Patricia Donovan

Yale-New Haven Hospital, New Haven, Connecticut, United States

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Publications (20)79.68 Total impact

  • Robert Udelsman, Patricia Donovan, Cary Shaw
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    ABSTRACT: A mathematical model for primary hyperparathyroidism (1°HPTH) was developed and embedded in software to yield intraoperative predictability curves. A total of 1,754 consecutive 1°HPTH operative cases were screened to select 617 [554 single adenoma (SA), 63 multigland] patients with complete preoperative, intraoperative (pre-exploration, time 0, every 5 min post-resection), and postoperative parathyroid hormone (PTH) and calcium data. Data transformations and models were hypothesized and tested, including inverse functions, differences, half-lives, differences from projected half-lives, second-order kinetics, second-order derivatives, and time-dependent ratios. Sub-models of ratios were developed for time-dependent and initial-value combinations. For each time segment the log odds were modeled using multiple logistic stepwise regression. An idealized model was selected, embedded in software, and installed in a laptop computer to enable intraoperative decision analyses, PTH curve plotting, and storage and transmission of data. A subsequent cohort of 100 consecutive unselected patients [81 SAs, 19 multigland (13 hyperplasia, 2 MEN1, 1 lithium, 3 double adenomas)] inclusive of seven remedial cervical explorations were tested. The model predicted an overall curative resection in 95 % of patients. In SA patients, cure was predicted in 78/81 patients with a mean probability of 99.3 % at 11.8 ± 10.4 min post-resection. In three cured patients, the software failed to suggest cure, because of a low baseline PTH or delayed clearance. The model also correctly predicted residual hyperfunctioning tissue in all tested multigland patients. All multigland patients underwent additional exploration with resection of residual disease resulting in a mean predicted cure rate of 97.9 % at 10.6 ± 7.3 min post-resection completion in 17 patients. In two patients, the software predicted a mean cure rate of 22 % due to either a low PTH baseline or delayed clearance. Overall, the software accurately predicted cure in 95 of 100 cured cases. This intraoperative prediction software expedites termination of surgery with a high level of curative confidence. Alternatively, the model accurately predicts residual disease prompting additional exploration. Because the model is based on a large set of multivariate regression curves, PTH values obtained at any post-resection sampling interval generate prediction data with far greater accuracy than existing algorithms. The software is designed for convenient operative use and can print, store, and electronically transmit probability analyses and PTH curves in real-time.
    World Journal of Surgery 11/2013; · 2.23 Impact Factor
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    ABSTRACT: OBJECTIVES:: This prospective single-arm study investigated both laryngeal physiology and voice acoustic measures in patients undergoing minimally invasive parathyroidectomy (MIP) due to primary hyperparathyroidism (primary HPTH). BACKGROUND:: Avoidance of recurrent or superior laryngeal nerve injury and maintenance of normal laryngeal physiology and vocal function are key goals in the treatment of primary HPTH. No data are available comparing pre- and postoperative MIP laryngeal physiology and voice acoustics. METHODS:: Patients served as their own controls and underwent identical pre- and postoperative assessment. True vocal fold mobility was assessed and recorded using transnasal fiber-optic laryngoscopy. Vocal capacity was recorded with maximum phonation time and vocal stability by frequency-based voice measures, that is, mean fundamental frequency (F0), standard deviation of the fundamental frequency (F0SD), and jitter and shimmer as measured by relative average perturbation and mean shimmer in decibels, respectively. RESULTS:: A total of 104 patients were enrolled [26 men, mean age = 53 years, range 29-79 years; 78 women, mean age = 56 years, range 16-83 years). All completed the protocol and were analyzed according to intent to treat. MIP was accomplished in 95 patients, and 9 were converted to general anesthesia. The cure rate was 100%, as evidenced by normalization of serum calcium levels. Both real-time agreement and blinded inter- and intrarater reliability testing for laryngeal physiology ratings were 100%. One patient (<1%) exhibited a recurrent laryngeal nerve injury. No significant differences (P > 0.05) were found for any voice acoustic parameter between pre- and postoperative MIP (ie, maximum phonation time, F0, F0SD, relative average perturbation, or shimmer in decibels). CONCLUSIONS:: MIP can be performed with exquisite disease control and without significant effects on laryngeal physiology or voice acoustic measures. For the first time, both physiologic and acoustic data support the use of MIP.
    Annals of surgery 03/2013; · 7.90 Impact Factor
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    ABSTRACT: OBJECTIVE: To compare outcomes between children (<18 yrs) and adults undergoing total thyroidectomy for Graves' disease (GD) at a high volume, multidisciplinary thyroid center.Summary of background data: Reported complication rates for children undergoing surgery for Graves' disease are worse than for adults. METHODS: 100 consecutive patients (32 children; 68 adults) who underwent total thyroidectomy for Graves' disease (GD) by a high-volume endocrine surgery team from were compared. RESULTS: The mean patient age was 9.7 yrs (range 3.4-17.9 yrs) in children versus 44.9 yrs (range 18.4-84.2 yrs) in adults. Operative times were longer in children (2.18 +/- 0.08 hrs) than in adults (1.66 +/- 0.03 hrs) (p = 0.003). Pediatric thyroid specimens averaged 38.6.0 +/- 8.9 gm (range: 9--293 gm) and adult thyroid specimens averaged 48.0 +/- 6.4 gm (range: 6.6-203 gm) (p = 0.34). Thyroid to body weight ratios were greater in children (0.94 +/- 0.11 gm/kg) than adults (0.67 +/- 0.8gm/kg) (p = 0.05). In all patients, the hyperthyroid state resolved after surgery. There was no operative mortality, recurrence, or permanent hypoparathyroidism. Transient post-operative hypocalcemia requiring calcium infusion was greater in children than adults (6/32 vs. 1/68; p = 0.004). Transient recurrent laryngeal nerve dysfunction occurred in two children and in no adults (p = 0.32). Postoperative hematoma occurred in two adults and in no children (p = 0.46). The length of stay was longer for children (1.41 +/- 0.12 days) than for adults (1.03 +/-0.03 days) (p = 0.004). CONCLUSION: Surgical management of GD is technically more challenging in children as evidenced by longer operative times. Whereas temporary hypocalcemia occurs more commonly in children than adults, the risks of major complications including disease recurrence, permanent hypoparathyroidism, recurrent laryngeal nerve injury, or neck hematoma were indistinguishable. These data suggest that excellent and equivalent outcomes can be achieved for GD surgery in children and adults when care is rendered by a high volume, endocrine surgery team.
    International Journal of Pediatric Endocrinology 01/2013; 2013(1):1.
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    ABSTRACT: Patients receiving lithium therapy are at elevated risk of developing hyperparathyroidism. In lithium-associated hyperparathyroidism (LAH), the incidence of multiglandular disease (MGD) is unclear, and the need for routine bilateral cervical exploration remains controversial. Therefore, in LAH patients, surgical approaches, pathologic findings, cure rates, and factors associated with persistent or recurrent disease were investigated. Retrospective analysis of 27 patients with LAH undergoing parathyroidectomy with the intraoperative parathyroid hormone (PTH) assay. The median postoperative follow-up was 7 months; 17 patients had >6 months follow-up. Cervical exploration was unilateral in 9, bilateral in 18 (3 were converted from unilateral). Sixteen patients (62 %) had MGD, 12 with four-gland hyperplasia and 4 with double adenomas. Ten patients (38 %) had a single adenoma. Twenty-five (93 %) of 27 patients had initially successful surgery. Of the 17 patients with >6 months follow-up, two had persistent disease and two experienced recurrent disease. All patients with a single adenoma remain free of disease. Three (75 %) of four patients with persistent/recurrent disease had MGD and were receiving lithium at the time of surgery. Patients with persistent/recurrent disease were older (p = 0.01) and had experienced a longer duration of hypercalcemia (p = 0.04). LAH patients have a high incidence of MGD, and bilateral exploration is frequently necessary. With access to the intraoperative PTH assay, it is reasonable to initiate a unilateral approach because many patients will harbor single adenomas and can be reliably rendered normocalcemic. Patients with MGD remain at higher risk of persistent/recurrent disease.
    Annals of Surgical Oncology 06/2012; 19(11):3465-71. · 4.12 Impact Factor
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    ABSTRACT: Familial primary hyperparathyroidism (FPHPT) may occur due to an underlying germ-line mutation in the MEN1, CASR, or HRPT2/CDC73 genes. The disease may be undiagnosed in the absence of a history suggestive of FHPT. Young PHPT patients (≤45 years of age) are more likely to harbor occult FPHPT. A total of 1,161 (136 were ≤45 years of age) PHPT patients underwent parathyroidectomy from 2001 to 2009. Thirty-four patients declined participation. Sixteen patients were diagnosed in the clinical routine with FPHPT (11 MEN1, four MEN2A, and one HPT-JT) and were not included in the genetic analysis. Eighty-six young (≤45 years of age) patients with clinically non-syndromic PHPT underwent genetic analysis. Sanger sequencing of all coding regions of the MEN1, CASR, and the HRPT2/CDC73 genes was performed. Eight of 86 (9.3%) young patients with clinically non-familial PHPT displayed deleterious germ-line mutations in the susceptibility genes (4 MEN1, 3 CASR, and 1 HRPT2/CDC73). There was one insertion, one deletion, two nonsense, and four missense mutations, all predicted to be highly damaging to protein function and absent in 3,244 control chromosomes. Germ-line mutations in known susceptibility genes within young patients with PHPT, including those diagnosed in the clinical routine, was 24/102 (23.5%; 15 MEN1, four RET, three CASR, and two HRPT2/CDC73). We demonstrate that germ-line inactivating mutations in susceptibility genes are common in young patients with clinically non-familial PHPT. Thus, enhanced use of genetic analysis may be warranted in clinically non-familial young PHPT patients.
    Hormones and Cancer 12/2011; 3(1-2):44-51.
  • Robert Udelsman, Zhenqiu Lin, Patricia Donovan
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    ABSTRACT: To compare the results of minimally invasive parathyroidectomy (MIP) and conventional parathyroid surgery. Primary hyperparathyroidism is a common endocrine disorder often treated by surgical intervention. Outpatient MIP, employing image-directed focused exploration under cervical block anesthesia, has replaced traditional surgical approaches for many patients with primary hyperparathyroidism. This retrospective review of a prospective database compared MIP with conventional parathyroid surgery. One thousand six hundred fifty consecutive patients underwent surgery for primary hyperparathyroidism by a single surgeon between 1990 and 2009 at 2 tertiary care academic hospitals. Conventional bilateral cervical exploration under general anesthesia was performed in 613 patients and MIP was performed in 1037 cases. Cure rates, complication rates, pathologic findings, length of hospital stay, and total hospital costs were compared. Minimally invasive parathyroidectomy is associated with improvements in the cure rate (99.4%) and the complication rate (1.45%) compared to conventional exploration with a cure rate of 97.1% and a complication rate of 3.10%. In addition, the hospital length of stay and total hospital charges were also improved compared to conventional surgery. Minimally invasive parathyroidectomy is a superior technique and should be adopted for the majority of patients with sporadic primary hyperparathyroidism.
    Annals of surgery 03/2011; 253(3):585-91. · 7.90 Impact Factor
  • Lori J. Sokoll, Patricia I. Donovan, Robert Udelsman
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    ABSTRACT: The National Academy of Clinical Biochemistry developed clinical practice guidelines for the use of intraoperative parathyroid hormone (PTH) at the point-of-care (and in the central laboratory) based on a systematic review of the literature. Parathyroid hormone plays an adjunct role as a functional measure in parathyroid surgery to confirm the adequacy of parathyroid gland resection. Although controlled trials are few, based on evidence for improved patient/health, operational, and economic outcomes, intraoperative PTH is recommended for routine use in patients undergoing initial or reoperative surgery for primary hyperparathyroidism, particularly in directed or limited surgical approaches. No recommendation was made for or against use in patients with secondary/tertiary hyperparathyroidism, familial disease (multiple endocrine neoplasia 1), or parathyroid cancer. Use of rapid parathyroid hormone for diagnostic localization is recommended for use in the interventional radiology suite, but no recommendation was made for use in the operating suite. Recent studies suggest an additional role for preoperative localization using ultrasound-guided biopsies and for tissue identification intraoperatively. There was no evidence to recommend a specific assay or location for PTH testing on site or in the central laboratory. Timing of samples and criteria for interpretation of results are more established for primary hyperparathyroidism than other parathyroid diseases. Although additional refinement and studies may be needed, the National Academy of Clinical Biochemistry guidelines for intraoperative PTH have useful information for the surgical and clinical laboratory communities and are reflected in current clinical practice as illustrated by a case presentation.
    Point of Care The Journal of Near-Patient Testing & Technology 11/2007; 6(4):253-260.
  • Christina Maser, Patricia Donovan, Robert Udelsman
    Journal of the American College of Surgeons 04/2007; 204(3):512-4. · 4.50 Impact Factor
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    ABSTRACT: Persistent or recurrent primary hyperparathyroidism (1 degrees HPTH) is ideally treated with limited dissection, based on accurate localization, to minimize operative risks. To accurately localize parathyroid tissue, we employed ultrasound-guided fine needle aspiration (US FNA) with an on-site rapid parathyroid hormone (PTH) assay to confirm localization. Of the 272 patients evaluated for 1 degrees HPTH, 34 had persistent or recurrent disease. Standard localization was equivocal in 12, who were referred for US FNA. Suspicious tissue was identified on US and FNA was performed. Analysis with a rapid PTH assay provided on-site result within 12 min. Patients were monitored clinically, and then discharged after observation. Twelve patients were referred for US FNA; eight were female. Ten patients had persistent disease, one had recurrent, and one had 1 degrees HPTH following thyroidectomy. Two of the 12 were excluded due to negative ultrasound examination. Of the remaining ten, positive aspirates were found in nine, and seven proceeded to surgery. In six patients there was 100% correlation between sonographic and operative findings. The remaining patient had no identifiable adenoma, but PTH normalized after arterial ligation. All patients received a limited directed surgical approach, employing cervical block anesthesia in three. Four were discharged on the day of surgery and all were cured. There was one infectious complication of US FNA. The use of rapid PTH assay can be effectively utilized for localization of parathyroid tissue in remedial parathyroid surgery. Confirmation of localization markedly improves subsequent surgery and allows selective use of minimally invasive techniques.
    Annals of Surgical Oncology 01/2007; 13(12):1690-5. · 4.12 Impact Factor
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    Robert Udelsman, Patricia Irvin Donovan
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    ABSTRACT: To review the outcomes in 130 consecutive remedial explorations for primary hyperparathyroidism. Remedial surgery for primary hyperparathyroidism is challenging and requires meticulous preoperative evaluation and imaging to expedite a focused surgical exploration that has traditionally been performed under general anesthesia. This prospective series of 130 consecutive remedial operations for primary hyperparathyroidism selectively used minimally invasive techniques and tested the hypothesis that these techniques could improve outcomes. Between 1990 and 2005, 1,090 patients were evaluated and explored for primary hyperparathyroidism. Of these, 130 remedial explorations were performed in 128 patients who underwent either conventional exploration under general anesthesia (n = 107) or minimally invasive parathyroidectomy (n = 23) employing cervical block anesthesia, directed exploration, and curative confirmation with the rapid intraoperative parathyroid hormone assay. The sensitivity of preoperative imaging were: Sestamibi (79%), ultrasound (74%), MRI (47%), CT (50%), venous localization (93%), and ultrasound guided parathyroid fine needle aspiration (78%). The cure rate in the conventional remedial group (n = 107) was 94% and was associated with a mean length of stay of 1.6 +/- 0.2 days. Remedial exploration employing minimally invasive techniques (n = 23) resulted in a cure rate of 96% and a mean length of stay of 0.4 +/- 0.1 days. Complications were rare in both remedial groups. These results were almost identical to those achieved in 960 unexplored patients. Remedial parathyroid surgery can be accomplished with acceptable cure and complication rates. Minimally invasive techniques can achieve outcomes that are similar to those obtained in unexplored patients.
    Annals of Surgery 10/2006; 244(3):471-9. · 6.33 Impact Factor
  • Jason S Gold, Patricia I Donovan, Robert Udelsman
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    ABSTRACT: Parathyroid exploration through a standard cervical approach is adequate for the resection of most mediastinal parathyroid glands. A subset of mediastinal parathyroid glands causing hyperparathyroidism, however, cannot be removed in this manner. We reviewed our experience with the use of partial median sternotomy in the treatment of these patients. Over a 14-year period, all but 10 of 937 (1.1%) consecutive patients explored for hyperparathyroidism by a single endocrine surgeon were treated by a cervical approach. Partial median sternotomy was performed in 10 cases and was successful in seven cases (70%), with conversion to a complete sternotomy being required in three cases. Six of these seven patients had failed a previous parathyroid exploration (86%), including one patient who had a previous complete sternotomy. Cure of hyperparathyroidism was achieved in all seven patients undergoing partial median sternotomy. In five patients a mediastinal parathyroid gland was removed (71%), and in one patient a parathyroid adenoma in the carotid sheath was eventually found, and the location of the hyperfunctioning parathyroid gland in one patient was never determined although the patient was cured. The mean length of hospital stay after a partial median sternotomy was 2.6 days. One patient sustained a recurrent laryngeal nerve injury at the time of a repeat cervical exploration and partial median sternotomy. Rarely, mediastinal parathyroid glands cannot be resected through a cervical approach. In these cases the use of partial median sternotomy is an attractive technique in achieving cure of hyperparathyroidism and is associated with minimal morbidity and a short length of hospital stay.
    World Journal of Surgery 08/2006; 30(7):1234-9. · 2.23 Impact Factor
  • Thyroid 07/2006; 16(6):619-20. · 3.54 Impact Factor
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    ABSTRACT: We investigated the frequency and reasons for conversion from cervical block anesthesia to general anesthesia (GA) in patients undergoing minimally invasive parathyroidectomy for primary hyperparathyroidism. Prospective case series. Tertiary university hospital. A total of 441 consecutive patients with primary hyperparathyroidism undergoing minimally invasive parathyroidectomy under cervical block and monitored anesthesia care using midazolam and narcotics were included. Patients with known multiglandular, familial, or secondary hyperparathyroidism or noninformative preoperative localization or those electing minimally invasive parathyroidectomy under GA were excluded. All patients underwent cervical block anesthesia and focused exploration using minimally invasive techniques. Intraoperative need for conversion from cervical block anesthesia to general endotracheal anesthesia. Of the 441 patients, 47 (10.6%) required conversion to GA. In all instances, conversion was performed in a controlled fashion using neuromuscular blockade, endotracheal intubation, and maintenance of the original surgical field preparation. Sixteen procedures were converted to accomplish simultaneous thyroid resections. An additional 15 were converted because the intraoperative parathyroid hormone level failed to decrease by at least 50% from the baseline after resection of the incident parathyroid tumor and extensive exploration was required. Eight procedures were converted because of technical difficulties related to ensuring adequate protection of the recurrent laryngeal nerve. Five procedures were converted to optimize patient comfort, and 2 were converted because of the intraoperative recognition of parathyroid carcinoma. One patient experienced a toxic reaction to lidocaine, causing a seizure. The vast majority of minimally invasive parathyroidectomies can be performed using cervical block anesthesia. However, conversion to GA is appropriate when unexpected intraoperative findings are encountered or for patient comfort.
    Archives of Surgery 05/2006; 141(4):401-4; discussion 404. · 4.10 Impact Factor
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    ABSTRACT: The sensitivity of sestamibi scanning techniques used for preoperative localization in primary hyperparathyroidism is a function of the parameters of image acquisition and processing. Criterion standard vs optimized technique. Tertiary referral center. One hundred forty-eight consecutive patients with primary hyperthyroidism were analyzed. Under the initial protocol, 97 patients underwent a preexisting standard sestamibi--single-photon emission computed tomographic scan and surgical exploration. The scanning technique was modified and in the revised protocol, 51 patients underwent imaging and surgical exploration. Image acquisition and processing revisions as follows: patient positioning standardized, collimator resolution adjusted, radioactive tracer delay extended, visualization field broadened, data extraction refined, and image processing filter modified. concordance among the scan and operative localization, lateralization, and cure rate. Initial protocol: 97 patients underwent surgery for primary hyperthyroidism with the initial sestamibi design. Eighty-one patients (83%) had a positive result, that is, at least 1 gland was identified; 77 patients (79%) had correct lateralization; and 49 patients (52%) had precise localization. Revised protocol: 51 patients underwent imaging under the optimized protocol. Forty-nine patients (96) had a positive result; 47 patients (92%) had correct lateralization; and 36 patients (70%) had precise localization. These improvements were significant, with P<.05 for localization and P<.01 for lateralization. Cure rates were 96% in both groups, confirmed by laboratory and pathologic findings. Sestamibi optimization in primary hyperparathyroidism can improve scan sensitivity. This may permit a focused minimally invasive operation.
    Archives of Surgery 04/2005; 140(4):383-6. · 4.10 Impact Factor
  • Patricia I Donovan
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    ABSTRACT: Nursing assessment and management regarding the care of patients with primary hyperparathyroidism (1 degrees HPTH) has evolved in parallel with the marked changes in diagnosis and surgical approach to the disease. Earlier diagnosis and vast advancements in surgical approach has shifted the paradigm of nursing intervention into the outpatient setting. The early detection of 1 degrees HPTH has become more prevalent in the preceding three decades. The clinical profile has shifted to minimally symptomatic or asymptomatic patients who have excess serum PTH levels, along with hypercalcemia. A recent consensus conference proposed diagnostic guidelines relevant to the decision making process regarding the advisability of surgical intervention vs. medical management. With surgical intervention as the only definitive treatment for 1 degrees HPTH, the successful outcomes associated with outpatient minimally invasive parathyroidectomy have shifted the patterns of recommendation for surgery, even within the group of asymptomatic patients. The endocrine nurse is integral in the successful team management of patients diagnosed with 1 degrees HPTH. From a nursing perspective, the paradigm has shifted from an inpatient focus centered around the progressive clinical signs and symptoms of the disease, to a comprehensive patient care model of assessment, education, and pre, peri and postoperative monitoring of patients who benefit from the demonstrated positive outcomes associated with parathyroid surgery in the outpatient setting.
    Current Opinion in Oncology 02/2005; 17(1):28-32. · 4.03 Impact Factor
  • Robert Udelsman, Patricia I Donovan
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    ABSTRACT: Outpatient minimally invasive parathyroidectomy (MIP) employs (1) preoperative parathyroid localization with high quality sestamibi scans, (2) cervical block anesthesia, (3) limited exploration, and (4) the rapid intraoperative parathyroid hormone assay to confirm an adequate resection. The technical aspects of this procedure are described, and the results obtained in 255 patients who underwent MIP are compared with those of 401 patients who underwent conventional bilateral cervical exploration under general anesthesia. MIP and standard exploration were indistinguishable with regard to high cure and low complication rates. MIP, however, was superior with regard to operating time, length of hospital stay, patient comfort, and costs.
    World Journal of Surgery 01/2005; 28(12):1224-6. · 2.23 Impact Factor
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    ABSTRACT: To determine the usefulness of the rapid parathyroid hormone (PTH) assay during venous localization for primary hyperparathyroidism (1 degrees HPTH). Remedial exploration for persistent 1 degrees HPTH poses a significant challenge when noninvasive preoperative localization studies are negative. Based on experience with the intraoperative rapid PTH assay, this technique was extrapolated to the interventional radiology suite and generated near real-time data for the interventional radiologist employing on-site hormone analysis, with a 12-minute turnaround time from blood sampling to assay result. Between November 1997 and July 2002, 446 patients with 1 degrees HPTH were referred for treatment. Of these, 56 (12.5%) represented remedial patients who had each undergone one or more previous cervical explorations. Noninvasive imaging studies were positive for or suggestive of localized disease in 49/56 (87.5%) of these patients, who therefore proceeded directly to surgical exploration. Seven patients with persistent 1 degrees HPTH and negative noninvasive studies underwent selective venous sampling employing a rapid PTH assay in the interventional suite. Venous localization demonstrated an apparent PTH gradient in six of the seven patients. In three, a subtle gradient demonstrated in near real-time prompted additional sampling, which confirmed an unequivocal hormone gradient. In an additional case, the absence of a gradient on initial sampling prompted further sampling, which was positive. All of the patients were explored, and in five of the six patients with a positive PTH gradient, a parathyroid adenoma (mean weight 636 +/- 196 mg) was resected from a location predicted by venous localization. In the sixth patient with a positive gradient, parathyroid tissue was not identified; however, there was a significant fall in the intraoperative PTH values, and immediate postoperative and follow-up laboratory data at 1 month are indicative of a cure. In the one patient with negative localization, abnormal parathyroid tissue could not be located during surgical exploration. The rapid PTH assay is a major adjunct for obtaining informative venous localization in patients with persistent 1 degrees HPTH. This information is extremely helpful to the surgeon in this challenging group of patients and resulted in a 100% cure rate when a venous gradient was demonstrated. The authors now employ this technique routinely in remedial patients with negative noninvasive imaging studies.
    Annals of Surgery 06/2003; 237(5):714-9; discussion 719-21. · 6.33 Impact Factor
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    ABSTRACT: Delayed technetium-99m sestamibi single photon emission computed tomography (SPECT) scans were prospectively analyzed in a large series of patients with primary hyperparathyroidism. Three hundred thirty-eight patients underwent sestamibi-SPECT and were explored. Prospective data included preoperative demographics, clinical, sestamibi, and operative findings, laboratory values, and pathologic and follow-up laboratory results from all patients. Between 1994 and 2000, 287 unexplored patients (85%) and 51 re-explored patients (15%) participated. The abnormal parathyroid glands excised from 336 of 338 patients included 299 single adenomas (88%) and 23 double adenomas (7%), and 14 patients had multigland hyperplasia (4%). Sestamibi SPECT correctly lateralized 349 of 400 abnormal parathyroid glands, with an overall sensitivity of 87%, an accuracy of 94%, and a positive predictive value of 86%. Precise localization occurred in 82% of the abnormal parathyroid glands. Sestamibi sensitivity was similar in unexplored (87%) and reoperative (92%) cases; two hundred eighty-six of 299 (96%) solitary adenomas, 38 of 46 (83%) double adenomas, but only 25 of 55 (45%) hyperplastic glands were identified. The mean weight of the true-positive glands (1252 +/- 1980 mg) was greater than that of the false-negative glands (297 +/- 286 mg) (P <.005). Three patients had persistent primary hyperparathyroidism, in spite of the excision of sestamibi-identified lesions in 2 cases. Follow-up indicated curative resection in 99% of the unexplored cases and 94% of the remedial cases. Sestamibi SPECT is highly accurate for the localization of parathyroid adenomas in unexplored and re-explored cases, where it is often the only imaging required. Its sensitivity is limited in multiglandular disease.
    Surgery 02/2002; 131(2):149-57. · 3.37 Impact Factor
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    ABSTRACT: To evaluate the clinical utility of frozen section in patients with follicular neoplasms of the thyroid in a randomized prospective trial. The finding of a follicular neoplasm on fine-needle aspiration prompts many surgeons to perform intraoperative frozen section during thyroid lobectomy. However, the focal distribution of key diagnostic features of malignancy contributes to a high rate of noninformative frozen sections. The series comprised 68 consecutive patients with a solitary thyroid nodule in whom fine-needle aspiration showed a follicular neoplasm. Patients were excluded for bilateral or nodal disease, extrathyroidal extension, or a definitive fine-needle aspiration diagnosis. Final pathologic findings were compared with frozen sections, and cost analyses were performed. Sixty-one patients met the inclusion criteria. Twenty-nine were randomized to the frozen-section group and 32 to the non-frozen-section group. In the non-frozen-section group, one patient was excluded when gross examination of the specimen was suggestive of malignancy and a directed frozen section was diagnostic of follicular carcinoma. Frozen-section analysis rendered a definitive diagnosis of malignancy in 1 of 29 (3.4%) patients, who then underwent a one-stage total thyroidectomy. In the remaining 28 patients, frozen section showed a "follicular or Hürthle cell neoplasm." Permanent histology demonstrated well-differentiated thyroid cancer in 6 of these 28 patients (21%). Of the 31 patients in the non-frozen-section group, 3 (10%) showed well-differentiated thyroid carcinoma on permanent histology. Complications were limited to one transient unilateral vocal cord dysfunction. All but one patient had a 1-day hospital stay. There were no significant differences between the groups in surgical time or total hospital charges; however, the charge per informative frozen section was approximately $12,470. For the vast majority of patients (96.4%) with follicular neoplasms of the thyroid, frozen section is neither informative nor cost-effective.
    Annals of Surgery 06/2001; 233(5):716-22. · 6.33 Impact Factor
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    R Udelsman, P I Donovan, L J Sokoll
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    ABSTRACT: To review the outcomes of 100 consecutive minimally invasive parathyroid explorations. Minimally invasive parathyroidectomy (MIP) has challenged the traditional approach of bilateral neck exploration for patients with primary hyperparathyroidism. Most patients with primary hyperparathyroidism have a single adenoma that when resected results in cure. It therefore appears logical to perform a directed approach to adenoma extirpation. MIP involves high-quality sestamibi images obtained with single photon emission computed tomography to localize enlarged parathyroid glands in three dimensions, limited exploration after surgeon-administered cervical block anesthesia, rapid intraoperative parathyroid hormone assay to confirm the adequacy of resection, and discharge within 1 to 3 hours of surgery. MIP was offered to 100 selected consecutive patients during an 18-month period beginning in March 1998. Ninety-two cases were accomplished under cervical block anesthesia and 89 of these on an ambulatory basis. The cure rate was 100%, and there were no long-term complications. The mean hospital charge for MIP was less than 40% of that associated with traditional exploration. Outpatient MIP appears to be the procedure of choice for most patients with primary hyperparathyroidism.
    Annals of Surgery 10/2000; 232(3):331-9. · 6.33 Impact Factor

Publication Stats

455 Citations
79.68 Total Impact Points

Institutions

  • 2005–2013
    • Yale-New Haven Hospital
      • Department of Pathology
      New Haven, Connecticut, United States
  • 2005–2012
    • Yale University
      • Department of Surgery
      New Haven, CT, United States
  • 2002
    • Johns Hopkins Medicine
      • Division of Nuclear Medicine
      Baltimore, MD, United States