Outcomes of Preoperative Medical Therapy for Thyroidectomy in Autoimmune Thyroid Disease.

INTRODUCTION: Thyroidectomy provides definitive treatment for autoimmune thyroid disease (AITD) often resulting in improved quality of life. Historically, patients with AITD undergoing thyroidectomy have increased rates of postoperative hypoparathyroidism and recurrent laryngeal nerve palsy. We investigated the outcomes of preoperative medications in patients with AITD undergoing thyroidectomy. METHODS: We performed a retrospective analysis of patients who underwent thyroidectomy for AITD at a single institution from 2015 to 2021. Surgical outcomes and perioperative laboratory values were analyzed by type of AITD and type of preoperative medical treatment: none, saturated solution of potassium iodide (SSKI), corticosteroids, or both SSKI and corticosteroids. RESULTS: A total of 123 patients underwent thyroidectomy for AITD and were included in analysis: 50 received no preoperative medications, 40 received SSKI, 20 received corticosteroids, and 13 received both. Seventy-six patients had Graves' disease and 47 had Hashimoto's thyroiditis. There were no significant differences in blood loss, operative time, wound complications, hematoma, or recurrent laryngeal nerve injury for patients treated with preoperative corticosteroids compared to those who were not. Patients who received corticosteroids and patients with Graves' disease more commonly had at least one instance of hypocalcemia postoperatively (P < 0.01, P = 0.01), although only on postoperative day 1 was mean calcium < 8.5 mg/dL. There was no difference in rate of transient or permanent hypoparathyroidism. CONCLUSIONS: Patients who received corticosteroids preoperatively had no increased risk of complications. They did have mildly lower calcium levels in the early postoperative period, although no difference in hypoparathyroidism. Further exploration is warranted to investigate the impact of preoperative corticosteroids on operative difficulty, quality of life, and autoantibody clearance.

Emergency department use after outpatient thyroidectomy across three states.

BACKGROUND: Although outpatient thyroidectomy has become common, few large-scale studies have examined post-thyroidectomy emergency department use, readmission, and encounters not resulting in readmission, known as "treat-and-release" encounters. We evaluated post-outpatient thyroidectomy emergency department use and readmission and characterized associated factors. METHODS: Using the Healthcare Cost and Utilization Project databases, we identified adult outpatient (same-day or <24-hour discharge) thyroidectomies performed in Florida, Maryland, and New York from 2016 to 2017. We identified the procedures linked with emergency department treat-and-release encounters and readmissions within 30 days postoperatively and the factors associated with post-thyroidectomy emergency department use and readmission. RESULTS: Of the 17,046 patients who underwent outpatient thyroidectomy at 374 facilities, 7.5% had emergency department treat-and-release encounters and 2.3% readmissions. The most common reasons for emergency department treat-and-release encounters (9.9%) and readmissions (22.2%) were hypocalcemia-related diagnoses. Greater odds of treat-and-release were associated with identifying as non-Hispanic Black (adjusted odds ratio: 1.5, 95% confidence interval: 1.3-1.8) or Hispanic race/ethnicity (adjusted odds ratio: 1.4, 95% CI: 1.1-1.6), having Medicaid insurance (adjusted odds ratio: 2.7, 95% CI: 2.3-3.2), and living in non-metropolitan areas (adjusted odds ratio: 1.6, 95% CI: 1.1-2.2). We observed no associations between these factors and the odds of readmission. CONCLUSION: Emergency department use after outpatient thyroidectomy is common. Racial, ethnic, socioeconomic, and geographic disparities are associated with treat-and-release encounters but not readmissions. Standardization of perioperative care pathways, focusing on identifying and addressing specific issues in vulnerable populations, could improve care, reduce disparities, and improve patient experience by avoiding unnecessary emergency department visits after outpatient thyroidectomy.

Multifocal C-cell Hyperplasia and Marked Hypercalcitoninemia in a Diabetic Patient Treated With Glucagon-Like Peptide-1 Agonist With Concurrent Multinodular Goiter and Hyperparathyroidism.

Thyroid C-cell hyperplasia (CCH) is divided into physiologic or reactive CCH and neoplastic CCH. Glucagon-like peptide-1 receptor agonists (GLP-1 Ra) is a group of medications used to treat type 2 diabetes that has documented C-cell stimulation effect in rodents, leading to subsequent CCH and medullary thyroid carcinoma (MTC) in rats and/or mice. Currently, there is no sufficient evidence supporting the association between GLP-1 Ra and human thyroid CCH and/or MTC. Here, we present a case of significant hypercalcitoninemia in a 53-year-old diabetic male patient receiving GLP-1 Ra treatment with concurrent multinodular goiter and hyperparathyroidism. Total thyroidectomy and central neck dissection revealed multifocal CCH involving bilateral thyroid lobes and several negative lymph nodes. Subsequent genetic testing did not detect germline mutation of RET gene. However, due to marked hypercalcitoninemia and massive thyromegaly, unsampled medullary thyroid microcarcinoma cannot be completely ruled out. The patient's postsurgical calcitonin level was back to normal. Our case indicates the significant clinical value of monitoring serum calcitonin levels in patients receiving GLP-1 Ra, especially in presence of other thyroid and/or parathyroid pathology that may be associated with increased calcitonin and/or CCH. Literature regarding the association between GLP-1 Ra and CCH is also reviewed.

Demographics and medical school exposures to rural health influence future practice.

BACKGROUND: One-fifth of the US population lives in rural areas. A record number of rural hospitals have closed, creating increased burdens on regional centers and delays in care. This study aimed to assess medical student perceptions of rural surgery and health care, and to elucidate influential factors for future practice. METHODS: We administered a survey to medical schools throughout Indiana, Illinois, and Michigan. The survey was designed and evaluated by a survey content expert and piloted among a group of students. Student and faculty liaisons disseminated the survey between February and May 2021. Descriptive analysis of data was completed using Stata v.16.1 (StataCorp, LLC, College Station, TX). RESULTS: The respondents included 700 medical students; 59.5% were female, with an equal distribution across medical school classes. More than 98% of students believe we "lack" or "are in great need of" rural health care providers, as well as rural surgeons; however, more than half of the students did not agree that the rural workforce is declining. Only 15.7% of students reported an interest in "pursuing a future career in a rural setting." Students with exposure to rural health care, coming from a rural hometown, or having a dependent had a positive association with interest in pursuing rural practice. CONCLUSION: Although students are aware of the lack of rural surgeons and health care providers, there remains an educational deficit. Expanding exposure to rural health care and surgery while in medical school may increase the number of students interested in pursuing a career in a rural setting, potentially shrinking the rural workforce gap.

Uncovering the Overlap of Global and Domestic Rural Surgery for Medical Trainees.

INTRODUCTION: Medical trainees who participate in global rotations demonstrate improved cultural sensitivity, increased involvement in humanitarian efforts, and ability to adapt to limited resources. The global coronavirus pandemic halted global rotations for medical trainees. Domestic rural surgery (DRS) may offer a unique alternative. We aimed to understand medical students' perceptions of the similarities and differences between global surgery and DRS and how students' priorities impact career choices. METHODS: An electronic survey was administered at eleven medical training institutions in Indiana, Illinois, and Michigan in spring 2021. Mixed methods analysis was performed for students who reported an interest in global surgery. Quantitative analysis was completed using Stata 16.1. RESULTS: Of the 697 medical student respondents, 202 were interested in global surgery. Of those, only 18.3% were also interested in DRS. Students interested in DRS had more rural exposures. Rural exposures associated with DRS interest were pre-clinical courses (P = 0.002), clinical rotations (P = 0.045), and rural health interest groups (P < 0.001). Students interested in DRS and those unsure were less likely to prioritize careers involving teaching or research, program prestige, perceived career advancement, and well-equipped facilities. The students who were unsure were willing to utilize DRS exposures. CONCLUSIONS: Students interested in global surgery express a desire to practice in low-resource settings. Increased DRS exposures may help students to understand the overlap between global surgery and DRS when it comes to working with limited resources, achieving work-life balance and practice location.

Impact of Endocrinologist and Surgeon Density on Well-Differentiated Thyroid Cancer Survival.

BACKGROUND: The influence of provider density and access on well-differentiated thyroid cancer (DTC) survival is uncertain. METHODS: We used the SEER18 database to study DTC patients undergoing surgery from 2000-2012. County-level endocrinologist and surgeon density were calculated. We evaluated the relationship between provider density and cause-specific survival controlling for demographic, socioeconomic, and treatment characteristics. RESULTS: Median endocrinologist density was 1.4/100 000 residents, with 15.5% of patients living in a county with no endocrinologist. Survival increased by 11% for each endocrinologist/100,000 people (P = .007). Median surgeon density was 14.8/100 000 residents, with only 1.7% of patients living in a county with no general surgeon or otolaryngologist. No significant association between surgeon density and survival was identified (P = .06). Rural residence was independently associated with lower survival (P = .009). CONCLUSIONS: County-level endocrinologist density is associated with improved DTC survival. Results may reflect endocrinologist expertise, earlier diagnosis, or represent surrogacy for higher county-level access to specialized care.

Hypercalcemic Crisis Caused by a Parathyroid Mass Requiring Thoracoscopic Resection.

OBJECTIVE: To describe the presentation, work up, and treatment of a giant parathyroid adenoma presenting as hypercalcemic crisis that ultimately weighed 57 g and extended into the mediastinum, requiring hand-assisted thoracoscopic resection. METHODS: The patient is a 68-year-old man with a prior history of parathyroidectomy, who initially presented with a severe hypercalcemia of 16.3 mg/dL and a parathyroid hormone (PTH) level of 2692 pg/mL on routine labs. RESULTS: Diagnostic and staging work up revealed a 7.2-cm mass extending from just superior to the sternal notch into the right posterior mediastinum to the carina, causing esophageal displacement. No evidence of local invasion or distant metastasis was observed on further imaging, and cytology demonstrated hypercellular parathyroid tissue. The PTH level of the aspirate was >5000 pg/mL. The patient subsequently underwent a right hand-assisted video-assisted thoracoscopic resection of the intrathoracic mass. Final pathology identified a 7.0-cm, 57-g parathyroid adenoma, without any pathologic findings suspicious for malignancy. However, the endocrine surgery team plans for annual laboratory assessment to ensure no recurrence. CONCLUSION: Primary hyperparathyroidism is most commonly caused by a single adenoma. However, in the setting of severe hypercalcemia and elevated PTH, one must have a high suspicion for malignancy, and care should be taken to remove the mass en bloc. For extremely large adenomas extending into the mediastinum, a minimally invasive, hand-assisted, thoracoscopic approach is a safe and effective method of resection.

Thyroid Lobectomy for Low-Risk Papillary Thyroid Cancer: A National Survey of Low- and High-Volume Surgeons.

BACKGROUND: The 2015 American Thyroid Association guidelines endorsed lobectomy for patients with low-risk papillary thyroid cancer (PTC) measuring 1-4 cm. Attitudes about the use of lobectomy for these patients are lacking, particularly from low-volume surgeons who perform the majority of thyroidectomies in the US. METHODS: A survey was mailed to 1000 surgeons stratified by specialty (500 general surgeons and 500 otolaryngologists) registered with the American Medical Association, to evaluate beliefs and practices about the extent of surgery for low-risk PTC. Comparisons examined differences by surgeon volume. RESULTS: Of 320 respondents who have performed thyroidectomy since 2015 (150 general surgeons, 170 otolaryngologists), 206 (64.4%) were low volume (< 26 thyroidectomies/year). The proportion of surgeons recommending lobectomy for low-risk PTC measuring 1.1 to < 4 cm ranged from 43.1 to 2.6%. High-volume surgeons recommended lobectomy more frequently for PTC measuring 1.1-3 cm, although this was not statistically significant. Thirty-three percent of respondents believed lobectomy is underused for low-risk PTC, while 10.0% believed it is overused. Additionally, 19.6% of respondents believed recurrence is more likely after lobectomy than total thyroidectomy, and 3.3% believed mortality is higher. Few believed quality of life is better after lobectomy (12.3%). Low-volume surgeons were less likely to be aware guidelines support lobectomy for low-risk PTC 1-4 cm (p < 0.001) and less likely to use clinical practice guidelines (p = 0.004). CONCLUSIONS: Most surgeons do not support lobectomy for patients with low-risk PTC > 1 cm. Awareness of guidelines and concerns about increased risk of recurrence after lobectomy may drive surgeons' preference for total thyroidectomy.

Factors associated with physicians' recommendations for managing low-risk papillary thyroid cancer.

BACKGROUND: The 2015 American Thyroid Association endorsed less aggressive management for low-risk papillary thyroid cancer (LR-PTC). We aimed to identify factors influencing physicians' recommendations for LR-PTC. METHODS: We surveyed members of three professional societies and assessed respondents' recommendations for managing LR-PTC using patient scenarios. Multivariable logistic regression models identified clinical and non-clinical factors associated with recommending total thyroidectomy (TT) and active surveillance (AS). RESULTS: The 345 respondents included 246 surgeons and 99 endocrinologists. Physicians' preference for their own management if diagnosed with LR-PTC had the strongest association with their recommendation for TT and AS (TT: OR 12.3; AS: OR 7.5, p < 0.001). Physician specialty and stated patient preference were also significantly associated with their recommendations for both management options. Respondents who received information about AS had increased odds of recommending AS. CONCLUSIONS: Physicians' recommendations for LR-PTC are strongly influenced by non-clinical factors, such as personal treatment preference and specialty.

Adoption of Active Surveillance for Very Low-Risk Differentiated Thyroid Cancer in the United States: A National Survey.

CONTEXT: Active surveillance (AS) of thyroid cancer with serial ultrasounds is a newer management option in the United States. OBJECTIVE: This work aimed to understand factors associated with the adoption of AS. METHODS: We surveyed endocrinologists and surgeons in the American Medical Association Masterfile. To estimate adoption, respondents recommended treatment for 2 hypothetical cases appropriate for AS. Established models of guideline implementation guided questionnaire development. Outcome measures included adoption of AS (nonadopters vs adopters, who respectively did not recommend or recommended AS at least once; and partial vs full adopters, who respectively recommended AS for one or both cases). RESULTS: The 464 respondents (33.3% response) demographically represented specialties that treat thyroid cancer. Nonadopters (45.7%) were significantly (P < .001) less likely than adopters to practice in academic settings, see more than 25 thyroid cancer patients/year, be aware of AS, use applicable guidelines (P = .04), know how to determine whether a patient is appropriate for AS, have resources to perform AS, or be motivated to use AS. Nonadopters were also significantly more likely to be anxious or have reservations about AS, be concerned about poor outcomes, or believe AS places a psychological burden on patients. Among adopters, partial and full adopters were similar except partial adopters were less likely to discuss AS with patients (P = .03) and more likely to be anxious (P = .04), have reservations (P = .03), and have concerns about the psychological burden (P = .009) of AS. Few respondents (3.2%) believed patients were aware of AS. CONCLUSION: Widespread adoption of AS will require increased patient and physician awareness, interest, and evaluation of outcomes.

Outcomes after completion thyroidectomy versus total thyroidectomy for differentiated thyroid cancer: A single-center experience.

BACKGROUND: Thyroid cancer diagnoses are often discovered after diagnostic thyroid lobectomy. Completion thyroidectomy (CT) may be indicated for intermediate or high-risk tumors to facilitate surveillance and/or adjuvant treatment. The completeness of thyroid resection and the safety of CT compared to total thyroidectomy (TT) is unclear. We assessed outcomes after TT or CT to determine completeness of resection and risk of complications. METHODS: Patients undergoing TT or CT between 2000 and 2018 were retrospectively reviewed. Pathology, unstimulated thyroglobulin (uTg), parathyroid hormone (PTH), rates of hematoma, and recurrent laryngeal nerve (RLN) injury were compared. RESULTS: Differentiated thyroid cancer (DTC) was identified in 954 patients undergoing TT and 142 patients undergoing CT. Postoperative uTg at 6 months was not different between TT and CT, 0.2 vs 0.2 ng/mL, P = .37. Transient hypoparathyroidism with immediate postoperative PTH less than 10 was more common after TT, 14.3 vs 6.0% (P = .009). No differences were noted regarding postoperative hematoma, transient RLN injury, permanent hypoparathyroidism, and permanent RLN injury. CONCLUSIONS: If CT is required for DTC, a complete resection, as assessed by postoperative uTg, can be achieved. Furthermore, CT is significantly less likely to result in transient hypoparathyroidism and poses no additional risk of RLN injury, hematoma, or permanent hypoparathyroidism.

Surgical Coaching for Advancement of Global Surgical Skills and Capacity: A Systematic Review.

BACKGROUND: Surgical coaching is an emerging concept of education and collaboration to improve surgical performance. Surgical education in low-resource settings remains a challenge because of confounding barriers of access, resources, and sustainability. No formal assessments of coaching as a means to improve surgical quality in low- or middle-income countries (LMICs) exist. The purpose of this review is to explore if surgical coaching could serve as an effective method of fostering continued education and advancement of surgical skills in low-resource settings. METHODS: We conducted a systematic literature search in July 2018. Included studies were peer-reviewed and met preestablished study criteria. Studies must have assessed surgical coaching, specifically defined as a means to establish continuous professional growth of trainees and practicing surgeons. RESULTS: Of 2189 articles, 175 were selected for full-text analysis, 23 met inclusion criteria for analysis, 13 of these 23 articles evaluated coaching of trainees, 10 articles assessed coaching surgeons in established careers. 18 of the 23 articles discussed skill acquisition, 4 of which assessed nontechnical skills alone, and 14 assessed technical skills or both technical and nontechnical skills. Remote or cross-institutional coaching was explored in 8 of the 23 studies. None of the studies discussed or evaluated coaching in LMICs. CONCLUSIONS: Coaching is a method of teaching surgeons at multiple stages of a career. The explored advantages of surgical coaching may be applied to continuous performance improvement and collaboration with surgeons in LMICs. Furthermore, coaching may aid in advancement of the well-established Lancet Global Surgery Indicators, improving surgical capacity and quality in LMICs.

Impact of Rurality on National Trends in Thyroid Cancer Incidence and Long-Term Survival.

PURPOSE: Thyroid cancer incidence is rising, possibly secondary to increased imaging and surveillance. Based on rural access to care disparities, we hypothesized that incidence would be greater in urban compared to rural counties with no significant difference in long-term survival. METHODS: An observational study was performed on thyroid cancer patients using Surveillance Epidemiology and End Results data (2000-2012). Age-adjusted incidence rates, incidence rate ratios, and survival rates were calculated across rural-urban designations. FINDINGS: Incidence rates were 11.2, 9.8, and 10.1 per 100,000 for urban, rural-adjacent, and rural-nonadjacent counties, respectively. Statistically significantly lower incidence was noted in rural-adjacent and rural-nonadjacent compared to urban areas. Five-year and 10-year survival was significantly lower in rural-nonadjacent counties compared to urban counties. CONCLUSIONS: Higher incidence and increased long-term survival for thyroid cancer were noted in urban areas compared to rural areas. It is uncertain if rural-urban differences in long-term survival reflect health care disparities, differences in therapy, or other origins.

Utility of Early Postoperative Unstimulated Thyroglobulin in Influencing Decision Making in Patients with Papillary Thyroid Carcinoma.

BACKGROUND: Serum thyroglobulin is used to screen for disease persistence or recurrence of papillary thyroid carcinoma (PTC). We sought to assess the utility of early postoperative unstimulated thyroglobulin levels (uTg) as a decision-making tool to guide the use of radioactive iodine (RAI) in PTC patients. METHODS: We performed a retrospective analysis of a prospectively maintained database of patients surgically treated for PTC from 2015 to 2017. We analyzed uTg approximately 6 weeks postoperatively. Patients undergoing total thyroidectomy or completion thyroidectomy were included in the study, and patients were analyzed according to postoperative uTg and receipt of RAI. RESULTS: A total of 255 patients were analyzed, with 134 patients meeting the inclusion criteria. The median postoperative uTg was 0.3 ng/mL. Overall, 49.3% (66/134) of patients achieved the target uTg of ≤ 0.2 ng/mL at a mean time of 7.9 ± 0.3 weeks postoperatively; 60% (40/66) of patients who achieved uTg ≤ 0.2 ng/mL postoperatively did not receive RAI. A uTg ≤ 0.2 ng/mL was maintained at 6 months in 98.1% of patients, including 100% of patients who received RAI and 96.7% of patients who did not receive RAI (p = 0.8). Of those who did not receive RAI, none demonstrated structural disease recurrence on 6-month ultrasound. Patients with early postoperative uTg > 0.2-2.0 ng/mL showed benefit from RAI, while patients with uTg > 2.0 ng/mL did not achieve the targeted uTg level regardless of receipt of RAI. CONCLUSIONS: Postoperative uTg may be used to guide the use of RAI. Achieving near-undetectable uTg within 6 weeks postoperatively could aid providers in assessing disease burden and minimize RAI use for patients with a low-risk of disease recurrence. Continued follow-up is necessary to accurately determine long-term outcomes.

Extent of Surgery for Low-Risk Differentiated Thyroid Cancer.

Although the incidence of thyroid cancer is increasing, survival remains unchanged. Due to concern for overtreatment, surgical management of thyroid cancer has evolved. Papillary thyroid microcarcinoma measuring 1 cm or smaller are considered very low risk and can be managed with either thyroid lobectomy or active surveillance. Total thyroidectomy is no longer recommended for these cancers unless there is evidence of metastasis, local invasion, or aggressive disease. Recommendations for low-risk differentiated thyroid cancer measuring 1 cm to 4 cm remain controversial. This article explores the controversies over the extent of surgery for patients with very low-risk and low-risk differentiated thyroid cancer.

Improving Surgical Outreach in Palestine: Assessing Goals of Local and Visiting Surgeons.

BACKGROUND: Short-term surgical outreach is often criticized for lack of sustainability and partnership with local collaborators. As global surgical capability increases, there is increased focus on educating local providers. We sought to assess and compare the educational goals of local surgeons in the Palestinian territories with goals of visiting volunteer providers. METHODS: Electronic surveys were sent to Palestinian surgeons and compared with evaluation data collected from Palestine Children's Relief Fund volunteer providers. RESULTS: The response rate was 52% from Palestinian surgeons and 100% from volunteer providers, giving a combined response rate of 83%. Ninety-two percent of Palestinian surgeons desired protected time during each mission trip for formal didactic teaching and 92% learn new techniques best by performing skills on patients with expert surgeons observing and providing feedback. Most respondents requested the addition of case reviews or debriefing sessions after completion of surgical cases. Volunteer providers indicate that 86% of prior mission trips involved training of local surgeons and 100% plan to volunteer with the organization again in the future. CONCLUSIONS: Surgical education is a vital component of any successful outreach program. Adult learning theory emphasizes the necessity of understanding the specific educational needs of participants to foster the most successful learning environment. This survey highlights the value of tailoring surgical specialty outreach to the explicit needs of local providers and patient populations, while also clearly demonstrating the importance of collaboration, feedback, and protected educational didactics as a critical focus of future surgical humanitarian endeavors.

Should Symptoms Be Considered an Indication for Parathyroidectomy in Primary Hyperparathyroidism?

Asymptomatic primary hyperparathyroidism is a very common endocrine condition, yet management of this disease process remains controversial. Primary hyperparathyroidism can lead to a myriad of symptoms which not only decreases the quality of life of patients but also increases the risk of cardiovascular disease, osteoporosis, and kidney stones. Parathyroidectomy is the only known cure for the disease. This review explores the definition of asymptomatic primary hyperparathyroidism, the burden of disease, and the overwhelming benefits of parathyroidectomy.

Portal Vein Thrombosis in the Setting of Newly Diagnosed Cushing's Syndrome.

The hallmark manifestations of Cushing's syndrome (CS) are well known, but hypercoagulability is perhaps least recognized. Patients with CS are at increased risk of both spontaneous and postoperative thromboembolism, with the significant majority of events occurring in the lower extremity and pulmonary venous circulations. We present a case of portal vein thrombosis (PVT) occurring in the setting of newly diagnosed CS due to a left adrenal adenoma. Factor VIII activity was approximately 2.5-fold elevated, a known mechanism by which hypercortisolemia predisposes to venous thrombosis. Acute abdominal pain and fever responded well to unfractionated heparin and parenteral antibiotics, and CS was eventually cured by left adrenalectomy. No thromboembolic events have occurred since surgery. PVT is uncommon and usually occurs as a complication of primary or secondary hepatobiliary malignancies and cirrhosis. To the best of our knowledge, this is just the second reported case of PVT due to CS and the first published in the English language literature.