Best Practices and a Business Case for Surgical Site Infection Prevention.

Surgical site infections (SSIs) can be costly and result in prolonged hospital stays; readmissions; and additional diagnostic tests, therapeutic antibiotic treatments, and surgical procedures. Evidence-based practices for preventing SSIs include environmental cleaning; instrument cleaning, decontamination, and sterilization; preoperative bathing; preoperative Staphylococcus aureus decolonization; intraoperative antimicrobial prophylaxis; hand hygiene; and surgical hand antisepsis. Strong partnerships among infection prevention personnel, perioperative nurses, surgeons, and anesthesia professionals may enhance perioperative infection prevention. Facility and physician-specific SSI rates should be reported to physicians and frontline personnel in a timely, accessible manner. Together with costs associated with SSIs, these data help determine the success of an infection prevention program. Leaders can develop a comprehensive business case proposal for perioperative infection prevention programs. The proposal should describe the need for the program and anticipated return on investment; it also should focus on the goal of decreasing SSIs by establishing metrics for assessing outcomes and addressing barriers.

Using telemedicine on an acute care surgery service: improving clinic efficiency and access to care.

BACKGROUND: Telemedicine has been shown to improve patient access to medical care while potentially improving overall healthcare efficiency. It has not been consistently explored on an acute care surgery service as a method of increasing clinic availability and efficiency within a safety-net hospital system. Socioeconomic hardships associated with an in-person clinic visit can deter patients with limited resources. A virtual clinic for post-operative laparoscopic cholecystectomy patients was developed. We hypothesized that a virtual follow-up increases clinic efficiency and availability for new patients without compromising patient safety. METHODS: A retrospective review of patient and clinic outcomes before and after implementing virtual post-op visits for uncomplicated laparoscopic cholecystectomy patients on an acute care surgery service was performed. Providers called post-operative patients using a standardized questionnaire. Data included outpatient clinic composition (new vs. post-operative patients), elective operations scheduled, emergency department visits, and loss to follow-up rates. RESULTS: February to March 2017 was the baseline pre-intervention period, while February to March 2019 was post-intervention. Pre-intervention clinics consisted of 17% new and 50% post-op visits, in comparison to 31% new and 27% post-op visits in the post-intervention group (p < 0.01). Elective operations scheduled increased slightly from 8.4 to 11.5 per 100 patient visits, but was not statistically significant (p = 0.09). There was no change in the number of post-operative patients returning to the emergency department (p = 0.91) or loss to follow-up (p = 0.30) rates. CONCLUSIONS: Through the implementation of virtual post-operative visits for laparoscopic cholecystectomy patients, clinic efficiency improved by increasing new patient encounters, decreasing post-operative volume, and trending towards increased operations scheduled. This change did not compromise patient safety. Further implementation of telemedicine on an acute care surgery service is a promising method to expand services offered to an at-risk population and increase efficiency in a resource-limited environment.

Phosphoprotein-based biomarkers as predictors for cancer therapy.

Disparities in cancer patient responses have prompted widespread searches to identify differences in sensitive vs. nonsensitive populations and form the basis of personalized medicine. This customized approach is dependent upon the development of pathway-specific therapeutics in conjunction with biomarkers that predict patient responses. Here, we show that Cdk5 drives growth in subgroups of patients with multiple types of neuroendocrine neoplasms. Phosphoproteomics and high throughput screening identified phosphorylation sites downstream of Cdk5. These phosphorylation events serve as biomarkers and effectively pinpoint Cdk5-driven tumors. Toward achieving targeted therapy, we demonstrate that mouse models of neuroendocrine cancer are responsive to selective Cdk5 inhibitors and biomimetic nanoparticles are effective vehicles for enhanced tumor targeting and reduction of drug toxicity. Finally, we show that biomarkers of Cdk5-dependent tumors effectively predict response to anti-Cdk5 therapy in patient-derived xenografts. Thus, a phosphoprotein-based diagnostic assay combined with Cdk5-targeted therapy is a rational treatment approach for neuroendocrine malignancies.

Evaluation of an Adrenal Incidentaloma.

Given the frequent use of cross-sectional imaging in medicine, adrenal masses are discovered at an increasing rate. Once detected, it is critical to ensure the patient undergoes the appropriate biochemical/hormonal workup to rule out any aberrant activity and ensure imaging features do not raise suspicion for a malignant neoplasm. Patients with hormonal overactivity, concerning size, and/or imaging characteristics must be referred for surgical consideration. For those not requiring adrenalectomy, it is important to determine which patients mandate follow-up to ensure no further growth or development of hormonal production. It is also critical to understand what is the appropriate follow-up.

Rapid Relief: Thyroidectomy is a Quicker Cure than Radioactive Iodine Ablation (RAI) in Patients with Hyperthyroidism.

BACKGROUND: Time to hormonal control after definitive management of hyperthyroidism is unknown but may influence patient and physician decision making when choosing between treatment options. The hypothesis is that the euthyroid state is achieved faster after thyroidectomy than RAI ablation. METHODS: A retrospective review of all patients undergoing definitive therapy for hyperthyroidism was performed. Outcomes after thyroidectomy were compared to RAI. RESULTS: Over 3 years, 217 patients underwent definitive therapy for hyperthyroidism at a county hospital: 121 patients received RAI, and 96 patients underwent thyroidectomy. Age was equivalent (p = 0.72). More males underwent RAI (25% vs 15%, p = 0.05). Endocrinologists referred for both treatments equally (p = 0.82). Both treatments were offered after a minimum 1-year trial of medical management (p = 0.15). RAI patients mostly had Graves (93%), versus 73% of thyroidectomy patients (p < 0.001). Thyroidectomy patients more frequently had eye symptoms (35% vs 13%, p < 0.001), compressive symptoms (74% vs 15%, p < 0.001), or were pregnant/nursing (14% vs 0, p < 0.001). While the thyroidectomy patients had a documented discussion of all treatment modalities, 79% of RAI patients did not have a documented discussion regarding the option of surgical management (p < 0.001). Both treatment groups achieved an euthyroid state (71% vs 65%, p = 0.39). Thyroidectomy patients became euthyroid faster [3 months (2-7 months) versus 9 months (4-14 months); p < 0.001]. CONCLUSIONS: Thyroidectomy for hyperthyroidism renders a patient to an euthyroid state faster than RAI. This finding may be important for patients and clinicians considering definitive options for hyperthyroidism.

Access to Paid Parental Leave for Academic Surgeons.

BACKGROUND: Parental leave is linked to health benefits for both child and parent. It is unclear whether surgeons at academic centers have access to paid parental leave. The aim of this study was to determine parental leave policies at the top academic medical centers in the United States to identify trends among institutions. METHODS: The top academic medical centers were identified (US News & World Report 2016). Institutional websites were reviewed, or human resource departments were contacted to determine parental leave policies. "Paid leave" was defined as leave without the mandated use of personal time off. Institutions were categorized based on geographical region, funding, and ranking to determine trends regarding availability and duration of paid parental leave. RESULTS: Among the top 91 ranked medical schools, 48 (53%) offer paid parental leave. Availability of a paid leave policy differed based on private versus public institutions (70% versus 38%, P < 0.01) and on medical center ranking (top third = 77%; middle third = 53%; and bottom third = 29%; P < 0.01) but not based on region (P = 0.06). Private institutions were more likely to offer longer paid leaves (>6 wk) than public institutions (67% versus 33%; P = 0.02). No difference in paid leave duration was noted based on region (P = 0.60) or rank (P = 0.81). CONCLUSIONS: Approximately, 50% of top academic medical centers offer paid parental leave. Private institutions are more likely to offer paid leave and leave of longer duration. There is considerable variability in access to paid parenteral leave for academic surgeons.

Preclinical characterization of tyrosine kinase inhibitor-based targeted therapies for neuroendocrine thyroid cancer.

Medullary thyroid carcinoma (MTC) is a slow growing neuroendocrine (NE) tumor for which few treatment options are available. Its incidence is rising and mortality rates have remained unchanged for decades. Increasing the repertoire of available treatments is thus crucial to manage MTC progression. Scarcity of patient samples and of relevant animal models are two challenges that have limited the development of effective non-surgical treatments. Here we use a clinically accurate mouse model of MTC to assess the effects and mode of action of the tyrosine kinase inhibitor (TKI) Vandetanib, one of only two drugs currently available to treat MTC. Effects on tumor progression, histopathology, and tumorigenic signaling were evaluated. Vandetanib blocked MTC growth through an anti-angiogenic mechanism. Furthermore, Vandetanib had an apparent anti-angiogenic effect in a patient MTC sample. Vandetanib displayed minimal anti-proliferative effects in vivo and in human and mouse MTC tumor-derived cells. Based on these results, we evaluated the second-generation TKI, Nintedanib, alone and in combination with the histone deacetylase (HDAC) inhibitor, Romidepsin, as potential alternative treatments to Vandetanib. Nintedanib showed an anti-angiogenic effect while Romidepsin decreased proliferation. Mechanistically, TKIs attenuated RET-, VEGFR2- and PI3K/AKT/FOXO signaling cascades. Nintedanib alone or in combination with Romidepsin, but not Vandetanib, inhibited mTOR signaling suggesting Nintedanib may have broader anti-cancer applicability. These findings validate the MTC mouse model as a clinically relevant platform for preclinical drug testing and reveal the modes of action and limitations of TKI therapies.

Early endocrine attending surgeon presence increases operating room efficiency.

BACKGROUND: Preincision operating room (OR) preparation varies greatly. Cases requiring exacting preoperative setup may be more sensitive to inconsistent team members and trainees. Leadership and oversight by the surgeon may facilitate a timely start. The study hypothesized that early attending presence in the OR expedites surgery start time, improving efficiency, and decreasing cost. METHODS: Prospective data collection of endocrine surgery cases at an urban teaching hospital was performed. Time points recorded in minutes. Cost/min of OR time was $54. Patients classified as in the OR ≤10 min before attending arrival or >10 min before attending arrival. RESULTS: A total of 227 cases (166 thyroid, 54 parathyroid, 10 adrenal) were performed over 14 mo. Of the patients, 128 were in the OR ≤10 min before attending arrival, and 99 patients were >10 min (3 ± 3 min versus 35 ± 14 min, P < 0.01). The ≤10 min procedures started sooner after patient arrival in OR (40 ± 11 versus 63 ± 19, P < 0.01) which equated to $1202 of savings before incision. Although attending time in the OR before incision was equivalent between groups for adrenal and parathyroid, time to incision was shorter in the ≤10 min groups, saving $2416 ± 477 and $1458 ± 244, respectively (P < 0.01). Attending time in OR before thyroidectomy was 13 min longer in ≤10 min than >10 min (P < 0.01), but incisions were made 20 min sooner (P < 0.01) equating to $1076 ± 120 in savings. CONCLUSIONS: Early attending presence in the OR shortens time to incision. For parathyroid and adrenal cases, this does not require additional surgeon time. In ORs without consistent teams, early attending presence in the OR improves efficiency and yields significant cost savings.

Antiplatelet and Anticoagulant Medications Significantly Increase the Risk of Postoperative Hematoma: Review of over 4500 Thyroid and Parathyroid Procedures.

PURPOSE: Antiplatelet and/or anticoagulant medication use is common. Abstinence a week before surgery may still result in altered hemostasis. The study aim was to report on perioperative antiplatelet and anticoagulant use in thyroidectomy and parathyroidectomy patients, and to determine the association with postoperative hematoma (POH) rates. METHODS: Retrospective review of a prospective endocrine surgery database was performed. Procedure extent was defined as unilateral, bilateral, or extensive. Antiplatelets were categorized as none, 325 mg aspirin (ASA), <325 mg ASA, clopidogrel, or other. Anticoagulants were categorized as none, oral, or injectable. RESULTS: A total of 4514 patients were identified. POH developed in 22 patients (0.5 %). Rates were similar between age, gender, and reoperative status. POH were seven times more common after thyroidectomy (0.8 vs. 0.1 %, p < 0.01). Unilateral procedures had lower POH rates than bilateral or extensive (0.1 vs. 0.9 vs. 0.8 %, p < 0.01). POH rates in patients receiving 325 mg ASA (0.8 %) or clopidogrel (2.2 %) were much higher than patients not receiving antiplatelets (0.5 %) or receiving <325 mg ASA (0.1 %, p = 0.04). Oral anticoagulants (2.2 %) and injectable anticoagulants (10.7 %) had much higher POH rates than patients not receiving anticoagulants (0.4 %, p < 0.01). Target organ, patient gender, procedure extent, antiplatelet use, and anticoagulant use were included on logistic regression to determine association with POH. Bilateral procedures, thyroidectomy, clopidogrel, oral, and injectable anticoagulants were all independently associated with POH. CONCLUSIONS: POH occur more frequently after thyroidectomy and during bilateral procedures. Patients requiring clopidogrel or any anticoagulant coverage are at much higher risk for POH. These higher-risk patients should be considered for observation to ensure prompt POH recognition and intervention.

Contralateral adrenal abnormalities in Conn's syndrome.

BACKGROUND: During the course of evaluation for primary hyperaldosteronism, cross-sectional imaging is obtained in efforts to identify patients with an aldosterone producing adenoma (APA). A subset of these patients will have a synchronous, contralateral adrenal abnormality. Adrenal vein sampling (AVS) further guides clinical decision making by identifying unilateral (APA) versus bilateral hypersecretion. In the subset of patients with contralateral adrenal abnormalities, it is unclear how this affects the durability of an adrenalectomy for APA. This study characterizes this group of patients to assess the efficacy of surgical intervention. METHODS: A retrospective review of patients undergoing adrenalectomy for APA based on AVS at a university practice. Preoperative and postoperative patient characteristics, laboratory evaluations, imaging results, and final pathology were noted. RESULTS: From 2000 to 2011, 103 patients with APA underwent unilateral adrenalectomy. Eighteen patients (17%) had discordant results between AVS and imaging. Most of these patients were male (78%), and the mean age was 57 ± 13 y. Median duration of follow-up was 3.5 y [1 y, 6 y]. All patients with initial hypokalemia were rendered normokalemic after the operation. Four patients increased their antihypertensive regimen during the follow-up period. These patients all had nodular hyperplasia on final pathology. CONCLUSIONS: In patients with bilateral adrenal abnormalities who have undergone unilateral adrenalectomy for primary hyperaldosteronism, patients with clear APAs on final pathology appear to have durable outcomes after resection. Conversely, nodular hyperplasia on final pathology may be a risk factor for ongoing aldosterone hypersecretion. An algorithm for biochemical surveillance in this subset of patients should be considered.

Kidney Disease Improving Global Outcomes guidelines and parathyroidectomy for renal hyperparathyroidism.

BACKGROUND: Patients with end-stage renal disease develop hypocalcemia, resulting in secondary hyperparathyroidism (SHPT). No clear criterions exist to aid in surgical decision making for SHPT. The 2009 Kidney Disease Improving Global Outcomes (KDIGO) guidelines provide target ranges for serum calcium, phosphate, and parathyroid hormone (PTH) levels in patients with end-stage renal disease. Parathyroidectomy can help achieve these targets. The study purpose was to examine how parathyroidectomy for SHPT impacts KDIGO targets during immediate and long-term follow-up and to evaluate KDIGO categorization with receipt of additional surgical intervention. METHODS: A retrospective review of a prospective parathyroidectomy database was performed. Included patients had SHPT, were on dialysis, and underwent parathyroidectomy. Calcium, phosphate, and PTH values were classified as below, within, or above KDIGO targets. RESULTS: Between 2000 and 2013, 36 patients with SHPT met criteria. Subtotal parathyroidectomy was performed in 89%, total parathyroidectomy in 11%. Follow-up time was 54 ± 7 mo. Eight patients (22%) required additional surgery. Twenty-eight patients (76%) were alive at the last follow-up. At the last-follow up, patients had phosphate (46%), and PTH (17%) above KDIGO ranges. Factors associated with reoperation were assessed. Patient PTH within or above target immediately postoperative had a higher rate of reoperation (P < 0.01). At the last follow-up, higher phosphate (P = 0.054) and PTH (P < 0.001) were associated with higher reoperation rates, but calcium (P = 0.33) was not. CONCLUSIONS: PTH and phosphate levels above KDIGO indices were associated with additional surgical intervention. Many patients had laboratory indices above range at the last follow up, suggesting more patients had persistent or recurrent disease than those who underwent reoperation. Patients may benefit from more aggressive medical and/or surgical management.

PDZK1 prevents neointima formation via suppression of breakpoint cluster region kinase in vascular smooth muscle.

Scavenger receptor class B, type I (SR-BI) and its adaptor protein PDZK1 mediate responses to HDL cholesterol in endothelium. Whether the receptor-adaptor protein tandem serves functions in other vascular cell types is unknown. The current work determined the roles of SR-BI and PDZK1 in vascular smooth muscle (VSM). To evaluate possible VSM functions of SR-BI and PDZK1 in vivo, neointima formation was assessed 21 days post-ligation in the carotid arteries of wild-type, SR-BI-/- or PDZK1-/- mice. Whereas neointima development was negligible in wild-type and SR-BI-/-, there was marked neointima formation in PDZK1-/- mice. PDZK1 expression was demonstrated in primary mouse VSM cells, and compared to wild-type cells, PDZK1-/- VSM displayed exaggerated proliferation and migration in response to platelet derived growth factor (PDGF). Tandem affinity purification-mass spectrometry revealed that PDZK1 interacts with breakpoint cluster region kinase (Bcr), which contains a C-terminal PDZ binding sequence and is known to enhance responses to PDGF in VSM. PDZK1 interaction with Bcr in VSM was demonstrated by pull-down and by coimmunoprecipitation, and the augmented proliferative response to PDGF in PDZK1-/- VSM was abrogated by Bcr depletion. Furthermore, compared with wild-type Bcr overexpression, the introduction of a Bcr mutant incapable of PDZK1 binding into VSM cells yielded an exaggerated proliferative response to PDGF. Thus, PDZK1 has novel SR-BI-independent function in VSM that affords protection from neointima formation, and this involves PDZK1 suppression of VSM cell proliferation via an inhibitory interaction with Bcr.

Is intraoperative parathyroid hormone testing in patients with renal insufficiency undergoing parathyroidectomy for primary hyperparathyroidism accurate?

BACKGROUND: Our aim was to determine whether chronic renal insufficiency (CRI) impacted intraoperative parathyroid hormone (ioPTH) monitoring during parathyroidectomy. We hypothesized that ioPTH monitoring in patients with CRI would show slower decline, but would still accurately predict cure. METHODS: A retrospective review was conducted of patients with primary hyperparathyroidism who underwent curative single adenoma parathyroidectomy. The percentage of patients reaching 50% decline of ioPTH was compared between groups stratified by renal function. RESULTS: Between 2000 and 2013, 950 patients met inclusion criteria. At 5 minutes, 66% of patients with CRI met curative criteria versus 77% of normal renal function patients (P = .001). At 10 minutes, 89% vs 92% met criteria (P = .073), and by 15 minutes, the gap narrowed to 95% vs 97% (P = .142), respectively. CONCLUSIONS: Despite CRI patients with primary hyperparathyroidism having slower ioPTH decline after curative parathyroidectomy, 95% met ioPTH criteria by 15 minutes. Standard ioPTH criteria can be used with CRI patients.

Preoperative impairment is associated with a higher postdischarge level of care.

BACKGROUND: Although preoperative risk factors have been shown to lead to postdischarge institutionalization, an association between preoperative risk factors, preoperative level of required care, and discharge to higher levels of care has not previously been demonstrated. MATERIALS AND METHODS: Using an institutional American College of Surgeons National Surgical Quality Improvement Program database, a retrospective review of elderly patients undergoing nonemergent inpatient general surgery procedures was performed with the goal of identifying preoperative risk factors that indicated the need for a higher level of care on hospital discharge. Univariate and multivariate analyses were performed on the patient population. RESULTS: Over a 4-y period, 585 patients (29%) within the database were aged ≥65 y. In this population, 12% of patients required discharge to a higher level of care compared with their preoperative origin. In patients aged ≥65 y, impaired cognition, decreased functional capacity, advanced age (≥79 y), high American Society of Anesthesiologists class, and long hospital length of stay were found in univariate analysis to be associated with postoperative discharge to a higher level of care, although all of these variables except decreased functional capacity were also associated with a higher discharge level of care in multivariate analysis. CONCLUSIONS: Cognitive and functional capacity scoring can be used as simple ways to indicate discharge to a higher level of care for older adults. Preoperative counseling in high-risk older adults needs to include the likelihood for discharge to a higher level of care, so that a possible referral to social work can be placed during discharge planning.

Justified follow-up: a final intraoperative parathyroid hormone (ioPTH) Over 40 pg/mL is associated with an increased risk of persistence and recurrence in primary hyperparathyroidism.

INTRODUCTION: After parathyroidectomy for sporadic primary hyperparathyroidism (PHPT), overall rates of persistence/recurrence are extremely low. A marker of increased risk for persistence/recurrence is needed. We hypothesized that final intraoperative parathyroid hormone (FioPTH) ≥40 pg/mL is indicative of increased risk for disease persistence/recurrence, and can be used to selectively determine the degree of follow-up. METHOD: A retrospective review of PHPT patients undergoing parathyroidectomy with ioPTH monitoring was performed. An ioPTH decline of 50 % was the only criteria for operation termination. Patients were grouped based on FioPTH of <40, 40-59, and >60 pg/mL. RESULTS: Between 2001 and 2012, 1,371 patients were included. Mean age was 61 ± 0.4 years, and 78°% were female. Overall persistence rate was 1.4°%, with a 2.9°% recurrence rate. Overall, 976 (71°%) patients had FioPTH < 40, 228 (16.6°%) had FioPTH 40-59, and 167 (12.2°%) had FioPTH ≥60. Mean follow-up was 21 ± 0.6 months. Patients with FioPTH <40 were younger, with lower preoperative serum calcium, PTH, and creatinine (all p ≤ 0.001). Patients with FioPTH <40 had the lowest persistence rate (0.2 %) versus patients with FioPTH 40-59 (3.5 %) or FioPTH ≥60 (5.4 %; p < 0.001). Recurrence rate was also lowest in patients with FioPTH <40 (1.3 vs. 5.9 vs. 8.2 %, respectively; p < 0.001). Disease-free status was greatest in patients with FioPTH <40 at 2 years (98.5 vs. 96.8 vs. 90.5 %, respectively) and 5 years (95.7 vs. 72.3 vs. 74.8 %, respectively; p < 0.01). CONCLUSIONS: Patients with FioPTH < 40 pg/mL had lower rates of persistence and recurrence, than patients with FioPTH 40-59, or ≥60. Differences became more apparent after 2 years of follow-up. Patients with FioPTH ≥40 pg/mL warrant close and prolonged follow-up.

Preventing postoperative hypocalcemia in patients with Graves disease: a prospective study.

BACKGROUND: Hypocalcemia occurs after total thyroidectomy (TT) for Graves disease via parathyroid injury and/or from increased bone turnover. Current management is to supplement calcium after surgery. This study evaluates the impact of preoperative calcium supplementation on hypocalcemia after Graves TT. METHODS: A prospective study of patients with Graves disease undergoing TT was performed. Patients with Graves disease managed over a 9-month period took 1 g of calcium carbonate (CC) three times a day for 2 weeks before TT. Those managed the previous year without supplementation served as historic controls. Age-, gender-, and thyroid weight-matched, non-Graves TT patients were procedure controls. Patient demographics, postoperative laboratory values, complaints, and medications were reviewed. Parathyroid hormone (PTH)-based postoperative protocols dictated postoperative CC and calcitriol use. RESULTS: Forty-five patients with Graves disease were treated with CC before TT, and 38 patients with Graves disease were not. Forty control subjects without Graves disease were identified. Age, gender, and thyroid weight were comparable. Preoperative calcium and PTH levels were equivalent. PTH values immediately after surgery, at postoperative day 1, and at 2-week follow-up were equivalent. Postoperative use of scheduled CC (p = 0.10) and calcitriol (p = 0.60) was similar. Postoperatively, patients with untreated Graves disease had lower serum calcium levels than pretreated patients with Graves disease or control subjects without Graves disease (8.3 mg/dL vs. 8.6 vs. 8.6, p = 0.05). Complaints of numbness and tingling were more common in nontreated Graves disease (26%) than in pretreated Graves disease (9%) or in control subjects without Graves disease (10%, p < 0.05). CONCLUSIONS: Calcium supplementation before TT for Graves disease significantly reduced biochemical and symptomatic postoperative hypocalcemia. Preoperative calcium supplementation is a simple treatment that can reduce symptoms of hypocalcemia after Graves TT.

Outcomes after subtotal parathyroidectomy for primary hyperparathyroidism due to hyperplasia: significance of whole vs. partial gland remnant.

INTRODUCTION: Primary hyperparathyroidism (PHPT) due to multigland hyperplasia is managed by subtotal parathyroidectomy (sPTX), with a partial gland left in situ. However, smaller, hyperplastic glands may be encountered intraoperatively, and it is unclear if leaving an intact gland is an equivalent alternative. This study evaluates the rates of permanent hypoparathyroidism and cure of PHPT patients with four-gland hyperplasia that were left with either a whole gland remnant (WGR) or a partial gland remnant (PGR) after sPTX. METHODS: We reviewed the outcomes of PHPT patients with hyperplasia who underwent sPTX at an academic institution. Surgeon intraoperative judgment determined remnant size (a WGR vs. a PGR). RESULTS: Between 2002 and 2013, 172 patients underwent sPTX for PHPT. There were 108 patients (62.8%) who had a WGR. Another 64 patients (37.2%) had a PGR. Mean age was 60 ± 14 years. There were 82.6% female patients. Cases with positive family history for PHPT were more likely to have a PGR (12.5 vs. 3.7%; p = 0.03). Patients had similar preoperative and postoperative laboratories. Individuals with a PGR tended to have larger glands encountered by surgeons intraoperatively (525 ± 1,308 vs. 280 ± 341 mg; p = 0.02). One patient with a WGR developed permanent hypocalcemia. Overall, the cure rate was 97.1%. A mean of 29 ± 28.7 months follow-up revealed a recurrence rate of 5.2%. Disease persistence and recurrence rates were similar in patients. CONCLUSION: PHPT due to hyperplasia is managed by sPTX, leaving WGR without increased rates of disease persistence/recurrence. Patients without family history for hyperparathyroidism and those with smaller glands may be the best candidates for this approach.

All thyroid ultrasound evaluations are not equal: sonographers specialized in thyroid cancer correctly label clinical N0 disease in well differentiated thyroid cancer.

BACKGROUND: Ultrasound (US) is a standard preoperative study in thyroid cancer. Accurate identification of lymph node (LN) disease in the central neck by US is debated, leading some surgeons to perform prophylactic central dissection. The purpose of this study was to evaluate if US performed by a surgeon with specialization in thyroid sonography correctly determined clinical N0 status. METHODS: Retrospective identification of cN0 thyroid cancer patients from a prospectively maintained database was performed. Exclusion criteria included LN dissection with thyroidectomy or missing preoperative US. Demographics and outcomes were reviewed. Patients were categorized by who performed the thyroid US (surgeon vs. non-surgeon). Additional radioactive iodine (RAI) treatments or subsequent positive pathology defined recurrence. RESULTS: From 2005 to 2012, 177 patients met criteria. Forty-eight patients had surgeon US versus 129 patients with non-surgeon US. Groups were equivalent in age, gender, and tumor size. Forty-six percent had a preoperative diagnosis of cancer, whereas 19 % had benign and 35 % had indeterminate diagnoses. Surgeon US documented LN status more frequently (69 vs. 20 %, p < 0.01). RAI treatment and dose were equivalent. RAI uptake was lower with surgeon US (0.06 % ± 0.02 vs. 0.20 % ± 0.03, p < 0.01). Recurrence rates were higher in non-surgeon US (12 vs. 0 %, p = 0.01). Median time to recurrence was 11 months. CONCLUSIONS: Surgeons with thyroid US expertise correctly identify patients as N0, which may eliminate the need for prophylactic LN dissection without increasing risk of early recurrence. Because not all thyroid cancers are diagnosed preoperatively, US examination of the thyroid should include routine evaluation of the cervical LNs.