Bariatric Surgery vs. Medical Therapy for Diabetes and Obesity

Schauer PR, Bhatt DL, Kirwan JP, et al. Bariatric Surgery versus Intensive Medical Therapy for Diabetes–5-Year Outcomes.N Engl J Med. 2017;376(7):641–651.

Full-text for Emory users.

“At 5 years, the criterion for the primary end point was met by 2 of 38 patients
(5%) who received medical therapy alone, as compared with 14 of 49 patients (29%) who underwent gastric bypass (unadjusted P=0.01, adjusted P=0.03, P=0.08 in the intention to-treat analysis) and 11 of 47 patients (23%) who underwent sleeve gastrectomy (unadjusted P=0.03, adjusted P=0.07, P=0.17 in the intention-to-treat analysis). Patients who underwent surgical procedures had a greater mean percentage reduction from baseline in glycated hemoglobin level than did patients who received medical therapy alone (2.1% vs. 0.3%, P=0.003). At 5 years, changes from baseline observed in the gastric-bypass and sleeve-gastrectomy groups were superior to the changes seen in the medical-therapy group with respect to body weight (−23%, −19%, and −5% in the gastric-bypass, sleeve gastrectomy, and medical-therapy groups, respectively), triglyceride level (−40%, −29%, and −8%), high-density lipoprotein cholesterol level (32%, 30%, and 7%), use of insulin (−35%, −34%, and −13%), and quality-of-life measures (general health score increases of 17, 16, and 0.3; scores on the RAND 36-Item Health Survey ranged from 0 to 100, with higher scores indicating better health) (P<0.05 for all comparisons).”

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Lobectomy vs total thyroidectomy for intermediate-size papillary thyroid cancer

One discussion last week included the extent of surgery for intermediate-size papillary thyroid cancer: lobectomy vs total thyroidectomy.


Reference: Adam MA, et al. Extent of surgery for papillary thyroid cancer is not associated with survival: an analysis of 61,775 patients. Annals of Surgery. 2014 Oct;260(4):601-605. doi:10.1097/SLA.0000000000000925.

Summary: Guidelines recommend total thyroidectomy for PTC tumors >1 cm, based on older data demonstrating an overall survival advantage for total thyroidectomy over lobectomy.

Adult patients with PTC tumors 1.0-4.0 cm undergoing thyroidectomy in the National Cancer Database between 1998-2006 were included, totaling 61,775 patients. Median follow-up was 82 months (range, 60-179 months).

Lobectomy (n=6849)

Total thyroidectomy (n=54,926)

Nodal disease

7%

27%

Extrathyroidal disease

5%

16%

Multifocual disease

29%

44%

After multivariable adjustment, overall survival was similar in patients undergoing total thyroidectomy versus lobectomy for tumors 1.0-4.0 cm and when stratified by tumor size: 1.0-2.0 cm and 2.1-4.0 cm. Older age, male sex, black race, lower income, tumor size, and presence of nodal or distant metastases were independently associated with compromised survival (P < 0.0001).

Adam et al (2014) conclude that although current guidelines suggest total thyroidectomy for PTC tumors >1 cm, they did not observe a survival advantage associated with total thyroidectomy compared with lobectomy. These findings call into question whether tumor size should be an absolute indication for total thyroidectomy.

Symptomatic hyperthyroidism following parathyroidectomy

A discussion in January included postoperative hyperthyroidism following parathyroidectomy.


Reference: Patel SG, et al. Hyperthyroidism after parathyroid surgery: A prospective analysis of potential contributing factors. (unpublished)

Summary:

In a prospective study of 101 patients between 2014 and 2015, Patel et al examined surgical extent, anatomic findings, thyroid manipulation, anesthetic medication, and outcomes in order to identify potential intraoperative contributing factors for hyperthyroidism after parathyroidectomy.

Unilateral exploration was found to be significantly less often associated with postoperative hyperthyroidism than bilateral exploration. Additionally, incidence was lower with intraoperative ephedrine and four-fold higher with bilateral exploration. The authors recommend that “postoperative TSH screening for those who require bilateral exploration and/or symptoms of hyperthyroidism should be strongly considered.”

It is stated that this prospective study is the first “to evaluate the type and extent of thyroid manipulation during parathyroid exploration as a cause of hyperthyroidism.”

Due to the fact that the data/manuscript is currently unpublished, minimal information is shared here. We will post a notification when it is published. Our deepest thanks to Dr. Patel for his generosity in sharing this information.

Additional reading: Madill EM, Cooray SD, Bach LA. Palpation thyroiditis following subtotal parathyroidectomy for hyperparathyroidism. Endocrinology, Diabetes & Metabolism Case Reports. 2016 July; pii: 16-0049. doi: 10.1530/EDM-16-0049

Mai VQ et al. Palpation thyroiditis causing new-onset atrial fibrillation. Thyroid. 2008;18(5):571-573. doi:10.1089/thy.2007.0246

Stang MT, et al. Hyperthyroidism after parathyroid exploration. Surgery. 2005 Dec;138(6):1058-1064.

 

Thymus carcinoid in multiple endocrine neoplasia syndrome type 1 (MEN-1)

A discussion this week included thymus carcinoid in MEN-1.


References: Sadacharan D, et al. Rapid development of thymic neuroendocrine carcinoma despite transcervical thymectomy in a patient with multiple endocrine neoplasia type 1. Indian Journal of Endocrinology and Metabolism. 2013 Jul-Aug;17(4):743-746. doi:10.4103/2230-8210.113774.

Teh BT, et al. Thymic carcinoids in multiple endocrine neoplasia type 1. Annals of Surgery. 1998 Jul;228(1):99-105.

Summary: Thymic carcinoid is a rare malignancy, associated with MEN-1 and has no effective treatment (Teh et al, 1998). This is an insidious tumor not associated with Cushing’s or carcinoid syndrome. Local invasion, recurrence, and distant metastasis are common.

Teh et al (1998) recommended the following:

  • In asymptomatic gene carriers with biochemical evidence of hyperparathyroidism, parathyroidectomy with concurrent thymectomy should be considered as soon as possible.
  • In young gene carriers without evidence of hyperparathyroidsim, careful and regular follow-up should be done, including a CT scan or MRI of the chest as well as an octreoscan.

(p.104)

A case report by Sadacharan et al (2013) estimate that thymic neuroendocrine (NE) tumors are reported in only 1-8% of cases and are a major cause of mortality in MEN-1 and gastroentero pancreatic tumors, and are detected approximately 7-29 years after surgical treatment of primary hyperparathyroidism (PHPT). They found a complete surgical excision through a trans-sternal route is the only curative treatmet for thymic NE tumors. Aggressive enbloc resection of involved structures is recommended. Some have advocated routine postop radiotherapy to prevent loco-regional recurrence (Teh et al, 2013).

They further claim that MEN-1 patients need to be screened for thymic NE tumors by routine annual CT or MRI of the thorax even after transcervical thymetcomy (TCT) at the time of parathyroid surgery.

 

 

Mortality risk reduction associated with PTH reduction for Secondary Hyperparathyroidism

One discussion this week included parathyroid hormone (PTH) levels.


Reference: Komaba H, et al. Parathyroidectomy and survival among Japanese hemodialysis patients with secondary hyperparathyroidism. Kidney International. 2015 Aug;88(2):350-359. doi: 10.1038/ki.2015.72

Summary: In a nationwide study of 114,064 hemodialysis patients, Komaba et al asked if PTx for severe SHPT improves survival of dialysis patients.  They compared patient outcomes by PTH levels, and by those with a history of parathyroidectomy (PTx) (6,6280) and those without PTx (107,436).

fig2

(p.353)

Excess PTH is shown to increase cardiac fibrosis; elevations in serum calcium, phophorus, and PTH levels are associated with death and cardiovascular events primarily due to vascular calcification (p.350).

fig4

(p.355)

For cardiovascular death, there was a significant increase in the multivariate-adjusted HR for patients with intact PTH levels < 60 pg/ml (HR, 1.11; 95% CI, 1.02–1.20) and those with intact PTH levels >500 pg/ml (HR, 1.41; 95% CI, 1.20–1.64). In contrast, such an increased risk of mortality was not observed in patients with a history of PTx, despite the fact that these patients had severe SHPT preoperatively.