Future of thyroid surgery and training surgeons to meet the expectations of 2000 and beyond

Impact of fellowship training for specialists on thyroidectomy outcomes of patients with thyroid cancer

We aimed to evaluate the impact of fellowship training (FT) for thyroid specialists on the outcomes of patients with thyroid cancer. We reviewed surgeries performed for thyroid cancer before (non-FT group) and after (FT group) fellowship training and compared several variables, including length of stay of patients, tumor diameter, surgical method, lymph node dissection, parathyroid implantation, surgical duration, intraoperative blood loss, and postoperative complications. Compared with the non-FT group, the FT group had a shorter hospital stay, more adequate fine needle aspiration biopsy of the thyroid, less intraoperative blood loss, higher rate of parathyroid implantation, higher lymph node dissection rate, and lower nerve injury and hypoparathyroidism rates. When the surgical duration was < 200 min and/or only central lymph node dissection was performed, the FT group had a lower incidence of postoperative complications than the non-FT group. When, the incidence of postoperative complications, including postoperative nerve injury and hypoparathyroidism. In conclusion, FT for thyroid specialists is beneficial for patients with thyroid cancer and may allow a shorter hospital stay and reduced incidence of postoperative complication. Accordingly, FT may facilitate a more appropriate surgical approach with a preoperative pathological diagnosis.

Training in endocrine surgery

BACKGROUND/PURPOSE

In Europe, the Division of Endocrine Surgery (DES) determines the number of operations (thyroid, neck dissection, parathyroids, adrenals, neuroendocrine tumors of the gastro-entero-pancreatic tract (GEP-NETs)) to be required for the European Board of Surgery Qualification in (neck) endocrine surgery. However, it is the national surgical boards that determine how surgical training is delivered in their respective countries. There is a lack of knowledge on the current situation concerning the training of surgical residents and fellows with regard to (neck) endocrine surgery in Europe.

METHODS

A survey was sent out to all 28 current national delegates of the DES. One questionnaire was addressing the training of surgical residents while the other was addressing the training of fellows in endocrine surgery. Particular focus was put on the numbers of operations considered appropriate.

RESULTS

For most of the operations, the overall number as defined by national surgical boards matched quite well the views of the national delegates even though differences exist between countries. In addition, the current numbers required for the EBSQ exam are well within this range for thyroid and parathyroid procedures but below for neck dissections as well as operations on the adrenals and GEP-NETs.

CONCLUSIONS

Training in endocrine surgery should be performed in units that perform a minimum of 100 thyroid, 50 parathyroid, 15 adrenal, and/or 10 GEP-NET operations yearly. Fellows should be expected to have been the performing surgeon of a minimum of 50 thyroid operations, 10 (central or lateral) lymph node dissections, 15 parathyroid, 5 adrenal, and 5 GEP-NET operations.

Surgical Complications After Thyroid Surgery: A 10-Year Experience at Jeddah, Saudi Arabia

To evaluate the incidence and predictive risk factors of complications in patients who underwent thyroid surgery at our hospital with a residency training program. This retrospective cohort study analyzed the complications in all patients who underwent thyroid surgery between January 2008 and December 2017. Demographic data, preoperative diagnosis based on fine needle aspiration cytology, surgical approach, permanent pathology, postoperative complications, and factors associated with complications were recorded. At our hospital, 456 patients underwent thyroidectomy. The most common surgical complications were asymptomatic biochemical hypocalcemia and symptomatic hypocalcemia in 109 (23.9%) and 50 (11%) patients, respectively. Other surgical complications included permanent hypocalcemia, transient vocal cord palsy, permanent vocal cord palsy, hematoma, seroma, chyle fistula, and Horner's syndrome. Mean age > 45 years and more extensive surgery were significantly associated with overall complications (P = 0.003; < 0.001). Mean age > 50 years and vitamin D level < 25 nmol/L (< 10 ng/mL) were significantly associated with hypocalcemia (P = 0.008; < 0.001). Moreover, the extent of surgery and advanced thyroid carcinoma were significantly associated with vocal cord palsy (P < 0.001; 0.05). Hypocalcemia and vocal cord palsy are the most significant complications. Thyroid surgery can be performed safely by senior residents in the residency training program under the direct supervision of an experienced surgeon.

Surgical impact of a dedicated endocrine surgeon on an academic otolaryngology department

OBJECTIVES

Endocrine surgery is emerging as a dedicated subspecialty in otolaryngology. We assess the impact of an endocrine surgeon on an academic otolaryngology department's thyroid and parathyroid surgery volume.

METHODS

A retrospective study of overall endocrine caseloads and resident case logs at a single academic center in the Midwest was performed. All thyroid and parathyroid cases performed by the otolaryngology department at an academic center from 2011 to 2017 were reviewed. In September 2012, an otolaryngologist who had completed an American Head and Neck Society endocrine surgery fellowship joined the faculty. The volume of endocrine surgery performed by the residents was also analyzed. Comparison of means and linear regression models were performed.

RESULTS

From 2011 to 2012, the department performed a mean of 77 thyroid and 11.5 parathyroid surgeries annually. After the endocrine surgeon joined the department, this increased to an average of 212.8 thyroidectomies (P < 0.01) and 72.4 parathyroidectomies (P < 0.01) a year. The head and neck surgeons and generalists still performed an average of 42.4 thyroidectomies and 2.6 parathyroidectomies a year. For graduating residents, the average number of thyroid/parathyroid cases increased from 42.5 in 2012 to 151 in 2016.

CONCLUSION

The addition of a fellowship-trained endocrine surgeon substantially increased the thyroid and parathyroid surgical volume of the otolaryngology department. Importantly, generalists and head and neck surgeons in the department continued to perform a significant number of these cases. Departments seeking similar surgical growth and expanded resident experience may consider the value of engaging a dedicated endocrine surgeon.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:832-835, 2020.

A model for a career in a specialty of general surgery: One surgeon's opinion

BACKGROUND

The integration of general and endocrine surgery was studied as a potential career model for fellowship trained general surgeons.

METHODS

Case logs collected from 1991-2016 and academic milestones were examined for a single general surgeon with a focused interest in endocrine surgery. Operations were categorized using CPT codes and the 2017 ACGME "Major Case Categories" and there frequencies were determined.

RESULTS

10,324 operations were performed on 8209 patients. 412.9 ± 84.9 operations were performed yearly including 279.3 ± 42.7 general and 133.7 ± 65.5 endocrine operations. A high-volume endocrine surgery practice and a rank of tenured professor were achieved by years 11 and 13, respectively. At year 25, the frequency of endocrine operations exceeded general surgery operations.

CONCLUSION

Maintaining a foundation in broad-based general surgery with a specialty focus is a sustainable career model. Residents and fellows can use the model to help plan their careers with realistic expectations.

Thyroid Surgery in a Resource-Limited Setting: Feasibility and Analysis of Short- and Long-term Outcomes

Objective

The present study reviews a series of patients who underwent thyroid surgery in Eldoret, Kenya, to demonstrate the feasibility of conducting long-term (>1 year) outcomes research in a resource-limited setting, impact on the quality of life of the recipient population, and inform future humanitarian collaborations.

Study Design

Case series with chart review.

Setting

Tertiary public referral hospital in Eldoret, Kenya.

Subjects and Methods

Twenty-one patients were enrolled during the study period. A retrospective chart review was performed for all adult patients who underwent thyroid surgery during humanitarian trips (2010-2015). Patients were contacted by mobile telephone. Medical history and physical examination, including laryngoscopy, were performed, and the SF-36 was administered (a quality-of-life questionnaire). Laboratory measurements of thyroid function and neck ultrasound were obtained.

Results

The mean follow-up was 33.6 ± 20.2 months after surgery: 37.5% of subtotal thyroidectomy patients and 15.4% of lobectomy patients were hypothyroid postoperatively according to serologic studies. There were no cases of goiter recurrence or malignancy. All patients reported postoperative symptomatic improvement and collectively showed positive pre- and postoperative score differences on the SF-36.

Conclusion

Although limited by a small sample size and the retrospective nature, our study demonstrates the feasibility of long-term surgical and quality-of-life outcomes research in a resource-limited setting. The low complication rates suggest minimal adverse effects of performing surgery in this context. Despite a considerable rate of postoperative hypothyroidism, it is in accordance with prior studies and emphasizes the need for individualized, longitudinal, and multidisciplinary care. Quality-of-life score improvements suggest benefit to the recipient population.

Can Total Thyroidectomy Be Safely Performed by Residents?: A Comparative Retrospective Multicenter Study

This retrospective comparative multicenter study aims to analyze the impact on patient outcomes of total thyroidectomy (TT) performed by resident surgeons (RS) with close supervision and assistance of attending surgeons (AS).All patients who underwent TT between 2009 and 2013 in 10 Units of endocrine surgery (8 in Italy, 1 in France, and 1 in UK) were evaluated. Demographic data, preoperative diagnosis, extension of goiter, type of surgical access, surgical approach, operative time, use and duration of drain, length of hospitalization, histology, and postoperative complications were recorded. Patients were divided into 3 groups: A, when treated by an AS assisted by an RS; B and C, when treated by a junior and a senior RS, respectively, assisted by an AS.The 8908 patients (mean age 51.1 ± 13.6 years), with 6602 (74.1%) females were enrolled. Group A counted 7092 (79.6%) patients, Group B 261 (2.9%) and Group C 1555 (17.5%). Operative time was significantly greater (P < 0.001) in B (101.3 ± 43.0 min) vs A (71.8 ± 27.6 min) and C (81.2 ± 29.9 min). Duration of drain was significantly lower (P < 0.001) in A (47.4 ± 13.2 h) vs C (56.4 ± 16.5 h), and in B (42.8 ± 14.9 h) vs A and C. Length of hospitalization was significantly longer (P < 0.001) in C (3.8 ± 1.8 days) vs B (2.4 ± 1.0 days) and A (2.6 ± 1.5 days). No mortality occurred. Overall postoperative morbidity was 22.3%: it was significantly higher in B vs A (29.5% vs 22.3%; odds ratio [OR] 1.46, 95% confidence interval [CI] 1.11-1.92, P = 0.006) and C (21.3%; OR 1.55, 95% CI 1.15-2.07, P = 0.003). No differences were found for recurrent laryngeal nerve palsy, hypoparathyroidism, hemorrhage, and wound infection. The adjusted ORs in multivariate analysis showed that overall morbidity remained significantly associated with Group B vs A (OR 1.48, 95% CI 1.12-1.96, P = 0.005) and vs C (OR 1.60, 95% CI 1.19-2.17, P = 0.002), while no difference was observed in Group A vs B + C.TT can be safely performed by residents correctly supervised. Innovative gradual training in dedicated high-volume hospitals should be proposed in order to allow adequate autonomy for the RS and safeguard patient outcome.

The endocrine surgery job market: a survey of fellows, department chairs, and surgery recruiters

INTRODUCTION

Fifty endocrine surgery (ES) fellows have completed their training since the American Association of Endocrine Surgeons initiated a formal match process in 2007. This study was designed to better understand the job prospects of current and future endocrine surgeons and to evaluate the evolution of ES practices nationwide.

METHODS

Three surveys were conducted of former fellows, surgery department chairs, and surgery recruiters.

RESULTS

Of former fellows, 90% are working in academic centers and 10% in private practice. Average number of job interviews was 3.1 and job offers was 2.2. Eighty-eight percent have a practice that attends to ≥50% ES cases, and 45% practice entirely ES. Ninety-eight percent are satisfied with their job. Subjectively, 57% believe that there are not enough job opportunities for young endocrine surgeons, and 50% believe that there are too many ES fellowships. Department chair survey showed that the average number of endocrine surgeons in their department increased from 1.3 to 2.2 in the past decade. A recognized ES section exists in 49% of centers, and 39% of chairs feel that they will need to recruit another endocrine surgeon in the next 2 years. Only 3 of 10 recruiters were familiar with ES, and all had<5 of their hiring institutions asking for endocrine surgeons.

CONCLUSIONS

To date, there have been adequate job opportunities to sustain currently trained endocrine surgeons. This contrasts with their subjective belief of limited job prospects. This information can guide the optimal number of fellowship positions and alerts the American Association of Endocrine Surgeons to the opportunity to promote the creation of formal ES sections.

Training our future endocrine surgeons: a look at the endocrine surgery operative experience of U.S. surgical residents

BACKGROUND

During the last 10 years, the number of endocrine procedures performed in the United States has increased significantly. We sought to determine whether this has translated into an increase in operative volume for general surgery and otolaryngology residents.

METHODS

We evaluated records from the Resident Statistic Summaries of the Residency Review Committee (RRC) for U.S. general surgery and otolaryngology residents for the years 2004-2008, specifically examining data on thyroidectomies and parathyroidectomies.

RESULTS

Between 2004 and 2008, the average endocrine case volume of U.S. general surgery and otolaryngology residents increased by approximately 15%, but otolaryngology residents performed more than twice as many operations as U.S. general surgery residents. The growth in case volume was mostly from increases in the number of thyroidectomies performed by U.S. general surgery and otolaryngology residents (17.9 to 21.8, P = .007 and 46.5 to 54.4, P = .04). Overall, otolaryngology residents also performed more parathyroidectomies than their general surgery counterparts (11.6 vs 8.8, P = .007).

CONCLUSION

Although there has been an increase in the number of endocrine cases performed by graduating U.S. general surgery residents, this is significantly smaller than that of otolaryngology residents. To remain competitive, general surgery residents wishing to practice endocrine surgery may need to pursue additional fellowship training.

Resident/fellow assistance in the operating room for endocrine surgery in the era of fellowships

BACKGROUND

Historically, a high percentage of endocrine surgical procedures are performed by general surgeons in nonteaching environments. With the institution of accredited fellowships, we sought to determine whether that dynamic is changing.

MATERIALS AND METHODS

The American College of Surgeons-National Surgeons Quality Improvement Program was queried for all thyroid, parathyroid, and adrenal operations performed during 2005-2008. Resident assistance was classified as none, junior (postgraduate years 1-3), senior (postgraduate years 4 and 5) or fellow (≥ postgraduate year 6). Data were also examined for associations between resident/fellow assistance and surgical outcomes.

RESULTS

In all, 24.7% of endocrine operations (7,140/29,161) were performed by an attending surgeon operating alone (17.1% adrenals, 27.4% thyroids, and 20.6% parathyroids). Fellows assisted in 6.6% of operations (18.3% adrenals, 4.7% thyroids, and 8.2% parathyroids; 2006: 586 operations, 2007: 629 operations, and 2008: 720 operations). Comparing attending surgeons operating alone with those assisted by residents/fellows, they had shorter operative times (P < .001), longer surgical duration of stay (parathyroid: 1.73 days, thyroid: 1.80 days, P < .001), and a higher prevalence of obese, diabetic, or octogenarian patients. However, no significant difference was found in the rates of wound infections, medical complications, return to the operating room, or overall morbidity.

CONCLUSION

Even with the increase in endocrine surgery fellowships, almost one fourth of all endocrine operations are still performed by attending surgeons operating alone. Although operations assisted by residents/fellows took longer and patients had a greater duration of stay, there were no significant differences in measured outcomes.

Short-Term Outcomes after Unilateral versus Complete Thyroidectomy for Malignancy: A National Perspective

The extent of thyroidectomy for well-differentiated thyroid cancer (WDTC) remains controversial. We compared outcomes of patients undergoing unilateral thyroid lobectomy (UTL) versus complete thyroidectomy (CT) to determine the best operative management of WDTC. We compared outcomes of patients who underwent UTL or CT for malignancy using the 1999 to 2003 editions of the National Inpatient Sample database. A total of 13,854 patients underwent UTL (n = 4,238) and CT (n = 9,616). The CT group was more likely to have complications than the UTL group (15% vs 6%, P < 0.0001). Mean total charges were higher in the CT group ($11,432) versus the UTL group ($9,739), as was LOS (2 days versus 1 day); P < 0.0001. Complete thyroidectomy is associated with increased morbidity, total charges, and length of stay. The higher risk of short-term complications should be considered when considering performing a complete thyroidectomy for WDTC.

Need for an Individualized and Aggressive Management of Multinodular Goiters of Endemic Zones by Specially Trained Surgeons: Experience in Western Nepal

BACKGROUND

The goals of the present study were to explore the presentation of multinodular goiter (MNG) and solitary thyroid nodules (STN) in the sub-Himalayan belt, including the risk of malignancy, and to evaluate whether specialized surgeon training in endocrine surgery has an effect on reducing complications.

METHODS

This retrospective study (1998-2003) analyzed 624 patients with thyroid disorders seen in the thyroid clinic of a tertiary care hospital in western Nepal. The findings included 67.7% (n = 423: euthyroid, 297, toxic, 126) multinodular goiters (MNG) and 18.5% (n = 116) STN. Rest of patients of other thyroid disorders were excluded from the study. Ultrasonography and fine-needle aspiration cytology (FNAC) were the available diagnostic adjuncts. To evaluate the role of surgeon training, outcomes were compared between patients cared for by surgeons specially trained in endocrine surgery and those who were not. Prognostic markers indicated aggressiveness of cancers.

RESULTS

Of the 539 MNG and STN patients in this series, 236 underwent operation. Of these, 25.7% (139/539) were toxic, and 11.31% had associated carcinoma. Aggressive cancers, like poorly differentiated (4.9%) and anaplastic types (18%), were more common than in series of patients from iodine-sufficient regions. Patients 40-55 years of age were more likely to have toxicity, and those > 60 years of age were more likely to have aggressive cancers. Postoperative complication rates were lower in the group treated by surgeons who had special training in endocrine surgery.

CONCLUSIONS

There is a higher incidence of toxicity and malignancy in MNG in an endemic goiter zone. The limited diagnostic and therapeutic facilities in the region under study warrant a high degree of clinical suspicion and judgment, sound knowledge of thyroid physiology, thorough interpretation of hormone test results, and meticulous surgical techniques. The treatment must be individualized with consideration of humanitarian and socioeconomic factors, without compromising the quality of care and its long-term consequences. Aggressive management of malignancy and toxicity with total thyroidectomy is needed as primary therapy in many instances. However, subtotal excision is more useful in carefully selected cases with a small remnant. Specialized training in thyroid surgery appears to be valuable in reducing complications.

Influencia de la superespecialización en cirugía endocrina en los resultados de la tiroidectomía en un servicio de cirugía general

INTRODUCTION

The aim of this study was to analyze the influence of superspecialization in endocrine surgery on the standard of thyroidectomy, both before and after the creation of an endocrine surgery unit.

PATIENTS AND METHODS

We performed a retrospective, comparative study of two 7-year periods. Three hundred forty thyroidectomies (G1) were performed before the instauration of the unit, and 583 were carried out afterwards (G2). The variables of age, gender, anesthesia risk, surgeon expertise (staff vs. resident), thyroid function, pathological features, intrathoracic growth, extent of the procedure (unilateral or bilateral), neck drainage, morbidity and mortality and length of hospital stay were compared.

RESULTS

Age was older in G2 (G1: 44.7 +/- 15 years old, G2: 48.09 +/- 16.3 years old; p < 0.001). There were no differences (p NS) between the two groups in gender, anesthesia risk, thyroid function or rate of benign/malignant disease, but there was a greater frequency of nodular (p = 0.009) and intrathoracic goiters (p = 0.0004) in the second period. Residents operated on more patients in G2 (p < 0.001). Bilateral thyroidectomy was more frequent in G2 (G1: 155, G2: 315; p = 0.016) as was the rate of total thyroidectomy vs. subtotal or near total thyroidectomy (p < 0.001). Neck drainage also showed statistically significant differences (G1: 75.29%, G2: 12.18%; p < 0.001). No differences were found in overall postoperative complications. Although the procedures used were more aggressive in G2, similar rates of transient asymptomatic hypocalcemia (p NS) and transient symptomatic (p NS) and permanent hypocalcemia were found (G1: 1.17%, G2: 0.68%, p NS). The rate of transitory recurrent laryngeal nerve paralysis was similar with regard to patients (p NS) or nerves at risk (p NS). Permanent inferior laryngeal nerve paralysis was no different regarding patients (p = 0.083) but statistically significant differences were found with regard to nerves at risk (G1: 1.44%, G2: 0.33%; p = 0.04). One patient in G2 died (p NS). Length of hospital stay was shorter in G2 (p < 0.001) and more patients in this group stayed in hospital for only one day (p < 0.001) or were operated on in the outpatient setting (0 versus 71; p < 0.001).

CONCLUSIONS

An endocrine surgical unit allows more efficient management of thyroidectomy. It increases the rate of total thyroidectomy, reduces definitive complications and improves training of resident surgeons. In addition, it reduces resource use and allows the development of programs of outpatient thyroid surgery.

[Rational diagnosis and surgical treatment of solitary thyroid nodules]

Few subjects in endocrine surgery have generated as much controversy as the management of thyroid nodule. The controversial issues include evaluation of laboratory findings and imaging diagnostic procedures in the patient with solitary thyroid nodule. The major issue in relation to controversies is choice of optimal diagnostic workup.

Differentiated Operative Strategy in Minimally invasive, Video-assisted Thyroid Surgery Results in 196 Patients

To date, experience in minimally invasive thyroid surgery has been limited to unilateral lobectomy and total thyroidectomy. There are no reports regarding selective operative strategy, guided by morphology and function, which is widely accepted in endemic goiter regions. To analyze the efficiency and outcome of tissue-preserving thyroid surgery using a minimally invasive video-assisted technique (MIVA-T), a total of 196 patients were operated on for thyroid nodules between February 1999 and October 2003. Concurrent primary hyperthyroidism was treated in 22 (11%) cases. Indications for operation were solitary, multiple unilateral, or bilateral nodules with a maximum diameter of 30 mm and a maximum lobe volume of 15 ml. Contraindications for minimally invasive operation were thyroid malignancy diagnosed by fine-needle aspiration (FNA), recurrent goiter, and Hashimoto's thyroiditis. Nodule excision was performed in 6% of these cases; subtotal lobectomy, in 6%; selective resection, in 48%; and total lobectomy, in 39%. Histological examination revealed follicular adenoma in 82%, colloid and cystic lesions in 11%, thyroiditis in 1%, and differentiated thyroid carcinoma in 6%. Conversion to open surgery was necessary in 7.7% of the patients (secondary to malignancy demonstrated on frozen section in 3% and to technical difficulties in 4.7%). Transient and permanent laryngeal nerve palsy occurred in 2.0% and 0.5% of patients, respectively. Temporary hypoparathyroidism occurred in 5.6% of patients exclusively after conversion to open total thyroidectomy or in those patients ( n = 22) with additional primary hyperparathyroidism. Given a correct indication, MIVA-T technique can be performed with low conversion and complication rates. Selective operative strategy, guided by morphology and thyroid function, with a variety of operative procedures fitting the individual situation may be performed by this minimally invasive technique.