The Importance of Surgeon Experience for Clinical and Economic Outcomes From Thyroidectomy

Sosa, Julie Ann; Bowman, Helen M.; Tielsch, James M.; Powe, Neil R.; Gordon, Toby A.; Udelsman, Robert

doi:10.1097/00000658-199809000-00005

Cited by 1,020 publications

(669 citation statements)

References 23 publications

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“…Cure rates for classic disease are 95%-98% with complication rates of 1%-2% [55][56][57]. A study by Sosa et al [58] demonstrated that surgeon experience determined the length of stay and number of complications and that hospital volume was not consistently associated with outcomes. If undertaken by an experienced endocrine surgeon, minimally invasive parathyroidectomy is an ideal operation if preoperative imaging localizes an adenoma, otherwise bilateral neck exploration is undertaken [59].…”

Section: Surgicalmentioning

confidence: 99%

Mild Primary Hyperparathyroidism: A Literature Review

Applewhite

Schneider

2014

The Oncologist

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The biochemical profile of classic primary hyperparathyroidism (pHPT) consists of both elevated calcium and parathyroid hormone levels. The standard of care is parathyroidectomy unless prohibited by medical comorbidities. Because more patients are undergoing routine bone density evaluation and neck imaging studies for other purposes, there is a subset of people identified with a biochemically mild form of the pHPT that expresses itself as either elevated calcium or parathyroid hormone levels. These patients often do not fall into the criteria for operation based on the National Institutes of Health consensus guidelines, and they can present a challenge of diagnosis and management. The purpose of this paper is to review the available literature on mild pHPT in an effort to better characterize this patient population and to determine whether patients benefit from parathyroidectomy. Evidence suggests that there are patients with mild pHPTwho have overt symptoms that are found to improve after parathyroidectomy. There is also a group of patients with biochemically mild pHPT who are found to progress to classic pHPT over time; however, it is not predictable which group of patients this will be. Early intervention for this group with mild pHPT may prevent progression of bone, psychiatric, and renal complications, and parathyroidectomy has proven safe in appropriately selected patients at high volume centers. The Oncologist 2014;19:919-929 Implications for Practice: Mild primary hyperparathyroidism (pHPT) is a disease that is being diagnosed with increased frequency; however, recommendations for treatment are not uniform. Current NIH guidelines do not recommend parathyroidectomy for these patients if they are asymptomatic; however, upon focused questioning, many of these patients are found to have subtle symptoms.The biochemically mild nature of the disease has been found to delay diagnosis and treatment, but after it is identified, surgery has shown to provide an improvement in quality of life and bone health. Although the current body of literature suggests that patients with mild pHPT benefit from parathyroidectomy, careful patient and surgeon selection is critical to ensuring safety and efficacy. Universal acceptance of parathyroidectomy in this subset of patients will require more high quality, prospective studies and improved definitions of long-term cure.

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Section: Surgicalmentioning

confidence: 99%

Mild Primary Hyperparathyroidism: A Literature Review

Applewhite

Schneider

2014

The Oncologist

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“…In Brazil, complications occurred in 34.7% of the thyroidectomies performed in a University Hospital, including hypoparathyroidism in 8.8% (12). Complication rates of thyroid surgeries in a US population-based study were found to be 10.1% for surgeons who did between one and nine cases per year, and 5.9% for surgeons who did more than one hundred cases per year (13). In fact, over 50% of thyroid surgeries in the US are performed by surgeons who do five or fewer cases per year (14), placing many patients at a higher risk of complications.…”

Section: Cost Morbidity and Risk Of Mortality From Surgerymentioning

confidence: 99%

Molecular markers in the diagnosis of thyroid nodules

Ward

Kloos²

2013

Arq Bras Endocrinol Metab

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SUMMARYAn indeterminate thyroid nodule cytology result occurs about every sixth fine-needle aspiration. These indeterminate nodules harbor a 24% risk of malignancy (ROM); too high to ignore, but driving surgery where most nodules are benign. Molecular diagnostics have emerged to ideally avoid surgery when appropriate, and to trigger the correct therapeutic surgery when indicated, as opposed to an incomplete diagnostic surgery. No current molecular test offers both high sensitivity and high specificity. A molecular diagnostic test with high sensitivity (e.g. Afirma Gene Expression Classifier sensitivity 90%) offers a high Negative Predictive Value when the ROM is relatively low, such as < 30%. Only such tests can "rule-out" cancer. In this setting, a molecularly benign result suggests the same ROM as that of operated cytologically benign nodules (~6%). Thus, clinical observation can replace diagnostic surgery; increasing quality of life and decreasing medical costs. However, its low specificity cannot "rule-in" cancer as a suspicious result has a Positive Predictive Value (PPV) of ~40%, perhaps too low to routinely reflex to definitive cancer surgery. Conversely, high specificity tests (BRAF, RAS, PPAR/PAX-8, RET/PTC, PTEN) offer high PPV results, and only these tests can "rule-in" cancer. Here a positive molecular result warrants definitive therapeutic surgery. However, their low sensitivity cannot "rule-out" cancer and a negative molecular result cannot dissuade diagnostic surgery; limiting their cost-effectiveness. Whether or not there is a useful and cost-effective role to sequentially combine these approaches, or to modify existing approaches, is under investigation. Arq Bras Endocrinol Metab. 2013;57(2):89-97 Keywords Biopsy, fine-needle; DNA mutational analysis; gene expression; genomics; molecular diagnostic techniques SUMáRioResultados indeterminados na citologia de um nódulo tireoidiano ocorrem em cerca de um a cada seis punções aspirativas por agulha fina. Esses nódulos indeterminados apresentam risco de malignidade (RM) de cerca de 24%, um valor alto demais para ser ignorado e que leva à cirurgia em casos em que a maioria dos nódulos é benigna. O diagnóstico molecular é uma forma ideal de se evitar a cirurgia quando apropriado e de se levar ao correto procedimento cirúrgico terapêutico quando indicado, em oposição à cirurgia diagnóstica incompleta. Atualmente, não existem testes moleculares com alta sensibilidade e especificidade. Um teste molecular de alta sensibilidade (por exemplo, a sensibilidade do teste Afirma Gene Expression Classifier é de 90%) tem um alto Valor Preditivo Negativo quando o RM é relativamente baixo, por exemplo, < 30%. Apenas esses testes podem "excluir" o câncer. Nesse contexto, um resultado molecular benigno sugere o mesmo RM de nódulos com resultado benigno na citologia e operados (~6%). Assim, a observação clínica pode substituir a cirurgia diagnóstica, aumentando a qualidade de vida e diminuindo os custos médicos. Entretanto, a baixa especificidade não pode "incluir" o cân...

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“…The main concern is the potentially high rate of complications such as hematoma, permanent recurrent laryngeal nerve (RLN) paralysis and hypoparathyroidism [8,9]. A large or intrathoracic goiter, extensive malignancy, secondary procedure, inexperience of the surgical team and extent of the operation are the criteria that increase the complication rate [10][11][12]. The aim of this retrospective study is to identify factors influencing complications in benign nodular thyroid surgery.…”

Section: Introductionmentioning

confidence: 99%

The Factors Related with Postoperative Complications in Benign Nodular Thyroid Surgery

et al. 2010

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Thyroid gland is an important endocrine organ because of its functions. Although the morbidity and mortality of thyroid surgery have decreased markedly, serious complications may still occur. The aim of this retrospective study was to identify the factors influencing the complications in benign nodular thyroid surgery. A total of 332 patients who underwent thyroid surgery between April 2004 and May 2008 were evaluated retrospectively to identify the factors influencing the complications. We found that in surgery lasting more than 90 minutes the risk of permanent recurrent laryngeal nerve (RLN) injury was high, daily drainage more than 50 cc increases the risk of seroma formation, retrosternal goiter surgery have higher risk for bleeding. The flap edema rates were high found in the operations made by resident surgeon and patients with size 3-4 thyroid glands. Low complication rates can be achieved after thyroidectomy with better knowledge of the surgical anatomy of the neck, thyroid pathology and required surgical treatment.

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The Importance of Surgeon Experience for Clinical and Economic Outcomes From Thyroidectomy

Cited by 1,020 publications

References 23 publications

Mild Primary Hyperparathyroidism: A Literature Review

Mild Primary Hyperparathyroidism: A Literature Review

Molecular markers in the diagnosis of thyroid nodules

The Factors Related with Postoperative Complications in Benign Nodular Thyroid Surgery

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