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Objective. To prospectively evaluate the impact of parathyroidectomy on swallowing-related quality of life using the Swallowing Quality Of Life (SWAL-QOL) validated outcomes assessment tool. Background. Many patients with primary hyperparathyroidism report nonspecific symptoms, such as fatigue, irritability, cognitive impairment, sleep disturbances, and dysphagia. To date, there have been no prospective studies evaluating swallowing function before and after parathyroid surgery. Methods. Patients undergoing parathyroidectomy from September 2007 to January 2009 completed the SWALQOL questionnaire before and one year after surgery.Data were collected on demographic and clinicopathologicvariables. Comparisons were made to determine the effect of surgery on patients' perceptions of swallowing function.Results. Of 151 eligible patients, 102 (68%) completed the study. The mean patient age was 60 years, and 79%were female. A total of 73 patients (67%) had minimally invasiveparathyroidectomies, whereas the remainder had bilateral explorations. In all, 83 patients (81%) had a parathyroidadenoma, 16 patients (16%) had hyperplasia, and3 patients (3%) had a double adenoma on final pathologicinterpretation. Mean preoperative SWAL-QOL scores were<90 for 4 of the 11 domains, indicating the perception of oropharyngeal dysphagia and diminished quality of life.Following parathyroidectomy, significant improvements were demonstrated in eight SWAL-QOL domains.Conclusions. Many patients with parathyroid disease have the perception of abnormal swallowing function. In these patients with symptoms of dysphagia, parathyroid surgery leads to significant improvements in many aspects of swallowing-related quality of life measured by the SWAL-QOL instrument. This study represents the first use of a condition-specific instrument to assess swallowingrelatedquality of life for patients with parathyroid disease before and after parathyroid surgery. The Oncologist 2012;17:1271-1276 [ABSTRACT FROM AUTHOR]

Background.Recent match trends by medical graduates have revealed a declining interest in general surgery. Our study evaluates the academic strength of recent graduates to determine the quality of those matching to general surgery residencies.Methods.All third-year students rotating through the 8-week surgical clerkship from July 1998–June 2000 (n = 291) were followed at the University of Wisconsin Medical School. Each student completed 4 weeks of general surgery and 4 weeks of surgical subspecialties. Match data provided residency choices and students were divided into general surgery (GS), surgical subspecialty (SS), and nonsurgical (NS) residencies. Student performance was based upon National Board of Medical Experiences (NBME) surgery exam, class rank and Alpha Omega Alpha (AOA) status.Results.Students at our institution scored at the national mean on the NBME exam. GS team, session, and timing of GS rotation had no relationship to exam score. Total number of operative cases observed was inversely related to exam performance (P = 0.02). Of students entering a GS career, most scored below the mean on the NBME exam, 46% graduated in the bottom two thirds of the class, and only 6% of AOA members entered a GS residency.Conclusion.Although many of the strongest medical students select surgical residencies, they choose to enter SS careers and not GS careers. [Copyright &y& Elsevier]

Background: The cost-effectiveness of routine preoperative imaging for patients undergoing parathyroidectomy is controversial. The purpose of this study is to evaluate whether omission of routine preoperative imaging would affect efficiency or safety of parathyroidectomy., Methods: We implemented a no-imaging protocol for patients with primary hyperparathyroidism and no prior neck surgery. If the patient did not have preoperative parathyroid imaging before evaluation by a surgeon, no radiologic studies were ordered, and the patient was scheduled for parathyroidectomy. We used propensity matching to address differences between the imaging and no-imaging groups., Results: From 2000 to 2015, 83 patients underwent parathyroidectomy without imaging compared to 1245 patients with preoperative imaging. We successfully matched 64 patients with no preoperative imaging to equivalent patients who had imaging prior to surgery. Median age was 60 y, and 84% were women. There was no significant difference in operative time between patients with and without preoperative imaging (84 min for both groups, P < 0.32). Intraoperative parathyroid hormone levels dropped by at least 50% in all patients without preoperative imaging and in 98% of patients with imaging (P < 0.24). Neither group had recurrences 6 mo after surgery. Overall complication rates in the no-imaging (5%) and the imaging group (11%) were also similar (P < 0.18)., Conclusions: Parathyroid surgery without preoperative imaging is safe, effective, and offers equivalent outcomes compared to an approach based on routine preoperative imaging. Experienced surgeons can consider omitting preoperative imaging in patients without a history of neck surgery as this may reduce overall treatment costs., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Little is known about care coordination and communication with outpatient endocrine surgery patients. This study evaluated phone calls between office nurses and surgical patients to identify common issues addressed and their effect on patient care., Methods: Qualitative analysis of preoperative and postoperative phone conversations between office nurses and endocrine surgery patients., Results: We identified 183 thyroidectomy patients with 38% contacting our office before surgery and 54% within 30 days after surgery. Common reasons for preoperative calls included questions about preoperative evaluation (21%), medications (18%), and insurance and/or work paperwork (12%). Postoperatively, common topics included medications (23%), laboratory results (23%), and concerns about wounds (12%). Nursing staff prevented unnecessary readmission in 7 patients (4%) whereas appropriately referring 16 (9%) for early evaluation., Conclusions: Patients frequently contact their surgeons before and after endocrine surgery cases. Our findings suggest several areas for improving communication with patients., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: The necessity and frequency of postoperative surveillance for appendiceal carcinoid tumors ≤1 cm are undetermined., Methods: A retrospective review was conducted of all patients with appendiceal carcinoid tumors ≤1 cm managed at an academic, tertiary referral center. Clinicopathologic characteristics, treatment, surveillance, recurrence, and survival were assessed and analyzed., Results: Over a 16-year period, 31 patients met the inclusion criteria. Appendicitis (n = 17) and pelvic mass (n = 5) were the most common presentations. Median tumor diameter was 5 mm (range, 1-10 mm). Two patients had mesoappendiceal involvement. No patients had regional lymph node involvement or distant metastasis. Postoperatively, 14 patients (45%) received follow-up recommendations, including ≥1 of the following: imaging (n = 9), medical oncology referral (n = 7), colonoscopy (n = 5), and laboratory studies (n = 5). There were no recurrences or disease-specific deaths during a median follow-up period of 5 years (range, 0-15 years)., Conclusions: Appendiceal carcinoids ≤1 cm are unlikely to recur. Therefore, postoperative surveillance may be unnecessary., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: The purpose of this study was to determine whether the operative approach independently influenced recurrence and to identify perioperative predictors of recurrence., Background: Intraoperative parathyroid hormone (IoPTH) monitoring has enabled surgeons to perform minimally invasive parathyroidectomy (MIP). Yet, the long-term durability of this approach has recently been questioned., Study Design: A retrospective review was performed, and cases of initial neck surgery for nonfamilial primary hyperparathyroidism were selected for analysis. Cases were classified as either open parathyroidectomy (OP) when both sides of the neck were explored or MIP when only one side was explored. Kaplan-Meier estimates were plotted for disease-free survival, and a Cox proportional hazards model was developed to evaluate factors associated with recurrence for both the entire cohort and the MIP subset. Further comparisons were made between those who recurred and those who did not recur., Results: In the past 10-year period, 1368 parathyroid operations for primary hyperparathyroidism were performed at our institution. A total of 1006 were MIP whereas 380 were OP. There were no differences in recurrence between the MIP and OP groups (2.5% vs 2.1%; P = 0.68), and the operative approach (MIP vs OP) did not independently predict recurrent disease in our multivariate analysis. The percentage decrease in IoPTH was protective against recurrence for both the entire cohort (hazard ratio = 0.96; 95% confidence interval = 0.93-0.99; P = 0.03) and the MIP subset. A higher postoperative PTH also independently predicted disease recurrence., Conclusions: Operative approach does not independently predict recurrent hyperparathyroidism. The percentage decrease in IoPTH is one of many adjuncts the surgeon can use to determine which patients are best served by bilateral exploration whereas the postoperative PTH can guide follow-up after parathyroidectomy.

Background: There is a known association between the development of papillary thyroid cancer (PTC) after a primary nonthyroidal cancer (NTC). However, the prevalence of synchronous or antecedent NTCs in patients with PTC is undetermined, as are the clinicopathologic characteristics of PTC in these patients., Study Design: A review was performed of our prospectively maintained PTC database between January 1995 and December 2010. Information collected included patient and tumor characteristics, medical history, PTC presentation, and treatment modality., Results: Four hundred and thirty-three adult patients underwent thyroid resection and had PTC on final pathology. Sixty-seven cases of synchronous or antecedent NTCs were observed in 60 patients (13.9%). The most commonly associated antecedent NTCs were breast (n = 11), prostate (n = 8), and melanoma (n = 5), whereas renal cell carcinoma (n = 3) and melanoma (n = 3) were the synchronous NTCs most observed. Compared with patients without an NTC, those with an NTC were older (56.4 ± 15.5 years vs 44.9 ± 14.2 years; p < 0.0001), had experienced radiation exposure (35.0% vs 3.5%; p < 0.001), and more commonly presented with a thyroid mass incidentally on imaging (41.7% vs 9.1%; p ≤ 0.001). Papillary thyroid cancer tumor characteristics were similar between groups, except that NTC patients presented at a more advanced stage. However, when analyzed independently, primary tumor size, and nodal and distant metastases were comparable., Conclusions: The prevalence of synchronous or antecedent NTCs in patients surgically treated for PTC is 13.9%. These patients present with PTC tumor characteristics similar to those without additional NTCs, and should therefore be managed equivalently. In addition, surgeons should be aware of the frequency of synchronous PTC with these types of tumors and consider evaluation of the neck at the time of NTC diagnosis., (Copyright © 2013 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Thyroidectomy in the pediatric population is often avoided due to perceived risks in children. With growing subspecialization and establishment of high volume endocrine surgery centers, the indications for thyroid surgery and extent of resection continue to change. We examined the evolution of pediatric thyroid surgery at a high volume tertiary medical center., Methods: From our prospectively collected database, we reviewed medical records of individuals younger than 19 y who underwent thyroidectomy at our institution from 1994 to 2009. Patients were divided into two groups: (1) before establishment of our endocrine surgery center (1994-2001) and (2) since establishment of the center (2002-2009)., Results: We identified 78 operations performed on 74 patients with a median age of 15 (range 3-18) y. We found that the number of patients doubled in the later time period, with 26 operations in group 1 and 52 in group 2. The age of patients and percentage of females were similar between groups. After establishment of the endocrine surgery center, there was a significant increase in total thyroidectomies for all indications, including significantly more for benign disease. Overall, 9% of the patient population experienced transient complications, with no permanent complications or long-term sequelae., Conclusions: Pediatric thyroid surgery is extremely safe, especially when performed at a high volume endocrine surgery center. We more often select surgical treatment for benign disease and choose total thyroidectomy over limited resection. This may reflect increasing confidence in the safety and efficacy of surgery and reliability of thyroid hormone replacement., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Multinodular goiters (MNG) have recently been shown to have an incidence of cancer that approaches that of solitary thyroid nodule. However, fine needle aspiration (FNA) of a MNG is limited due to the presence of multiple nodules. Therefore we sought to identify risk factors for malignancy in patients with MNG., Methods: A total of 1791 consecutive patients underwent thyroidectomy at a single academic institution between May 1994 and December 2009. Of these, 838 patients had a MNG, which we defined as ≥ 2 nodules on preoperative ultrasound. The medical records of these patients were reviewed and analyzed., Results: A final pathologic diagnosis of malignancy was found in 260 of 838 (31%) of MNG patients. Of the 260 patients with malignancy, 113 (44%) had a focus of cancer <1 cm. Of the patients with malignancy on final pathology, preoperative FNA detected only 46% (n = 120). Of the 140 cancers not recognized preoperatively, 61 (44%) were >1 cm in size. On univariate analysis risk factors for malignancy were younger age and male gender. Patients with malignant nodules also had smaller nodules, smaller thyroids, and fewer nodules than those patients with benign findings on pathology. On multivariate analysis all predictors remained independently associated with malignancy with the exception of thyroid weight., Conclusion: Risk factors for malignancy in a MNG included male gender, younger age, fewer nodules, and smaller nodule size. The low predictive value of FNA in our population suggests there needs to be better ways to predict malignancy in patients with MNG. Therefore, these clinical risk factors should be considered when consulting patients with MNG in regards to their risk of malignancy., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objective: To determine the impact of neck ultrasonography in predicting papillary thyroid cancer persistence or recurrence., Methods: Between March 2005 and March 2009, we identified patients with a preoperative diagnosis of papillary thyroid cancer. Exclusion criteria included no documented preoperative ultrasonography and initial surgery at an outside institution. Patients with positive preoperative ultrasonography were compared with patients who had negative preoperative ultrasonography by assessing rates of neck dissection, complications, disease persistence or recurrence, and the need for repeated surgery., Results: Of 127 patients initially identified, 16 did not have preoperative ultrasonography and 4 did not have their initial surgery at our institution, leaving 107 patients in our cohort. Twenty-two patients had positive preoperative ultrasonography and 85 patients had negative preoperative ultrasonography. Patients with positive preoperative ultrasonography had a higher rate of repeated surgery than those with negative preoperative ultrasonography (27% vs 4.7%, P = .003). There was no difference in postoperative complication rates. No patients with negative preoperative ultrasonography and an ultrasound report stating specifically "no suspicious lymph nodes" required repeated surgery., Conclusions: Negative preoperative ultrasonography with specific lymph node evaluation predicts a low risk of needing early reoperation. Positive preoperative ultrasonography may be a marker for more aggressive disease and the best predictor of the need for additional surgery in the future.

Objective: To determine whether surgical volume influences the cause of operative failures after parathyroidectomy for hyperparathyroidism., Summary and Background Data: The surgical success rate for hyperparathyroidism from high-volume centers exceeds 95%, but some patients have unsuccessful parathyroidectomies. Although operative failure can be due to hyperfunctioning parathyroid glands in ectopic locations, less experienced surgeons may be more likely to miss an abnormal parathyroid in normal anatomic locations, which we describe as "preventable operative failure.", Methods: We used 2 prospective databases containing over 2000 consecutive patients who underwent parathyroidectomy. We identified 159 patients with persistent/recurrent hyperparathyroidism subsequently cured with additional surgery. The initially failed operations were classified as being performed at high- (>50 cases/yr) or low-volume (<50 cases/yr) hospitals. Hospital volume was obtained from a Wisconsin state database of 89 hospitals, which reported 6336 parathyroid operations during the same decade., Results: Patients who initially failed their operation performed at the high- or low-volume centers were similar with regard to age, laboratory values, gender, and parathyroid weights. Despite a higher incidence of multigland disease (which increases the likelihood of operative failure) in the high-volume group, patients in the low-volume group were more likely to have a missed parathyroid gland in a normal anatomic location (89% vs. 13%, P < 0.0001), and thus a higher proportion of preventable operative failures., Conclusions: Surgical volume influences the failure pattern after parathyroidectomy for hyperparathyroidism. Preventable operative failures are more common in low-volume centers.

Background: Parathyroid hormone (PTH) deficiency or hypoparathyroidism after total thyroidectomy is not an uncommon postoperative complication. Patients who have PTH deficiency will develop profound hypocalcemia if not properly treated with oral calcium supplementation and activated vitamin D (1,25-dihydroxycholecalciferol or calcitriol). However, there is little published on the long-term outcomes of these patients. The aim of this study was to determine the incidence of PTH deficiency and the time course to resolution after total thyroidectomy., Methods: We identified 271 consecutive patients who underwent total thyroidectomy from January 2006 to December 2008. All patients had serum PTH levels tested 4 h after surgery and the morning after surgery. Patients were diagnosed with PTH deficiency if their serum PTH was <10 pg/mL. The outcomes of patients with PTH deficiency (group 1) were then compared with patients who did not have PTH deficiency (group 2). Patients in group 1 were evaluated for parathyroid function by measuring serum PTH levels as well as documenting usage of supplemental calcium and 1,25-dihydroxycholecalciferol., Results: Of the 271 patients, 33 (12%) were found to have PTH deficiency. In comparing PTH deficient patients (group 1) with patients in group 2, there were no differences in age, gender, thyroid pathology, the incidence of thyroiditis, or other factors that would predict hypoparathyroidism. Twenty-four patients (73%) had recovery of their PTH levels to > or =10 pg/mL at their 1 wk follow-up appointment, while 9 (27%) patients still had PTH levels <10 pg/mL. With long term follow-up, 27 (82%) patients had recovered with a PTH level of > or = 10 pg/mL, while 6 (18%) patients had a serum PTH level <10 pg/mL. However, three of the 33 patients in group 1 (9%) required long-term 1,25-dihydroxycholecalciferol, but only two of these patients had undetectable PTH levels. Thus, the overall rate of hypocalemia requiring 1,25-dihydroxycholecalciferol was <1% (two of 271 total patients)., Conclusions: We concluded that approximately 12% (33 of 271) of patients undergoing total thyroidectomy will develop PTH deficiency. Of the PTH deficient patients, 73% will return to normal parathyroid function within 1 wk of surgery. Furthermore, 82% of these PTH deficient patients will return to normal parathyroid function with long-term follow-up. Less than 1% (two of 271) of patients undergoing total thyroidectomy will require 1,25-dihydroxycholecalciferol for long-term hypocalcemia., (Copyright 2010 Elsevier Inc. All rights reserved.)

Background: Interest in general surgical residencies has decreased significantly. Because medical student clerkship experiences may affect specialty preferences, we attempted to determine if the degree of exposure to surgical procedures influenced career choices., Methods: Operations observed by students who completed the third-year surgical clerkship between 1998 and 1999 were reviewed. These 146 medical students, who matched to residency training programs in March 2000, were then divided into three groups based upon residency fields. Surgical case exposures were then compared between the groups., Results: The total number of operations observed was similar between the groups. However, students who matched into categorical general surgical programs participated in significantly more abdominal and general surgical procedures than those matching in surgical subspecialty or nonsurgical residencies (P < 0.01)., Conclusions: There appears to be a correlation between surgical case exposure during the third-year clerkships and future residency fields. Thus, the degree of exposure to surgical procedures may influence medical student career choices.