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Purpose of review Although traditionally an inpatient procedure, outpatient thyroidectomy has gained traction as a viable and well tolerated alternative for selected patients, with an added benefit of cost savings. Recent findings Research on outpatient thyroidectomy has focused on establishing its noninferiority in outcomes compared to the standard inpatient or overnight observation. Numerous studies have found comparable low rates of postoperative complications and no increase in readmission. Selection criteria have been well established by professional societies and research studies support the selection bias benefitting appropriately selected patients. The primary benefit of outpatient thyroidectomy reported is a decrease in cost, though additional theoretical benefits such as decreased exposure to nosocomial infections. Summary Outpatient thyroidectomy is a well tolerated approach in appropriately selected candidates, with cost reduction benefits. Adherence to societal guidelines for patient selection is paramount.

Background Current thyroid hormone replacement therapy (THRT) is built on weight-based standard calculation of dose. A novel Poisson regression model, which accounts for seven clinical variables, was recently proposed to improve accuracy of THRT. We aimed to compare the accuracy of estimated THRT dose to reach euthyroid and the difference in predicted dose between the Poisson (scheme A) and the weight-based standard (scheme B) in patients following total thyroidectomy for benign disease. Methods We retrospectively reviewed medical record of patients who underwent total or completion thyroidectomy for benign disease at a single institution between 2011 and 2019. The THRT dose was calculated using both schemes. We compared the difference between calculated THRT and prediction rates for optimal THRT dosing needed to achieve a euthyroid state between dosing schemes. Patients were evaluated for achieving euthyroid state, defined as TSH 0.45-4.5 mIU/L. We also compared dosing error rates (> 25 mcg over- and underdosing) between schemes. Prediction rates were compared by BMI tertiles to account for the effect of BMI extremes in achieving euthyroid state. The difference in predicted dose between schemes was calculated in both the total sample size and patients that met euthyroid. A measure of agreement, Kappa, was used to estimate agreement between dosing schemes. Results A total of 406 patients underwent total thyroidectomy for benign disease, with 184 having sufficient follow up data confirming euthyroid state. Of the 184 patients, 85.9% (n = 158) were women, 81% (n = 149) were Hispanic, and 56.5% (n = 104) were obese with a median BMI of 30.8 kg/m2. Scheme A resulted in a higher, but not statistically significant, accuracy rate (A: 60.3%, n = 111 versus B: 53.8%, n = 99; P = 0.21). Overdosing errors were lower with Scheme A (A:17.9% versus B: 32.1%; P = 0.0025) and less extreme > 25 µg (A: 17.9% versus B: 26.1%; P = 0.08). A trend in improved accuracy in patients with a BMI > 35 kg/m2 was noted (A: 46.9% versus B: 34.4%; P = 0.20). Scheme A also resulted in less overdosing errors in obese patients compared to Scheme B (A: 19.2% versus 45.2%; P = 0.0006). The average difference in predicted dose between schemes was an entire dose difference, mean of 16.0 µg and 15.8 µg for the total and euthyroid samples respectively. Furthermore, for the majority of patients the predicted dose did not match between the two dosing schemes for total and euthyroid samples, 76% (n = 311) and 76% (n = 141) respectively. In patients that achieved euthyroid, agreement between dosing schemes was low to moderate (Kappa = 0.360). Conclusions Lower rates of overdosing were found for scheme A, particularly with obese patients. No statistically significant differences in predicted THRT dose was observed between schemes. The difference in predicted dose between schemes was on average 15 ug, correlating with an entire dose. The consideration of clinical variables other than weight (scheme A) when determining optimal THRT dosing may be of importance to prevent overdoses, with particular clinical relevance in patients with higher BMIs.

Background Cure of hypertension after adrenalectomy for primary aldosteronism is no certainty and therefore preoperative patient counseling is essential. The Primary Aldosteronism Surgical Outcome (PASO) Score is a useful prediction model with an area under the curve (AUC) of 0.839. The PASO Score includes ‘Target Organ Damage’ (TOD) (i.e., left ventricular hypertrophy and/or microalbuminuria), which is often unavailable during preoperative counseling and might therefore limit its use in clinical practice. We hypothesized that the PASO score would still be useful if TOD is unknown at time of counseling. Therefore, we aimed to examine the predictive performance of the simplified PASO Score, without taking TOD into account. Materials and methods In this retrospective cohort study, patients who underwent unilateral adrenalectomy between 2010 and 2016 in 16 medical centers from North America, Europe and Australia were included. TOD was unknown in our database and therefore assigned as absent. Patients were classified as complete, partial or absent clinical success using the PASO consensus criteria. Results A total of 380 (73.9%) patients were eligible for analysis. Complete, partial and absent clinical success were observed in 29.5%, 55.8% and 14.7% of patients, respectively. The simplified PASO Score had an AUC of 0.730 (95% confidence interval 0.674–0.785) in our total cohort. Conclusion Without taking TOD into account, the simplified PASO Score had a lower predictive value as compared to the original derivation cohort. Ideally, the complete PASO Score should be used, but when data on TOD are not readily available, the simplified PASO Score is a useful and reasonable alternative., Highlights • We aimed to examine the predictive performance of the PASO Score, without taking ‘target organ damage’ (TOD) into account. • This simplified PASO Score had a lower predictive value as compared to the PASO Score in the original derivation cohort. • The simplified PASO Score increases the applicability of the model and is reasonable for clinicians to use in daily practice. • Ideally, the complete PASO Score should be used, but the simplified PASO Score is a useful and reasonable alternative.

Background Blogging is a new and innovative means of information exchange in the surgical community. We examined the Association of Women Surgeons (AWS) blog to understand its audience and most read content. Methods Google Analytics was used to assess the AWS blog site data. A search was performed from February 2018 to February 2019. Demographic data, blog posts, and tags sorted by unique pageviews were recorded. Results There were 31,221 unique pageviews during the search period. The AWS Blog readership was mostly women (75%), ages 25–44 years (70.3%). The three tags that elicited the most pageviews were “residency (16.95%),” “medical students (12.12%),” and “family life (10.38%).” The most read blog post was responsible for 9.7% of total pageviews. Discussion & conclusion Most of the AWS Blog readership are young, women, and interested in content related to graduate and postgraduate medical education or family life. Blogging may be a good vehicle for topics not covered in traditional scientific literature.

Background: In a first step toward standardization, the Primary Aldosteronism Surgical Outcomes investigators introduced consensus criteria defining the clinical outcomes after adrenalectomy for primary aldosteronism. Within this retrospective cohort study, we evaluated the use of these consensus criteria in daily clinical practice in 16 centers in Europe, Canada, Australia, and the United States.Methods: Patients who underwent unilateral adrenalectomy for primary aldosteronism between 2010 and 2016 were included. Patients with missing data regarding preoperative or postoperative blood pressure or their defined daily dose were excluded. According to the Primary Aldosteronism Surgical Outcomes criteria, patients were classified as complete, partial, or absent clinical success.Results: A total of 380 patients were eligible for analysis. Complete, partial, and absent clinical success was achieved in 30%, 48%, and 22%, respectively. Evaluation of the Primary Aldosteronism Surgical Outcomes criteria showed that in 11% and 47% of patients with partial and absent clinical success, this classification was incorrect or debatable (16% of the total cohort). This concept of a "debatable classification of success" was due mainly to the cutoff of >= 20 mmHg used to indicate a clinically relevant change in systolic blood pressure and the use of percentages instead of absolute values to indicate a change in defined daily dose.Conclusion: Although introduction of the Primary Aldosteronism Surgical Outcomes consensus criteria induced substantial advancement in the standardization of postoperative outcomes, our study suggests that there is room for improvement in the concept for success given the observed limitations when the criteria were tested within our international cohort. In line, determining clinical success remains challenging, especially in patients with opposing change in blood pressure and defined daily dose. (C) 2019 Elsevier Inc. All rights reserved.

Background Non-White and female surgeons are underrepresented in academic surgery faculty. We hypothesized that the leadership of major U.S. regional and national general surgery societies reflects these same racial and gender disparities. We suspected that attending a medical school or residency program with academic prestige would be more common for surgeons from underrepresented backgrounds. Materials and methods Race/ethnicity and gender of the 2020-21 executive council members and 2012-21 society presidents of 25 major general surgery societies (7 regional, 18 national) was assessed. Academic prestige was determined by reputational top 25 programs, identified using U.S. News and World Report and Doximity rankings for medical school and residency, respectively. Results Surgical society executive council members (n = 204) were predominantly White (75.5%) and male (67.2%). The 50 non-White council members were Asian (n = 37), Black (n = 7), and Latinx (n = 6). 14 (6.9%) were international medical graduates (IMGs). 56.4% attended a school or program ranked in the Top 25 (n = 115). Surgical society presidents 2012-21 (n = 242) have been mostly White (87.6%) and male (83.4%). Non-White, male surgical society presidents were Asian (n = 13), Black (n = 9), and Latino (n = 6). Of the 41 female surgery society presidents, 92.7% were White, 7.3% (n = 3) Asian, and none Black or Latina. 13 were IMGs (5.3%). 55.0% of society presidents attended Top 25 (n = 133) schools or programs. The three non-White, female presidents all attended Top 25 schools/programs (100%). Of the 15 unique individuals who were male, non-White presidents, 12 attended top 25 schools or programs (80%). Conclusion Women, non-White surgeons, and IMGs are underrepresented in U.S. surgical society leadership. Increasing racial diversity in U.S. surgical society leadership may require intentionality in mentorship and sponsorship, particularly for surgeons who did not attend prestigious schools or programs.

BACKGROUND Our aim was to examine differences in clinical outcomes between Hispanic subgroups who underwent emergency general surgery (EGS). METHODS Retrospective cohort study of the HCUP State Inpatient Database from New Jersey (2009-2014), including Hispanic and non-Hispanic White (NHW) adult patients who underwent EGS. Multivariable analyses were performed on outcomes including 7-day readmission and length of stay (LOS). RESULTS 125,874 patients underwent EGS operations. 22,971 were Hispanic (15,488 with subgroup defined: 7,331 - Central/South American; 4,254 - Puerto Rican; 3,170 - Mexican; 733 - Cuban). On multivariable analysis, patients in the Central/South American subgroup were more likely to be readmitted compared to the Mexican subgroup (OR 2.02; p

Background The opioid epidemic prompted reevaluation of surgeons’ opioid prescribing practices. This study aimed to demonstrate noninferiority of a staged analgesic regimen after endocrine surgery. Methods We conducted a randomized controlled trial comparing analgesic regimens after thyroidectomy and/or parathyroidectomy. Adult patients (≥18 years) were randomized to study arm (A) as-needed acetaminophen + codeine or (B) scheduled acetaminophen/as-needed tramadol. Patients recorded pain scores and analgesics consumed in a study log. Clinical variables were collected from the medical record. Results Target enrollment was achieved (n = 126), and randomization was even (A: 44.5%, B: 55.6%). There was no difference between enrolled patients and those who returned the study log (52.4%) by sex (P = .667), age (P = .513), final pathology (P = .137), procedure (P = .667), or randomization arm (P = .795). Most patients (50.8%) reported moderate pain scores (4–6) with no difference between study arms (P = .451). There was no difference in average consumption by morphine milligram equivalents (A: 11.5 ± 12.1 vs B: 12.49 ± 18.07; P = .792) nor total analgesic doses (A: 7.29 ± 7.48 vs B: 8.5 ± 5.36; P = .445). However, a significant difference in average percentage of opioid doses was noted (A: 79.71 ± 33.31 vs B: 27.38 ± 31.88; P Conclusion Patients reported moderate pain scores with low requirements for analgesics after endocrine surgery. The staged analgesic regimen is noninferior to combination opioids and led to reduced overall consumption.

This study assesses ways in which General Surgery residency program websites demonstrate diversity.Literature review and diversity expert opinion informed selection of diversity elements. We limited our evaluation to residency program-specific webpages. We identified 8 program website elements that demonstrate programmatic commitment to diversity: (1) standard nondiscrimination statement; (2) program-specific diversity and inclusion message; (3) community demographics; (4) personalized biographies of faculty, (5) personalized biographies of residents; (6) individual photographs of faculty; (7) individual photographs of residents; and (8) list of additional resources available for trainees. We evaluated the impact of program type (university, independent, or military); city population; region; program director gender and ethnicity; and program size on incorporation of these eight elements. We dichotomized programs that had ≥4 of these elements on their website and determined association with the above factors using chi-square or Fisher's exact test.Website review July to December 2019.All nonmilitary-based general surgery residency program members of the Association of Program Directors in Surgery (APDS) (n = 242/251).General Surgery residency program websites included a mean of 2.7 ± 1.5 elements that showcase diversity. Most program websites (n = 215, 89%) featured ≤4 elements (range 1-4), while 15 (6.2%) had none. When stratified by programs having 4 or more elements on their website, university-based program (p0.001) was the only factor associated. Resident photos (n = 147, 61%), resources available to trainees (n = 146, 60%), faculty photos (n = 139, 57%), and community demographics (n = 93, 38%) were the most common of the 8 website elements.Residency program websites are vital to recruiting applicants. Featuring specific elements on the General Surgery residency website that display a program's commitment to diversity and inclusion may be important in attracting a diverse candidate pool. This research highlights opportunities programs may use to demonstrate more effectively a residency program's commitment to diversity and inclusion.

Background A call to increase diversity among academic surgery faculty (ASF) was made in 2008, after recognizing the lack of surgeons considered underrepresented in medicine (URM). We aimed to quantify and assess trends among URM ASF in the interval since that call to action. Methods Publicly available data on ASF were reviewed. We calculated the percentage of ASF in 2018 by URM group, then stratified by academic rank of assistant professor, associate professor, and full professor. We compared 2005-2018 ASF of Hispanic or Latino (HL) and African American (AA) background; 2005 data were unavailable for other URM groups. Results In 2018, URM surgeons accounted for 7.06% (n = 1013/14,340) of ASF (AA: n = 492, 3.43%; HL: n = 485, 3.38%; American Indian or Alaskan Native: n = 23, 0.16%; and Native Hawaiian/Pacific Islander: n = 13, 0.09%). When comparing 2005-2018, AA ASF remained stable across ranks (total: n = 298, 3.12% versus n = 492, 3.43%; P = 0.09), whereas HL ASF decreased across ranks (total: n = 415, 4.35% versus n = 485, 3.38%; P = 0.00007). Conclusions Surgeons from URM backgrounds account for 7% of ASF. No increase in AA and a decrease in HL ASF occurred from 2005 to 2018. There is a paucity of data for other URM groups. Active strategies to increase diversity and inclusion in academic surgery are necessary.

Background Blood-borne pathogen exposures (BBPEs) pose a risk to health care workers (HCWs). Needlestick injuries (NSIs) have declined overall, but not for surgical HCWs. There are limited data regarding BBPEs among medical students (MSs) in their clinical years. We aimed to quantify this risk for third- and fourth-year MSs. Methods A literature review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The PUBMED database was searched to identify studies of third- and fourth-year MSs using the terms BBPE, NSI, and MS. Studies of other HCWs were excluded if MS data were not extractable. Additional studies were identified from references. Descriptive analysis was performed. Results Seven of 171 articles published from 2002 to 2018 met study criteria. All used self-reported data from surveys/questionnaires. One-third of MSs reported BBPEs (n = 194/600, 32.3%) with a mean of 1 in 3.09 and a median of 1 in 3.53 (range: 1 in 1.9-8.3 students). Most events were NSIs (144/194, 74%) with a mean of 1 NSI per 4.05 MSs and median of 1 in 4.625 (range: 1 in 2.47-10.71). The remaining BBPEs reported included blood and bodily fluid splashes (n = 37, 19%), other mucocutaneous exposures (n = 7, 3.6%), and uncategorized injuries (n = 2, 1%). Conclusions One-third of senior MSs reported BBPEs during clinical rotations. Most BBPEs were NSIs. Quantifying this risk allows for anticipatory education and protocol development to protect students and other new HCWs. Educational efforts focused on NSI prevention before and during clinical rotations may help reduce BBPEs.

BACKGROUND. No guidelines exist regarding physicians’ duty to inform former patients about novel genetic tests that may be medically beneficial. Research on the feasibility and efficacy of disseminating information and patient opinions on this topic is limited. METHODS. Adult patients treated at our institution from 1950 to 2010 for medullary thyroid cancer, pheochromocytoma, or paraganglioma were included if their history suggested being at-risk for a hereditary syndrome but genetic risk assessment would be incomplete by current standards. A questionnaire assessing behaviors and attitudes was mailed 6 weeks after an information letter describing new genetic tests, benefits, and risks was mailed. RESULTS. Ninety-seven of 312 (31.1%) eligible patients with an identified mailing address returned the questionnaire. After receiving the letter, 29.2% patients discussed genetic testing with their doctor, 39.3% considered pursuing genetic testing, and 8.5% underwent testing. Nearly all respondents (97%) indicated that physicians should inform patients about new developments that may improve their or their family’s health, and 71% thought patients shared this responsibility. Most patients understood the letter (84%) and were pleased it was sent (84%), although 11% found it upsetting. CONCLUSIONS. Patients believe it is important for physicians to inform them of potentially beneficial developments in genetic testing. However, physician-initiated letters to introduce new information appear inadequate alone in motivating patients to seek additional genetic counseling and testing. Further research is needed regarding optimal methods to notify former patients about new genetic tests and corresponding clinical and ethical implications.

Adrenocortical carcinoma (ACC) has a poor prognosis and there is an unmet clinical need for biomarkers to improve both diagnostic and prognostic assessment. Pituitary-tumor transforming gene (PTTG1) has been shown to modulate cancer invasiveness and response to therapy. The potential role of PTTG1 protein levels in ACC has not been previously addressed. We assessed whether increased nuclear protein expression of PTTG1 distinguished ACCs from adrenocortical adenomas (ACAs). Patients with ACC or ACA were identified from prospective tissue banks at two independent institutions. Two tissue microarrays (TMAs) consisting of adrenal specimens from 131 patients were constructed and clinically annotated. Immunohistochemical analysis for PTTG1 and Ki-67 was performed on each TMA. TMA-1 (n = 80) contained 20 normal adrenals, 20 ACAs, and 40 ACCs, and the validation, TMA-2 (n = 51), consisted of 10 normal adrenals, 14 ACAs, and 27 ACCs. On TMA-1, nuclear staining of PTTG1 was detected in 12 (31%) ACC specimens, while all ACAs and normal adrenal glands were negative for PTTG1. On TMA-2, 20 (74%) of the ACC tumors demonstrated PTTG1 nuclear staining of PTTG1, and 13 (93%) ACA and 4 (44%) normal adrenal glands were negative for PTTG1. ACC tumors with increased PTTG1 protein staining had a significantly higher Ki-67 index (p

IMPORTANCE In addition to biochemical cure, clinical benefits after surgery for primary aldosteronism depend on the magnitude of decrease in blood pressure (BP) and use of antihypertensive medications with a subsequent decreased risk of cardiovascular and/or cerebrovascular morbidity and drug-induced adverse effects.OBJECTIVE To evaluate the change in BP and use of antihypertensive medications within an international cohort of patients who recently underwent surgery for primary aldosteronism.DESIGN, SETTING, AND PARTICIPANTS A cohort study was conducted across 16 referral medical centers in Europe, the United States, Canada, and Australia. Patients who underwent unilateral adrenalectomy for primary aldosteronism between January 2010 and December 2016 were included. Data analysis was performed from August 2017 to June 2018. Unilateral disease was confirmed using computed tomography, magnetic resonance imaging, and/or adrenal venous sampling. Patients with missing or incomplete preoperative or follow-up data regarding BP or corresponding number of antihypertensive medications were excluded.MAIN OUTCOMES AND MEASURES Clinical success was defined based on postoperative BP and number of antihypertensive medications. Cure was defined as normotension without antihypertensive medications, and clear improvement as normotension with lower or equal use of antihypertensive medications. In patients with preoperative normotensivity, improvement was defined as postoperative normotension with lower antihypertensive use. All other patients were stratified as no clear success because the benefits of surgery were less obvious, mainly owing to postoperative, persistent hypertension. Clinical outcomes were assessed at follow-up closest to 6 months after surgery.RESULTS On the basis of inclusion and exclusion criteria, a total of 435 patients (84.6%) from a cohort of 514 patients who underwent unilateral adrenalectomy were eligible. Of these patients, 186 (42.3%) were women; mean (SD) age at the time of surgery was 50.7 (11.4) years. Cure was achieved in 118 patients (27.1%), clear improvement in 135 (31.0%), and no clear success in 182 (41.8%). In the subgroup classified as no clear success, 166 patients (91.2%) had postoperative hypertension. However, within this subgroup, the mean (SD) systolic and diastolic BP decreased significantly by 9 (22) mm Hg (P CONCLUSIONS AND RELEVANCE In this study, for most patients, adrenalectomy was associated with a postoperative normotensive state and reduction of antihypertensive medications. Furthermore, a significant proportion of patients with postoperative, persistent hypertension may benefit from adrenalectomy given the observed clinically relevant and significant reduction of BP and antihypertensive medications.

Background The 2015 American Thyroid Association (ATA) guidelines called for consideration of thyroid lobectomy (TL) as an acceptable surgical treatment for small and less aggressive papillary thyroid cancers (PTC) with no clinical evidence of metastasis or extrathyroidal extension. Optimal extent of surgery, however, remains controversial. Methods A systematic literature review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. PUBMED, EMBASE, Scopus, and Cochrane Library databases were searched to identify studies comparing TL to total thyroidectomy (TT) for low-risk PTC. Studies were grouped according to the major outcomes in the literature: survival and the need for completion thyroidectomy (CT). Results Overall survival for low-risk PTC patients who underwent TL was comparable to TT. Locoregional recurrence (LRR) rate following TL was less than 6% and salvaged with CT. The proportion of patients meeting the 2015 ATA guidelines selection criteria for TL who subsequently would need CT varied by study but averaged 34%. After excluding microscopic extrathyroidal extension and positive resection margin as indications for CT to facilitate radioactive iodine ablation, the estimated rate across the included studies was 11%. Conclusions We performed a systematic review of outcomes following TL or CT for low-risk PTC according to 2015 ATA guidelines. Initial operative approach did not have a negative impact on overall survival. There is a paucity of high-quality data on this topic across the literature. Long-term follow-up studies on oncologic and patient-centered outcomes are essential.

Background Perioperative opioid use has been linked to abuse potential by patients, leading surgeons to scrutinize their postoperative prescribing practices. The goal of the study was to review analgesic regimens for patients undergoing thyroidectomy and parathyroidectomy and extrapolate changes that could be made to decrease opioid use while maintaining adequate pain control. Materials and methods A literature review was performed. Inclusion criteria were studies 1) written in English, 2) published within the last 20 years, and 3) that included human subjects. Exclusion criteria were studies that 1) evaluated anesthesia regimens exclusively, 2) compared surgical approaches and their effects on pain (e.g., open neck exposure vs. transoral route for thyroidectomy), or 3) included patients undergoing concurrent lateral neck dissection. Of 951 studies originally identified, 10 studies met the criteria. Results Ten studies were identified, and each evaluated a different analgesic regimen. Five of the studies found a decrease in pain with multimodal regimens. Of the remaining studies, three found no difference in pain control, one found an increase in pain when only an opioid patient-controlled analgesia was used, and one found that 93% of patients required less than 20 oral morphine equivalents postoperatively. Conclusions There is no postoperative analgesic regimen that has been established as optimal for patients undergoing parathyroidectomy and thyroidectomy in the current medical literature. However, half of the studies included in this review found that nonopioid adjuncts decreased patients’ need for postoperative opioids.

We assessed the efficiency, consistency, and appropriateness of perioperative processes for standard (total) thyroidectomy and devised a valuable strategy to decrease variability and waste.Our multidisciplinary team evaluated23-hour stay standard thyroidectomy performed by 3 surgical endocrinologists. We used the nominal group technique, process flowcharts, and root cause analysis to evaluate 6 perioperative processes. Anticipated decreases in costs, charges, and resources from improvements were calculated.Median total charge for standard thyroidectomy was $27,363 (n = 80; $48,727 variation). Perioperative coordination between surgery and anesthesia clinics could eliminate unnecessary testing (potential decrease in charges of $1,505). Nonoperating room time was less in the outpatient operating room (43 vs 52 minutes; P.001). Consistent scheduling could decrease charges by $585.49 per case. By decreasing 20% of nondisposable instruments on the surgical tray, we could decrease sterile processing costs by $13.30 per case. Modification of postoperative orders could decrease charges by $643 per patient. Overall, this comprehensive analysis identified an anticipated decrease in cost/charge of$200,000 annually.Perioperative process analyses revealed wide variability for a single, presumed uniform procedure. Systematic assessment helped to identify opportunities to improve efficiency, decrease unnecessary waste and procedures/instrument usage, and focus on patient-centered, quality care. This multidisciplinary strategy could substantially decrease costs/charges for common operative procedures.

Multiple endocrine neoplasia type 1 (MEN1) is a rare, autosomal-dominant disorder caused by alterations in the MEN1 gene on chromosome 11.1 Ninety percent of patients with MEN1 initially present with hyperparathyroidism (HPT), affecting men and women equally (unlike sporadic HPT) and at a younger age of onset (compared with sporadic HPT).2 Other commonly affected endocrine glands include the pancreas and pituitary; >20 different types of tumors have been described in MEN1 patients. Of particular concern is the development of pancreatic neuroendocrine tumors (PNET), some of which produce gastrin, insulin, or other secretory hormones; metastatic PNETs are the leading cause of disease-specific death in MEN1 patients.3,4 Identifying a cellular mechanism behind the multiple neoplasms occurring in MEN1 patients could eventually enable clinicians to predict and properly screen for the development of PNET at the time of HPT presentation has the important potential to prevent downstream morbidity and mortality. A number of genes are known to be involved in neuroendocrine tumorigenesis, including MEN1, RET, VHL, TSC1, and TSC2,5 with mutations in MEN1 remaining the most common form of genetic predisposition to neuroendocrine tumors. More than 1,300 mutations6 in the MEN1 gene have been reported in families with MEN1 syndrome, yet the exact mechanisms by which these mutations cause the MEN1-related pathologies are not known.3,7,8 The heterozygous germline-inactivating mutation in the MEN1 may be followed by loss of the normal copy of this gene or a somatic inactivating mutation (second hit), leading to complete loss of function of the encoded protein menin. However, genotype–phenotype analysis has not revealed a clear pattern of disease penetrance in MEN1 patients.9,10 Additionally, it is reported that 5–30% of MEN1 patients do not have an identifiable mutation by standard testing.7,11 Loss of heterozygosity (LOH) has been described in parathyroid tissue of sporadic HPT patients, particularly in chromosome 11 in association with MEN1 gene alterations.8,12 No relationship has been found between MEN1-related HPT and tumor suppressor genes, such as TP53,13 although mutations of this gene have been associated with other neuroendocrine tumors. In contrast, whole-exome sequencing of parathyroid tissue from sporadic HPT patients has not revealed clear mutation patterns. Somatic mutations in the MEN1 gene have been described in 15– 35% of non-MEN1 parathyroid adenomas and are implicated in the pathology of sporadic HPT.8,12,14 However, few other somatic variants have been found to be harbored with significant frequency in sporadic HPT adenomas.12 Whole-exome sequencing has previously been used to identify somatic mutations in samples from sporadic HPT adenomas, parathyroid carcinomas, and other sites (ie, PNET), but not MEN1-related HPT.8,12,15 Because of the known germline mutation in MEN1 patients, we hypothesized that whole-exome sequencing on blood and tissue samples of HPT patients could aid in the following goals: (1) Identify acquired somatic mutations involved in functional pathways and tumorigenic networks, and (2) elucidate additional germline risk factors associated with outcomes.

Background This study compared reoperative complication rates after initial minimally invasive parathyroidectomy and standard cervical exploration. Methods Records from patients who underwent 1 reoperative parathyroidectomy at a single institution (1998 to 2012) were retrospectively reviewed. Results Seventy-seven patients were included; 74% underwent initial standard cervical exploration. Preoperative and operative characteristics were similar between groups; 74% underwent focused, unilateral reoperation. A significantly higher rate of postoperative complications occurred in the initial standard cervical exploration group (42% vs 15%, P = .03) that could not be explained by differences in the rates of symptomatic hypocalcemia ( P = .5). The type of prior parathyroidectomy was significantly associated with postoperative complications (odds ratio 4.1, 95% confidence interval 1.1 to 15.7, P = .04). In a multivariable logistic regression model that included body mass index, type of operation (for initial and reoperation), and initial operation performed prereferral as covariates, type of prior parathyroidectomy remained a significant predictor of postoperative complications. Conclusion Higher rates of postoperative sequelae after initial standard cervical exploration should be considered before performing routine 4-gland exploration.

Primary hyperparathyroidism (PHPT) is uncommon in children. The surgical management of PHPT in children has evolved over the past two decades.A retrospective study of patients who underwent parathyroidectomy for PHPT diagnosed at age18 years and managed at a tertiary referral center for endocrine and familial disorders.Thirty-eight patients met eligibility criteria (1981-2012). Median age at PHPT diagnosis was 15 years. Two-thirds of patients were symptomatic (68%, n=26), most commonly from nephrolithiasis. Twenty-six (68%) patients underwent a standard cervical exploration while 32% underwent a focused unilateral parathyroidectomy. Multiple endocrine neoplasia type 1 (MEN1) was diagnosed preoperatively in 22/26 patients. Patients with a preoperative diagnosis of MEN1 were more likely to undergo a complete initial operation (≥ 3 gland parathyroidectomy with transcervical thymectomy, 13/22, 59% vs. 0/4, 0%; P=0.03) and less likely to have recurrent disease (10/22, 45% vs. 3/4, 75%; P0.001) during follow up than patients diagnosed postoperatively.Children with PHPT should raise suspicion for MEN1. Preoperative MEN1 evaluation helped guide the extent of initial parathyroidectomy and was associated with lower rates of recurrence in sporadic and familial PHPT in pediatric patients. Management should occur at a high volume center with experienced clinicians and genetic counseling services.

The benefit of adrenalectomy (ADX) for adrenal metastasis is not established. We evaluated outcomes after ADX for patients with adrenal metastasis. We retrospectively analyzed the records of 90 patients who underwent ADX for metastatic disease. Overall survival (OS) after ADX was calculated using the Kaplan–Meier method. Clinical factors were evaluated for associations with OS using a Cox regression model, and with operative factors using the Wilcoxon two-sample or Fisher’s exact test. The most common primary tumor types were melanoma (35, 39 %) and lung cancer (32, 35 %). A total of 49 (54 %) patients had isolated adrenal metastasis; 55 (61 %) underwent laparoscopic resection (LADX). Median OS was 2.46 years (range

Whether thyroidectomy for metastases to the thyroid is associated with a survival benefit remains debatable; in general, palliation and disease control are accepted goals in this setting. We evaluated the clinical features and overall survival of patients with thyroid metastasis treated by thyroid resection or nonoperatively.This retrospective analysis included 90 patients identified with metastasis to the thyroid confirmed pathologically via thyroidectomy (n = 31) or fine-needle aspiration biopsy (n = 59). Overall survival was calculated by the Kaplan-Meier method, and differences between groups were calculated by Pearson's χ (2) coefficient.The most common primary malignancies were renal cell (20%), head and neck (19%), and lung (18%). The median time from primary tumor diagnosis to thyroid metastasis diagnosis was 37.4 months (range 0-210 months). Most metastases (69%) were metachronous, and 12% were isolated. The median follow-up after diagnosis of thyroid metastasis was 11.5 months (range 0-112 months). Median overall survival was longer in thyroidectomy patients compared to the fine-needle aspiration group (34 vs. 11 months, P0.0001). Patients with renal cell primary tumors were more likely to undergo thyroidectomy than patients with other primary tumors (78 vs. 24%, P0.0001). Nearly all patients with lung primary tumors died within 24 months of thyroid metastasis diagnosis, and thyroidectomy was only offered to three patients.Thyroidectomy was safe for selected patients with metastatic disease to the thyroid. Patients with metachronous or renal cell metastasis to the thyroid and whose primary tumor is/was treatable may be appropriate candidates for resection. Lung cancer metastasis to the thyroid is generally an ominous sign.

Dr. Arthur M. Shipley (1878–1955) was a renowned American surgeon and native Marylander. In 1911, Dr. Shipley was appointed chairman of surgery at the University of Maryland in Baltimore. He was a wartime surgeon and published 80 diverse manuscripts ranging from femoral fractures to dehisced abdominal incisions. Of historical significance is the fact that Dr. Shipley resected the first preoperatively diagnosed pheochromocytoma on June 27, 1928. He was well known by his contemporaries as a clinician with compulsive attention to detail and in-depth knowledge of the medical and surgical literature. Dr. Shipley was elected to membership in the Southern Surgical Association in 1927, and in 1943 served as vice president of the American Surgical Association. He remained at the University of Maryland School of Medicine until his retirement in 1948.

Sinus histiocytosis with massive lymphadenopathy (SHML) was first described in 1969 by Rosai and Dorfman [1]. It is a rare inflammatory disorder with key clinicopathological characteristics such as emperipolesis and positive immunostaining for S-100 protein [2] and CD68. Rosai–Dorfman disease (RDD) is primarily manifested in the lymph nodes, yet extranodal disease has been reported in as many as half of patients [3]. Such cases affect primarily the head and neck, upper respiratory tract, and central nervous system, although the disease has been found in almost every organ system. The gastrointestinal tract is rarely involved, and only two cases of primary involvement of the pancreas have been previously described [4, 5].