American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

New Crucial Literature: The Science You Need to Know

Literature selections curated by Lewis Flint, MD, FACS, and reviewed by the Bulletin Brief editorial board.

Pair of JACS

Examining Risk Factors for Recurrent Kidney Stone Disease following Parathyroidectomy

Islam AK, Holt S, Reisch J, Nwariaku F, Antonelli J, Maalouf NM. What Predicts Recurrent Kidney Stone after Parathyroidectomy in Patients with Primary Hyperparathyroidism? J Am Coll Surg. 2020;231(1):74-82.

A significant proportion of patients with primary hyperparathyroidism and kidney stone disease suffer recurrence of kidney stone disease following parathyroidectomy despite control of hypercalcemia. This article sought to identify risk factors for recurrent kidney stone disease. A single institution retrospective study of 69 patients was reported. Following parathyroidectomy, hypercalcemia was eliminated in all patients and parathyroid hormone levels normalized in 62 of 69 patients. Recurrent kidney stone disease was documented in 23 percent of patients and persistent hypercalciuria was identified in 54 percent of patients.

The main risk factor identified was younger age (51 versus 60 years); the authors recommended closer monitoring of younger patients. Additional research will be necessary to identify causative factors for recurrent kidney stone disease. This report was presented at the 2019 meeting of the Western Surgical Association. Readers are encouraged to review the discussion that accompanied the article.

Partial Thyroidectomy for Papillary Thyroid Carcinoma Shows Increased Long-term Mortality versus Total Thyroidectomy in High-Risk Tumors

Suman P, Razdan SN, Wang CE, et al. Thyroid Lobectomy for T1b-T2 Papillary Thyroid Cancer with High-Risk Features. J Am Coll Surg. 2020;230(1):136-144.

Thyroid lobectomy has been recommended for patients diagnosed with papillary thyroid carcinoma and tumor size up to 4 centimeters in diameter. After these recommendations became available, the numbers of thyroid lobectomies for tumors with high-risk characteristics such as lymphovascular invasion, nodal involvement, extrathyroidal extension, and positive tumor margins increased, even though these characteristics were emphasized as indications for total thyroidectomy in available clinical practice guidelines.

The authors queried the National Cancer Database and reported data on 8,083 patients who underwent thyroid lobectomy; within this cohort, 1,552 (19.2 percent) patients had high-risk characteristics and should have undergone total thyroidectomy. Patients with high-risk characteristics who were treated with thyroid lobectomy had significantly increased long-term mortality even when the data were adjusted for known risk factors. The authors recommend a detailed preoperative evaluation and a careful review of pathology reports in patients who undergo thyroid lobectomy; completion total thyroidectomy was recommended for patients who have high-risk tumor characteristics identified on pathologic examination.

Other Article

Understanding Postoperative Neurocognitive Disorders in Elderly Patients

Vacas S, Cole DJ, Cannesson M. Cognitive Decline Associated with Anesthesia and Surgery in Older Patients. JAMA. August 2, 2021 [Epub ahead of print].

This article provides a concise and clear summary of current information on epidemiology, risk factors, diagnosis, prevention, and management of postoperative neurocognitive disorders (PND) in elderly patients. The authors noted that PND may present as delirium, acute confusion, inattention, or postoperative cognitive dysfunction. The etiologies of PND are not fully understood, but may include neuroinflammation as a result of operative stress, vascular disorders, and acceleration of previously undiagnosed neurodegenerative disorders. Data cited in the article showed that up to 65 percent of patients over the age of 65 develop delirium after surgery and 10 percent have long-term cognitive dysfunction.

Known risk factors for PND include urgent surgery, older age, compromised cognitive skills, and postoperative admission to an ICU. Reduction of risk of PND can be facilitated by conducting a thorough evaluation of the patient to identify risk factors. A detailed preoperative conversation with the patient, family, and/or surrogate caregivers to discuss risks and preventive measures is recommended. Additional, potentially valuable, preventive interventions include cessation of alcohol and tobacco use, optimization of nutrition, avoidance of medications such as benzodiazepines and other psychoactive drugs, control of hyperglycemia, and use of postoperative multimodal pain control. Pre- and postoperative physical therapy and cognition improvement exercises may be valuable as well. Organizations such as the ACS NSQIP® Geriatrics group and the World Health Organization have published guidelines for perioperative management of elderly patients; readers are encouraged to review these resources.