Search

Healthcare systems are transitioning to value-based payment models based on analysis of quality over cost. To gain an understanding of the relationship between surgeon volume and health care costs, we compared the direct costs of thyroidectomy performed by dedicated high-volume endocrine surgeons and low-volume surgeons within a large health care system. We evaluated all thyroid surgeries performed within a single billing year at a single health care system. We defined high-volume surgeons as those who treated >50 thyroid cases yearly and compared them to low-volume surgeons. To account for multicomponent procedures, we added the relative value units for the components of the cases. Then, we divided them into low–relative value units, intermediate–relative value units, and high–relative value units groups. We analyzed categorical and continuous variables using the χ2 analysis and Wilcoxon rank sum test, respectively. We identified 674 thyroidectomy procedures performed by 27 surgeons, of whom 6 high-volume surgeons performed 79% of cases. Relative value unit distribution differed between the groups, with high-volume surgeons performing more intermediate–relative value unit (58% vs 34.7%, P <.01) and high–relative value unit (24.6% vs 20.6%, P <.01) cases, whereas low-volume surgeons performed more low–relative value unit cases (45% vs 17%, P <.01). Overall, high-volume surgeons incurred a 26% reduction in total costs (P <.01) and a 33% reduction in discretionary expenses (P <.01) across all relative value unit groups. High-volume endocrine surgeons perform thyroid procedures at a lower cost than their low-volume counterparts, a difference that is magnified when stratified by relative value unit groups. [ABSTRACT FROM AUTHOR]

Near-infrared autofluorescence imaging is an adjunct to parathyroid identification. As it does not show perfusion, it is important to study its impact during thyroidectomy by measuring quantifiable data on parathyroid detection rather than function. The aim of this study was to compare incidental parathyroidectomy rates in patients undergoing total thyroidectomy with or without near-infrared autofluorescence. Retrospective study of patients who underwent total thyroidectomy between 2014 and 2022 at one center. Clinical parameters, including rates of incidental parathyroid tissue on pathology reports, were compared between near-infrared autofluorescence and non-near-infrared autofluorescence groups. Near-infrared autofluorescence was used to guide dissection (identification) and/or to confirm tissue as parathyroid (confirmation). Statistical analysis was done with Wilcoxon rank sum test and χ2 analysis. There were 300 patients in the near-infrared autofluorescence and 750 patients in the non-near-infrared autofluorescence group. The rate of incidental parathyroid tissue detection on final pathology was 13.3% (n = 40) in the near-infrared autofluorescence and 23.2% (n = 174) in the non-near-infrared autofluorescence group (P <.001). The rate of incidental parathyroid tissue detected on pathology with near-infrared autofluorescence decreased when used for identification and confirmation of parathyroid tissue (30.0% to 13.4%, P <.001), but not when used for confirmation only (19.6% to 18.5%, P =.89). Impact of near-infra red autofluorescence in decreasing the rate of incidental parathyroid tissue was more profound for early (38.5% to 17.1%) versus mid-late career surgeons (20% to 13%). Our results suggest that the use of near-infrared autofluorescence may help decrease the rate of incidental parathyroid tissue detected on final pathology if used for both identification and confirmation of parathyroid glands during thyroidectomy. [ABSTRACT FROM AUTHOR]

The usefulness of incorporating near-infrared autofluorescence into the surgical workflow of endocrine surgeons is unclear. Our aim was to develop a prospective registry and gather expert opinion on appropriate use of this technology. This was a prospective multicenter collaborative study of patients undergoing thyroidectomy and parathyroidectomy at 7 academic centers. A questionnaire was disseminated among 24 participating surgeons. Overall, 827 thyroidectomy and parathyroidectomy procedures were entered into registry: 42% of surgeons found near-infrared autofluorescence useful in identifying parathyroid glands before they became apparent; 67% correlated near-infrared autofluorescence pattern to normal and abnormal glands; 38% of surgeons used near-infrared autofluorescence, rather than frozen section, to confirm parathyroid tissue; and 87% and 78% of surgeons reported near-infrared autofluorescence did not improve the success rate after parathyroidectomy or the ability to find ectopic glands, respectively. During thyroidectomy, 66% of surgeons routinely used near-infrared autofluorescence to rule out inadvertent parathyroidectomy. However, only 36% and 45% felt near-infrared autofluorescence decreased inadvertent parathyroidectomy rates and improved ability to preserve parathyroid glands during central neck dissections, respectively. This survey study identified areas of greatest potential use for near-infrared autofluorescence, which can form the basis of future objective trials to document the usefulness of this technology. [ABSTRACT FROM AUTHOR]

The Afirma Genomic Sequencing Classifier uses whole transcriptome RNA sequencing to identify thyroid nodules as benign or suspicious. The Afirma Xpression Atlas became available in 2018 and reports findings across 593 genes, including 905 variants and 235 fusions. When an alteration is identified, its risk of malignancy and associated neoplasm type is listed. We report the results of Afirma Xpression Atlas testing at our institution during its first 2 years of clinical use. All patient charts with indeterminate thyroid nodules and Afirma Xpression Atlas results at our institution were reviewed. Thyroid nodule characteristics, cytology, Afirma Genomic Sequencing Classifier results, Afirma Xpression Atlas results, and final histopathology were reported. Afirma Xpression Atlas was performed on 136 indeterminate nodules since May 2018, and 103 met inclusion criteria. Forty-three nodules had positive Afirma Xpression Atlas results, and of these, 83.7% were follicular cell-derived thyroid cancer on surgical histopathology. This is similar to the overall 82.5% positive predictive value among Afirma Genomic Sequencing Classifier–suspicious indeterminate nodules during the same time period. Of the 60 nodules with negative Afirma Xpression Atlas, 73.3% were follicular cell-derived thyroid cancer on surgical histopathology. Afirma Xpression Atlas positivity is predictive of follicular cell-derived thyroid cancer, but its positive predictive value is similar to that of Genomic Sequencing Classifier–suspicious results alone at our institution, which is higher than previously published. Specific mutations likely predict follicular cell-derived thyroid cancer with higher accuracy, but our current sample size of any given mutation is too small to evaluate this further. Larger studies are needed to determine whether Afirma Xpression Atlas results predictably inform the risk of malignancy and tumor characteristics in thyroid nodules. [ABSTRACT FROM AUTHOR]

Preoperative localization studies are essential for parathyroid re-exploration. When noninvasive studies do not regionalize the abnormal parathyroid gland, selective parathyroid venous sampling may be employed. We studied the utility of parathyroid venous sampling in reoperative parathyroid surgery and the factors that may affect parathyroid venous sampling results. Patients with hyperparathyroidism and previous cervical surgery undergoing evaluation for reoperative parathyroidectomy over a 20-year period were identified. Patients with indeterminate or negative noninvasive studies underwent parathyroid venous sampling. Parathyroid hormone values were mapped with a ≥2-fold increase above peripheral signifying positive parathyroid venous sampling. These results were correlated with reoperative findings. Parathyroid venous sampling was positive in 113 of 140 (81%). Re-exploration occurred in 75 (66%). Parathyroid venous sampling correctly detected the region of abnormal glands in 58 (77%). With 1 gradient, 1 abnormal gland was found in 81%. With multiple gradients, 1 abnormal gland was found in 78%, most often at the site with the largest gradient. Eighty percent of patients who underwent reoperative parathyroidectomy were biochemically cured. Parathyroid venous sampling can guide parathyroid re-exploration when noninvasive localizing studies are indeterminate. Expectation of 1 versus multiple remaining glands was key in interpreting the results. [ABSTRACT FROM AUTHOR]

Under recognition of primary hyperparathyroidism can lead to delays in diagnosis and surgical management. We aimed to establish a time course for primary hyperparathyroidism from initial hypercalcemia to surgery and evaluate the impact of guidelines for surgical referral on this time course. A retrospective review was conducted on all patients undergoing parathyroidectomy for primary hyperparathyroidism in 2013 at the Cleveland Clinic. Patients were stratified by adherence to 2008 indications for surgery guidelines, age, calcium values, osteoporosis, history of nephrolithiasis, 24-hour urinary calcium values, and estimated glomerular filtration rate. 219 patients with sporadic primary hyperparathyroidism underwent initial surgery. Twenty-three (10.5%) normocalcemic patients were excluded. Time course from initial hypercalcemia to surgery was 3.9 years for 137 (70%) patients who met objective guideline criteria versus 3.8 years for 59 (30%) patients who did not meet objective guideline criteria (P =.87). Stratification by age <50 years and calcium value >11.5 mg/dL revealed earlier times to surgery. However, osteoporosis, nephrolithiasis, 24-hour urinary calcium values, and estimated glomerular filtration rate had no impact. There is a delayed time course for patients with sporadic primary hyperparathyroidism from initial hypercalcemia to surgery. Despite published objective criteria, one third of the patients who underwent surgery did not meet criteria, signifying the importance of clinician and patient decision making. Furthermore, patients with osteoporosis and nephrolithiasis who can significantly benefit from surgical cure have no apparent impact on the time to surgery. Overall, the objective guideline criteria have no effect in referral patterns suggesting a call for revision. [ABSTRACT FROM AUTHOR]

The aim of this study was to determine both the accuracy of near infrared fluorescence imaging to detect parathyroid glands and the potential indications of near infrared fluorescence imaging in thyroid and parathyroid surgery by correlating the autofluorescence signature with the pathologic specimen. This was an institutional review board-approved, prospective study of patients undergoing thyroidectomy and parathyroidectomy with near infrared fluorescence imaging. Each specimen sent to pathology was inspected with near infrared fluorescence imaging and predicted to be either parathyroid or non-parathyroid tissue by its autofluorescence signature and then correlated with the pathologic findings. Autofluorescence was demonstrated to be present in 98% of the parathyroid glands, with 23% identified correctly with infrared based on the autofluorescence signature before visual identification by the surgeon. There were 550 specimens that were imaged with autofluorescence and then sent to pathology. For these samples, sensitivity, specificity, and positive and negative predictive values to predict parathyroid tissue were 98.5%, 97.2%, 95.1%, and 99.1%. In 5% of the total thyroidectomy specimens, incidentally resected parathyroid glands were identified with autofluorescence, leading to their subsequent reimplantation. In patients with parathyroid disease and negative preoperative localization, 21% of abnormal glands were recognized with autofluorescence before visual identification by the surgeon. Although the ability of infrared autofluorescence to confirm the presence of parathyroid tissue within surgical specimens was high, its power to find parathyroid glands in situ before visual recognition by surgeons was low. These advantages and limitations should be kept in mind when incorporating this technology into an endocrine surgical practice. Once a parathyroid seems to have been identified by the surgeon or tissue that looks like a parathyroid gland is identified, the autofluorescence signature is a very accurate assurance of parathyroid tissue. [ABSTRACT FROM AUTHOR]

Although frequently used as an adjunct to cytology in patients with differentiated thyroid cancers, interpretation of thyroglobulin washout remains unclear. We aim to compare the utility of different analytic tools to develop recommendations for use in post-total thyroidectomy follow-up. This is an institutional review board-approved retrospective study of patients who underwent lymph node fine needle aspiration biopsy with thyroglobulin washout between 2012 and 2018, during the post-total thyroidectomy follow-up of differentiated thyroid cancer. The utilities of thyroglobulin washout concentration, thyroglobulin washout/serum thyroglobulin ratio, and absolute thyroglobulin content were compared. Sixty-four patients underwent 79 fine needle aspirations with thyroglobulin washout of cervical lymph nodes. Fifty-two lymph nodes were found to be metastatic and 27 benign. One patient had a pathologically confirmed lymph node metastasis despite a thyroglobulin washout of 0. The optimal cutoffs of thyroglobulin washout, thyroglobulin washout/serum thyroglobulin ratio, and absolute thyroglobulin content to predict metastatic involvement were 2.5 ng/ml (94% sensitive, 100% specific), 0.1 (100% sensitive and specific), and 12.5 (94% sensitive, 100% specific), respectively. The second measure lacked utility in patients with undetectable serum thyroglobulin. The use of thyroglobulin washout concentration or thyroglobulin washout/serum thyroglobulin ratio has drawbacks based on variations in technique and clinical scenario. Absolute thyroglobulin content is an alternative that may be a more objective expression of thyroglobulin washout. [ABSTRACT FROM AUTHOR]

Abstract Background Patient-reported outcome measures are being used increasingly to assess disease severity and response to surgery. The purpose of this study was to create and validate a patient-reported outcome measure for symptoms of thyroid enlargement and hyperparathyroidism, 2 conditions where the presence of preoperative symptoms and response to surgery is often questioned. Methods A questionnaire reviewing common symptoms was developed from a literature review and expert opinion. Internal validity, reliability, and initial responsiveness to surgery were evaluated. Results Patient-Reported Outcome Measure for Parathyroid and Thyroid Disease (PROMPT) consists of 30 items: 10 compressive items and 20 hyperparathyroidism items; we evaluated 302 surveys collected over 10 months. PROMPT showed high internal consistency for compressive and hyperparathyroid constructs (Cronbach's α 0.84 and 0.95). Constructs were scored from 0–100, with greater scores corresponding to increased severity of symptoms. Preoperatively, patients with a goiter demonstrated greater compressive scores compared with other thyroid patients and hyperparathyroid patients (goiter, 47.5; nodule/other, 38.4; hyperparathyroid, 29.8; P <.0001). PROMPT demonstrated high test–retest reliability with acceptable intraclass correlation coefficients for both compressive score and hyperparathyroid score (0.840 and 0.646). Hyperparathyroid scores improved 2 weeks after (48.6 postop, 44.0 preop, P =.0470). Conclusion We validated a novel measure for symptoms of hyperparathyroidism and goiter. PROMPT demonstrates high internal consistency, test–retest reliability, and preliminary analysis, which suggests that it is sensitive to change after surgery. [ABSTRACT FROM AUTHOR]

Metal Organic Frameworks (MOFs) have the potential to be used as adsorbents in industrial separations. Different ligand lengths can generate MOFs with similar topology but differing pore sizes. Molecular simulations were used in this work to assess the adsorption isotherms, heats of adsorption and selectivity of H 2 S and CH 4 in MOF UiO-66, UiO-67, and UiO-68. Detailed analysis of the distribution of molecules in the cages and the radial distribution functions suggest that the effect of the linker on the macroscopic properties is negligible at low pressures, but it becomes evident at high pressures, where adsorption far from the linker is observed in large pore materials. Based on the adsorption selection parameter, UiO-67 shows better performance in a wider range of conditions than the other materials. [ABSTRACT FROM AUTHOR]

Abstract Background Although the concept of surgeon-performed fine needle aspiration of thyroid nodules is established, experience with surgeon-performed lymph node fine needle aspiration is scant. We aimed to study the efficacy of surgeon-performed lymph node fine needle aspiration in patients with thyroid pathologic conditions. Methods This is an institutional review board–approved study of patients with thyroid pathologic conditions who underwent surgeon-performed lymph node fine needle aspiration between 2002 and 2017. Efficacy and utility were analyzed. Results A total of 201 patients with benign nodular goiter (n = 30) and thyroid cancer (n = 200) underwent 230 lymph node fine needle aspirations (89 during preoperative workup, 141 at postoperative follow-up). Insufficient aspiration rate was 6% and indeterminate cytologic results 3%. In 91% of patients with suspicious lymph nodes, definite diagnosis could be obtained by fine needle aspiration; 51% (n = 118) of fine needle aspirations indicated metastasis from thyroid cancer and 40% (n = 91) benign findings. Sensitivity and specificity of lymph node fine needle aspiration in diagnosing nodal metastasis were 92% and 89%, respectively. Cytologic testing and thyroglobulin washout indicated 95% concordance. On logistic regression, spherical shape, microcalcifications, cystic appearance, and loss of hilum on ultrasound independently predicted lymph node metastasis. Conclusion Our data indicate that an adequate surgeon-performed lymph node fine needle aspiration is highly accurate in diagnosing nodal status in thyroid pathologic conditions. We recommend adoption of this technique, when feasible, to develop an efficient, comprehensive thyroid practice. [ABSTRACT FROM AUTHOR]

Background and Aims: The use of the word retard ("the r-word") among adolescents sheds light on societal views about individuals with intellectual disability and the need to address the colloquial use of this word and its underlying stigma. Schools provide an important platform for intervening to promote social change among youth. The present study examined the impact of a schoolwide social inclusion program on students' bystander behavior against the use of the r-word.Methods and Procedures: 1233 students from 5 high schools were surveyed about the prevalence of the r-word in their school, the contexts in which it is used, and their bystander behavior in response to the word. Approximately 40% of surveyed students participated in an R-word Campaign, Unified Sports team, and/or Unified Club as part of the Special Olympics Unified Champion Schools (UCS) program.Outcomes and Results: Students' prosocialness, the context in which the r-word was used, and participation in UCS activities significantly predicted active bystander behavior in response to the r-word.Conclusions and Implications: By empowering students to be active bystanders against the use of the r-word in school, school-based interventions provide a promising avenue for addressing both the use of the r-word and its underlying stigma. [ABSTRACT FROM AUTHOR]

Background Primary aldosteronism causes hypertension and hypokalemia and is often surgically treatable. Diagnosis includes elevated plasma aldosterone, suppressed plasma renin activity, and elevated aldosterone renin ratio. Adrenalectomy improves hypertension and hypokalemia. Postoperative plasma aldosterone and plasma renin activity may be useful in documenting cure or failure. Method A retrospective analysis of patients who underwent adrenalectomy for primary aldosteronism from 2010 to 2016 was performed, analyzing preoperative and postoperative plasma aldosterone, plasma renin activity, hypertension, and hypokalemia. The utility of postoperative testing was assessed. Clinical cure was defined as improved hypertension control and resolution of potassium loss. Biochemical cure was defined as aldosterone renin ratio reduction to <23.6. Results Forty-four patients were included; 20 had plasma aldosterone and plasma renin activity checked on postoperative day 1. In the study, 40/44 (91%) were clinically cured. All clinical failures had of biochemical failure at follow-up. Postoperative day 1aldosterone renin ratio <23.6 had PPV of 95% for clinical cure. Cured patients had mean plasma aldosterone drop of 33.1 ng/dL on postoperative day 1; noncured patient experienced 3.9 ng/dL increase. A cutoff of plasma aldosterone decrease of 10 ng/dL had high positive predictive value for clinical cure. Conclusion Changes in plasma aldosterone and plasma renin activity after adrenalectomy correlate with improved hypertension and hypokalemia. The biochemical impact of adrenalectomy manifests as early as postoperative day 1. We propose a plasma aldosterone decrease of 10 ng/dL as a criterion to predict clinical cure. [ABSTRACT FROM AUTHOR]

Introduction A comprehensive cervical ultrasound evaluation is essential in the operative planning of patients with thyroid disease. Reliance on radiographic reports alone may result in incomplete operative management as pathologic lymph nodes are often not palpable and evaluation of the lateral neck is not routine. This study examined the role of surgeon-performed ultrasound in the evaluation of patients who underwent lateral neck dissection for thyroid cancer. Methods We conducted a retrospective review of a prospectively maintained database of patients who underwent therapeutic lymph node dissection for thyroid cancer between 2001 and 2016 at our tertiary referral center. All patients had surgeon-performed ultrasound preoperatively by 1 of 7 endocrine surgeons. These findings were compared with prereferral imaging studies to determine the value of surgeon-performed ultrasound to their overall treatment. Results Of 92 patients who underwent thyroidectomy with lateral neck dissection, 97% had prereferral imaging of the neck (ultrasonography, computed tomography, positron emission tomography). Of these patients, nodal disease was suggested by computed tomography scanning in 70.8% and by ultrasonography in 54%. Of all patients, 45% had positive lateral neck nodes detected only on surgeon-performed ultrasound despite prior neck imaging. Nodal disease was identified in 50% of patients with only 1 study and 50% of patients with greater than 1 study before surgeon-performed ultrasound. Of patients with nodes detected by surgeon-performed ultrasound, only 67% had a prereferral diagnosis of thyroid cancer. Conclusions Our data demonstrate that reliance on standard preoperative imaging alone would have led to an incorrect initial operation in 45% of our patients. Awareness of the limitations of prereferral imaging is important for surgeons treating patients with thyroid and parathyroid disease. Surgeon-performed ultrasound is a useful tool in the diagnosis and accurate staging of patients. [ABSTRACT FROM AUTHOR]

Background At 12 months after a parathyroid operation, we expect cured patients to have biochemical profiles similar to those of healthy individuals. The aim of the current study was to compare the biochemical characteristics patients at 12 months after parathyroidectomy for primary sporadic hyperparathyroidism with those of healthy controls. Methods A total of 547 patients who underwent parathyroid neck operation for primary sporadic hyperparathyroidism from 2000–2014 were analyzed. A control group consisted of 74 healthy subjects. Calcium and parathyroid hormone were collected perioperatively. Graphic plots of the relationship between calcium versus parathyroid hormone (95% confidence intervals) were used to compare the biochemical profiles of patients after parathyroid operation and controls. Results Preoperatively, patients with primary sporadic hyperparathyroidism had a calcium level of 10.9 ± 0.5 mg/dL and parathyroid hormone level of 124.4 ± 68.5 pg/dL vs controls' values of 9.2 ± 0.3 mg/dL and 34.4 ± 13.4 pg/dL, respectively. Before operation, all primary sporadic hyperparathyroidism patients had calcium versus parathyroid hormone values outside the normal zone. At 12 months after operation, 335 (69%) patients showed normalization of the chemical profile; 13 (2.7%) had absolute elevation of calcium and parathyroid hormone, reflecting persistent disease; 2 (0.4%) patients had hypoparathyroidism after subtotal parathyroidectomy; and 149 (31%) had calcium and parathyroid hormone values outside the normal zone, not fitting into the above categories. There were no marked differences between patients with simple adenoma those with multiple-gland disease. Conclusion Longer follow-up might be needed for patients after parathyroid operation to confirm stabilization of biochemical profiles. [ABSTRACT FROM AUTHOR]

In this study, cadmium and lead ions removal from aqueous solutions using a commercial activated carbon adsorbent (CGAC) were investigated under batch conditions. The adsorbent was observed to have a coarse surface with crevices, high resistance to attrition, high surface area and pore volume with bimodal pore size distribution which indicates that the material was mesoporous. Sorption kinetics for Cd(II) and Pb(II) ions proceeded through a two-stage kinetic profile-initial quick uptake occurring within 30 min followed by a gradual removal of the two metal ions until 180 min with optimum uptake (q e,exp ) of 17.23 mg g −1 and 16.84 mg g −1 for Cd(II) and Pb(II) ions respectively. Modelling of sorption kinetics indicates that the pseudo first order (PFO) model described the sorption of Pb(II) ion better than Cd(II), while the reverse was observed with respect to the pseudo second order (PSO) model. Intraparticle diffusion modelling showed that intraparticle diffusion may not be the only mechanism that influenced the rate of ions uptake. Isotherm modelling was carried out and the results indicated that the Langmuir and Freundlich models described the uptake of Pb(II) ion better than Cd(II) ion. A comparison of the two models indicated that the Langmuir isotherm is the better isotherm for the description of Cd(II) and Pb(II) ions sorption by the adsorbent. The maximum loading capacity (q max ) obtained from the Langmuir isotherm was 27.3 mg g −1 and 20.3 mg g −1 for Cd(II) and Pb(II) ions respectively. [ABSTRACT FROM AUTHOR]

Background. Given the increasing number of endocrine surgery fellowship graduates, we investigated if expectations and job opportunities changed over time. Methods. American Association of Endocrine Surgeons (AAES) fellowship graduates, surgery department chairs, and physician recruiters were surveyed. Univariate analysis was performed with JMP Pro 12 software. Results. We identified 141 graduates from 2008--2015; survey response rate was 72% (n = 101). Compared to earlier graduates, fewer academic opportunities were available for the recent graduates who intended to join them (P = . 001). Unlike earlier graduates, recent graduates expected to also perform elective general surgery, which ultimately represented a greater percentage of their practices (both P < .05). Interview offers increased for recent graduates, but job offers decreased. Overall, 84% of graduates matched their intended practice type and 98 % reported being satisfied. Reponses from graduates, department chairs, and physician recruiters highlighted opportunities to improve mentor involvement, job search strategies, and online job board utilization. Conclusion. The endocrine surgery job market has diversified resulting in more graduates entering nonacademic practices and performing general surgery. This rapid evolution supports future analyses of the job market and opportunities for job creation. Almost every graduate reported job satisfaction, which encourages graduates to consider joining both academic and nonacademic practices equally. [ABSTRACT FROM AUTHOR]

Background We analyzed the demographics of high-volume surgeons (HVS) for endocrine operations. Methods We characterized HVS by region, specialty, gender, teaching-affiliation, American Association of Endocrine Surgeons (AAES) membership, and decade they entered practice. Providers were general surgeons (GS) and otolaryngologists (ENT); fellowship trained (FT) or not FT (NFT). Results We identified 395 HVS in 47 states entering practice between 1958 and 2011. Sixty-eight percent were GS, 35% were FT, and 35% were AAES members. GS, FT surgeons, and endocrine surgery FT surgeons (ES) performed more operations per surgeon. More FT surgeons were in Northeast, West (W), and Midwest than Southeast (SE) and Southwest (SW; P < .0001). More teaching surgeons and AAES members were in the Northeast and Midwest than SE, W, and SW ( P < .0001). FT-GS increased over decades ( P < .0001) but not FT-ENT ( P = .3). Representation of ES, AAES members, and females increased over decades ( P < .0001). Conclusion The workforce for endocrine operations displayed increased representation of GS, FT surgeons, and women, correlating with the profile of recent AAES fellowship graduates. More insight is needed to understand why most HVS were not AAES members. Regional disparities can guide the placement of endocrine surgeons into both academic and community practices, increasing trainee exposure and patient access to specialty care. [ABSTRACT FROM AUTHOR]

Background The aim of this study was to analyze the usefulness of thyrotropin receptor messenger RNA (TSHR-mRNA) combined with neck ultrasonography (US) in the management of thyroid nodules with Bethesda III-V cytology. Methods Cytology slides of patients with a preoperative fine needle aspiration (FNA) and TSHR-mRNA who underwent thyroidectomy between 2002 and 2011 were recategorized based on the Bethesda classification. Results of thyroid FNA, TSHR-mRNA, and US were compared with the final pathology. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. Results There were 12 patients with Bethesda III, 112 with Bethesda IV, and 58 with Bethesda V cytology. The sensitivity of TSHR-mRNA in predicting cancer was 33%, 65%, and 79 %, and specificity was 67%, 66%, and 71%, for Bethesda III, IV, and V categories, respectively. For the same categories, the PPV of TSHR-mRNA was 25%, 33%, and 79%, respectively; whereas the NPV was 75%, 88%, and 71%, respectively. The addition of neck US to TSHR-mRNA increased the NPV to 100% for Bethesda III, and 86%, for Bethesda IV, and 82% for Bethesda V disease. Conclusion This study documents the potential usefulness of TSHR-mRNA for thyroid nodules with Bethesda III-V FNA categories. TSHR-mRNA may be used to exclude Bethesda IV disease. A large sample analysis is needed to determine its accuracy for Bethesda category III nodules. [ABSTRACT FROM AUTHOR]

Background The multidimensional nomogram calculating the upper limit of normal PTH (maxPTH) model identifies a personalized upper limit of normal parathyroid hormone (PTH) and successfully predicts classical primary hyperparathyroidism (PHP). We aimed to assess whether maxPTH can distinguish normocalcemic PHP (NCPHP) from secondary hyperparathyroidism (SHP), including subjects who underwent bariatric surgery (BrS). Methods A total of 172 subjects with 359 complete datasets of serum calcium (Ca), 25-OH vitamin D, and intact PTH from Oregon were analyzed: 123 subjects (212 datasets) with PHP and 47 (143) with SHP, including 28 (100) with previous BrS. An improved prediction model, MultIdimensional evaluation for Primary hyperparaTHyroidism (Mi-PTH), was created with the same variables as maxPTH by the use of a combined cohort (995 subjects) including participants from previous studies. Results In the Oregon cohort, maxPTH's sensitivity was 100% for classical PHP and 89% for NCPHP, but only 50% for normohormonal PHP (NHPHP) and 40% specific for SHP. In comparison, although sensitivity for NCPHP was similar (89%), Mi-PTH vastly improved SHP specificity (85%). In the combined cohort, Mi-PTH had better sensitivity of 98.5% (vs 95%) and specificity 97% (vs 85%). Conclusion MaxPTH was sensitive in detecting PHP; however, there was low specificity for SHP, especially in patients who underwent BrS. The creation of Mi-PTH provided improved performance measures but requires further prospective evaluation. [ABSTRACT FROM AUTHOR]

Background Our aim was to analyze the utility of peripheral thyrotropin receptor (TSHR) messenger RNA (mRNA) in predicting and detecting the recurrence of differentiated thyroid cancer. Methods Peripheral blood TSHR-mRNA was obtained in 103 patients before and after total thyroidectomy. An analysis was performed to correlate peripheral blood TSHR-mRNA concentration with oncologic outcomes. Results Tumor types were papillary ( n = 92), follicular ( n = 9) and Hürthle cell ( n = 2) cancer. Preoperative TSHR-mRNA was ≥1.02 ng/μg in 85% (88/103). On follow-up (median 48 months), 10 patients (10 %) developed recurrence. Recurrence rate in patients with a preoperative TSHR-mRNA ≥ 1.02 ng/μg was 11% versus 0% in those with a lesser concentration. TSHR-mRNA correctly diagnosed 7 (70%) of 10 recurrences. Of 19 patients with positive thyroglobulin (Tg) antibodies, TSHR-mRNA confirmed disease-free status in 12 (63%) and recurrence in 1 (5%). For Tg, TSHR-mRNA and whole-body radioactive iodine scan, sensitivity was 70%, 70%, and 75%; specificity 94%, 76%, 97%; PPV 54%, 24%, and 67%; and NPV 97%, 96%, and 98%, respectively, in detecting recurrent disease. Conclusion This study shows that patients with preoperative TSHR-mRNA ≥1.02 ng/μg may be at a greater risk for recurrence compared with those with a lesser concentration. In the presence of Tg antibodies, TSHR-mRNA accurately predicted disease status in 68% of patients. Its overall performance in detecting recurrence was similar to Tg and whole-body radioactive iodine scan, albeit with lower specificity and PPV. [ABSTRACT FROM AUTHOR]

Background The recurrence rate of pheochromocytoma after adrenalectomy is 6.5–16.5%. This study aims to identify predictors of recurrence and optimal biochemical testing and imaging for detecting the recurrence of pheochromocytoma. Methods In this retrospective study we reviewed all patients who underwent adrenalectomy for pheochromocytoma during a 14-year period at a single institution. Results One hundred thirty-five patients had adrenalectomy for pheochromocytoma. Eight patients (6%) developed recurrent disease. The median time from initial operation to diagnosis of recurrence was 35 months. On multivariate analysis, tumor size >5 cm was an independent predictor of recurrence. One patient with recurrence died, 4 had stable disease, 2 had progression of disease, and 1 was cured. Recurrence was diagnosed by increases in plasma and/or urinary metanephrines and positive imaging in 6 patients (75%), and by positive imaging and normal biochemical levels in 2 patients (25%). Conclusion Patients with large tumors (>5 cm) should be followed vigilantly for recurrence. Because 25% of patients with recurrence had normal biochemical levels, we recommend routine imaging and testing of plasma or urinary metanephrines for prompt diagnosis of recurrence. [ABSTRACT FROM AUTHOR]

Background Tc-99 sestamibi (MIBI) scan is the imaging study most frequently used in primary hyperparathyroidism (PHP). Transcutaneous cervical ultrasonography (US) is the other modality used for preoperative localization. The aim of this study was to determine whether surgeon-performed neck US can be used as the primary localizing study in PHP. Methods This was a prospective study of 1,000 consecutive patients with first-time, sporadic PHP who underwent parathyroidectomy at a tertiary academic center. All patients had surgeon-performed neck US and MIBI before bilateral neck exploration. Results The findings at exploration were 72% single adenoma, 15% double adenoma, and 13% hyperplasia. When US suggested single-gland disease ( n = 842), MIBI was concordant in 82.5%, discordant and false in 8%, negative in 7%, and discordant but correct in 2.5%. When US suggested multigland disease ( n = 68), MIBI was concordant in 47%, discordant and false in 41%, and negative in 12%. When US was negative ( n = 90), MIBI was positive and correct in 43%, negative in 31%, and positive but false in 26%. Surgeon-performed neck US identified unrecognized thyroid nodules in 326 patients (33%), which led to fine-needle aspiration biopsy in 161 (49%) patients and thyroid surgery in 103 (32%) patients, with a final diagnosis of thyroid cancer in 24 (7%) patients. Conclusion Our results show that MIBI provides additional useful information in only a minority of patients with a positive US in PHP. Nevertheless, MIBI benefits about half of patients with a negative US. Because one-third of this patient population has unrecognized thyroid nodules as well, we propose that the most cost-effective algorithm would be to do US first and reserve MIBI for US-negative cases. [ABSTRACT FROM AUTHOR]

Purpose The goal of this study was to examine how industrial process improvement techniques could help streamline the preoperative workup. Methods Lean process improvement was used to streamline patient workup at an endocrine surgery service at a tertiary medical center utilizing multidisciplinary collaboration. The program consisted of several major changes in how patients are processed in the department. The goal was to shorten the wait time between initial call and consult visit and between consult and surgery. Results We enrolled 1,438 patients enrolled in the program. The wait time from the initial call until consult was reduced from 18.3 ± 0.7 to 15.4 ± 0.9 days. Wait time from consult until operation was reduced from 39.9 ± 1.5 to 33.9 ± 1.3 days for the overall practice and to 15.0 ± 4.8 days for low-risk patients. Patient cancellations were reduced from 27.9 ± 2.4% to 17.3 ± 2.5%. Overall patient flow increased from 30.9 ± 5.1 to 52.4 ± 5.8 consults per month (all P < .01). Conclusion Utilizing process improvement methodology, surgery patients can benefit from an improved, streamlined process with significant reduction in wait time from call to initial consult and initial consult to surgery, with reduced cancellations. This generalized process has resulted in increased practice throughput and efficiency and is applicable to any surgery practice. [ABSTRACT FROM AUTHOR]

Background Although adrenal incidentalomas (AI) are detected in ≤5% of patients undergoing chest and abdominal computed tomography (CT), their management is challenging. The current guidelines include recommendations from the National Institutes of Health, the American Association of Endocrine Surgeons (AAES), and the American Association for Cancer Education (AACE). The aim of this study was to develop a new risk stratification model and compare its performance against the existing guidelines for managing AI. Methods A risk stratification model was designed by assigning points for adrenal size (1, 2, or 3 points for tumors <4, 4–6, or >6 cm, respectively) and Hounsfield unit (HU) density on noncontrast CT (1, 2, or 3 points for HU <10, 10–20, or >20, respectively). This model was applied retrospectively to 157 patients with AI managed in an endocrine surgery clinic to assign a score to each tumor. The utility of this model versus the AAES/AACE guidelines was assessed. Results Of the 157 patients, 54 (34%), had tumors <4 cm with HU <10 (a score of 2). One third of these were hormonally active on biochemical workup and underwent adrenalectomy. The remaining two thirds were nonsecretory lesions and have been followed conservatively with annual testing. In 103 patients (66%), the adrenal mass was >4 cm and/or had indeterminate features on noncontrast CT (HU >10, irregular borders, heterogeneity), and adrenalectomy was performed after hormonal evaluation was completed (10 were hormonally active on biochemical testing). Seven of these patients (7%) had adrenocortical cancer on final pathology with tumor size <4 cm in 0, 4–6 cm in 1, and >6 cm in 5 patients. Of the hormonally inactive patients, 32% had a score of 3, 38% 4, and 30% 5 or 6. The incidence of adrenocortical cancer in these subgroups was 0, 0, and 25%, respectively. Conclusion This study shows that an algorithm that utilizes the hormonal activity at the first decision step followed by a consolidated risk stratification, based on tumor size and HU density, has a potential to spare a substantial number of patients from unnecessary “diagnostic” surgery for AI. [ABSTRACT FROM AUTHOR]

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. [Copyright &y& Elsevier]

Background: The electronic medical record (EMR) of a large, tertiary referral center was examined to study the prevalence of undiagnosed and unrecognized primary hyperparathyroidism (PHPT). Methods: The EMR was queried for outpatient serum calcium >10.5 mg/dL over a 2-year period. Results: Of 2.7 million patients, 54,198 (2%) had hypercalcemia (>10.5 mg/dL). In a 2-year sample of 7,269 patients, 1.3% (95 patients) had a recorded diagnosis of PHPT, and 0.3% (16 patients) had parathyroidectomy. Of the remaining patients, parathyroid hormone (PTH) values were recorded in 32% (2,337 patients). Of patients with PTH measured, 71% (1,662 patients) had PHPT (PTH > 30 pg/mL). Patients with calcium of 11.1–11.5 mg/dL were most likely to have PHPT (55%). Patients with calcium >12 mg/dL were most likely to have PTH measured (52%). Of hypercalcemic patients, 67% never had PTH obtained, 28% of whom were likely to have PHPT. It is estimated that 43% of hypercalcemic patients are likely to have PHPT. The estimated prevalence of PHPT in the general population is 0.86%. Conclusion: PHPT is a more common disorder than previously documented. It is crucial to evaluate even mild hypercalcemia, because 43% of these patients have PHPT. PHPT is underdiagnosed and undertreated. [Copyright &y& Elsevier]

Background: Over the last decade, radiofrequency thermal ablation (RFA) has been incorporated into the treatment algorithm of patients with unresectable colorectal liver metastases (CLM). For this population, the local recurrence (LR) rate is a key parameter used to assess the success of RFA. LR is defined as development of new tumor abutting and/or in 1 cm of an ablation zone. The aim of this study is to correlate LR with other hepatic or extrahepatic recurrence and patient survival. Methods: Between 2000 and 2011, 252 patients with CLM underwent laparoscopic RFA of 883 lesions. These patients were followed under a prospective protocol with quarterly liver computed tomography and blood work, including carcinoembryonic antigen levels quarterly for the first 2 years and then biannually. Clinical scenarios associated with LR were identified and categorized as being “isolated LR,” “LR associated with new liver disease,” or “LR associated with systemic disease.” Demographic, clinical, and survival data were assessed using analysis of variance, Chi-square test, and univariate and multivariate Kaplan–Meier analysis. Results: One hundred eighteen patients (47%) developed LR after their initial laparoscopic RFA. These were 85 men (72%) and 33 women (28%), with a mean age of 70 ± 8 years. For this cohort, the mean of number of lesions was 3.1 ± 0.2 cm (range, 1–11) and dominant tumor size 2.9 ± 0.1 cm (range, 0.7–6.5) at the time of initial RFA. The LR rate per lesion was 29%. Of the patients who developed treatment failure at the RFA site, this was an isolated LR in 31 (26%) patients, associated with new liver disease in 51 (43%) and systemic metastases in 36 patients (31%). When patients with different clinical scenarios associated with LR were compared, no clinical predictors were identified to differentiate these subgroups. At a median follow up of 30 months (range, 3–113), the Kaplan-Meier median overall survival (OS) for patients with and without LR were 28 vs 31 months, respectively (P = .103). The OS for patients whose LR was isolated, associated with new liver and systemic recurrences was 39, 26, and 22 months, respectively (P = .009). Conclusion: This study shows that, although the presence of LR does not negatively impact on survival, the pattern of recurrent disease does. LR after RFA for CLM is most often associated with new liver and systemic recurrences, reflecting the aggressive biology of cancer in patients channeled to this treatment modality. [Copyright &y& Elsevier]

Purpose: To determine practice patterns/outcomes and educational opportunities in endocrine surgery by resident involvement in general surgery (GS) and otolaryngology (ENT). Methods: We queried the American College of Surgeon National Surgical Quality Improvement Program for thyroid/parathyroid operations. Resident involvement was categorized by postgraduate year (PGY) and specialty. Results: Of 38,257 thyroid patients, attendings alone performed 28% in GS versus 65% in ENT, and of 17,145 parathyroid patients, 22.1% vs 66.5%. Of GS cases done with housestaff, the percentages with junior residents (PGY1–3), senior residents (PGY4,5), and fellows were 42%, 50%, and 7%, respectively, whereas for ENT operations, the percentages were 35%, 46%, and 16%. For parathyroidectomies, the percentages were 41.1%/46.8%/12.1% vs 38.7%/45.9%/15.5%. Operative time was less for GS (115 minutes) versus ENT (123 minutes). Time in the operating room increased with increasing PGY in ENT, but not in GS. Case complexity and outcomes were similar. Duration of hospital stay was greater in ENT. Conclusion: No differences exist in case complexity between specialties. More thyroid/parathyroid operations are performed with residents in GS; junior residents in GS perform a large percentage of these cases (∼40%), indicating early exposure to endocrine surgery and balanced experience between resident levels with minimal effect of fellows. Although junior residents receive exposure in ENT, a greater proportion is performed by fellows. Outcomes were similar by resident level, except operative time, which was greater for ENT at all levels. Ultimately, equal outcomes but lesser operating times and durations of hospital stay are seen with GS residents than their ENT counterparts. [Copyright &y& Elsevier]

Background: Although radiofrequency ablation (RFA) has been incorporated to the treatment algorithm of patients with unresectable colorectal liver metastasis (CLM), its utility in patients with resectable disease has not been well studied. The aims of this study were to define the clinical profile of patients with a solitary CLM who underwent laparoscopic RFA and to analyze their oncologic outcomes. Methods: Between 2000 and 2011, 44 patients underwent laparoscopic RFA and 60 patients resection of solitary CLM ≤3 cm. Data were analyzed from a prospectively maintained institutional review board-approved database using Student's t test, Chi-square, and Kaplan–Meier tests. Results: The indications for RFA were patient decision in 61% (n = 27), comorbidities in 34% (n = 15), and intraoperative findings in 5% (n = 2). In comparison with the resection group, RFA patients had a greater American Society of Anesthesiologists score (3.0 ± 0.1 vs 2.6 ± 0.1, respectively; P = .002), more frequent incidence of cardiopulmonary comorbidities (60% vs 38%, respectively; P = .045), and tumors located deeper in the liver parenchyma (39% vs 12%) that would have required a formal lobectomy. The 2 groups were otherwise similar for age, gender, carcinoembrradyogenic antigen, synchronous versus metachronous presentation of CLM, tumor size, and tumor and nodal status of primary colorectal cancer. The local recurrence rate was 18% after RFA and 4% after resection (P = .012). The overall Kaplan–Meier, cancer-specific, 5-year survival was 47% for RFA and 57% for resection (P = .464). Median disease-free survival was 25 months after RFA and 22 months after resection (P = .973). Conclusion: Our results suggest that laparoscopic RFA might spare a number of patients at greater risk with a small solitary CLM the risk of morbidity from a formal liver resection. Furthermore, laparoscopic RFA might also be acceptable as the first line of therapy for patients with tumors that otherwise would have required a formal lobectomy or open resection. Nevertheless, the local recurrence rate of RFA should be kept in mind and the patients followed closely to treat failures promptly. [Copyright &y& Elsevier]

Highlights: [•] Virtual models of OMIMs were constructed using molecular simulation tools. [•] OMIM termini’s structure determines the adsorbent density but not its gas capacity. [•] Adsorbent properties are closely related to the packing ability of OMIMs. [•] Similar adsorption regimes are found in OMIMs and MOFs. [Copyright &y& Elsevier]

Background: There is controversy in the literature about whether robotic total thyroidectomy should be performed through unilateral or bilateral axillary incisions. The aim of this study was to perform a detailed critical analysis of the single-incision technique with a focus on postoperative pain, morbidity, and oncologic outcomes. Methods: Between June 2009 and May 2012, 30 patients underwent robotic neck surgery through a single axillary incision. The perioperative outcomes of 16 patients who underwent robotic total thyroidectomy were compared with 30 consecutive patients undergoing conventional total thyroidectomy. Data were collected from a prospectively maintained, institutional review board-approved database. All data are presented as mean values ± standard error of the mean. Results: Both groups were similar regarding age, gender, body mass index, tumor size, and tumor type. For all patients, skin-to-skin operative time (OT) was less in the conventional group (139 ± 8 vs 183 ± 11 minutes, respectively; P = .002). In the robotic group, a significant improvement of the OT occurred after the 6th case: 245 ± 12 minutes for the first 6 cases versus 153 ± 10 minutes for the last 10 cases (P < .001). Estimated blood loss was similar between groups. The median hospital stay was 1 day for both groups. The morbidity was 13% in the conventional and 19% in the robotic group (P = .631). Conclusion: Our results show that robotic total thyroidectomy through a single axillary incision is feasible, with similar short-term oncologic results. However, owing to the extent of dissection, the 2-week operative site discomfort is greater after robotic versus conventional total thyroidectomy. [Copyright &y& Elsevier]

Background: Cowden syndrome (CS) is dominantly inherited and predisposes patients to tumors in multiple organs. We characterized CS-associated malignant and benign thyroid disease. Methods: Of data from 3,477 prospectively recruited CS patients with known genetic analysis, we analyzed 225 PTEN mutation+ patients whose treatment occurred at our center (n = 25) or other hospitals nationwide (n = 200). Results: A total of 32 of 225 PTEN mutation+ patients (14%) had thyroid cancer: 52% papillary, 28% follicular-variant papillary, 14% follicular, and 6% anaplastic. Median age at diagnosis was 35 years compared with 49 years for Surveillance Epidemiology and End Results population data. Initial thyroid ultrasonography in 16 of 25 patients revealed thyroiditis/goiters in all >13 years age, leading to FNA in 7 (64%), thyroidectomy in 3 (27%), and new cancer diagnosis in 2 (18%). Three with severe autism required intraoperative sedation for ultrasonography. A total of 9 of 25 patients were monitored after multiple partial thyroidectomies for goiters by age 42 (n = 5), thyroiditis, or cancer detected by age 36 (n = 3). Conclusion: PTEN mutation+ patients with CS have an enormous prevalence of thyroid disease. Earlier screening may be advisable because thyroiditis and nodules are seen by the time patients reach adolescence, and cancer diagnosis occurs on average 14 years earlier than expected. Furthermore, the risks observed may justify prophylactic total thyroidectomy in select, if not all, patients, particularly those with developmental disorders. [ABSTRACT FROM AUTHOR]

Background: We aimed to validate a nomogram for diagnosing primary hyperparathyroidism (PHP), particularly when normocalcemic PHP and vitamin D (VitD25) deficiency coexist. Methods: The nomogram calculates maximal upper limit of normal PTH unique for each person by maxPTH = 120 − [6*calcium] − [½*VitD25] + [¼*age]. PHP is suspected when serum PTH exceeds maxPTH. Normocalcemic PHP (NCPHP) was defined as always normal serum calcium (8.5–10.5 mg/dL) with PTH >60 pg/mL preoperatively and VitD25 deficiency as <31 ng/mL. Results: A total of 477 patients had operatively and histologically proven PHP. Overall and including those with classical presentation (high serum levels of calcium and PTH), the nomogram predicted PHP in 97% patients. A total of 66 had NCPHP: 47 with low VitD25 levels (20 ± 0.4 ng/mL) made initial PHP diagnosis challenging; 19 had normal VitD25 status. Although the level of serum calcium concentrations were equivalent in these 2 groups (10.1 ± 0.4 mg/dL), PTH was greater in patients with concurrent VitD25 deficiency (129 vs 97 pg/mL, P = .04). However, when used to calculate maxPTH, the nomogram predicted PHP correctly in all 66 NCPHP patients (100%). Conclusion: The maxPTH nomogram functions as expected to classify patients with PHP and may aid in the diagnosis of NCPHP regardless of vitamin D status and repletion, reassuring primary providers and surgeons alike to embark on appropriate and timely PHP management. [ABSTRACT FROM AUTHOR]

Background: There are no objective selection criteria described in the literature for the laparoscopic posterior retroperitoneal (PR) versus lateral transabdominal (LT) approach in a given patient. The aim of this study is to quantify the algorithm we have been using in our practice. Methods: Within 11 years, 219 patients underwent laparoscopic adrenalectomy at one institution. The laparoscopic LT technique was used in patients with unilateral tumors >6 cm. In those patients with unilateral tumors <6 cm, anthropometric parameters were used to select between laparoscopic PR and LT approaches. These parameters were quantified for 82 patients from computed tomography scans and their effects on operative time were calculated. Statistical analyses were performed by use of the t test and logistic regression analysis. Results: Fifty-two patients underwent laparoscopic LT and 30 patients underwent PR adrenalectomy. Patients were selected for the PR approach if the distance from Gerota’s fascia to the skin was less than 5 cm and the 12th rib was at or rostral to the level of renal hilum. On multivariate analysis, total operative time correlated with body mass index in the LT approach and thickness of the perinephric fat and the distance between the adrenal tumor and the upper pole of kidney in the PR approach. Conclusion: In this study, we have described an objective algorithm that can be used to select patients with unilateral adrenal tumors <6 cm for a laparoscopic PR or LT approach with favorable perioperative outcomes. [Copyright &y& Elsevier]

Background: Recently, robotic techniques have been described for adrenalectomy. However, scant data exist in the literature regarding the comparison of robotic with the conventional laparoscopic approach. We aimed to analyze intraoperative time use and perioperative outcomes in robotic vs laparoscopic adrenalectomy for both lateral transabdominal (LT) and posterior retroperitoneal (PR) approaches. Methods: A robotic adrenalectomy program was started in September 2008, and techniques for both the LT (n = 32) and PR (n = 18) approaches were established. Data of robotic cases were compared with those of 50 consecutive laparoscopic cases (LT = 32, PR = 18) before the onset of the program from a prospective, institutional review board-approved database. Operative times for individual steps of the procedures were captured from operative video recordings, including docking, exposure, dissection, and hemostasis. Results: For both LT and PR approaches, there was no difference when we compared the robotic with the laparoscopic groups regarding demographics, tumor type, and body mass index. For the LT approach, despite larger tumor size (x ± SEM) in the robotic vs the laparoscopic group (4.7 ± 0.4 vs 3.8 ± 0.4 cm, P = .05), the operative times were similar (168 ± 10 minutes vs 159 ± 8 minutes, P = .5). There was no difference between the two approaches regarding the time spent for the individual steps of the operation. In the PR approach, with similar tumor sizes (2.7 ± 0.3 cm vs 2.3 ± 0.3 cm, P = .4), operative time (minutes) was equivalent (166 ± 9 vs 170 ± 15; P = .8). Time spent intra-operatively for each step was similar, except for shorter hemostasis time in the robotic group (23 ± 4 minutes vs 42 ± 9 minutes, P = .03). The robotic docking time (21 vs 25 minutes) decreased by 50% in the second year of the study for both approaches. The presence of two staff surgeons vs a staff and a fellow decreased operative time for the robotic LT (P < .02) but not the robotic PR approach. For laparoscopic and robotic procedures, the morbidity was 10% and 2%, respectively. Overall, hospital stay was 1.5 ± 0.9 days (range, 1–4 vs 1.1 ± 0.3 days) (range, 1–2; P = .006). The percentage of patients requiring more than 1 day of hospital stay was 28% vs 14% (P = .09). Conclusion: To our knowledge, this is the first study reporting an intraoperative time analysis for robotic adrenalectomy. Intraoperative time use was similar between the laparoscopic and robotic groups for both LT and PR approaches. However, the morbidity was less and hospital stay was shorter after the robotic procedures. [ABSTRACT FROM AUTHOR]