RESUMO
While there has been great progress in the past few decades in the management of endocrine surgery disorders, with adoption of new technologies and approaches, standardization of practice patterns, and guideline recommendations, unequal implementation of these improvement has led to differences in access and outcomes. Health disparities are well documented in this population; however, literature lacks discussion of strategies to decrease disparities. In this article, the authors will describe the current status of health care-related disparities in endocrine surgical care, and discuss opportunities for future investigation and issue an urgent call to action items.
Assuntos
Procedimentos Cirúrgicos Endócrinos , Doenças do Sistema Endócrino , Disparidades em Assistência à Saúde , Humanos , Doenças do Sistema Endócrino/cirurgia , Acessibilidade aos Serviços de Saúde , Estados UnidosRESUMO
BACKGROUND: Pediatric endocrine disorders requiring surgical intervention are rare and so are experienced surgeons dealing with these. The aim of the current study was to investigate disease profile and perioperative outcome of pediatric patients with surgical endocrine disorders in an endocrine surgery unit. METHODS: This retrospective study (Sep 1989-Aug 2019) consisted of pediatric endocrine surgery patients (<18 years) who were managed by a team of pediatric endocrinologists and endocrine surgeons at our center. Patients were divided into three cohorts consisting of a decade each. Clinico-pathologic variables, perioperative events operative and follow-up details were recorded. RESULTS: A total of 332 children were included and their mean age was 14.6 ± 3.9 years (M:F = 1:1.6). Thyroid disorders were most prevalent (59.8%), followed by adrenal (28.2%), parathyroid (10.4%), and pancreas (1.5%). Incidence of benign, malignant, and congenital/developmental disorders were 65.4, 28.1 and 8.3, respectively. Familial association was observed in 8.9% children, which is highest among pheochromocytoma patients. Overall, 201 thyroidectomies + associated procedures, 35 parathyroidectomies, 96 adrenal and paraganglioma resections, and 5 pancreatic procedures were performed. Median hospital stay was 5.6 ± 4.1 days. The number of cases increased significantly over 3 decades. Clinical profile and outcome did not vary except for significant decrease in incidence of malignant pathology (p = 0.04) and increase in VHL cases (p = 0.04) in the last decade though overall increase in familial cases was nonsignificant (p = 0.11). No perioperative mortality was observed except for 3% after adrenalectomy. CONCLUSION: A team of dedicated endocrine surgeons and pediatric endocrinologists is effective in management of pediatric endocrine surgery.
Assuntos
Neoplasias das Glândulas Suprarrenais , Procedimentos Cirúrgicos Endócrinos , Doenças do Sistema Endócrino , Feocromocitoma , Cirurgiões , Humanos , Criança , Adolescente , Estudos Retrospectivos , Feocromocitoma/cirurgia , Doenças do Sistema Endócrino/epidemiologia , Doenças do Sistema Endócrino/cirurgia , Neoplasias das Glândulas Suprarrenais/cirurgiaRESUMO
In recent years, the number of surgical cases involving patients with comorbidities has been increasing due to the aging society. Such patients may have a higher risk of postoperative morbidity or mortality. Therefore, surgeons are required to evaluate the current control status of the comorbidity, and perform appropriate perioperative management to decrease perioperative risk. This article focuses on the preoperative evaluation and management, as well as intraoperative and postoperative management of diabetes mellitus, thyroid dysfunction, which are frequently encountered among patients with metabolic and endocrine disorders, and paraganglioma, which is a rare disease but requires special attention in the field of thoracic surgery.
Assuntos
Doenças do Sistema Endócrino , Procedimentos Cirúrgicos Torácicos , Doenças da Glândula Tireoide , Humanos , Doenças do Sistema Endócrino/cirurgia , Doenças da Glândula Tireoide/cirurgia , Comorbidade , Cuidados Pré-Operatórios , Complicações Pós-OperatóriasRESUMO
BACKGROUND: The COVID-19 pandemic profoundly impacted the delivery of care and timing of elective surgical procedures. Most endocrine-related operations were considered elective and safe to postpone, providing a unique opportunity to assess clinical outcomes under protracted treatment plans. METHODS: American Association of Endocrine Surgeon members were surveyed for participation. A Research Electronic Data Capture survey was developed and distributed to 27 institutions to assess the impact of COVID-19-related delays. The information collected included patient demographics, primary diagnosis, resumption of care, and assessment of disease progression by the surgeon. RESULTS: Twelve out of 27 institutions completed the survey (44.4%). Of 850 patients, 74.8% (636) were female; median age was 56 (interquartile range, 44-66) years. Forty percent (34) of patients had not been seen since their original surgical appointment was delayed; 86.2% (733) of patients had a delay in care with women more likely to have a delay (87.6% vs 82.2% of men, χ2 = 3.84, P = .05). Median duration of delay was 70 (interquartile range, 42-118) days. Among patients with a delay in care, primary disease site included thyroid (54.2%), parathyroid (37.2%), adrenal (6.5%), and pancreatic/gastrointestinal neuroendocrine tumors (1.3%). In addition, 4.0% (26) of patients experienced disease progression and 4.1% (24) had a change from the initial operative plan. The duration of delay was not associated with disease progression (P = .96) or a change in operative plan (P = .66). CONCLUSION: Although some patients experienced disease progression during COVID-19 delays to endocrine disease-related care, most patients with follow-up did not. Our analysis indicated that temporary delay may be an acceptable course of action in extreme circumstances for most endocrine-related surgical disease.
Assuntos
COVID-19 , Doenças do Sistema Endócrino , Masculino , Humanos , Feminino , Pessoa de Meia-Idade , Pandemias , SARS-CoV-2 , Tempo para o Tratamento , Doenças do Sistema Endócrino/epidemiologia , Doenças do Sistema Endócrino/cirurgia , Progressão da DoençaRESUMO
â¢Background: The Affordable Care Act's Medicaid expansion increased insurance coverage and access to care for endocrine cancers, though impact on benign endocrine disease is unknown. â¢Methods: Patients undergoing operations for benign thyroid, parathyroid, and adrenal disease were collected from the Vizient® Clinical Data Base from 2009 to 2016 and grouped by state Medicaid expansion status in January 2014. Insurance coverage was analyzed by difference-in-differences analysis, and logistic regression evaluated odds of operation by insurance status. â¢Results: 134,242 patients were included. Medicaid coverage in expansion states increased for all operations (Adj-DD 5.78%, p < 0.001) with decreases in uninsured and private insurance. Medicaid patients had increased odds of undergoing thyroid operations (OR 1.56, p < 0.001) and decreased odds of parathyroid (OR 0.68, p < 0.001) or adrenal operations (OR 0.70, p < 0.001) versus private insurance. â¢Conclusion: Medicaid expansion increased insurance coverage for benign endocrine disease, however, barriers remain for Medicaid patients with parathyroid and adrenal disease.
Assuntos
Procedimentos Cirúrgicos Endócrinos , Doenças do Sistema Endócrino , Estados Unidos , Humanos , Medicaid , Patient Protection and Affordable Care Act , Pessoas sem Cobertura de Seguro de Saúde , Cobertura do Seguro , Doenças do Sistema Endócrino/cirurgiaAssuntos
Transtornos do Desenvolvimento Sexual , Doenças do Sistema Endócrino , Ilustração Médica , Medicina nas Artes , Médicas/história , Procedimentos de Cirurgia Plástica , Transtornos do Desenvolvimento Sexual/etiologia , Transtornos do Desenvolvimento Sexual/cirurgia , Doenças do Sistema Endócrino/complicações , Doenças do Sistema Endócrino/cirurgia , Feminino , Genitália Feminina/cirurgia , História do Século XV , Humanos , Procedimentos de Cirurgia Plástica/história , Procedimentos de Cirurgia Plástica/métodosRESUMO
In the last decades, the incidence of thyroid cancer (TC) has more than doubled, but the disease-specific mortality rate was stable. To date, 30-40% of all TC is represented by papillary microcarcinomas (mPTC), an indolent tumor, that probably remained undiagnosed before routine ultrasound use. In 1993, Miyauchi was the first who hypothesized a conservative approach for low-risk mPTC and introduced the concept of active surveillance (AS) in its clinical management. The progression rate of mPTC during AS was low and delaying surgery did not impact the efficacy of treatment or outcome. Since then, several authors from all over the world have reported their experience of AS in mPTCs. As suggested by current guidelines, AS can be considered as an alternative to immediate surgery to avoid overtreatment in low-risk mPTC and may be the strategy to avoid complications from unnecessary surgery. In the last years, AS inclusion criteria have been extended to both bigger tumors and to younger/healthier patients. The adoption of AS should take into consideration not only tumor characteristics but also patient psychological profiles and medical team expertise. Its safety and efficacy have been demonstrated in long-term outcome studies and in other types of tumors; however, skepticism in patients, families and physicians should be overcome by strong recommendations coming from scientific guidelines. This review analyses the several and different experiences of AS and the potential obstacles in implementing it as a routine approach in mPTC patients.
Assuntos
Doenças do Sistema Endócrino/cirurgia , Animais , Carcinoma Papilar/diagnóstico , Carcinoma Papilar/tratamento farmacológico , Carcinoma Papilar/cirurgia , Doenças do Sistema Endócrino/diagnóstico , Doenças do Sistema Endócrino/tratamento farmacológico , Humanos , Neoplasias da Glândula Tireoide/diagnóstico , Neoplasias da Glândula Tireoide/tratamento farmacológico , Neoplasias da Glândula Tireoide/cirurgia , Tireoidectomia/normas , Tireoidectomia/estatística & dados numéricos , Conduta Expectante/normas , Conduta Expectante/estatística & dados numéricosRESUMO
BACKGROUND AND OBJECTIVE: The opioid epidemic has stimulated initiatives to reduce the number of unnecessary narcotic prescriptions. We adopted an opt-in prescription system for patients undergoing ambulatory cervical endocrine surgery (CES). We hypothesized that empowering patients to decide whether or not to receive narcotics for pain control would result in fewer unnecessary opioid prescriptions. METHODS: We enrolled all patients scheduled for outpatient CES between July 2017 and June 2018 in a narcotic opt-in program. Patient demographics, procedure characteristics, and postoperative pain scores were collected prospectively. Statistical analyses were performed to correlate clinical predictors with narcotic request. Results were compared against a historical control group. The study was approved by the University IRB. RESULTS: A total of 216 consecutive patients underwent outpatient CES following implementation of the program. Only nine (4%) requested prescription narcotic medication at discharge, and no patient called after discharge to request analgesic medications. Compared with our prior treatment paradigm, we achieved a 96.6% reduction in the number of narcotic tablets prescribed, and a 98% reduction in unconsumed tablets. Univariate analysis suggested history of substance abuse (P < 0.001), anxiety (P = 0.01), depression (P < 0.001), baseline narcotic use (P = 0.004), highest pain postoperatively (P = 0.004), and incision length (P = 0.007) as predictive for narcotic request. Multivariate analysis retained significance with incision length and history of substance abuse. CONCLUSION: By empowering patients undergoing ambulatory CES to accept or decline a prescription, we reduced the number of prescribed narcotic tablets by 96.6%. Although longer incisions and prior substance abuse predict higher likelihood of requesting pain medication on discharge, 207 of 216 patients were treated with acetaminophen alone.
Assuntos
Acetaminofen/uso terapêutico , Procedimentos Cirúrgicos Ambulatórios , Analgésicos Opioides/uso terapêutico , Doenças do Sistema Endócrino/cirurgia , Pescoço/cirurgia , Manejo da Dor/métodos , Dor Pós-Operatória/tratamento farmacológico , Aceitação pelo Paciente de Cuidados de Saúde , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
Primary aldosteronism is common and contributes to adverse cardiovascular, kidney, and metabolic outcomes. When instituted early and effectively, targeted therapies can mitigate these adverse outcomes. Surgical adrenalectomy is among the most effective treatments because it has the potential to cure, or attenuate the severity of, pathologic aldosterone excess, resulting in a host of biochemical and clinical changes that improve health outcomes. Herein, we review the role of surgical adrenalectomy in primary aldosteronism while emphasizing the physiologic ramifications of surgical intervention, and compare these to other targeted medical therapies for primary aldosteronism. We specifically review the role of curative adrenalectomy for unilateral primary aldosteronism, the role of non-curative adrenalectomy for bilateral primary aldosteronism, and how these interventions influence biochemical and clinical outcomes in relation to medical therapies for primary aldosteronism.
Assuntos
Adrenalectomia/tendências , Aldosterona/sangue , Hiperaldosteronismo/sangue , Hiperaldosteronismo/cirurgia , Adrenalectomia/métodos , Doenças do Sistema Endócrino/sangue , Doenças do Sistema Endócrino/cirurgia , Cardiopatias/sangue , Cardiopatias/prevenção & controle , Humanos , Nefropatias/sangue , Nefropatias/prevenção & controleRESUMO
BACKGROUND: Endocrine surgery (ES) is a relatively young subspecialty of general surgery, and prior research has shown low public awareness of these specialists' roles. We hypothesized that a video-based intervention could increase public knowledge of the specialty in an effective and efficient manner. METHODS: Participants were recruited at three public locations (a farmer's market, a public park, and a university hospital) and were given a three-question survey to assess baseline knowledge of ES. They then watched one of two video-based educational interventions and completed an identical postintervention survey. Two surveyors recruited 80 individuals per site, with 40 participants in each intervention group. Participants' sex and age and whether or not they were on clinical staff at the University of Alabama at Birmingham were recorded. RESULTS: A total of 240 participants were recruited; 61.3% female with median age 40 y. Preintervention, only 42.1% of participants could correctly define ES. ES were confused with endocrinologists by 44.6%, which was not different between sites (P = 0.09). Significantly, more participants at all sites could correctly define ES postintervention (67.9% versus 42.1%; P < 0.001). Clinical staff did not perform better than the lay public at any location (P = 0.32). The long video had a significantly greater increase in correct responses compared with the short video overall (32.5% versus 19.1%; P < 0.001) and at each location. CONCLUSIONS: This study confirms the public's general lack of knowledge about ES and their scope of practice. A video-based intervention was successful in improving knowledge of the practice of ES, with a longer, explanatory video being most effective.
Assuntos
Procedimentos Cirúrgicos Endócrinos/métodos , Doenças do Sistema Endócrino/cirurgia , Educação em Saúde/métodos , Disseminação de Informação/métodos , Gravação em Vídeo , Adolescente , Adulto , Idoso , Endocrinologia/métodos , Feminino , Cirurgia Geral/métodos , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Inquéritos e Questionários/estatística & dados numéricos , Adulto JovemRESUMO
The ongoing spread of the coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) poses a significant threat to global health. As the coronavirus outbreak began spreading, hospitals were forced to relocate resources to treat the growing number of COVID-19 patients. As a consequence, doctors across the country canceled tens of thousands of nonurgent surgeries. However, recognizing that the COVID-19 situation may be highly variable and fluid in different communities across the country, elective surgery could be still allowed in some centers for patients included in the high-priority class. The majority of endocrine disorders requiring surgical treatment in patients identifiable as first-priority class, or needing hospitalization within 30 days, are generally represented by malignant thyroid tumors, hyperthyroidism, hyperparathyroidism, and some adrenal disorders. The need for urgent intervention is evaluated on a case-by-case basis according to the severity of the symptoms, the likelihood of progression, and global clinical judgment. On the basis of the above indications, during the last 4 weeks, we performed 18 planned surgical treatments in patients with thyroid cancer (total thyroidectomies, plus lymph node dissection if needed) or multinodular toxic goiter. In no case, postoperative ventilatory support was needed, and the average hospital stay was 3 days. The negative COVID-19 status for all the treated patients was appropriately evaluated beforehand. Nobody knows how long the current COVID-19 pandemic will be lasting. Certainly, we will be requested in the next future to incrementally offer surgical services for endocrine disorders that have been deferred for the COVID-19 pandemic.
Assuntos
Betacoronavirus , Infecções por Coronavirus , Procedimentos Cirúrgicos Endócrinos , Doenças do Sistema Endócrino/cirurgia , Pandemias , Pneumonia Viral , Doenças das Glândulas Suprarrenais/cirurgia , COVID-19 , Infecções por Coronavirus/epidemiologia , Procedimentos Cirúrgicos Eletivos , Tratamento de Emergência , Humanos , Hiperparatireoidismo/cirurgia , Hipertireoidismo/cirurgia , Itália/epidemiologia , Pneumonia Viral/epidemiologia , Guias de Prática Clínica como Assunto , Prognóstico , SARS-CoV-2 , Índice de Gravidade de Doença , Neoplasias da Glândula Tireoide/cirurgiaRESUMO
The COVID-19 pandemic commands a major reorganisation of the entire French healthcare system. In France, general rules have been issued nationally and implemented by each healthcare centre, both public and private, throughout France. Guidelines drafted by an expert group led by the French-speaking Association of Endocrine Surgery (AFCE) propose specific surgical management principles for thyroid, parathyroid, endocrine pancreas and adrenal surgery during and after the COVID-19 epidemic.
Assuntos
Infecções por Coronavirus , Procedimentos Cirúrgicos Endócrinos , Doenças do Sistema Endócrino/cirurgia , Pandemias , Pneumonia Viral , COVID-19 , Árvores de Decisões , HumanosRESUMO
BACKGROUND: In the face of the COVID-19 pandemic, cancer care has had to adapt rapidly given the Centers for Disease Control and Prevention and the American College of Surgeons (ACS) issuing recommendations to postpone nonurgent surgeries. METHODS: An institutional multidisciplinary group of Head and Neck Surgical Oncology, Surgical Endocrinology, and Medical Endocrinology devised Surgical Triaging Guidelines for Endocrine Surgery during COVID-19, aligned with phases of care published by the ACS. RESULTS: Phases of care with examples of corresponding endocrine cases are outlined. Most cases can be safely postponed with active surveillance, including most differentiated and medullary thyroid cancers. During the most acute phase, all endocrine surgeries are deferred, except thyroid tumors requiring acute airway management. CONCLUSIONS: These guidelines provide context for endocrine surgery within the spectrum of surgical oncology, with the goal of optimal individualized multidisciplinary patient care and the expectation of significant resource diversion to care for patients with COVID-19.
Assuntos
Betacoronavirus , Infecções por Coronavirus/epidemiologia , Doenças do Sistema Endócrino/cirurgia , Seleção de Pacientes , Pneumonia Viral/epidemiologia , Triagem , Algoritmos , COVID-19 , Infecções por Coronavirus/prevenção & controle , Infecções por Coronavirus/transmissão , Doenças do Sistema Endócrino/patologia , Humanos , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Pneumonia Viral/transmissão , Guias de Prática Clínica como Assunto , SARS-CoV-2RESUMO
Although endocrine emergencies are not common occurrences, their identification and careful perioperative management are of paramount importance for reduction of patient morbidity and mortality. The most common critical endocrine abnormalities are associated with functional tumors, such as pheochromocytomas, insulinomas, and carcinoid tumors, leading to carcinoid syndrome, abnormal thyroid function, or disturbances in the hypothalamus-pituitary-adrenal axis, causing adrenal insufficiency. This article aims to discuss the pathophysiology, diagnosis, and perioperative management of pheochromocytomas, hyperthyroidism, hypothyroidism, adrenal insufficiency, carcinoid disease, and insulinomas.
Assuntos
Anestesia/métodos , Doenças do Sistema Endócrino/cirurgia , Neoplasias das Glândulas Suprarrenais/diagnóstico , Neoplasias das Glândulas Suprarrenais/cirurgia , Insuficiência Adrenal/cirurgia , Emergências , Humanos , Hipotireoidismo/cirurgia , Insulinoma/cirurgia , Síndrome do Carcinoide Maligno/cirurgia , Assistência Perioperatória , Feocromocitoma/diagnóstico , Feocromocitoma/cirurgia , Tireotoxicose/diagnóstico , Tireotoxicose/cirurgiaRESUMO
The cytochrome P450 17A1 catalyzes the formation of 17-hydroxysteroids and 17-ketosteroid. Most defects in CYP17A1 impair both enzymatic activities and cause a combined 17α-hydroxylase/17,20-lyase deficiency, which impairs hormone production (cortisol and sex steroids), sexual development, and puberty. Isolated 17,20-lyase deficiency is usually defined by evidently normal activity of 17α-hydroxylase with a dramatic decline of 17,20-lyase activity or complete inactivity. The changes in enzyme activity lead to a lack in the production of sex steroids with normal levels of glucocorticoid and mineralocorticoid hormones. A 24-years-old married woman, as a product of a consanguineous marriage, presented with infertility and a background marked by primary amenorrhea. Laboratory data showed low normal serum cortisol levels and low levels of 17-hydroxyprogesterone. Also, her adrenal androgens were low but estradiol was normal. The chromosomal investigation uncovered a male karyotype of 46, XY. These clinical and laboratory evidence confirm the determination of an isolated 17,20-lyase deficiency in a genotypic male.