Practice patterns and job satisfaction in fellowship-trained endocrine surgeons.

BACKGROUND: Debates about the difficult job market for young endocrine surgeons are ongoing. This study aimed to analyze the practice patterns and work-related satisfaction levels of recently trained endocrine surgeons. METHODS: An anonymous survey was utilized. Participants were divided into 3 groups: "Young" (<3 years in practice), "middle" (3-5 years), and "older" (>5 years). RESULTS: Fifty-six of 78 surgeons (72%) responded to the survey. Time in practice ranged from 1 to 9 years (mean, 3.9 ± 0.28). Forty-five (80%) described their practice as academic. Participants performed 244.1 ± 17.8 operations within the last year; 75.4 ± 3.3% were endocrine cases. More surgeons in the "young" group have academic practices (92%) and joined established endocrine surgery groups (54%) versus older surgeons (67% and 42%; P = .05). Of surgeons in the "young" group, 4% started their own practice versus 33% in the "older" group (P = .04). Level of satisfaction with financial compensation (3.2 on a 4-point scale versus 2.9) and lifestyle (3.6 vs 3.1) was also higher in the younger group (P = .009). CONCLUSION: Despite widespread speculation about scarcity of academic jobs after fellowship, recently trained endocrine surgeons are more likely to practice in academic settings and join established endocrine surgery practices when compared with older surgeons. Overall satisfaction level is higher among recently trained surgeons.

Impact of race on intraoperative parathyroid hormone kinetics: an analysis of 910 patients undergoing parathyroidectomy for primary hyperparathyroidism.

HYPOTHESIS African American patients exhibit different intraoperative parathyroid hormone (IOPTH) profiles than non-African American patients. DESIGN Retrospective review. SETTING University medical center. PATIENTS Nine hundred ten patients who underwent parathyroidectomy for primary hyperparathyroidism between July 2005 and August 2010. INTERVENTIONS All patients underwent preoperative imaging with ultrasonography and sestamibi; operative exploration; and IOPTH measurement at 2 points preexcision and 5 and 10 minutes postexcision. MAIN OUTCOME MEASURES Preexcision and postexcision IOPTH measurements. RESULTS Of the 910 patients, 734 self-reported their race as white (81%); 91, Latino/other (10%); 56, Asian (6%); and 28, African American (3%). African American patients had significantly higher initial preexcision IOPTH levels compared with white patients (348 vs 202 pg/mL; P = .048) and significantly higher 5-minute postexcision IOPTH levels (151 vs 80 pg/mL; P = .01). The 10-minute postexcision IOPTH levels were similar between the 2 groups (52 vs 50 pg/mL). A similar percentage of white and African American patients had a 50% drop in IOPTH level at 10 minutes postexcision. No differences in IOPTH kinetics were observed in the other racial groups examined. CONCLUSIONS African American patients with primary hyperparathyroidism exhibit significantly higher preincision and 5-minute postexcision IOPTH values when compared with white patients. The 10-minute postexcision IOPTH values did not differ between races. The altered IOPTH kinetics identified in African American patients may reflect the severity of biochemical disease but may also be related to genetically predetermined differences in parathyroid hormone metabolism.

Subclinical Cushing's syndrome.

Subclinical Cushing's syndrome (SCS) refers to subtle autonomous cortisol hypersecretion that is insufficient to generate the typical, clinically recognizable overt syndrome. Diagnosis of SCS is challenging. The combination of 1 mg overnight dexamethasone suppression test, serum ACTH level, and urinary cortisol level are used to diagnose SCS. Laparoscopic adrenalectomy is the treatment of choice for SCS. Patients with adrenal incidentalomas and SCS should be treated with perioperative steroids to prevent post-operative hypocortisolism.

Comparison of laparoscopic versus open liver tumor resection: a case-controlled study.

BACKGROUND: Although there are data in the literature about the safety and efficacy of laparoscopic liver resections, there are not many studies comparing laparoscopic versus open approaches in a case-matched design. The purpose of this study is to compare the perioperative outcome of laparoscopic versus open liver resections from a single institution. METHODS: Thirty-one patients underwent laparoscopic liver resection between April 1997 and August 2007, with a prospective laparoscopic program started in April 2006 (n=25). This group of patients was compared with 43 consecutive patients undergoing open resection who were matched by size of the lesion (5 cm or less for malignant and 8 cm or less for benign), anatomical location (segments 2, 3, 4b, 5, 6), and type of resection (wedge resection, segmentectomy, partial liver resection). Data were obtained from medical records as well as from a prospective database. Statistical analysis was performed using t-test and chi-square. All data are expressed as mean +/- standard error on the mean (SEM). RESULTS: Mean age in the laparoscopic group was 57.6+/-2.7 years versus 61.9+/-2.3 years in the open group (p=0.2). There were more women in the laparoscopic group [74% females (n=23) and 26% males (n=8)] versus in the open group [40% females (n=17) and 60% males (n=26)] (p=0.003). There were more patients with malignant lesions in the open group (73%) versus in the laparoscopic group (45%) (p=0.01). Eight patients underwent partial and 23 patients segmental/wedge liver resection in the laparoscopic group versus 15 patients who underwent partial and 28 patients segmental/wedge liver resection in the open group (p=0.7). Mean tumor size was 3.9+/-0.4 cm in the laparoscopic group versus 4.2+/-0.3 cm in the open group (p=0.5). Ten (32%) out of 31 cases in the laparoscopic group were hand-assisted. Inflow occlusion was used in 1 case (3%) in the laparoscopic group versus 16 (37.2%) in the open group. Mean operating time was 201+/-15 min for the laparoscopic group and 172+/-12 min for the open group (p=0.1). Mean estimated blood loss during the procedure was 122.5+/-45.4 cc for the laparoscopic group and 299.6+/-33.6 cc for the open group (p=0.002). Surgical margin was similar for malignant cases in both groups. Mean hospital stay was 3.2+/-1.0 days for the laparoscopic group and 6.8+/-0.7 days for the open group (p=0.004). The incidence of postoperative complications was 13% (n=4) in the laparoscopic and 16% (n=7) in the open group (p=0.7). CONCLUSION: This study shows that, with a longer operative time, the laparoscopic approach, despite the learning curve, offers advantages regarding operative blood loss, postoperative analgesic requirement, time to regular diet, hospital stay, and overall cost compared with the open approach for minor liver resections.

Unrecognized adrenal insufficiency in patients undergoing laparoscopic adrenalectomy.

BACKGROUND: Subclinical Cushing's syndrome (SCS) is a well-described phenomenon where abnormalities of the hypothalamic-pituitary-adrenal axis exist in the absence of overt signs and symptoms of classic Cushing's syndrome. While this has been shown to exist in 5-20% of patients with adrenal lesions, no standardized biochemical regimen exists to screen for SCS. Consequently, many of these patients may not be diagnosed prior to adrenalectomy with the risk of postoperative adrenal insufficiency. We began checking morning (a.m.) serum cortisol levels on postoperative day 1 (POD1) following unilateral adrenalectomy for nonfunctioning adrenal lesions to determine the incidence of unrecognized adrenal insufficiency (AI) in these patients. METHODS: One hundred and five patients undergoing adrenalectomy at a tertiary care center from 1999 to 2007 were retrospectively evaluated. Patients with Cushing's syndrome, conditions associate with bilateral disease, and those receiving perioperative steroids were excluded, leaving 41 patients for analysis. A.m. serum cortisol levels were obtained in all patients POD1. Multiple factors were analyzed as possible predictors of AI. Analysis of variance (ANOVA), t-test, and chi-square test were used to determine statistical significance. RESULTS: The 41 patients' diagnoses included 13 pheochromocytomas, 15 nonsecreting adenomas, 5 aldosteronomas, 5 metastatic lesions, 1 adrenocortical carcinoma, and 2 other benign lesions. Three groups were identified based on POD1, a.m. cortisol levels: sufficient (>10 microg/dl; n = 25, 61%), low-normal (3.4-10 microg/dl; n = 7, 17%), and insufficient (<3.4 microg/dl; n = 9, 22%). Tumor size and presence of diabetes, hypertension, and obesity were predictive of postoperative AI (p < 0.05). CONCLUSIONS: AI after unilateral adrenalectomy without evidence of cortisol hypersecretion on preoperative screening was present in a significant number of patients in our series. Patients with diabetes, hypertension, obesity, and larger tumors may be at higher risk for postoperative AI. More thorough screening for cortisol hypersecretion may be warranted in patients with these characteristics, and obtaining routine postoperative cortisol levels may avoid potentially dangerous unrecognized adrenal insufficiency following adrenalectomy.

Predicting the success of limited exploration for primary hyperparathyroidism using ultrasound, sestamibi, and intraoperative parathyroid hormone: analysis of 1158 cases.

OBJECTIVE: The aim of this study was to determine the success of limited neck exploration (LE) for primary hyperparathyroidism (1 degrees HPT). METHODS: Between 1999 and 2007, 1407 patients with hyperparathyroidism underwent bilateral neck exploration (BE). Of these, 1158 patients with first-time sporadic 1 degrees HPT were analyzed prospectively. Based on surgeon-performed ultrasound (US) and sestamibi scan (MIBI), LE was initially performed. Regardless of results, BE followed to identify the presence of additional parathyroid pathology. RESULTS: Of 1158 patients, 242 (21%) were found to require concomitant thyroid surgery thus excluding LE. Of the remaining 916 patients, a single abnormal gland was identified on MIBI in 682 (74%), US in 731 (80%), and concordance of both in 588 (64%). Unsuspected multiglandular disease (MGD) was identified at BE in 22%, 22%, and 20% of patients, respectively. Adding intraoperative parathyroid hormone sampling (IOPTH) further reduced the rate of unsuspected MGD to 16%, 17%, and 16%. Overall, IOPTH correctly predicted MGD in only 22%. Neither concomitant nonsurgical thyroid disease nor more stringent selection criteria (preop Ca>11 mg/dL and PTH>120 pg/dL) altered success rates. In patients with MGD, a subsequent gland identified was larger than the index gland in 23%. Ninety-eight percent of BE patients were cured of 1 degrees HPT. CONCLUSIONS: This is the largest study to evaluate the prevalence of additional parathyroid pathology in patients who are candidates for LE. Limitations in localizing studies and IOPTH fail to identify MGD in at least 16% of patients, risking future recurrence.

Resection versus laparoscopic radiofrequency thermal ablation of solitary colorectal liver metastasis.

PURPOSE: There is scant data in the literature regarding radiofrequency thermal ablation (RFA) versus resection of colorectal liver metastases. The aim of this study is to compare the clinical profile and survival of patients with solitary colorectal liver metastasis undergoing resection versus laparoscopic RFA. METHODS: Between 1996 and 2007, 158 patients underwent RFA (n = 68) and open liver resection (n = 90) of solitary liver metastasis from colorectal cancer. Patients were evaluated in a multidisciplinary fashion and allocated to a treatment type. Data were collected prospectively for the RFA patients and retrospectively for the resection patients. RESULTS: Although the groups were matched for age, gender, chemotherapy exposure and tumor size, RFA patients tended to have a higher ASA score and presence of extra-hepatic disease (EHD) at the time of treatment. The main indication for referral to RFA included technical reasons (n = 25), patient comorbidities (n = 24), extra-hepatic disease (n = 10) and patient decision (n = 9). There were no peri-operative mortalities in either group. The complication rate was 2.9% (n = 2) for RFA and 31.1% (n = 28) for resection. The overall Kaplan-Meier median actuarial survival from the date of surgery was 24 months for RFA patients with EHD, 34 months for RFA patients without EHD and 57 months for resection patients (p < 0.0001). The 5-year actual survival was 30% for RFA patients and 40% for resection patients (p = 0.35). CONCLUSIONS: This study shows that, although patients in both groups had a solitary liver metastasis, other factors including medical comorbidities, technically challenging tumor locations and extra-hepatic disease were different, prompting selection of therapy. With a simultaneous ablation program, higher risk patients have been channeled to RFA, leaving a highly selected group of patients for resection with a very favorable survival. RFA still achieved long-term survival in patients who were otherwise not candidates for resection.