Incorporating Well-Being into Mentorship Meetings: A Case Demonstration at Massachusetts General Hospital Department of Surgery a Harvard Medical School Affiliate.

Surgeons have been under great pressure during the COVID pandemic. Their careers are filled with fast paced decisions, life and death situations, and long hours at work. The COVID pandemic created more tasks and even new responsibilities at times, but when the operating rooms were closed down, there was less work. The COVID experience invited the opportunity to rethink mentoring in the surgery department at the Massachusetts General Hospital. The leadership experimented with a new style of mentoring which involved a team approach. In addition, they tried something else that was new: adding a lifestyle medicine expert and wellness coach to the mentoring team. The program was tested on 13 early stage surgeons who found the experience to be beneficial, and they commented that they wished they had it even earlier in their careers. Including a non-surgeon who was a lifestyle medicine physician and wellness coach added an element of whole person health that was acceptable to the surgeons and even embraced as the majority of them elected to follow up with one on one coaching after the mentoring meeting. This team mentoring program with senior surgeons and a lifestyle medicine expert is one that can be explored by other departments and other hospitals given its success at the department of surgery at Massachusetts General Hospital.

Four-dimensional computed tomography (4D-CT) for preoperative parathyroid localization: A good study but are we using it?

BACKGROUND: Four-dimensional computed tomography (4D-CT) scan to localize abnormal parathyroid glands is diagnostically superior to ultrasound (US) and sestamibi. The implementation of 4D-CT imaging is unknown. METHODS: The Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) database from 2014 to 2018 was utilized. Patients with hyperparathyroidism undergoing an initial operation were included. The rate of US, sestamibi and 4D-CT performance was calculated for the entire study population, and for each institution. RESULTS: 7,959 patients were included. In 311(3.9%) patients, no preoperative imaging was recorded. Of patients with imaging, US was performed in 6,872(86.3%), sestamibi in 5,094(64.0%), and 4D-CT in 1,630(20.4%). The combination of US and sestamibi was most frequent (3,855, 48.4%). Institutional rates of 4D-CT performance varied from 0.1% to 88.7%. CONCLUSIONS: Of the imaging modalities, 4D-CT was utilized least frequently and with greatest variability. Given the high accuracy of 4D-CT, efforts to reduce this variation may improve overall preoperative localization in patients with hyperparathyroidism.

Practice patterns for surgical management of low-risk papillary thyroid cancer from 2014 to 2019: A CESQIP analysis.

BACKGROUND: Patients with low-risk-PTC who undergo thyroid lobectomy (TL) have comparable disease-specific survival with lower morbidity than total thyroidectomy (TT). We aim to describe the surgical management of low-risk-PTC using the Collaborative Endocrine Surgery Quality Improvement Program (CESQIP). METHOD: CESQIP thyroidectomies of PTC tumors <4 cm were analyzed from 2014 to 2019 (n = 740). Postoperative outcomes were compared. Subgroup analysis examined temporal and institutional trends, and stratified for tumor size. Statistics utilized t-test, ANOVA, and Chi-squared. RESULTS: TT patients had greater hypoparathyroidism, operative time, and length-of-stay (all p < 0.001). Incidence of TL decreased with increasing tumor size (24.2% for <1 cm, 15.8% for 1-2 cm, 6.1% for 2-4 cm). TL rates increased from 2.0% in 2014 to 21.2% in 2018-19. Completion thyroidectomy was recommended in 12.0% of TL subjects. There was significant variation in TL rate by institution (p < .001). CONCLUSIONS: For low-risk-PTC, TT remained the most commonly utilized operation. TL rates increased following release of the new ATA guidelines. TT was associated with higher perioperative morbidity. Further insight is needed to understand factors influencing operative approach.

The Presence of Hürthle Cells Does Not Increase the Risk of Malignancy in Most Bethesda Categories in Thyroid Fine-Needle Aspirates.

Background: Hürthle cell/oncocytic change is commonly reported on thyroid fine-needle aspiration (FNA) and may be considered an "atypical cell" by clinicians. This study aims to delineate the association between Hürthle cells in preoperative cytology and subsequent pathology of the indexed thyroid nodule and to report rates of malignancy. Methods: Retrospective review of records of 300 patients with Hürthle cell/oncocytic change on FNA and final surgical pathology at a tertiary referral center between 2000 and 2013 was performed and compared with a multi-institutional FNA cohort. The degree of Hürthle cell presence was correlated with histopathologic diagnoses. Results: In the Hürthle cell FNA group, Bethesda System for Reporting Thyroid Cytopathology (BSRTC) categories were as follows: I (nondiagnostic) 14 (4.7%); II (benign) 113 (37.7%); III (atypia of undetermined significance/follicular lesion of undetermined significance) 33 (11%); IV (follicular neoplasm/suspicious for a follicular neoplasm) 125 (41.6%); V (suspicious for malignancy) 12 (4%); and VI (malignant) 3 (1%). When categorized based on the degree of Hürthle cell change, 59 (29%) were classified as mild, 13 (6%) moderate, and 131 (65%) as predominant. When comparing the results with a multi-institutional FNA cohort (all with surgical confirmation), the presence of Hürthle cells was found to be associated with a lower risk of malignancy in all BSRTC categories, with a statistically significant difference in the BSRTC IV and V groups. The sole exception was when Hürthle cell presence was classified as predominant (defined as >75% of the cellular population); the rate of malignancy was significantly elevated in FNAs interpreted as benign/Bethesda II. Conclusions: Although Hürthle cells have been considered by clinicians as an "atypical cell," their presence does not increase the risk of malignancy within BSRTC categories overall. However, when predominant Hürthle cell change is present, the risk of malignancy is increased in the benign cytology/BSRTC category II.

Normocalcemic hyperparathyroidism: A Collaborative Endocrine Surgery Quality Improvement Program analysis.

BACKGROUND: Normocalcemic primary hyperparathyroidism may be more challenging to cure compared with classical primary hyperparathyroidism. The aim of this study was to utilize a multi-institutional database to better characterize this condition. METHODS: The Collaborative Endocrine Surgery Quality Improvement Program database was queried for all patients who underwent parathyroidectomy for sporadic primary hyperparathyroidism. Patient characteristics, operative details, pathology, and outcomes data were compared between patients with normocalcemic primary hyperparathyroidism and those with hypercalcemia. RESULTS: Among 7,569 patients, 9.7% (733) were normocalcemic primary hyperparathyroidism. Mean age at surgery and sex were similar for normocalcemic primary hyperparathyroidism and primary hyperparathyroidism with hypercalcemia. The primary hyperparathyroidism with hypercalcemia cohort had a single parathyroid resected more frequently than the normocalcemic primary hyperparathyroidism group (73.3%% vs 47.5%, P < .05). Patients with normocalcemic primary hyperparathyroidism had a higher rate of subtotal (3.5 gland) resection (10.0% vs 4.7%, P < .05). Pathology reported a higher frequency of multigland hyperplasia in the normocalcemic primary hyperparathyroidism cohort (43.1% vs 21.9%, P <.05). In the normocalcemic primary hyperparathyroidism cohort, 47 patients (6.4%) underwent remedial surgery compared with 307 patients (4.5%) with primary hyperparathyroidism with hypercalcemia (P < .05). The rate of clinical concern for persistent hyperparathyroidism was similar between the 2 groups (P = .09) but not reported in 25% overall. CONCLUSION: Patients with normocalcemic primary hyperparathyroidism have higher rates of multigland disease and remedial surgery compared with primary hyperparathyroidism with hypercalcemia.

Using Smartphones to Capture Novel Recovery Metrics After Cancer Surgery.

Importance: Patient-generated health data captured from smartphone sensors have the potential to better quantify the physical outcomes of surgery. The ability of these data to discriminate between postoperative trends in physical activity remains unknown. Objective: To assess whether physical activity captured from smartphone accelerometer data can be used to describe postoperative recovery among patients undergoing cancer operations. Design, Setting, and Participants: This prospective observational cohort study was conducted from July 2017 to April 2019 in a single academic tertiary care hospital in the United States. Preoperatively, adults (age ≥18 years) who spoke English and were undergoing elective operations for skin, soft tissue, head, neck, and abdominal cancers were approached. Patients were excluded if they did not own a smartphone. Exposures: Study participants downloaded an application that collected smartphone accelerometer data continuously for 1 week preoperatively and 6 months postoperatively. Main Outcomes and Measures: The primary end points were trends in daily exertional activity and the ability to achieve at least 60 minutes of daily exertional activity after surgery among patients with vs without a clinically significant postoperative event. Postoperative events were defined as complications, emergency department presentations, readmissions, reoperations, and mortality. Results: A total of 139 individuals were approached. In the 62 enrolled patients, who were followed up for a median (interquartile range [IQR]) of 147 (77-179) days, there were no preprocedural differences between patients with vs without a postoperative event. Seventeen patients (27%) experienced a postoperative event. These patients had longer operations than those without a postoperative event (median [IQR], 225 [152-402] minutes vs 107 [68-174] minutes; P < .001), as well as greater blood loss (median [IQR], 200 [35-515] mL vs 25 [5-100] mL; P = .006) and more follow-up visits (median [IQR], 2 [2-4] visits vs 1 [1-2] visits; P = .002). Compared with mean baseline daily exertional activity, patients with a postoperative event had lower activity at week 1 (difference, -41.6 [95% CI, -75.1 to -8.0] minutes; P = .02), week 3 (difference, -40.0 [95% CI, -72.3 to -3.6] minutes; P = .03), week 5 (difference, -39.6 [95% CI, -69.1 to -10.1] minutes; P = .01), and week 6 (difference, -36.2 [95% CI, -64.5 to -7.8] minutes; P = .01) postoperatively. Fewer of these patients were able to achieve 60 minutes of daily exertional activity in the 6 weeks postoperatively (proportions: week 1, 0.40 [95% CI, 0.31-0.49]; P < .001; week 2, 0.49 [95% CI, 0.40-0.58]; P = .003; week 3, 0.39 [95% CI, 0.30-0.48]; P < .001; week 4, 0.47 [95% CI, 0.38-0.57]; P < .001; week 5, 0.51 [95% CI, 0.42-0.60]; P < .001; week 6, 0.73 [95% CI, 0.68-0.79] vs 0.43 [95% CI, 0.33-0.52]; P < .001). Conclusions and Relevance: Smartphone accelerometer data can describe differences in postoperative physical activity among patients with vs without a postoperative event. These data help objectively quantify patient-centered surgical recovery, which have the potential to improve and promote shared decision-making, recovery monitoring, and patient engagement.

Mindfulness in Surgery.

In the past 20 years, interest in mindfulness and its cultivation through various meditative practices has increased astronomically. This is reflected in the popularity of mindfulness training programs, its ever-widening exposure in popular culture, and in the number of scientific articles published on the topic. With the recent focus on burnout in the medical profession and reports of high levels of anxiety and depression among residents and staff physicians, the potential applications of mindfulness are becoming increasingly apparent in the hospital setting. Mindfulness meditation may be particularly useful for surgeons because they are required to maintain their presence of mind and mental focus in the setting of challenging physical and mental tasks. Furthermore, personality traits such as perfectionism and intensity, which may have facilitated success in the competitive environment of medical school and residency training, may later manifest as intolerance and impatience, contributing to frustration and anger. A mindfulness meditation practice may help reduce the tendency to react to these emotions, yet still allow surgeons to remain motivated to excel. This article provides a definition of mindfulness and describes its introduction to Western culture. The connection of a regular meditation practice to improvements in focus and performance are reviewed. The potential benefits of mindfulness training to a surgical career are discussed, and an approach to introducing mindfulness and meditation to individual surgeons and surgical departments is outlined. We hypothesize that the introduction of department-wide training programs in mindfulness and meditation could benefit surgeons with regard to technical performance, empathy toward patients, academic productivity, and general life and career satisfaction.

A Long, Unnerving Road: Malpractice Claims Involving the Surgical Management of Thyroid and Parathyroid Disease.

BACKGROUND: Given their profound emotional, physical, and financial toll on patients and surgeons, we studied the characteristics, costs, and contributing factors of thyroid and parathyroid surgical malpractice claims. METHODS: Using the Controlled Risk Insurance Company Strategies' Comparative Benchmarking System database, representing ~30% of all US paid and unpaid malpractice claims, 5384 claims filed against general surgeons and otolaryngologists from 1995-2015 were reviewed to isolate claims involving the surgical management of thyroid and parathyroid disease. These claims were studied, and multivariable regression analysis was performed to identify factors associated with plaintiff payout. RESULTS: One hundred twenty-eight thyroid and parathyroid surgical malpractice claims were isolated. The median time from alleged harm event to closure of a malpractice case was 39 months. The most common associated complications were bilateral recurrent laryngeal nerve (RLN) injury (n = 23) and hematoma (n = 18). Complications led to death in 18 cases. Patient payout occurred in 33% of claims (n = 42), and the median cost per claim was $277,913 (IQR $87,343-$783,663). On multivariable analysis, bilateral RLN injury was predictive of patient payout (OR 3.58, p = 0.03), while procedure, death, and surgeon specialty were not. CONCLUSION: Though rare, malpractice claims related to thyroid and parathyroid surgery are costly, time-consuming, and reveal opportunities for early surgeon-patient resolution after poor outcomes.

Indications for Surgical Management of Hyperparathyroidism: A Review.

IMPORTANCE: Primary hyperparathyroidism (pHPT) is a common clinical entity, with approximately 100 000 new cases diagnosed each year in the United States. Most patients with pHPT have a relatively mild form of the disease and present with few if any overt signs or symptoms. This has led to a dilemma regarding which patients should be considered for parathyroid surgery. In this article, we review the established literature on the indications for surgery in asymptomatic pHPT and discuss the most recent consensus conference guidelines. OBSERVATIONS: The reviewed literature suggests that there were improved outcomes among patients with asymptomatic pHPT who underwent curative surgery. CONCLUSIONS AND RELEVANCE: Most patients with pHPT should be considered for parathyroidectomy. More randomized clinical trials are needed to strongly support a surgical recommendation for all asymptomatic patients with pHPT.

Measurement and Variation in Estimation of Quality of Life Effects of Patients Undergoing Treatment for Papillary Thyroid Carcinoma.

BACKGROUND: Thyroid cancer incidence is increasing. The effect of diagnosis and treatment on health-related quality of life (HRQoL) is an essential variable in the absence of a change in life span for the majority of patients. HRQoL instruments, with data useful for between-disease comparisons, are being increasingly used for health policy and outcomes evaluation. Variation exits among the instruments based on the impact of a specific disease. We assessed which of four well-validated, preference-based surveys detect changes in health and clinical intervention in patients diagnosed with papillary thyroid cancer (PTC). METHODS: Four commonly used HRQoL questionnaires (Short Form-12v2® [SF6D], EuroQol-5D [EQ5D], and Health Utilities Index Mark 2 and 3 [HUI2, HUI3]) were administered to patients with the diagnosis of PTC at three perioperative time points during the first year of treatment. Clinicopathological and treatment course data were assessed for HRQoL impact including complications from surgery, re-operation for persistence/early recurrence, and adjuvant radioactive iodine treatment. We compared standard metrics, including ceiling effect, intraclass correlation coefficient, effect sizes, and quality-adjusted life-years between the four instruments. RESULTS: Of 117 patients, 27% had a preoperative diagnosis of anxiety or depression, 41% had regional lymph node metastases, three had distant metastases and 49% underwent adjuvant radioactive iodine treatment. The ceiling effect (i.e., proportion with a perfect score) was greatest with EQ5D and least with SF6D. Index scores ranged from 0.77 (SF6D) to 0.90 (EQ5D). All scores declined at two weeks postoperatively and returned to pretreatment levels at six months. The SF6D was the only instrument to exceed the conventional minimally important difference between all three time points. Quality-adjusted life-years were as follows: SF6D, 0.79; EQ5D, 0.90; HUI2, 0.88; and HUI3, 0.86. CONCLUSIONS: Our results reflect the general good health of PTC patients. The effect on quality of life is primarily related to emotional and social impacts of treatment. The results support the measurement of a similar underlying construct, although variation in detecting changes in health exists between the instruments. Of the instruments assessed, the SF6D is the most responsive to treatment effects and should be utilized in future economic analyses in this patient population.

The Truth about Double Adenomas: Incidence, Localization, and Intraoperative Parathyroid Hormone.

BACKGROUND: Double adenoma is reported in 3% to 12% of patients with primary hyperparathyroidism. The aim of this study was to determine the true incidence of double adenoma and analyze the use of localization studies and intraoperative parathyroid hormone (IOTPH) assay in these cases. STUDY DESIGN: We conducted a retrospective review of a series of consecutive parathyroid surgical operations from 2010 to 2013. According to the surgical findings, the series was divided into single-gland disease (SGD), double-gland disease (DGD), and multi-gland disease (MGD, more than 2 glands). The sensitivity of ultrasound, technetium 99m-sestamibi, and 4-dimensional CT to correctly lateralize each gland in the DGD group was calculated. Results of the IOPTH assay and how they impacted the extent of surgery were analyzed. RESULTS: Three hundred and forty-seven patients had SGD (69%), 68 patients had DGD (13.5%), and 86 had MGD (17%). In the DGD group, sensitivity of ultrasound, technetium 99m-sestamibi, and 4-dimensional CT to lateralize each adenoma was 42%, 34.5%, and 64%, respectively. Initially, 27 patients (40%) with DGD had been planned for a focal exploration. The conversion to bilateral neck exploration was due to the IOPTH assay in 18 cases (two-thirds of the initially planned focal explorations). At 6-month follow-up, all DGD patients were normocalcemic. CONCLUSIONS: Localization studies in DGD can be misleading by reporting SGD. Four-dimensional CT seems to have the highest sensitivity. In focal explorations, the excision of all hyperfunctioning parathyroid tissue should be verified by IOPTH measurement.

Reliability of Shear-Wave Elastography Estimates of the Young Modulus of Tissue in Follicular Thyroid Neoplasms.

OBJECTIVE: The purpose of this study is to determine the reliability of shear-wave elastographic estimates of the Young modulus in thyroid follicular neoplasms. SUBJECTS AND METHODS: In this study, 35 adults with follicular nodules diagnosed by fine-needle aspiration (FNA) biopsy were enrolled. A single sonographer examined all nodules in three planes (sagittal, transverse, and transverse center). Two raters independently placed ROIs in each nodule. Intra- and interrater reliability were computed as intraclass correlation coefficients (ICCs) and were reported using the Guidelines for Reporting Reliability and Agreement Studies. RESULTS: Thirty-five subjects with 35 follicular pattern nodules diagnosed by FNA biopsy were enrolled; 23 (65.7%) patients were female, with a mean age of 55.1 years (range, 23-85 years). For rater 1, intrarater agreement showed ICCs for single measurements of 0.87, 0.87, and 0.90 in the sagittal, transverse, and transverse center plans, respectively; ICCs for the median of multiple measurements were 0.97, 0.94, and 0.96 in the sagittal, transverse, and transverse center planes, respectively. For rater 2, intrarater agreement showed ICCs for single measurements of 0.94, 0.86, and 0.92 in the sagittal, transverse, and transverse center planes, respectively; ICCs for the median of multiple measurements were 0.97, 0.92, and 0.96 in the sagittal, transverse, and transverse center planes, respectively. Interrater agreement between measurements performed for the same subject showed ICCs for single measurements of 0.87, 0.87, and 0.80 in the sagittal, transverse, and transverse center planes, respectively; ICCs for the median of multiple measurements were 0.96, 0.93, and 0.92 in the sagittal, transverse, and transverse center planes, respectively. CONCLUSION: ROI placement is a reliable method for estimating the Young modulus of tissue in follicular thyroid nodules.

Upper neck papillary thyroid cancer (UPTC): A new proposed term for the composite of thyroglossal duct cyst-associated papillary thyroid cancer, pyramidal lobe papillary thyroid cancer, and Delphian node papillary thyroid cancer metastasis.

OBJECTIVES/HYPOTHESIS: Thyroglossal duct cyst (TGDC) is a common congenital anomaly, but TGDC carcinoma is rare. Thyroglossal duct cyst carcinoma management is controversial, especially that of the orthotopic thyroid gland. We aim to provide an insight into the pathologic basis of this management controversy through the review of 28 TGDC cancer cases, thus far the largest such series to our knowledge. STUDY DESIGN: Retrospective. METHODS: Twenty-eight cases recorded as TGDC cancer in the hospital database were reviewed; their initial clinical diagnosis from medical chart review (DX1) and final pathological review diagnosis (DX2) through pathology slides review by our pathologist (blinded to DX1) were compared. The thyroid gland management and pathology were evaluated. RESULTS: In the 28 TGDC carcinoma (hospital-recorded diagnosis) patients, DX1 and DX2 were respectively reported as 53% and 14% TGDC carcinoma, 11% and 29% as pyramidal lobe primary, and 4% and 25% as metastatic Delphian node. Thirty-two percent of cases were in the indeterminate category, in both DX1 and DX2, but included different patients. Thyroidectomy was performed in 54% of the cases, papillary thyroid cancer (PTC) was reported in 37% of these thyroid glands. Concurrent thyroid gland malignancy was reported in all Delphian node and pyramidal lobe PTC patients. CONCLUSION: The diagnosis of TGDC cancer comprises a heterogeneous group that includes true TGDC cancer, pyramidal lobe primary, Delphian node metastasis, and indeterminate cases. We propose a new terminology of upper neck papillary thyroid carcinoma (UPTC) to denote this heterogeneous group and recommend a rational algorithm for management. Correct pathologic subcategory and thyroid ultrasonography are essential for optimal management of thyroid gland in UPTC cases. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:1709-1714, 2016.

Molecular Characterization of an Endometrial Endometrioid Adenocarcinoma Metastatic to a Thyroid Hürthle Cell Adenoma Showing Cancerization of Follicles.

Tumor-to-tumor metastasis is rare. Herein, we present a unique case of endometrial endometrioid adenocarcinoma metastatic to a thyroid Hürthle cell adenoma 9 years after initial diagnosis. On histologic examination of the thyroid, the malignant endometrioid glands and single cells (donor tumor) were dispersed within the Hürthle cell adenoma (recipient tumor). In several sections of the adenoma with still preserved microfollicular architecture, malignant endometrial adenocarcinoma cells were admixed within oncocytic adenomatous epithelium (so-called "cancerization of the follicles"). This unusual phenomenon, to our knowledge, is a novel finding in the thyroid gland. Immunohistochemistry, subsequently elicited clinical history, and morphologic comparison of the tumor in the thyroid to the primary endometrial tumor confirmed the origin of the donor tumor cells. Molecular analysis of both the metastatic and primary endometrial tumors demonstrated PIK3CA and PTEN mutations in both tumors, as is characteristic of well-differentiated endometrioid tumors of the endometrium. Amplification of chromosome 1q was detected in both sites; however, only the metastatic tumor showed loss of chromosomes 2, 9, and 22. The morphologic differential diagnosis of metastatic endometrioid adenocarcinoma in the thyroid includes columnar cell variant of papillary thyroid carcinoma (CCVPTC) arising in a preexisting adenoma, endocrine glandular atypia within an adenoma, and metastasis from other anatomic sites. Histomorphologic differences among these entities may be subtle; therefore, knowledge of and morphologic comparison with prior malignancies and immunohistochemistry can be helpful in rendering the correct diagnosis.

Should specific patient clinical characteristics discourage adrenal surgeons from performing laparoscopic transperitoneal adrenalectomy?

BACKGROUND: Although laparoscopic transperitoneal adrenalectomy (LTA) has become a standard operative approach to patients with benign adrenal masses, some authors have suggested that LTA should be avoided in obese patients, patients who have had previous abdominal surgery, and in cases of bilateral adrenalectomy. We sought to determine whether LTA in these clinical situations is associated with worse outcomes. METHODS: Consecutive patients who underwent LTA at a tertiary care center (1/2002-8/2014) were reviewed retrospectively. Study endpoints included operative time, duration of stay, conversion to open procedure, and postoperative complications. Statistical analyses were performed by use of Wilcoxon rank sum test, Kruskal-Wallis test, Fisher exact test, χ(2) test, and binary logistic regression analyses. RESULTS: A total of 365 patients had a planned LTA, 6 of whom were converted to an open adrenalectomy. Obesity, history of previous abdominal surgery, and bilateral adrenalectomy were not associated with greater conversion rates or postoperative complications. Male sex, tumor size ≥ 4 cm and obesity (body mass index ≥ 30 kg/m(2)) were significant factors associated with increased operative time. Bilateral adrenalectomy, age, and pheochromocytomas were associated with increased hospital stays. CONCLUSION: Obesity, history of prior abdominal surgery and bilateral adrenalectomy should not be used to discourage experienced adrenal surgeons from performing LTA.

Pediatric thyroidectomy in a high volume thyroid surgery center: Risk factors for postoperative hypocalcemia.

INTRODUCTION: Hypocalcemia is a common complication following thyroid surgery. We seek to report on our experience in pediatric thyroidectomy in a high volume thyroid surgery center and accurately assess the incidence of postoperative hypocalcemia. MATERIALS AND METHODS: A retrospective review of patients aged 18 and younger who underwent thyroid surgery between 1992 and 2013. The primary endpoints were the occurrence of postoperative hypocalcemia as by defined as a nadir calcium <8.0mg/dL and being discharged on oral calcium supplementation, need for intravenous calcium and the occurrence of permanent hypoparathyroidism. RESULTS: 171 patients who underwent 186 thyroid operations were analyzed. The average age was 15.4years with 82.3% female. The most common indications for surgery were nodular disease (74.7%) and hyperthyroidism (12.4%). 24 patients (12.9%) experienced postoperative hypocalcemia with 13 (7.0%) requiring intravenous calcium infusion. One patient (0.9%) experienced permanent hypoparathyroidism. Risk factors for postoperative hypocalcemia included total thyroidectomy (OR 7.39, p<0.01), central and bilateral lateral neck dissection (OR 22.26, p=0.01), Graves' disease (OR 3.99, p=0.02), and malignancy (OR 2.96, p=0.03). CONCLUSIONS: Pediatric patients who undergo total thyroidectomy for underlying malignancy or Graves' disease and those who have more extensive nodal dissections are at increased risk of developing this postoperative hypocalcemia. These patients may benefit from more vigilant preoperative preparation and postoperative calcium and vitamin D supplementation.

A multi-institutional international study of risk factors for hematoma after thyroidectomy.

BACKGROUND: Cervical hematoma can be a potentially fatal complication after thyroidectomy, but its risk factors and timing remain poorly understood. METHODS: We conducted a retrospective, case-control study identifying 207 patients from 15 institutions in 3 countries who developed a hematoma requiring return to the operating room (OR) after thyroidectomy. RESULTS: Forty-seven percent of hematoma patients returned to the OR within 6 hours and 79% within 24 hours of their thyroidectomy. On univariate analysis, hematoma patients were older, more likely to be male, smokers, on active antiplatelet/anticoagulation medications, have Graves' disease, a bilateral thyroidectomy, a drain placed, a concurrent parathyroidectomy, and benign pathology. Hematoma patients also had more blood loss, larger thyroids, lower temperatures, and higher blood pressures postoperatively. On multivariate analysis, independent associations with hematoma were use of a drain (odds ratio, 2.79), Graves' disease (odds ratio, 2.43), benign pathology (odds ratio, 2.22), antiplatelet/anticoagulation medications (odds ratio, 2.12), use of a hemostatic agent (odds ratio, 1.97), and increased thyroid mass (odds ratio, 1.01). CONCLUSION: A significant number of patients with a postoperative hematoma present >6 hours after thyroidectomy. Hematoma is associated with patients who have a drain or hemostatic agent, have Graves' disease, are actively using antiplatelet/anticoagulation medications or have large thyroids. Surgeons should consider these factors when individualizing patient disposition after thyroidectomy.

Surgery for Graves' disease: a 25-year perspective.

BACKGROUND: Optimal treatment of Graves' disease (GD) remains controversial. The authors retrospectively reviewed the surgical cases of GD at a single academic tertiary center. METHODS: Demographic, clinical, and surgical data were analyzed for all patients with GD undergoing thyroidectomy over 25 years, in 3 periods: 1985 to 1993 (n = 32), 1994 to 2002 (n = 91), and 2003 to 2010 (n = 177). RESULTS: There were 300 patients with GD (85.7% women; mean age, 39.3 years; median length of follow-up, 24.6 months). Overall, perioperative morbidity occurred in 36 patients (12.0%), and there was no mortality. Thyroidectomy-specific morbidity was very low, and the incidental malignancy rate was 10.3%. CONCLUSIONS: Surgical treatment of GD has a very high safety profile, with low perioperative and thyroidectomy-specific morbidity, even in patients with overt hyperthyroidism. Incidental malignancy in patients with GD is not uncommon.

BRAF V600E status adds incremental value to current risk classification systems in predicting papillary thyroid carcinoma recurrence.

BACKGROUND: Papillary thyroid cancer (PTC) recurrence risk is difficult to predict. No current risk classification system incorporates BRAF mutational status. Here, we assess the incremental value of BRAF mutational status in predicting PTC recurrence relative to existing recurrence risk algorithms. METHODS: Serial data were collected for a historical cohort having undergone total thyroidectomy for papillary thyroid carcinoma (PTC) during a 5-year period. Corresponding BRAF(V600E) testing was performed and Cox proportional hazard regression modeling, with and without BRAF status, was used to evaluate existing recurrence risk algorithms. RESULTS: The 5-year cumulative PTC recurrence incidence within our 356 patient cohort was 15%. A total of 205 (81%) of associated archived specimens were successfully genotyped, and 110 (54%) harbored the BRAF(V600E) mutation. The 5-year cumulative recurrence incidence among BRAF(V600E) patients was 20% versus 8% among BRAF wild type. BRAF(V600E) was significantly associated with time to recurrence when added to the following algorithms: AMES (hazard ratio [HR] 2.43 [confidence interval 1.08-5.49]), MACIS category (HR 2.46 [1.09-5.54]), AJCC-TNM (HR 2.51 [1.11-5.66]), and ATA recurrence-risk category (HR 2.44 [1.08-5.50]), and model discrimination improved (incremental c-index range 0.046-0.109). CONCLUSION: The addition of BRAF mutational status to established risk algorithms improves the discrimination of risk recurrence in patients undergoing total thyroidectomy for PTC.