Endocrine Surgery Quality Improvement Program Research Articles

Nerve monitoring in endocrine surgery: Practice patterns differ among surgeons for parathyroidectomy and thyroidectomy

BackgroundIt is unknown whether intraoperative nerve monitoring is associated with reduced vocal cord dysfunction after parathyroidectomy. We aimed to investigate intraoperative nerve monitoring use among Collaborative Endocrine Surgery Quality Improvement Program surgeons and factors associated with vocal cord dysfunction after parathyroidectomy. MethodsPatients who underwent parathyroidectomy included in the Collaborative Endocrine Surgery Quality Improvement Program (2014–2022) were identified. The annual percent change in parathyroidectomies performed with intraoperative nerve monitoring was calculated using joinpoint regression. Multivariable logistic regression was used to compare outcomes between patients undergoing parathyroidectomy with/without intraoperative nerve monitoring. To compare surgeon-specific trends, Collaborative Endocrine Surgery Quality Improvement Program thyroidectomy and parathyroidectomy datasets (2014–2021) were combined. Parathyroidectomies performed by surgeons who used intraoperative nerve monitoring consistently in thyroidectomy were identified. Factors associated with intraoperative nerve monitoring were examined using multivariable logistic regression. ResultsA total of 9,813 patients underwent parathyroidectomy. Intraoperative nerve monitoring was used in 49% of cases (n = 4,818). There was an increase in parathyroidectomies with intraoperative nerve monitoring from 2014 to 2018 (annual percent change 22.2, P = .01), followed by a plateau (2018–2022 annual percent change −0.66, P = .85). Few patients (0.44%, n = 43) developed vocal cord dysfunction. Vocal cord dysfunction was not associated with intraoperative nerve monitoring (adjusted odds ratio 0.92, P = .75). Whereas 41% (n = 56/138) of surgeons used intraoperative nerve monitoring routinely in parathyroidectomy, 65% (n = 90/138) used it routinely in thyroidectomy. Among surgeons who used intraoperative nerve monitoring routinely in thyroidectomy, only 57% used it routinely in parathyroidectomy; factors associated with intraoperative nerve monitoring during parathyroidectomy included reoperation (adjusted odds ratio 2.51, P < .01), secondary/tertiary hyperparathyroidism (adjusted odds ratio 1.42, P = .02), multiglandular disease (adjusted odds ratio 1.76, P < .001), and non-localized disease (adjusted odds ratio 1.65, P < .001). ConclusionEndocrine surgeons use intraoperative nerve monitoring selectively. Surgeons who routinely use intraoperative nerve monitoring during thyroidectomy are more likely to use it during parathyroidectomy. Future studies should determine who may benefit most from intraoperative nerve monitoring in parathyroidectomy.

Incidence of venous thromboembolism following adrenalectomy: A CESQIP analysis

BackgroundWe aim to evaluate the incidence of venous thromboembolism (VTE) following adrenalectomy. MethodsA retrospective analysis of the Collaborative Endocrine Surgery Quality Improvement Program was performed to assess incidence for VTE, including pulmonary embolism or deep vein thrombosis, in adults undergoing adrenalectomy (2014–2022). Results2567 patients undergoing adrenalectomy were included. Surgical approach was 10% open and 90% minimally invasive. Pathology was 13% malignant and 87% benign; 19% had hypercortisolism. VTE developed in 0.27% at a median of 8 days from surgery. The incidence was higher in primary adrenal malignancy compared to benign or metastases to the adrenals, p ​< ​0.01. VTE was associated with longer hospital stay, longer operative time, readmission, and mortality. VTE rates were similar for hypercortisolism vs no hypercortisolism and between patients with clinical vs subclinical hypercortisolism. ConclusionAlthough VTE following adrenalectomy is rare, it is more common in cases of primary adrenal malignancy, those with longer operations, or those requiring prolonged hospitalization.

Routine use of intraoperative nerve monitoring is associated with a reduced risk of vocal cord dysfunction after thyroid cancer surgery

BackgroundThe aim of this study was to investigate the associations between individual surgeon’s intraoperative nerve monitoring (IONM) practice and factors associated with vocal cord (VC) dysfunction in patients with thyroid cancer undergoing thyroidectomy.MethodsUsing Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) 2014-21 data, multivariable logistic regression analyses investigated variables associated with short- and long-term VC-dysfunction, associations of routine use of IONM with postoperative outcomes, and patient characteristics associated with IONM use.ResultsAmong 5,446 patients (76.7% female, mean age 49 years), 68.5% had surgery by surgeons using IONM in ≥ 90% of cases (63% of surgeons, n = 73). Post-operative VC-dysfunction was diagnosed by laryngoscopy in 3.0% of patients in the short-term and 2.7% in the long-term. When surgeons routinely used IONM, the incidence of VC-dysfunction was 2.4% in the short-term and 2.2% in the long-term, compared to 4.4% and 3.7%, respectively, when surgeons did not routinely use IONM (p < 0.01). After adjustment, routine use of IONM was independently associated with reduced risk of short- (OR 0.48, p < 0.01) and long-term (OR 0.52, p < 0.01) VC-dysfunction, a lower risk of postoperative hypoparathyroidism in the short- (OR 0.67, p < 0.01) and long-term (OR 0.54, p < 0.01), and higher likelihood of same-day discharge (OR 2.03, p < 0.01). Extrathyroidal tumor extension and N1-stage were factors associated with postoperative VC-dysfunction in the short- (OR 3.12, p < 0.01; OR 1.92, p = 0.01, respectively) and long-term (OR 3.11, p < 0.01; OR 2.32, p < 0.01, respectively).ConclusionRoutine use of IONM was independently associated with a lower risk of endocrine surgery-specific complications and greater likelihood of same-day discharge.

Increased Risk of Complications Associated With Concurrent Parathyroidectomy in Patients Undergoing Total Thyroidectomy

IntroductionWe sought to investigate the association of concurrent parathyroidectomy (PTX) with risks of total thyroidectomy (TTX) through analysis of Collaborative Endocrine Surgery Quality Improvement Program data. TTXis a common operation with complications including recurrent laryngeal nerve injury, neck hematoma, and hypoparathyroidism. A subset of patients undergoing thyroidectomy undergoes planned concurrent PTX for treatment of primary hyperparathyroidism. There are limited data on the risk profile of TTX with concurrent PTX (TTX + PTX). MethodsWe queried the Collaborative Endocrine Surgery Quality Improvement Program database for patients who underwent TTX or TTX + PTX from January 2014 through April 2020. Multivariable logistic regression was performed to predict hypoparathyroidism, vocal cord dysfunction, neck hematoma, and postoperative emergency department visit. Covariates included patient demographics, patient body mass index, indication for surgery, central neck dissection, anticoagulation use, and surgeon volume. ResultsThirteen thousand six hundred forty seven patients underwent TTX and 654 patients underwent TTX + PTX. Unadjusted rates of hypoparathyroidism were higher in TTX + PTX patients at 30 d (9.6% versus 7.4%, P = 0.04) and 6 mo (7.9% versus 3.1%, P < 0.001). On multivariable regression, TTX + PTX was associated with an increased risk of hypoparathyroidism at 30 d (odds ratio [OR] 2.09, 95% confidence interval [CI] 1.57-2.79) and 6 mo (OR 4.63, 95% CI 3.06-7.00) and an increased risk of postoperative emergency department visit (OR 1.66, 95% CI 1.20-2.31). TTX + PTX was not associated with recurrent laryngeal nerve injury or neck hematoma. ConclusionsConcurrent PTX in patients undergoing TTX is associated with increased risk of immediate and long-term hypoparathyroidism, which should be considered in informed consent discussions and operative decision-making.

Parathyroidectomy trends and surgical trainee parathyroidectomy experience based on the Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) database

BackgroundThe parathyroidectomy approach has shifted over the last few decades from routine bilateral to more commonly focused exploration. The purpose of this study is to assess the operative experience in parathyroidectomy for surgical trainees as well as overall parathyroidectomy trends. MethodsData from the Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) were analyzed between 2014 and 2019. ResultsThe overall distribution of focused versus bilateral parathyroidectomy remained stable (2014: 54 % focused and 46 % bilateral approach; 2019: 55 % focused and 45 % bilateral). Ninety three percent of procedures involved a trainee (fellow or resident) in 2014, this dropped to 74 % in 2019 (P < 0.005). Fellow involvement decreased significantly from 31 % to 17 % (P < 0.05) over the six-year period. ConclusionsResident exposure to parathyroidectomies mirrored that of practicing endocrine surgeons. This works highlights the opportunities to capture more information regarding the surgical trainee experience in endocrine surgeries.

A comparison of NSQIP and CESQIP in data quality and ability to predict thyroidectomy outcomes

BackgroundThe Collaborative Endocrine Surgery Quality Improvement Program tracks thyroidectomy outcomes with self-reported data, whereas the National Surgical Quality Improvement Program uses professional abstractors. We compare completeness and predictive ability of these databases at a single-center and national level. MethodData consistency in the Collaborative Endocrine Surgery Quality Improvement Program and the National Surgical Quality Improvement Program at a single institution (2013–2020) was evaluated using McNemar’s test. At the national level, data from the Collaborative Endocrine Surgery Quality Improvement Program and the National Surgical Quality Improvement Program (2016–2019) were used to compare predictive capability for 4 outcomes within each data source: thyroidectomy-specific complication, systemic complication, readmission, and reoperation, as measured by area under curve. ResultsIn the single-center analysis, 66 cases were recorded in both the Collaborative Endocrine Surgery Quality Improvement Program and the National Surgical Quality Improvement Program. The reoperation variable had the most discrepancies (2 vs 0 in the National Surgical Quality Improvement Program versus the Collaborative Endocrine Surgery Quality Improvement Program, respectively; χ2 = 2.00, P = .16). At the national level, there were 24,942 cases in the National Surgical Quality Improvement Program and 17,666 cases in the Collaborative Endocrine Surgery Quality Improvement Program. In the National Surgical Quality Improvement Program, 30-day thyroidectomy-specific complication, systemic complication, readmission, and reoperation were 13.25%, 2.13%, 1.74%, and 1.39%, respectively, and in the Collaborative Endocrine Surgery Quality Improvement Program 7.27%, 1.95%, 1.64%, and 0.81%. The area under curve of the National Surgical Quality Improvement Program was higher for predicting readmission (0.721 [95% confidence interval 0.703–0.737] vs 0.613 [0.581–0.649]); the area under curve of the Collaborative Endocrine Surgery Quality Improvement Program was higher for thyroidectomy-specific complication (0.724 [0.708–0.737] vs 0.677 [0.667–0.687]) and reoperation (0.735 [0.692–0.775] vs 0.643 [0.611-0.673]). Overall, 3.44% vs 27.22% of values were missing for the National Surgical Quality Improvement Program and the Collaborative Endocrine Surgery Quality Improvement Program, respectively. ConclusionThe Collaborative Endocrine Surgery Quality Improvement Program was more accurate in predicting thyroidectomy-specific complication and reoperation, underscoring its role in collecting granular, disease-specific variables. However, a higher proportion of data are missing. The National Surgical Quality Improvement Program infrastructure leads to more rigorous data capture, but the Collaborative Endocrine Surgery Quality Improvement Program is better at predicting thyroid-specific outcomes.

Intraoperative Nerve Monitoring Is Associated with Less Postoperative Vocal Cord Dysfunction and Hypoparathyroidism in Patients Undergoing Thyroidectomy for Thyroid Cancer

INTRODUCTION: Intraoperative nerve monitoring (IONM) during thyroid operation for benign disease is associated with a lower risk of recurrent laryngeal nerve injury. This study aimed to investigate factors associated with short- and long-term vocal cord (VC) dysfunction in patients undergoing operation for thyroid cancer. METHODS: Patients ≥18 years of age undergoing thyroid operation for malignant disease from January 2014 to April 2021 in the Collaborative Endocrine Surgery Quality Improvement Program database were included. Multivariable logistic regression analyses investigated variables associated with short-term (≤30 days postoperative) and long-term (31 to 180 days) VC dysfunction and characteristics associated with IONM use. RESULTS: Among 5,446 patients, 76.7% were women, and the mean age was 49 years. Papillary thyroid cancer (PTC) was the most common type (84.6%). Few patients had nodal metastases or extrathyroidal extension (27.3% and 3.9%, respectively). Postoperative VC dysfunction was diagnosed by laryngoscopy in 3.0% of patients in the short term and in 2.7% in the long term. Patients with tumors who had extrathyroidal extension or nodal metastases were at higher risk for short-term (odds ratio [OR] 3.17, p < 0.001; OR 1.91, p = 0.005, respectively) and long-term (OR 3.1, p < 0.001; OR 2.34, p < 0,001, respectively) VC dysfunction. IONM was independently associated with a reduced risk of short-term (OR 0.61, p = 0.006) and long-term (OR 0.48, p < 0.001) VC dysfunction. IONM use was associated with outpatient surgery (OR 1.61, p < 0.001) and fewer postoperative hypoparathyroidism events in the short (OR 0.7, p < 0.001) and long term (OR 0.64, p = 0.002). CONCLUSION: IONM is independently associated with a lower rate of endocrine-specific complication and more outpatient surgery. Future studies are needed to identify barriers to broader IONM use.

Endocrine surgeons are performing more thyroid lobectomies for low-risk differentiated thyroid cancer since the 2015 ATA guidelines

BackgroundThe 2015 American Thyroid Association guidelines recommended either total thyroidectomy or lobectomy for surgical treatment of low-risk differentiated thyroid cancer and de-escalated recommendations for central neck dissections. The study aim was to investigate how practice patterns among endocrine surgeons have changed over time. MethodsAll adult patients with low-risk differentiated thyroid cancers (T1–T2, N0/Nx, M0/Mx) in the Collaborative Endocrine Surgery Quality Improvement Program (2014-2021) were identified. The outcomes between patients undergoing lobectomy versus total thyroidectomy were compared using multivariable logistic regression. The annual percent change in the proportion of lobectomies and central neck dissections performed was estimated using joinpoint regression. ResultsIn total, 5,567 patients with low-risk differentiated thyroid cancers were identified. Of these, 2,261 (40.6%) were very low-risk tumors ≤1 cm, and 2,983 (53.6%) were low-risk tumors >1 and <4 cm. Most patients (67.9%) underwent total thyroidectomy. Compared to total thyroidectomy, lobectomy was associated with outpatient surgery (adjusted odds ratio 5.19, P < .001), a decreased risk of postoperative emergency department visits (adjusted odds ratio 0.63, P = .03), and decreased risk of hypoparathyroidism events (adjusted odds ratio 0.03, P < .001). Compared to before (2014–2015), patients undergoing surgery after publication of the revised guidelines (2016–2021) had higher odds of lobectomy and lower odds of central neck dissection for tumors ≤1 cm (lobectomy adjusted odds ratio 2.70, P < .001; central neck dissections adjusted odds ratio 0.64, P = .03) and tumors between 1 and 4 cm (lobectomy adjusted odds ratio 2.27, P < .001; central neck dissection adjusted odds ratio 0.62, P < .001). ConclusionAfter publication of the 2015 American Thyroid Association guidelines, there has been an increase in thyroid lobectomies as a proportion of all thyroid operations performed by endocrine surgeons for low-risk differentiated thyroid cancer. This has implications for reduced health care use and costs, with potential population-level benefits.

Towards Personalized Musculoskeletal Interventional Oncology: Enhanced Image-Guided Biopsies and Interventions

Studies comparing endocrine-specific outcomes following parathyroidectomy (PTx) versus concurrent parathyroidectomy and thyroidectomy (PTx + Tx) are few.10,019 patients were selected from the Collaborative Endocrine Surgery Quality Improvement Program (2014–2019). Baseline characteristics and short-term (≤30 days) outcomes for PTx + Tx vs PTx patients were compared using bivariate and multivariable methods.PTx + Tx patients were more likely to experience clinical hypoparathyroidism (6.7% vs 0.5%, p < 0.001), recurrent laryngeal nerve transection, (0.4% vs 0.1%, p = 0.002) and hematoma requiring evacuation (1.0% vs 0.2%, p < 0.001). Readmissions and ED visits for hypocalcemia were more frequent after PTx + Tx vs PTx. Concurrent surgery was associated with an 8-fold increase in risk of short-term complications (Odds Ratio (OR): 8.0, 95% Confidence Interval (CI): 5.7–11.1, p < 0.001).Patients undergoing PTx + Tx have increased rates of postoperative complications, ED visits, and readmissions compared to patients undergoing parathyroidectomy alone. These findings could help guide surgeon-patient discussions on the risks of concurrent surgery.

Outcomes of concurrent parathyroidectomy and thyroidectomy among CESQIP surgeons

BackgroundStudies comparing endocrine-specific outcomes following parathyroidectomy (PTx) versus concurrent parathyroidectomy and thyroidectomy (PTx + Tx) are few. Methods10,019 patients were selected from the Collaborative Endocrine Surgery Quality Improvement Program (2014–2019). Baseline characteristics and short-term (≤30 days) outcomes for PTx + Tx vs PTx patients were compared using bivariate and multivariable methods. ResultsPTx + Tx patients were more likely to experience clinical hypoparathyroidism (6.7% vs 0.5%, p < 0.001), recurrent laryngeal nerve transection, (0.4% vs 0.1%, p = 0.002) and hematoma requiring evacuation (1.0% vs 0.2%, p < 0.001). Readmissions and ED visits for hypocalcemia were more frequent after PTx + Tx vs PTx. Concurrent surgery was associated with an 8-fold increase in risk of short-term complications (Odds Ratio (OR): 8.0, 95% Confidence Interval (CI): 5.7–11.1, p < 0.001). ConclusionsPatients undergoing PTx + Tx have increased rates of postoperative complications, ED visits, and readmissions compared to patients undergoing parathyroidectomy alone. These findings could help guide surgeon-patient discussions on the risks of concurrent surgery.

The impact of patient age on practice patterns and outcomes for primary hyperparathyroidism

BackgroundManagement of asymptomatic primary hyperparathyroidism (PHPT) in older patients (age >50) is controversial. The 4th International Workshop on the Management of Asymptomatic PHPT recommends surveillance for older patients who lack objective signs of disease, whereas The American Association of Endocrine Surgeons (AAES) guidelines recommend consideration of parathyroidectomy for patients of any age with subjective constitutional, neuropsychiatric, or cognitive symptoms. Therefore, the primary objective of this study was to evaluate the association between patient age and both practice patterns and outcomes in the management of patients with sporadic PHPT. MethodsThe Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) database was queried for all adults (age ≥18) who underwent an index parathyroidectomy for sporadic primary hyperparathyroidism between 2014 and 2020. Associations between patient age (≤50 years vs. >50 years) and both practice patterns and outcomes were evaluated separately using adjusted multivariable logistic and multinomial regression models. ResultsOf 9,938 patients who underwent parathyroidectomy, 8,080 (81.3%) were >50 years old and 1,858 (18.7%) were ≤50. Of this cohort, 17% of older patients and 26% of younger patients presented with only subjective symptoms. Compared to younger patients, older patients were more likely to have an objective indication for parathyroidectomy (aOR = 1.8, 95%CI: 1.6–2.0, p < 0.001). They were also more likely to undergo ≥2 imaging studies pre-operatively (aOR = 1.2, 95%CI: 1.1–1.3, p = 0.003), to undergo bilateral neck exploration (aOR = 1.4, 95%CI: 1.3–1.6, p < 0.001), and to have multi-gland disease (aOR = 1.6, 95%CI: 1.4–1.8, p < 0.001). There was no difference between age groups and parathyroidectomy-related complications including hypocalcemia, vocal cord dysfunction, hematoma requiring evacuation, or reintubation, however, older patients were less likely to have any peri-operative morbidity (aOR = 0.7, 95%CI: 0.6–0.9, p = 0.011). ConclusionsOlder patients were more likely to meet objective criteria prior to undergoing parathyroidectomy by CESQIP participating high-volume endocrine surgeons, however they were less likely to have peri-operative complications compared to younger patients. Given the growing evidence demonstrating improvement of both objective and subjective symptoms after parathyroidectomy for PHPT, additional studies are still needed to fully understand the benefit of surgical referral in older adults for less objective indications.

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

BackgroundFour-dimensional computed tomography (4D-CT) scan to localize abnormal parathyroid glands is diagnostically superior to ultrasound (US) and sestamibi. The implementation of 4D-CT imaging is unknown. MethodsThe Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) database from 2014 to 2018 was utilized. Patients with hyperparathyroidism undergoing an initial operation were included. The rate of US, sestamibi and 4D-CT performance was calculated for the entire study population, and for each institution. Results7,959 patients were included. In 311(3.9%) patients, no preoperative imaging was recorded. Of patients with imaging, US was performed in 6,872(86.3%), sestamibi in 5,094(64.0%), and 4D-CT in 1,630(20.4%). The combination of US and sestamibi was most frequent (3,855, 48.4%). Institutional rates of 4D-CT performance varied from 0.1% to 88.7%. ConclusionsOf the imaging modalities, 4D-CT was utilized least frequently and with greatest variability. Given the high accuracy of 4D-CT, efforts to reduce this variation may improve overall preoperative localization in patients with hyperparathyroidism.

Diabetes mellitus and hyperglycemia are associated with inferior oncologic outcomes in adrenocortical carcinoma.

Prior literature suggests that cancer patients with hyperglycemia and type 2 diabetes mellitus (DM) exhibit worse oncologic and overall outcomes. Tumor metabolism and anabolism pathophysiology may explain this association, although this has not been adequately studied in adrenocortical carcinoma (ACC). We hypothesized that DM would be associated with worse oncological outcomes in ACC, and we utilized data from a national database and institutional sources for multimodal analysis. Both a multi-institutional database (the Collaborative Endocrine Surgery Quality Improvement Program or CESQIP) and a single-center longitudinal cohort (Dana Farber Cancer Institute or DFCI) were queried as unique retrospective cohorts to identify patients with ACC. Patient demographics, tumor characteristics, DM-specific variables, and oncologic outcome data were assessed. Results were analyzed via univariate analysis and multivariable linear regression analysis. Statistical significance was defined as p < 0.05. Forty-eight CESQIP patients met inclusion criteria; 16 (33.0%) had DM. DM patients had a higher frequency of recurrence on longitudinal follow-up (12.5% v 0.0%, p = 0.04). Persistent disease was observed in 68.8% of DM patients and 40.6% of non-DM patients (p = 0.06). Patients in the DFCI cohort with lower average glucose values (< 110mg/dL) had a significant survival benefit (p < .0001). A mean serum glucose > 110mg/dL had increased risk (HR 36.3, 95% confidence interval 1.6, 831.3) for all-cause mortality. This multi-institutional, multimodal analysis suggests that patients with DM have worse oncologic and overall outcomes for ACC. While further study is warranted, consideration should be given among clinicians to optimize glycemic control as part of their ACC management.

Parathyroidectomy for Tertiary Hyperparathyroidism: A Multi-Institutional Analysis of Outcomes

BackgroundPatients with tertiary hyperparathyroidism (HPT) often experience delays between diagnosis and referral for surgical treatment. We hypothesized that patients with tertiary HPT experience similarly high cure rates and low complication rates after parathyroidectomy compared with patients with primary HPT. MethodsWe retrospectively identified patients undergoing parathyroidectomy from the Collaborative Endocrine Surgery Quality Improvement Program for primary or tertiary HPT from January 2014 to April 2019. Patients were categorized according to their primary diagnosis and compared for cure rates and surgical complications. ResultsThe study included 9030 patients, with 334 (3.7%) being treated for tertiary HPT. Parathyroidectomy provided a high cure rate (93.7%) in patients with tertiary HPT. However, adjusting for age, sex, and prior thyroid or parathyroid surgery, tertiary HPT was associated with a greater chance of persistent disease than was primary HPT (odds ratio: 2.3, 95% confidence interval: 1.3-4.0). Overall, complications were low for patients across both groups. However, patients with tertiary HPT were more likely to present to the emergency department (7.5% versus 3.3%; P < 0.001), be readmitted (5.1% versus 1.1%; P < 0.001), and develop a hematoma (1.5% versus 0.2%; P = 0.002). Both groups of patients shared similarly low rates of other complications, including mortality, vocal cord dysfunction, and surgical site infections (P < 0.5% for all). ConclusionsPatients undergoing parathyroidectomy for tertiary HPT experience high cure rates and low complication rates. However, tertiary HPT is associated with a greater chance of persistent disease and select complications. Nevertheless, the low rates of persistent disease and complications should not deter early referral for the treatment of tertiary HPT.

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

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

Racial Disparities of Adrenalectomy.

PurposeRacial disparities of surgical outcomes have been demonstrated for a variety of operations. We sought to determine whether minority status is associated with disparate care for adrenalectomy.MethodsThis study is a retrospective database review of the Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) from January 1, 2014 through April 30, 2018. Primary outcome was complication rate. Secondary outcomes were length of stay and surgeon experience. Minority status was defined as Black or Hispanic and outcomes were compared with White patients.ResultsFor the study period, 1141 patients who underwent adrenalectomies were included, of whom 69.9% were White and 22.6% minority. The minority patients were significantly younger with higher rates of diabetes mellitus. Minority patients had higher rates of complication and longer length of stay. Minority patients were more likely to have an adrenalectomy by a low-volume surgeon. In multivariate logistic regression, minority status remained associated with complication rate.ConclusionsMinority patients undergoing adrenalectomy have higher rates of complication and longer lengths of stay when controlling for common comorbidities. Minority patients have decreased access to high-volume surgeons.

Post-thyroidectomy emergency room visits and readmissions: Assessment from the Collaborative Endocrine Surgery Quality Improvement Program (CESQIP)

BackgroundThis study analyzed independent factors associated with post-thyroidectomy Emergency Room (ER) visits and Hospital Readmissions (HR). MethodsThis is a retrospective review from the CESQIP registry of 8381 thyroidectomy patients by 173 surgeons at 46 institutions. A total of 7142 ER visits and 7265 HR were analyzed. Multivariable logistic regression analysis was performed to determine the risk factors for an ER visit or HR. ResultsWithin 30-days of surgery, rates of all ER visits were 3.4% (n = 250) and all HR were 2.3% (n = 170). Hypocalcemia was the reason for 21.9% of ER encounters and 36.4% of HR. BMI >40 kg/m2 was a risk factor for both ER visit (OR1.86) and HR (OR1.94). Surgical duration >3 h (OR2.63), and transection of recurrent laryngeal nerve (OR4.58) were risk factors for HR. ConclusionsStrategies to decrease hypocalcemia and improve perioperative care of patients with BMI >40 kg/m2 may improve post-thyroidectomy outcome.

Normocalcemic hyperparathyroidism: A Collaborative Endocrine Surgery Quality Improvement Program analysis

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

Patient selection and outcomes of laparoscopic transabdominal versus posterior retroperitoneal adrenalectomy among surgeons in the Collaborative Endocrine Surgery Quality Improvement Program (CESQIP)

BackgroundLaparoscopic adrenalectomy can be performed using a transabdominal or posterior retroperitoneal approach. Choosing the optimal approach can be challenging. MethodsUsing data from the Collaborative Endocrine Surgery Quality Improvement Program (2014–2018), baseline patient characteristics and outcomes were compared with bivariate methods; univariate and multivariate analyses were used to estimate the association between operative approach and complication risk. ResultsAmong 833 patients, 35.3% underwent posterior retroperitoneal. Median age was 54 years. Patients undergoing posterior retroperitoneal had lesser rates of body mass index >40 (9.2% vs 17.4%, P = .001), smaller nodules (median 2.4 vs 3.2 cm, P < .001), and more commonly right-sided nodules (46.6% vs 36.9%, P = .02). Posterior retroperitoneal was associated with a lesser rate of conversion to an open procedure (0.7% vs 4.1%, P = .004), less complications (3.1% vs 8.7%, P = .002), and shorter hospital stay (≤48 h: 92.2% vs 76.6%, P < .001), but a greater rate of capsular disruption (12.6% vs 7.6%, P = .02). For posterior retroperitoneal cases with capsular disruption, median nodule size was 2.2 cm, and 16.2% were metastatic tumors. After multivariate adjustment, posterior retroperitoneal was 2.2 times as likely to result in capsular disruption as transabdominal (95% confidence interval, 1.04–4.79, P = .04). ConclusionThis study revealed a greater rate for capsular disruption during posterior retroperitoneal even for small tumors. Our findings from the Collaborative Endocrine Surgery Quality Improvement Program (2014–2018) suggests that posterior retroperitoneal should be used selectively, especially when a malignancy is suspected.

Factors influencing the quality of clinical trials on traditional Chinese medicine—Qualitative interviews with trial auditors, clinicians and academic researchers

Multi-institutional data describing remedial parathyroidectomy compared with index parathyroidectomy are scarce.Using data in the Collaborative Endocrine Surgery Quality Improvement Program (2014–2017), baseline characteristics and outcomes of patients undergoing remedial parathyroidectomy versus index parathyroidectomy were examined using bivariate and multivariate methods. Rates of hypercalcemia and hypocalcemia at ≥ 180 days were assessed.Among 6,795 patients, 367 (5.4%) underwent remedial parathyroidectomy. A single localization study was done in 24.8% versus 26.9% of remedial parathyroidectomy versus index parathyroidectomy (P = .37). Patients undergoing remedial parathyroidectomy had higher rates of preoperative laryngoscopy (45.5% versus 6.2%, P < .001), intraoperative nerve monitoring (57.5% versus 34.5%, P < .001), and < 50% drop in hyperparathyroidism than those undergoing index parathyroidectomy (9.6% versus 3.3%, P < .001). Among patients with ≥ 180 days follow-up, none of the remedial parathyroidectomy versus three index parathyroidectomy patients (0.3%) had vocal cord dysfunction. Hypercalcemia rates for remedial parathyroidectomy and index parathyroidectomy were 10.5% versus 5.0 (P = .07), and hypocalcemia rates were 10.5% versus 2.4% (P < .001). After multivariate adjustment, failure to cure was 4.0 times more likely in remedial parathyroidectomy than index parathyroidectomy (P < .001).This is the first multi-institutional examination of remedial parathyroidectomy outcomes in the Collaborative Endocrine Surgery Quality Improvement Program. Nerve injury rates are low; high rates of hypercalcemia and hypocalcemia suggest potential opportunities to refine the preoperative and intraoperative management of patients undergoing remedial parathyroidectomy.