Contemporary trends in extent of surgery for differentiated thyroid cancer with extrathyroidal extension.

OBJECTIVE: Although lobectomy is acceptable for patients with small, low-risk differentiated thyroid cancer (DTC), gross extrathyroidal extension (ETE) remains an indication for total thyroidectomy (TT). Here we investigate evolving trends in extent of surgery for â€‹+ â€‹ETE DTC. METHODS: Patients with +ETE DTC who underwent resection from 2010 to 2020 were identified using the National Cancer Database. The primary outcome was performance of TT versus lobectomy. RESULTS: Among 5851 patients, most were female (79.7%), white (80.0%), and had minimal ETE (91.8%). Ninety-two percent of patients received TT. Year of treatment was influential (p â€‹< â€‹0.001), with increasing lobectomy rates in later years. On multivariable analyses, a decreased likelihood of TT was seen in years 2015 through 2020. CONCLUSIONS: Most patients with +ETE DTC underwent guideline-concordant TT, but lobectomy rates doubled over the study period. These findings may reflect increased preference for lobectomy in low-risk DTC, but could undertreat patients with high-risk features.

Impact of faculty well-being on medical student education.

Purpose: The prevalence of physician burnout has risen and negatively impacts patient care, healthcare costs, and physician health. Medical students are heavily influenced by the medical teams they rotate with on the wards. We postulate that faculty well-being influences student perception of clerkships. Methods: Medical student evaluations core clerkships at one academic institution were compared with results of faculty well-being scores over 2 years (2018-2020). Linear mixed models were used to model each outcome adjusting for year, mean faculty distress score, and the standard deviation (SD) of WBI mean distress scores. Clerkships and students were treated as random effects. Results: Two hundred and eighty Well-Being Index evaluations by faculty in 7 departments (5 with reportable means and standard deviations), and clerkship evaluations by 223 students were completed. Higher faculty distress scores were associated with lower student evaluation scores of the clerkship (- 0.18 per unit increase in distress, std. err = 0.05, p < 0.01). Increased SD (variability) of faculty distress was associated with higher student overall ratings (0.49 points per unit increase in variability, std. err = 0.11, p < 0.01), as was year with 2019-2020 having lower overall ratings (- 0.17, std. err = 0.06, p < 0.01). Findings were similar for ratings of faculty teaching: mean faculty distress (- 0.15, std. err = 0.25), SD faculty distress (0.33, std. err = 0.12), 2019-2020 vs. 2018-2019 (- 0.19, std. err = 0.06) (all p < 0.01). Conclusions: Physician well-being is not only associated with quality of patient care and physician health, but also with medical student perceptions of clinical education. These findings provide yet another indirect benefit to improved physician well-being: enhanced undergraduate medical educational experience.

Evolving variation in the extent of surgery for low-risk papillary thyroid cancer in the United States.

BACKGROUND: The continued debate over total thyroidectomy versus lobectomy and declining favor for prophylactic central neck dissection for patients with clinically node-negative papillary thyroid cancer ≤4 cm is ongoing after the 2015 guideline updates from the American Thyroid Association. This study aimed to evaluate contemporary trends in the extent of surgery in this low-risk cohort. METHODS: Retrospective data from the National Cancer Database were used to identify adult patients with clinically node-negative papillary thyroid cancer ≤4 cm who underwent resection from 2012 to 2020. The primary outcome was the extent of surgery (lobectomy or total thyroidectomy, with or without prophylactic central neck dissection). Multivariable regression was performed to identify characteristics associated with variation in the extent of surgery. RESULTS: Of 83,464 included patients, 79.3% were female patients with a median age of 51 years. The majority underwent total thyroidectomy either with prophylactic central neck dissection (39.1%) or without (37.5%) versus lobectomy with prophylactic central neck dissection (7.2%) or without (16.2%). Lobectomy rates increased from 18.3% in 2012 to 29.9% in 2020. Prophylactic central neck dissection rates also increased (42.9% to 52.1%). Patients who were male sex, Asian American, had smaller tumors or were treated at community cancer programs had a decreased likelihood of total thyroidectomy. Patients who were older, male sex, Black race, with smaller tumors, or were treated at community cancer programs or mid- or low-volume facilities had decreased likelihood of prophylactic central neck dissection. CONCLUSION: Proportional use rates of operative approaches for low-risk, clinically node-negative papillary thyroid cancer have changed in recent years after the American Thyroid Association guideline changes, including increasing overall rates of lobectomy as well as prophylactic central neck dissection, with differences noted based on patient- and facility-level factors.

Comparison of Perioperative Outcomes Between Single-Port and Multi-Port Robotic Adrenalectomy.

BACKGROUND: Single-port (SP) robotic surgery has been utilized in several surgical procedures. We aim to describe our institution's approach and perioperative experience with SP robotic adrenalectomy and compare it to the traditional multi-port (MP) approach. METHODS: We retrospectively reviewed all patients who underwent robotic adrenalectomy by a single surgeon between March 2019 and March 2020. Patient demographic, perioperative factors, and pathologic outcomes were recorded and analyzed using t-tests, chi-square, or Fisher's exact tests. RESULTS: Thirty-six patients underwent SP (n = 11) and MP (n = 25) robotic adrenalectomy. Age, body mass index, gender, operative time, major Clavien-Dindo complications, and margin status showed no differences. Patients undergoing SP adrenalectomy had a lower estimated blood loss (18.1 ± 13.0 vs 65.6 ± 95.0 cc, P = .02) and smaller lesion size (2.8 ± 1.3 vs 4.1 ± 1.8 cm, P = .04) compared to those undergoing MP. CONCLUSIONS: SP adrenalectomy appears to be a feasible approach in select adrenal masses. Further studies are needed to establish its safety and cost effectiveness.

Comparative utility of preoperative imaging in normocalcemic versus hypercalcemic primary hyperparathyroidism.

BACKGROUND: Normocalcemic primary hyperparathyroidism (PHPT) has been shown to benefit from parathyroidectomy. PHPT may be localized preoperatively with various imaging modalities, but the utility of preoperative imaging in normocalcemic PHPT compared to hypercalcemic PHPT is not well defined. METHODS: Retrospective review was performed on all PHPT patients who underwent parathyroidectomy from 2001 to 2019. Patients were stratified into normocalcemic and hypercalcemic groups. Patient and outcomes data were analyzed. RESULTS: All 2218 patients in this database were included. 433 patients had normocalcemic PHPT (19.5%) and 1785 had hypercalcemic PHPT (80.5%). Among normocalcemic patients, equivalent cure rates were seen between patients with preoperative imaging versus those without (100% vs 99%). No differences in postoperative complications were demonstrated except for a slightly increase in transient hypocalcemia in patients without imaging. CONCLUSIONS: Normocalcemic PHPT patients had equivalent cure and similar complication rates with or without preoperative imaging compared to hypercalcemic patients. Routine localization studies in normocalcemic PHPT may be safely omitted in favor of exploration with intraoperative adjuncts by experienced surgeons.

Leadership Development Among Junior Surgery Residents: Communication and Perception.

INTRODUCTION: Leadership is necessary for effective health care teams, particularly for surgeons. Trainees similarly must acquire foundational leadership skills to maximize effectiveness. However, surgical leadership is rarely formally assessed, particularly for junior trainees. We aimed to establish themes of communication, perception and engagement styles, as well as strengths and weaknesses among junior surgical residents at a single institution. METHODS: The Data Dome Inc. (datadome.com) DISC personality assessment was administered in 2018-2021 to junior residents at an academic general surgery training program at a single institution. Resident demographics were recorded, and themes from deidentified reports were analyzed by year (PGY-1 and PGY-2) using JMP 16 Pro Text Explorer. RESULTS: PGY-1 communication was most frequently described as "accomplished best by well-defined avenues" with "duties and responsibilities of others who will be involved explained" in "friendly terms." PGY-2 communication involved "deal [ing] with people," "strong feelings about a particular problem," and being "good at giving verbal and nonverbal feedback." In ideal environments, PGY-1s self-perceived as "good listener [s]," "good-natured," and "team player [s]." However, under stress, PGY-1s were perceived by others as "poor listener [s]," "self-promoter [s]," "detached," and "insensitive." In ideal environments, PGY-2s were also "good listener [s]," "good-natured," and "team player [s]." However, under stress, PGY-2 external perception was "overly confident," "poor listener [s]," and "self-promoter [s]." CONCLUSIONS: Clear expectations, friendly work environments, and opportunities to succeed are key to effectively train junior surgical residents. In environments where time is often a limited resource, surgical simulation, stress training, and standardized teaching methods from attending surgeons are needed to develop competent trainees.

Patient Satisfaction is Equivalent for Inpatient and Outpatient Minimally-Invasive Adrenalectomy.

INTRODUCTION: Same-day surgery in the carefully selected patient decreases costs, improves inpatient capacity, and decreases patient exposure to hospital-acquired conditions. Outpatient adrenalectomy has been shown to be safe and effective, but patients' perspectives have yet to be addressed. This study compares patient satisfaction following inpatient and outpatient adrenalectomy. METHODS: An institutional database was queried for minimally-invasive adrenalectomies performed from 2017 to 2020. Patients were contacted up to two times to participate in a phone survey consisting of 25 questions modeled after the Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems Survey (OAS CAHPS) assessing preparation for surgery, discharge experience, post-operative course, and overall satisfaction. Statistical analysis was performed using Kruskal Wallis, Wilcoxon-Mann Whitney, and Chi-square tests, as appropriate. RESULTS: One hundred five adrenalectomy patients were identified, of which 98 were contacted and 58 responded (59%). Two surgeons contributed patients, with no difference in the percentage of patients in the outpatient group (51.7% versus 62.1%, P = 0.423). Outpatient adrenalectomy patients had slightly higher overall experience scores, but this difference was not statistically significant (9.12 ± 1.36 versus 8.93 ± 1.51, P = 0.367). Patients undergoing outpatient adrenalectomy were more likely to have their discharge plan discussed pre-operatively (94% versus 62%, P = 0.005), but no significant differences were noted between inpatient and outpatient groups regarding preparation for surgery, readiness for discharge, night of surgery experiences, or self-reported pain or complications (P > 0.05 for all). Significantly higher overall experience scores were reported by patients counseled about their discharge plan (9.27 versus 7.9, P = 0.036), felt prepared for recovery (9.39 versus 5.5, P < 0.001), received information about pain control (9.13 versus 7.00, P = 0.031), felt prepared at time of discharge (9.33 versus 5.80, P < 0.001), and received information about potential complications (9.29 versus 7.00, P = 0.001). Although not statistically significant, there was a trend towards outpatients being more likely to choose the same approach if they were to undergo surgery again (97% versus 84%, P = 0.081). CONCLUSIONS: Patient satisfaction following adrenalectomy is significantly associated with patients' self-reported degree of preparation for surgery and discharge, with no significant difference in patient satisfaction between inpatient and outpatient groups. Patients undergoing outpatient adrenalectomy would be likely to choose the same approach compared to inpatients. Targeted pre-operative counseling can contribute to enhanced patient outcomes for all patients undergoing adrenalectomy.

"Finding a General Surgeon: Self-Referral in the Digital Era".

BACKGROUND: As technology becomes more prominent in today's society, more patients turn to the Internet to self-refer for a range of surgical problems. Frequently, patients search a nearby hospital's website in order to find a physician. We hypothesized that the variability in hospital websites would make it difficult for patients to find a general surgeon for their care. METHODS: We used the US News and World Report's Hospital Rankings 2018-2019 for this study. The "Find A Doctor" page within each hospital's website was searched for the following conditions: "hernia" and "gallbladder." Information on all suggested providers was collected, including medical specialty and gender. Descriptive statistics were used to analyze the data. RESULTS: The median number of providers listed in each search was 18 (range: 1-204). For "hernia," general surgeons were not the majority of providers suggested at 12/16 institutions. For "gallbladder," general surgeons were not the majority of providers suggested at 14/16 institutions, and 3/16 institutions did not suggest any. All 16 institutions suggested a strong majority of male providers (range: 62-100% male; median: 83% male). DISCUSSION: Considerable variation exists in the suggestion of medical providers for common general surgical problems among the top academic hospitals. Most notably, general surgeons are not listed as the primary providers for these conditions which they commonly manage. Health systems need to examine how their website suggest providers and ensure that patients can easily find the physician most suitable for their care.

A single institution experience with papillary thyroid cancer: Are outcomes better at comprehensive cancer centers?

INTRODUCTION: Papillary thyroid cancer (PTC) is the most common form of thyroid cancer. Although the survival rate is excellent, recurrence is as high as 20%. The mainstay of therapy is thyroidectomy and lymph node dissection based on risk factors. Data from other cancers suggest that surgical outcomes are most optimal at comprehensive cancer centers. We hypothesize that patients with PTC who had their initial operation at a comprehensive cancer center would have a better oncologic outcome. METHODS: We utilized an IRB-approved cancer care registry database of patients with thyroid cancer who were seen at our institution between 2000 and 2018. Patient records were updated with cancer-specific outcomes including recurrence and need for re-intervention. Clinical and surgical outcomes were then compared between patients who had their initial operation at a comprehensive cancer center (CCC group, n = 503) versus those who did not (non-CCC group, n = 72). RESULTS: Mean patient age was 49 ± 16 years and 70% were female. Average tumor size was 1.6 ± 1.6 cm. There was no difference in tumor size, age, gender or race between groups. Pre-operative ultrasound was more frequently performed at the CCC (89%) than at non-CCC's (51%, p < 0.001). CCC patients were more likely to undergo initial total thyroidectomies compared to non-CCC patients (76% vs. 21%, p < 0.001). Positive surgical margins were more frequently found in patients at non-CCC's (19%) than at the CCC (9.7%, p = 0.016). Finally, CCC patients had a significantly lower cancer recurrence rate (5.0% vs. 37.5%, p < 0.001). Therefore, the need for additional cancer operations was much greater in patients who had initial thyroid surgery at non-CCC (31.9% vs. 1.4%, p < 0.001). CONCLUSIONS: Patients with PTC who have their initial thyroidectomy at non-CCC have higher recurrence rates, higher rates of positive tumor margins on pathology, and increased need for additional operations. These data suggest that patients who have their initial procedure at a CCC for PTC have better long-term outcomes.

Tired of Being Ignored: Fatigue as a Presenting Symptom in Primary Hyperparathyroidism.

BACKGROUND: Fatigue is a common presenting symptom in primary hyperparathyroidism (PHPT). Although fatigue alone is not currently an indication for parathyroidectomy, it can have a significant detrimental effect on quality of life. The purpose of this study was to determine if there are underlying differences in demographic or disease characteristics in patients with PHPT who present with fatigue compared with those who do not. METHODS: We reviewed a prospective database of 2197 patients undergoing parathyroidectomy for PHPT by three endocrine surgeons from 2001 to 2019. Patients were divided into two groups based on the presence or absence of fatigue as a presenting symptom. Objective measures of disease severity were then compared between groups. RESULTS: A total of 1379 (63%) patients presented with fatigue. Patients presenting with fatigue were more likely to be female and to have a prior fracture, lower preoperative serum calcium (Ca), and normocalcemic PHPT. There were no statistically significant differences between groups in age, body mass index, history of nephrolithiasis, or preoperative serum parathyroid hormone levels. Patients presenting with fatigue were also more likely to have smaller parathyroid glands and multiglandular disease. No statistically significant differences were detected in postoperative serum Ca and parathyroid hormone levels, or cure or recurrence rates. CONCLUSIONS: Patients with PHPT who report fatigue as a presenting symptom present with more complex disease as manifested by a higher incidence of multiglandular disease and normocalcemic PHPT. Despite this, surgical cure is equivalent to other patients. Therefore, fatigue should be a discrete indication for parathyroidectomy in PHPT.

Can the Use of Video-Based Interventions Increase Public Knowledge About Endocrine Surgeons?

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.

Preoperative parathyroid localization does not improve surgical outcomes for patients with primary hyperparathyroidism.

BACKGROUND: Most patients with primary hyperparathyroidism undergo localization prior to operation with variable success. Therefore, in this study we investigated the safety of parathyroidectomy without imaging. METHODS: A prospective database of 2057 surgical patients with primary hyperparathyroidism from 2001 to 2019 was reviewed. Patients were categorized by use of preoperative imaging (ultrasound, sestamibi, CT scan), pathology, and cure. RESULTS: 1879 (91%) patients underwent preoperative imaging. CT scan was the most sensitive study (92%), though specificity was only 64%. Patients with imaging were older, had higher pre- and postoperative calcium, more likely to undergo unilateral exploration and have an adenoma (p < 0.001-0.038). No differences were seen in nerve injury (<1%), postoperative hypocalcemia (<1%), or cure rate. CONCLUSIONS: While localization may lead to minimally-invasive operations, we observed no differences in postoperative complications or cure rates in the hands of an experienced surgeon. Therefore, preoperative parathyroid localization does not improve outcomes for hyperparathyroidism and can be ordered sparingly.

Analysis of Open Payments Receipts Among Surgical Faculty at a Large Academic Institution.

BACKGROUND: Section 6002 of the Affordable Care Act, commonly referred to as "The Sunshine Act," is legislation designed to provide transparency to the relationship between physicians and industry. Since 2013, medical product and pharmaceutical manufacturers were required to report any payments made to physicians to the Centers for Medicare and Medicaid Services (CMS). We predicted that most clinical faculty at our institution would be found on the Open Payments website. We elected to investigate payments in relationship to divisions within the department of surgery and the level of professorship. METHODS: All clinical faculty (n = 86) within the department of surgery at our institution were searched within the database: https://openpaymentsdata.cms.gov/. The total amount of payments, number of payments, and the nature of payments (food and beverage, travel and lodging, consulting, education, speaking, entertainment, gifts and honoraria) were recorded for 2017. Comparison by unpaired t-test (or ANOVA) where applicable, significance defined as P < 0.05. RESULTS: Of the 86 faculty studied, 75% were found within the CMS Open Payments database in 2017. The mean amount of payment was $4024 (range $13-152,215). Median amount of payment was $434.90 (range $12.75-152,214.70). Faculty receiving outside compensation varied significantly by division and academic rank (P < 0.05). Plastic surgery had the highest percentage of people receiving any form of payment ($143-$1912) and GI surgery had the largest payments associated with device management ($0-$152,215). The variation seen by rank was driven by a small number of faculty with receipt of large payments at the associate professor level. The median amount of payment was $428.53 (range $13.97-2306.05) for assistant professors, $5328.03 (range $28.30-152,214.70) for Associate Professors, and $753.82 (range $12.75-17,708.65) for full professors. CONCLUSIONS: Reporting of open payments to CMS provides transparency between physicians and industry. The significant relationship of division and rank with open payments database is driven by relatively few faculty. The majority (94%) received either no payments or less than $10,000.

What Does the Average Person Know About Endocrine and Vascular Surgeons?

INTRODUCTION: Surgical fields are becoming increasingly specialized. This can lead to misunderstanding or confusion about the scope of practice of different surgeons by the individual seeking specialized surgical care. To assess public understanding of subspecialty surgeons, we sought to survey general knowledge of the specialty areas of Endocrine Surgery and Vascular Surgery. METHODS: A survey was conducted in three locations in Birmingham, Alabama: a local farmers market, a public park, and the University of Alabama at Birmingham hospital. Fifty people were surveyed at random at each of the three locations, with hospital staff identified by wearing a hospital ID badge recruited at the University of Alabama at Birmingham hospital location. Participants were asked to define both an endocrine surgeon and vascular surgeon, as well as identify aspects of their practice. Participant's answers to the survey were recorded and coded by three evaluators (two MDs, one PharmD candidate). Survey responses were assessed for correct definition of the specialty (yes/no), recognition of being a surgeon (yes/no), spectrum of practice (none, partial, or complete), and presence of a common misconception (yes/no). Interrater reliability (kappa) was calculated for each question. Chi-square test was used to compare the difference in each answer between the two specialties. RESULTS: A total of 150 people participated in the study. The majority were female (58%) and approximately 50 y of age or less (65%). Interrater reliability from 0.32 to 0.84 was observed, and agreement from 40% to 98% between raters was achieved for all questions. Significantly more respondents recognized endocrine surgery as a surgical profession (21%) compared to vascular surgeons (18%) (P < 0.001). However, significantly fewer could define what an endocrine surgeon does (14%) than could define what a vascular surgeon does (57%). Only 3% of respondents could identify the entire spectrum of practice of an endocrine surgeon, with 42% and 55% providing partially or completely incorrect responses, respectively. Significantly more respondents could identify all of a vascular surgeon's spectrum of practice (11%), with 60% and 29% providing partial or completely incorrect responses, respectively (P < 0.001). Endocrine surgeons were most often confused for endocrinologists (40%), whereas vascular surgeons were most often confused for cardiovascular surgeons (22%). CONCLUSIONS: This study reveals an overall lack of understanding among the general public about what endocrine and vascular surgeons are and their spectrum of practice and shows that public understanding of the field of endocrine surgery is very low. More efforts need to be made to increase the visibility of these fields and communicate these surgeons' specialized expertise.

Condyloma Acuminatum, Anal Intraepithelial Neoplasia, and Anal Cancer in the Setting of HIV: Do We Really Understand the Risk?

BACKGROUND: The gold standard for surveillance of patients with anal lesions is unclear. OBJECTIVE: The aim of this study was to stratify patients for risk of progression of disease and to determine appropriate intervals for surveillance of patients with anal disease. DESIGN: This was a retrospective chart review for patients treated for anal lesions between 2007 and 2014. Only patients with ≥1 year of follow-up from index evaluation, pathology, documented physical examination, and anoscopy findings were included for analysis. SETTINGS: The study was conducted at an urban university hospital. PATIENTS: HIV-positive patients with anal lesions treated with excision and fulguration were included. MAIN OUTCOME MEASURES: Recurrence of anal lesions, progression of disease, and progression to cancer were measured. RESULTS: Ninety-one patients met inclusion criteria. The mean age was 41.6 years, and mean follow-up was 38.6 months (range, 11.0-106.0 mo). On initial pathology, 8 patients (8.8%) had a diagnosis of condyloma acuminatum without dysplasia, 20 patients (22%) had anal intraepithelial neoplasia I, 32 (35.2%) had anal intraepithelial neoplasia II, and 31 (34.1%) had anal intraepithelial neoplasia III. Sixty-nine patients (75.8%) had repeat procedures. Seven (87.5%) of 8 patients with condyloma and 6 (30%) of 20 patients with anal intraepithelial neoplasia I progressed to high-grade lesions. Five (15.6%) of 32 patients progressed from anal intraepithelial neoplasia II to III, and 2 patients with anal intraepithelial neoplasia III (6.5%) developed squamous cell carcinoma (2.3% for the entire cohort). LIMITATIONS: This was a single institution study. High-resolution anoscopy was not used. CONCLUSIONS: All of the HIV-positive patients with condyloma or anal intraepithelial neoplasia, regardless of the presence of dysplasia, should be surveyed at equivalent 3-month time intervals, because their risk of progression of disease is high. Video Abstract at http://links.lww.com/DCR/A389.