The Connell Stitch: A Two-Generation Contribution to Gastrointestinal Surgery.

The history of the Connell Stitch begins at the Milwaukee County Hospital in 1887 and continues across two generations of surgeons, Dr. M.E.

Concurrent endocrine and other surgical procedures: an institutional experience.

Inroduction: The number of endocrine procedures, specifically parathyroidectomy, thyroidectomy, and adrenalectomy, being performed is increasing. There is a paucity of literature on the feasibility of combining these procedures with other surgical procedures. Therefore, the aim of this study was to determine the effect of performing concurrent surgical procedures on postoperative outcomes.

Using parathyroid hormone spikes during parathyroidectomy to guide intraoperative decision-making.

Background: Intraoperative parathyroid hormone (IOPTH) level monitoring is a useful adjunct to parathyroidectomy for primary hyperparathyroidism (pHPT). Occasionally, increases ("spikes") in IOPTH levels from the preoperative baseline parathyroid hormone may occur, which may lead to longer operative times or more extensive neck exploration or both. The aim of this study was to determine if the extent of IOPTH level increase predicts single gland disease (SGD).

Analysis of an institutional protocol for thyroid lobectomy: Utility of routine intraoperative frozen section and expedited (overnight) pathology.

Background: Intraoperative frozen section (FS) often is performed in patients who undergo thyroid lobectomy to determine the need for completion thyroidectomy. At our institution, if FS pathology is benign, final pathology is expedited overnight. The aim of this study was to determine the utility of FS and to identify a cost-effective management algorithm for thyroid lobectomy.

Low 24-hour urine calcium levels in patients with sporadic primary hyperparathyroidism: is further evaluation warranted prior to parathyroidectomy?

Background: Low 24-hour urine calcium (uCa) levels in patients with primary hyperparathyroidism (pHPT) raise concern for familial hypocalciuric hypercalcemia. This study evaluated patients with a low 24-hour uCa level for potential differences that may guide the extent of preoperative evaluation needed.

Methods: A retrospective review was conducted of 1,139 sporadic pHPT patients who underwent parathyroidectomy between December 1999 and May 2011.

Focused parathyroidectomy with intraoperative parathyroid hormone monitoring in patients with lithium-associated primary hyperparathyroidism.

Background: Lithium-associated hyperparathyroidism has been attributed to multigland hyperplasia requiring bilateral exploration and subtotal parathyroidectomy. Recent studies suggest that some patients may have single gland disease and be eligible for minimally invasive parathyroidectomy.

Methods: We performed a retrospective review of a prospective, single institution parathyroid database of 1,010 patients who underwent parathyroidectomy between December 1999 and October 2010.

Predicting the need for calcium and calcitriol supplementation after total thyroidectomy: results of a prospective, randomized study.

Background: The optimal protocol for the detection and treatment of postthyroidectomy hypoparathyroidism is unknown. We sought to identify and treat patients at risk for symptomatic hypocalcemia on the basis of a single parathyroid hormone (PTH) obtained the morning after surgery (POD1).

Methods: We performed a prospective, randomized study of total thyroidectomy patients who had POD1 calcium and PTH (pg/mL) levels.

Zollinger-Ellison syndrome associated with a history of alcohol abuse: coincidence or consequence?

Background: This 47-year observational study suggests that sporadic Zollinger-Ellison (Z-E) syndrome, particularly duodenal wall gastrinomas (DWG), is associated with a history of alcohol abuse.

Methods: Thirty-nine consecutive Z-E patients were followed from 1962 through 2010. The drinking patterns of these patients were assessed and compared with 3,786 community controls.

Primary hyperparathyroidism with a history of head and neck irradiation: the consequences of associated thyroid tumors.

Background: Information on thyroid tumors is scant in patients with primary hyperparathyroidism (HPT) and history of head and neck irradiation. The study objective was to investigate thyroid pathology in primary HPT patients with irradiation history presenting for parathyroidectomy.

Methods: A prospective database of 1,020 parathyroidectomy patients was analyzed.

The value of postoperative parathyroid hormone levels in predicting the need for long-term vitamin D supplementation after total thyroidectomy.

Background: Few studies have examined the need for vitamin D supplementation after total thyroidectomy. This study examines the role of postoperative day (POD) 1 serum calcium and parathyroid hormone (PTH) levels in predicting the need for long-term vitamin D supplementation after total thyroidectomy.

Methods: A retrospective, single institutional study of patients who underwent total thyroidectomy between January 2007 and December 2008 was performed.

Operative failures after parathyroidectomy for hyperparathyroidism: the influence of surgical volume.

Objective: To determine whether surgical volume influences the cause of operative failures after parathyroidectomy for hyperparathyroidism.

Summary And Background Data: The surgical success rate for hyperparathyroidism from high-volume centers exceeds 95%, but some patients have unsuccessful parathyroidectomies. Although operative failure can be due to hyperfunctioning parathyroid glands in ectopic locations, less experienced surgeons may be more likely to miss an abnormal parathyroid in normal anatomic locations, which we describe as "preventable operative failure.

Small pancreatic and periampullary neuroendocrine tumors: resect or enucleate?

Objective: The aim of this study was to compare the outcomes of enucleation versus resection in patients with small pancreatic, ampullary, and duodenal neuroendocrine tumors (NETs).

Methods: Multi-institutional retrospective review identified all patients with pancreatic and peri-pancreatic NETs who underwent surgery from January 1990 to October 2008. Patients with tumors < or =3 cm and without nodal or metastatic disease were included.

The influence of surgery in MEN-1 syndrome: observations over 150 years.

Background: Efficacy and timing of operative intervention in patients with multiple endocrine neoplasia type 1 (MEN-1) syndrome remains controversial. This report utilizes a novel approach to evaluate the influence of evolving operative interventions for patients with MEN-1 syndrome.

Methods: Six generations from a large MEN-1 family pedigree were studied.

Reoperative parathyroidectomy: an algorithm for imaging and monitoring of intraoperative parathyroid hormone levels that results in a successful focused approach.

Background: Advances in preoperative imaging and use of intraoperative parathyroid hormone (IOPTH) levels are changing the approach to reoperative parathyroidectomy (ReopPTX). We sought to develop a protocol for imaging and IOPTH monitoring that allows for a focused, successful operative approach.

Methods: We reviewed our prospective database of consecutive patients with primary hyperparathyroidism who underwent ReopPTX with IOPTH monitoring between December 1999 and June 2007.

Palliative stenting for late malignant gastric outlet obstruction.

Malignant gastric outlet obstruction (MGO) is a late complication of pancreatobiliary and gastric cancers. Although surgical gastrojejunostomy provides good palliation, many of these patients may be nonoperative candidates or underwent previous extensive resection such as a Whipple procedure. Recently, endoscopically placed self-expanding metallic stents (SEMS) have been used to palliate MGO.

The role of parathyroid hormone measurements after surgery for primary hyperparathyroidism.

Background: During parathyroidectomy for primary hyperparathyroidism (pHPT), intraoperative parathyroid hormone (IOPTH) levels are used to confirm removal of all hyperfunctioning parathyroid tissue. The phenomenon of elevated parathyroid hormone (PTH) levels with normocalcemia after curative parathyroidectomy, seen in up to 40% of patients, continues to be an unexpected and unexplained finding. We therefore investigated whether postoperative PTH levels are as reliable as IOPTH levels in predicting cure after surgery for pHPT.

Neuroendocrine hepatic metastases: does aggressive management improve survival?

Objective: The aim of this study was to determine whether aggressive management of neuroendocrine hepatic metastases improves survival.

Summary Background Data: Survival in patients with carcinoid and pancreatic neuroendocrine tumors is significantly better than adenocarcinomas arising from the same organs. However, survival and quality of life are diminished in patients with neuroendocrine hepatic metastases.

Detection of multiple gland primary hyperparathyroidism in the era of minimally invasive parathyroidectomy.

Background: A focused surgical approach for primary hyperparathyroidism relies on the ability of preoperative imaging and intraoperative parathyroid hormone monitoring (IOPTH) to detect multiple gland disease (MGD). The study objective was to determine the best predictor for MGD.

Methods: First time parathyroidectomy was performed on 233 patients with primary hyperparathyroidism who underwent preoperative sestamibi imaging, ultrasound, and IOPTH between December 1999 and January 2004.

Cystic pancreatic neoplasms: observe or operate.

Objective: The objectives of this analysis were to define the incidence, natural history, and predictors of neoplasia in pancreatic cysts to determine which patients can safely be observed and which should undergo an operation.

Summary Background Data: With advancements in imaging technology, cystic lesions of the pancreas are being detected with increased frequency. Many of these lesions are small and asymptomatic, but they may be associated with pancreatitis or have malignant potential.

Cystic pancreatic neoplasms: enucleate or resect?

Asymptomatic cystic pancreatic neoplasms are being detected by abdominal imaging with increasing frequency. Enucleation of small cystic neoplasms can be performed without recurrence but has been associated with a higher incidence of pancreatic fistula. Thus the procedure has been modified to include intraoperative ultrasound imaging and closure of the pancreatic defect.

Adrenal cortical adenoma with adrenalin-type neurosecretory granules clinically mimicking a pheochromocytoma.

Adrenal tumors often present with clinical features that are specific and unique to their endocrine metabolism. When these features are in conflict with the pathologic appearance of the tumor, there can be great consternation for both the pathologist and the surgeon. In the case reported herein, an adrenalectomy was performed for clinical features of pheochromocytoma that on gross and histologic examination had the pathologic features of an adrenal cortical adenoma.

Improved survival in resected biliary malignancies.

Background: For many years the prognosis for patients with biliary malignancies has been poor. However, recent advances in radiology and laparoscopy have improved staging, and active biliary stent management may improve outcome in these patients. In the past the goal with surgery was to excise all gross tumor.

Cystic pancreatic neuroendocrine tumors: is preoperative diagnosis possible?

Pancreatic neuroendocrine tumors rarely undergo cystic degeneration leading to a radiologic appearance, which is often interpreted as a pancreatic mucinous cystadenoma or pseudocyst. We reviewed our experience with 38 neuroendocrine tumors, four of which were cystic, and 24 other cystic pancreatic tumors (mucinous cystadenoma [n = 5], cystadenocarcinoma [n = 6], serous cystadenoma [n = 3], solid/cystic papillary neoplasm [n = 3], intraductal papillary mucinous tumor [n = 6], and mucinous adenocarcinoma [n = 1]) managed operatively between 1990 and 2000. This review was undertaken to identify clinical and pathologic features useful for preoperative diagnosis of cystic neuroendocrine tumors.