Faculty Bibliography

OBJECTIVE: Thoracoabdominal aortic aneurysms (TAAAs) occur most commonly in elderly individuals, who are often suboptimal candidates for open repair because of significant comorbidities. The availability of a hybrid option, including open visceral debranching with endovascular aneurysm exclusion, may have advantages in these patients who are at high-risk for conventional repair. This report details the evolution of our technique and results with complete visceral debranching and endovascular aneurysm exclusion for TAAA repair in high-risk patients. METHODS: Between March 2005 and June 2011, 47 patients (51% women) underwent extra-anatomic debranching of all visceral vessels, followed by aneurysm exclusion by endovascular means at a single institution. A median of four visceral vessels were bypassed. The debranching procedure was initially performed through a partial right medial visceral rotation approach, leaving the left kidney posterior in the first 22 patients, and in the last 25 by a direct anterior approach to the visceral vessels. The debranching and endovascular portions of the procedure were performed in a single operation in the initial 33 patients and as a staged procedure during a single hospital stay in the most recent 14. RESULTS: Median patient age was 71.0 +/- 9.8 years. All had significant comorbidity and were considered suboptimal candidates for conventional repair: 55% had undergone previous aortic surgery, 40% were American Society of Anesthesiologists (ASA) class 4, and baseline serum creatinine was 1.5 +/- 1.3 mg/dL. The 30-day/in-hospital rates of death, stroke, and permanent paraparesis/plegia were 8.5%, 0%, and 4.3%, respectively, but 0% in the most recent 14 patients undergoing staged repair. These patients had significantly shorter combined operative times (314 vs 373 minutes), decreased intraoperative red blood cell transfusions (350 vs 1400 mL), and were more likely to be extubated in the operating room (50% vs 12%) compared with patients undergoing simultaneous repair. Over a median follow-up of 19.3 +/- 18.5 months, visceral graft patency was 97%; all occluded limbs were to renal vessels and clinically silent. There have been no type I or III endoleaks or reinterventions. Kaplan-Meier overall survival is 70.7% at 2 years and 57.9% at 5 years. CONCLUSIONS: Hybrid TAAA repair through complete visceral debranching and endovascular aneurysm exclusion is a good option for elderly high-risk patients less suited to conventional repair in centers with the requisite surgical expertise with visceral revascularization. A staged approach to debranching and endovascular aneurysm exclusion during a single hospitalization appears to yield optimal results.

With changes in the Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements related to transitions in care effective July 1, 2011, sponsoring institutions and training programs must develop a common structure for transitions in care as well as comprehensive curricula to teach and evaluate patient handoffs. In response to these changes, within the Duke University Health System, the resident-led Graduate Medical Education Patient Safety and Quality Council performed a focused review of the handoffs literature and developed a plan for comprehensive handoff education and evaluation for residents and fellows at Duke. The authors present the results of their focused review, concentrating on the three areas of new ACGME expectations--structure, education, and evaluation--and describe how their findings informed the broader initiative to comprehensively address transitions in care managed by residents and fellows. The process of developing both institution-level and program-level initiatives is reviewed, including the development of an interdisciplinary minimal data set for handoff core content, training and education programs, and an evaluation strategy. The authors believe the final plan fully addresses both Duke's internal goals and the revised ACGME Common Program Requirements and may serve as a model for other institutions to comprehensively address transitions in care and to incorporate resident and fellow leadership into a broad, health-system-level quality improvement initiative.

BACKGROUND: Distinguishing between synchronous primary lung cancers and metastatic disease in patients with bilateral lung masses is often difficult. The objective of this study is to examine outcomes associated with a strategy of performing staged bilateral resections in patients without N2 disease based on invasive mediastinal staging and without distant metastases. METHODS: Patients undergoing resections of bilateral synchronous primary lung cancer at our institution between 1997 and 2010 were reviewed. Perioperative complications were graded according to National Cancer Institute guidelines. Survival was estimated using the Kaplan-Meier method and compared using a log-rank test. End points included overall survival, disease-free survival, operative death, cancer recurrence, and postoperative complications. RESULTS: Resections of bilateral synchronous primary lung cancers were performed in 47 patients. Forty-five patients (96%) had at least a unilateral thoracoscopic approach; 28 (60%) had bilateral thoracoscopic approaches. The median postresection length of stay was 3 days. Thirteen patients (28%) had a postoperative complication; only 3 (6%) were grade 3 or higher. There was 1 perioperative death (2%). Eleven patients received adjuvant therapy; only 3 patients in whom adjuvant therapy was indicated did not receive the recommended treatment. The overall 3-year survival was 35%. Survival of patients whose bilateral tumors had identical histology did not differ from patients whose histology was different (p = 0.57). Three-year disease-free survival was 24%. CONCLUSIONS: Aggressive surgical treatment of apparent synchronous bilateral primary lung cancer can be performed with low morbidity. Most patients tolerate the bilateral surgeries and adjuvant therapy. Overall survival is sufficiently high to support this aggressive approach.

BACKGROUND: Minimally invasive parathyroidectomy can reduce operative morbidity and operative time. Radio-guided parathyroidectomy utilizing Tc-99m Sestamibi is one approach to minimally invasive parathyroidectomy. Here, we report a multimedia case study of minimally invasive radio-guided parathyroidectomy. METHODS: A 60-year-old African American female was found to have total calcium of 11.1 mg/dl, intact parathyroid hormone (iPTH) of 175 pg/ml, and a 24-h urine calcium of 620 mg/24 h. A Tc-99 Sestamibi scan (23.5 mCi of Tc-99 Sestamibi injected i.v.) and ultrasound localized a candidate adenoma to the right upper position. The patient was injected with 5.3 mCi Tc-99m Sestamibi 3 h before incision. RESULTS: A gamma probe (C-Trak Automatic System, Care Wise Medical Products) recorded in vivo counts of the right upper parathyroid (3,465) that were 160% of the background. Background counts were recorded from the resected tumor bed (2,224). A 1.4-g adenoma was identified in this location; ex vivo counts (3,226) were 150% of the background. Intra-operative iPTH baseline values were 176 pg/ml and 148 pg/ml, and 5- and 10-min post-resection levels were 17 pg/ml (90% drop) and 18 pg/ml (90% drop), respectively. The patient's recovery was uncomplicated. At 1 week postoperatively, total calcium was 8.9 mg/dl and iPTH was 16 pg/ml. At 1 year, the calcium and iPTH levels were 8.7 mg/dl and 53 pg/ml, respectively. CONCLUSIONS: Radio-guided minimally invasive parathyroidectomy using Tc-99 Sestamibi localization is an effective approach to hyperparathyroidism. For patients without localization, exposure of all four parathyroid glands is preferable. Surgeons should be familiar with both techniques.

BACKGROUND: Successful parathyroidectomy for sporadic primary hyperparathyroidism (pHPT) is predicted by a 50% drop in PTH intra-operatively. Vitamin D is a known inhibitor of PTH secretion and is associated with secondary HPT following adenoma resection. This study examined the impact of 25-hydroxyvitamin D (25OHD) deficiency on perioperative PTH kinetics and outcomes following parathyroidectomy. METHODS: Patients undergoing adenoma resection for pHPT (n=93) had PTH levels recorded at six perioperative time points. Preoperative 25OHD levels were examined retrospectively. Patients were considered 25OHD deficient if the level was <25 ng/mL (n=47) and adequate if the level was >or=25 ng/mL (n=46). RESULTS: Patients with 25OHD-deficiency had significantly higher preoperative calcium, alkaline phosphatase, and PTH levels. PTH levels were significantly higher in 25OHD-deficient patients at incision, at 1 week postop and 1-3 months postop. Average drop in PTH level five minutes post resection was 79+/-14% in the deficient group and 72+/-22% in the non-deficient group (P=.03). 25OHD levels inversely correlated with adenoma weight (P=.03) and postoperative PTH measurements (P=.008). CONCLUSIONS: Sporadic pHPT patients with 25OHD deficiency have higher baseline and postoperative PTH levels compared to non-deficient patients but do not have altered intraoperative PTH kinetics. Vitamin D deficiency is associated with postoperative elevation of PTH.