Surgery and Surgical Training Prior to Graduate Medical Education: A Blue Ribbon Committee II, Medical Student Education Subcommittee Report.

OBJECTIVE: To update and add to the first report commissioned by the Blue Ribbon Committee about 20 years prior. SUMMARY OF BACKGROUND DATA: Following a summit in late 2022 commissioned by the American Board of Surgery regarding competency-based reforms in surgical education and via a partnership with the American College of Surgeons (ACS) and other stakeholders, a Blue Ribbon Committee (BRC-II) on surgical education was formed. The BRC-II would have seven subcommittees. This paper details the work of the Medical Student Subcommittee within the BRC- II. METHODS: The subcommittee's work, supported by staff from the ACS, entailed a thorough literature review, which involved collating and aggregating the findings, identifying key challenges and opportunities, and committing to draft recommendations. These recommendations were then presented and refined via discussions with the Blue Ribbon Committee at large in multiple virtual and in-person settings. RESULTS: The subcommittee's work is detailed below and further summarized in table format. The section below elucidates the medical student education continuum and discusses the pertinent topics of recruitment, surgical engagement in medical student training and the surgical image, training for the current surgical practice model, trainee selection for graduate medical education (GME), and optimizing the transition from undergraduate medical education (UME) to GME. CONCLUSIONS: The last two decades have shown significant changes and shifts in medical education and surgical practice. The findings of BRC-II in this manuscript help to structure the current and future necessary improvements, focusing on different aspects of medical student education.

Making Choices: A Multi-institutional, Longitudinal Cohort Study Assessing Changes in Treatment Outcome Valuation for Low-Risk Thyroid Cancer.

OBJECTIVE: To evaluate the relative importance of treatment outcomes to patients with low-risk thyroid cancer (TC). SUMMARY BACKGROUND DATA: Overuse of total thyroidectomy (TT) for low-risk TC is common. Emotions from a cancer diagnosis may lead patients to choose TT resulting in outcomes that do not align with their preferences. METHODS: Adults with clinically low-risk TC enrolled in a prospective, multi-institutional, longitudinal cohort study from 11/2019-6/2021. Participants rated treatment outcomes at the time of their surgical decision and again 9 months later by allocating 100 points amongst 10 outcomes. T-tests and Hotelling's T 2 statistic compared outcome valuation within and between subjects based on chosen extent of surgery (TT vs. lobectomy). RESULTS: Of 177 eligible patients, 125 participated (70.6% response) and 114 completed the 9-month follow-up (91.2% retention). At the time of the treatment decision, patients choosing TT valued the risk of recurrence more than those choosing lobectomy and the need to take thyroid hormone less ( P <0.05). At repeat valuation, all patients assigned fewer points to cancer being removed and the impact of treatment on their voice, and more points to energy levels ( P <0.05). The importance of the risk of recurrence increased for those who chose lobectomy and decreased for those choosing TT ( P <0.05). CONCLUSION: The relative importance of treatment outcomes changes for patients with low-risk TC once the outcome has been experienced to favor quality of life over emotion-related outcomes. Surgeons can use this information to discuss the potential for asthenia or changes in energy levels associated with total thyroidectomy.

Imaging Concordance With Vein Sampling for Primary Aldosteronism: A Cohort Study and Literature Review.

INTRODUCTION: Adrenal venous sampling (AVS) is used to distinguish unilateral from bilateral aldosterone hypersecretion as a cause of primary aldosteronism (PA). Unilateral disease is treated with adrenalectomy and bilateral hypersecretion managed medically. METHODS: We performed a single institution retrospective cohort study of adult patients undergoing adrenalectomy for PA from July 2013 to June 2022. Concordance of imaging findings with AVS was evaluated. Statistical analysis was performed with Mann-Whitney U and chi-squared Fisher's exact. Literature review performed via triple method search strategy. RESULTS: Twenty-one patients underwent AVS and adrenalectomy for PA. Two patients did not have imaging findings and 19 were localized with an adenoma. For patients with image localization, AVS was concordant in nine, discordant in four, and nondiagnostic in six. For patients with discordant findings, age range was 35.8 to 72.4 y compared with concordant patient age range of 49.8 to 71.7 y. Overall discordance between imaging results and AVS was 40%. The aldosterone level was associated with concordance with a median of 52 ng/dL compared with 26 ng/dL if discordant (P = 0.002). There was a significant reduction in antihypertensive medications for the entire cohort from a median of three medications (interquartile range 2-4) to 1 medication (interquartile range 1-2), P < 0.001. CONCLUSIONS: In this cohort, 40% of patients with selective AVS had discordant imaging and AVS results. Aldosterone level was associated with concordance. Hypertension was significantly improved with a median decrease of two antihypertensives. Our results support performance of AVS on all candidates for adrenalectomy for PA.

Feedback Versus Compliments Versus Both in Suturing and Knot Tying Simulation: A Randomized Controlled Trial.

INTRODUCTION: Suturing is an expected skill for students graduating from health professions programs. Previous studies investigated student experience with teaching sessions utilizing constructive feedback versus compliments but did not investigate the combination of both. METHODS: In this parallel, randomized controlled trial, participants were divided into three groups: feedback (F), compliments (C), or feedback and compliments (FC). Participants received standardized instruction on simple interrupted suturing and two-handed knot-tying, and were videotaped performing this skill before and after the intervention. Performance was evaluated using a validated Objective Structured Assessment of Technical Skills (OSATS) instrument. Participants completed a preintervention and postintervention survey rating their task enjoyment and self-assessment of performance. Analysis was performed to determine differences between and within the groups using Kruskal-Wallis, Wilcoxon rank-sum, and Mann-Whitney U tests. RESULTS: A total of 31 students participated: 11 in C, 10 in F, and 10 in FC. The groups had similar preintervention OSATS scores. The F and FC groups demonstrated significant improvement in OSATS score after intervention, group C was not significantly different: F median of 11.25-19.75 points (P = 0.002); FC median of 11.75-21 points (P = 0.002); C median of 13-14 points (P = 0.2266). Between the groups FC and F both had significant performance improvement compared with C (P < 0.001 and P = 0.001 respectively). The FC group had a significantly higher rating of their enjoyment of the task on the postintervention survey compared with both the C and F groups with a median rating of 10 compared with 8 and 8 (P = 0.0052 and P = 0.0126, respectively). CONCLUSIONS: The combination of feedback and compliments was associated with improvement in performance on suturing and knot-tying similar to the feedback-only group. The FC group rated a higher level of enjoyment of the activity compared to feedback or compliments alone.

Excellent Response to Therapy Occurs for Most Patients With Thyroid Cancer Treated With Lobectomy.

INTRODUCTION: American Thyroid Association (ATA) Guidelines for Management of Thyroid Nodules and Thyroid Cancer indicate that thyroid lobectomy (TL) or total thyroidectomy (TT) are appropriate surgery for low- and intermediate-risk well-differentiated thyroid carcinoma. We sought to determine outcomes of TL or TT by ATA response to therapy (RTT) classification. METHODS: This is a single-institution retrospective cohort study of adults with unilateral suspicious or malignant thyroid nodules under 4 cm from January 2016 through December 2021. Our primary outcome was ATA RTT. RESULTS: During the study period, 118 met inclusion criteria: 37 (31%) underwent TL and 81 (69%) TT. Of the TL patients, 7 (19%) underwent completion thyroidectomy. Response to therapy (RTT) was similar with TT versus TL: excellent response 56 (69%) versus 30 (81%), indeterminate response 20 (25%) versus 5 (14%), and biochemically incomplete response 5 (6%) versus 2 (5%), P = 0.20. There were no differences between the groups for age, sex, race or ethnicity, tumor size, histologic type, or complications. Thyroidectomy (TT) was associated with multiple nodules 47% versus 22% for TL (P = 0.009), bilateral nodules 43% versus 16% (P = 0.004), central neck lymph nodes removed median 3 (interquartile range [IQR] 1-8) versus 0 (IQR 0-2) P < 0.001, lymph node metastases median 0 (IQR 0-1) versus 0 (0-0) P = 0.02. Median follow-up was 32.5 mo (IQR 17-56 mo) and was similar between the groups. CONCLUSIONS: Patients with TL for well-differentiated thyroid carcinoma without high-risk features have an RTT similar to patients undergoing TT. In this cohort, 81% of patients treated with TL have not required additional intervention.

Parathyroid Carcinoma: A National Cancer Database Analysis.

INTRODUCTION: Parathyroid carcinoma is a rare diagnosis. The association of clinical and pathologic factors as well as treatment on overall survival (OS) is not well established. METHODS: A retrospective review of patients with parathyroid carcinoma was performed using the National Cancer Database for patients diagnosed from 2004 through 2017. Clinical and demographic variables were assessed. A Cox proportional hazards model was used to assess for factors associated with survival. OS rates were determined for 5 and 10 y. RESULTS: Data for 1057 patients were analyzed. The mean age at diagnosis was 57.5 y (standard deviation [SD] 14.0), and 542 (51.3%) were male. The median tumor size was 2.7 cm (interquartile range 2.0-3.7 cm). For the extent of surgery, 38 (3.6%) had no surgery, 568 (53.7%) had incomplete resection, 359 (34.0%) had complete resection, 58 (5.5%) had radical resection, and 34 (3.2%) did not have specified and were not used in the Cox proportional hazard regression model. For the cohort, 488 (46.2%) had lymph nodes resected with a mean of 5.5 (SD 6.6) removed. Of these, 32 (8.3%) had nodal metastases with one to six positive nodes. For adjuvant therapy, 159 (15.0%) had external beam radiation with a mean dose of 5463 cGy (SD 1464). Overall, 214 patients died (21.55%), and the estimated 5- and 10-y OS were 82.9% and 57.0%, respectively. In a Cox proportional hazard regression model, age at diagnosis as a continuous variable with hazard ratio (HR) 1.04, 95% confidence interval (CI) 1.01-1.06, P = 0.003, and extent of surgery as a categorical variable with no surgery as the referent group: incomplete surgery HR 0.05, 95% CI 0.01-0.19, P < 0.001; complete surgery HR 0.04, 95% CI 0.01-0.19, P < 0.001; radical surgery HR 0.10, 95% CI 0.02-0.45, P < 0.001; and tumor size as a continuous variable was not associated with OS with an HR of 1.00, 95% CI 0.99-1.00, P = 0.738. CONCLUSIONS: Patient age and extent of surgery are modestly associated with survival for parathyroid carcinoma but not patient sex, nodal metastases, or adjuvant therapy in this cohort.

Factors Associated With Persistent Post-transplant Hyperparathyroidism After Index Renal Transplantation.

INTRODUCTION: Secondary hyperparathyroidism (SHP) is common in end-stage renal disease and may progress to persistent post-transplant hyperparathyroidism (PTHP) following renal transplantation (RT). We sought to describe the frequency and determine factors associated with the incidence of PTHP for patients undergoing RT at a single institution that restricts RT for patients with uncontrolled SHP with a parathyroid hormone (PTH) of >800pg/mL at time of initial transplant evaluation. METHODS: We conducted a single-institution retrospective study of adults undergoing index RT from 2012 to 2020 who had a calcium and PTH level within 12 mo prior to RT and at least 6 mo following RT. PTHP was defined as calcium of >10 mg/dL with an elevated PTH > 88pg/mL at six or more months following RT. Univariate analysis and multivariable logistic regression were performed for factors associated with developing PTHP. RESULTS: We identified 1110 patients with RT, 65 were excluded for prior RT, 549 did not have a pre-RT and post-RT calcium, and PTH laboratories for inclusion, yielding 496 for analysis. Following RT, 39 patients (7.9%) developed PTHP, compared to those who did not develop PTHP; these patients had significantly higher pre-RT PTH, pre-RT calcium, and frequency of calcimimetic therapy. In multivariable logistic regression factors significantly associated with PTHP were pre-RT calcium of more than 10 mg/dL with an odds ratio (OR) of 3.57 (95% confidence interval [CI] 1.52-8.39, P = 0.003) and pre-RT calcimimetic therapy with an OR 1.30 (95% CI 1.06-2.85, P = 0.041). Compared with patients who had a pre-RT PTH of less than 200 pg/mL, a PTH of 200-399 pg/mL increased risk of PTHP with an OR of 4.52 (95% CI 1.95-21.5, P = 0.048) and a PTH of > 400 pg/mL increased risk of PTHP with an OR of 7.17 (95% CI 1.47-34.9, P = 0.015). In this cohort, 11 patients (28.2%) with PTHP underwent parathyroidectomy (PTx) at a mean of 1.4 y post-RT (standard deviation 0.87). CONCLUSIONS: For patients required to have a PTH < 800pg/mL for initial transplant candidacy, the subsequent incidence of PTHP is relatively low at 7.9%. Risk factors for PTHP include higher pre-RT calcium and PTH levels and pre-RT calcimimetic therapy. PTx remains underused in the treatment of PTHP. Further study is warranted to determine the optimal PTH cutoff for transplant candidacy and recommendation for PTx in patients requiring calcimimetic therapy for SHP.

Cross-Suturing is Effective for Teaching Suturing Skills: A Randomized, Controlled Trial.

INTRODUCTION: Basic suturing is a skill expected from graduating medical students. A proposed concept to increase suturing competency is to integrate art by mixing cross-stitching with suturing. We hypothesize that students trained with "cross-suturing" would improve suturing performance. METHODS: We performed a randomized controlled trial of preclinical medical students using an art-based cross-stitching method intervention compared with conventional suturing. Both groups were provided with an introductory suturing video. Assessment of simple interrupted suturing were conducted preintervention and postintervention, and at 2-wk follow-up with a video review by blinded expert raters using the American College of Surgeons basic suturing and knot tying performance rating tool. Students completed a self-assessment of proficiency, confidence, and anxiety. Statistical analysis was performed using unpaired t-tests. RESULTS: A total of 16 preclinical medical students participated. Self-assessment and objective suturing performance were comparable in the preintervention measurements. The intervention group showed significant improvement compared to the control group with median (interquartile range) self-assessment scores 9 (8.5-9) compared with 6.5 (6-7.5) (P < 0.01) and objective performance scores of 25.25 (22.75-27) compared with 16.5 (14.5-18.5) (P < 0.01). The intervention group showed retained skills at the 2-wk follow up with no differences in self-assessment or objective suturing scores immediately postintervention compared with two-wk follow-up with self-assessment scores of 9 (8.5-9) versus 9 (8-9) at 2 wk (P = 0.16) and objective performance score of 25.25 (22.75-27) versus 24.75 (23.5-26.5) at 2 wk (P = 0.29). CONCLUSIONS: The cross-suturing intervention improved suturing skills in this cohort. This low-cost approach to medical student surgical education should be explored on a larger scale.

Evaluation for Primary Hyperparathyroidism in Patients Who Present With Nephrolithiasis.

BACKGROUND: The incidence of primary hyperparathyroidism (PHP) is likely underestimated. Nephrolithiasis may indicate PHP with indication for parathyroidectomy. We sought to determine the proportion of patients with an index diagnosis of nephrolithiasis that have serum calcium levels measured, parathyroid hormone (PTH) levels measured if hypercalcemic, and time to referral for definitive management if PHP is diagnosed. METHODS: A single-institution retrospective review was performed of adult patients presenting with nephrolithiasis between July 1, 2016 and December 31, 2018. Exclusion criteria included currently admitted patients, prior nephrolithiasis, congenital or acquired urinary tract anomalies, and patients on calciuretics. Records were assessed for serum calcium and PTH measurement, as well as referrals. Univariate statistical analysis was performed. RESULTS: Of 1782 patients with nephrolithiasis screened, 968 met inclusion criteria. Patients were 49.8% female, 88.9% white. Mean age was 53 y. Within this cohort, 620 (64.0%) patients had a calcium measured, with a mean elapsed time from presentation of 27 d (interquartile range [IQR] 0-8). Twelve patients (1.58%) with calcium measured were hypercalcemic and eight (66.7%) had PTH measured with a mean elapsed time from presentation of 183 d (IQR 72-310), all had elevated or non-suppressed PTH. Five (62.5%) were referred to surgeons with mean elapsed referral time of 270 d (IQR 95-492). CONCLUSIONS: Many with index nephrolithiasis are not assessed for hypercalcemia or hyperparathyroidism. Patients with serum calcium and PTH values indicating PHP diagnosis may have significant delay to parathyroidectomy. Targeted interventions with electronic health record alerts or automated reflex testing may improve care in this domain.

Accuracy of 4-Dimensional Computed Tomography for Localization in Primary Hyperparathyroidism.

BACKGROUND: The etiology of primary hyperparathyroidism (PHP) is single-gland adenoma in most patients. Imaging localization of single-gland disease allows for a focused operation. We sought to determine the accuracy of imaging for localizing a solitary parathyroid adenoma. METHODS: A single-institution retrospective review was performed of adult patients with PHP undergoing parathyroidectomy from January 2017 through December 2018. Surgeon-performed ultrasound (US), four-dimensional computed tomography (4DCT), and sestamibi were assessed for localization of a parathyroid adenoma yielding a single-gland parathyroidectomy. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated for each imaging modality. RESULTS: One hundred fifty-four patients underwent parathyroidectomy for PHP during the study period, with 100 patients meeting inclusion criteria with a mean age of 61.1 (SD 10) y and 80% women. Mean calcium was 11.1 mg/dL (SD 0.7) and mean PTH was 116 pg/mL (SD 66). All 100 patients had surgeon-performed US with 17 localized, 51 patients had 4DCT with 41 (80%) localized, and 69 patients had sestamibi with 53 (77%) localized. Eighty-two patients underwent successful unilateral parathyroidectomy, 18 required bilateral neck exploration. US was the most specific imaging modality at 94%. Accuracy of imaging localization was 32% for US, 70% for sestamibi, and 86% for 4DCT. CONCLUSIONS: Surgeon-performed US is a highly specific imaging modality for preoperative localization of solitary parathyroid adenoma in patients with PHP. 4DCT is the most accurate imaging localization study and should be considered for patients with a nonlocalized US.

Patient Reported Outcome Measures of Health-Related Quality of Life and Asthenia after Thyroidectomy.

BACKGROUND: After thyroidectomy some patients experience a chronic fatigue syndrome called asthenia. The purpose of this study was to determine the post-operative health related quality of life (HRQOL) and risk of asthenia in patients undergoing thyroidectomy. METHODS: A single institution prospective observational cohort study of adults undergoing thyroidectomy from September 2016 to July 2019 with four HRQOL surveys: preoperative baseline, 2 wk-, 6 mo- and 12 mo-postoperatively. Patients were surveyed using the Short Form 36 version 2 and Brief Fatigue Inventory. Asthenia was defined as Brief Fatigue Inventory > 60 at 12 mo. HRQOL was compared between patients undergoing thyroid lobectomy (TL) or total thyroidectomy (TT) with benign (-B) or malignant (-Ca) final pathology. RESULTS: A total of 182 patients were included: 67 (37%) with TL-B, 32 (17%) with TL-Ca, 40 (22%) with TT-B, and 43 (24%) with TT-Ca. The incidence of asthenia was 42% for TT and 4% for TL. In the TL-B group, 2 patients (3%) developed asthenia, compared with 2 patients (6.25%) in the TL-Ca group, 14 patients (35%) in the TT-B group, and 21 (48.8%) in the TT-Ca group (P = 0.0001). The odds ratio of asthenia for TT compared to TL was 10.4 (95% CI 3.86-28.16) and for patients with malignancy compared to benign disease was 2.05 (95% CI 1.17-3.61). CONCLUSIONS: Patients undergoing TT have a higher risk of developing asthenia than those undergoing TL, particularly if the final pathology shows malignancy.

Is Less More? A Microsimulation Model Comparing Cost-effectiveness of the Revised American Thyroid Association's 2015 to 2009 Guidelines for the Management of Patients With Thyroid Nodules and Differentiated Thyroid Cancer.

OBJECTIVE: To assess relative clinical and economic performance of the revised American Thyroid Association (ATA) thyroid cancer guidelines compared to current standard of care. BACKGROUND: Diagnosis of thyroid cancer in the United States has tripled whereas mortality has only marginally increased. Most patients present with small papillary carcinomas and have historically received at least a total thyroidectomy as a treatment. In 2015, the ATA released the revised guidelines recommending an option for active surveillance (AS) of small papillary thyroid carcinoma and thyroid lobectomy for larger unifocal tumors. METHODS: We created a Markov microsimulation model to evaluate the performance of the ATA's 2015 guidelines compared to the ATA's 2009 guidelines. We modeled a cohort of simulated patients with demographic and thyroid nodule characteristics representative of those presenting clinically in the United States. Outcome measures include life expectancy, quality-adjusted life years, costs, and frequency of surgical adverse events. RESULTS: In our base case analysis, the ATA 2015 strategy dominates the ATA 2009 strategy. The ATA 2015 strategy delivers greater discounted average quality-adjusted life years (13.09 vs 12.43) at a lower discounted average cost ($14,752 vs $20,126). Deaths due to thyroid cancer under the 2015 strategy are higher than the 2009 strategy but this is offset by a reduction in surgical deaths, leading to greater average life expectancy under the ATA 2015 strategy. The optimal strategy is sensitive to patients who experience a greater decrement in quality of life while undergoing AS. CONCLUSIONS: The ATA 2015 Guidelines represent a cost-effective strategy regarding AS and extent of surgery.

Impact of Surgeon Gender on Online Physician Reviews.

BACKGROUND: The increasing use of review websites by consumers has become a crucial first step in choosing a physician with more than half of Americans consulting review sites before physician selection. We sought to identify whether differences exist in the quality and content of online reviews for men versus women surgeons. METHODS: Using a deliberate sampling algorithm of the two most populated physician review websites, RateMDs.com and Yelp.com, we purposefully sampled reviews for the top 20 surgeons per tercile from the four most populated urban areas in the United States: New York, Houston, Los Angeles, and Chicago. A grounded theory qualitative assessment was performed of major and minor thematic elements including global rating, communication, technical skills, and comments on ancillary elements. RESULTS: Four-hundred and thirty-one online patient reviews of 238 surgeons were identified from RateMDs.com (51%) and Yelp.com (49%) with available information on gender for analysis. Seventy-six percent of reviews were of male surgeons. Reviewers were more likely to mention a global rating and technical skill for men compared with women surgeons. Most reviews were positive with no difference in global rating by gender (83.7% positive for men and 74.3% positive for women, P = 0.08). Women surgeons were more likely to have positive comments on social interactions as compared with men (94.7% versus 88.0%, P = 0.03); whereas men surgeons were more likely to have a positive rating on technical skill compared with women (88.2% versus 76.2%, P = 0.04). CONCLUSIONS: The content and quality of online surgeon reviews differ by gender. There is no difference in global rating between men and women. Women are rated higher for social interaction domains and men are rated higher on technical skill domains.

Cardiovascular Outcomes of Thyroidectomy or Radioactive Iodine Ablation for Graves' Disease.

BACKGROUND: Treatment options for Graves' disease (GD) include medical management with antithyroid medications, radioactive iodine (RAI) ablation, or total thyroidectomy (TT). Definitive treatment with RAI ablation may be associated with worse cardiovascular morbidity and mortality than TT. We sought to determine the rate of cardiovascular morbidity before and after definitive treatment for GD. METHODS: This study is a retrospective single-institution study of sequential adult patients with GD from 2012 to 2018 treated with RAI ablation or TT. Patients with prior thyroid surgery or RAI ablation with subsequent thyroidectomy were excluded. Demographic and clinical variables were collected from diagnosis of GD to last follow-up. Data analysis was performed with descriptive statistics, univariate analysis with Fisher's exact test for categorical variables and the Mann-Whitney U test for continuous variables. RESULTS: One-hundred and eighty-four patients underwent definitive treatment for GD during the study period, of which 164 met inclusion criteria. One hundred and ten patients (67%) in the study group had TT and 54 (33%) had RAI ablation with a mean dose of 18.4 mCi (standard deviation 6.1). There were no differences in clinical or demographic factors in patients undergoing RAI ablation versus TT for definitive treatment including age, sex, thyroid-stimulating hormone level, free thyroxine level, or thyroid-stimulating immunoglobulin level at time of diagnosis, nor was there any difference in pretreatment cardiovascular comorbidity. Patients with TT had higher rates of resolution of arrhythmia after treatment than those undergoing RAI ablation, P = 0.02. There were no differences in treatment-related complications between the groups. CONCLUSIONS: For patients undergoing definitive treatment for GD, TT is associated with improved rate of resolution of cardiac arrhythmia compared with RAI ablation.

BRAFV600E Mutation is Associated with an Increased Risk of Papillary Thyroid Cancer Recurrence.

BACKGROUND: Papillary thyroid carcinoma is the most common endocrine malignancy and one of the most common cancers worldwide. However, the optimal timing and frequency of surveillance to assess for recurrence remain undetermined. As the incidence of thyroid cancer continues to rise worldwide, identifying risk factors for recurrence and investigating intervals and durations of surveillance are paramount to adapt treatment and follow-up plans to high-risk individuals and to reduce interventions for low-risk patients. METHODS: Our dataset included an unselected cohort of papillary thyroid carcinoma (PTC) patients who underwent a total thyroidectomy (or unilateral then completion thyroidectomy) at a single institution from 2000 to 2007. BRAF genotyping was performed on available specimens by a validated PCR-based assay. Pathologic structural recurrence was the primary outcome. We performed univariate and multivariable analyses to identify predictors of cancer recurrence. RESULTS: In total, 599 patients underwent complete resection of the thyroid gland for PTC. The cohort was young (mean age 45.0 years), predominately female (n = 462, 76.9%), and median follow-up was 10.3 years (IQR 5.4-12.2). Recurrence occurred more commonly in the BRAFV600E group (18.6 vs. 9.9%, p = 0.02). BRAF independently predicted PTC recurrence (HR 2.81, p = 0.006). CONCLUSIONS: BRAF mutation is an independent predictor of papillary thyroid carcinoma long-term recurrence. Understanding molecular characteristics of individual thyroid cancers may help risk-stratify patients and direct them toward more appropriate initial care and long-term surveillance strategies.

Hemithyroidectomy for Thyroid Cancer: A Review.

Thyroid cancer incidence is on the rise; however, fortunately, the death rate is stable. Most persons with well-differentiated thyroid cancer have a low risk of recurrence at the time of diagnosis and can expect a normal life expectancy. Over the last two decades, guidelines have recommended less aggressive therapy for low-risk cancer and a more personalized approach to treatment of thyroid cancer overall. The American Thyroid Association (ATA) and National Comprehensive Cancer Network (NCCN) thyroid cancer guidelines recommend hemithyroidectomy as an acceptable surgical treatment option for low-risk thyroid cancer. Given this change in treatment paradigms, an increasing number of people are undergoing hemithyroidectomy rather than total or near-total thyroidectomy as their primary surgical treatment of thyroid cancer. The postoperative follow-up of hemithyroidectomy patients differs from those who have undergone total or near-total thyroidectomy, and the long-term monitoring with imaging and biomarkers can also be different. This article reviews indications for hemithyroidectomy, as well as postoperative considerations and management recommendations for those who have undergone hemithyroidectomy.

The Innovator of Electrosurgery.

Hemostasis has been a major risk in the surgical field, causing Halsted to preach for the need for better control of bleeding to improve the morbidity and mortality many surgeons faced at the time. This problem, while combated by suturing methods for many, remained an issue in the neurosurgical field. Dr. Cushing sought out the help of William Bovie, leading to the creation of electrosurgery. This invention changed the way surgery could be performed and remains to be a mainstay in the operating room and countless other procedures, withstanding the test of time and proving its importance in the surgical world.

Cost Effectiveness of Routine Laryngoscopy in the Surgical Treatment of Differentiated Thyroid Cancer.

BACKGROUND: Some surgeons perform flexible fiberoptic laryngoscopy (FFL) in all patients prior to thyroid cancer operations. Given the low likelihood of recurrent laryngeal nerve (RLN) or aerodigestive invasion in clinically low-risk thyroid cancers, the value of routine FFL in this group is controversial. We hypothesized that routine preoperative FFL would not be cost effective in low-risk differentiated thyroid cancer (DTC). METHODS: A decision model was constructed comparing preoperative FFL versus surgery without FFL in a clinical stage T2 N0 DTC patient without voice symptoms. Total thyroidectomy and definitive hemithyroidectomy were both modeled as possible initial surgical approaches. Outcome probabilities and their corresponding utilities were estimated via literature review, and costs were estimated using Medicare reimbursement data. Sensitivity analysis was conducted to examine the uncertainty of cost, probability, and utility estimates in the model. RESULTS: When the initial surgical strategy was total thyroidectomy, routine preoperative FFL produced an incremental cost of $183 and an incremental effectiveness of 0.000126 quality-adjusted life-years (QALYs). The incremental cost-effectiveness ratio (ICER) for routine FFL prior to total thyroidectomy was $1.45 million/QALY, exceeding the $100,000/QALY threshold for cost effectiveness. Routine FFL became cost effective if the preoperative probability of asymptomatic vocal cord paralysis increased from 1.0% to 4.9%, or if the cost of preoperative FFL decreased from $128 to $27. Changing the extent of initial surgery to hemithyroidectomy produced a higher ICER for routine FFL of $1.7 million/QALY. CONCLUSION: Routine preoperative FFL is not cost effective in asymptomatic patients with sonographically low-risk DTC, regardless of the initial planned extent of surgery.

Thoracoscopic lobectomy for type I pleuropulmonary blastoma in an infant.

Pleuropulmonary blastoma (PPB) is a rare, aggressive, intrathoracic mesenchymal neoplasm associated with cystic lung lesions. The authors describe an 8-month-old male who underwent thoracoscopic left upper lobectomy for a cystic lung lesion initially diagnosed as congenital pulmonary airway malformation. Pathology revealed type I PPB.