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Ectopic ACTH syndrome (EAS) is rare. We established a national cohort to increase awareness and address unmet needs.The Finnish national EAS cohort includes 60 patients diagnosed in 1997-2016. We assessed clinical features, diagnostic work-ups, treatments, incidence, and outcomes of subgroups occult tumor (OT), well-differentiated neuroendocrine tumor G1/G2 (NETG1/G2) and NET G3/neuroendocrine carcinoma (NETG3/NEC).The distribution of OT, NETG1/G2, and NETG3/NEC was 10 (17%), 20 (33%), and 30 (50%), respectively; and median follow-up 22 months (0-249). Annual incidence (0.20-0.93 per million inhabitants) and tumor subgroups (OT vs. NEC) varied across the country. The longest diagnostic delay from EAS onset to radiological tumor identification was 48 months. In NET/NEC, 6/50 (12%) were diagnosed 1-24 years before EAS onset. Osteoporotic fractures (32%) and severe infections (55%) were common. The CRH stimulation test accurately diagnosed EAS in 25/31 (81%). Metyrapone (≤6 g daily, prescribed in 88%) was well tolerated. In NETG1/G2, 13/20 (65%) underwent curative resection of the primary tumor; four experienced recurrence within 2-12 years. In OT, 70% underwent bilateral adrenalectomy. Five-year overall survival in OT, NETG1/G2, and NETG3/NEC was 90%, 55%, and 0%, respectively (P 0.001). Morning cortisol, hypokalemia, infections, metastatic disease, and acute onset were negative, whereas resection of the primary tumor and bilateral adrenalectomy were positive predictors of survival.NET/NEC may precede EAS onset by several years. In NETG1/G2, recurrences may occur10 years after successful primary surgery. Tumor subgroup (OT, NETG1/G2, NEC) was an independent predictor of survival.

Parathyroid carcinoma (PC) is rare and diagnostically challenging. Reported outcomes are rather poor and the incidence might be increasing.We performed a nationwide study on all cases (n= 32) diagnosed in 2000-2011 in Finland, and compared clinical and histopathological characteristics and outcome to atypical parathyroid (APA; n= 28) and parathyroid adenomas (PA; n= 72). The incidence in years 1955-1999 was compared to that in 2000-2013.Preoperatively, calcium and parathyroid hormone concentrations were higher in PC compared to APA and PA (1.76, 1.56 and 1.44 mmol/l, p .001; and 989, 355 and 160 μmol/l, p .001, respectively). Calcium was ≤1.77 mmol/l for all PAs. Hospitalization (44% vs. 22% and 3%, respectively, p = .01), renal (50% vs. 48% vs. 22%, respectively, p = .01) and bone (47% vs. 15% vs. 38%, respectively p = .002) manifestations were more common. PC and APA tumors were larger than PA (p .001). Histopathological characteristics of PC compared to PA are increased mitotic activity (p= .001), chief cells (p = .003), diffuse growth pattern (p .001), higher Ki67 (p .001) and negative parafibromin (p .001). One PC (1/18) and one APA (1/16) patient had a CDC73 mutation. After 6.7 (2-13.9) years of follow-up, 9.4% of PC had residual, 21% recurrent disease and 12.5% died of disease. Overall mortality did not differ between subgroups (p = .094). Recurrent PC was characterized by vascular invasion, lymph node metastases, high mitotic activity, necrosis and negative parafibromin. Incidence increased from 1.42 (range 0.52-2.14) to 7.14 (range 3.42-10.38)/10.000.000/years; (p .001).PC associates with severe primary hyperparathyroidism and must be suspected if calcium ≥1.77 mmol/l. The prevalence of CDC73 germline mutations in PC and APA in Finland is 6%. PC has distinct histopathological characteristics and its incidence has increased over the past decades.

Enhanced recovery after surgery (ERAS) programs are well established for patients undergoing colorectal surgery. Relatively little is known about ERAS following bariatric surgery in general or following laparoscopic Roux-en-Y gastric bypass (LRYGB) in particular. This is a prospective, observational study of 388 consecutive patients that underwent LRYGB with ERAS in a general hospital. The ERAS protocol included standardizations of pre-, intra-, and postoperative modalities in order to reduce the stress response of the patients. Primary outcome measures were length of stay (LOS), postoperative morbidity, readmissions, and reoperations. Mean (SD) baseline body mass index (BMI) and age was 46.4 (6.7) kg/m2 and 45.1 (11.2) years, respectively. Fifty-four percent of the patients were on medication for hypertension (HT) and 38 % for type 2 diabetes mellitus (DM2). Mean (SD) and median (range) surgical time was 73.8 (16.9) and 65 (40–143) min, respectively. Mean LOS was 1.3 days (1.1), median 1 day (1–14). Of all patients, 322 (83 %) were discharged on the first postoperative day (POD). Overall morbidity was 9.8 %. Three patients (0.8 %) had life-threatening complications. The readmission rate was 4.9 %, and 3.4 % of the patients had to be reoperated. With a follow-up rate of 83 % at 1 year, total weight loss (TWL) was 31 % and excess BMI loss (EBMIL) 70 %. Total remission of DM2 and HT was achieved in 70 and 42 % of the patients, respectively. Enhanced recovery following LRYGB with ERAS programs is possible and safe even in a low volume, general hospital. Early discharge does not increase postoperative morbidity or readmissions.

Relatively little is known about the use of fast track protocols in bariatric surgery.We carried out an observational study of 422 consecutive patients who underwent bariatric surgery by a fast track protocol.Mean length of stay was 1.3 days, median 1 day. Of all patients, 83% were discharged on the first postoperative day. Three patients (0.7%) had life-threatening complications. The readmission rate was 4.7%, and 3.3% of the patients had to be reoperated. The body weight dropped 31% in a year.Early discharge does not seem to increase postoperative morbidity or readmissions.