Thanks to LeslieAnn S. Kao, MD (General Surgery PGY-4) for suggesting this topic.
Somagutta MR, et al. Euglycemic Diabetic Ketoacidosis and Sodium-Glucose Cotransporter-2 Inhibitors: A Focused Review of Pathophysiology, Risk Factors, and Triggers. Cureus. 2021 Mar 3;13(3):e13665.
The underlying mechanism is mainly enhanced lipolysis and ketone body reabsorption. SGLT2i also stimulates pancreatic alpha cells and inhibits beta cells, causing an imbalance in glucagon/insulin levels, further contributing to lipolysis and ketogenesis. Most patients were diagnosed with blood glucose less than 200 mg/dL, blood pH <7.3, increased anion gap, increased blood, or urine ketones. Perioperative fasting, pancreatic etiology, low carbohydrate or ketogenic diet, obesity, and malignancy are identified precipitants in this review. As normoglycemia can conceal the underlying acidosis, physicians should be cognizant of the EDKA diagnosis and initiate prompt treatment. Patient education on risk factors and triggers is recommended to avoid future events.
Fu SQ, Wang SY, Chen Q, Liu YT, Li ZL, Sun T. Laparoscopic versus open surgery for pheochromocytoma: a meta-analysis. BMC Surg. 2020 Jul 25;20(1):167.
Results: Fourteen studies involving 626 patients were included in this meta-analysis. LS was associated with lower rates of intraoperative haemodynamic instability (IHD) [odds ratio (OR) = 0.61, 95% CI: 0.37 to 1.00, P = 0.05], less intraoperative blood loss [weighted mean difference (WMD) = – 115.27 ml, 95% confidence interval (CI): – 128.54 to – 101.99, P < 0.00001], lower blood transfusion rates [OR = 0.33, 95% CI: 0.21 to 0.52, P < 0.00001], earlier ambulation (WMD = – 1.57 d, 95% CI: – 1.97 to – 1.16, P < 0.00001) and food intake (WMD = – 0.98 d, 95% CI: – 1.36 to – 0.59, P < 0.00001), shorter drainage tube indwelling time (WMD = – 0.51 d, 95% CI: – 0.96 to – 0.07, P = 0.02) and postoperative stay (WMD = – 3.17 d, 95% CI: – 4.76 to – 1.58, P < 0.0001), and lower overall complication rates (OR = 0.56, 95% CI: 0.35 to 0.88, P = 0.01). However, no significant differences in operative time, postoperative blood pressure control, rates of severe complications, postoperative hypotension or cardiovascular disease (CVD) were found between the two groups.
Conclusions: LS is safe and effective for PHEO resection. Compared with OS, LS caused less IHD, providing an equal chance to cure hypertension while also yielding a faster and better postoperative recovery.
Andreassen M, Ilett E, Wiese D, et al. Surgical Management, Preoperative Tumor Localization, and Histopathology of 80 Patients Operated on for Insulinoma. J Clin Endocrinol Metab. 2019 Dec 1;104(12):6129-6138.
Full-text for Emory users.
Results: Eighty patients were included. Seven had a malignant tumor. A total of 312 diagnostic examinations were performed: endoscopic ultrasonography (EUS; n = 59; sensitivity, 70%), MRI (n = 33; sensitivity, 58%), CT (n = 55; sensitivity, 47%), transabdominal ultrasonography (US; n = 45; sensitivity, 40%), somatostatin receptor imaging (n = 17; sensitivity, 29%), 18F-fluorodeoxyglucose positron emission tomography/CT (n = 1; negative), percutaneous transhepatic venous sampling (n = 10; sensitivity, 90%), arterial stimulation venous sampling (n = 20; sensitivity, 65%), and intraoperative US (n = 72; sensitivity, 89%). Fourteen tumors could not be visualized. Invasive methods were used in 7 of these 14 patients and localized the tumor in all cases. Median tumor size was 15 mm (range, 7 to 80 mm). Tumors with malignant vs benign behavior showed less staining for insulin (3 of 7 vs 66 of 73; P = 0.015) and for proinsulin (3 of 6 vs 58 of 59; P < 0.001). Staining for glucagon was seen in 2 of 6 malignant tumors and in no benign tumors (P < 0.001). Forty-three insulinomas stained negative for somatostatin receptor subtype 2a.
Conclusion: Localization of insulinomas requires many different diagnostic procedures. Most tumors can be localized by conventional imaging, including EUS. For nonvisible tumors, invasive methods may be a useful diagnostic tool. Malignant tumors showed reduced staining for insulin and proinsulin and increased staining for glucagon.
Morgan KA, Lancaster WP, Owczarski SM, et al. Patient Selection for Total Pancreatectomy with Islet Autotransplantation in the Surgical Management of Chronic Pancreatitis. J Am Coll Surg. 2018 Apr;226(4):446-451.
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Results: One hundred and ninety-five patients (141 women, aged 40.3 years, BMI 26.5 kg/m2) underwent TPIAT. Mean duration of disease before operation was 8.1 years. Fifty-six (29%) patients had pancreatic operations before TPIAT, 37 (19%) patients were diabetic preoperatively, and 52 (27%) patients were smokers. A mean of 3,253 islet equivalents transplanted/kg were harvested. Insulin independence was achieved in 29%, 28%, and 23% of patients at 1, 2, and 5 years postoperative. Nonsmokers with a shorter duration of chronic pancreatitis and no earlier pancreas operation were more likely to be insulin free. Median number of preoperative emergency department visits and hospitalizations were 6.6 and 4.3 annually, respectively, compared with 0 at 1, 2, and 5 years postoperative. Median oral morphine equivalents were 214 mg/kg preoperation and 60, 64, 69, at 1, 2, 5 years postoperative. Preoperative, 1, 2, 5 years postoperative QOL scores were 29, 36, 34, and 33 (physical; p < 0.01) and 39, 44, 42, and 42 (mental health; p < 0.02). Genetic pancreatitis patients were more often narcotic free and had better QOL than patients with pancreatitis of other causes. At 5 years, overall survival was 92.3%.
Ramonell KM, Saunders ND, Sarmiento J, Bercu Z, Martin L, Weber CJ, Sharma J, Patel SG. Avoiding pitfalls in insulinomas by preoperative localization with a dual imaging approach. Am Surg. 2019 Jul 1;85(7):742-746.
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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.
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“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).”
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).
Total thyroidectomy (n=54,926)
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.
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)
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.
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.
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.
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).
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).
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.