RESUMO
BACKGROUND: Most thyroid and parathyroid surgeries are performed by nonfellowship trained, low-volume surgeons with associated higher complication rates. Furthermore, the average number of endocrine procedures performed by general surgery residents is decreasing. While previous studies have documented a lack of general surgery resident confidence in performing these procedures, the specific knowledge gaps in endocrine surgery remain unexplored. METHODS: We conducted semi-structured interviews with surgical residents (clinical PGY3-PGY5) at a high-volume academic center with an endocrine surgery fellowship to discuss their experience, knowledge, and deficits managing patients with surgical thyroid and parathyroid disease. Interviews were audio-recorded, de-identified, and transcribed verbatim. Content analysis was used to identify areas of confidence and knowledge deficits in all phases of care. RESULTS: Overall, 14 trainees participated in the study (50% women, mean PGY: 3.8). Preoperatively, residents were confident with thyroid nodule and primary hyperparathyroidism work-up, but less comfortable with rare conditions. Residents were uncomfortable using ultrasound to identify suspicious lymph nodes or abnormal parathyroid glands. Residents perceived knowledge deficits in the multidisciplinary care and work-up of patients with advanced thyroid cancer. Intraoperatively, most residents were confident performing thyroidectomy and focused parathyroidectomy, but less comfortable performing 4-gland explorations or neck dissections. Several had concern with independently identifying and protecting the recurrent laryngeal nerve or locating parathyroid glands in the setting of negative localization. Residents noted a lack of autonomy in both thyroidectomy and parathyroidectomy. Postoperatively, residents felt confident in the acute management of patients, but identified deficits in long-term management of patients with thyroid cancer or chronic complications. CONCLUSIONS: Despite confidence in managing "bread and butter" cervical endocrine surgery in all phases of care, residents perceive a lack of meaningful autonomy intraoperatively. Further educational endeavors may be required to ensure graduating residents are "practice ready" for straightforward cases they may encounter in practice as a general surgeon. A lack of exposure to complex endocrinopathy even at a high-volume center suggests that comprehensive endocrine surgery fellowship remains critical.
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Competência Clínica , Cirurgia Geral , Internato e Residência , Humanos , Feminino , Masculino , Cirurgia Geral/educação , Pesquisa Qualitativa , Entrevistas como Assunto , Educação de Pós-Graduação em Medicina/métodos , Tireoidectomia/educação , Adulto , Procedimentos Cirúrgicos Endócrinos/educação , Doenças da Glândula Tireoide/cirurgiaRESUMO
Thyroid cancer is the most common endocrine malignancy. With increasing imaging utilization, there has been an increase in the recognition of small, indolent cancers that would otherwise go undiagnosed. Historically, the surgical recommendation for all patients with thyroid cancer was a total thyroidectomy. However, over the last 20 years, there have been numerous studies evaluating the de-escalation of interventions for low-risk thyroid cancers, transitioning from total thyroidectomy to thyroid lobectomy or active surveillance when indicated. Here, we review the current literature and recommendations with each of these treatment options.
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Câncer Papilífero da Tireoide , Neoplasias da Glândula Tireoide , Tireoidectomia , Humanos , Tireoidectomia/métodos , Neoplasias da Glândula Tireoide/terapia , Neoplasias da Glândula Tireoide/diagnóstico , Neoplasias da Glândula Tireoide/cirurgia , Câncer Papilífero da Tireoide/terapia , Câncer Papilífero da Tireoide/cirurgia , Câncer Papilífero da Tireoide/diagnóstico , Câncer Papilífero da Tireoide/patologia , Conduta ExpectanteRESUMO
Background: Total thyroidectomy (TT) and hemithyroidectomy (HT) are acceptable surgical options for the treatment of low-risk differentiated thyroid cancer (DTC). While previous data suggest similar disease-free and disease-specific survival regardless of initial surgical treatment, the effect of the extent of surgery on health-related quality of life (HRQOL) is less clear. This systematic review aimed to examine HRQOL in low-risk DTC survivors after TT compared with HT. Methods: A search of PubMed, CINAHL, Cochrane, PsycINFO, and Scopus databases was conducted to identify studies published between January 1, 2011, and December 31, 2022, that assessed HRQOL predominantly in patients with low-risk DTC who underwent open thyroid surgery. Covidence™ software was used to apply the inclusion criteria, and a validated instrument was used to assess study quality. Results: Sixteen of the 1402 identified studies were included: 5 prospective and 11 retrospective cohort studies. The majority of included studies were of good quality (n = 14) and were from Asia and the Middle East (n = 11). Overall, six studies concluded that HT led to a better HRQOL than TT, two concluded that HT only resulted in better HRQOL compared with TT with central neck dissection (CND), and two concluded HT resulted in better short-term HRQOL that dissipated by 6 months postoperatively. The HRQOL domains found across all studies to be most consistently improved after HT included physical health, psychological/emotional, and social function. Factors found to be associated with HRQOL in more than one study included age, stage, and marital status. Conclusion: Differences in HRQOL after HT and TT tended to favor HT particularly when measured <6 months after surgery or when compared with TT with CND. Additional prospective and ideally randomized data are needed to fully determine the impact of the extent of surgery on HRQOL in patients with low-risk thyroid cancer.
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Adenocarcinoma , Neoplasias da Glândula Tireoide , Humanos , Qualidade de Vida , Tireoidectomia/métodos , Estudos Retrospectivos , Estudos Prospectivos , Neoplasias da Glândula Tireoide/cirurgia , Adenocarcinoma/cirurgiaRESUMO
INTRODUCTION: The 2015 American Thyroid Association (ATA) guidelines established that hemithyroidectomy (HT) is an appropriate treatment for patients with low-risk thyroid cancer. HT rates increased since the ATA guidelines were released; however, the relationship between surgeon volume and the initial extent of surgery has not been established. METHODS: A statewide database was used to identify patients with thyroid cancer who underwent initial thyroidectomy from 2013 to 2020. High-volume thyroid surgeons were defined as those who performed >25 thyroid procedures per year. A mixed-effect logistic model was used to compare low- and high-volume surgeons' initial extent of surgery pre-2015 and post-2015 ATA guidelines. Descriptive statistics were used to describe other surgical outcomes. RESULTS: The analysis included 3199 patients with thyroid cancer who underwent initial thyroidectomy. Twenty-four surgeons (6%) were considered high-volume; they performed 48% (n = 1349) of the operations. After the 2015 ATA guidelines were released, the rate of HT increased significantly for low- (23% to 28%, P = 0.042) but not high-volume (19% to 23%, P = 0.149) surgeons. Low-volume surgeons had significantly higher rates of readmission (P = 0.008), re-operation (P = 0.030), complications (P < 0.001), and emergency room visits (P = 0.002) throughout the entire study period. CONCLUSIONS: The publication of the 2015 ATA guidelines was associated with a significant increase in HT rates, primarily in low-volume thyroid surgeons. While low-volume surgeons began performing more HTs, they continued to have higher rates of readmission, reoperations, complications, and emergency room visits than high-volume surgeons.
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Cirurgiões , Neoplasias da Glândula Tireoide , Humanos , Estados Unidos/epidemiologia , Tireoidectomia/métodos , Neoplasias da Glândula Tireoide/cirurgia , Neoplasias da Glândula Tireoide/etiologia , Reoperação , Estudos RetrospectivosRESUMO
BACKGROUND: Shared decision-making about treatment for low-risk thyroid cancer requires patients and surgeons to work together to select treatment that best balances risks and expected outcomes with patient preferences and values. To participate, patients must be activated and ask questions. We aimed to characterize what topics patients prioritize during treatment decision-making. METHODS: We identified substantive questions by patients with low-risk (cT1-2, N0) thyroid cancer during audio-recorded consultations with 9 surgeons at 2 unique health care systems. Logistics questions were excluded. Qualitative content analysis was used to identify major themes among patients' questions and surgeon responses. RESULTS: Overall, 28 of 30 patients asked 253 substantive questions, with 2 patients not asking any substantive questions (median 8, range 0-25). Patients were 20 to 71 years old, mostly White (86.7%) and female (80.0%). The questions addressed extent of surgery, hormone supplementation, risk of cancer progression, radioactive iodine, and etiology of thyroid cancer. When patients probed for a recommendation regarding extent of surgery, surgeons often responded indirectly. When patients asked how surgery could impact quality of life, surgeons focused on oncologic benefits and surgical risk. Patients commonly asked about hormone supplementation and radioactive iodine. CONCLUSION: Patient questions focused on the decision regarding extent of surgery, quality of life, and nonsurgical aspects of thyroid cancer care. Surgeon responses do not consistently directly answer patients' questions but focus on the risks, benefits, and conduct of surgery itself. These findings suggest an opportunity to help surgeons with resources to improve shared decision-making by providing information that patients prioritize.
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Relações Médico-Paciente , Neoplasias da Glândula Tireoide , Humanos , Feminino , Adulto Jovem , Adulto , Pessoa de Meia-Idade , Idoso , Neoplasias da Glândula Tireoide/cirurgia , Radioisótopos do Iodo , Qualidade de Vida , Hormônios , Tomada de DecisõesRESUMO
BACKGROUND: Nephrolithiasis is a sequela of primary hyperparathyroidism and an indication for parathyroidectomy. The prevalence of primary hyperparathyroidism in patients with nephrolithiasis is 3% to 5%; however, recent studies suggest that many hypercalcemic patients with nephrolithiasis never undergo workup for primary hyperparathyroidism. Our goal is to evaluate primary hyperparathyroidism screening rates at a tertiary academic health institution and identify opportunities to increase referral rates in patients presenting with nephrolithiasis. METHODS: We retrospectively reviewed 15,725 patients across an academic health system who presented with nephrolithiasis between 2012 and 2020. Calcium levels measured within 6 months of presentation were identified, and those with hypercalcemia (≥10.3 mg/dL) were reviewed if parathyroid hormone levels were measured. Patients with primary hyperparathyroidism were evaluated to see if they were referred to a specialist for treatment. RESULTS: Of 15,725 patients presenting with nephrolithiasis, 12,420 (79%) had calcium levels measured; 630 patients (4.0%) were hypercalcemic, and 207 (33%) had parathyroid hormone levels measured. Patients were more likely to have parathyroid hormone levels sent if they were older, had higher calcium levels, or presented to an outpatient clinic (P = .028, P = .002, P < .001). We identified 89 patients (0.6%) with primary hyperparathyroidism, of which only 35 (39%) were referred for treatment. CONCLUSION: The proportion of patients presenting with nephrolithiasis ultimately diagnosed with primary hyperparathyroidism was significantly lower than others have reported. Additionally, a substantial number of patients with nephrolithiasis did not have calcium and/or parathyroid hormone levels measured. These missed opportunities for diagnosis are critical as early definitive management of primary hyperparathyroidism can prevent recurrent nephrolithiasis and other primary hyperparathyroidism-related end organ effects.