = .17). All symptoms of GERD improved after parathyroidectomy for hyperparathyroidism. Despite the decrease in symptoms, there was not a change in the number of patients who remained on anti-reflux therapy. For patients with symptoms of GERD, a trial off antireflux medications after parathyroidectomy should be considered.
  Surgery 12/2012; 152(6):1232-7. · 3.10 Impact Factor
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  Available from: Haggi Mazeh

  Article: Same-day thyroidectomy program: Eligibility and safety evaluation.

  Haggi Mazeh, Qasim Khan, David F Schneider, Sarah Schaefer, Rebecca S Sippel, Herbert Chen
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  ABSTRACT: Same-day thyroidectomy has not gained widespread acceptance owing to concerns of life-threatening complications. The aim of this study is to describe a single institution same-day thyroidectomy results. We included patients who underwent thyroid surgery between 2005 and 2011 by a single surgeon. The outcomes of patients who underwent inpatient (IP) and same-day thyroidectomy were compared. Routine postoperative parathyroid hormone testing for same-day thyroidectomy commenced in 2010, and results were also compared after that date. Thyroid surgery was performed in 608 patients; 298 (49%) were performed as same-day thyroidectomy. Patients undergoing same-day thyroid lobectomy had similar, low documented complication rate as IP lobectomy. Patients with same-day total thyroidectomy (SDTT) had similar rates of documented transient hypocalcemia and neck hematoma compared with IPs. After 2010, all patients without restrictive underlying comorbidities were scheduled for same-day thyroidectomy unless otherwise specifically requested by the patient. Only 4 (3%) patients scheduled for SDTT were converted to IPs, all without neck complications. Same-day thyroidectomy is safe and can be routinely performed by experienced surgeons who have low complication rates and a patient support system.
  Surgery 12/2012; 152(6):1133-41. · 3.10 Impact Factor
• Article: Toxic Nodular Goiter and Cancer: A Compelling Case for Thyroidectomy.

  J Joshua Smith, Xi Chen, David F Schneider, Ratnam Nookala, James T Broome, Rebecca S Sippel, Herbert Chen, Carmen C Solorzano
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  ABSTRACT: BACKGROUND: Recent American Thyroid Association guidelines call for thyroidectomy or (131)I (Recommendation 31) in managing hyperthyroidism due to toxic nodular goiter (TNG). Concern for concomitant malignancy favors surgery. A 3 % thyroid cancer incidence in TNG patients has been reported, yet recent studies suggest this rate is underestimated. This multi-institutional study examined cancer incidence in TNG patients referred to surgery. METHODS: Patients referred for thyroidectomy at three tertiary-care institutions were included (2002-2011). Patients with concurrent indeterminate or malignant diagnosis by fine-needle aspiration (FNA) were excluded. Cancer incidence in TNG patients was determined. Fisher's exact and chi-square tests and nonparametric t tests were used. RESULTS: Among 2,551 surgically treated patients, 164 had TNG (6.4 %). Median age at presentation was 49.7 years, and 86 % were female. Overall cancer incidence was 18.3 % (30 of 164), and rates were not significantly different between institutions. A significantly greater cancer rate was noted in toxic multinodular goiter versus single toxic nodule patients (21 vs. 4.5 %, P < 0.05). Mean tumor size was 0.71 cm (range 0.1-1.5 cm; 23 % ≥1 cm). Most patients underwent total or near-total thyroidectomy. There were no significant differences in tumor sizes among institutions (P > 0.05). No significant cancer association was noted with age, preoperative dominant nodule size, lymphocytic thyroiditis or preoperative FNA (P > 0.05). CONCLUSIONS: These data demonstrate a higher than expected incidental cancer rate in TNG patients compared to historical reports (18.3 vs. 3 %). This higher cancer incidence may alter the risk/benefit analysis regarding TNG treatment. This information should be provided to TNG patients before decision making regarding treatment.
  Annals of Surgical Oncology 10/2012; · 4.17 Impact Factor
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  Available from: Haggi Mazeh

  Article: Is previous same quadrant surgery a contraindication to laparoscopic adrenalectomy?

  Haggi Mazeh, Alexander B Froyshteter, Tracy S Wang, Amanda L Amin, Douglas B Evans, Rebecca S Sippel, Herbert Chen, Tina W Yen
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  ABSTRACT: BACKGROUND: Previous abdominal surgery may present a challenge to safely completing laparoscopic adrenalectomy. We evaluated the impact of previous ipsilateral upper abdominal surgery on laparoscopic adrenalectomy outcomes. METHODS: A retrospective analysis of prospective databases was performed for patients that underwent laparoscopic transabdominal adrenalectomy at 2 tertiary centers between 2001 and 2011. Patients with previous ipsilateral upper abdominal surgery, contralateral upper abdominal surgery, or no relevant surgery were compared. RESULTS: Of the 217 patients, 38 (17%) had previous ipsilateral upper abdominal surgeries, 17 (8%) had contralateral upper abdominal surgeries, and 162 (75%) had no relevant surgery. Adhesions were more common in the ipsilateral upper abdominal surgery group (63% vs 24% vs 17%; P < .001). Mean operative times (173 ± 100 vs 130 ± 76 vs 149 ± 77 minutes; P = .16) and intraoperative complication rates (3% vs 0% vs 3%; P = .55) were not different. The rate of conversion to open surgery was similar for the 3 groups (11% vs 6% vs 3%; P = .08); all 4 conversions in the ipsilateral upper abdominal surgery group followed previous open procedures. Mean duration of stay and postoperative complication rates were also comparable between the 3 groups. CONCLUSION: Laparoscopic adrenalectomy in patients with previous ipsilateral upper abdominal surgery is feasible and safe, with comparable outcomes to those without previous relevant surgery, including contralateral upper abdominal surgery.
  Surgery 10/2012; · 3.10 Impact Factor
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  Available from: Haggi Mazeh

  Article: Intrathyroidal parathyroid glands: Small, but mighty (a Napoleon phenomenon).

  Haggi Mazeh, Guennadi Kouniavsky, David F Schneider, Konstantinos I Makris, Rebecca S Sippel, Alan P B Dackiw, Herbert Chen, Martha A Zeiger
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  ABSTRACT: BACKGROUND: Intrathyroidal parathyroid adenomas (ITPAs) are a rare entity. The aim of this study is to describe the experience of 2 endocrine surgery centers and to distinguish characteristics of intrathyroidal parathyroid adenoma and nonintrathyroidal parathyroid adenomas. METHODS: We included patients who had undergone operations for primary hyperparathyroidism who had intrathyroidal parathyroid adenomas. Patients with single intrathyroidal parathyroid adenomas were also compared to age- and sex-matched controls with nonintrathyroidal parathyroid adenomas. RESULTS: Of 4,868 patients who underwent parathyroidectomy between January 2002 and June 2011, we identified 53 (1%) patients with intrathyroidal parathyroid adenoma. Sestamibi and ultrasound scans correctly identified the adenoma in 35 (70%) and 11 (61%) cases, respectively. Single adenomas were identified in 44 (83%) patients, double adenomas in 4 (8%) patients, and hyperplasia in 5 (9%) patients. Lobectomy was performed in 17 (32%) patients; enucleation was used in 36 (68%) patients. Cure was achieved in all patients and no patients experienced a recurrence. Patients with single intrathyroidal parathyroid adenomas had significantly smaller glands than patients with nonintrathyroidal parathyroid adenomas (325 ± 47 vs 772 ± 61 mg; P < .0001); however, no significant difference was identified between the groups with regard to demographics, symptoms, preoperative laboratory values, or outcomes. CONCLUSION: Single intrathyroidal parathyroid adenomas are smaller than nonintrathyroidal parathyroid adenomas, but patients with intrathyroidal parathyroid adenomas present with similar laboratory values and symptoms. Recognition of this rare entity can lead to a successful surgical outcome.
  Surgery 10/2012; · 3.10 Impact Factor
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  Available from: Haggi Mazeh

  Article: Is minimally invasive parathyroidectomy associated with greater recurrence compared to bilateral exploration? Analysis of more than 1,000 cases.

  David F Schneider, Haggi Mazeh, Rebecca S Sippel, Herbert Chen
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  ABSTRACT: BACKGROUND: The durability of minimally invasive parathyroidectomy (MIP) has been questioned, and some advocate for routine open parathyroidectomy (OP). This study compared outcomes between patients treated with MIP compared with OP for primary hyperparathyroidism (PHPT). METHODS: A retrospective review was performed to identify cases of PHPT with single adenomas (SA) between 2001 and 2011. Operations were classified as OP when both sides were explored. Kaplan-Meier estimates were plotted and compared by the log-rank test. RESULTS: We analyzed 1,083 patients with PHPT with SA; 928 (85.7%) were MIP and 155 (14.3%) were OP. There was no difference in the rates of persistence (0.2% MIP vs 0% OP, P = .61) or recurrence (2.5% MIP vs 1.9% OP, P = .68) between the 2 groups. The Kaplan-Meier estimates did, however, began to separate beyond 8 years' follow-up. The OP group did experience a greater incidence of transient hypocalcemia postoperatively (1.9% vs 0.1%, P = .01). CONCLUSION: MIP appears equivalent to OP in single-gland disease. Although patients undergoing OP experienced more transient hypocalcemia, patients undergoing MIP appear to have a greater long-term recurrence rate. Therefore, proper patient selection and counseling of these risks is necessary for either approach.
  Surgery 10/2012; · 3.10 Impact Factor
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  Available from: Haggi Mazeh

  Article: Safety and Feasibility of Laparoscopic Resection for Large (≥6 CM) Pheochromocytomas Without Suspected Malignancy.

  Yvette M Carter, Haggi Mazeh, Rebecca S Sippel, Herbert Chen
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  ABSTRACT: Objective: To determine whether laparoscopic adrenalectomy in patients without radiologic evidence of cancer compromises the perioperative and long-term outcomes in patients with large (≥6 cm) pheochromocytomas.Methods: We analyzed a prospective adrenal database of consecutive patients who underwent adrenalectomy at our institution between September 2000 and September 2010. Patients with diagnosed pheochromocytoma who underwent laparoscopic adrenalectomy were included. Patients with tumors smaller than 6 cm were compared with those presenting with tumors 6 cm or larger.Results: One hundred fifty-seven patients underwent adrenalectomy, and there were 32 catecholamine-secreting tumors. Of the 33, 7 were excluded from the study because of open surgery. Thus, 25 patients presented with 26 pheochromocytomas and underwent laparoscopic adrenalectomy. Thirteen of the 25 patients (52%) were women. Mean age (± standard error of the mean) was 53 ± 3 years. Mean tumor size was 5.2 ± 0.5 cm, and 11 pheochromocytomas (42%) were 6 cm or larger. Tumor size was significantly different between the large pheochromocytoma and the small pheochromocytoma groups (7.6 ± 0.4 vs 3.6 ± 0.4 cm, P<.001), but there was no significant difference in intraoperative complications, estimated blood loss, cancer diagnosis, or recurrence. The length of stay was comparable between the 2 cohorts, and there were no incidents of capsular invasion or adverse cardiovascular events.Conclusion: Laparoscopic adrenalectomy of pheochromocytomas larger than 6 cm is feasible and safe with comparable results to those achieved with laparoscopic adrenalectomy in patients with smaller pheochromocytomas.
  Endocrine Practice 09/2012; 18(5):720-6. · 2.49 Impact Factor
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  Available from: Haggi Mazeh

  Article: Incidence and Localization of Ectopic Parathyroid Adenomas in Previously Unexplored Patients.

  Madhuchhanda Roy, Haggi Mazeh, Herbert Chen, Rebecca S Sippel
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  ABSTRACT: BACKGROUND: Parathyroidectomy has a success rate of >95 % for cure of primary hyperparathyroidism. In about 6-16 % of cases, one or more hyperfunctioning parathyroid gland(s) are found in an ectopic location. Accurate preoperative imaging can aid in detecting these ectopically located glands and allow a focused surgical approach with an even higher success rate. The objective of this study was to assess the utility of ultrasonography (US) and technetium-99m-sestamibi (MIBI) scans in locating ectopic parathyroid glands in previously unexplored patients who presented with primary hyperparathyroidism. METHODS: We analyzed a total of 1,562 patients who underwent surgery for hyperparathyroidism at our institution from 2000 to 2010. Ectopic parathyroid adenomas were identified in 346 of the patients (22 %). Of the 346 patients, we excluded 144 who underwent reoperations, had four-gland hyperplasia or were missing imaging details. We carefully reviewed the data, including demographics, laboratory values, preoperative localizing imaging details, and operative findings. Preoperative US and MIBI results were compared to the intraoperative findings. RESULTS: We analyzed 202 patients with ectopic glands for accuracy of preoperative localization. Of these 202 patients, a single adenoma was the most common (89 %) followed by double adenoma (11 %). The ectopic parathyroid glands were predominantly located in the thymus (38 %) followed by 31 % in the retroesophageal region; 18 % were intrathyroidal. Preoperative MIBI scans had a sensitivity of 89 % (161/197), whereas US had a sensitivity of 59 % (35/63) for detecting ectopic glands. Overall, both imaging modalities had a positive predictive value of 90 %, with MIBI correctly predicting ectopic glands best in the thymus, mediastinum, or the retroesophageal space, and US was most accurate at detecting intrathyroidal glands. CONCLUSIONS: Based on the data available at our institution, MIBI has a higher sensitivity than US in correctly localizing ectopic parathyroid adenomas, but the accuracy of detection varies based on location. Both imaging techniques have a high PPV for detecting an ectopic gland. Therefore, imaging with MIBI and US can be complementary, and positive localization of an ectopic gland with either modality is highly accurate and can facilitate a more focused surgical approach.
  World Journal of Surgery 09/2012; · 2.36 Impact Factor
• Article: Persistent hypertension after adrenalectomy for an aldosterone-producing adenoma: Weight as a critical prognostic factor for aldosterone's lasting effect on the cardiac and vascular systems.

  Yvette Carter, Madhuchhanda Roy, Rebecca S Sippel, Herbert Chen
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  ABSTRACT: Primary aldosteronism caused by an aldosterone producing adrenal tumor/aldosteronoma (APA), is a potentially curable form of hypertension, via unilateral adrenalectomy. Resolution of hypertension (HTN) is not as prevalent after tumor resection, as are the normalization of aldosterone secretion, hypokalemia, and other metabolic abnormalities. Here, we review the immediate and long-term medical outcomes of laparoscopic adrenalectomy in patients with an APA, and attempt to identify any distinctive sex differences in the management of resistant HTN. We performed a retrospective review of the prospective adrenal database at the University of Wisconsin between January 2001 and October 2010. Of the 165 adrenalectomies performed, 32 were for the resection of an APA. Patients were grouped according to their postoperative HTN status. Those patients with normal blood pressure (≤120/80 mm Hg) and on no antihypertensive medication (CURE) were compared with those who continued to require medication for blood pressure control (HTN). We evaluated sex, age, body mass index, tumor size, duration of time with high blood pressure, and the differences in systolic and diastolic blood pressure following adrenalectomy. Statistical analysis was performed using Student's t-test. Statistical significance was defined as a P value of <0.05. We identified 32 patients with an APA based on biochemical and radiographic studies, two patients were excluded, due to missing data. There were 19 males (63%) and 11 (37%) females, with a mean age was 48.3 ± 2.1 y, and mean tumor size was 24 ± 3 mm. Postoperatively, patients required significantly fewer antihypertensive medications (1.5 ± 0.2 versus 3.3 ± 0.3, P < 0.001). Nine patients (31%) had complete resolution of their HTN, requiring no postoperative antihypertensive medication. The only significant difference between the sexes, was a lower body mass index in women (27.6 ± 1.7 versus 33.4 ± 2.1 kg/m(2), P = 0.04). Ninety percent of the cohort had at least a 20 mm Hg decline in their systolic blood pressure postoperatively, placing them in the prehypertensive or normal blood pressure categories. Sixty-six percent of the CURE patients required at least 6 mo for resolution of their HTN. All 20 patients who presented with hypokalemia, had immediate resolution postoperatively and did not require continuance of the preoperative spironolactone or potassium supplementation. Laparoscopic adrenalectomy for aldosterone producing adenoma results in the normalization of, or more readily manageable blood pressure in 90% of patients, within 6 mo. Metabolic disturbances are immediately corrected with tumor resection. Weight is an important contributing factor in resolving HTN.
  Journal of Surgical Research 08/2012; 177(2):241-7. · 2.25 Impact Factor
• Article: Sestamibi imaging for primary hyperparathyroidism: the impact of surgeon interpretation and radiologist volume.

  Saqib Zia, Rebecca S Sippel, Herbert Chen
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  ABSTRACT: Preoperative localization is the first step towards minimally invasive targeted parathyroidectomy. While there are data emphasizing that surgeon experience optimizes operative outcomes, the role of the radiologist's experience in successful preoperative imaging is unclear. We hypothesized that the accuracy of sestamibi scanning for primary hyperparathyroidism is dependent upon surgeon interpretation and radiologist volume. Between January 2000 to August 2009, 1,255 patients underwent parathyroidectomy for hyperparathyroidism at our institution. Of these, 763 had sestamibi scans for primary hyperparathyroidism. All scans were reviewed by surgeons and radiologists blinded, and were correlated with the operative findings and pathological reports. Radiologists were grouped into high volume (>50 cases/year, HV-RAD) or low volume (<50 cases/year, LV-RAD) based upon a database of >6,000 parathyroid cases reported by 89 regional hospitals. Of the 763 patients, 77 % were female and the mean age was 60 years. Mean baseline calcium and parathyroid hormone levels were 11.2 ± 0.03 mg/dl and 133 ± 3.27 pg/ml, respectively. The sensitivity of the surgeon (93 %) was higher than both HV (83 %) and LV (72 %) radiologists. Importantly, the positive predictive values were similar: 96 % for surgeon, 93 % for HV-RAD, and 98 % for LV-RAD. As a result, out of 99 scans which were correctly read by the surgeon but not by radiologist, 84 were read as negative by radiologist, 11 on the wrong side of the neck, and 4 on the same side but the wrong gland. Surgeon interpretation and radiologist volume increase the likelihood of successful preoperative sestamibi parathyroid localization for primary hyperparathyroidism. We recommend that imaging be reviewed by experienced parathyroid surgeons rather than relying on radiological interpretation alone.
  Annals of Surgical Oncology 08/2012; 19(12):3827-31. · 4.17 Impact Factor