Courtney J. Balentine

Trends in the presentation, treatment, and survival of patients with medullary thyroid cancer over the past 30 years.

Background. The impact of recent medical advances on disease presentation, extent of operation, and disease‐specific survival for patients with medullary thyroid cancer is unclear. Methods. We used the Surveillance, Epidemiology, and End Results registry to compare trends over 3 time periods, 1983–1992, 1993–2002, and 2003–2012. Results. There were 2,940 patients diagnosed with medullary thyroid cancer between 1983 and 2012. The incidence of medullary thyroid cancer increased during this time period from 0.14 to 0.21 per 100,000 population, and mean age at diagnosis increased from 49.8 to 53.8 (P < .001). The proportion of tumors ≤1 cm also increased from 11.4% in 1983–1992, 19.6% in 1993–2002, to 25.1% in 2003–2012 (P < .001), but stage at diagnosis remained constant (P = .57). In addition, the proportion of patients undergoing a total thyroidectomy and lymph node dissection increased from 58.2% to 76.5% during the study period (P < .001). In the most recent time interval, 5‐year, disease‐specific survival improved from 86% to 89% in all patients (P < .001) but especially for patients with regional (82% to 91%, P = .003) and distant (40% to 51%, P = .02) disease. Conclusion. These data demonstrate that the extent of operation is increasing for patients with medullary thyroid cancer. Disease‐specific survival is also improving, primarily in patients with regional and distant disease.

Postacute Care After Major Abdominal Surgery in Elderly Patients: Intersection of Age, Functional Status, and Postoperative Complications

IMPORTANCEnAdvanced age is an important risk factor for discharge to postacute care (PAC) facilities including skilled nursing and rehabilitation. Factors modifying the age-related risk of discharge to PAC have not been adequately examined for surgical patients.nnnOBJECTIVEnTo evaluate how preoperative functional status and postoperative complications affect age-related risk of discharge to PAC facilities following major abdominal surgery.nnnDESIGN, SETTING, AND PARTICIPANTSnRetrospective cohort study of 55u202f238 patients aged 18 years or older having colorectal, pancreas, or liver operations in 2011 and 2012 at hospitals participating in the National Surgical Quality Improvement Program. Age was classified as younger than 65 years, 65 to 74 years, 75 to 84 years, and 85 years or older. The study was conducted between July 1, 2014, and July 1, 2015.nnnMAIN OUTCOMES AND MEASURESnThe primary outcome was discharge to a PAC facility following surgery. The secondary outcome was type of PAC facility (skilled nursing, rehabilitation, or other facility).nnnRESULTSnAmong 55u202f238 patients (mean [SD] age, 61 [15] years; 49% male) having colorectal, pancreas, or liver operations, 5325 (10%) were discharged to PAC facilities after major abdominal surgery. Skilled nursing facilities were the most common type of PAC (63%), followed by rehabilitation hospitals (30%) and other facilities (7%). Older age was an important predictor of discharge to PAC facilities, but there were significant interaction effects with age and postoperative complications. Among functionally independent patients who avoided postoperative complications, rates of discharge to PAC increased from 1% in the group younger than 65 years to 30% in the group aged 85 years or older. For functionally independent patients with multiple complications, 13% of patients younger than 65 years were discharged to PAC facilities compared with 66% of those aged 85 years or older. After risk adjustment, the oldest patients were 27 times more likely to be discharged to PAC than the youngest group when there were no postoperative complications (odds ratiou2009=u200926.6; 95% CI, 21.6-32.7) and 11 times more likely after multiple complications (odds ratiou2009=u200911.4; 95% CI, 8.3-15.6). Among functionally dependent patients, the overall risk of discharge to PAC facilities was increased, but age was not as important a predictor for discharge to PAC.nnnCONCLUSIONS AND RELEVANCEnOlder patients are frequently discharged to PAC facilities even when they are functionally independent and without postoperative complications. Helping older patients to return home after surgery and avoid placement in PAC facilities will require innovative programs that go beyond reducing complication rates and enhance postoperative recovery.

Optimizing Outpatient Pain Management After Thyroid and Parathyroid Surgery: A Two-Institution Experience

BackgroundThyroidectomy and parathyroidectomy are the most commonly performed endocrine operations, and are increasingly being completed on a same-day basis; however, few data exist regarding the outpatient postoperative pain requirement of these patients. We aimed to describe the outpatient narcotic medication needs for patients undergoing thyroid and parathyroid surgery, and to identify predictors of higher requirement.MethodWe examined patients undergoing thyroid and parathyroid surgery at two large academic institutions from 1 January–30 May 2014. Prospective data were collected on pain scores and the oral morphine equivalents (OMEQs) taken by these patients by their postoperative visit.ResultsOverall, 313 adult patients underwent thyroidectomy or parathyroidectomy during the study period; 83% of patients took ten or fewer OMEQs, and 93% took 20 or fewer OMEQs. Patients who took more than ten OMEQs were younger (pxa0<xa00.001) and reported significantly higher overall mean pain scores at their postoperative visit (pxa0<xa00.001) than patients who took fewer than ten OMEQs. A multivariate model was constructed on pre- and intraoperative factors that may predict use of more than ten OMEQs postoperatively. Age <45xa0years (pxa0=xa00.002), previous narcotic use (pxa0=xa00.037), and whether parathyroid or thyroid surgery was performed (pxa0=xa00.003) independently predicted the use of more than ten OMEQs after surgery. A subgroup analysis was then performed on thyroidectomy-only patients.ConclusionOverall, 93% of patients undergoing thyroidectomy and parathyroidectomy require 20 or fewer OMEQs by their postoperative visit. We therefore recommend these patients be discharged with 20 OMEQs, both to minimize waste and increase patient safety.

How long should we follow patients after apparently curative parathyroidectomy

Background. Little is known about the long‐term recurrence risk for primary hyperparathyroidism after immediately “curative” parathyroidectomy. This study aimed to evaluate the risk of recurrent hyperparathyroidism in the 10 years after operation. Method. We retrospectively identified patients with sporadic primary hyperparathyroidism undergoing initial parathyroidectomy between November 1, 2000 and June 30, 2005. Recurrence was defined as serum calcium >10.2 mg/dL after 6 months from operation. Kaplan‐Meier estimates and Cox proportional hazards were used to evaluate disease‐free survival and predictors of recurrence. Results. We evaluated 196 patients with a 14.8% 10‐year recurrence rate. Median time to recurrence was 6.3 years (interquartile range 3.4–10.8 years), and 34.5% of all recurrences were identified >10 years after operation. There was no difference in recurrence between open and minimally invasive operation (P = .448). Double adenomas (P = .006), intraoperative parathyroid hormone drop <70% (P = .015), and young age (P = .032) were predictive of disease recurrence. Multivariable analysis demonstrated that older age was protective against recurrence (hazard ratio 0.97, 95% confidence interval 0.94–0.99, P = .034), while double adenomas (hazard ratio 3.52, 95% confidence interval 1.23–10.08, P = .019) were an independent predictor for recurrence. Conclusion. The long‐term recurrence rate for sporadic primary hyperparathyroidism after “curative” parathyroidectomy is likely greater than reported. With over one‐third of our institutional recurrences at >10 years after the initial operation, long‐term follow‐up is essential.

Outpatient Thyroidectomy: Is it Safe?

Outpatient thyroid surgery is controversial because of concerns over life-threatening cervical hematoma. Despite this concern, outpatient thyroidectomy is becoming increasingly common, especially among high-volume endocrine surgeons. Multiple studies have now demonstrated that careful patient selection combined with surgeon experience can result in successful and safe surgery without a full inpatient admission. This article reviews the data on safety and outcomes for outpatient thyroidectomy and discusses several techniques used to minimize risk to patients.

Selective Versus Non-selective α-Blockade Prior to Laparoscopic Adrenalectomy for Pheochromocytoma

BackgroundThe optimal preoperative α-blockade strategy is debated for patients undergoing laparoscopic adrenalectomy for pheochromocytomas. We evaluated the impact of selective versus non-selective α-blockade on intraoperative hemodynamics and postoperative outcomes.MethodsWe identified patients having laparoscopic adrenalectomy for pheochromocytomas from 2001 to 2015. As a marker of overall intraoperative hemodynamics, we combined systolic blood pressure (SBP)xa0>xa0200, SBPxa0<xa080, SBPxa0<xa080 andxa0>200, pulsexa0>xa0120, vasopressor infusion, and vasodilator infusion into a single variable. Similarly, the combination of vasopressor infusion in the post-anesthesia care unit (PACU) and the need for intensive care unit (ICU) admission provided an overview of postoperative support.ResultsWe identified 52 patients undergoing unilateral laparoscopic adrenalectomy for pheochromocytoma. Selective α-blockade (i.e. doxazosin) was performed in 35xa0% (nxa0=xa018) of patients, and non-selective blockade with phenoxybenzamine was performed in 65xa0% (nxa0=xa034) of patients. Demographics and tumor characteristics were similar between groups. Patients blocked selectively were more likely to have an SBPxa0<xa080 (67xa0%) than those blocked with phenoxybenzamine (35xa0%) (pxa0=xa00.03), but we found no significant difference in overall intraoperative hemodynamics between patients blocked selectively and non-selectively (pxa0=xa00.09). However, postoperatively, patients blocked selectively were more likely to require additional support with vasopressor infusions in the PACU or ICU admission (pxa0=xa00.02). Hospital stay and complication rates were similar.ConclusionLaparoscopic adrenalectomy for pheochromocytoma is safe regardless of the preoperative α-blockade strategy employed, but patients blocked selectively may have a higher incidence of transient hypotension during surgery and a greater need for postoperative support. These differences did not result in longer hospital stay or increased complications.

Chasing Calcitonin: Reoperations for Medullary Thyroid Carcinoma

In their article, ‘‘Biochemical Cure Following Reoperations for Medullary Thyroid Carcinoma: A MetaAnalysis,’’ Rowland et al. provide a very insightful review of the optimal surgical approach for recurrent medullary thyroid cancer. Because no randomized studies exist to guide practicing thyroid surgeons, these authors conducted a thorough meta-analysis of existing studies to determine whether patients with persistently elevated calcitonin after their initial surgery should undergo a targeted procedure removing gross disease or a more extensive compartmentoriented approach. The overall success rate in their study, defined as normalization of calcitonin, was 16.2 %. When classified by surgical technique, a selective approach yielded a biochemical cure rate of 10.5 % (95 % confidence interval [CI], 6.4–14.7), whereas a compartmentoriented approach led to a biochemical cure for 18.6 % (95 % CI, 15.9–21.3). The higher rate of calcitonin normalization with a compartment-oriented surgery was balanced, however, by a higher complication rate that included recurrent laryngeal nerve injury in 5.7 % compared with 1.9 % in the selective surgery group. The compartment-oriented group also experienced an increased incidence of thoracic duct injury, Horner’s syndrome, spinal accessory nerve injury, wound infection, and seromas, but the rate of permanent hypoparathyroidism actually appeared to be higher in the targeted surgery group. The authors note that their data on complications should be interpreted cautiously because their study was not designed to assess this end point. However, it does seem reasonable that more extensive surgery leads to an overall higher complication rate. The current study continues a long tradition by Dr. Moley’s group of important contributions to our understanding of medullary thyroid cancer, especially regarding the surgical management of recurrent or persistent disease. The philosophy of compartment-orientated neck dissection represents the preferred approach for both medullary thyroid cancer and the more common papillary thyroid cancer. However, several questions must be considered when this approach is applied to clinical practice, and some of the most important issues focus on timing and duration. Should we chase calcitonin levels? When is the right time to reoperate? Will this operation prolong survival or palliate symptoms? Will the normalization of calcitonin be durable? The authors were not able to provide data on the duration of biochemical cure, so long-term benefits of compartment-oriented surgery are unclear. They also were unable to determine whether survival or quality of life was improved by a compartment-oriented operation because the included studies focused on biochemical cure as the primary end point. Although they correctly note that biochemical cure correlates with prolonged survival, the argument for a particular surgical approach would have been strengthened by estimating more definitive end points. An aggressive compartment-oriented surgery with a higher complication rate is reasonable if it leads to prolonged survival or palliation of symptoms but becomes less palatable when it is only the first of many reoperations. Identifying patients who derive the most benefit from a compartment-oriented resection is clearly not an easy task because more than 80 % of the patients in this study still had persistent disease after reoperation. Before adopting a more aggressive surgical approach it will be important for future work to better identify patients likely to obtain a Society of Surgical Oncology 2014

GAUGING THE EXTENT OF THYROIDECTOMY FOR INDETERMINATE THYROID NODULES: AN ONCOLOGIC PERSPECTIVE

OBJECTIVEnIncreasing emphasis is being placed on appropriateness of care and avoidance of over- and under-treatment. Indeterminate thyroid nodules (ITNs) present a particular risk for this problem because cancer found via diagnostic lobectomy (DL) often requires a completion thyroidectomy (CT). However, initial total thyroidectomy (TT) for benign ITN results in lifelong thyroid hormone replacement. We sought to measure the accuracy and factors associated with the extent of initial thyroidectomy for ITN.nnnMETHODSnWe queried a single institution thyroid surgery database for all adult patients undergoing an initial operation for ITN. Multivariate logistic regression identified factors associated with either oncologic under- or overtreatment at initial operation.nnnRESULTSnThere were 639 patients with ITN. The median age was 52 (range, 18 to 93) years, 78.4% were female, and final pathology revealed a cancer >1 cm in 24.7%. The most common cytology was follicular neoplasm (45.1%) followed by Hürthle cell neoplasm (20.2%). CT or initial oncologic undertreatment was required in 58 patients (9.3%). Excluding those with goiters, 19.0% were treated with TT for benign final pathology. Multivariate analysis failed to identify any factor that independently predicted the need for CT. Female gender was associated with TT in benign disease (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.0 to 4.5; P = .05). Age >45 years predicted correct initial use of DL (OR, 2.6; 95% CI, 1.2 to 5.7; P = .02). Suspicious for papillary thyroid carcinoma (OR, 5.7; 95% CI, 2.1 to 15.3; P<.01) and frozen section (OR, 9.7; 95% CI, 2.5 to 38.6; P<.01) were associated with oncologically appropriate initial TT. The highest frequency of CT occurred in patients with follicular lesion of undetermined significance (11.6%). TT for benign final pathology occurred most frequently in patients with a Hürthle cell neoplasm (24.8%).nnnCONCLUSIONnIn patients with ITN, nearly 30% received an inappropriate extent of initial thyroidectomy from an oncologic standpoint. Tools to pre-operatively identify both benign and malignant disease can assist in the complex decision making to gauge the proper extent of initial surgery for ITN.nnnABBREVIATIONSnATA = American Thyroid Association AUS = atypia of undetermined significance CI = confidence interval CT = completion thyroidectomy FLUS = follicular lesion of undetermined significance ITN = indeterminate thyroid nodule OR = odds ratio PTC = papillary thyroid carcinoma TT = total thyroidectomy.

Should vitamin D deficiency be corrected before parathyroidectomy

BACKGROUNDnVitamin D deficiency is common in patients with hyperparathyroidism, but the importance of replacement before surgery is controversial. We aimed to evaluate thexa0impact of vitamin D deficiency on the extent of resection and risk of postoperative hypocalcemia for patients undergoing parathyroidectomy for primary hyperparathyroidism.nnnMETHODSnWe identified patients with primary hyperparathyroidism undergoing parathyroid surgery between 2000 and 2015 using a prospectively maintained database. Patients with normal (≥30xa0ng/mL) vitamin D were compared to those with levels less than 30xa0ng/mL.nnnRESULTSnThere were 1015 (54%) patients with normal vitamin D and 872 (46%) patients with vitamin D deficiency undergoing parathyroidectomy for primary hyperparathyroidism. Vitamin D deficiency was associated with higher preoperative parathyroid hormone (median 90 versus 77 pg/mL, Pxa0<xa00.001) and calcium (median 10.5 versus 10.4xa0mg/dL, Pxa0<xa00.001) compared with normal vitamin D. To achieve similar cure rates, patients withxa0vitamin D deficiency were less likely to require removal of more than one gland (20%xa0versus 30%, Pxa0<xa00.001) than patients with normal vitamin D. Patients with vitamin Dxa0deficiency had similar rates of persistent (1.5% versus 2.0%, Pxa0=xa00.43) and recurrent (1.7%xa0versus 2.6%, Pxa0=xa00.21) hyperparathyroidism. Postoperatively, both groups had equivalent rates of transient (2.3% versus 2.3%, Pxa0=xa00.97) and permanent (0.2% versus 0.4%, Pxa0=xa00.52) hypocalcemia.nnnCONCLUSIONSnRestoring vitamin D in deficient patients should not delay the appropriate surgical treatment of primary hyperparathyroidism. Deficient patients are more likely to be cured with the excision of a single adenoma and no more likely to suffer persistence, recurrence, or hypocalcemia than patients with normal vitamin D.

When patients call their surgeon's office: an opportunity to improve the quality of surgical care and prevent readmissions

BACKGROUNDnLittle is known about care coordination and communication with outpatient endocrine surgery patients. This study evaluated phone calls between office nurses and surgical patients to identify common issues addressed and their effect on patient care.nnnMETHODSnQualitative analysis of preoperative and postoperative phone conversations between office nurses and endocrine surgery patients.nnnRESULTSnWe identified 183 thyroidectomy patients with 38% contacting our office before surgery and 54% within 30xa0days after surgery. Common reasons for preoperative calls included questions about preoperative evaluation (21%), medications (18%), and insurance and/or work paperwork (12%). Postoperatively, common topics included medications (23%), laboratory results (23%), and concerns about wounds (12%). Nursing staff prevented unnecessary readmission in 7 patients (4%) whereas appropriately referring 16 (9%) for early evaluation.nnnCONCLUSIONSnPatients frequently contact their surgeons before and after endocrine surgery cases. Our findings suggest several areas for improving communication with patients.