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Total thyroidectomy (TT) has been shown to be a safe and effective treatment for Graves' disease. However, the time course for improvement of symptoms has not been defined.With an institutional review board approval, we prospectively gathered survey data of all patients (n = 79) undergoing TT for Graves' disease at a single institution from 2019 to 2021. After informed consent was obtained, patients completed surveys preoperatively and at 2 wk followed by monthly postoperative visits/phone calls. Patient demographics and survey results were collected and analyzed. Symptom recovery time was evaluated using Kaplan-Meier analysis.A total of 50 patients completed the survey on postoperative follow-up (response rate 63%). Average age was 38 y (range 12-80 y) and 88% of patients were female. The most common preoperative symptoms were fatigue (90%) and heat/cold intolerance (88%). Tremor (median time to resolution: 1 wk; interquartile range [IQR] 1-3), diarrhea (median 1 wk [IQR 1-3]), and palpitations (median 1 wk [IQR 1-3]) resolved the most rapidly followed by eye symptoms (median 3 wk [IQR 1-6]), heat/cold intolerance (median 3 wk [IQR 3-30]), memory deficits (median 3 wk [IQR 1-undefined]), and fatigue (median: 3 wk [IQR 1-14]). There were no significant differences in time to resolution of symptoms by gender or age (less than versus 40 y and older). Those with uncontrolled Graves' had more severe symptoms but no difference in time to resolution from the euthyroid Graves' patients.Many Graves' disease symptoms improve rapidly following TT, with a median time to improvement of less than 1 mo.

Increasing levels of burnout among trainees and faculty members at all levels is a major problem in academic medicine. Junior faculty members may be at unique risk for burnout and have unique needs and barriers that contribute to attrition, job satisfaction, and overall workplace well-being.Twenty-seven faculty members at the assistant professor level at a large, quaternary referral academic medical institution were interviewed. A qualitative analyst with no reporting relationship to faculty was used as the proctor. Seven scripted questions targeting faculty well-being and institutional barriers to well-being were administered, and the responses were coded for common themes between respondents.Respondents most commonly identified clinical work (26%), research (19%), and teaching (19%) as the best aspects of their job. Among respondents, 3% stated they were not able to devote as much time as they would like to work they enjoyed and found most meaningful. Of these respondents, 44% cited "insufficient help" as the root cause. Also, 33% stated time spent writing and managing institutional review board requirements was a major contributor, and 22% cited both clinical volume/performance benchmarks and administrative responsibilities as significant barriers. The most common responses to departmental factors that can be improved included moving meetings to during the workday versus after hours, establishing a similar value system/metric for all faculty, and providing more opportunities to interact with faculty across divisions. The most common barriers to change identified were difficulty hiring research support, patient volume and clinical demands, and a pervasive culture of continuing to work after the workday has ended. At an institutional level, provision of childcare and promotion of basic science research were identified as areas for improvement. More actionable items were identified at the departmental rather than institutional level (53 vs 34).Junior faculty well-being is most affected at the department level. Qualitative data collection from junior faculty regarding barriers to well-being and academic/clinical productivity can be invaluable for departments and institutions seeking to make cultural or systemic improvements.

Functional dependency has been associated with increased risk of adverse events following many surgical procedures. We hypothesized that dependent patients would have an increased risk of complications following thyroidectomy.We performed a retrospective review of total thyroidectomies performed from 1/2012-12/2019 as identified by CPT codes using the National Surgical Quality Improvement Project (NSQIP) database. Functional dependent status was identified from within the NSQIP database with partially or totally dependent combined into the dependent group.A total of 64,978 patients were included, with 0.53% identified as functionally dependent (FD). Functional dependency was associated with an increased risk of wound disruption, pneumonia, UTI, stroke, cardiac arrest, PE/DVT, and sepsis/septic shock. Dependent patients had higher rates of unplanned intubation, ventilator use, and significant bleeding. On multivariate analysis, FD patients were more likely to suffer from major complications and have an increased length of stay.Dependent status was associated with an increased risk of complications following thyroidectomy. Focused preoperative and disposition planning for these patients can help to minimize adverse outcomes and optimize resource utilization.

Functional dependence (FD) is associated with poor postoperative outcomes. We investigated the influence of FD on the postoperative outcomes of colectomy.The 2012-2020 National Surgical Quality Improvement Program was queried for patients who had undergone colectomy for diverticulitis. The patients were analyzed based on FD or functionally independent (FI) status.Of the 62,409 patients 991 (1.6%) were FD. Compared to FI patients, those with FD were older (mean age, 72.7 vs. 59.1 years, p 0.001), with higher comorbidities and more unplanned open procedures (79.7% vs. 38.0%, p 0.001). After adjusting for American Society of Anesthesia status, age, and comorbidities, the FD patients were 1.12 times (95% CI:1.07-1.17) more likely to have postoperative morbidity and 1.53 times (95% CI: 1.2-1.82) more likely to have 30-day mortality.Dependent functional status is an independent risk factor for complications after surgery for diverticulitis.

Primary hyperparathyroidism (PHPT) with low preoperative vitamin D levels is thought to be related to 4-gland hyperplasia. We reviewed final parathyroid pathology in relationship to preoperative vitamin D levels.A retrospective review was performed for all PHPT patients undergoing parathyroidectomy from 2001 to 2019. Patient demographics, laboratory studies, and final pathology were reviewed.2230 patients were included in the analysis, 78.1% were female with a mean age of 59 years. Patients were stratified into 3 groups based on their preoperative 25-hydroxy vitamin D levels; "deficient" (20 ng/mL) (n = 319), "insufficient" (20-30 ng/mL) (n = 1108), or "sufficient" (30 ng/mL) (n = 803). Patients with deficient vitamin D had a higher frequency of single adenoma (71%) compared to sufficient vitamin D patients (62%) (p 0.001) and fewer hyperplastic glands (19%) compared to sufficient vitamin D level patients (25%) (p 0.001).Vitamin D deficiency is more strongly associated with single-gland parathyroid disease than 4-gland hyperplasia. Further investigation into the complex interplay between vitamin D levels and autonomous parathyroid function is warranted.

It is unclear what drives variation in timing to tracheostomy among different patients.Age, ethnicity, admission service, and income were retrospectively collected for patients undergoing tracheostomy in a Level 1 trauma center from 2007 to 2017. The primary outcome was time to tracheostomy with early tracheostomy (ET) or late tracheotomy (LT) defined as 3-7 or ≥ 10 days post-intubation, respectively. Secondary outcomes included length of stay (LOS), ventilator associated pneumonia, and mortality.Among 1,640 patients, more men had ET compared to women (30% vs 28%; p = 0.05). The mean time to tracheostomy was 11.2 ± 7.7 days. Neurology and trauma patients had significantly shorter time to tracheostomy compared to other services. Age, ethnicity, and income showed no differences in timing to tracheostomy. Patients who underwent LT had a longer LOS (46 vs 32 days, p 0.01) and higher mortality (19% vs 13% p 0.01).There were no disparities in timing to tracheostomy based on age, ethnicity, or income. We detected a hesitation in performing tracheostomies by certain providers with shorter LOS and improved mortality in ET.

Normocalcemic primary hyperparathyroidism (PHPT) has been shown to benefit from parathyroidectomy. PHPT may be localized preoperatively with various imaging modalities, but the utility of preoperative imaging in normocalcemic PHPT compared to hypercalcemic PHPT is not well defined.Retrospective review was performed on all PHPT patients who underwent parathyroidectomy from 2001 to 2019. Patients were stratified into normocalcemic and hypercalcemic groups. Patient and outcomes data were analyzed.All 2218 patients in this database were included. 433 patients had normocalcemic PHPT (19.5%) and 1785 had hypercalcemic PHPT (80.5%). Among normocalcemic patients, equivalent cure rates were seen between patients with preoperative imaging versus those without (100% vs 99%). No differences in postoperative complications were demonstrated except for a slightly increase in transient hypocalcemia in patients without imaging.Normocalcemic PHPT patients had equivalent cure and similar complication rates with or without preoperative imaging compared to hypercalcemic patients. Routine localization studies in normocalcemic PHPT may be safely omitted in favor of exploration with intraoperative adjuncts by experienced surgeons.

Epidermal Nevus Syndrome (ENS), also known as Cutaneous Skeletal Hypophosphatemia Syndrome or Linear Sebaceous Nevus Syndrome, is caused by a mosaic somatic mutation of

Mentorship in academic medicine serves to promote career advancement and job satisfaction. This study was to evaluate the initial results of a faculty mentorship program in an academic Department of Surgery.A faculty mentorship program was initiated in July 2015 with 63 participants. Junior faculty mentees (n = 35) were assigned senior faculty mentors (n = 28). After three years, an electronic survey was administered and the results analyzed.Response rate was 67% (n = 42). 34 (81%) respondents had met with their mentor/mentee at least once. Topics discussed included: research (76%), leadership (52%), work-life balance (45%), and promotion (5%). Mentees endorsed achieving promotion (n = 2), increasing research productivity (n = 2), and obtaining national committee positions (n = 2). 61% of mentors and 53% of mentees felt they benefitted personally from the program. Actionable improvements to the mentorship program were identified including more thoughtful pairing of mentors and mentees with similar research interests.Participants felt the mentorship program was beneficial. Further investigation regarding the optimization of the mentor-mentee pairing is warranted to maximize the benefits from structured mentorship in academic surgery.

Anaplastic thyroid cancer (ATC) is a rare but very aggressive form of undifferentiated thyroid cancer. Due to its rapid rate of progression and invasive nature, ATC poses significant risks of morbidity and mortality. The cornerstone in the management of ATC remains a prompt diagnosis of the disease and timely management of complications depending on the stage of disease. Surgery continues to offer a higher chance of a cure, although not all patients are candidates for surgical management. Patients with advanced disease may be considered for palliative surgery to reduce morbidity and complications from advanced disease. With the advent of new molecular testing and improved methods of diagnosis, novel therapeutic targets have been identified. Systemic therapy (chemotherapy and radiation therapy) as well as novel immunotherapy have shown some promise in patients with targetable genetic mutations. Patients should therefore have molecular testing of their tumor-if it is unresectable-and be tested for mutations that are targetable. Mutation-targeted therapy may be effective and may result in a significant response to allow surgical intervention for exceptional responders. Overall, patients who receive all three modalities of therapy (surgery, chemotherapy, and radiation therapy) have the highest overall survival.

Adrenocortical carcinoma (ACC) is a rare malignancy that is frequently asymptomatic at presentation, yet has a high rate of metastatic disease at the time of diagnosis. Prognosis is overall poor, particularly with cortisol-producing tumors. While the treatment of ACC is guided by stage of disease, complete surgical resection is the most important step in the management of patients with primary, recurrent, or metastatic ACC. Triphasic chest, abdomen, and pelvis computer tomography (CT) scans and 18F flourodeoxyglucose positron emission tomography CT scanning are essential for accurate staging; moreover, MRI may be helpful to identify liver metastasis and evaluate the involvement of adjacent organs for operative planning. Surgical resection with negative margins is the single most important prognostic factor for survival in patients with ACC. To achieve the highest rate of R0 resection, open adrenalectomy is the gold standard surgical approach for confirmed or highly suspected ACC. It is extremely important that the tumor capsule is not ruptured, regardless of the surgical approach used. The best post-operative outcomes (complications and oncologic) are achieved by high-volume surgeons practicing at high-volume centers.

Background and purpose The relationship between tumor-node-metastasis (TNM) stage and patterns of failure in limited-stage small cell lung cancer (LS-SCLC) remains unclear. We hypothesized that TNM stage predicts brain metastasis risk, and could inform the use of prophylactic cranial irradiation. Material and methods We reviewed 283 patients with stage I–IIIB SCLC. Competing-risks regression was used to analyze local, distant, and brain failure. Multivariate analysis was used to evaluate the effect of treatment and clinical factors on failure and OS. Results Patients with stage I or II SCLC (35% of cohort) had significantly better survival and lower risk of distant and brain metastasis, compared with stage III patients. The 5-year cumulative incidence of brain metastasis for stage I/II and III were 12% and 26%, respectively. Stage had no correlation with local failure. On multivariate analysis, stage was independently prognostic for survival, distant metastasis risk, and brain metastasis risk. Conclusions TNM staging predicts likelihood of distant metastasis, brain metastasis, and survival in LS-SCLC. This supports the routine use of TNM staging in clinical practice. The lower risk of brain metastasis in stage I and II SCLC suggests that prophylactic cranial irradiation could play a more limited role in treatment of early-stage disease.

Vascular malformations involving the gastrointestinal tract are uncommon and have a variety of clinical presentations. In this paper, we present a case of a jejunal vascular malformation presenting as a small bowel obstruction in a 2-year-old boy. After clinical and radiologic evaluation, the patient underwent an exploratory laparotomy during which a jejunal mass was identified as the cause of the obstruction and was removed. Pathologic diagnosis confirmed the mass as a benign cavernous hemangioma within the jejunum. The patient recovered well post-operatively. Keywords: Hemangioma, Small bowel obstruction, Vascular malformation