Early Water Seal of Chest Tubes Following Video-Assisted Thoracic Surgery Pleurodesis.

INTRODUCTION: Early water seal following minimally invasive pulmonary lobectomy has been shown to reduce chest tube duration and postoperative length of stay (LOS). We evaluated chest tube duration and postoperative LOS following a standardized chest tube management protocol change (water seal on postoperative day 1) after video-assisted thoracic surgery (VATS) pleurodesis. METHODS: We identified adult patients undergoing VATS pleurodesis from August 2013 to December 2021. The chest tube protocol was changed in January 2017 such that patients were placed to water seal on the morning of postoperative day 1. Patients were divided into two groups, before the change (Group 1: August 2013-December 2016) and after (Group 2: January 2017-December 2021). We compared demographics, clinical characteristics, operative details, postoperative chest tube duration and output, and postoperative LOS between the groups. Descriptive statistics and log-transformed multivariable linear regression models were used to identify differences in patient outcomes that were associated with the protocol change. RESULTS: A total of 488 patients underwent VATS pleurodesis during the study period (Group 1: 329 patients; Group 2: 159 patients). The median age was 61 y (interquartile range [IQR] 49-68), 51% were females, 69% were White, and 29% were Black. For postoperative LOS, Group 1 had an IQR of 3-7 d, while Group 2 had an IQR of 2-6 d (P < 0.001). The multivariable log-transformed linear regression models demonstrated that the practice change was associated with reduced chest tube duration (0.77 times the chest tube duration before the change; P < 0.001) and reduced LOS (0.81 times the LOS before the change; P = 0.006). There was an associated reduction in patients needing to return to the operating room (P = 0.048) and needing postoperative extended ventilatory support (P = 0.035). CONCLUSIONS: Development of a standardized protocol to water seal chest tubes on postoperative day 1 following VATS pleurodesis is associated with reduced chest tube duration and LOS without an increase in postoperative complication rates.

Analysis of Applicants' Perspectives of Cardiothoracic Surgery Fellowship Program Websites.

BACKGROUND: Cardiothoracic (CT) surgery fellowship websites help applicants determine where they apply and/or accept an interview. However, relevant information from programs is not communicated in a standardized way. METHODS: We used Fellow and Residency Electronic Interactive Database Access (FREIDA) Online to identify residency programs with traditional CT fellowships. Program-specific variables included presence or absence of tracks, track duration, and annual cardiac and thoracic cases. Resident-specific variables included number of resident(s) a program accepts and case numbers per fellow. Current CT residents completed an online survey in which they rated how important they deemed the presence of these variables in program websites. RESULTS: According to FREIDA Online, 74 traditional CT surgery fellowship websites were analyzed. Among the websites listed on FREIDA, only 16 (22%) linked directly to the CT fellowship page. Surveys were sent to all trainees enrolled in the 74 programs, and 24 responded. There were marked deficiencies in the availability of information on program websites that was highly valued by trainees. Only 31% of websites reported annual program volume, and 14% reported resident case numbers, while this data was highly valued by >60% of respondents. Similarly, 11% of program websites described their education curriculum, while 81% of respondents highly valued this information. One-quarter of respondents were dissatisfied with the overall information provided by program websites. CONCLUSIONS: CT fellowship program websites lack crucial content that is deemed highly valued by applicants. This study suggests the possible need for a single comprehensive data repository or a standardized method for communicating information through program websites.

A single institution experience with papillary thyroid cancer: Are outcomes better at comprehensive cancer centers?

INTRODUCTION: Papillary thyroid cancer (PTC) is the most common form of thyroid cancer. Although the survival rate is excellent, recurrence is as high as 20%. The mainstay of therapy is thyroidectomy and lymph node dissection based on risk factors. Data from other cancers suggest that surgical outcomes are most optimal at comprehensive cancer centers. We hypothesize that patients with PTC who had their initial operation at a comprehensive cancer center would have a better oncologic outcome. METHODS: We utilized an IRB-approved cancer care registry database of patients with thyroid cancer who were seen at our institution between 2000 and 2018. Patient records were updated with cancer-specific outcomes including recurrence and need for re-intervention. Clinical and surgical outcomes were then compared between patients who had their initial operation at a comprehensive cancer center (CCC group, n = 503) versus those who did not (non-CCC group, n = 72). RESULTS: Mean patient age was 49 ± 16 years and 70% were female. Average tumor size was 1.6 ± 1.6 cm. There was no difference in tumor size, age, gender or race between groups. Pre-operative ultrasound was more frequently performed at the CCC (89%) than at non-CCC's (51%, p < 0.001). CCC patients were more likely to undergo initial total thyroidectomies compared to non-CCC patients (76% vs. 21%, p < 0.001). Positive surgical margins were more frequently found in patients at non-CCC's (19%) than at the CCC (9.7%, p = 0.016). Finally, CCC patients had a significantly lower cancer recurrence rate (5.0% vs. 37.5%, p < 0.001). Therefore, the need for additional cancer operations was much greater in patients who had initial thyroid surgery at non-CCC (31.9% vs. 1.4%, p < 0.001). CONCLUSIONS: Patients with PTC who have their initial thyroidectomy at non-CCC have higher recurrence rates, higher rates of positive tumor margins on pathology, and increased need for additional operations. These data suggest that patients who have their initial procedure at a CCC for PTC have better long-term outcomes.

A prediction model for postoperative urinary retention after thoracic surgery.

Background: Urinary retention remains a frequent postoperative complication, associated with patient discomfort and delayed discharge following general thoracic surgery (GTS). We aimed to develop and prospectively validate a predictive model of postoperative urinary retention (POUR) among GTS patients. Methods: We retrospectively developed a predictive model using data from the Society of Thoracic Surgeons GTS Database at our institution. The patient study cohort included adults undergoing elective in-patient surgical procedures without a history of renal failure or Foley catheter on entry to the recovery suite (August 2013 to March 2017). Multivariable logistic regression models identified factors associated with urinary retention, and a nomogram to aid medical decision making was developed. The predictive model was validated in a cohort of GTS patients between April 2017 and November 2018 using receiver operating characteristic (ROC) analysis. Results: The predictive model was developed from 1484 GTS patients, 284 of whom (19%) experienced postoperative urinary retention within 24 hours of the operation. Risk factors for POUR included older age, male sex, higher preoperative creatinine, chronic obstructive pulmonary disease, primary diagnosis, primary procedure, and use of postoperative patient-controlled analgesia. A logistic nomogram for estimating the risk of POUR was created and validated in 646 patients, 65 of whom (10%) had urinary retention. The ROC curves of development and validation models had similar favorable c-statistics (0.77 vs 0.72; P > .05). Conclusions: Postoperative urinary retention occurs in nearly 20% of patients undergoing major GTS. Using a validated predictive model may help by targeting certain patients with prophylactic measures to prevent this complication.

A Cost-Utility Analysis Comparing Immediate Oncoplastic Surgery with Delayed Oncoplastic Surgery in Smoking Breast Cancer Patients.

BACKGROUND: Oncoplastic reduction mammoplasty for smoking breast cancer patients committed to smoking cessation may be performed immediately (increasing smoking-related risk) or in a delayed fashion (increasing radiation-related risk). OBJECTIVE: Our aim was to examine the cost utility of immediate versus delayed oncoplastic reconstruction when operating on a smoking patient with breast cancer and macromastia with a long-term commitment to smoking cessation. METHODS: A literature review determined the probabilities and outcomes for the treatment of unilateral breast cancer with immediate or delayed oncoplastic surgery. Reported utility scores were used to estimate quality-adjusted life-years (QALYs) for varying health states. A decision analysis tree was constructed with rollback analysis to highlight the more cost-effective strategy, and an incremental cost-utility ratio (ICUR) was calculated. Sensitivity analyses were performed to validate the robustness of the results. RESULTS: Immediate oncoplastic surgery is associated with a higher clinical effectiveness (QALY) of 33.3 compared with delayed oncoplastic surgery (33.26), with a higher increment of clinical effectiveness of 0.07 and relative cost reduction of $3458.11. This resulted in a negative ICUR of -50,194, which favored immediate reconstruction, indicating a dominant strategy. In one-way sensitivity analyses, delayed reconstruction was the more cost-effective strategy if the probability of successful immediate reconstruction falls below 29% or its cost exceeds $29,611. Monte-Carlo analysis showed a confidence of 99% that immediate oncoplastic surgery is more cost effective. CONCLUSIONS: Despite the risk of postoperative complications associated with smoking, immediate oncoplastic surgery is more cost effective compared with delayed oncoplastic surgery in which reconstructive surgery would occur after radiation.

Is Immediate Lymphatic Reconstruction Cost-effective?

Mini: We conducted a cost-utility analysis to evaluate the cost and quality of life of patients undergoing axillary lymph node dissection (ALND) and ALND with regional lymph node radiation (RLNR), with and without lymphatic microsurgical preventive healing approach (LYMPHA), in a node-positive breast cancer population. We found that the addition of LYMPHA to both ALND or ALND with RLNR is more cost-effective. Objective: This manuscript is the first to employ rigorous methodological criteria to critically appraise a surgical preventative technique for breast cancer-related lymphedema from a cost-utility standpoint. Summary of Background Data: Breast cancer-related lymphedema is a well-documented complication of breast cancer survivors in the US. In this study, we conduct a cost-utility analysis to evaluate the cost-effectiveness of the LYMPHA. Methods: Lymphedema rates after each of the following surgical options: (1) ALND, (2) ALND + LYMPHA, (3) ALND + RLNR, (4) ALND + RLNR + LYMPHA were extracted from a recently published meta-analysis. Procedural costs were calculated using Medicare reimbursement rates. Average utility scores were obtained for each health state using a visual analog scale, then converted to quality-adjusted life years (QALYs). A decision tree was generated and incremental cost-utility ratios (ICUR) were calculated. Multiple sensitivity analyses were performed to evaluate our findings. Results: ALND with LYMPHA was more cost-effective with an ICUR of $1587.73/QALY. In the decision tree rollback analysis, a clinical effectiveness gain of 1.35 QALY justified an increased incremental cost of $2140. Similarly, the addition of LYMPHA to ALND with RLNR was more cost-effective with an ICUR of $699.84/QALY. In the decision tree rollback analysis, a clinical effectiveness gain of 2.98 QALY justified a higher incremental cost of $2085.00. Conclusions: Our study supports that the addition of LYMPHA to both ALND or ALND with RLNR is the more cost-effective treatment option.

Hyperthyroidism Symptoms, Management, and Outcomes in Children and Adults Seeking Definitive Surgical Treatment.

OBJECTIVE: To identify the difference in presentation, time to treatment, and outcomes between hyperthyroid adults and children referred to surgical evaluation. BACKGROUND: There is little data on differences in presenting symptoms, time to treatment, and outcomes between adults and children presenting for thyroidectomy for Graves' disease. METHODS: We retrospectively reviewed records of patients with hyperthyroidism referred for thyroidectomy between January 2016 and April 2017. We divided our cohort into 2 groups based on age, children (age ≤18 years), and adults (age >18), and evaluated the difference in prevalence of symptoms, time from diagnosis, and initiation of antithyroid medications to surgery, and outcomes. RESULTS: We identified 38 patients (27 adults and 11 children) with data on hyperthyroidism symptoms referred for thyroidectomy. Relative to hyperthyroid adults, children with hyperthyroidism were more likely to present with hoarseness (55% vs 15%, P = 0.01) and difficulty concentrating (45% vs 7%, P = 0.01) at initial presentation. There was no statistically significant difference in prevalence of vision changes, exophthalmos, pretibial myxedema, palpitations, fatigue, temperature intolerance, dysphagia, tremors, or constitutional symptoms. A median of 15 months elapsed from diagnosis to thyroidectomy among adult and 6 months among pediatric patients. Adult and pediatric patients waited a median of 13 and 6 months from initiation of antithyroid medications to thyroidectomy, respectively. There was no significant difference in outcomes. CONCLUSIONS: Children with hyperthyroidism were more likely to present with hoarseness and difficulty concentrating than adults. Concentration and communication are critical skills in developing children, and early intervention with definitive therapy may improve such symptoms.

Reasons for extended length of stay following chest tube removal in general thoracic surgical patients.

BACKGROUND: Many patients undergoing general thoracic surgery can be discharged on the same day as chest tube removal, but some are not, leading to increased resource utilization. This study assesses the frequency and duration of extended length of stay (ELOS) after tube removal and identifies risk factors for ELOS. METHODS: We retrospectively reviewed all adult patients undergoing general thoracic surgery at a tertiary referral medical center captured in the Society of Thoracic Surgeons General Thoracic Surgery Database and obtained detailed clinical data on chest tube management from August 2013 to April 2017. Pre-operative demographics, procedures, diagnoses, comorbidities, hospital service category, and lab values were examined to identify risk factors associated with ELOS after chest tube removal using multivariable generalized linear regression models. RESULTS: One thousand and four hundred seventy patients had ≥1 chest tubes placed at the time of operation and discharged after chest tube removal: anatomic lung resection (34%), wedge resection (29%), decortication (16%), and other (21%). Fifty-one percent of these patients were male, 81% were white, and the mean age was 59 years (SD: 15 years). One-third of the patients had prior cardiothoracic operations. Twenty-three percent of these patients had ELOS, defined as discharge ≥1 calendar day after chest tube removal with a median additional hospital stay of 3 days (interquartile range, 2-7 days). A multivariable regression model demonstrated that risk factors for ELOS included being admitted to an oncology or transplant service, undergoing decortication procedure, active smoking, and increased disability. CONCLUSIONS: Patients with obesity, more severe disability, or actively smoking, undergoing, decortication, admitted to transplant and oncology services were more likely to experience ELOS. These factors should be considered when identifying appropriate patient groups for fast-track algorithms.

Mechanical or chemical and mechanical pleurodesis for spontaneous pneumothorax: what is the most effective approach in preventing recurrence? A systematic review and meta-analysis.

OBJECTIVES: Surgical management of spontaneous pneumothorax typically involves wedge resection and mechanical pleurodesis. It is unclear whether combining mechanical and chemical pleurodesis can further reduce the recurrence rate. We have performed a meta-analysis of studies comparing the combined approach with mechanical pleurodesis alone. METHODS: A comprehensive search of the existing literature was performed using PubMed, EMBASE and Web of Science for all types of studies that compared combined pleurodesis to a single approach. We used the Cochrane Risk of Bias Tool and Strengthening The Reporting of OBservational Studies in Epidemiology (STROBE) to assess the quality of the studies. Relative risk of pneumothorax recurrence was calculated, and the differences between the studies were examined. The primary outcome was the recurrence of pneumothorax. RESULTS: Of 2301 eligible studies, 5 studies were included. Five hundred sixty-one patients who received combined pleurodesis were compared to 286 patients who received mechanical pleurodesis only. Patients treated with combined intervention had a 63% lower risk of developing a recurrent pneumothorax compared to single intervention [relative risk 0.37, 95% confidence interval (CI) 0.18-0.76; P = 0.006]. There were no statistically significant differences in the length of stay (standardized mean difference -0.17, 95% CI -0.39 to 0.05, P = 0.138), the duration of postoperative air leak (standardized mean difference 0.17, 95% CI -1.14 to 1.47, P = 0.804) or the duration of postoperative chest tube drainage (standardized mean difference -0.07, 95% CI -0.27 to 0.12, P = 0.471). CONCLUSIONS: This meta-analysis demonstrated that combined intervention with mechanical and chemical pleurodesis for spontaneous pneumothorax may be more effective in preventing recurrence than mechanical pleurodesis alone. These findings will provide some guidance to surgeons in the decision-making process.

Cardiac Surgery and Postoperative Renal Allograft Failure.

BACKGROUND: Although cardiac surgery among renal allograft recipients is relatively safe, less is known about the impact of cardiac surgery on the functioning renal allograft. This study assessed postoperative renal failure among renal transplant recipients undergoing cardiac surgery. METHODS: The study population was identified by matching medical record numbers from the United Network for Organ Sharing Kidney Transplant Database to a cardiovascular surgery database and The Society of Thoracic Surgeons Adult Cardiac Surgery Database for the authors' institution from January 1992 through August 2018. RESULTS: One hundred seventy-nine renal transplant recipients with a functioning allograft underwent cardiac surgery a mean of 6.4 ± 5.6 years after renal transplantation. Thirty (17.6%) of the 170 patients either died or had allograft failure during the first postoperative year. Receiver-operating characteristics curve analysis using Cox regression demonstrated an optimal cutoff point for preoperative serum creatinine predicting postoperative allograft loss is 1.9 mg/dL (hazard ratio 3; 95% confidence interval, 1.5 to 6.9) with a model C statistic of 0.642. CONCLUSIONS: The current study affirms findings in the literature that cardiac surgery in renal transplant recipients carries acceptable perioperative morbidity and mortality. Renal transplant recipients who underwent cardiac surgery had a constant hazard of renal allograft loss similar to that of the general transplant population. A preoperative serum creatinine value greater than 1.9 mg/dL increases the risk for long-term renal allograft loss after cardiac surgery.

Increasing Use of Thyroidectomy as Definitive Treatment for Hyperthyroidism.

BACKGROUND: Thyroidectomy is a definitive treatment for hyperthyroidism. The purpose of this study is to examine how often patients with hyperthyroidism are referred for thyroidectomy and what are the common reasons for referral. MATERIALS AND METHODS: We identified 864 patients with hyperthyroidism diagnosis. A total of 237 patients underwent thyroidectomy from January 2011 to December 2016. Patients were divided into six groups according to the year of thyroidectomy, group 1 to group 6, from 2011 to 2016, respectively. Primary and secondary outcomes: reasons why patient was referred for thyroidectomy, time from diagnosis, and/or start of antithyroid drugs (ATDs) to thyroidectomy as well as the trend and total number of thyroidectomies each surgeon did during the study period. RESULTS: The mean age was 44 ± 15 y, 73% were women, and 54% were African American. A significant increase in the rate of thyroidectomy over the study period was observed where 31 patients underwent thyroidectomy in 2011 compared with 61 patients in 2016. The most common reasons patients were referred for thyroidectomy were resistance or intolerance to ATDs followed by patient's preference, and presentation with obstructive symptoms with no statistically significant difference between groups. The median time from diagnosis to surgery was 8 mo (0 to 204 mo) and 7 mo from initiation of ATDs to thyroidectomy with no significant difference between groups. CONCLUSIONS: An increase of thyroidectomy rate was observed at our institution over the last 6 y. Patients were mostly referred due to resistance or intolerance to antithyroid medications, patients' preference of surgery, and presentation with obstructive symptoms.

Gender and Racial Disparities in Survival After Surgery Among Papillary and Patients With Follicular Thyroid Cancer: A 45-Year Experience.

BACKGROUND: Demographic disparities have been described for survival after thyroid cancer surgery using national registries and databases. At the institution level, we hypothesized that assessing survival after thyroid cancer surgery in a long-term cohort with diverse gender and racial groups would reveal disparities in survival. METHODS: We examined medical records of patients with papillary or follicular thyroid cancer undergoing thyroidectomy, lobectomy, and other surgical procedures from 1971 to 2016 at a tertiary referral center. We obtained information on demographics, cancer stage, procedure, and radioactive iodine (RAI). We measured survival using Kaplan-Meier estimates and Cox proportional hazards models. RESULTS: A total of 1440 (91%) patients with papillary cancer and 144 (9%) patients with follicular thyroid cancer underwent total thyroidectomy (1297, 82%), lobectomy (261, 16.5%), and other surgical procedures (26, 1.5%). Most patients (1131, 71%) were woman, and 909 (57%) were older than 45 years. Race/ethnicity included 805 (51%) white, 161 (10%) African Americans, and 618 (39%) other race/ethnicities. Both 10- and 20-year survival rates in nonwhite males were worse compared with nonwhite females (P < .0001). After controlling for age, cancer type, stage, surgical procedure, RAI, and year of surgery, nonwhite males had a higher mortality risk compared with nonwhite females (P = .0376, confidence interval (CI): 1.03-2.43), white males (P < .0001, CI: 1.88-6.54), and white females (P < .0001, CI: 3.31-9.90). CONCLUSIONS: Our diverse cohort demonstrates significant gender and racial disparities in survival after thyroid cancer surgery. To improve health outcomes and reduce health disparities among nonwhite males, interventions and long-term care management should target potentially modifiable causes of worse outcomes in this group.

What Does the Average Person Know About Endocrine and Vascular Surgeons?

INTRODUCTION: Surgical fields are becoming increasingly specialized. This can lead to misunderstanding or confusion about the scope of practice of different surgeons by the individual seeking specialized surgical care. To assess public understanding of subspecialty surgeons, we sought to survey general knowledge of the specialty areas of Endocrine Surgery and Vascular Surgery. METHODS: A survey was conducted in three locations in Birmingham, Alabama: a local farmers market, a public park, and the University of Alabama at Birmingham hospital. Fifty people were surveyed at random at each of the three locations, with hospital staff identified by wearing a hospital ID badge recruited at the University of Alabama at Birmingham hospital location. Participants were asked to define both an endocrine surgeon and vascular surgeon, as well as identify aspects of their practice. Participant's answers to the survey were recorded and coded by three evaluators (two MDs, one PharmD candidate). Survey responses were assessed for correct definition of the specialty (yes/no), recognition of being a surgeon (yes/no), spectrum of practice (none, partial, or complete), and presence of a common misconception (yes/no). Interrater reliability (kappa) was calculated for each question. Chi-square test was used to compare the difference in each answer between the two specialties. RESULTS: A total of 150 people participated in the study. The majority were female (58%) and approximately 50 y of age or less (65%). Interrater reliability from 0.32 to 0.84 was observed, and agreement from 40% to 98% between raters was achieved for all questions. Significantly more respondents recognized endocrine surgery as a surgical profession (21%) compared to vascular surgeons (18%) (P < 0.001). However, significantly fewer could define what an endocrine surgeon does (14%) than could define what a vascular surgeon does (57%). Only 3% of respondents could identify the entire spectrum of practice of an endocrine surgeon, with 42% and 55% providing partially or completely incorrect responses, respectively. Significantly more respondents could identify all of a vascular surgeon's spectrum of practice (11%), with 60% and 29% providing partial or completely incorrect responses, respectively (P < 0.001). Endocrine surgeons were most often confused for endocrinologists (40%), whereas vascular surgeons were most often confused for cardiovascular surgeons (22%). CONCLUSIONS: This study reveals an overall lack of understanding among the general public about what endocrine and vascular surgeons are and their spectrum of practice and shows that public understanding of the field of endocrine surgery is very low. More efforts need to be made to increase the visibility of these fields and communicate these surgeons' specialized expertise.

Considerations for Thyroidectomy as Treatment for Graves Disease.

Hyperthyroidism is a clinical state that results from abnormally elevated thyroid hormones. Thyroid gland affects many organ systems; therefore, patients usually present with multiple clinical manifestations that involve many organ systems such as the nervous, cardiovascular, muscular, and endocrine system as well as skin manifestations. Hyperthyroidism is most commonly caused by Graves disease, which is caused by autoantibodies to the thyrotropin receptor (TRAb). Other causes of hyperthyroidism include toxic multinodular goiter, toxic single adenoma, and thyroiditis. Diagnosis of hyperthyroidism can be established by measurement of thyroid-stimulating hormone (TSH), which will be suppressed with either elevated free T4 and/or T3 (overt hyperthyroidism) or normal free T3 and T4 (subclinical hyperthyroidism). Hyperthyroidism can be treated with antithyroid drugs (ATDs), radioactive iodine (RAI), or thyroidectomy. ATDs have a higher replacement rate when compared with RAI or thyroidectomy. Recent evidence has shown that thyroidectomy is a very effective, safe treatment modality for hyperthyroidism and can be performed as an outpatient procedure. This review article provides some of the most recent evidence on diagnosing and treating patients with hyperthyroidism.

Failure to Diagnose and Treat Hyperparathyroidism Among Patients with Hypercalcemia: Opportunities for Intervention at the Patient and Physician Level to Increase Surgical Referral.

BACKGROUND: Hyperparathyroidism is both underdiagnosed and undertreated, but the reasons for these deficiencies have not been described. The purpose of this study was to identify reasons for underdiagnosis and undertreatment of hyperparathyroidism that could be addressed by targeted interventions. MATERIALS AND METHODS: We identified 3,200 patients with hypercalcemia (serum calcium >10.5 mg/dL) who had parathyroid hormone (PTH) levels evaluated at our institution from 2011 to 2016. We randomly sampled 60 patients and divided them into three groups based on their PTH levels. Two independent reviewers examined clinical notes and diagnostic data to identify reasons for delayed diagnosis or referral for treatment. RESULTS: The mean age of the patients was 61 ± 16.5 years, 68% were women, and 55% were white. Fifty percent of patients had ≥1 elevated calcium that was missed by their primary care provider. Hypercalcemia was frequently attributed to causes other than hyperparathyroidism, including diuretics (12%), calcium supplements (12%), dehydration (5%), and renal dysfunction (3%). Even when calcium and PTH were both elevated, the diagnosis was missed or delayed in 40% of patients. For 7% of patients, a nonsurgeon stated that surgery offered no benefit; 22% of patients were offered medical treatment or observation, and 8% opted not to see a surgeon. Only 20% of patients were referred for surgical evaluation, and they waited a median of 16 months before seeing a surgeon. CONCLUSION: To address common causes for delayed diagnosis and treatment of hyperparathyroidism, we must improve systems for recognizing hypercalcemia and better educate patients and providers about the consequences of untreated disease. IMPLICATIONS FOR PRACTICE: This study identified reasons why patients experience delays in workup, diagnosis, and treatment of primary hyperparathyroidism. These data provide valuable information for developing interventions that increase rates of diagnosis and referral.

A cost-utility analysis comparing large volume displacement oncoplastic surgery to mastectomy with free flap reconstruction in the treatment of breast cancer.

PURPOSE: Breast cancer surgical treatment may include large volume displacement oncoplastic surgery (LVOS) or mastectomy with free flap reconstruction (MFFR). We investigated the cost-utility between LVOS versus MFFR to determine which approach was most cost-effective. METHODS: A literature review was performed to calculate probabilities for clinical outcomes for each surgical option (LVOS versus MFFR), and to obtain utility scores that were converted into quality adjusted life years (QALYs) as measures for clinical effectiveness. Average Medicare payments were surrogates for cost. A decision tree was constructed and an incremental cost-utility ratio (ICUR) was used to calculate cost-effectiveness. RESULTS: The decision tree demonstrates associated QALYs and costs with probabilities used to calculate the ICUR of $3699/QALY with gain of 2.7 QALY at an additional cost of $9987 proving that LVOS is a cost-effective surgical option. One-way sensitivity analysis showed that LVOS became cost-ineffective when its clinical effectiveness had a QALY of less than 30.187. Tornado Diagram Analysis and Monte-Carlo simulation supported our conclusion. CONCLUSION: LVOS is cost-effective when compared to MFFR for the appropriate breast cancer patient. CLINICAL QUESTION/LEVEL OF EVIDENCE: II.

Outcomes of Abdominal Surgery in Patients With Mechanical Ventricular Assist Devices: A Multi-institutional Study.

OBJECTIVE: The aim of this study was to examine the outcomes of elective and emergent abdominal operations performed in end-stage heart failure patients supported with ventricular assist devices (VADs). SUMMARY OF BACKGROUND DATA: With the growing volume of end-stage heart failure patients receiving VADs, an increasing number of these patients require surgery for noncardiac pathology. There is a paucity of studies on the safety of abdominal operations in this population. METHODS: We performed a retrospective chart review across 3 hospitals of patients with VADs who underwent abdominal surgeries between 2003 and 2015. We used Chi-square, Fisher exact, and Mann-Whitney U tests for comparison of elective and emergent cases. RESULTS: Fifty-seven patients underwent 63 operations, of which 23 operations were elective, 24 were emergent, and 16 were emergently performed in the same admission as VAD placement and analyzed separately. Patients undergoing elective versus emergent procedures had similar comorbidities (Charlson score 2.9 vs 3.0). 43% versus 32% of patients had VADs as a destination therapy. Although perioperative anticoagulation approach was variable, holding warfarin and starting heparin/enoxaparin/bivalirudin bridge was most common (65% vs 54%). Although 2-fold higher in the emergent group (50 vs 100 mL, P = 0.06), median estimated blood loss was low. Postoperative bleeding requiring transfusion was not very common (13% vs 8%), whereas rate of ischemic cerebrovascular accident (4% each) and venous thromboembolism was low (0% vs 13%, P = 0.23). Thirty-day mortality rate was 4% versus 17%, P = 0.19. CONCLUSION: VAD patients have an acceptable risk profile for abdominal surgery.