[Show abstract][Hide abstract] ABSTRACT: Currently, thyroid cancer is one of the most common
endocrine cancer in the United States. A recent involvement
of sub-population of stem cells, cancer stem cells,
has been proposed in different histological types of thyroid
cancer. Because of their ability of self-renewal and
differentiation into various specialized cells in the body,
these putative cells drive tumor genesis, metastatic
activity and are responsible to provide chemo- and
radioresistant nature to the cancer cells in the thyroid
gland. Our Review was conducted from previously published
literature to provide latest apprises to investigate
the role of embryonic, somatic and cancer stem cells,
and discusses the hypothesis of epithelial-mesenchymal
transition. Different methods for their identification
and isolation through stemness markers using various
in vivo and in vitro methods such as flow cytometry,
thyrosphere formation assay, aldehyde dehydrogenase
activity and ATP-binding cassette sub-family G member
2 efflux-pump mediated Hoechst 33342 dye exclusion
have been discussed. The review also outlines various
setbacks that still remain to target these tumor initiating
cells. Future perspectives of therapeutic strategies
and their potential to treat advanced stages of thyroid
cancer are also disclosed in this review.
[Show abstract][Hide abstract] ABSTRACT: Background. Recently, a single remote access retroauricular robotic technique has been described for thyroid lobectomy. We aimed to explore the feasibility and safety of modifying this novel approach using preclinical cadaver model followed by performing the same operation in a real patient. Methods. The modified retroauricular approach was performed by creating a working space between the 2 heads of the sternocleidomastoid muscle, instead of that anterior to muscle. This was performed to create a wider working space. Two operations were initially performed in human cadavers. Subsequently, robotic-assisted thyroid lobectomy was performed using this novel modified retroauricular approach. Results. Robotic-assisted hemithyroidectomy was performed successfully in 2 cadavers and subsequently in one patient using modified approach. The patient was discharged on the same day of surgery and had no complications. Conclusions. The modified retroauricular approach with creation of a working space between the 2
[Show abstract][Hide abstract] ABSTRACT: It was with great interest that we read the editorial by Dr. Julie Ann Sosa, “What’s Old is New Again,” which reviews our recent publication ‘Total thyroidectomy is associated with increased risk of complications for low- and high-volume surgeons,’’ in the current issue of Annals of Surgical Oncology.1Dr. Sosa has been a pioneer in the field of endocrine surgery and has paved the way for studies examining the relationships between volume and outcomes such as ours.We agree with Dr. Sosa that the relationship between provider volume and improved patient outcomes is not a novel discovery and has been demonstrated for a number of operations. With regard to thyroid surgery, these relationships have been demonstrated in both pediatric and geriatric thyroid patients.2–6Our study confirms previous findings as Dr. Sosa suggests, and it is currently the largest study of its kind. The fact that it confirms previous findings suggests that such findings are reproducible, and this should not be felt ...
Annals of Surgical Oncology 11/2014; 21(12). · 4.12 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Robotic approaches have become increasingly used for colorectal surgery. The aim of this study is to examine the safety and efficacy of robotic colorectal procedures in an adult population.
A systematic review of articles in both PubMed and Embase comparing laparoscopic and robotic colorectal procedures was performed. Clinical trials and observational studies in an adult population were included. Approaches were evaluated in terms of operative time, length of stay, estimated blood loss, number of lymph nodes harvested, and perioperative complications. Mean net differences and odds ratios were calculated to examine treatment effect of each group.
Two hundred eighteen articles were identified, and 17 met the inclusion criteria, representing 4,342 patients: 920 robotic and 3,422 in the laparoscopic group. Operative time for the robotic approach was 38.849 minutes longer (95% confidence interval: 17.944 to 59.755). The robotic group had lower estimated blood loss (14.17 mL; 95% confidence interval: -27.63 to -1.60), and patients were 1.78 times more likely to be converted to an open procedure (95% confidence interval: 1.24 to 2.55). There was no difference between groups with respect to number of lymph nodes harvested, length of stay, readmission rate, or perioperative complication rate.
The robotic approach to colorectal surgery is as safe and efficacious as conventional laparoscopic surgery. However, it is associated with longer operative time and an increased rate of conversion to laparotomy. Further prospective randomized controlled trials are warranted to examine the cost-effectiveness of robotic colorectal surgery before it can be adopted as the new standard of care.
JSLS: Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons 10/2014; 18(4). · 0.81 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Over the years, there has been a continual shift toward more minimally invasive surgical techniques, such as the use of laparoscopy in colorectal surgery. Recently, there has been increasing adoption of robotic technology. Our study aims to compare and contrast robot-assisted and laparoscopic approaches to colorectal operations.
Forty patients undergoing laparoscopic or robotic colorectal surgery performed by 2 surgeons at an academic center, regardless of indication, were included in this retrospective review. Patients undergoing open approaches were excluded. Study outcomes included operative time, estimated blood loss, length of stay, complications, and conversion rate to an open procedure.
Twenty-five laparoscopic and fifteen robot-assisted colorectal surgeries were performed. The mean patient age was 61.1 ± 10.7 years in the laparoscopic group compared with 61.1 ± 8.5 years in the robotic group (P = .997). Patients had a similar body mass index and history of abdominal surgery. Mean blood loss was 163.3 ± 249.2 mL and 96.8 ± 157.7 mL, respectively (P = .385). Operative times were similar, with 190.8 ± 84.3 minutes in the laparoscopic group versus 258.4 ± 170.8 minutes in the robotic group (P = .183), as were lengths of hospital stay: 9.6 ± 7.3 and 6.5 ± 3.8 days, respectively (P = .091). In addition, there was no difference in the number of lymph nodes harvested between the laparoscopic group (14.0 ± 6.5) and robotic group (12.3 ± 4.2, P = .683).
In our early experience, the robotic approach to colorectal surgery can be considered both safe and efficacious. Furthermore, it also preserves oncologically sufficient outcomes when performed for cancer operations.
JSLS: Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons 10/2014; 18(4). · 0.81 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: There has been an increased use of total thyroidectomy (TT), including in the management of benign thyroid diseases. We sought to compare the risk of complications between TT and unilateral thyroidectomy (UT) and to evaluate the effect of surgeon's experience on outcomes.
Annals of Surgical Oncology 06/2014; · 4.12 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: New approaches for robotic-assisted thyroidectomy, including the retroauricular approach, were recently described. We have modified the established surgical approach for retroauricular robotic thyroidectomy. Herein, we report our initial experience to identify challenges and limitations of this new surgical approach.
[Show abstract][Hide abstract] ABSTRACT: Surgeon experience has been demonstrated to result in better outcomes after a variety of advanced operations. Less information is available regarding adrenal surgery. We compared the outcomes after adrenalectomy for a variety of indications and determined the effect of surgeon's case volume.
Cross-sectional analysis was performed using ICD-9 procedure codes included in the Nationwide Inpatient Sample from 2003 to 2009 to identify all adult patients who underwent unilateral or bilateral adrenalectomy for benign or malignant conditions. Logistic regression was used to test for interaction between surgeon case volume (low = 1, intermediate = 2-5, and high = >5 adrenalectomies per year), diagnosis, type of operation performed, and risk of complications.
A total of 7,829 adrenalectomies were included. Risk of complications after bilateral adrenalectomy was 23.4 % compared to 15.0 % for unilateral adrenalectomy (odds ratio 2.165, 95 % confidence interval 1.335, 3.512). Malignancy was associated with higher risk of complication (23.1 %) than benign disease (13.2 %) (odds ratio 1.685, 95 % confidence interval 1.371, 2.072). Complication rates for low- and intermediate-volume surgeons were 18.8 and 14.6 %, respectively, and both were significantly higher than complications by high-volume surgeons (11.6 %, p < 0.05). Length of stay and charges were both significantly less for high-volume surgeons compared to lower-volume groups (p < 0.05).
Low surgeon case volumes and adrenal surgery for malignant or bilateral disease are associated with increased risk of postoperative complications. Length of stay and charges were significantly less when high-volume surgeons perform adrenal surgery.
Annals of Surgical Oncology 05/2014; · 4.12 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The aim of this study was to evaluate the association between surgeon volume and patient outcomes among different race ethnicities undergoing thyroid or parathyroid surgery.
The nationwide inpatient sample was used to identify all thyroidectomy and parathyroidectomy admissions from 2003 to 2009, using International Classification of Diseases, 9th Clinical Modification (ICD-9-CM) procedure codes. Race, demographic, and clinical characteristics of patients were collected, along with surgeon volume, to predict the length of stay (LOS), complication rates, mortality, and total charges by racial group, using univariate and multivariate analyses.
A total of 106,314 thyroid and parathyroid surgeries were included in the current analysis. Of these patients, 54 % were Caucasian, 11 % African American, 7 % Hispanic, and 3 % Asian. Mean LOS was longer for African American patients (4 ± 8.7 days) than for Caucasians (2.3 ± 5.5 days) [p < 0.001]. African Americans had higher overall complications (16.8 %) compared with Caucasians (11 %), Hispanics (13.5 %), and Asians (12 %) [p < 0.001]. In-hospital mortality was higher for African Americans (0.8 %) compared with that from other race groups (0.3 %) [p < 0.001]. Mean total charges were significantly higher for African Americans ($33,292 ± $67,387) compared with those for Caucasians ($22,855 ± $40,167) (p < 0.001). African Americans had less access to intermediate- (10-99 cases) and high- (>100 cases) volume surgeons compared with Caucasians-45 versus 49 %, and 16 versus 19 %, respectively (p < 0.001). Higher surgeon volume was associated with improved outcomes (p < 0.001). Racial disparity in all investigated outcomes was still significantly evident even after stratification by surgeon volume.
Higher surgeon volume is associated with improved patient outcomes. However, our data suggests that the observed racial disparities in thyroid and parathyroid surgery go beyond access to quality healthcare providers.
Annals of Surgical Oncology 03/2014; · 4.12 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective Recurrent Laryngeal Nerves' (RLN) extralaryngeal branching conveys an increased risk of nerve injury during thyroid surgery. We hypothesized that racial and gender variations in prevalence of branched RLN exist. Study Design A retrospective review of all patients who underwent thyroid surgery in a four year period in a single surgeon practice. Methods The RLN was routinely identified during thyroid surgery. Presence of RLN branching, its distance from the laryngeal nerve entry point(NEP) and functionality of the branches were ascertained. Patient demographics, rates of neural branching and distance of bifurcation from the NEP were evaluated using statistical analysis. Results We identified 719 RLNs at risk in 491 patients who underwent central neck surgery. Four hundred and five(82.5%) patients were female and 86 (17.5%) were male. There were 218(44.4%) African American and 251(51.1 %) Caucasian patients. In African Americans, 42.1% RLNs bifurcated compared to 33.2% RLN in Caucasians(p =0.017). African Americans' and Caucasians' RLNs bifurcated at comparable distances(p=0.30). In males, 39.1% RLNs bifurcated while in female patients, 36.2% bifurcated(p=0.53). On average, RLN bifurcation in female patients was at a longer distance from NEP compared to male patients(p=0.012). Electrophysiologic testing found motor fibers in all anterior branches and three posterior extralaryngeal RLN branches. Conclusion: African American patients have a higher rate of RLN bifurcation compared Caucasian patients but no statistically significant difference in distance from NEP. Female patients tend to have longer branching variants of bifid RLNs. RLN motor fibers reside primarily in the anterior branch but may occur in the posterior branch.
[Show abstract][Hide abstract] ABSTRACT: Background: Invasive differentiated thyroid cancer (DTC) is relatively frequent, yet there is a paucity of specific guidelines devoted to its management. The Endocrine Committee of the American Head and Neck Society (AHNS) convened a panel to provide clinical consensus statements based on review of the literature, synthesized with the expert opinion of the group. Methods: An expert panel, selected from membership of the AHNS constructed the manuscript and recommendations for management of DTC with invasion of recurrent laryngeal nerve, trachea, esophagus, larynx and major vessels based on current best evidence. A Modified Delphi survey was then constructed by another expert panelist utilizing 9 anchor points, 1= strongly disagree to 9 = strongly agree. Results of the survey were utilized to determine which statements achieved consensus, near-consensus, or non-consensus. Results: After endorsement by the AHNS Endocrine Committee and Quality of Care Committee, it received final approval from the AHNS Counsil. Head Neck, 2014.