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Vascular adhesion protein-1 (VAP-1) is an ectoenzyme that functions as a copper-containing amine oxidase and is involved in leukocyte adhesion at sites of inflammation. Inhibition of VAP-1 oxidative deamination has become an attractive target for anti-inflammatory therapy with demonstrated efficacy in rodent models of inflammation. A previous comparison of purified recombinant VAP-1 from mouse, rat, monkey, and human gene sequences predicted that rodent VAP-1 would have higher affinity for smaller hydrophilic substrates/inhibitors because of its narrower and more hydrophilic active site channel. An optimized in vitro oxidative deamination fluorescence assay with benzylamine (BA) was used to compare inhibition of five known inhibitors in recombinant mouse, rat, and human VAP-1. Human VAP-1 was more sensitive compared to rat or mouse VAP-1 (lowest IC50 concentration) to semicarbazide but was least sensitive to hydralazine and LJP-1207. Hydralazine had a lower IC50 in rats compared to humans, although not significant. However, the IC50 of hydralazine was significantly higher in the rat compared to mouse VAP-1. The larger hydrophobic compounds from Astellas (compound 35c) and Boehringer Ingelheim (PXS-4728A) were hypothesized to have higher binding affinity for human VAP-1 compared to rodent VAP-1 since the channel in human VAP-1 is larger and more hydrophobic than that in rodent VAP-1. Although the sensitivity of these two inhibitors was the lowest in the mouse enzyme, we found no significant differences between mouse, rat, and human VAP-1. Michaelis-Menten kinetics of the small primary amines phenylethylamine and tyramine were also compared to the common marker substrate BA demonstrating that BA had the highest affinity among the substrates. Rat VAP-1 had the highest affinity for all three substrates and mouse VAP-1 had intermediate affinity for BA and phenylethylamine, but tyramine was not a substrate for mouse VAP-1 under these assay conditions. These results suggest that comparing oxidative deamination in mouse and rat VAP-1 may be important if using these species for preclinical efficacy models.

Increased exposure to blue or visible light, fluctuations in oxygen tension, and the excessive accumulation of toxic retinoid byproducts places a tremendous amount of stress on the retina. Reduction of visual chromophore biosynthesis may be an effective method to reduce the impact of these stressors and preserve retinal integrity. A class of non-retinoid, small molecule compounds that target key proteins of the visual cycle have been developed. The first candidate in this class of compounds, referred to as visual cycle modulators, is emixustat hydrochloride (emixustat). Here, we describe the effects of emixustat, an inhibitor of the visual cycle isomerase (RPE65), on visual cycle function and preservation of retinal integrity in animal models. Emixustat potently inhibited isomerase activity in vitro (IC50 = 4.4 nM) and was found to reduce the production of visual chromophore (11-cis retinal) in wild-type mice following a single oral dose (ED50 = 0.18 mg/kg). Measure of drug effect on the retina by electroretinography revealed a dose-dependent slowing of rod photoreceptor recovery (ED50 = 0.21 mg/kg) that was consistent with the pattern of visual chromophore reduction. In albino mice, emixustat was shown to be effective in preventing photoreceptor cell death caused by intense light exposure. Pre-treatment with a single dose of emixustat (0.3 mg/kg) provided a ~50% protective effect against light-induced photoreceptor cell loss, while higher doses (1-3 mg/kg) were nearly 100% effective. In Abca4-/- mice, an animal model of excessive lipofuscin and retinoid toxin (A2E) accumulation, chronic (3 month) emixustat treatment markedly reduced lipofuscin autofluorescence and reduced A2E levels by ~60% (ED50 = 0.47 mg/kg). Finally, in the retinopathy of prematurity rodent model, treatment with emixustat during the period of ischemia and reperfusion injury produced a ~30% reduction in retinal neovascularization (ED50 = 0.46mg/kg). These data demonstrate the ability of emixustat to modulate visual cycle activity and reduce pathology associated with various biochemical and environmental stressors in animal models. Other attributes of emixustat, such as oral bioavailability and target specificity make it an attractive candidate for clinical development in the treatment of retinal disease.

Introduction: Medicare determines reimbursement rates for medical services, often setting a benchmark that is followed by private insurers. Across various medical specialties, decreases in Medicare reimbursement have been observed. However, the extent of Medicare reimbursement for endocrine surgery remains unexplored. This study investigates the trajectory of reimbursement rates for endocrine surgical procedures., Methods: Data spanning 2003 to 2023 were gathered from the Physician Fee Schedule Look-Up Tool for 16 endocrine operations and procedures. Each operation's or procedure's relative value units and conversion factor, which accounts for geographic variation in relative value units, are determined annually by the Centers for Medicare and Medicaid Services. The total annual Medicare reimbursement for each operation or procedure was determined by multiplying procedure-specific relative value units with the conversion factor. Raw yearly percentage changes in reimbursement were computed and compared to changes in the general consumer price index. All data were then corrected for inflation. The compound annual growth rate for each procedure was calculated using inflation-adjusted data., Results: From 2003 to 2023, the mean unadjusted percentage change for all queried procedures was +14.14% (standard deviation 0.28). During this same time, the consumer price index increased by 69.15% (P < .001). After adjusting for inflation, the mean total adjusted percentage change for all queried procedures over the entire study period was -31% (standard deviation 0.17). The adjusted average yearly compound annual growth rate was -1.93% (standard deviation 0.92). Only 1 procedure showed an increase in reimbursement (image-guided fine-needle aspiration, +32%)., Conclusion: Inflation-adjusted Medicare reimbursement rates for endocrine surgical procedures have consistently declined. Stakeholders must address these trends to ensure access to quality surgical endocrine care in an evolving health care landscape., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Stigma surrounds parental leave during general surgery residency, yet 25% to 29% of general surgery residents have children. Parental leave experiences of non-childbearing general surgery resident parents have not been described. This study aimed to describe the non-childbearing population's parental leave experiences., Methods: Using a purposive sampling strategy, semi-structured interviews (n = 20) were conducted via Zoom (August 2021-March 2022) with current general surgery residents or fellows who had at least 1 child during residency as the non-childbearing parent. Interviews explored participants' experiences with parental leave policies, timing, structure, motivations/influences for taking leave, career/training impacts, and reflections on their experiences. Transcripts were analyzed using thematic content analysis. Participant demographics were analyzed using univariate analysis., Results: Of the 20 participants, there were 31 unique parental leave experiences. The following 6 themes were identified from interviews: program/professional policies, cultural climate, support (institutional and social), parental leave experiences, impact, and recommendations. Participants cited needing to rely on informal support (eg, the assistance of other residents) to arrange leave and feeling compelled not to take the full time allowed in order to not burden co-residents or because others took less time. Overall, participants felt dissatisfied with their parental leave experiences., Conclusion: Non-childbearing general surgery resident parents underuse parental leave due to perceived or actual lack of access to leave and stigma. This results in dissatisfaction with their parental leave experiences and has the potential to lead to negative professional and personal outcomes. There is a critical need for improved support through cultural change and policy revision, implementation, and adherence., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Endocrine surgery is a core component of general surgery training. The landscape of endocrine surgery education in surgical residency and association with entrance into endocrine surgery fellowships is unknown., Methods: In total, 353 Accreditation Council for Graduate Medical Education-accredited general surgery program websites were identified and categorized by US region, program type and size, and endocrine surgery educational experience type. Self-identified endocrine surgeons were defined as American Association of Endocrine Surgeons members or fellowship graduates (American Association of Endocrine Surgeons surgeons) or having a thyroid/parathyroid/adrenal practice. Programs that graduated an American Association of Endocrine Surgeons fellow from 2012 onwards were identified, and characteristics associated with endocrine surgery-experience type, self-identified endocrine or American Association of Endocrine Surgeons faculty, and entrance into endocrine surgery fellowship were assessed., Results: In total, 353 programs were studied. The median number of general surgery residents per program was 25, with 165 (46.7%) small programs (<25 residents) and 188 (53.3%) large (≥25) programs. There were 122 (34.6%) university-based programs, 82 (23.2%) community-based, 139 (39.4%) community-based/university-affiliated, and 10 (2.8%) military. A total 665 self-identified endocrine surgeons were identified at 303 (85.8%) programs; 15 (14.2%) programs had no self-identified endocrine surgeon. There were 361 American Association of Endocrine Surgeons surgeons located at 163 (46.2%) residency programs. In total, 323 (91.5%) programs had information on curriculum/rotations available, 58 (17.9%) with dedicated endocrine surgery educational experiences, 226 (70%) with rotations mixed with other subspecialties, and 39 (12.1%) with none reported. A total 113 (35%) general surgery programs produced a future endocrine surgery fellow and were most likely to be large (81%, P < .001), university-based (64%, P < .001) programs and were more likely to have a self-identified endocrine (102, 90.3%, P = .016) or an American Association of Endocrine Surgeons surgeon (82, 72.6%, P = .004)., Conclusion: Program size and type were strongly associated with endocrine surgery exposure, presence of a self-identified endocrine surgeon, and same-site American Association of Endocrine Surgeons fellowship. Endocrine surgery educational experiences are inconsistent across residencies, and efforts are needed to ensure that surgical residents receive comprehensive, equitable endocrine surgery education., Competing Interests: Conflict of Interest/Disclosure The authors of this work have no competing interests to declare and report no proprietary or commercial interest in any product mentioned in this article. The authors have no relevant financial disclosures or conflicts of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Future income potential can impact surgical trainees' career choices, particularly when deciding to subspecialize, which often requires additional training and research time. This study quantifies the effects of added time on career value for eight surgical subspecialties., Methods: The Net present value(NPV) was calculated for eight subspecialties and general surgery over a 35-year career, factoring in salary, educational debt, tax, inflation, and practice setting. NPV for each was compared over a number of research years (0, 1, 2) using data from the MGMA, AAMC, and US government records., Results: After a 35-year career, six subspecialties in private practice increased career NPV(>$14,000) with 0 research years. One additional research year yielded negative career values for transplant, trauma, and vascular; with two, only cardiovascular and pediatric retained a positive NPV. In academia, 1-2 research years resulted in negative NPV for all but cardiovascular and thoracic surgery., Conclusions: The financial return of additional training years is highly variable., Competing Interests: Declaration of competing interest This research did not receive any grants from any funding agencies. The authors of this work have no competing interests to declare and report no proprietary or commercial interest in any product mentioned in this article., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Medicare significantly influences reimbursement rates, setting a standard that impacts private insurance policies. Despite declining rates in various specialties, the magnitude of these trends has not been examined in breast surgery. This study examines Medicare reimbursement trends for breast surgery operations., Methods: Data for 10 breast operations from 2003 to 2023 were collected from the Medicare Physician Fee Look-Up Tool and yearly reimbursement was computed using the conversion factor. The year-to-year percentage change in reimbursement was calculated, and the overall median change was compared with the consumer price index (CPI) for inflation evaluation. All data were adjusted to 2023 United States dollars. The compound annual growth rate (CAGR) was calculated using inflation-adjusted data., Results: Over the study period, reimbursement for the 10 breast operations had a mean unadjusted percentage increase of + 25.17%, while the CPI increased by 69.15% (p < 0.001). However, after adjustment, overall reimbursement decreased by - 20.70%. Only two operations (lumpectomy and simple mastectomy) saw increased inflation-adjusted Medicare reimbursement (+ 0.37% and + 3.58%, respectively). The CAGR was - 1.54% overall but remained positive for the same two operations (+ 0.02% and + 0.18%, respectively). Based on these findings, breast surgeons were estimated to be reimbursed $107,605,444 less in 2023 than if rates had kept pace with inflation over the past decade., Conclusion: Inflation-adjusted Medicare reimbursement rates for breast surgeries have declined from 2003 to 2023. This downward trend may strain resources, potentially leading to compromises in care quality. Surgeons, administrators, and policymakers must take proactive measures to address these issues and ensure the ongoing accessibility and quality of breast surgery., (© 2024. The Author(s).)

Introduction: Presenting health information at a sixth-grade reading level is advised to accommodate the general public's abilities. Breast cancer (BC) is the second-most common malignancy in women, but the readability of online BC information in English and Spanish, the two most commonly spoken languages in the United States, is uncertain., Methods: Three search engines were queried using: "how to do a breast examination," "when do I need a mammogram," and "what are the treatment options for breast cancer" in English and Spanish. Sixty websites in each language were studied and classified by source type and origin. Three readability frameworks in each language were applied: Flesch Kincaid Reading Ease, Flesch Kincaid Grade Level, and Simple Measure of Gobbledygook (SMOG) for English, and Fernández-Huerta, Spaulding, and Spanish adaptation of SMOG for Spanish. Median readability scores were calculated, and corresponding grade level determined. The percentage of websites requiring reading abilities >sixth grade level was calculated., Results: English-language websites were predominantly hospital-affiliated (43.3%), while Spanish websites predominantly originated from foundation/advocacy sources (43.3%). Reading difficulty varied across languages: English websites ranged from 5th-12th grade (Flesch Kincaid Grade Level/Flesch Kincaid Reading Ease: 78.3%/98.3% above sixth grade), while Spanish websites spanned 4th-10th grade (Spaulding/Fernández-Huerta: 95%/100% above sixth grade). SMOG/Spanish adaptation of SMOG scores showed lower reading difficulty for Spanish, with few websites exceeding sixth grade (1.7% and 0% for English and Spanish, respectively)., Conclusions: Online BC resources have reading difficulty levels that exceed the recommended sixth grade, although these results vary depending on readability framework. Efforts should be made to establish readability standards that can be translated into Spanish to enhance accessibility for this patient population., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Primary hyperparathyroidism (PHPT) is a treatable cause of nephrolithiasis. However, PHPT is not consistently evaluated in nephrolithiasis patients. Symptoms of parathyroid disease were explored in relation to evaluation of PHPT in nephrolithiasis patients., Methods: Patients with nephrolithiasis on imaging between 2017 and 2021 were identified. Measurement of serum calcium levels after nephrolithiasis diagnosis was determined. Patients with hypercalcemia (≥ 10.2 ​mg/dL) were identified. Characteristics associated with parathyroid hormone (PTH) evaluation and specialist referral were assessed., Results: Of 2264 nephrolithiasis patients with calcium levels measured, 383 (17.1 ​%) had hypercalcemia. Of those, 107 (27.9 ​%) had PTH levels drawn. PTH was more often assessed in patients with higher median calcium levels, recurrent nephrolithiasis, depression, and osteopenia/osteoporosis. PTH was elevated (>64 ​pg/mL) or non-suppressed (40-64 ​pg/mL) in 68 (63.6 ​%) patients. Of those, 31 (45.6 ​%) were referred to a parathyroid specialist. Referred patients had higher PTH and calcium levels than those without referral, and higher rates of osteopenia/osteoporosis., Conclusions: PTH evaluation in hypercalcemic nephrolithiasis patients was low. The majority of patients evaluated had elevated or non-suppressed PTH levels, but only a fraction were referred to a specialist., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships, with respect to employment, consultancies, stock ownership, honoraria, paid expert testimony, patent applications/registrations, research grants or other funding, that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Parathyroidectomy is recommended for severe secondary hyperparathyroidism (SHPT) due to end-stage kidney disease (ESKD), but surgery is underutilized. High quality and accessible online health information, recommended to be at a 6th-grade reading level, is vital to improve patient health literacy. This study evaluated available online resources for SHPT from ESKD based on information quality and readability., Methods: Three search engines were queried using the terms "parathyroidectomy for secondary hyperparathyroidism," "parathyroidectomy kidney/renal failure," "parathyroidectomy dialysis patients," "should I have surgery for hyperparathyroidism due to kidney failure?," and "do I need surgery for hyperparathyroidism due to kidney failure if I do not have symptoms?" Websites were categorized by source and origin. Two independent reviewers determined information quality using JAMA (0-4) and DISCERN (1-5) frameworks, and scores were averaged. Cohen's kappa evaluated inter-rater reliability. Readability was determined using the Flesch Kincaid Reading Ease, Flesch Kincaid Grade Level, and Simple Measure of Gobbledygook tools. Median readability scores were calculated, and corresponding grade level determined. Websites with reading difficulties >6th grade level were calculated., Results: Thirty one (86.1%) websites originated from the U.S., with most from hospital-associated (63.9%) and foundation/advocacy sources (30.6%). The mean JAMA and DISCERN scores for all websites were 1.3 ± 1.4 and 2.6 ± 0.7, respectively. Readability scores ranged from grade level 5-college level, and most websites scored above the recommended 6th grade level., Conclusions: Patient-oriented websites tailoring SHPT from ESKD are at a reading level higher than recommended, and the quality of information is low. Efforts must be made to improve the accessibility and quality of information for all patients., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Patients use the internet to learn more about health conditions. Non-English-speaking patients may face additional challenges. The quality of online breast cancer information, the most common cancer in women, is uncertain. This study aims to examine the quality of online breast cancer information for English and non-English-speaking patients., Methods: Three search engines were queried using the terms: "how to do a breast examination," "when do I need a mammogram," and "what are the treatment options for breast cancer" in English, Spanish, and Chinese. For each language, 60 unique websites were included and classified by type and information source. Two language-fluent reviewers evaluated website quality using the Journal of American Medical Association benchmark criteria (0-4) and the DISCERN tool (1-5), with higher scores representing higher quality. Scores were averaged for each language. Health On the Net code presence was noted. Inter-rater reliability between reviewers was assessed., Results: English and Spanish websites most commonly originated from US sources (92% and 80%, respectively) compared to Chinese websites (33%, P < 0.001). The most common website type was hospital-affiliated for English (43%) and foundation/advocacy for Spanish and Chinese (43% and 45%, respectively). English websites had the highest and Chinese websites the lowest mean the Journal of American Medical Association (2.2 ± 1.4 versus 1.0 ± 0.8, P = 0.002) and DISCERN scores (3.5 ± 0.9 versus 2.3 ± 0.6, P < 0.001). Health On the Net code was present on 16 (8.9%) websites. Inter-rater reliability ranged from moderate to substantial agreement., Conclusions: The quality of online information on breast cancer across all three languages is poor. Information quality was poorest for Chinese websites. Improvements to enhance the reliability of breast cancer information across languages are needed., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Some patients undergo thyroidectomy while hospitalized for a related or independent indication. Outcomes have not been described in this group., Methods: The 2016-2018 thyroidectomy-targeted NSQIP datasets were queried for patients admitted for ≥1 day preoperatively. 1:1 propensity score matching was employed to compare the outcomes of admitted patients to outpatients, including surgical and thyroidectomy-specific outcomes. Multivariable logistic regression determined factors associated with poor outcomes., Results: Of 18,078 patients, 312 were admitted at least 1 day prior to surgery. Inpatients had higher ASA classifications and rates of several comorbidities compared to the general population. After propensity score matching, inpatients had higher rates of overall complications, unplanned reoperation, and bleeding. They also experienced higher rates of thyroidectomy-specific complications such as hypocalcemia and neck hematoma. By multivariable regression, admission prior to surgery was associated with development of any complications., Conclusion: Thyroidectomy in hospitalized patients carries an increased risk of complications. Patients requiring thyroidectomy while already hospitalized should be counseled accordingly., Competing Interests: Declaration of competing interest The authors have no financial, personal, or professional conflicts of interest to disclose which may have biased this work. No portions of this manuscript were generated using any form of artificial intelligence technology., (Copyright © 2024. Published by Elsevier Inc.)

Introduction: Adrenalectomy generally has favorable outcomes. It is unknown if patients with functional adrenal tumors experience different clinical outcomes than those with benign adrenal tumors, due to the presence of comorbid conditions secondary to the functional tumor. We investigated outcomes following open and laparoscopic adrenalectomy for benign nonfunctional (BNF) versus functional adrenal masses., Methods: Patients undergoing adrenalectomy were identified in the 2015-2020 National Surgical Quality Improvement Program database, then categorized as BNF, hyperaldosteronism, hypercortisolism, and pheochromocytoma. The primary outcome of interest was 30-d morbidity and secondary outcomes included 30-d mortality, 30-d readmission, and postoperative length of stay (LOS). Subgroup analysis was performed based upon surgical approach. Univariate analysis was performed, followed by multivariable logistic regression for individual outcomes that differed significantly between patients with BNF and functional neoplasm, factoring in patient demographics and operative approach with statistical significance on univariate analysis. Descriptive statistics and outcomes were analyzed using Pearson's χ 2 test and Mann-Whitney U-test as appropriate., Results: There were 3291 patients with BNF while 484 had hyperaldosteronism, 263 hypercortisolism, and 46 pheochromocytomas. Within the laparoscopic group of 3615 (88.5%) of adrenalectomy patients, compared to BNF patients, patients with hyperaldosteronism had lower rates of postoperative morbidity (1.9% versus 5.2%, P < 0.001) and shorter LOS (1 d, interquartile range (IQR) [1-1] versus 1d IQR [1-2], P = 0.003); these persisted on multivariate analysis (OR 0.32, 95% confidence interval [CI] 0.14-0.74 and odds ratio 0.47, 95% CI 0.36-0.60, P < 0.001). Patients with hypercortisolism had higher morbidity (7.3% versus 5.2%, P < 0.001), 30-d readmission rates (5.3% versus 2.9%, P = 0.042) and longer LOS (2d, IQR [1-3] versus 1d, IQR [1-2, P < 0.001). On multivariate analysis, presence of hypercortisolism was independently associated with increased likelihood of readmission within 30 d (OR 2.20, 95% CI 1.11-2.99, P = 0.012) and longer LOS (>1 d) (OR 1.79, 95% CI 1.33-2.40, P < 0.001). Compared to BNF patients, patients with pheochromocytoma had higher rates of postoperative morbidity (6.2% versus 5.2%, P < 0.001). Within the open group of 469 (11.5% of adrenalectomy patients), there were no statistically significant differences in outcomes between patients with BNF and functional adrenal masses., Conclusions: Outcomes after adrenalectomy performed for functional neoplasms differ based on surgical indication., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: The risk of adverse outcomes after adrenal metastasectomy is not well defined. Knowledge of these risks is essential to guide patient counseling., Methods: The 2015-2020 National Surgical Quality Improvement Program datasets were combined. Patients who underwent adrenalectomy for secondary adrenal malignancy (SM) and benign nonfunctional (BNF) adrenal neoplasms were identified; BNF neoplasms were chosen as a comparison as functional neoplasms can contribute to comorbidity. Patients who had additional surgery at the time of adrenalectomy were excluded. Patient demographics, comorbidities, perioperative factors, and outcomes were compared between groups. Multivariable logistic regression analysis was performed., Results: Of 3496 adrenalectomy patients, 332 had SM and 3164 had BNF neoplasms. Patients with SM were older (65 versus 54 y) and more often had chronic obstructive pulmonary disease (7.5% versus 4.4%), chronic steroid use (10.5% versus 3.8%), and bleeding disorders (4.5% versus 2.2%) than patients with BNF, respectively (P < 0.01 for all). Laparoscopic adrenalectomy was the most common operative approach for both groups (74.7% versus 88.3%). Rates of mortality, morbidity, reoperation, readmission, and nonhome discharge did not differ significantly between groups. Patients with SM had higher rates of postoperative bleeding than patients with BNF (6.3% versus 2.6%, P < 0.001). This persisted on multivariable regression analysis that adjusted for demographics, comorbidities, and operative approach (odds ratio 2.34, 95% confidence interval 1.19-4.64)., Conclusions: Adrenalectomy for SM is associated with an increased risk of postoperative bleeding compared to adrenalectomy for BNF adrenal neoplasms. Patients with SM that meet criteria for adrenal metastasectomy should be counseled appropriately., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Most adrenal incidentalomas are not appropriately evaluated. Reporting the mass in the radiology report summary and providing recommendations in the report can positively impact evaluation. This study evaluated the effect of reporting Hounsfield units(HU) on adrenal incidentaloma follow-up., Methods: Patients with adrenal incidentalomas identified on noncontrast CT scan from 2015 to 2020 ​at a tertiary care institution were studied. Chart review was conducted. Patient and imaging characteristics were compared between patients who did and did not have HU reported. Outcomes of interest were 1)outpatient referral, 2)biochemical evaluation, and 3)dedicated imaging if appropriate. Multivariate analysis determined the impact of HU, reporting in the summary and provision of recommendations on the outcomes., Results: 363 patients were studied, 36(9.9 ​%) had HU reported. When HU were used in addition to recommendations and reporting in the summary, the likelihood of outpatient referral increased from 10.1 to 32.6-fold (95%CI 7.7-138.1, p ​< ​0.001). Similarly, the likelihood of biochemical workup increased from 2.5 to 7.8-fold (95%CI 2.5-24.1, p ​< ​0.001)., Conclusion: Recording adrenal incidentaloma HU on non-contrast CT scans was associated with increased rates of outpatient referral and biochemical workup., Competing Interests: Declaration of competing interest The authors of this work have no competing interests to declare and report no proprietary or commercial interest in any product mentioned in this article., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Practice consolidation by vertical and horizontal integration is a growing trend in surgery. Practice consolidation has not been previously examined in vascular surgery., Methods: The Medicare Provider Enrollment, Chain, and Ownership System data were used to identify vascular providers and vascular surgery practices in the United States in 2015 and 2020. Practices were categorized as solo (1 surgeon), small (2), medium (3-5), and large (≥6). The number of providers and the number of practices in each size group were determined. The Hirfendahl-Hirshman index (HHI), a measure of market consolidation, was calculated. Provider count, practice size, and HHI were additionally analyzed by urban and rural regions. All values were calculated for each time point and compared., Results: Vascular providers increased in number from 2929 to 3154 (7.7%) from 2015 to 2020. The number of practices decreased from 1351 to 1090 (19.3%). The number of large practices increased by 49.4%; the number of small or solo practices decreased by 42.1%. The mean HHI increased from 0.486 in 2015 to 0.498 in 2020. Both urban and rural regions had a decrease in solo practices (43.3% and 2.3%, respectively) and an increase in HHI (from 0.499 to 0.509 and 0.793 to 0.818, respectively). All changes were statistically significant., Conclusions: From 2015 to 2020, there is a trend toward vascular providers working in larger practice groups and a corresponding increase in measures of market consolidation., Competing Interests: Disclosures None., (Copyright © 2023 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

The significant volume-outcome relationship has triggered interest in improving quality of care by directing patients to high-volume centers and surgeons. However, significant disparities exist for different racial/ethnic, geographic, and socioeconomic groups for thyroid, parathyroid, adrenal, and pancreatic neuroendocrine surgical diseases disease., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Racial disparities in care exist for diseases with heterogeneous treatment guidelines. The impact of these disparities on outcomes after parathyroidectomy for secondary(2HPT) and tertiary hyperparathyroidism(3HPT) was explored., Methods: The 2015-2019 NSQIP datasets were used. Patients who underwent parathyroidectomy for 2HPT and 3HPT were identified and analyzed separately. Patients were stratified by race (white vs. non-white); demographics, comorbidities, and outcomes were compared. Studied outcomes included 30-day morbidity, mortality, unplanned reoperation, readmission, and postoperative length of stay(LOS)., Results: There were 1,150 patients with 2HPT and 262 with 3HPT. For 2HPT, 65.5% were non-white; morbidity, reoperation, and prolonged LOS(>3days) occurred disproportionately more often in non-white patients. Non-white race was independently associated with morbidity; higher ASA class and alkaline phosphatase levels were associated with prolonged LOS. For 3HPT, 53.1% were non-white; a prolonged LOS(>1day) occurred disproportionately more often in non-white patients. Higher alkaline phosphatase levels were independently associated with prolonged LOS., Conclusion: Race and markers of advanced disease negatively impact outcomes after parathyroidectomy for 2HPT and 3HPT. Attention to racial disparities and earlier referral may positively impact outcomes., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships, with respect to employment, consultancies, stock ownership, honoraria, paid expert testimony, patent applications/registrations, research grants or other funding, that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: Surgical residents make decisions that may have a dramatic impact on career earnings based off conceptions regarding future income potential. This study examines the effect of debt burden, repayment plan, and practice setting on a general surgeon's career value., Methods: Debt levels, repayment plans, and practice setting were considered to model a surgeon's career value using net present value (NPV) across 35 scenarios. The NPV was calculated using salary, education debt, yearly spending, and a discount rate of 5%. Salary data were obtained from the Medical Group Management Association, student debt information from the Association of American Medical Colleges, and tax and household spending data from U.S. government records. Assumptions included no gaps in training, no prior debt, single-person household, and career duration of 35 y., Results: A general surgeon's salary adequately repays debt burdens from $100,000-$300,000 over 10-25 y, regardless of repayment plan or practice setting. Practice setting decreased career value for academic surgeons when debt burden and repayment plan were held constant: the NPV for an academic surgeon was $382,000 compared to $500,000 for a nonacademic surgeon with the same debt and repayment plan. Debt burden repaid through unsubsidized and income-based repayment plans reduced NPV for all surgeons, while subsidized plans increased NPV. The projected NPV for all scenarios ranged $2.35M-$2.87 M., Conclusions: Though the modeled scenarios do not account for prior debt burden, major expenditures, or increases in yearly household spending beyond national averages, surgery residents should be aware that general surgery remains a financially feasible career., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Adrenalectomy is well tolerated with low complication rates. It is unclear if these excellent outcomes are consistent across all age groups., Methods: The 2015-2020 American College of Surgeons National Surgical Quality Improvement Program datasets were used. Patients who underwent adrenalectomy were identified and grouped based on age: ≤60, 61 to 70, 71 to 80, and >80 years. Patient characteristics, surgical indications, operative characteristics, and postoperative outcomes were compared between age groups. Primary outcome measures were mortality, morbidity, postoperative length of stay, non-home discharge, and unplanned readmission. Multivariable logistic regression analysis was performed., Results: Adrenalectomy was performed on 6,114 patients. Younger patients more frequently had surgery for non-functional benign neoplasms compared with older (55.7% vs 52.8% vs 45.9% vs 45.3%, for patients ≤60, 61 to 70, 71 to 80, and >80 years, respectively, P < .001), and less frequently had surgery for malignancy (8.8% vs 14.4% vs 22.5% vs 24.5%, P < .001). The median length of stay for patients ≤60 was 1 day compared with 2 days for patients 61-70, 71-80, and >80 (P < .001). The overall mortality rate was <1% and did not differ based on age (P = .18). Morbidity occurred less frequently in the younger age groups (7.3% vs 8.9% vs 11.2% vs 16.0%, P < .001) compared with older. Similar trends were seen for non-home discharge (1.4% vs 2.5% vs 4.8% vs 17.0%, P < .001). On multivariable analysis, patients aged >80 had a 2-fold increased likelihood of morbidity and a 9-fold increased likelihood of non-home discharge compared to patients aged ≤60., Conclusion: Older age is associated with morbidity and non-home discharge after adrenalectomy. Knowledge of these risks is critical when counseling an aging surgical population., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: Tertiary hyperparathyroidism (3HPT) is common after renal transplant. However, guidelines for diagnosis are not clear and few patients are treated surgically. This study aims to determine rates of diagnosis and treatment of 3HPT in renal transplant patients with hypercalcemia., Materials and Methods: This retrospective chart review identified all renal transplant recipients at a single tertiary care institution between 2011 and 2021. Patients with post-transplant hypercalcemia (> 10.2 mg/dL) were identified. The time in months of index hypercalcemia was noted. Measurement of parathyroid hormone (PTH) levels after index hypercalcemia was determined and noted as elevated if > 64 pg/mL at least 6 mo after transplant. Documentation of symptoms of hyperparathyroidism, a diagnosis of hyperparathyroidism in the electronic medical record, and medical or surgical management of patients with classic 3HPT (elevated calcium and PTH) were determined., Results: Of 383 renal transplant recipients, hypercalcemia was identified in 132 patients. The majority of hypercalcemic patients had PTH levels measured (127, 96.2%). PTH was elevated in 109 (82.6%). Among the 109 patients with classic 3HPT, 54 (49.5%) had a documented diagnosis of hyperparathyroidism in the electronic medical record (P = 0.01). Kidney stones or abnormal DEXA scan were present in 16 (14.7%) and 18 (16.5%), respectively. Most patients were managed non-surgically (101, 92.6%); calcimimetics were prescribed for 42 (38.5%, P = 0.01). Eight (7.3%) patients with classic 3HPT were referred to a surgeon (P = 0.35); all were initially prescribed calcimimetics (P = 0.001)., Conclusions: 3HPT is underdiagnosed in patients with elevated calcium and PTH levels post-transplant. A significant percentage of these patients go without surgical referral and curative treatment., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: In 2019, Centers for Medicare and Medicaid Services (CMS) established a new requirement that all hospitals publish information on the standard costs of services provided. Increased price transparency allows patients to compare healthcare costs and make informed decisions about their care. We investigated compliance with this rule with regards to laparoscopic cholecystectomy, a commonly performed operation and one of the 70 shoppable services (SSs) included in the CMS requirement, among prominent hospitals in the United States., Methods: The 2021-2022 US News "Best Hospitals for Gastroenterology and GI Surgery" was used to identify the top 50 hospitals for gastrointestinal surgery. Each hospital's website was assessed for the presence of a machine-readable file (MRF) as required by CMS. Each MRF was then evaluated for inclusion of all seven required elements: description of item/service, gross charge, payer-specific negotiated charge, deidentified minimum and maximum negotiated charges, discounted cash price, and billing code. The presence of a consumer-friendly display of SSs was also evaluated. The Current Procedural Terminology code 47562 (removal of gallbladder with an endoscope) was used to search for all six required elements: payer-specific negotiated charge, discounted cash price, de-identified minimum and maximum negotiated charges, campus location of the SS, and billing code. The SS display was further evaluated for provision of additional information on ancillary charges, which are recommended but not required. The MRF and SS were also evaluated for accessibility and date of last update. Hospitals were analyzed according to rank. Compliance with CMS requirements was compared between hospitals., Results: Fifty one hospitals were included. Of these 51 hospitals, one (2%) provided all the required information for both MRF and SS, 44 (86%) did not provide all necessary components of both the MRF and SS, six (12%) had all necessary elements of an MRF only, and two (4%) had all necessary elements of the SS only. The MRF was accessible in 80% (41) of studied hospitals and 76% (39) provided a gross charge but just 35% (18) of hospitals included the discounted cash price. The SS specified location for all hospitals, indicated a billing code in 96% (49), and provided a payer-specific charge in 96% (48), but less often provided de-identified minimum (30; 59%) and maximum (30; 59%) charges. Thirty nine (76%) hospitals reported that the listed price included an ancillary charge. There was no significant difference between hospitals in having all required elements of both the MRF and SS or the MRF only or SS only., Conclusions: Hospitals are providing healthcare consumers with standard charge information, although with significant variation in what is disclosed. There is no association between hospital reputation and provision of standard charge information., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Importance: There is a growing trend toward conservative management for certain low-risk cancers. Hospital and health-system factors may play a role in determining how these patients are managed., Objective: To explore the contribution of hospitals on patients' odds of nonoperative management for low-risk cancer., Design, Setting, and Participants: In this cross-sectional study, individuals with low-risk papillary thyroid cancer and solitary kidney masses were identified, and those receiving nonoperative management vs surgery were compared. Patients with low-risk thyroid cancer and kidney cancer from 2015 to 2017 eligible for nonoperative management according to National Comprehensive Cancer Network guidelines within the National Cancer Database were included. Data were analyzed from October 2021 to March 2022., Main Outcomes and Measures: For each facility, the proportion of these patients who received operative and nonoperative management was calculated. A mixed-effects logistic regression model with a hospital-level random effects term was used to calculate factors associated with nonoperative management. Between-hospital variability was assessed using ranked caterpillar plots., Results: There were 19 570 individuals with low-risk thyroid cancer (15 344 women [78.4%]; mean [SD] age, 51.74 [95% CI, 51.39-52.08] years) and 41 403 with kidney cancer (25 253 men [61.0%]; mean [SD] age, 61.93 [95% CI, 61.70-62.17] years). In the group with low-risk thyroid cancer, 2.1% (419 patients) received nonoperative management, and in the group with kidney cancer, 9.5% (3928 patients) received nonoperative management. This varied between hospitals from 1.1% (95% CI, 1.0%-1.1%) in the bottom decile to 10.3% (95% CI, 8.0%-12.4%) in the top decile for low-risk thyroid cancer, and from 4.3% (95% CI, 4.1%-4.4%) in the bottom decile to 24.6% (95% CI, 22.7%-26.5%) in the top decile for small kidney masses. For both cancers, age was associated with increased odds of nonoperative treatment. The hospital-level odds of nonoperative management of thyroid and kidney cancer using unadjusted probabilities (observed proportions) were minimally correlated (Spearman ρ = .33; P < .001)., Conclusions and Relevance: The findings of this study suggest that although health systems factors may be associated with the tendency to pursue nonoperative management, hospital-level factors may differ when comparing unrelated cancers.

Objective: To develop evidence-based recommendations for safe, effective, and appropriate treatment of secondary (SHPT) and tertiary (THPT) renal hyperparathyroidism., Background: Hyperparathyroidism is common among patients with chronic kidney disease, end-stage kidney disease, and kidney transplant. The surgical management of SHPT and THPT is nuanced and requires a multidisciplinary approach. There are currently no clinical practice guidelines that address the surgical treatment of SHPT and THPT., Methods: Medical literature was reviewed from January 1, 1985 to present January 1, 2021 by a panel of 10 experts in SHPT and THPT. Recommendations using the best available evidence was constructed. The American College of Physicians grading system was used to determine levels of evidence. Recommendations were discussed to consensus. The American Association of Endocrine Surgeons membership reviewed and commented on preliminary drafts of the content., Results: These clinical guidelines present the epidemiology and pathophysiology of SHPT and THPT and provide recommendations for work-up and management of SHPT and THPT for all involved clinicians. It outlines the preoperative, intraoperative, and postoperative management of SHPT and THPT, as well as related definitions, operative techniques, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Preoperative and Perioperative Care, Surgical Planning and Parathyroidectomy, Adjuncts and Approaches, Outcomes, and Reoperation., Conclusions: Evidence-based guidelines were created to assist clinicians in the optimal management of secondary and tertiary renal hyperparathyroidism., Competing Interests: S.M.M.: Scientific Advisor to Amgen, Ardelyx, and Sanifit. S.M.S.: Research Grants Amgen, Ardelyx, and Opko, Consulting Ardelyx. M.W. has received research support, honoraria or consultant fees from Akebia, Ardelyx, AstraZeneca, Bayer, Jnana, Pharmacosmos, Unicycive, and Walden Biosciences and has equity interests in Akebia, Unicycive and Walden Biosciences. The remaining authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Thyroidectomy and parathyroidectomy are relatively safe procedures, with overall morbidity rates of 2%-5%. The increasing age is associated with higher likelihood of poor outcomes. The modified five-point frailty index (mFI-5) is associated with complications, but many surgeons are unfamiliar with mFI-5. We assessed the accuracy of the mFI-5 versus the commonly-used American Society of Anesthesiologists (ASA) classification to predict complications following thyroidectomy and parathyroidectomy., Methods: Patients undergoing thyroidectomy or parathyroidectomy in 2015-2018 NSQIP datasets were identified. The mFI-5 scores were calculated by adding the number of the following comorbidities: congestive heart failure, hypertension requiring medication, chronic obstructive pulmonary disease, diabetes, and nonindependent functional status. Receiver operating characteristics curves were plotted for 30-d mortality and serious morbidity (defined as deep surgical site infection, dehiscence, unplanned intubation, failure to wean from the ventilator 48-h postoperatively, acute renal failure, pneumonia, pulmonary embolism, myocardial infarction, cardiac arrest requiring cardiopulmonary resuscitation, sepsis, septic shock, cerebrovascular accident, or reoperation) using mFI-5 and ASA classification. Areas under these curves (AUC) were compared., Results: Ninety-two thousand, six hundred and ninety-one patients were studied. The mFI-5 and ASA were fair predictors of 30-d mortality (AUC 0.75 and 0.82, respectively) and good predictors of serious morbidity (AUC 0.61 and 0.64). After stratification by age, ASA was superior to mFI-5 in predicting mortality for patients aged 65, 70, 80 y, and older, for the entire population and for thyroidectomy and parathyroidectomy separately., Conclusions: The ASA classification is a better predictor of mortality and serious morbidity than mFI-5 among patients undergoing thyroidectomy or parathyroidectomy and may be a better prognostic indicator to use when counseling patients before low-risk neck surgery., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: Colorectal surgery is a core component of general surgery. The volume of colorectal surgery performed by general surgery residents throughout training has not been studied. This study aims to analyze trends observed in colorectal-specific case numbers logged by general surgery residents over 16 years., Design: Case number data for general surgery residents was extracted from the publicly available, annually published Accreditation Council for Graduate Medical Education (ACGME) database from 2003 to 2019. Cases were categorized as open or laparoscopic colectomy/proctectomy, colectomy with ileoanal pull-thru, abdomino-perineal resection (APR), transanal rectal tumor excision (TRE), anorectal procedure, colonoscopy, and total colorectal cases. The average case numbers per category was calculated for each year. Linear regression analyzed trends in case categories for all residents and those logged as surgeon chief and junior residents., Setting: ACGME accredited general surgery residency programs., Participants: Not applicable., Results: General surgery residents reported increased numbers of all, chief, and junior resident colorectal cases over the study period (124.5-173.7 cases/yr; 38.4-53.0 cases/yr; 86.4-120.6 cases/yr, all p = 0.00). Average cases for all, chief, and junior residents have increased for laparoscopic colectomy/proctectomy (4.6-26.4 cases/year; 2.7-12.9 cases/year; 2.0-13.5 cases/year, all p = 0.00), anorectal surgeries (26.7-37.7 cases/year; 5.4-9.9 cases/year; 21.3-27.8 cases/year, all p = 0.00), and colonoscopies (35.9-70.6 cases/year, p = 0.00; 6.6-14.1 cases/year, p = 0.01; 29.4-56.5 cases/year, p = 0.00). Average cases for all, chief, and junior residents have decreased for open colectomy/proctectomy (52.0-34.9 cases/year; 21.2-14.3 cases/year; 30.9-20.6 cases/year, all p = 0.00), APR (3.3-2.7 cases/year, p = 0.00; 1.8-1.3 cases/year, p = 0.00; 1.5-1.4 cases/year, p = 0.02), TRE (1.9-1.1 cases/year; 0.7-0.4 cases/year; 1.2-0.6 cases/year, all p = 0.00). Ileoanal pull-thru did not demonstrate a linear trend., Conclusions: The increase in exposure to colectomies/proctectomies, anorectal procedures and colonoscopies is encouraging, as these common colorectal operations will be encountered in general surgery practice. The observed low case numbers for TRE, APR, and ileoanal pull-thru suggest a need for specialized training., (Copyright © 2021 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Four-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., Methods: The 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., Results: 7,959 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%., Conclusions: Of 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., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Adrenal metastasectomy is associated with increased survival in non-small cell lung cancer (NSCLC) with isolated adrenal metastases. Although clinical use of adrenal metastasectomy has expanded, indications remain poorly defined. The aim of this study was to evaluate the clinical benefit of adrenal metastasectomy for all lung cancer subtypes., Patients and Methods: We performed a retrospective cohort study of patients who underwent adrenal metastasectomy for metastatic lung cancer at six institutions between 2001 and 2015. The primary outcomes were disease-free survival (DFS) and overall survival (OS). Cox proportional hazards regressions and Kaplan-Meier survival analysis were performed., Results: For 122 patients, the mean age was 60.5 years and 49.2% were female. Median time to detection of the metastasis was 11 months, and 41.8% were ipsilateral to the primary lung cancer. Median DFS was 40 months (1 year: 64.8%; 5 year: 42.9%). Factors associated with longer DFS included primary tumor resection [hazard ratio (HR): 0.001; p = 0.005], longer time to adrenal metastasis (HR: 0.94; p = 0.005), and ipsilateral metastases (HR: 0.13; p = 0.004). Shorter DFS corresponded with older age (HR: 1.11; p = 0.01), R1 resection (HR: 8.94; p = 0.01), adjuvant radiation (HR: 9.45; p = 0.02), and open adrenal metastasectomy (HR: 10.0; p = 0.03). Median OS was 47 months (1 year: 80.2%; 5 year: 35.2%). Longer OS was associated with ipsilateral metastasis (HR: 0.55; p = 0.02) and adjuvant chemotherapy (HR: 0.35; p = 0.02). Shorter OS was associated with extra-adrenal metastases at adrenalectomy (HR: 3.52; p = 0.007), small cell histology (HR: 15.0; p = 0.04), and lung radiation (HR: 3.37; p = 0.002)., Discussion: Durable survival was observed in patients undergoing adrenal metastasectomy and should be considered for isolated adrenal metastases of NSCLC. Small cell histology and extra-adrenal metastases are relative contraindications to adrenal metastasectomy., (© 2022. Society of Surgical Oncology.)

Background: Routine preoperative laboratory testing is not recommended for American Society of Anesthesiologists classification 1 or 2 patients before low-risk ambulatory surgery., Methods: The 2017 National Surgical Quality Improvement Program data set was retrospectively queried for American Society of Anesthesiologists class 1 and 2 patients who underwent low-risk, elective outpatient anorectal, breast, endocrine, gynecologic, hernia, otolaryngology, oral-maxillofacial, orthopedic, plastic/reconstructive, urologic, and vascular operations. Preoperative laboratory testing was defined as any chemistry, hematology, coagulation, or liver function studies obtained ≤30 days preoperatively. Demographics, comorbidities, and outcomes were compared between those with and without testing. The numbers needed to test to prevent serious morbidity or any complication were calculated. Laboratory testing costs were estimated using Centers for Medicare and Medicaid Services data., Results: Of 111,589 patients studied, 57,590 (51.6%) received preoperative laboratory testing; 26,709 (46.4%) had at least 1 abnormal result. Factors associated with receiving preoperative laboratory testing included increasing age, female sex, non-White race/ethnicity, American Society of Anesthesiologists class 2, diabetes, dyspnea, hypertension, obesity, and steroid use. Mortality did not differ between patients with and without testing. The complication rate was 2.5% among tested patients and 1.7% among patients without tests (P < .01). The numbers needed to test was 599 for serious morbidity and 133 for any complication. An estimated $373 million annually is spent on preoperative laboratory testing in this population., Conclusion: Despite American Society of Anesthesiologists guidelines, a majority of American Society of Anesthesiologists class 1 and 2 patients undergo preoperative laboratory testing before elective low-risk outpatient surgery. The differences in the rates of complications between patients with and without testing is low. Preoperative testing should be used more judiciously in this population, which may lead to cost savings., (Copyright © 2021. Published by Elsevier Inc.)

Background: Many low-risk patients receive preoperative laboratory testing (PLT) prior to elective outpatient surgery, with no effect on postoperative outcomes. This has not been studied in patients undergoing anorectal surgery. The aim of this study was to determine if PLT in this population was predictive of perioperative complications., Materials and Methods: The 2015-2018 National Surgical Quality Improvement Program (NSQIP) databases were queried for elective ambulatory anorectal surgeries. PLT was defined as chemistry, hematology, coagulation, or liver function studies obtained ≤30 days preoperatively. American Society of Anesthesiologists (ASA) class 1 and 2 patients were included who underwent elective, ambulatory, benign anorectal surgery. Patient demographics, comorbidities, and postoperative outcomes were compared between those who did and did not receive PLT. Postoperative outcomes were defined as wound-related, procedure-related, major complications, unplanned readmission, and death occurring within 30 days. Multivariate regression analysis determined patient characteristics predictive of receiving testing., Results: Of 3309 patients studied, 48.6% received PLT. On multivariate analysis, older age, female sex, Black race, ASA class 2, and comorbidities were predictive of receiving testing. The complication rates were similar between patients who did and did not receive testing (4.3% versus 3.5%, P = 0.22)., Conclusions: PLT is performed in over half of low-risk patients receiving elective anorectal surgery. There was no difference in the rate of postoperative complications between patients who received testing or not, nor with normal versus abnormal results. PLT can be used more judiciously in this population., (Copyright © 2021. Published by Elsevier Inc.)

Background: Despite increasing numbers of women in surgery, female underrepresentation in surgical societies remains an ongoing issue. We sought to determine the gender composition of presenters at the American Association of Endocrine Surgery annual meetings., Methods: Utilizing previous meeting data, we collected gender information for presenters from 2010 to 2019, including first/senior author combinations. Awards winners and invited lecturers were also reviewed. We performed binomial testing to analyze proportions of male to female presenters, with significance set at P < .05. Temporal trends were analyzed via linear regression., Results: Fifty-six percent of American Association of Endocrine Surgery fellows and 36% of members are female. Of 354 podium and 477 poster presentations, women were listed less often as first (42.7%, P = .007) and senior (30.6%, P < .0001) podium authors and less often as first (42.8%, P = .002) and senior (29.8%, P < .0001) poster authors. The most common combination of first/senior authors was male-male (43.1%), followed by female-male (26.8%), female-female (16.1%), and male-female (14.0%). Less than 15% of invited lecturers were women, and women represented a minority in nearly all award categories. We observed a positive trend in female first authorship over time (slope = 0.766, 95% confidence interval, 0.70%-2.23%, P = .26) but no change in female senior authorship over time (slope = 0.03348, 95% confidence interval, 1.086%-1.153%, P = .95)., Conclusion: Women are underrepresented as American Association of Endocrine Surgery presenters and less likely to receive awards or deliver invited lectures. Although female first authorship increased over time, women continued to lag behind men as senior authors and mentors to trainees and junior faculty. Opportunities to improve speaker and awardee representation should be explored., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Patients frequently use online physician ratings websites (PRWs) to identify physicians for care. PRWs provide physician information and reviews. However, the accuracy of PRWs is uncertain. We investigated the accuracy and validity of Healthgrades with respect to endocrine surgery. We identified factors associated with reported board certification inaccuracy, higher ratings, greater quantity of ratings., Materials and Methods: The search term "endocrine surgery specialist" was used and the search was limited to a 25-mile radius around Philadelphia, PA. Data was collected on physician sex, age, board certification, surgical specialty, quantity of ratings, average rating, response to comments, and provision of a self-description. Descriptive statistics were performed to examine surgeon characteristics, ratings, and reported board certifications. Board certification accuracy was determined by searching the corresponding American Board website and calculating a kappa statistic. Logistic regression was performed to identify factors associated with board certification inaccuracy, higher average ratings, and higher quantity of ratings., Results: A total of 300 physicians were identified. Eighty-four percent of listed board certifications were accurate; the kappa statistic for accuracy of board certification was 0.634. Providing a response to comments and greater quantity of ratings were associated with higher average ratings. Provision of a self-description, male sex, and younger age were identified as factors associated with higher quantity of ratings., Conclusions: A wide range of specialties are identified as endocrine surgery specialists. The reliability of board certification reporting was moderate. Increased surgeon involvement with the Healthgrades site was inconsistently associated with higher average ratings and higher quantity of ratings but lower accuracy., (Copyright © 2021. Published by Elsevier Inc.)

Objective: The goal of this study was to examine a multi-institutional experience with adrenal metastases to describe survival outcomes and identify subpopulations who benefit from adrenal metastasectomy., Background: Adrenalectomy for metastatic disease is well-described, although indications and outcomes are incompletely defined., Methods: A retrospective cohort study was performed of patients undergoing adrenalectomy for secondary malignancy (2002-2015) at 6 institutions. The primary outcomes were disease free survival (DFS) and overall survival (OS). Analysis methods included Kaplan-Meier and Cox proportional hazards., Results: Of 269 patients, mean age was 60.1 years; 50% were male. The most common primary malignancies were lung (n = 125, 47%), renal cell (n = 38, 14%), melanoma (n = 33, 12%), sarcoma (n = 18, 7%), and colorectal (n = 12, 5%). The median time to detection of adrenal metastasis after initial diagnosis of the primary tumor was 17 months (interquartile range: 6-41). Post-adrenalectomy, the median DFS was 18 months (1-year DFS: 54%, 5-year DFS: 31%). On multivariable analysis, lung primary was associated with longer DFS [hazard ratio (HR): 0.49, P = 0.008). Extra-adrenal oligometastatic disease at initial presentation (HR: 1.84, P = 0.016), larger tumor size (HR: 1.07, P = 0.013), chemotherapy as treatment of the primary tumor (HR: 2.07 P = 0.027) and adjuvant chemotherapy (HR: 1.95, P = 0.009) were associated with shorter DFS. Median OS was 53 months (1-year OS: 83%, 5-year OS: 43%). On multivariable analysis, extra-adrenal oligometastatic disease at adrenalectomy (HR: 1.74, P = 0.031), and incomplete resection of adrenal metastasis (R1 margins; HR: 1.62, P = 0.034; R2 margins; HR: 5.45, P = 0.002) were associated with shorter OS., Conclusions: Durable survival is observed in patients undergoing adrenal metastasectomy and should be considered for subjects with isolated adrenal metastases., Competing Interests: The authors report no conflicts of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Preoperative laboratory tests (PLTs) are not associated with complications among healthy patients in various ambulatory procedures. This association has not been studied in ambulatory endocrine surgery., Methods: The 2015-2018 NSQIP datasets were queried for elective outpatient thyroid and parathyroid procedures in ASA class 1 and 2 patients. Outcomes were compared between those with and without PLTs. Multivariate regression examined factors predictive of receiving PLTs. Testing costs were calculated., Results: 58.7% of the cohort received PLTs. There were no differences in outcomes between those who were and those who were not tested. Non-white ethnicity, dyspnea, and non-general anesthesia were strongly predictive of receiving PLTs. Over $2.6 million is spent annually on PLTs in this population., Conclusions: Over half of healthy patients undergoing elective thyroid and parathyroid surgery receive PLTs. Complication rates did not differ between those with and without PLTs. Preoperative testing should be used more judiciously in these patients, which may lead to cost savings., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Women are disproportionately underrepresented in American academic surgery and surgical society leadership; we investigated the proportion of speaking roles held by women across a wide variety of surgical society meetings., Methods: Publicly-available data on invited speakers, panelists, and moderators at 23 national surgical societies' annual meetings from 2002 to 2019 were collected. Mixed effects logistic regression was used to evaluate the adjusted trend of gender representation over time for each role., Results: 15.9% of invited speakers were women. Adjusted analysis showed an 8% increase in odds of having female speakers per year (OR1.08, p = 0.002, 95%CI 1.03-1.14). 24.4% of moderators and 22.5% of panelists were female; there was increasing trend in adjusted analysis for both moderators (OR1.09, p < 0.001, 95%CI 1.07-1.11) and panelists (OR1.13, p < 0.001, 95%CI 1.11-1.43)., Conclusions: There is a wide range in speaking roles held by women at surgical society meetings, but an encouraging trend towards greater parity was seen overall., Competing Interests: Declaration of competing interest The authors declare no conflicts of interest, and have no funding to disclose., (Copyright © 2020. Published by Elsevier Inc.)

Study Objectives: To examine the current use of routine preoperative laboratory testing in low-risk patients undergoing ambulatory gynecologic surgery and to determine if such testing affects surgical outcomes., Design: The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was queried for ambulatory gynecologic surgeries between 2015 and 2018. Low-risk patients included in this study were defined as being American Society of Anesthesiologists class 1 or 2. The rate of preoperative laboratory testing before ambulatory gynecologic surgery in low-risk patients was determined and factors associated with testing including patient characteristics and comorbidities were evaluated. NSQIP-defined complications were compared between those with and without preoperative laboratory testing. Preoperative laboratory testing was defined as chemistry, hematology, coagulation, or liver function studies obtained within 30 days preoperatively., Setting: National health systems that participate in the NSQIP., Patients: There were 19 855 patients who underwent an ambulatory gynecologic procedure., Interventions: Preoperative laboratory testing in low-risk patients before ambulatory gynecologic surgery., Measurements and Main Results: Of the 19 855 patients studied, 14 258 (71.8%) received preoperative laboratory testing. Statistically significant differences were seen between patients who underwent preoperative testing and patients who did not. The most frequent preoperative test was a complete blood cell count (70.4%). Among patients who received preoperative testing, 4053 (28.4%) had at least 1 abnormal result. No statistically significant difference was seen in overall postoperative complication rate when comparing patients who received preoperative laboratory testing with those who did not (2.5% vs 2.2%, p = .30). Specifically, no statistically significant difference was seen among wound complications (1.0% vs 1.0%, p = .78), major complications (1.0% vs 0.8%, p = .11), unplanned return to the operating room (0.1% vs 0.2%, p = .40), unplanned readmission (0.7% vs 0.5%, p = .10), or overall morbidity (2.1% vs 1.9%, p = .38). Chi-square analyses were performed to compare categoric variables. Continuous variables were compared using unpaired t tests., Conclusion: This large study using a reputable national database revealed that despite updated evidence-based guidelines that recommend against the practice, preoperative laboratory testing continues to be performed for most low-risk patients undergoing ambulatory gynecologic surgery. This study also further supports current guidelines in demonstrating no difference in surgical outcomes between low-risk patients who did and did not receive preoperative laboratory testing. Preoperative laboratory testing practices for low-risk patients undergoing ambulatory gynecologic surgery do not follow current evidence-based guidelines and should be re-evaluated., (Copyright © 2021 AAGL. Published by Elsevier Inc. All rights reserved.)

Objective: Resident attrition from the field of General Surgery has been extensively studied. Attrition from one General Surgery program to the benefit of another has not. General Surgery programs can be negatively affected when a resident decides to leave the program for another. When a resident in a general surgery residency program decides to attempt transfer to another program several decisions must be made. The resident applies for the open position, interviews and then may be offered a position in that program. If an offer is made and the resident accepts, at what point is the resident's current Program Director notified? At what point in the process does the resident leave his/her current program to begin the new program? At what point does the new Program Director obtain a summative evaluation of the resident? Does the resident experience retribution as a result of informing his/her fellow residents and faculty that s/he is leaving? These are all questions that Program Directors struggle with when they find themselves with an unexpected opening to fill. The APDS Task Force on Resident Transfers attempted to answer these and other questions., Design: A 19-question survey was distributed via the APDS to all General Surgery Program Directors who utilize the list serve. The survey asked questions related to the following: acceptable reasons for transfer; timeline for the application, interview and transfer process; retaliation against residents who chose to transfer; and transparency in the transfer process., Setting: The survey was distributed via e-mail nationwide., Participants: General Surgery Residency Program Directors are participated in the survey., Results: The majority of the 99 respondents agreed to the following guidelines: (1) Program Directors must promote transparency in the transfer process; (2) Program Directors must make a statement against retaliation; (3) personal or family preference is the most acceptable reason for transfer; (4) an established transfer date must be agreeable to both programs; and, (5) a recruitment timeline should be established for both programs. All data are included below., Conclusions: The reasons that a resident chooses to leave a program and the effect this has on the program and the other residents requires further study. Program Directors should educate residents about the transfer process and that procedure should be available as a written policy. When a resident desires transfer to another program, following these guidelines may make the transition easier for all involved. The APDS supports putting them into practice., (Published by Elsevier Inc.)

Background: The albumin-bilirubin score (ALBI) has recently been shown to have increased accuracy in predicting post-hepatectomy liver failure and mortality compared with the Model for End-Stage Liver Disease (MELD). However, the use of ALBI as a predictor of postoperative mortality for other surgical procedures has not been analyzed. The aim of this study was to measure the predictive power of ALBI compared with MELD-sodium (MELD-Na) across a wide range of surgical procedures., Study Design: Patients undergoing cardiac, pulmonary, esophageal, gastric, gallbladder, pancreatic, splenic, appendix, colorectal, adrenal, renal, hernia, and aortic operations were identified in the 2015-2018 American College of Surgeons NSQIP database. Patients with missing laboratory data were excluded. Univariable analysis and receiver operator characteristic curves were performed for 30-day mortality and morbidity. Areas under the curves were calculated to validate and compare the predictive abilities of ALBI and MELD-Na., Results: Of 258,658 patients, the distribution of ALBI grades 1, 2, 3 were 51%, 42%, and 7%, respectively. Median MELD-Na was 7.50 (interquartile range 6.43 to 9.43). Overall 30-day mortality rate was 2.7% and overall morbidity was 28.6%. Increasing ALBI grade was significantly associated with mortality (ALBI grade 2: odds ratio [OR] 5.24; p < 0.001; ALBI grade 3: OR 25.6; p < 0.001) and morbidity (ALBI grade 2: OR 2.15; p < 0.001; ALBI grade 3: OR 6.12; p < 0.001). On receiver operator characteristic analysis, ALBI outperformed MELD-Na with increased accuracy in several operations., Conclusions: ALBI score predicts mortality and morbidity across a wide spectrum of surgical procedures. When compared with MELD-Na, ALBI more accurately predicts outcomes in patients undergoing pulmonary, elective colorectal, and adrenal operations., (Copyright © 2020 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Adverse surgical events are a major cause of morbidity, mortality, and disability worldwide. Serious reportable events, such as wrong site surgery, retained foreign bodies, and surgical fires, are preventable adverse events that have significant consequences. These "never events" are costly to the patient, health care systems, and society and have led to many efforts to reduce their occurrence. However, these costly events still occur, and more research is needed to obtain a better understanding of their causes and how to prevent them., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: The 2015 American Thyroid Association (ATA) guidelines recommended that low-risk, differentiated thyroid cancers (DTC) between 1 and 4 cm may be treated with thyroid lobectomy alone. We sought to determine the effect of these guideline changes on the rate of completion thyroidectomy (CT) for low-risk DTC and factors influencing surgical decision-making., Methods: All patients from 2014 to 2018 who received an initial thyroid lobectomy at our institution with final pathology demonstrating DTC were included. Patients were divided into "pre" and "post" guideline cohorts (2014-2015 and 2016-2018, respectively). The rate of CT was compared between the two cohorts. Patient demographics and tumor characteristics were examined for association with CT., Results: A total of 163 patients met study criteria: 63 patients in the 2014-2015 ("pre") and 100 in the 2016-2018 ("post") group. In the "pre" period, 41 (65.1%) patients received CT compared with 43 (43.0%) in the "post" period (p < 0.01)-a 34% decrease in the rate of completion surgery (p < 0.01). Of low-risk patients with DTC between 1 and 4 cm in size, 17 of 35 (48.6%) received CT in the "pre" period compared with 15 of 60 (25.0%) in the post period-a 48.6% decrease in the rate of completion surgery (p = 0.02). Greater tumor size, capsular invasion, and multifocality were associated with CT in low-risk "post" guideline patients (p < 0.05 for all)., Conclusions: The rate of CT decreased significantly by 48.6% for low-risk patients with DTC between 1 and 4 cm, demonstrating recognition of the 2015 ATA guidelines. However, 25% of these patients underwent CT, suggesting additional factors influencing the decision for further treatment.

Importance: Women are disproportionately underrecognized as award winners within medical societies. The presence of this disparity has not been investigated in training programs., Objective: To determine the presence of a gender disparity in award winners in general surgery residency programs., Design, Setting, and Participants: In this retrospective survey study, 32 geographically diverse academic and independent general surgery residency programs were solicited for participation. The 24 participating programs (75.0%) submitted deidentified data regarding the gender distribution of residents and trainee award recipients for the period from July 1, 1996, to June 30, 2017. Data were analyzed from September 11, 2017, to December 21, 2018., Exposures: Time and the proportion of female trainees., Main Outcomes and Measures: The primary outcome was the percentage of female award winners. A multilevel logistic regression model accounting for the percentage of female residents in each program compared the odds of a female resident winning an award relative to a male resident. This analysis was repeated for the first and second decades of the study. Award winners were further analyzed by type of award (clinical excellence, nonclinical excellence, teaching, or research) and selection group (medical students, residents, or faculty members)., Results: A total of 5030 of 13 760 resident person-years (36.6%) and 455 of 1447 award winners (31.4%) were female. Overall, female residents were significantly less likely to receive an award compared with male residents (odds ratio [OR], 0.44; 95% CI, 0.37-0.54; P < .001). During the first decade of the study, female residents were 70.8% less likely to receive an award compared with male residents (OR, 0.29; 95% CI, 0.19-0.45; P < .001); this improved to 49.9% less likely in the second decade (OR, 0.50; 95% CI, 0.42-0.61; P < .001). Female residents were less likely to receive an award for teaching (OR, 0.33; 95% CI, 0.26-0.42; P < .001), clinical excellence (OR, 0.44; 95% CI, 0.31-0.61; P < .001), or nonclinical excellence (OR, 0.69; 95% CI, 0.48-0.98; P = .04). No statistical difference was observed for research award winners (OR, 0.76; 95% CI, 0.42-1.12; P = .17). The largest discrepancies were observed when award recipients were chosen by residents (OR, 0.23; 95% CI, 0.14-0.39; P < .001) and students (OR, 0.32; 95% CI, 0.25-0.42; P < .001) compared with faculty members (OR, 0.52; 95% CI, 0.42-0.66; P < .001)., Conclusions and Relevance: This study found that female residents were significantly underrepresented as award recipients. These findings suggest the presence of ongoing implicit bias in surgery departments and training programs.

The appropriate use of the robot in surgery continues to evolve. Robotic operations (RO) are particularly advantageous for deep pelvic and retroperitoneal procedures, but the implementation of RO is unknown. We aimed to examine regional variation for the most commonly performed RO in general, gynecologic, and urologic surgery. A three-state inpatient database from 2008 to 2011 was used. Nine common robotic inpatient general, gynecologic and urologic surgery procedures were analyzed. States were divided into hospital service areas (HSAs). The percentage of RO was calculated for each operation. Hospital service areas that had < 50% or > 150% of the RO average were outliers. Hospital service areas were compared based on demographics, patterns of adoption, variation in usage, and association with population, physician and hospital density. Hysterectomies were the procedure that was performed most often robotically. Over 50% of radical prostatectomies were performed robotically. Procedures with the highest rate of RO performance were performed with the least variation. Characteristics that were significantly correlated with RO included provider and hospital density. Variation in the utilization of RO is common and differs by operation. Physician density impacts access to care and is associated with the variation in use of RO depending on procedure type. Further research is needed to understand the causes of variation and adoption of RO.

Background: Normocalcemic 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., Methods: The 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., Results: Among 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., Conclusion: Patients with normocalcemic primary hyperparathyroidism have higher rates of multigland disease and remedial surgery compared with primary hyperparathyroidism with hypercalcemia., (Copyright © 2019. Published by Elsevier Inc.)