BACKGROUND:The substantial increase in the use of donation after circulatory death livers enabled by normothermic machine perfusion, along with associated improvements in post-transplant outcomes, has raised important questions regarding the contemporary role of living donor liver transplantation. METHODS:Using Scientific Registry of Transplant Recipients data from January 2021 to August 2024, we compared real-world outcomes of living donor liver transplantation versus donation after circulatory death liver transplantation with and without normothermic machine perfusion and whether these outcomes differed across recipient-, donor-, and center-level subgroups. Death-censored graft and overall patient survival were evaluated using Kaplan-Meier methods and multivariable Cox proportional hazards models adjusted for clinically relevant covariates. RESULTS:Among 6,105 adult recipients, 42.9% underwent donation after circulatory death without normothermic machine perfusion, 28.4% donation after circulatory death with normothermic machine perfusion, and 28.7% living donor liver transplantation. Over time, donation after circulatory death normothermic machine perfusion use expanded broadly across states with increasing adoption at multiple centers, whereas living donor liver transplantation activity remained concentrated in a limited number of high-volume regions and showed minimal growth nationally. Compared with donation after circulatory death transplantation with normothermic machine perfusion, donation after circulatory death transplantation without normothermic machine perfusion was associated with a higher adjusted hazard of graft failure (adjusted hazard ratio, 1.88; 95% confidence interval, 1.25-2.84; P = .0025), whereas living donor liver transplantation was not associated with a statistically significant difference in graft failure (adjusted hazard ratio, 0.82; 95% confidence interval, 0.48-1.41; P = .4814). Adjusted mortality did not differ significantly for either donation after circulatory death without normothermic machine perfusion (adjusted hazard ratio, 1.06; 95% confidence interval, 0.80-1.42; P = .6708) or living donor liver transplantation (adjusted hazard ratio, 0.96; 95% confidence interval, 0.69-1.33; P = .8169) compared with donation after circulatory death with normothermic machine perfusion. CONCLUSION:Donation after circulatory death with normothermic machine perfusion and living donor liver transplantation were not associated with statistically significant differences in adjusted graft failure or mortality, although these findings do not establish equivalence. Living donor liver transplantation was associated with lower unadjusted graft-loss hazards in shorter recipients and selected center-volume subgroups, supporting individualized graft selection.
Background Neck hematoma and hypocalcemia are among the most significant complications after thyroidectomy, but their relationship remains unclear. We hypothesized that post-thyroidectomy neck hematoma is associated with increased postoperative hypocalcemia risk. We aimed to test this hypothesis using a large national cohort and identify high-risk patients. Methods We performed a retrospective cohort analysis of thyroidectomy patients using the ACS-NSQIP database (2016-2023). The primary exposure was postoperative neck hematoma and outcomes included multiple hypocalcemia metrics. Associations were evaluated using χ2 or Fisher’s exact test, and multivariable logistic regression. Results Among 53,091 thyroidectomy patients, most patients were female (76.8%) and White (70.2%), with a median age of 53 years (IQR 40–64). Most cases were performed for a solitary nodule (N=20,894, 40.6%). Postoperative hematoma complicated 916 (1.7%) cases, of which 223 (24.3%) were managed non-operatively. The hematoma cohort exhibited higher frequency of Graves’ disease (10.2% vs 6.7%, p<0.001). Hematoma patients had higher rates of all hypocalcemia metrics, including hypocalcemia before discharge (6.6% vs 3.7%, p<0.001) and severe hypocalcemia events (5.2% vs 3.3%, p=0.005). These associations persisted even for hematomas managed non-operatively. Among non-reoperative open thyroidectomies without neck dissection (n=22,157), similar results were observed: e.g. hypocalcemia before discharge (6.0% vs 2.8%, p<0.001) and severe hypocalcemia events (6.5% vs 2.8%, p<0.001). Findings were more pronounced among Graves’ disease patients (e.g. IV calcium requirement 16.2% vs 5.8%, p<0.001). Conclusion Post-thyroidectomy neck hematoma is associated with increased risk of hypocalcemia-related complications even when managed non-operatively. This suggests a possible pathophysiologic mechanism such as hematoma-induced parathyroid ischemia or venous congestion. Proactive calcium monitoring and supplementation are warranted in patients developing postoperative hematoma. Further studies are needed to elucidate the underlying pathophysiology.
Background Inadvertent parathyroidectomy (IP) is a well-recognized complication of thyroid surgery which is associated with postoperative hypoparathyroidism and hypocalcemia. Reported incidence rates of IP vary widely in the existing literature, and patient- and procedure-specific risk factors remain incompletely defined. This study analyzes the incidence and risk factors associated with IP during thyroidectomy. Methods We conducted a retrospective cohort study of 830 patients that underwent thyroidectomy at a single high-volume endocrine surgery center from 2016 to 2022. The primary outcome was the occurrence of IP, which was obtained from final surgical pathology reports. Multivariable analysis using logistic regression was performed to assess adjusted outcomes. Results Among 830 patients, the overall incidence of IP was 13.5%. After adjustment, thyroidectomy with central neck dissection (adjusted odds ratio [aOR], 4.35; 95% CI, 2.29-8.24) was independently predictive of IP, while age >65 years (aOR, 0.59; 95% CI, 0.36-0.99), goiter (aOR 0.76; 95% CI 0.60-0.95), and total thyroidectomy (aOR, 0.41; 95% CI, 0.28-0.59) were associated with lower odds of IP. Gender, malignancy, specimen weight, operative time, and prior neck surgery were not associated with IP. Conclusions IP is common following thyroidectomy and is associated with select patient- and procedure-related factors. Recognition of high-risk cases may support targeted intraoperative mitigation strategies to improve parathyroid identification and preservation, including auto-transplantation when in situ preservation is not feasible. Future efforts should focus on investigation of emerging strategies, such as indocyanine green fluorescence imaging and near-infrared autofluorescence, to enhance intraoperative parathyroid identification and preservation.
Background Recurrent Laryngeal Nerve (RLN) injury during thyroid surgery can result in clinically significant airway compromise, particularly in patients with limited pulmonary reserve. While intraoperative nerve monitoring (IONM) is widely used to reduce nerve injury, its association with postoperative airway complications has not been well characterized. This study evaluates trends in IONM and its relationship with postoperative airway compromise following thyroidectomy. Methods We performed a retrospective cohort study of adult patients undergoing thyroid surgery between 2018 and 2022 used the National Surgical Quality Improvement Program (NSQIP) database. Patients were stratified by use of intraoperative nerve monitoring. The primary outcome was postoperative airway compromise, defined as prolonged ventilation (>48 hours postoperatively) and unplanned postoperative reintubation. Secondary outcomes included RLN injury, neck hematoma, and pneumonia. Univariate and multivariate analyses were performed to identify factors independently associated with airway complications. Results A total of 33,211 patients were included; 23,757 (71.5%) underwent surgery with IONM. On univariate analysis, patients undergoing IONM had lower rates of postoperative airway compromise compared with those without monitoring (0.4% vs 0.6%, p = 0.048). Though individual airway events were infrequent and did not differ significantly between groups, IONM was associated with a lower rate of RLN injury (5.7% vs 6.5%, p < 0.001). On multivariable analysis, preoperative dyspnea, ASA class III or higher, advanced tumor stage (T3–4), chronic obstructive pulmonary disease, older age, and longer operative time were independently associated with increased odds of postoperative airway compromise. After adjustment for patient, tumor, and operative factors, IONM remained independently associated with decreased odds of postoperative airway compromise (OR 0.64, p=0.04). In subgroup analysis of patients with ASA class III or higher, RLN monitoring was associated with lower adjusted odds of postoperative airway compromise (adjusted OR 0.68), consistent with findings in the overall cohort, though estimates were limited by low event rates. Conclusions In this large national cohort, intraoperative recurrent laryngeal monitoring was independently associated with reduced postoperative airway complications following thyroidectomy. Airway risk was driven primarily by patient comorbidity, physiologic reserve, disease severity, and operative complexity. These findings suggest that RLN monitoring may be of greatest benefit in high-risk surgical patients.
Background Patients with advanced nodal disease (clinical (c) N2/N3) are underrepresented in neoadjuvant chemotherapy (NAC) trials evaluating feasibility and oncologic safety of sentinel lymph node (SLN) surgery. Current practice favors axillary lymph node dissection (ALND) despite increasing NAC use and improved response rates. This study evaluates axillary management strategies and compares clinicopathologic characteristics and outcomes following NAC in cN2/N3 breast cancer. Methods A retrospective single-institutional study of patients with cN2/cN3 who received NAC between 2016-2024 was conducted. Demographic, clinicopathologic characteristics, treatment response, recurrence, and survival were collected. Patients were stratified according to axillary surgical management strategy into SLN alone, SLN+ALND, and upfront ALND. Pathologic complete response (pCR), residual cancer burden (RCB), recurrence, and survival were compared. Statistical analysis used ANOVA, Chi-squared, and Fisher's exact tests with p<0.05 considered significant. Results Among 1,642 patients, 217 (13.21%) had cN2/cN3 disease. The median age was 53 years (28-87). Upfront ALND was performed in 122 patients (56.22%), while 60 (27.65%) underwent SLN alone and 35 (16.13%) SLN+ALND. Clinicopathologic characteristics differed across surgical subgroups, including receptor status (p=0.048), cT category (p=0.042), histologic grade (p=0.038), extranodal extension (p<0.001), and lymphovascular invasion (p=0.005). Among 142 patients with cN2 disease, 66 (46.7%) were ypN0, compared to 39 (52%) with cN3 disease. Triple negative breast cancer (TNBC) had the highest axillary pCR rate (n=35,33.3%) followed by HER2+ (n=29,27.6%) breast cancer. Patients demonstrating a favorable imaging response were more likely to undergo SLN, with higher rates of axillary pCR (n=52,86.67%; p<0.0001), combined breast/axillary pCR (n=36,60%; p<0.0001), and lower RCB scores (p<0.0001). Adjuvant radiation was administered in 92.6% (201 patients), with no sub-group differences (p=0.282). At a median follow-up of 46 months (10-114 months), there were 9 (4.15%) locoregional and 30 (13.8%) distant recurrence events. Overall crude recurrence rates differed significantly with 6.7% of patients undergoing SLN, 14.3% SLN+ALND, and 24.6% ALND (p=0.0103) developing recurrence at follow-up. Recurrence was most common in hormone positive and TNBC (each n=16, 41%). Conclusion In patients presenting with cN2/N3 breast cancer who demonstrate a favorable imaging response to NAC, selective axillary de-escalation with SLN and adjuvant radiation may be considered.
Background Gastrostomy tube (G-tube) placement is commonly performed in children with autism spectrum disorder (ASD), yet it remains unclear whether ASD is independently associated with postoperative outcomes. We compared short-term outcomes after primary G-tube placement by ASD and developmental delay (DD) status. Methods Children (<17 years) undergoing laparoscopic G-tube placement were identified from the American College of Surgeons National Surgical Quality Improvement Program Pediatric (NSQIP-Pediatric) (2019–2024). Patient selection was limited to a single institution (n=386). ASD status (confirmed [F84.0] or suspected [R68.89]) solicited from individual medical records was linked to NSQIP-Pediatric data. Primary outcomes were postoperative length of stay (LOS) and a composite 30-day complication outcome. The relationship between ASD and postoperative outcomes was assessed using multivariable regression, accounting for age, sex, DD, and preoperative nutritional support. Results Patients with ASD (n=82) were older (4.9 vs. 1.3 years, p<0.001) and more likely to have DD (72% vs. 41%, p<0.001) than those without. ASD was not associated with longer LOS (adjusted geometric means ratio 0.80, p=0.27) or postoperative complications (aOR 0.98, p=0.97). DD similarly was not associated with longer LOS (adjusted geometric means ratio 0.52, p<0.001), although it was independently associated with short-term postoperative complications (aOR 1.94, p<0.05). Nutritional support was independently associated with longer LOS (adjusted geometric means ratio 1.68, p<0.01) and higher odds of complications (aOR 2.36, p=0.02). Conclusion ASD is not associated with postoperative LOS or complications after G-tube placement. Preoperative nutritional support is strongly associated with postoperative outcomes, suggesting these are driven by overall medical complexity rather than ASD diagnosis.
