Diagnostic Accuracy of Ultrasound in Predicting Extrathyroidal Extension and Its Relation to Body Mass Index in a North American Population.

Detection of extrathyroidal extension (ETE) in patients with papillary thyroid carcinoma (PTC) influences treatment plan and surgical aggressiveness. Ultrasound (US) is the long-standing preoperative imaging method of choice. Recent literature from Asia suggests US accuracy to be influenced by patient characteristics, such as body mass index (BMI). Here, we examine the effect of BMI on the accuracy of US at a North American tertiary referral center. A total of 204 PTC-confirmed patients were retrospectively read by a radiologist blinded to surgical pathology findings. The radiologist recorded multiple sonographic features, including ETE, loss of echogenic capsule, nodule vascularity, capsular abutment, and bulging of contour. When considering all patients, the ultrasonographic feature with the best overall performance was loss of echogenic capsule (diagnostic odds ratio (DOR) = 4.48, 95% confidence interval (CI) = 1.86-10.78). Sub-group analysis by patient BMI found that area under the curve (AUC) for sonographic features was greater in non-obese BMI patients (0.71 ± 0.06) when compared with obese patients (0.43 ± 0.05; p = 0.001). Overall, US diagnostic performance was significantly better in non-obese (DOR = 3.70, 95%CI = 1.53-8.94) patients when compared to those who were obese (DOR = 1.12, 95%CI = 0.62-2.03; p = 0.03). Loss of the echogenic capsule did not differ between the two cohorts with respect to DOR (p = 0.51), specificity (p = 0.52), or sensitivity (p = 0.09). Our work suggests that the diagnostic value of ETE detection by US is impaired in obese patients. Considering that loss of the echogenic capsule did not differ with respect to diagnostic performance, specificity, nor sensitivity between non-obese and obese patients, it could be considered the most important predictor of US-determined ETE.

Predictive factors of radioiodine therapy failure in Graves' Disease: A meta-analysis.

BACKGROUND: I-131 therapy is a common treatment modality for adults with Graves' Disease (GD). Utilizing meta-analysis, we examined patient specific factors that predict I-131 therapy failure. METHODS: Literature search followed PRISMA. Comprehensive Meta-analysis (version 3.0) was used. Mantel-Haenszel test with accompanying risk ratio and confidence intervals evaluated categorical variables. Continuous data was analyzed using inverse variance testing yielding mean difference or standardized mean difference. Decision tree algorithms identified variables of high discriminative performance. RESULTS: 4822 collective patients across 18 studies were included. Male sex (RR = 1.23, 95%CI = 1.08-1.41, p = 0.002), I-131 therapy 6 months after GD diagnosis (RR = 2.10, 95%CI = 1.45-3.04, p < 0.001) and history of anti-thyroid drugs (RR = 2.05, 95%CI = 1.49-2.81, p < 0.001) increased the risk of I-131 therapy failure. Elevated free thyroxine, 24-h radioactive iodine uptake scan ≥60.26% and thyroid volume ≥35.77 mL were also associated with failure. CONCLUSION: Patient characteristics can predict the likelihood of I-131 therapy failure in GD. Definitive surgical treatment may be a reasonable option for those patients.

Effect of postsurgical chronic hypoparathyroidism on morbidity and mortality: a systematic review and meta-analysis.

BACKGROUND: Hypoparathyroidism (HypoPT) is a common sequela of anterior neck surgeries. While the acute risks of HypoPT are well known, emerging evidence is beginning to define the risks chronic HypoPT poses to patients. This meta-analysis aims to evaluate that risk and give more insight into its consequences. METHODS: A systematic review and meta-analysis were performed, searching EMBASE, Web of Science, and Scopus for studies published up to July 1, 2020 and reported following PRISMA guidelines. Pooled analysis was estimated using the Mantel-Haenszel method and a random-effects model. A sub-analysis of the pooled data for each morbidity was performed and demonstrated in forest plots. RESULTS: Patients with postsurgical chronic HypoPT had a high risk of cardiac morbidities [odds ratio (OR) =1.43; 95% confidence interval (95% CI): 1.21 to 1.70; P<0.001] in the absence of elevated risk of cardiac arrhythmias (OR =1.35, 95% CI: 0.96 to 1.79, P=0.08). Analysis also showed higher odds of developing renal disease (OR =4.85, 95% CI: 3.54 to 6.67, P<0.001), renal stones (OR =3.86, 95% CI: 1.81 to 8.23, P<0.001), seizures (OR =2.41, 95% CI: 1.66 to 3.5, P<0.001), mental health problems (OR =1.46, 95% CI: 1.21 to 1.77, P<0.001), and infections (OR =1.51, 95% CI: 1.28 to 1.78, P<0.001). Conversely, HypoPT has no effect on mortality risk (OR =1.19, 95% CI: 0.96 to 1.49, P=0.12). CONCLUSIONS: Postsurgical HypoPT patients are vulnerable to a variety of medical and psychiatric diseases. This meta-analysis should guide surgeons in preoperative counseling and postoperative care for patients undergoing anterior neck surgeries.

Robotic-assisted parathyroidectomy via transaxillary approach: feasibility and learning curves.

BACKGROUND: There have been few reports of robotic-assisted transaxillary parathyroidectomy in the literature. We aim to report our experience with robotic-assisted transaxillary parathyroidectomy for primary hyperparathyroidism (PHPT) in the Western population. METHODS: A retrospective study was performed from July 2010 through July 2019 at two institutions, one in the United States and one in France. Demographic characteristics and perioperative data were collected for all patients undergoing robotic-assisted transaxillary parathyroidectomy by a single surgeon at each institution. A linear regression model was developed to describe the learning curve for this procedure at each institution. RESULTS: One-hundred and two patients with PHPT were included with a median age of 55.6±12.4 years and median body mass index (BMI) of 25.5±6.1 kg/m2. The majority of patients were female (80.4%). Median total operative time was 116±53 minutes. Minor complications were reported in 2 patients (1.96%), and one case was converted to a trans-cervical approach (TCA) for four-gland exploration. Median patient follow-up time was 6.5±12.2 months, and disease recurrence was reported in one patient. Calculated learning curves showed that one surgeon achieved proficiency by the eighth case, and the other achieved proficiency by the fourteenth case. CONCLUSIONS: This is the largest reported experience of robotic-assisted transaxillary parathyroidectomy for PHPT in the Asian and Western population. Analysis of the procedural learning curve demonstrates that proficiency in this technique was achieved after performance of less than 15 surgeries. This procedure is safe and feasible in the hands of experienced surgeons for select patients with localized disease.

Prophylactic external beam radiation therapy for keloid prevention in thyroid surgery patients.

BACKGROUND: Poor cosmesis, secondary to keloid or hypertrophic scar, following thyroid surgery may cause considerable patient distress and be a significant challenge to treat. In this case series we examined the efficacy of prophylactic external beam radiation therapy (EBRT) for prevention of keloid formation in keloid-prone patients undergoing thyroid surgery. While much has been published about documenting the efficacy in reducing keloid formation following keloid excision, very little literature exists documenting prophylactic use related to surgeries with the goal of prevent de novo keloid formation. METHODS: We retrospectively evaluated a series of ten patients, who underwent a prophylactic EBRT for keloid prevention after thyroid surgery between January 2013 and February 2019. Patient demographics, primary diagnosis, surgical procedure, EBRT dosage, and post-operative visit records were reviewed. RESULTS: All ten patients who received EBRT for keloid prophylaxis following a thyroid surgery were female. Half of the patients were African Americans, 40% Caucasians, and 10% Hispanic. The mean age was 46.40±15.63 years with BMI of 31.5±5.5 kg/m2. Radiation was initiated within 6 hours of the surgery with an average radiation dose per session of 5.7±1.7 Gy. The total average EBRT dose delivered was 17.4±4.2 Gy. Mean follow-up period was 13 months post-thyroidectomy, with the longest follow-up at 23 months. One patient, who underwent a lateral neck dissection in addition to thyroid surgery, developed hypertrophic scar in less than 10% of her incision length. Nine other patients (90%) showed no post-surgical keloid nor hypertrophic scar formation and patients were satisfied with postsurgical cosmesis. CONCLUSIONS: We examined the efficacy of prophylactic EBRT in keloid-prone patients undergoing thyroid surgery. Prophylactic EBRT following thyroid surgery is effective in achieving a satisfactory cosmetic outcome in patients at high risk for keloid formation.

Residents' perspectives: Does the Saudi general surgery residency training program apply CanMEDS competencies and prepare future leaders?

BACKGROUND: This study investigates leadership skills and Canadian Medical Education Directives for Specialists (CanMEDS) competencies acquisition within the General Surgery Residency Training Program (GSRTP). The Saudi Commission for Health Specialties (SCFHS) incorporates the CanMEDS Competency Framework into its curriculum to prepare the resident for healthcare needs. METHODS: This is a descriptive-analytical study. A questionnaire was used to collect data from 117 General Surgery residents (GS) at seven institutes in Jeddah, Saudi Arabia. RESULTS: The GS residents reported an acceptable self-perceived level of Clinical Leadership Skills (mean ± standard deviation). The most dominant skill was working with others (1.98 ± 1.03), followed by demonstrating personal qualities (2.07 ± 0.88), the ability to manage services (2.21 ± 1.37), improving services (2.22 ± 1.84) and last, setting directions (2.39 ± 0.95). Regarding the CanMEDS competencies, the respondents showed a generally positive perception with an "agree" level (Mean = 1.83). Of the CanMEDS competency roles, Collaborator ranked first followed by Professional and then Communicator. Leader competency ranked fourth followed by Health Advocate, Medical Expert and last, Scholar. CONCLUSION: The GSRTP residents showed satisfactory self-assessed clinical leadership skills and acquirement of the CanMEDS competencies during their training, which will prepare them to lead in the future.

CONTEXTE: Cette étude se penche sur les compétences en leadership et l'acquisition de compétences CanMEDS (Canadian Medical Education Directives for Specialists - directives canadiennes en formation médicale pour les spécialistes) au sein du GSRTP (programme de formation en résidence en chirurgie générale). La SCFHS (commission saoudienne pour les spécialistes de la santé) intègre le cadre des compétences CanMEDS dans son programme pour préparer les résidents aux besoins en matière de soins de santé. MÉTHODES: Il s'agit d'une étude descriptive et analytique. Un questionnaire a été utilisé pour collecter des données auprès de 117 résidents en chirurgie générale dans sept instituts médicaux à Djeddah, Arabie saoudite. RÉSULTATS: Les résidents en chirurgie générale ont rapporté un niveau perçu acceptable de compétences en leadership clinique (moyenne ± écart type) La compétence la plus dominante était le travail avec les autres (1,98 ± 1,03), suivi par la démonstration de qualités personnelles (2,07 ± 0,88), la capacité de gérer les services (2,1 ± 1,37), l'amélioration des services (2,22 ± 1,84) et, finalement, l'établissement des orientations (2,39 ± 0,95). En ce qui a trait aux compétences CanMEDS, les répondants ont montré une perception généralement positive avec un niveau « d'accord ¼ (moyenne = 1,83). En ce qui a trait aux rôles associés aux compétences CanMEDS, celui de collaborateur s'est classé au premier rang, suivi par celui de professionnel et ensuite de communicateur. Le rôle de chef de file s'est classée quatrième en matière de compétence, suivie de défenseur de la santé, d'expert médical et, finalement, d'érudit. CONCLUSION: Les résidents du GSRTP ont montré une satisfaction en matière de compétences de leadership clinique autoévaluées et d'acquisition des compétences CanMEDS lors de leur formation, laquelle les préparera à jouer un rôle de premier plan dans l'avenir.

Robotic Thyroidectomy: Past, Future, and Current Perspectives.

Through the past decades, there was a tremendous revolution in the surgical approaches for thyroidectomy. Remote access approaches (RAA) use the axillary approach, the axillary-bilateral breast approach, the bilateral axilla-breast approach, the retroauricular approach, and the transoral approach. The installation of the robotic system in surgery overcomes many limitations of the RAA. Although there are various types of robotic thyroidectomy by far, transaxillary is the commonly used approach. Moreover, the transoral approach is the most novel approach. In this article, the authors demonstrate the benefits and the constraints of each method and future directions of robotic thyroidectomy.

Impact of Surgeon-Performed Ultrasound on Treatment of Thyroid Cancer Patients.

BACKGROUND: The 2015 American Thyroid Association Management Guidelines for patients with thyroid nodules recommended a comprehensive sonographic evaluation of thyroid nodules' characteristics and the presence of any suspicious cervical lymph nodes (LNs) in the central and lateral compartments. This detailed sonographic assessment is still not routinely performed. We hypothesized that an endocrine surgeon-performed ultrasound (SUS) significantly enhances the management of thyroid cancer patients when compared with referral ultrasound (RUS). METHODS: We conducted a retrospective review of 267 consecutive thyroid surgery patients who were diagnosed with thyroid cancer on final pathology. All patients had undergone a SUS, but only 130 cohorts with both RUS and SUS were included. Features of thyroid nodules and LN and changes in the management plan were recorded. RESULTS: Based on SUS assessment, 26 patients (20%) were noted to have suspicious thyroid nodules which warranted a fine-needle aspiration (FNA) and were missed in RUS. On FNA, there were 12 patients with Bethesda categories III/IV and 14 patients with Bethesda V/VI. Those 26 patients were found to have a malignancy in the final pathology assessment. Thirty-eight patients (29.2%) were noted to have suspicious central/lateral neck findings on SUS but were not reported in RUS. Additionally, 8 patients (6.1%) were found to have a parathyroid adenoma by SUS and required concurrent parathyroidectomy. DISCUSSION: A comprehensive neck ultrasound in thyroid cancer patients, performed by their endocrine surgeon, could enhance management planning and outcomes. This finding highlights the critical need for education and improvement of routine neck ultrasonographic examination performed in the community.