Risk factors for postoperative complications after adrenalectomy for phaeochromocytoma: multicentre cohort study

BACKGROUND

To determine the incidence and risk factors for postoperative complications and prolonged hospital stay after adrenalectomy for phaeochromocytoma.

METHODS

Demographics, perioperative outcomes and complications were evaluated for consecutive patients who underwent adrenalectomy for phaeochromocytoma from 2012 to 2020 in nine high-volume UK centres. Odds ratios were calculated using multivariable models. The primary outcome was postoperative complications according to the Clavien---Dindo classification and secondary outcome was duration of hospital stay.

RESULTS

Data were available for 406 patients (female n = 221, 54.4 per cent). Two patients (0.5 per cent) had perioperative death, whilst 148 complications were recorded in 109 (26.8 per cent) patients. On adjusted analysis, the age-adjusted Charlson Co-morbidity Index ≥3 (OR 8.09, 95 per cent c.i. 2.31 to 29.63, P = 0.001), laparoscopic converted to open (OR 10.34, 95 per cent c.i. 3.24 to 36.23, P <0.001), and open surgery (OR 11.69, 95 per cent c.i. 4.52 to 32.55, P <0.001) were independently associated with postoperative complications. Overall, 97 of 430 (22.5 per cent) had a duration of stay ≥5 days and this was associated with an age-adjusted Charlson Co-morbidity Index ≥3 (OR 4.31, 95 per cent c.i. 1.08 to 18.26, P = 0.042), tumour size (OR 1.15, 95 per cent c.i. 1.05 to 1.28, P = 0.006), laparoscopic converted to open (OR 32.11, 95 per cent c.i. 9.2 to 137.77, P <0.001), and open surgery (OR 28.01, 95 per cent c.i. 10.52 to 83.97, P <0.001).

CONCLUSION

Adrenalectomy for phaeochromocytoma is associated with a very low mortality rate, whilst postoperative complications are common. Several risk factors, including co-morbidities and operative approach, are independently associated with postoperative complications and/or prolonged hospitalization, and should be considered when counselling patients.

Risk factors for postoperative hypotension after adrenalectomy for phaeochromocytoma: derivation of the PACS risk score

BACKGROUND

Due to the risk of postoperative hypotension (PH), invasive monitoring is recommended for patients who undergo adrenalectomy for phaeochromocytoma. Due to high costs and limited availability of intensive care, our aim was to identify patients at low risk of PH who may not require invasive monitoring.

METHODS

Data for patients who underwent adrenalectomy for phaeochromocytoma between 2012 and 2020 were retrospectively collected by nine UK centres, including patient demographics, intraoperative and postoperative haemodynamic parameters. Independent risk factors for PH were analysed and used to develop a clinical risk score.

RESULTS

PH developed in 118 of 430 (27.4%) patients. On univariable analysis, female sex (p = 0.007), tumour size (p < 0.001), preoperative catecholamine level (p < 0.001), open surgery (p < 0.001) and epidural analgesia (p = 0.006) were identified as risk factors for PH. On multivariable analysis, female sex (OR 1.85, CI_95%, 1.09-3.13, p = 0.02), preoperative catecholamine level (OR: 3.11, CI_95%, 1.74-5.55, p < 0.001), open surgery (OR: 3.31, CI_95%, 1.57-6.97, p = 0.002) and preoperative mean arterial blood pressure (OR: 0.59, CI_95%, 0.48-1.02, p = 0.08) were independently associated with PH, and were incorporated into a clinical risk score (AUROC 0.69, C-statistic 0.69). The risk of PH was 25% and 68% in low and high risk patients, respectively.

CONCLUSION

The derived risk score allows stratification of patients at risk of postoperative hypotension after adrenalectomy for phaeochromocytoma. Postoperatively, low risk patients may be managed on a surgical ward, whilst high risk patients should undergo invasive monitoring.

1276 Is There Enough Time to Train? An Audit of Core Surgical Training Rotas

Aim

This audit aims to compare Core Surgical Training (CST) rotas in our region against the Joint Committee on Surgical Training (JCST) Quality Indicator (QI) 10’s minimum standard of 5 consultant supervised training sessions per week.

Method

Core surgical trainees in one training region were contacted requesting their on-call rotas from rotations undertaken during the 2019/20 academic year. Rotas were analysed in a protocolised manner, with the number of potential training sessions available calculated and compared against the JCST QI 10 minimum recommendation.

Results

Twenty-four rotas were assessed across 17 hospitals. Only six (25%) rotas achieved the JCST QI 10 recommended minimum 5 training sessions per week. There was a mean deficit of 18.5 (+/-29.5) training sessions per 6-month rotation. Rotas compliant with JCST QI 10 used a mean rota pattern of 1 in 11 compared to 1 in 9 for those failing to meet the target. Sub-analysis, comprising of the addition of expected consultant supervised training whilst on call, led to an improvement in compliance. 9 (38%) rotas met JCST QI 10's minimum standard when 0.5 hours of consultant supervised training time per on-call session was included, and 13 (54%) rotas met the standard when 1 hour was included.

Conclusions

Core surgical trainee rotas in the region are failing to provide the minimum number of consultant supervised training sessions set out by JCST QI 10. A move to reduced on-call commitment, increased use of supporting medical practitioners and regular perceived consultant supervised training whilst on call should be considered to improve this.

Is there enough time to train? An audit of core surgical training rotas

BACKGROUND

The Joint Committee on Surgical Training (JCST) have published a series of quality indicators (QIs) which act as a benchmark against which the quality of surgical training can be assessed. This audit aims to compare core surgical training (CST) rotas in our region against the JCST QI 10's minimum standard of 5 consultant supervised training sessions per week.

METHODS

Core surgical trainees in one training region were contacted requesting their on-call rotas from rotations undertaken during the 2019/20 academic year. Rotas were analysed in a protocolised manner, with the number of potential training sessions available calculated and compared against the JCST QI 10 minimum recommendation.

RESULTS

Twenty-four rotas were assessed across 17 hospitals. Only six (25%) of rotas achieved the JCST QI 10 standard. There was a mean deficit of 18.5 (±29.5) training sessions per 6-month rotation. Rotas compliant with JCST QI 10 used a mean rota pattern of 1 in 11 compared to 1 in 9 for those failing to meet the target. Further analysis, comprising of the addition of expected consultant led training whilst on call, led to an improvement in compliance to 9 (38%) and 13 (54%) of rotas when there was an addition of 0.5 h and 1 h of consultant supervised training time per on-call session respectively.

CONCLUSION

Many core surgical trainee rotas in the region are non-compliant with JCST QI 10, indicating a lack of regular consultant-led training opportunities. A move to a reduced on-call commitment with the use of supporting medical practitioners could be considered to improve this.

Challenging NICE guidelines on parathyroid surgery

BACKGROUND

National Institute of Clinical Excellence (NICE) recommend against routinely using Intra-Operative Parathyroid Hormone (IOPTH) for first-time parathyroid surgery due to its cost and minimal surgical benefit. The European Society of Endocrine Surgeons differ from this and recommends IOPTH with conflicting pre-operative or single imaging. NICE guidance acknowledged that this may change practice in larger centres. We devised a retrospective single-centre cohort study to analyse the impact of IOPTH on decision-making and cost-effectiveness.

METHODOLOGY

First-time parathyroidectomy procedures for primary hyperparathyroidism were assessed between 2017 and 2019. Ultrasound (US) and Sestamibi with parathyroid single-photon emission with computed tomography (SPECT-CT) were compared with IOPTH. The contribution of IOPTH to cure and cost effectiveness ratio was calculated.

RESULTS

114 cases were included, with IOPTH performed in all cases, SPECT-CT in 112 and US in 108 cases. A cure rate of 99.1% (113/114) was achieved. 11.4% (13/114) of the cure rate was influenced by IOPTH (P 0.01), instigating further exploration when its levels didn't decrease. This included 7.1% (4/56) in the concordant-imaging cohort. IOPTH accuracy (96.5%) was significantly superior (P = 0.03) to both US (80%) and SPECT-CT (81%). Comparing the total costs for IOPTH testing over 2 years (£39,721) with 13 potential re-operative procedures in its absence (£63,536), a positive cost-effectiveness ratio of £1832 per re-operative procedure averted was achieved.

CONCLUSION

Abandoning IOPTH in first-time parathyroid surgery is too ambitious when weighing the cost of re-operative surgery against cost savings obtained by using routine IOPTH to achieve an improved cure rate, even in concordant imaging.

Listening to core surgical trainees who drop out

What can we learn from surgeons who leave?

A Rare Case of Heterozygous Gain of Function Thyrotropin Receptor Mutation Associated with Development of Thyroid Follicular Carcinoma

Activating mutations in thyrotropin receptor (TSHR) have been previously described in the context of nonautoimmune hyperthyroidism and thyroid adenomas. We describe, for the first time, a mutation in TSHR contributing to follicular thyroid carcinoma (FTC) in an adolescent. A 12-year-old girl presented with a right-sided neck swelling, increasing in size over the previous four weeks. Clinical examination revealed a firm, nontender thyroid nodule. Ultrasound scan of the thyroid showed a heterogeneous highly vascular mass. Thyroid function tests showed suppressed TSH [<0.03mU/L], normal FT4 [10.1pmol/L, 9-19], and raised FT3 [9.1pmol/L, 3.6-6.4]. Thyroid [TPO and TRAB] antibodies were negative. A right hemithyroidectomy was performed and the histology of the sample revealed follicular carcinoma with mild to moderate nuclear pleomorphism and evidence of capsular and vascular invasion (pT1b). Sanger sequencing of DNA extracted from the tumour tissue revealed a missense somatic mutation (c.1703T>C, p.Ile568Thr) in TSHR. Papillary thyroid carcinomas constitute the most common thyroid malignancy in childhood, while FTC is rare. FTC due to TSHR mutation suggests an underlying, yet to be explored, molecular pathway leading to the development of malignancy. The case is also unique in that the clinical presentation of FTC as a toxic thyroid nodule has not been previously reported in children.

Ultrasound-guided fine needle aspiration cytology in the diagnosis and management of thyroid nodules

OBJECTIVE

To examine the accuracy of fine needle aspiration cytology (FNAC) in the diagnosis of thyroid nodules and compare the inadequacy rates for ultrasound-guided and freehand FNAC.

METHODS

A retrospective study of 434 patients with thyroid nodules who underwent diagnostic FNAC over a 2-year period. Cytological diagnoses have been compared with the histological assessment of resection specimens in 69 cases.

RESULTS

The inadequacy rate was significantly lower from ultrasound guided FNAC (24/373 cases, 6.4%) than from freehand FNAC (8/61 cases, 13.1%) (P = 0.043). Seventy-six percentage of patients had a non-neoplastic cytological diagnosis and, after multidisciplinary review, the patients were reassured and assigned to clinical follow-up. Sixty-seven patients had a resection for cytological appearances consistent with non-neoplastic disease (n = 34), suspicious of follicular neoplasia (n = 23), or suspicious of malignancy (n = 10), and two patients had resections following inadequate cytology with ultrasound appearances suspicious of a neoplasm. The overall accuracy of FNAC analysis for malignancy was 97.0%, with sensitivity 83.3%, specificity 98.0%, positive predictive value 71.4% and negative predictive value 98.4%. The overall accuracy of FNAC analysis for the prediction of neoplasia was 97.5%, with sensitivity 80.5%, specificity 97.8%, positive predictive value 89.2% and negative predictive value 95.9%. Difficulties in cytological diagnosis were associated with lymphoid infiltrates and with degenerative changes in follicular adenomas.

CONCLUSION

Ultrasound-guided FNAC has a significantly lower yield of inadequate aspirates than palpable FNAC. The ability of FNAC to predict neoplasia in 89% patients and to exclude neoplasia in 95.9% patients makes an important contribution to the multidisciplinary assessment of patients.

SNP genotyping using a simple and rapid single-tube modification of ARMS illustrated by analysis of 6 SNPs in a population of males with FRAXA repeat expansions

Microsatellites have been used extensively in gene mapping, linkage and association studies but with the near completion of the human genome project (HGP) single nucleotide polymorphisms (SNP) have become the marker of choice. However, for association studies to be useful large numbers of SNPs must be analysed. To make these studies cost effective a simple and non-labour intensive method for SNP genotyping is essential. This work describes a single-tube modification of the amplification refractory mutation system (Biallelic-ARMS). Control amplimers flanking the SNP were amplified in a single-tube multiplex PCR with two SNP specific primers that prime in opposite directions. The SNP allele was identified on the basis of PCR product size after gel electrophoresis. Biallelic-ARMS was used to analyse six SNPs within 300 kb of the FRAXA repeat, two from the HGP SNP Database (ATL1 and FMRb) and four novel SNPs (WEX1, WEX10, WEX17 and WEX28). The study population consisted of 649 males with a range of FRAXA (10 to >200) repeat sizes. Each SNP correlated with distinct haplogroups, as identified by DXS548, FRAXAC1 and FRAXAC2 flanking microsatellite repeat patterns and confirmed the initial choice of haplogroups for FRAXA repeat stability defined by Enniset al.

Understanding patients' views of a surgical outpatient clinic

For many people, the outpatient clinic is the first point of contact with a hospital. As clinical management moves from the in-patient setting, it is taking on a much greater importance. Yet there are still many gaps in our knowledge about how those who interact with it, whether as staff or patients, view it. This study sought to describe patients' perceptions and to explore some of the socio-demographic characteristics associated with these differing perceptions. The study took place in a district general hospital in southern England. A questionnaire seeking the experiences and views of patients was developed. After piloting, it was administered to patients attending surgical outpatient clinics. The results were supplemented by those of a study of times that the same patients waited to be seen and the duration of their consultations. We found that 288 patients attended the clinics of four consultant general surgeons in a week chosen to be typical of those throughout the year and, of these, 188 (76%) returned questionnaires. As far as could be ascertained, responders did not differ from non-responders. New patients only were asked about the time they had waited for an appointment and 32% felt that this had been excessive. Young patients were more likely to feel that the wait had been too long. Patients were more likely to overestimate the time that they waited than to underestimate it and 27% thought the time spent with the doctor had been too short. The perception of inadequate time was greatest among those attending clinics where the actual time available was least. Of the patients, 30% had questions they would have liked to have asked but did not, 32% of patients would definitely have liked a leaflet explaining their treatment, 44% of patients were very satisfied with how they were treated by the doctor and 3% were dissatisfied. Non-white patients tended to be less satisfied with both the overall attendance and the length of consultation, although the actual times spent with doctors were the same for both groups. Seventy-eight per cent of patients had no preference for being seen by a male or female doctor. Those expressing a preference tended to prefer a doctor of their own sex. We found that while many patients are satisfied with the outpatient experience, there are several issues that require attention. Patient's perceptions are often as important as more objective measures in determining whether an attendance is considered satisfactory.

Why is it so difficult to organise an outpatient clinic?

OBJECTIVES

The shift from inpatient to outpatient care in the UK is drawing attention to the role of the outpatient clinic. Yet, outpatient clinics have received less attention than other elements of hospital work. This study sought to identify key problems perceived by staff in the functioning of outpatient clinics and to understand their responses to these problems.

METHODS

Interviews were conducted with 57 hospital staff in two hospitals (one teaching, one district general) in South-East England. Staff were selected through snowball sampling to provide a cross-section of those working in, and interacting with, the outpatient department. Constant comparison was used to generate hypotheses from the data collected in the first hospital, which were then tested in the second hospital.

RESULTS

Four main themes emerged. These were the role of the individual consultant, pressure on time, weaknesses in communication and problems with training. The personality of the consultant--in particular, his or her attitude to risk--was often central to the functioning of the clinic. The actions arising from differing personalities were remarkably resilient to managerial action. Most clinics operated in the face of pervasive pressures on time, which created a service that was seen as meeting no-one's needs adequately. Communication was almost universally poor in all directions and through all media. Training of medical staff was haphazard.

CONCLUSIONS

Despite its growing importance, the hospital outpatient clinic is often ill-equipped to respond to the new challenges it faces. Overall, there is a need for the system to be managed, rather than simply to respond to whatever comes its way, and to ensure that the growing literature on individual and organisational change is understood and applied.

Surgical outpatient clinics: are we allowing enough time?

BACKGROUND

Performance management initiatives, such as the UK's Patient's Charter, are creating pressure for patients to be seen earlier at out patient clinics, thus increasing clinic workloads. There is, however, little information about whether this can be absorbed, either by utilizing spare capacity or by more efficient use of time, or whether it is likely to affect patient care adversely.

METHODS

Nine surgical clinics, run by four general surgeons, in an English district general hospital were studied during a typical week. Clinic schedules and numbers invited to attend were extracted from clinic records. An observer recorded the actual time each patient spent with the surgeon to the nearest 5 seconds. Scheduled and actual times of commencement and completion of clinics were also recorded.

RESULTS

The number of patients booked to attend each clinic varied from 11 to 82 (mean 37). The median consultation for new patients was 4.3 minutes and for follow-up patients it was 3 minutes. Consultants spent a median 2.7 minutes with patients whereas junior staff spent 4.2 minutes. These aggregate results conceal considerable variation between surgeons, even though the scheduled time available was similar. The median time spent with new patients by one consultant was 1.3 minutes and by another 13.1 minutes. Seven of the nine clinics overran their scheduled time (by up to 55 minutes). All doctors, with one exception, arrived late for the clinics (range 10 minutes early to 30 minutes late). The first patient was invariably seen after the scheduled starting time for the clinic (mean 17 minutes, range 5-50 minutes) and the median interval between a doctor arriving and seeing their first patient was 10.6 minutes. Overall, only 50% of the time spent by doctors at the clinics was with patients.

IMPLICATIONS

The amount of time spent by patients with surgeons is already so short as to cause concern about both the appropriateness and value of consultations. It is unreasonable to increase workload further. There is a clear need for outpatient clinics to be managed, with regular examination of what is taking place and how long it takes. Only then will it be possible to tailor schedules to the actual requirements of the service.

Surgical outpatients: challenges and responses

BACKGROUND

Faced with upward pressure on costs from ageing populations and new technologies, those responsible for funding health care are seeking innovative ways of providing that care at lower cost. A common strategy is to shift care from the inpatient to the outpatient setting. This, taken with pressure for greater accountability and improved training, is creating great challenges for those responsible for organizing outpatient care. This paper seeks to review these challenges and the various responses to them.

METHODS

A critical review of literature on the changing role of outpatient care, with an emphasis on the current situation in the United Kingdom.

RESULTS

Many diverse responses have been developed to address the changing nature of outpatient care. These have certain features, including the recognition that clinicians have the ability to initiate, rather than simply react to change, and an appreciation of the value of clear and definable objectives for outpatient care. They range from discrete interventions addressing a single concern to wholesale restructuring of the system of care, such as one-stop clinics.

CONCLUSION

There is now considerable evidence on what can and should be done to improve the existing system of outpatient care.