Central Surgical Association (CSA): Annual Meeting

MADISON, WIS. – Patients with normal calcium levels and elevated parathyroid hormone levels after curative parathyroidectomy do not have higher rates of recurrent primary hyperparathyroidism than those with normal parathyroid levels, according to a single-center review of 310 patients.

No patient developed recurrent disease after a mean follow-up of 26 months, Dr. Carrie Carsello said at the annual meeting of the Central Surgical Association.

"Given our lack of recurrence, routine measurement of PTH levels postoperatively may not be necessary in normocalcemic patients," she said. "Persistently elevated PTH levels in patients with normocalcemia likely do not matter."

This controversial conclusion sparked a lively debate, with some attendees calling for longer follow-up and others expressing concern at abandoning repeat parathyroid hormone (PTH) measurements.

Patrice Wendling/IMNG Medical Media

Invited discussant Dr. Rebecca Sippel, chief of endocrine surgery at the University of Wisconsin, Madison, observed that elevated PTH levels after curative parathyroidectomy are a common and poorly understood problem that causes a great deal of testing and angst for patients and physicians alike. She questioned whether longer follow-up would change the authors’ conclusion, citing a recent paper that reported multiple postoperative PTH fluctuations over 10 years’ follow-up and recurrence rates of 1.1% in patients with normal postoperative PTH and calcium levels and 5% in those with normocalcemic parathormone elevation (Surgery 2011;150:1076-84).

Dr. Carsello said that many reports have shown that PTH elevations are a transient phenomenon and that some of their own patients initially had an elevated PTH that normalized, while others developed elevated PTH over time. The only thing that jumped out when they compared patients who initially had a calcium level higher than the 9.7-ng/mL cutoff, was that they had smaller glands resected. She also noted that calcium follow-up in some patients reached almost 10 years, "so it’s kind of hard to say that with longer follow-up we would have seen an increase in recurrence."

In the current cohort, surgery was curative in 300 patients. Ten patients had hypercalcemia at 6 months, six with persistent primary hyperparathyroidism and four with recurrent primary hyperparathyroidism.

Among the remaining 300 patients, 62 (21%) had elevated PTH levels and 238 had normal PTH levels at 6 months, said Dr. Carsello, an endocrine surgery fellow at the Medical College of Wisconsin in Milwaukee. All had normal calcium levels, and 85% had single-gland disease at the time of surgery. Their mean age was 60 years.

Data available at 1 year for 155 of the 238 patients revealed elevated calcium levels in 3 patients and normal calcium in 152. Continued follow-up beyond 1 year in 118 of these patients showed that 106 remained normocalcemic with normal PTH levels and 12 had normal calcium, but developed elevated PTH (10%).

Among the 62 patients with elevated PTH at 6 months, all 38 with data available at 1 year had normal calcium, she said. Additional follow-up available in 32 of the 38 patients revealed that 15 remained normocalcemic with normal PTH levels, while 17 were normocalcemic with elevated PTH (53%).

Postoperative calcium levels measured at 3 months, 6 months, and at least 1 year were significantly different between the 238 patients with normal PTH levels and the 62 patients with elevated PTH only at 6 months (9.6 mg/dL vs. 9.7 mg/dL; P = .0009), Dr. Carsello said.

As expected, PTH levels were significantly higher in the elevated PTH group at 3 months (89 pg/mL vs. 44 pg/mL), 6 months (89 pg/mL vs. 39 pg/mL) and at least 1 year (78 pg/mL vs. 39 pg/mL) (P less than .001 for all three). In addition, patients with elevated PTH had significantly lower 25-OH vitamin D levels at 6 months (30 ng/mL vs. 36 ng/mL; P = .05).

"Given the small numbers, it is difficult to say whether elevated PTH levels were secondary to vitamin D deficiency alone or if other factors played a role," Dr. Carsello said.

Patrice Wendling/IMNG Medical Media

Still, the finding of lower 25-OH vitamin D levels supports aggressive vitamin D supplementation in patients following parathyroidectomy.

"We routinely recommend vitamin D supplementation in patients with levels less than 32 [ng/mL]," she said.

Attendee Dr. Christopher McHenry, director of general surgery at MetroHealth Medical Center in Cleveland, said the main message he took from the analysis is that measuring PTH levels after surgery is not necessary, because "the issue here is that you’re not going to intervene unless the patient is hypercalcemic and so probably the most reasonable way to follow these patients is with serum calcium levels."

Dr. Richard Prinz, a meeting attendee who is vice chair of surgery at NorthShore University HealthSystem in Evanston, Ill. rose to say he was "vexed" at the idea of abandoning postoperative PTH measurements as both calcium and PTH are used to diagnose patients, and that a substantial number of his surgical cases have high normal or borderline elevated calcium levels that are inappropriate for their PTH levels.

"These patients have similar levels, I think, to what you are describing as cured of the disease, so I find using only serum calcium as a marker of cure troubling," he added.

Dr. Carsello said their group uses 10.0 to 10.2 ng/mL as the upper limit of normal calcium.

At baseline, no significant differences were observed between patients in the elevated PTH group and the normal PTH group in preoperative calcium or creatinine, median percentage drop of intraoperative PTH at 10 minutes, or the percent undergoing minimally invasive or focused parathyroidectomy. Patients with elevated PTH, however, had larger glands resected (median 785 mg vs. 516 mg; P = .04).

Patients in the elevated PTH group also had a significantly higher body mass index than those in the normal PTH group (median 30.8 kg/m² vs. 27.2 kg/m²; P less than .0001), and were more likely to be black (19% vs. 6%).

Dr. Carsello and Dr. Sippel reported no conflicts of interest.

MADISON, WIS. – Patients with normal calcium levels and elevated parathyroid hormone levels after curative parathyroidectomy do not have higher rates of recurrent primary hyperparathyroidism than those with normal parathyroid levels, according to a single-center review of 310 patients.

No patient developed recurrent disease after a mean follow-up of 26 months, Dr. Carrie Carsello said at the annual meeting of the Central Surgical Association.

"Given our lack of recurrence, routine measurement of PTH levels postoperatively may not be necessary in normocalcemic patients," she said. "Persistently elevated PTH levels in patients with normocalcemia likely do not matter."

This controversial conclusion sparked a lively debate, with some attendees calling for longer follow-up and others expressing concern at abandoning repeat parathyroid hormone (PTH) measurements.

Patrice Wendling/IMNG Medical Media

Invited discussant Dr. Rebecca Sippel, chief of endocrine surgery at the University of Wisconsin, Madison, observed that elevated PTH levels after curative parathyroidectomy are a common and poorly understood problem that causes a great deal of testing and angst for patients and physicians alike. She questioned whether longer follow-up would change the authors’ conclusion, citing a recent paper that reported multiple postoperative PTH fluctuations over 10 years’ follow-up and recurrence rates of 1.1% in patients with normal postoperative PTH and calcium levels and 5% in those with normocalcemic parathormone elevation (Surgery 2011;150:1076-84).

Dr. Carsello said that many reports have shown that PTH elevations are a transient phenomenon and that some of their own patients initially had an elevated PTH that normalized, while others developed elevated PTH over time. The only thing that jumped out when they compared patients who initially had a calcium level higher than the 9.7-ng/mL cutoff, was that they had smaller glands resected. She also noted that calcium follow-up in some patients reached almost 10 years, "so it’s kind of hard to say that with longer follow-up we would have seen an increase in recurrence."

In the current cohort, surgery was curative in 300 patients. Ten patients had hypercalcemia at 6 months, six with persistent primary hyperparathyroidism and four with recurrent primary hyperparathyroidism.

Among the remaining 300 patients, 62 (21%) had elevated PTH levels and 238 had normal PTH levels at 6 months, said Dr. Carsello, an endocrine surgery fellow at the Medical College of Wisconsin in Milwaukee. All had normal calcium levels, and 85% had single-gland disease at the time of surgery. Their mean age was 60 years.

Data available at 1 year for 155 of the 238 patients revealed elevated calcium levels in 3 patients and normal calcium in 152. Continued follow-up beyond 1 year in 118 of these patients showed that 106 remained normocalcemic with normal PTH levels and 12 had normal calcium, but developed elevated PTH (10%).

Among the 62 patients with elevated PTH at 6 months, all 38 with data available at 1 year had normal calcium, she said. Additional follow-up available in 32 of the 38 patients revealed that 15 remained normocalcemic with normal PTH levels, while 17 were normocalcemic with elevated PTH (53%).

Postoperative calcium levels measured at 3 months, 6 months, and at least 1 year were significantly different between the 238 patients with normal PTH levels and the 62 patients with elevated PTH only at 6 months (9.6 mg/dL vs. 9.7 mg/dL; P = .0009), Dr. Carsello said.

As expected, PTH levels were significantly higher in the elevated PTH group at 3 months (89 pg/mL vs. 44 pg/mL), 6 months (89 pg/mL vs. 39 pg/mL) and at least 1 year (78 pg/mL vs. 39 pg/mL) (P less than .001 for all three). In addition, patients with elevated PTH had significantly lower 25-OH vitamin D levels at 6 months (30 ng/mL vs. 36 ng/mL; P = .05).

"Given the small numbers, it is difficult to say whether elevated PTH levels were secondary to vitamin D deficiency alone or if other factors played a role," Dr. Carsello said.

Patrice Wendling/IMNG Medical Media

Still, the finding of lower 25-OH vitamin D levels supports aggressive vitamin D supplementation in patients following parathyroidectomy.

"We routinely recommend vitamin D supplementation in patients with levels less than 32 [ng/mL]," she said.

Attendee Dr. Christopher McHenry, director of general surgery at MetroHealth Medical Center in Cleveland, said the main message he took from the analysis is that measuring PTH levels after surgery is not necessary, because "the issue here is that you’re not going to intervene unless the patient is hypercalcemic and so probably the most reasonable way to follow these patients is with serum calcium levels."

Dr. Richard Prinz, a meeting attendee who is vice chair of surgery at NorthShore University HealthSystem in Evanston, Ill. rose to say he was "vexed" at the idea of abandoning postoperative PTH measurements as both calcium and PTH are used to diagnose patients, and that a substantial number of his surgical cases have high normal or borderline elevated calcium levels that are inappropriate for their PTH levels.

"These patients have similar levels, I think, to what you are describing as cured of the disease, so I find using only serum calcium as a marker of cure troubling," he added.

Dr. Carsello said their group uses 10.0 to 10.2 ng/mL as the upper limit of normal calcium.

At baseline, no significant differences were observed between patients in the elevated PTH group and the normal PTH group in preoperative calcium or creatinine, median percentage drop of intraoperative PTH at 10 minutes, or the percent undergoing minimally invasive or focused parathyroidectomy. Patients with elevated PTH, however, had larger glands resected (median 785 mg vs. 516 mg; P = .04).

Patients in the elevated PTH group also had a significantly higher body mass index than those in the normal PTH group (median 30.8 kg/m² vs. 27.2 kg/m²; P less than .0001), and were more likely to be black (19% vs. 6%).

Dr. Carsello and Dr. Sippel reported no conflicts of interest.

MADISON, WIS. – Patients with normal calcium levels and elevated parathyroid hormone levels after curative parathyroidectomy do not have higher rates of recurrent primary hyperparathyroidism than those with normal parathyroid levels, according to a single-center review of 310 patients.

No patient developed recurrent disease after a mean follow-up of 26 months, Dr. Carrie Carsello said at the annual meeting of the Central Surgical Association.

"Given our lack of recurrence, routine measurement of PTH levels postoperatively may not be necessary in normocalcemic patients," she said. "Persistently elevated PTH levels in patients with normocalcemia likely do not matter."

This controversial conclusion sparked a lively debate, with some attendees calling for longer follow-up and others expressing concern at abandoning repeat parathyroid hormone (PTH) measurements.

Patrice Wendling/IMNG Medical Media

Invited discussant Dr. Rebecca Sippel, chief of endocrine surgery at the University of Wisconsin, Madison, observed that elevated PTH levels after curative parathyroidectomy are a common and poorly understood problem that causes a great deal of testing and angst for patients and physicians alike. She questioned whether longer follow-up would change the authors’ conclusion, citing a recent paper that reported multiple postoperative PTH fluctuations over 10 years’ follow-up and recurrence rates of 1.1% in patients with normal postoperative PTH and calcium levels and 5% in those with normocalcemic parathormone elevation (Surgery 2011;150:1076-84).

Dr. Carsello said that many reports have shown that PTH elevations are a transient phenomenon and that some of their own patients initially had an elevated PTH that normalized, while others developed elevated PTH over time. The only thing that jumped out when they compared patients who initially had a calcium level higher than the 9.7-ng/mL cutoff, was that they had smaller glands resected. She also noted that calcium follow-up in some patients reached almost 10 years, "so it’s kind of hard to say that with longer follow-up we would have seen an increase in recurrence."

In the current cohort, surgery was curative in 300 patients. Ten patients had hypercalcemia at 6 months, six with persistent primary hyperparathyroidism and four with recurrent primary hyperparathyroidism.

Among the remaining 300 patients, 62 (21%) had elevated PTH levels and 238 had normal PTH levels at 6 months, said Dr. Carsello, an endocrine surgery fellow at the Medical College of Wisconsin in Milwaukee. All had normal calcium levels, and 85% had single-gland disease at the time of surgery. Their mean age was 60 years.

Data available at 1 year for 155 of the 238 patients revealed elevated calcium levels in 3 patients and normal calcium in 152. Continued follow-up beyond 1 year in 118 of these patients showed that 106 remained normocalcemic with normal PTH levels and 12 had normal calcium, but developed elevated PTH (10%).

Among the 62 patients with elevated PTH at 6 months, all 38 with data available at 1 year had normal calcium, she said. Additional follow-up available in 32 of the 38 patients revealed that 15 remained normocalcemic with normal PTH levels, while 17 were normocalcemic with elevated PTH (53%).

Postoperative calcium levels measured at 3 months, 6 months, and at least 1 year were significantly different between the 238 patients with normal PTH levels and the 62 patients with elevated PTH only at 6 months (9.6 mg/dL vs. 9.7 mg/dL; P = .0009), Dr. Carsello said.

As expected, PTH levels were significantly higher in the elevated PTH group at 3 months (89 pg/mL vs. 44 pg/mL), 6 months (89 pg/mL vs. 39 pg/mL) and at least 1 year (78 pg/mL vs. 39 pg/mL) (P less than .001 for all three). In addition, patients with elevated PTH had significantly lower 25-OH vitamin D levels at 6 months (30 ng/mL vs. 36 ng/mL; P = .05).

"Given the small numbers, it is difficult to say whether elevated PTH levels were secondary to vitamin D deficiency alone or if other factors played a role," Dr. Carsello said.

Patrice Wendling/IMNG Medical Media

Still, the finding of lower 25-OH vitamin D levels supports aggressive vitamin D supplementation in patients following parathyroidectomy.

"We routinely recommend vitamin D supplementation in patients with levels less than 32 [ng/mL]," she said.

Attendee Dr. Christopher McHenry, director of general surgery at MetroHealth Medical Center in Cleveland, said the main message he took from the analysis is that measuring PTH levels after surgery is not necessary, because "the issue here is that you’re not going to intervene unless the patient is hypercalcemic and so probably the most reasonable way to follow these patients is with serum calcium levels."

Dr. Richard Prinz, a meeting attendee who is vice chair of surgery at NorthShore University HealthSystem in Evanston, Ill. rose to say he was "vexed" at the idea of abandoning postoperative PTH measurements as both calcium and PTH are used to diagnose patients, and that a substantial number of his surgical cases have high normal or borderline elevated calcium levels that are inappropriate for their PTH levels.

"These patients have similar levels, I think, to what you are describing as cured of the disease, so I find using only serum calcium as a marker of cure troubling," he added.

Dr. Carsello said their group uses 10.0 to 10.2 ng/mL as the upper limit of normal calcium.

At baseline, no significant differences were observed between patients in the elevated PTH group and the normal PTH group in preoperative calcium or creatinine, median percentage drop of intraoperative PTH at 10 minutes, or the percent undergoing minimally invasive or focused parathyroidectomy. Patients with elevated PTH, however, had larger glands resected (median 785 mg vs. 516 mg; P = .04).

Patients in the elevated PTH group also had a significantly higher body mass index than those in the normal PTH group (median 30.8 kg/m² vs. 27.2 kg/m²; P less than .0001), and were more likely to be black (19% vs. 6%).

Dr. Carsello and Dr. Sippel reported no conflicts of interest.

MADISON, WIS. – Only combined pharmacologic and mechanical prophylaxis was protective against venous thromboembolism following colectomy in a large prospective analysis of 3,464 patients.

Major bleeding events were significantly lower at 0.3% with combination prophylaxis, compared with 1.3% without combination prophylaxis (P = .005).

Patrice Wendling/IMNG Medical Media

There was no difference in major bleeding events with or without pharmacologic prophylaxis alone (0.6% vs. 0.7%; P = .45).

Counterintuitively, patients who received only sequential compression devices as prophylaxis had more major bleeding events than those who did not receive devices (1.6% vs. 0.4%; P = .009), vascular surgeon Dr. Peter Henke said at the annual meeting of the Central Surgical Association.

"All [colectomy patients] should have combined mechanical and pharmacologic VTE prophylaxis, unless their bleeding risk is deemed too high by surgeon judgment," he said.

Investigators at 15 hospitals prospectively collected data from 2008 to 2009 on 3,464 open and laparoscopic colectomy patients. Their mean age was 65 years, and 53% were female. Roughly 74% of patients were on combination prophylaxis during both years.

The VTE incidence was low overall at 2.2%, but as high as other high-risk surgical procedures such as total knee or hip replacement, said Dr. Henke, with the University of Michigan Health System in Ann Arbor.

VTEs occurred slightly more often with open left colectomy than with open right colectomy (3.1% vs. 2.3%). VTE rates for laparoscopic left and right colectomies were significantly lower (1.7% and 0.5%; P = .011), while rates were double for emergent vs. nonemergent cases (4% vs. 2%; P = .017).

In a univariate analysis of 2,263 patients with full data available, several significant risk factors for postoperative VTE emerged, including no combination prophylaxis; older age (65 vs. 62 years); higher body mass index (31 vs. 28 kg/m²); preoperative angina, anemia, and weight loss; surgical site infections; and postoperative infectious complications.

Notably, operative time, presence of malignancy, anastomotic leak, transfusion, and urinary tract infection were not significantly associated with VTE.

In a full multivariate model, postoperative infectious complications increased the risk for a postoperative VTE (odds ratio, 3.6; P less than .001), Dr. Henke said. This finding has also been observed in other studies.

Risk was also significantly higher with contaminated wounds (OR, 3.4; P = .001), postoperative surgical site infection (OR, 2.5; P = .01), anemia (OR, 2.4; P = .01), each additional year of age (OR, 1.05, P = .04), and increased BMI (OR, 1.03, P = .01). VTE risk increased with open as compared to laparoscopic surgery, but not with covariate adjustment, he said.

Protective factors included no history of preoperative angina (OR, 0.18; P = .01) or weight loss (OR, 0.33; P = .02).

The only really modifiable protective factor, however, was combined mechanical and pharmacologic prophylaxis (OR, 0.48; P = .02; area under the curve, 0.81), Dr. Henke said.

The investigators also performed a propensity-matched analysis of 1,006 patients for anticoagulant type and VTE in which unfractionated heparin was equivalent to low-molecular-weight heparin (1.6% vs. 1.4%; P = .5).

Limitations of the study were the determination of VTE on clinical grounds and not prospectively by protocol, the inability to assess for hypercoagulable states or prior history of VTE – a strong risk factor for recurrent VTE – and follow-up of only 30 days, while about 20% of VTEs occur outside this window. The findings also may not be reflective of rectal and small bowel surgical VTE risk, he said.

Dr. Susan Galandiuk, an invited discussant, asked why the analysis was limited to patients undergoing segmental colectomy, given that VTE rates and operating times are higher among patients undergoing rectal surgery. She also questioned why the group combined deep vein thrombosis (DVT) and pulmonary embolism into a VTE statistic. Dr. Galandiuk, with the University of Louisville (Ky.), noted that extensive work performed at her university has shown that while DVT is far more common, it is never really lethal, and although rare, pulmonary embolism is occasionally lethal.

Dr. Henke said the analysis focused on only four CPT codes to get as homogeneous a sample as possible, but agreed that rectal cases would be at even higher VTE risk and thus warrant combined prophylaxis. He also agreed that DVTs are not directly fatal, whereas pulmonary embolisms are, adding that interestingly, surgical patients tend to have less risk of fatal pulmonary embolism than do medically ill patients.

Dr. M. Ashraf Mansour, another invited discussant, who is interim chair of surgery at Michigan State University, Grand Rapids, asked how Dr. Henke would manage patients with a prophylaxis allergy or heparin-induced thrombocytopenia (HIT) and whether he would still recommend dual prophylaxis for patients with low DVT risk on the Caprini Risk Assessment Model.

Dr. Henke said parinox may be safe for patients with a history of HIT unless they are at really high risk, but that filters are overused and controversial. He noted that the same hospital consortium is trying to validate the Caprini score among 10,000 patients, with 90-day data now available on 8,500 patients.

"The interesting thing about this study that struck me initially as different is that, regardless of the other preoperative risk factors, dual prophylaxis was independently protective regardless of risk factors," he added. "So even with a low-risk Caprini score, they should probably have dual prophylaxis just because the overall [VTE] rate is quite high compared to many other surgical procedures."

Dr. Henke, Dr. Galandiuk and Dr. Mansour reported no relevant conflicts of interest.

MADISON, WIS. – Only combined pharmacologic and mechanical prophylaxis was protective against venous thromboembolism following colectomy in a large prospective analysis of 3,464 patients.

Major bleeding events were significantly lower at 0.3% with combination prophylaxis, compared with 1.3% without combination prophylaxis (P = .005).

Patrice Wendling/IMNG Medical Media

There was no difference in major bleeding events with or without pharmacologic prophylaxis alone (0.6% vs. 0.7%; P = .45).

Counterintuitively, patients who received only sequential compression devices as prophylaxis had more major bleeding events than those who did not receive devices (1.6% vs. 0.4%; P = .009), vascular surgeon Dr. Peter Henke said at the annual meeting of the Central Surgical Association.

"All [colectomy patients] should have combined mechanical and pharmacologic VTE prophylaxis, unless their bleeding risk is deemed too high by surgeon judgment," he said.

Investigators at 15 hospitals prospectively collected data from 2008 to 2009 on 3,464 open and laparoscopic colectomy patients. Their mean age was 65 years, and 53% were female. Roughly 74% of patients were on combination prophylaxis during both years.

The VTE incidence was low overall at 2.2%, but as high as other high-risk surgical procedures such as total knee or hip replacement, said Dr. Henke, with the University of Michigan Health System in Ann Arbor.

VTEs occurred slightly more often with open left colectomy than with open right colectomy (3.1% vs. 2.3%). VTE rates for laparoscopic left and right colectomies were significantly lower (1.7% and 0.5%; P = .011), while rates were double for emergent vs. nonemergent cases (4% vs. 2%; P = .017).

In a univariate analysis of 2,263 patients with full data available, several significant risk factors for postoperative VTE emerged, including no combination prophylaxis; older age (65 vs. 62 years); higher body mass index (31 vs. 28 kg/m²); preoperative angina, anemia, and weight loss; surgical site infections; and postoperative infectious complications.

Notably, operative time, presence of malignancy, anastomotic leak, transfusion, and urinary tract infection were not significantly associated with VTE.

In a full multivariate model, postoperative infectious complications increased the risk for a postoperative VTE (odds ratio, 3.6; P less than .001), Dr. Henke said. This finding has also been observed in other studies.

Risk was also significantly higher with contaminated wounds (OR, 3.4; P = .001), postoperative surgical site infection (OR, 2.5; P = .01), anemia (OR, 2.4; P = .01), each additional year of age (OR, 1.05, P = .04), and increased BMI (OR, 1.03, P = .01). VTE risk increased with open as compared to laparoscopic surgery, but not with covariate adjustment, he said.

Protective factors included no history of preoperative angina (OR, 0.18; P = .01) or weight loss (OR, 0.33; P = .02).

The only really modifiable protective factor, however, was combined mechanical and pharmacologic prophylaxis (OR, 0.48; P = .02; area under the curve, 0.81), Dr. Henke said.

The investigators also performed a propensity-matched analysis of 1,006 patients for anticoagulant type and VTE in which unfractionated heparin was equivalent to low-molecular-weight heparin (1.6% vs. 1.4%; P = .5).

Limitations of the study were the determination of VTE on clinical grounds and not prospectively by protocol, the inability to assess for hypercoagulable states or prior history of VTE – a strong risk factor for recurrent VTE – and follow-up of only 30 days, while about 20% of VTEs occur outside this window. The findings also may not be reflective of rectal and small bowel surgical VTE risk, he said.

Dr. Susan Galandiuk, an invited discussant, asked why the analysis was limited to patients undergoing segmental colectomy, given that VTE rates and operating times are higher among patients undergoing rectal surgery. She also questioned why the group combined deep vein thrombosis (DVT) and pulmonary embolism into a VTE statistic. Dr. Galandiuk, with the University of Louisville (Ky.), noted that extensive work performed at her university has shown that while DVT is far more common, it is never really lethal, and although rare, pulmonary embolism is occasionally lethal.

Dr. Henke said the analysis focused on only four CPT codes to get as homogeneous a sample as possible, but agreed that rectal cases would be at even higher VTE risk and thus warrant combined prophylaxis. He also agreed that DVTs are not directly fatal, whereas pulmonary embolisms are, adding that interestingly, surgical patients tend to have less risk of fatal pulmonary embolism than do medically ill patients.

Dr. M. Ashraf Mansour, another invited discussant, who is interim chair of surgery at Michigan State University, Grand Rapids, asked how Dr. Henke would manage patients with a prophylaxis allergy or heparin-induced thrombocytopenia (HIT) and whether he would still recommend dual prophylaxis for patients with low DVT risk on the Caprini Risk Assessment Model.

Dr. Henke said parinox may be safe for patients with a history of HIT unless they are at really high risk, but that filters are overused and controversial. He noted that the same hospital consortium is trying to validate the Caprini score among 10,000 patients, with 90-day data now available on 8,500 patients.

"The interesting thing about this study that struck me initially as different is that, regardless of the other preoperative risk factors, dual prophylaxis was independently protective regardless of risk factors," he added. "So even with a low-risk Caprini score, they should probably have dual prophylaxis just because the overall [VTE] rate is quite high compared to many other surgical procedures."

Dr. Henke, Dr. Galandiuk and Dr. Mansour reported no relevant conflicts of interest.

MADISON, WIS. – Only combined pharmacologic and mechanical prophylaxis was protective against venous thromboembolism following colectomy in a large prospective analysis of 3,464 patients.

Major bleeding events were significantly lower at 0.3% with combination prophylaxis, compared with 1.3% without combination prophylaxis (P = .005).

Patrice Wendling/IMNG Medical Media

There was no difference in major bleeding events with or without pharmacologic prophylaxis alone (0.6% vs. 0.7%; P = .45).

Counterintuitively, patients who received only sequential compression devices as prophylaxis had more major bleeding events than those who did not receive devices (1.6% vs. 0.4%; P = .009), vascular surgeon Dr. Peter Henke said at the annual meeting of the Central Surgical Association.

"All [colectomy patients] should have combined mechanical and pharmacologic VTE prophylaxis, unless their bleeding risk is deemed too high by surgeon judgment," he said.

Investigators at 15 hospitals prospectively collected data from 2008 to 2009 on 3,464 open and laparoscopic colectomy patients. Their mean age was 65 years, and 53% were female. Roughly 74% of patients were on combination prophylaxis during both years.

The VTE incidence was low overall at 2.2%, but as high as other high-risk surgical procedures such as total knee or hip replacement, said Dr. Henke, with the University of Michigan Health System in Ann Arbor.

VTEs occurred slightly more often with open left colectomy than with open right colectomy (3.1% vs. 2.3%). VTE rates for laparoscopic left and right colectomies were significantly lower (1.7% and 0.5%; P = .011), while rates were double for emergent vs. nonemergent cases (4% vs. 2%; P = .017).

In a univariate analysis of 2,263 patients with full data available, several significant risk factors for postoperative VTE emerged, including no combination prophylaxis; older age (65 vs. 62 years); higher body mass index (31 vs. 28 kg/m²); preoperative angina, anemia, and weight loss; surgical site infections; and postoperative infectious complications.

Notably, operative time, presence of malignancy, anastomotic leak, transfusion, and urinary tract infection were not significantly associated with VTE.

In a full multivariate model, postoperative infectious complications increased the risk for a postoperative VTE (odds ratio, 3.6; P less than .001), Dr. Henke said. This finding has also been observed in other studies.

Risk was also significantly higher with contaminated wounds (OR, 3.4; P = .001), postoperative surgical site infection (OR, 2.5; P = .01), anemia (OR, 2.4; P = .01), each additional year of age (OR, 1.05, P = .04), and increased BMI (OR, 1.03, P = .01). VTE risk increased with open as compared to laparoscopic surgery, but not with covariate adjustment, he said.

Protective factors included no history of preoperative angina (OR, 0.18; P = .01) or weight loss (OR, 0.33; P = .02).

The only really modifiable protective factor, however, was combined mechanical and pharmacologic prophylaxis (OR, 0.48; P = .02; area under the curve, 0.81), Dr. Henke said.

The investigators also performed a propensity-matched analysis of 1,006 patients for anticoagulant type and VTE in which unfractionated heparin was equivalent to low-molecular-weight heparin (1.6% vs. 1.4%; P = .5).

Limitations of the study were the determination of VTE on clinical grounds and not prospectively by protocol, the inability to assess for hypercoagulable states or prior history of VTE – a strong risk factor for recurrent VTE – and follow-up of only 30 days, while about 20% of VTEs occur outside this window. The findings also may not be reflective of rectal and small bowel surgical VTE risk, he said.

Dr. Susan Galandiuk, an invited discussant, asked why the analysis was limited to patients undergoing segmental colectomy, given that VTE rates and operating times are higher among patients undergoing rectal surgery. She also questioned why the group combined deep vein thrombosis (DVT) and pulmonary embolism into a VTE statistic. Dr. Galandiuk, with the University of Louisville (Ky.), noted that extensive work performed at her university has shown that while DVT is far more common, it is never really lethal, and although rare, pulmonary embolism is occasionally lethal.

Dr. Henke said the analysis focused on only four CPT codes to get as homogeneous a sample as possible, but agreed that rectal cases would be at even higher VTE risk and thus warrant combined prophylaxis. He also agreed that DVTs are not directly fatal, whereas pulmonary embolisms are, adding that interestingly, surgical patients tend to have less risk of fatal pulmonary embolism than do medically ill patients.

Dr. M. Ashraf Mansour, another invited discussant, who is interim chair of surgery at Michigan State University, Grand Rapids, asked how Dr. Henke would manage patients with a prophylaxis allergy or heparin-induced thrombocytopenia (HIT) and whether he would still recommend dual prophylaxis for patients with low DVT risk on the Caprini Risk Assessment Model.

Dr. Henke said parinox may be safe for patients with a history of HIT unless they are at really high risk, but that filters are overused and controversial. He noted that the same hospital consortium is trying to validate the Caprini score among 10,000 patients, with 90-day data now available on 8,500 patients.

"The interesting thing about this study that struck me initially as different is that, regardless of the other preoperative risk factors, dual prophylaxis was independently protective regardless of risk factors," he added. "So even with a low-risk Caprini score, they should probably have dual prophylaxis just because the overall [VTE] rate is quite high compared to many other surgical procedures."

Dr. Henke, Dr. Galandiuk and Dr. Mansour reported no relevant conflicts of interest.

MADISON, WIS. – Implementation of a small bowel obstruction guideline increased admissions to surgery, shortened the time to surgery, and decreased hospital length of stay, according to a review of 730 admissions.

"A multidisciplinary approach to guideline development and implementation for small bowel obstruction improved overall efficiency and resource utilization in the hospital, and appeared to decrease readmission for SBO [small bowel obstruction] in the short term," Dr. Wendy L. Wahl said at the annual meeting of the Central Surgical Association.

Patrice Wendling/IMNG Medical Media

She observed that prior to the guidelines, a controversy existed at the University of Michigan, Ann Arbor, over where SBO patients should be admitted, particularly those who didn’t need surgery or who had partial obstructions. This raised questions of whether there were delays in operative intervention or delays in admission from the emergency room. For some, there was also a sense that too many patients were being admitted to the medicine service with partial, or even full, obstructions.

As a result, the university’s Surgery Quality Improvement Committee partnered with the departments of surgery, medicine, and emergency medicine to create an SBO service triage and initial management guideline that was instituted in 2011. The new guidelines spell out that a patient will be admitted to a surgical service if a transition point or other concerning signs for bowel strangulation were identified on computed tomography (CT) or if the patient has had an abdominal surgery within the last 30 days.

Exceptions that may warrant medical service admission could be patients with: intra-abdominal metastases or active inflammatory bowel disease scheduled for a systemic therapy trial and acute, severe conditions requiring stabilization, explained Dr. Wahl, now the medical director of surgical quality at St. Joseph Mercy Hospital, also in Ann Arbor. Patients with known dilated bowel secondary to dysmotility problems or other medical conditions such cystic fibrosis or mental/developmental disorders could also be admitted to medicine.

The guidelines de-emphasize the use of CT scans in the absence of an absolute indication for an emergent surgical consultation such as free air, peritonitis, nonreducible symptomatic hernia, or abdominal surgery in the last 30 days. The guidelines also stress an early general surgical consultation as part of initial therapy, she added.

The investigators compared data for 490 patients admitted for SBO during 2010 with 240 patients admitted for SBO during the first 6 months of 2011 after guideline implementation. Age (roughly 57 years) and sex did not differ significantly between groups for the two time periods. All-Patient Refined Diagnostic Related Groups scores pre- and post-implementation were lower at 1.78 and 1.56 in the surgical service, compared with 3.52 and 2.23 in the medical service.

After implementation, the mean time to surgery fell significantly from 0.9 days to 0.4 days among surgical patients (P value less than .05) and from 7.6 days to 3.6 days among those admitted to medicine (P less than .001).

The percent of patients admitted to a medicine service requiring surgery for SBO did not change significantly from 14% in 2010 to 7% in 2011, but the reasons did, Dr. Wahl said. Of the 26 patients admitted to a medicine service in 2010, five had clear bowel obstructions and no reason for a medical admission, four had a missed SBO in the emergency room, and four had a late surgery consultation.

"About half of the patients could have had their process improved," she observed.

In contrast, all seven SBO patients admitted to medicine in 2011 had documented active medical issues such as myocardial infarction and lobe transplant rejection.

After guideline implementation, time to general surgery consultation among medical patients was significantly shorter at 1.7 days vs. 3.4 days (P less than .001).

The rate of SBO admissions to surgery also rose from 55% to 66% (P less than .01), while the rate of operative interventions increased from 36% to 45% (P less than .05).

Notably, the rate of readmission for SBO nonoperative patients fell from 16% to 6% after guideline implementation (P less than .01), Dr. Wahl said. Hospital length of stay decreased from 8 days to 6 days in the surgical group and from 31 days to 13 days in the medical group.

Invited discussant Dr. Fred Luchette, professor of surgery at Loyola University Chicago, Maywood, Ill., observed that SBO accounts for 15% of surgical admissions in the United States and that treatment costs exceed $1 billion.

"The improvement in care for these patients with your guideline is a step in the right direction for improving patient outcomes," he stated.

Notably, the average cost of care did not change significantly from $20,530 to $22,554 in the surgical group and from $49,956 to $36,726 in the medical group.

Dr. Luchette asked why the medical service is allowed to admit any patient with a bowel obstruction, and why medical patients waited 3 days for surgery whereas surgical patients underwent surgery that day. The surgical delay is particularly vexing given the "liberal" use of CT scans post guideline implementation at 83% among medical patients.

Dr. Wahl agreed that CT use for the medical service was liberal, but pointed out that the vast majority of these patients had other medical issues that required further investigation to differentiate whether surgery was indicated. The delay in time to laparotomy could be explained by the need to stabilize medical patients prior to surgery or the need to wait to assess improvement following medical therapy.

Dr. Wahl admitted to being somewhat surprised at the number of SBO patients who went to the medical service before guideline implementation, but reminded the audience that a lot of patients with small bowel obstructions may simply feel a "little burpy" and may not manifest with full-blown symptoms.

"There’s probably a lot of people with bowel obstructions that are never seen by a surgeon that you don’t really know about until you look, unfortunately," she said. "In this day and age where there is a limit to the amount of resident and physician capacity, you really want patients to go where they’d be best served."

When asked by the audience how the university achieved buy-in for the project and how the guidelines were disseminated, Dr. Wahl said buy-in was relatively easy since practitioners recognized there was a problem and the guidelines were posted on-line.

Dr. Wahl and her coauthors reported no conflicts of interest.

MADISON, WIS. – Implementation of a small bowel obstruction guideline increased admissions to surgery, shortened the time to surgery, and decreased hospital length of stay, according to a review of 730 admissions.

"A multidisciplinary approach to guideline development and implementation for small bowel obstruction improved overall efficiency and resource utilization in the hospital, and appeared to decrease readmission for SBO [small bowel obstruction] in the short term," Dr. Wendy L. Wahl said at the annual meeting of the Central Surgical Association.

Patrice Wendling/IMNG Medical Media

She observed that prior to the guidelines, a controversy existed at the University of Michigan, Ann Arbor, over where SBO patients should be admitted, particularly those who didn’t need surgery or who had partial obstructions. This raised questions of whether there were delays in operative intervention or delays in admission from the emergency room. For some, there was also a sense that too many patients were being admitted to the medicine service with partial, or even full, obstructions.

As a result, the university’s Surgery Quality Improvement Committee partnered with the departments of surgery, medicine, and emergency medicine to create an SBO service triage and initial management guideline that was instituted in 2011. The new guidelines spell out that a patient will be admitted to a surgical service if a transition point or other concerning signs for bowel strangulation were identified on computed tomography (CT) or if the patient has had an abdominal surgery within the last 30 days.

Exceptions that may warrant medical service admission could be patients with: intra-abdominal metastases or active inflammatory bowel disease scheduled for a systemic therapy trial and acute, severe conditions requiring stabilization, explained Dr. Wahl, now the medical director of surgical quality at St. Joseph Mercy Hospital, also in Ann Arbor. Patients with known dilated bowel secondary to dysmotility problems or other medical conditions such cystic fibrosis or mental/developmental disorders could also be admitted to medicine.

The guidelines de-emphasize the use of CT scans in the absence of an absolute indication for an emergent surgical consultation such as free air, peritonitis, nonreducible symptomatic hernia, or abdominal surgery in the last 30 days. The guidelines also stress an early general surgical consultation as part of initial therapy, she added.

The investigators compared data for 490 patients admitted for SBO during 2010 with 240 patients admitted for SBO during the first 6 months of 2011 after guideline implementation. Age (roughly 57 years) and sex did not differ significantly between groups for the two time periods. All-Patient Refined Diagnostic Related Groups scores pre- and post-implementation were lower at 1.78 and 1.56 in the surgical service, compared with 3.52 and 2.23 in the medical service.

After implementation, the mean time to surgery fell significantly from 0.9 days to 0.4 days among surgical patients (P value less than .05) and from 7.6 days to 3.6 days among those admitted to medicine (P less than .001).

The percent of patients admitted to a medicine service requiring surgery for SBO did not change significantly from 14% in 2010 to 7% in 2011, but the reasons did, Dr. Wahl said. Of the 26 patients admitted to a medicine service in 2010, five had clear bowel obstructions and no reason for a medical admission, four had a missed SBO in the emergency room, and four had a late surgery consultation.

"About half of the patients could have had their process improved," she observed.

In contrast, all seven SBO patients admitted to medicine in 2011 had documented active medical issues such as myocardial infarction and lobe transplant rejection.

After guideline implementation, time to general surgery consultation among medical patients was significantly shorter at 1.7 days vs. 3.4 days (P less than .001).

The rate of SBO admissions to surgery also rose from 55% to 66% (P less than .01), while the rate of operative interventions increased from 36% to 45% (P less than .05).

Notably, the rate of readmission for SBO nonoperative patients fell from 16% to 6% after guideline implementation (P less than .01), Dr. Wahl said. Hospital length of stay decreased from 8 days to 6 days in the surgical group and from 31 days to 13 days in the medical group.

Invited discussant Dr. Fred Luchette, professor of surgery at Loyola University Chicago, Maywood, Ill., observed that SBO accounts for 15% of surgical admissions in the United States and that treatment costs exceed $1 billion.

"The improvement in care for these patients with your guideline is a step in the right direction for improving patient outcomes," he stated.

Notably, the average cost of care did not change significantly from $20,530 to $22,554 in the surgical group and from $49,956 to $36,726 in the medical group.

Dr. Luchette asked why the medical service is allowed to admit any patient with a bowel obstruction, and why medical patients waited 3 days for surgery whereas surgical patients underwent surgery that day. The surgical delay is particularly vexing given the "liberal" use of CT scans post guideline implementation at 83% among medical patients.

Dr. Wahl agreed that CT use for the medical service was liberal, but pointed out that the vast majority of these patients had other medical issues that required further investigation to differentiate whether surgery was indicated. The delay in time to laparotomy could be explained by the need to stabilize medical patients prior to surgery or the need to wait to assess improvement following medical therapy.

Dr. Wahl admitted to being somewhat surprised at the number of SBO patients who went to the medical service before guideline implementation, but reminded the audience that a lot of patients with small bowel obstructions may simply feel a "little burpy" and may not manifest with full-blown symptoms.

"There’s probably a lot of people with bowel obstructions that are never seen by a surgeon that you don’t really know about until you look, unfortunately," she said. "In this day and age where there is a limit to the amount of resident and physician capacity, you really want patients to go where they’d be best served."

When asked by the audience how the university achieved buy-in for the project and how the guidelines were disseminated, Dr. Wahl said buy-in was relatively easy since practitioners recognized there was a problem and the guidelines were posted on-line.

Dr. Wahl and her coauthors reported no conflicts of interest.

MADISON, WIS. – Implementation of a small bowel obstruction guideline increased admissions to surgery, shortened the time to surgery, and decreased hospital length of stay, according to a review of 730 admissions.

"A multidisciplinary approach to guideline development and implementation for small bowel obstruction improved overall efficiency and resource utilization in the hospital, and appeared to decrease readmission for SBO [small bowel obstruction] in the short term," Dr. Wendy L. Wahl said at the annual meeting of the Central Surgical Association.

Patrice Wendling/IMNG Medical Media

She observed that prior to the guidelines, a controversy existed at the University of Michigan, Ann Arbor, over where SBO patients should be admitted, particularly those who didn’t need surgery or who had partial obstructions. This raised questions of whether there were delays in operative intervention or delays in admission from the emergency room. For some, there was also a sense that too many patients were being admitted to the medicine service with partial, or even full, obstructions.

As a result, the university’s Surgery Quality Improvement Committee partnered with the departments of surgery, medicine, and emergency medicine to create an SBO service triage and initial management guideline that was instituted in 2011. The new guidelines spell out that a patient will be admitted to a surgical service if a transition point or other concerning signs for bowel strangulation were identified on computed tomography (CT) or if the patient has had an abdominal surgery within the last 30 days.

Exceptions that may warrant medical service admission could be patients with: intra-abdominal metastases or active inflammatory bowel disease scheduled for a systemic therapy trial and acute, severe conditions requiring stabilization, explained Dr. Wahl, now the medical director of surgical quality at St. Joseph Mercy Hospital, also in Ann Arbor. Patients with known dilated bowel secondary to dysmotility problems or other medical conditions such cystic fibrosis or mental/developmental disorders could also be admitted to medicine.

The guidelines de-emphasize the use of CT scans in the absence of an absolute indication for an emergent surgical consultation such as free air, peritonitis, nonreducible symptomatic hernia, or abdominal surgery in the last 30 days. The guidelines also stress an early general surgical consultation as part of initial therapy, she added.

The investigators compared data for 490 patients admitted for SBO during 2010 with 240 patients admitted for SBO during the first 6 months of 2011 after guideline implementation. Age (roughly 57 years) and sex did not differ significantly between groups for the two time periods. All-Patient Refined Diagnostic Related Groups scores pre- and post-implementation were lower at 1.78 and 1.56 in the surgical service, compared with 3.52 and 2.23 in the medical service.

After implementation, the mean time to surgery fell significantly from 0.9 days to 0.4 days among surgical patients (P value less than .05) and from 7.6 days to 3.6 days among those admitted to medicine (P less than .001).

The percent of patients admitted to a medicine service requiring surgery for SBO did not change significantly from 14% in 2010 to 7% in 2011, but the reasons did, Dr. Wahl said. Of the 26 patients admitted to a medicine service in 2010, five had clear bowel obstructions and no reason for a medical admission, four had a missed SBO in the emergency room, and four had a late surgery consultation.

"About half of the patients could have had their process improved," she observed.

In contrast, all seven SBO patients admitted to medicine in 2011 had documented active medical issues such as myocardial infarction and lobe transplant rejection.

After guideline implementation, time to general surgery consultation among medical patients was significantly shorter at 1.7 days vs. 3.4 days (P less than .001).

The rate of SBO admissions to surgery also rose from 55% to 66% (P less than .01), while the rate of operative interventions increased from 36% to 45% (P less than .05).

Notably, the rate of readmission for SBO nonoperative patients fell from 16% to 6% after guideline implementation (P less than .01), Dr. Wahl said. Hospital length of stay decreased from 8 days to 6 days in the surgical group and from 31 days to 13 days in the medical group.

Invited discussant Dr. Fred Luchette, professor of surgery at Loyola University Chicago, Maywood, Ill., observed that SBO accounts for 15% of surgical admissions in the United States and that treatment costs exceed $1 billion.

"The improvement in care for these patients with your guideline is a step in the right direction for improving patient outcomes," he stated.

Notably, the average cost of care did not change significantly from $20,530 to $22,554 in the surgical group and from $49,956 to $36,726 in the medical group.

Dr. Luchette asked why the medical service is allowed to admit any patient with a bowel obstruction, and why medical patients waited 3 days for surgery whereas surgical patients underwent surgery that day. The surgical delay is particularly vexing given the "liberal" use of CT scans post guideline implementation at 83% among medical patients.

Dr. Wahl agreed that CT use for the medical service was liberal, but pointed out that the vast majority of these patients had other medical issues that required further investigation to differentiate whether surgery was indicated. The delay in time to laparotomy could be explained by the need to stabilize medical patients prior to surgery or the need to wait to assess improvement following medical therapy.

Dr. Wahl admitted to being somewhat surprised at the number of SBO patients who went to the medical service before guideline implementation, but reminded the audience that a lot of patients with small bowel obstructions may simply feel a "little burpy" and may not manifest with full-blown symptoms.

"There’s probably a lot of people with bowel obstructions that are never seen by a surgeon that you don’t really know about until you look, unfortunately," she said. "In this day and age where there is a limit to the amount of resident and physician capacity, you really want patients to go where they’d be best served."

When asked by the audience how the university achieved buy-in for the project and how the guidelines were disseminated, Dr. Wahl said buy-in was relatively easy since practitioners recognized there was a problem and the guidelines were posted on-line.

Dr. Wahl and her coauthors reported no conflicts of interest.

MADISON, WIS. – Nearly one-fifth of all patients referred for parathyroidectomy were misdiagnosed with primary hyperparathyroidism in a retrospective study of 324 consecutive patients.

Notably, many of these patients had undergone comprehensive work-ups prior to surgical referral that clearly diagnosed secondary hyperparathyroidism.

Patrice Wendling/IMNG Medical Media

"This demonstrates that there’s a prevalent misunderstanding of parathyroid pathophysiology," Dr. James Iannuzzi said at the annual meeting of the Central Surgical Association. "In particular, vitamin D deficiency accounted for the majority of misdiagnosis."

Using ICD-9 codes for hyperparathyroidism, benign, or malignant parathyroid tumors or hypercalcemia, the authors identified 381 patients who were referred to the endocrine surgery division at the University of Rochester (N.Y.) Medical Center between 2008 and 2011 for parathyroidectomy. Primary hyperparathyroidism (HPT) was defined by a calcium level of at least 10 mg/dL plus a parathyroid hormone (PTH) level of more than 50 pg/mL. Thirty patients were excluded for renal failure and 27, for coding errors.

Among the remaining 324 patients, 264 were correctly diagnosed and 60 (18.5%) were misdiagnosed with primary HPT, said Dr. Iannuzzi, a general surgery resident at the university. Fifty-four (90%) of the misdiagnosed patients had secondary HPT at the time of the referral. For 43 patients, this was clear at the time of referral, and 11 had secondary HPT as their sole diagnosis after follow-up. Six patients had hypercalcemia but not HPT. Half of the hypercalcemic patients were referred after a single spuriously elevated calcium level, only to have their calcium drop to normal levels after follow-up, he said.

Most of the 54 patients with secondary HPT had vitamin D deficiency (37 patients). Other causes were gastric bypass (4 patients), celiac disease (2 patients), and unclear etiology (11 patients). Mean calcium and PTH levels among patients with secondary HPT were 9.3 mg/dL and 92 pg/mL, respectively.

In all, 42 (70%) of the 60 misdiagnosed patients underwent inappropriate localized imaging, of which 57% were falsely positive.

"These studies are not indicated; likely to be falsely positive, as we show; and cause patients and referring physicians to more aggressively push for unindicated and potentially harmful surgery because of a finding on a scan," Dr. Jacob Moalem said in an interview. Dr. Moalem, an endocrine surgeon at the University of Rochester, was the senior author of the paper.

Part of the problem is that ultrasound is highly user dependent, and sonographers can be easily misled by exophytic nodules, hypoechoic structures that were subcentimeters, or lymph nodes. Sestamibi scans in this clinical setting also are likely to be positive because of the activated mitochondria. Thus, it is very important that the pretest diagnosis be correct, Dr. Moalem and Dr. Iannuzzi stressed.

Many patients were found to have an elevated PTH during evaluation for symptoms that could have been consistent with primary HPT. Such symptoms were present in 46 of the 60 misdiagnosed patients, the majority of which were from nephrolithiasis (22 patients), he said. Also relevant were bone loss in 15 and vague symptoms such as fatigue or depression in 11.

Although surgery may seem like a simple solution for patients who have an elevated PTH level, symptoms, and positive imaging findings, the operation can be harmful for those with secondary HPT because they’re dependent on increased PTH levels to maintain calcium homeostasis, Dr. Iannuzzi said. Parathyroidectomy is associated with 95%-98% cure rates for primary HPT, but patients with secondary HPT are unlikely to have an intraoperative drop in PTH levels. As a result, they often undergo a bilateral neck exploration that predisposes them to nerve injury. More importantly, if the parathyroid tissue they’re dependent on is removed, it may create irreversible hypoparathyroidism.

"Vigilance is absolutely necessary to avoid unindicated and potentially harmful surgery," Dr. Iannuzzi cautioned.

Invited discussant Dr. Herbert Chen, chair of general surgery and leader of the endocrine oncology group at the University of Wisconsin in Madison, said that the results underscore the role of surgeons as diagnosticians.

"This finding really emphasizes that as surgeons we are not merely technicians operating at the whim of our referring physicians, but have a responsibility to lead in the diagnostic phase of patient care," he said.

Those thoughts were echoed by fellow discussant Dr. Allan Siperstein, chair of endocrine surgery at the Cleveland Clinic, who also asked what lab panels are used to assess patients with mild hyperparathyroidism. Dr. Iannuzzi said that they use an extensive panel including ionized calcium, magnesium, phosphorus, vitamin D, and urinary calcium. Dr. Moalem emphasized that the diagnosis of primary HPT must be made based on simultaneously high or high-normal calcium and PTH measurements. Imaging studies have no role in making or refuting the diagnosis and should be used to guide the operative approach only when the diagnosis of primary HPT has been definitively established.

Dr. Iannuzzi and his coauthors reported no relevant financial disclosures.

MADISON, WIS. – Nearly one-fifth of all patients referred for parathyroidectomy were misdiagnosed with primary hyperparathyroidism in a retrospective study of 324 consecutive patients.

Notably, many of these patients had undergone comprehensive work-ups prior to surgical referral that clearly diagnosed secondary hyperparathyroidism.

Patrice Wendling/IMNG Medical Media

"This demonstrates that there’s a prevalent misunderstanding of parathyroid pathophysiology," Dr. James Iannuzzi said at the annual meeting of the Central Surgical Association. "In particular, vitamin D deficiency accounted for the majority of misdiagnosis."

Using ICD-9 codes for hyperparathyroidism, benign, or malignant parathyroid tumors or hypercalcemia, the authors identified 381 patients who were referred to the endocrine surgery division at the University of Rochester (N.Y.) Medical Center between 2008 and 2011 for parathyroidectomy. Primary hyperparathyroidism (HPT) was defined by a calcium level of at least 10 mg/dL plus a parathyroid hormone (PTH) level of more than 50 pg/mL. Thirty patients were excluded for renal failure and 27, for coding errors.

Among the remaining 324 patients, 264 were correctly diagnosed and 60 (18.5%) were misdiagnosed with primary HPT, said Dr. Iannuzzi, a general surgery resident at the university. Fifty-four (90%) of the misdiagnosed patients had secondary HPT at the time of the referral. For 43 patients, this was clear at the time of referral, and 11 had secondary HPT as their sole diagnosis after follow-up. Six patients had hypercalcemia but not HPT. Half of the hypercalcemic patients were referred after a single spuriously elevated calcium level, only to have their calcium drop to normal levels after follow-up, he said.

Most of the 54 patients with secondary HPT had vitamin D deficiency (37 patients). Other causes were gastric bypass (4 patients), celiac disease (2 patients), and unclear etiology (11 patients). Mean calcium and PTH levels among patients with secondary HPT were 9.3 mg/dL and 92 pg/mL, respectively.

In all, 42 (70%) of the 60 misdiagnosed patients underwent inappropriate localized imaging, of which 57% were falsely positive.

"These studies are not indicated; likely to be falsely positive, as we show; and cause patients and referring physicians to more aggressively push for unindicated and potentially harmful surgery because of a finding on a scan," Dr. Jacob Moalem said in an interview. Dr. Moalem, an endocrine surgeon at the University of Rochester, was the senior author of the paper.

Part of the problem is that ultrasound is highly user dependent, and sonographers can be easily misled by exophytic nodules, hypoechoic structures that were subcentimeters, or lymph nodes. Sestamibi scans in this clinical setting also are likely to be positive because of the activated mitochondria. Thus, it is very important that the pretest diagnosis be correct, Dr. Moalem and Dr. Iannuzzi stressed.

Many patients were found to have an elevated PTH during evaluation for symptoms that could have been consistent with primary HPT. Such symptoms were present in 46 of the 60 misdiagnosed patients, the majority of which were from nephrolithiasis (22 patients), he said. Also relevant were bone loss in 15 and vague symptoms such as fatigue or depression in 11.

Although surgery may seem like a simple solution for patients who have an elevated PTH level, symptoms, and positive imaging findings, the operation can be harmful for those with secondary HPT because they’re dependent on increased PTH levels to maintain calcium homeostasis, Dr. Iannuzzi said. Parathyroidectomy is associated with 95%-98% cure rates for primary HPT, but patients with secondary HPT are unlikely to have an intraoperative drop in PTH levels. As a result, they often undergo a bilateral neck exploration that predisposes them to nerve injury. More importantly, if the parathyroid tissue they’re dependent on is removed, it may create irreversible hypoparathyroidism.

"Vigilance is absolutely necessary to avoid unindicated and potentially harmful surgery," Dr. Iannuzzi cautioned.

Invited discussant Dr. Herbert Chen, chair of general surgery and leader of the endocrine oncology group at the University of Wisconsin in Madison, said that the results underscore the role of surgeons as diagnosticians.

"This finding really emphasizes that as surgeons we are not merely technicians operating at the whim of our referring physicians, but have a responsibility to lead in the diagnostic phase of patient care," he said.

Those thoughts were echoed by fellow discussant Dr. Allan Siperstein, chair of endocrine surgery at the Cleveland Clinic, who also asked what lab panels are used to assess patients with mild hyperparathyroidism. Dr. Iannuzzi said that they use an extensive panel including ionized calcium, magnesium, phosphorus, vitamin D, and urinary calcium. Dr. Moalem emphasized that the diagnosis of primary HPT must be made based on simultaneously high or high-normal calcium and PTH measurements. Imaging studies have no role in making or refuting the diagnosis and should be used to guide the operative approach only when the diagnosis of primary HPT has been definitively established.

Dr. Iannuzzi and his coauthors reported no relevant financial disclosures.

MADISON, WIS. – Nearly one-fifth of all patients referred for parathyroidectomy were misdiagnosed with primary hyperparathyroidism in a retrospective study of 324 consecutive patients.

Notably, many of these patients had undergone comprehensive work-ups prior to surgical referral that clearly diagnosed secondary hyperparathyroidism.

Patrice Wendling/IMNG Medical Media

"This demonstrates that there’s a prevalent misunderstanding of parathyroid pathophysiology," Dr. James Iannuzzi said at the annual meeting of the Central Surgical Association. "In particular, vitamin D deficiency accounted for the majority of misdiagnosis."

Using ICD-9 codes for hyperparathyroidism, benign, or malignant parathyroid tumors or hypercalcemia, the authors identified 381 patients who were referred to the endocrine surgery division at the University of Rochester (N.Y.) Medical Center between 2008 and 2011 for parathyroidectomy. Primary hyperparathyroidism (HPT) was defined by a calcium level of at least 10 mg/dL plus a parathyroid hormone (PTH) level of more than 50 pg/mL. Thirty patients were excluded for renal failure and 27, for coding errors.

Among the remaining 324 patients, 264 were correctly diagnosed and 60 (18.5%) were misdiagnosed with primary HPT, said Dr. Iannuzzi, a general surgery resident at the university. Fifty-four (90%) of the misdiagnosed patients had secondary HPT at the time of the referral. For 43 patients, this was clear at the time of referral, and 11 had secondary HPT as their sole diagnosis after follow-up. Six patients had hypercalcemia but not HPT. Half of the hypercalcemic patients were referred after a single spuriously elevated calcium level, only to have their calcium drop to normal levels after follow-up, he said.

Most of the 54 patients with secondary HPT had vitamin D deficiency (37 patients). Other causes were gastric bypass (4 patients), celiac disease (2 patients), and unclear etiology (11 patients). Mean calcium and PTH levels among patients with secondary HPT were 9.3 mg/dL and 92 pg/mL, respectively.

In all, 42 (70%) of the 60 misdiagnosed patients underwent inappropriate localized imaging, of which 57% were falsely positive.

"These studies are not indicated; likely to be falsely positive, as we show; and cause patients and referring physicians to more aggressively push for unindicated and potentially harmful surgery because of a finding on a scan," Dr. Jacob Moalem said in an interview. Dr. Moalem, an endocrine surgeon at the University of Rochester, was the senior author of the paper.

Part of the problem is that ultrasound is highly user dependent, and sonographers can be easily misled by exophytic nodules, hypoechoic structures that were subcentimeters, or lymph nodes. Sestamibi scans in this clinical setting also are likely to be positive because of the activated mitochondria. Thus, it is very important that the pretest diagnosis be correct, Dr. Moalem and Dr. Iannuzzi stressed.

Many patients were found to have an elevated PTH during evaluation for symptoms that could have been consistent with primary HPT. Such symptoms were present in 46 of the 60 misdiagnosed patients, the majority of which were from nephrolithiasis (22 patients), he said. Also relevant were bone loss in 15 and vague symptoms such as fatigue or depression in 11.

Although surgery may seem like a simple solution for patients who have an elevated PTH level, symptoms, and positive imaging findings, the operation can be harmful for those with secondary HPT because they’re dependent on increased PTH levels to maintain calcium homeostasis, Dr. Iannuzzi said. Parathyroidectomy is associated with 95%-98% cure rates for primary HPT, but patients with secondary HPT are unlikely to have an intraoperative drop in PTH levels. As a result, they often undergo a bilateral neck exploration that predisposes them to nerve injury. More importantly, if the parathyroid tissue they’re dependent on is removed, it may create irreversible hypoparathyroidism.

"Vigilance is absolutely necessary to avoid unindicated and potentially harmful surgery," Dr. Iannuzzi cautioned.

Invited discussant Dr. Herbert Chen, chair of general surgery and leader of the endocrine oncology group at the University of Wisconsin in Madison, said that the results underscore the role of surgeons as diagnosticians.

"This finding really emphasizes that as surgeons we are not merely technicians operating at the whim of our referring physicians, but have a responsibility to lead in the diagnostic phase of patient care," he said.

Those thoughts were echoed by fellow discussant Dr. Allan Siperstein, chair of endocrine surgery at the Cleveland Clinic, who also asked what lab panels are used to assess patients with mild hyperparathyroidism. Dr. Iannuzzi said that they use an extensive panel including ionized calcium, magnesium, phosphorus, vitamin D, and urinary calcium. Dr. Moalem emphasized that the diagnosis of primary HPT must be made based on simultaneously high or high-normal calcium and PTH measurements. Imaging studies have no role in making or refuting the diagnosis and should be used to guide the operative approach only when the diagnosis of primary HPT has been definitively established.

Dr. Iannuzzi and his coauthors reported no relevant financial disclosures.

MADISON, WIS. – Laparoscopic resection of hepatic colorectal cancer offered short-term benefits over open resection and equivalent cancer control in a propensity matched cohort study of 173 patients.

"The oncologic outcomes are really not affected at all by the performance of the minimally invasive procedure," lead author Robert Cannon said at the annual meeting of the Central Surgical Association.

He reported on 35 patients who underwent laparoscopic resection and 138 patients undergoing open resection during the same time period. To minimize selection bias, the two groups were matched on the basis of age, size and number of lesions, whether major hepatectomy (three or more segments) or synchronous colectomy was performed, and the Fong score.

The laparoscopic group had significantly less mean blood loss than did the open group (202 mL vs. 392 mL; P less than .001), fewer complications (23% vs. 48%; P = .007), and shorter length of stay (4.8 days vs. 7.8 days; P less than .001), said Dr. Cannon of the department of surgery as the University of Louisville (Ky.).

The ability to achieve microscopically negative margins was significantly higher in the laparoscopic group, at 97%, compared with 81% in the open group (P = .02). Mortality at 90 days was similar at 0% vs. 0.7%, respectively (P = 1.0).

At 1, 3, and 5 years, median disease-free survival rates were similar at 79.3%, 37% , and 15.4%, respectively, in the laparoscopic group vs. 78.4%, 35.4% and 21.6%, respectively, in the open group (P = .715). Likewise, median overall survival rates were similar at 97%, 62.6%, and 36% vs. 95.4%, 60.3%, and 36.6% (P = .911), he said.

Dr. Cannon pointed out that the benefits of laparoscopy were observed in "appropriately selected patients," and suggested that the procedure is ideal for patients with left lateral lesions and for those who are obese.

"A thick abdominal wall doesn’t really hurt you as much when you’re going through a scope as it does when you have to make an incision that goes through all that subcutaneous fat," he said. "Also, with the shorter hospitalization, we think [laparoscopy] minimizes recovery and duration of chemotherapy in selected patients."

The higher positive-margin rate in the open group suggests that some selection bias remains in the analysis, and supports the idea that some patients – notably those with portal vein embolization, extensive disease, or tumors close to major vessels – will always be candidates for open surgery, said invited discussant Dr. Sharon Weber, professor and vice chair of general surgery at the University of Wisconsin, Madison.

Dr. Weber asked whether it’s truly possible to compare the open and laparoscopic groups statistically, or whether one can only say that outcomes tend to be better for those patients who are candidates for laparoscopic resection.

"I agree that the two groups will probably never be strictly comparable," Dr. Cannon replied. "There’s always going to be a role for open operations, especially for the lesions you mentioned [and] for those who may require biliary reconstruction or resection, or [who] have centrally located tumors such as at the base of segment four and five." He added that the purpose of doing matched studies like this one is to show that, for a patient who could go either way, perhaps the laparoscopic procedure offers benefits.

Dr. Weber also questioned how the investigators chose the factors that went into their propensity scoring, observing that some would consider factors such as neoadjuvant therapy, bilateral disease, and underlying liver fibrosis and cirrhosis equally relevant. In addition, recent work from the Netherlands suggests that the clinical risk score has become less relevant for patients with colorectal-level metastases in the era of contemporary neoadjuvant chemotherapy (Ann. Surg. Oncol. 2011;18:2757-63).

Dr. Cannon said that the availability of data influenced what factors were selected, to a large extent. The two groups had a median of one tumor, a median Charlson Comorbidity Index score of 4, and a median Fong score of 2. Their average age was 62 years. The mean tumor sizes were 4.3 cm in the open group and 4.2 cm in the laparoscopic group; positive nodes were present in 64% and 57%, respectively, and mean carcinoembryonic antigen levels at hepatectomy were 91.6 and 52, respectively.

Left lateral segmentectomy was performed in 28.6% of the laparoscopic group and in 6.5% of the open group (P less than .001), whereas wedge/bisegmentectomy was significantly more common in the open group at 34.8% vs. 14.3% in the laparoscopic group (P = .019). Rates of major hepatectomy were similar at 55.8% in the open group and 54.3% in the laparoscopic group (P = .872).

The investigators did not control for the individual year when surgery was performed, choosing instead to limit the analysis to cases performed from 2004 on, when it could be reasonably assumed that adjuvant therapy would be comparable, Dr. Cannon said.

When asked whether a financial analysis of the two procedures had been performed because of the greater expense associated with laparoscopic instruments, Dr. Cannon replied that cost data will be presented at the upcoming Society of Surgical Oncology Annual Cancer Symposium.

Dr. Cannon and Dr. Weber reported no conflicts of interest.*

*Correction, 3/8/2012: This story was updated to reflect the fact that Dr. Cannon has no conflicts of interest. The conflicts that were initially attributed to Dr. Cannon were incorrectly reported by the meeting organizers.  

MADISON, WIS. – Laparoscopic resection of hepatic colorectal cancer offered short-term benefits over open resection and equivalent cancer control in a propensity matched cohort study of 173 patients.

"The oncologic outcomes are really not affected at all by the performance of the minimally invasive procedure," lead author Robert Cannon said at the annual meeting of the Central Surgical Association.

He reported on 35 patients who underwent laparoscopic resection and 138 patients undergoing open resection during the same time period. To minimize selection bias, the two groups were matched on the basis of age, size and number of lesions, whether major hepatectomy (three or more segments) or synchronous colectomy was performed, and the Fong score.

The laparoscopic group had significantly less mean blood loss than did the open group (202 mL vs. 392 mL; P less than .001), fewer complications (23% vs. 48%; P = .007), and shorter length of stay (4.8 days vs. 7.8 days; P less than .001), said Dr. Cannon of the department of surgery as the University of Louisville (Ky.).

The ability to achieve microscopically negative margins was significantly higher in the laparoscopic group, at 97%, compared with 81% in the open group (P = .02). Mortality at 90 days was similar at 0% vs. 0.7%, respectively (P = 1.0).

At 1, 3, and 5 years, median disease-free survival rates were similar at 79.3%, 37% , and 15.4%, respectively, in the laparoscopic group vs. 78.4%, 35.4% and 21.6%, respectively, in the open group (P = .715). Likewise, median overall survival rates were similar at 97%, 62.6%, and 36% vs. 95.4%, 60.3%, and 36.6% (P = .911), he said.

Dr. Cannon pointed out that the benefits of laparoscopy were observed in "appropriately selected patients," and suggested that the procedure is ideal for patients with left lateral lesions and for those who are obese.

"A thick abdominal wall doesn’t really hurt you as much when you’re going through a scope as it does when you have to make an incision that goes through all that subcutaneous fat," he said. "Also, with the shorter hospitalization, we think [laparoscopy] minimizes recovery and duration of chemotherapy in selected patients."

The higher positive-margin rate in the open group suggests that some selection bias remains in the analysis, and supports the idea that some patients – notably those with portal vein embolization, extensive disease, or tumors close to major vessels – will always be candidates for open surgery, said invited discussant Dr. Sharon Weber, professor and vice chair of general surgery at the University of Wisconsin, Madison.

Dr. Weber asked whether it’s truly possible to compare the open and laparoscopic groups statistically, or whether one can only say that outcomes tend to be better for those patients who are candidates for laparoscopic resection.

"I agree that the two groups will probably never be strictly comparable," Dr. Cannon replied. "There’s always going to be a role for open operations, especially for the lesions you mentioned [and] for those who may require biliary reconstruction or resection, or [who] have centrally located tumors such as at the base of segment four and five." He added that the purpose of doing matched studies like this one is to show that, for a patient who could go either way, perhaps the laparoscopic procedure offers benefits.

Dr. Weber also questioned how the investigators chose the factors that went into their propensity scoring, observing that some would consider factors such as neoadjuvant therapy, bilateral disease, and underlying liver fibrosis and cirrhosis equally relevant. In addition, recent work from the Netherlands suggests that the clinical risk score has become less relevant for patients with colorectal-level metastases in the era of contemporary neoadjuvant chemotherapy (Ann. Surg. Oncol. 2011;18:2757-63).

Dr. Cannon said that the availability of data influenced what factors were selected, to a large extent. The two groups had a median of one tumor, a median Charlson Comorbidity Index score of 4, and a median Fong score of 2. Their average age was 62 years. The mean tumor sizes were 4.3 cm in the open group and 4.2 cm in the laparoscopic group; positive nodes were present in 64% and 57%, respectively, and mean carcinoembryonic antigen levels at hepatectomy were 91.6 and 52, respectively.

Left lateral segmentectomy was performed in 28.6% of the laparoscopic group and in 6.5% of the open group (P less than .001), whereas wedge/bisegmentectomy was significantly more common in the open group at 34.8% vs. 14.3% in the laparoscopic group (P = .019). Rates of major hepatectomy were similar at 55.8% in the open group and 54.3% in the laparoscopic group (P = .872).

The investigators did not control for the individual year when surgery was performed, choosing instead to limit the analysis to cases performed from 2004 on, when it could be reasonably assumed that adjuvant therapy would be comparable, Dr. Cannon said.

When asked whether a financial analysis of the two procedures had been performed because of the greater expense associated with laparoscopic instruments, Dr. Cannon replied that cost data will be presented at the upcoming Society of Surgical Oncology Annual Cancer Symposium.

Dr. Cannon and Dr. Weber reported no conflicts of interest.*

*Correction, 3/8/2012: This story was updated to reflect the fact that Dr. Cannon has no conflicts of interest. The conflicts that were initially attributed to Dr. Cannon were incorrectly reported by the meeting organizers.  

MADISON, WIS. – Laparoscopic resection of hepatic colorectal cancer offered short-term benefits over open resection and equivalent cancer control in a propensity matched cohort study of 173 patients.

"The oncologic outcomes are really not affected at all by the performance of the minimally invasive procedure," lead author Robert Cannon said at the annual meeting of the Central Surgical Association.

He reported on 35 patients who underwent laparoscopic resection and 138 patients undergoing open resection during the same time period. To minimize selection bias, the two groups were matched on the basis of age, size and number of lesions, whether major hepatectomy (three or more segments) or synchronous colectomy was performed, and the Fong score.

The laparoscopic group had significantly less mean blood loss than did the open group (202 mL vs. 392 mL; P less than .001), fewer complications (23% vs. 48%; P = .007), and shorter length of stay (4.8 days vs. 7.8 days; P less than .001), said Dr. Cannon of the department of surgery as the University of Louisville (Ky.).

The ability to achieve microscopically negative margins was significantly higher in the laparoscopic group, at 97%, compared with 81% in the open group (P = .02). Mortality at 90 days was similar at 0% vs. 0.7%, respectively (P = 1.0).

At 1, 3, and 5 years, median disease-free survival rates were similar at 79.3%, 37% , and 15.4%, respectively, in the laparoscopic group vs. 78.4%, 35.4% and 21.6%, respectively, in the open group (P = .715). Likewise, median overall survival rates were similar at 97%, 62.6%, and 36% vs. 95.4%, 60.3%, and 36.6% (P = .911), he said.

Dr. Cannon pointed out that the benefits of laparoscopy were observed in "appropriately selected patients," and suggested that the procedure is ideal for patients with left lateral lesions and for those who are obese.

"A thick abdominal wall doesn’t really hurt you as much when you’re going through a scope as it does when you have to make an incision that goes through all that subcutaneous fat," he said. "Also, with the shorter hospitalization, we think [laparoscopy] minimizes recovery and duration of chemotherapy in selected patients."

The higher positive-margin rate in the open group suggests that some selection bias remains in the analysis, and supports the idea that some patients – notably those with portal vein embolization, extensive disease, or tumors close to major vessels – will always be candidates for open surgery, said invited discussant Dr. Sharon Weber, professor and vice chair of general surgery at the University of Wisconsin, Madison.

Dr. Weber asked whether it’s truly possible to compare the open and laparoscopic groups statistically, or whether one can only say that outcomes tend to be better for those patients who are candidates for laparoscopic resection.

"I agree that the two groups will probably never be strictly comparable," Dr. Cannon replied. "There’s always going to be a role for open operations, especially for the lesions you mentioned [and] for those who may require biliary reconstruction or resection, or [who] have centrally located tumors such as at the base of segment four and five." He added that the purpose of doing matched studies like this one is to show that, for a patient who could go either way, perhaps the laparoscopic procedure offers benefits.

Dr. Weber also questioned how the investigators chose the factors that went into their propensity scoring, observing that some would consider factors such as neoadjuvant therapy, bilateral disease, and underlying liver fibrosis and cirrhosis equally relevant. In addition, recent work from the Netherlands suggests that the clinical risk score has become less relevant for patients with colorectal-level metastases in the era of contemporary neoadjuvant chemotherapy (Ann. Surg. Oncol. 2011;18:2757-63).

Dr. Cannon said that the availability of data influenced what factors were selected, to a large extent. The two groups had a median of one tumor, a median Charlson Comorbidity Index score of 4, and a median Fong score of 2. Their average age was 62 years. The mean tumor sizes were 4.3 cm in the open group and 4.2 cm in the laparoscopic group; positive nodes were present in 64% and 57%, respectively, and mean carcinoembryonic antigen levels at hepatectomy were 91.6 and 52, respectively.

Left lateral segmentectomy was performed in 28.6% of the laparoscopic group and in 6.5% of the open group (P less than .001), whereas wedge/bisegmentectomy was significantly more common in the open group at 34.8% vs. 14.3% in the laparoscopic group (P = .019). Rates of major hepatectomy were similar at 55.8% in the open group and 54.3% in the laparoscopic group (P = .872).

The investigators did not control for the individual year when surgery was performed, choosing instead to limit the analysis to cases performed from 2004 on, when it could be reasonably assumed that adjuvant therapy would be comparable, Dr. Cannon said.

When asked whether a financial analysis of the two procedures had been performed because of the greater expense associated with laparoscopic instruments, Dr. Cannon replied that cost data will be presented at the upcoming Society of Surgical Oncology Annual Cancer Symposium.

Dr. Cannon and Dr. Weber reported no conflicts of interest.*

*Correction, 3/8/2012: This story was updated to reflect the fact that Dr. Cannon has no conflicts of interest. The conflicts that were initially attributed to Dr. Cannon were incorrectly reported by the meeting organizers.