Publications by authors named "Reese W Randle"

38 Publications

Outcomes Following Cholecystectomy on a Service Designed to Maximize Chief Resident Entrustment.

J Surg Res 2021 Apr 12;264:474-480. Epub 2021 Apr 12.

Department of Surgery, Wake Forest Baptist Health, Wake Forest University School of Medicine, Winston-Salem, NC. Electronic address:

Background: The chief resident service provides surgical trainees in their final year of training the opportunity to maximize responsibility, continuity, and decision-making. Although supervised, chief residents operate according to personal preferences instead of adapting to their attendings' preferences. We hypothesized that outcomes following cholecystectomy are equivalent between the chief resident service and standard academic services.

Methods: We matched adults undergoing cholecystectomy from 07/2016-06/2019 on the chief resident service to two standard academic service patients based on operative indication and age. We compared demographics, operative details, and 30-d complications.

Results: This study included 186 patients undergoing cholecystectomy. Body mass index (32.4 versus 32.0, P = 0.49) and Charlson comorbidity index (0.9 versus 1.4, P = 0.16) were similar between chief resident and standard academic services, respectively. Operative approach was similar (95.2% laparoscopic on chief resident service versus 94.4% on standard service), but residents on the chief resident service performed cholangiograms more often (48.4% versus 22.6%, P < 0.01) and averaged longer operative times during laparoscopic cholecystectomy with cholangiogram (146±28 versus 85±22 min, P < 0.01) and without (94±31 versus 76±35 min, P < 0.01) compared with standard academic services, respectively. 30-d complication rates were similar (5.2% chief resident versus 5.0% standard, P = 0.95). No patients suffered bile leak, bile duct injury, or reoperation. Emergency Department visits were similar (12.1% chief resident versus 7.4% standard, P = 0.32); readmissions were less frequent on the chief resident service (0.0% versus 5.0% standard, P = 0.03).

Conclusions: With appropriate supervision, chief residents provide safe care for patients undergoing cholecystectomy while directing medical decisions and practicing according to their preferences.
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http://dx.doi.org/10.1016/j.jss.2021.02.042DOI Listing
April 2021

Response Regarding: The Multifaceted Concept of Patient Ownership in the Era of Duty Hour Restrictions.

J Surg Res 2021 Mar 4. Epub 2021 Mar 4.

Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina.

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http://dx.doi.org/10.1016/j.jss.2021.02.001DOI Listing
March 2021

Parathyroidectomy for Tertiary Hyperparathyroidism: A Multi-Institutional Analysis of Outcomes.

J Surg Res 2021 02 9;258:430-434. Epub 2020 Oct 9.

Department of General Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina. Electronic address:

Background: Patients with tertiary hyperparathyroidism (HPT) often experience delays between diagnosis and referral for surgical treatment. We hypothesized that patients with tertiary HPT experience similarly high cure rates and low complication rates after parathyroidectomy compared with patients with primary HPT.

Methods: We retrospectively identified patients undergoing parathyroidectomy from the Collaborative Endocrine Surgery Quality Improvement Program for primary or tertiary HPT from January 2014 to April 2019. Patients were categorized according to their primary diagnosis and compared for cure rates and surgical complications.

Results: The study included 9030 patients, with 334 (3.7%) being treated for tertiary HPT. Parathyroidectomy provided a high cure rate (93.7%) in patients with tertiary HPT. However, adjusting for age, sex, and prior thyroid or parathyroid surgery, tertiary HPT was associated with a greater chance of persistent disease than was primary HPT (odds ratio: 2.3, 95% confidence interval: 1.3-4.0). Overall, complications were low for patients across both groups. However, patients with tertiary HPT were more likely to present to the emergency department (7.5% versus 3.3%; P < 0.001), be readmitted (5.1% versus 1.1%; P < 0.001), and develop a hematoma (1.5% versus 0.2%; P = 0.002). Both groups of patients shared similarly low rates of other complications, including mortality, vocal cord dysfunction, and surgical site infections (P < 0.5% for all).

Conclusions: Patients undergoing parathyroidectomy for tertiary HPT experience high cure rates and low complication rates. However, tertiary HPT is associated with a greater chance of persistent disease and select complications. Nevertheless, the low rates of persistent disease and complications should not deter early referral for the treatment of tertiary HPT.
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http://dx.doi.org/10.1016/j.jss.2020.08.079DOI Listing
February 2021

Unexpected arteriovenous malformation of the thyroid resulting in significant intraoperative blood loss.

J Surg Case Rep 2020 Sep 8;2020(9):rjaa277. Epub 2020 Sep 8.

Department of Surgery, Section of Endocrine Surgery, University of Kentucky, Lexington, KY, USA.

A 49-year-old morbidly obese woman with metastatic endometrial carcinoma was referred for evaluation of an incidentally identified large right thyroid nodule found on computed tomography performed for cancer evaluation. Ultrasound revealed a 9.7 cm solid isoechoic homogeneous right thyroid nodule. Fine needle aspiration was benign. Given size, resection was recommended following completion of chemotherapy and radiation. At the time of right thyroid lobectomy, extremely large vessels were encountered, and the procedure was complicated by estimated blood loss of 2 L. Final pathology revealed a large, benign adenomatous nodule and vascular features consistent with arteriovenous malformation (AVM). Unlike previously reported cases, the diagnosis of a thyroid AVM was not known preoperatively.
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http://dx.doi.org/10.1093/jscr/rjaa277DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7476780PMC
September 2020

Surgical Trainees' Sense of Responsibility for Patient Outcomes: A Multi-institutional Appraisal.

J Surg Res 2020 11 13;255:58-65. Epub 2020 Jun 13.

Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas.

Background: Surgeon educators express concern about trainees' sense of patient ownership. We aimed to compare resident and faculty perceptions on residents' sense of personal responsibility for patient outcomes and to correlate patient ownership with resident and residency characteristics.

Methods: An anonymous electronic questionnaire surveyed 373 residents and 390 faculty at seven academic surgery residencies across the United States. We modified an established psychological ownership scale to measure patient ownership among surgical trainees.

Results: Respondents included 123 residents and 136 faculty (response rate 33% and 35%, respectively). Overall, 78.0% of faculty agreed that residents took personal responsibility for patient outcomes, but only 26.4% thought residents felt a similar or higher degree of patient ownership compared with themselves. Faculty underestimated the proportion of residents that routinely checked on their patients when off-duty (36.8 versus 92.6%, P < 0.001). Higher means on the patient ownership scale correlated with female sex (5.9 versus. 5.5 for males, P = 0.009), advanced post graduate year level (5.3, 5.5, 5.7, 5.8, 6.1, for post graduate year 1-5, respectively, P = 0.02), and the sense that patient outcomes affected the resident respondent's mood (5.8 versus 4.8 for those whose mood was not affected, P < 0.001). In addition, trainees who perceived better resident camaraderie (P = 0.004), faculty mentorship (P < 0.001), and that their program provided appropriate autonomy (P = 0.03) felt greater responsibility for patient outcomes.

Conclusions: Most faculty agree that residents assume personal responsibility for patient outcomes, but many still underestimate residents' sense of patient ownership. Certain modifiable aspects of residency culture including camaraderie, mentorship, and autonomy are associated with patient ownership among trainees.
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http://dx.doi.org/10.1016/j.jss.2020.05.035DOI Listing
November 2020

Implementation of Opioid-Free Thyroid and Parathyroid Procedures: A Single Center Experience.

J Surg Res 2020 08 9;252:169-173. Epub 2020 Apr 9.

Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky.

Background: Initial opioid exposure for most individuals with substance use disorder comes from the healthcare system, and overprescription of opioids in ambulatory operations is common. This report describes an academic medical center's experience implementing opioid-free thyroid and parathyroid operations.

Materials And Methods: This is a retrospective chart review of patients undergoing a thyroid or parathyroid operation before and after implementation of an opioid-free analgesia protocol. The primary endpoint was new postoperative opioid prescription. Secondary endpoints included prescription characteristics and predictors of new opioid prescription.

Results: A total of 515 patients were enrolled in the study: 240 in the control or "pre-intervention" cohort (May through October 2017) and 275 in the intervention or "post" cohort (May through October 2018). Patients in the intervention cohort were significantly less likely to receive an opioid prescription (12.0% versus 59.6%, P < 0.001). When opioids were prescribed, they were used for shorter durations and at lower doses in the intervention cohort. Among the patients prescribed opioids in the intervention cohort (N = 33), the only significant predictor of postoperative opioid use was preoperative opioid use (P = 0.001).

Conclusions: Opioids may not be required after thyroidectomy and parathyroidectomy, especially for opioid-naïve patients. Future research should examine patient satisfaction with opioid-sparing analgesia.
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http://dx.doi.org/10.1016/j.jss.2020.03.010DOI Listing
August 2020

ASO Author Reflections: The Ability of the AJCC 8th Edition to Predict Risk of Recurrence in Differentiated Thyroid Cancer.

Ann Surg Oncol 2019 Dec 2;26(Suppl 3):672-673. Epub 2019 Aug 2.

Department of Surgery, College of Medicine, University of Kentucky, Lexington, KY, USA.

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http://dx.doi.org/10.1245/s10434-019-07683-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6906248PMC
December 2019

Variation in the Quality of Thyroid Nodule Evaluations Before Surgical Referral.

J Surg Res 2019 12 3;244:9-14. Epub 2019 Jul 3.

Section of Endocrine Surgery, Department of General Surgery, University of Kentucky, Lexington, Kentucky. Electronic address:

Background: Thyroid nodules are highly prevalent, and owing to their malignant potential, proper evaluation is imperative. The objective of this study was to characterize variation in thyroid nodule evaluations.

Materials And Methods: This retrospective review included all consecutive surgical referrals for thyroid nodules from October to December 2017 at a single institution. We determined the proportion of evaluations that contained a thyroid-stimulating hormone (TSH) level and a high-quality ultrasound because these components of thyroid nodule evaluations are common to several evidence-based guidelines.

Results: The study cohort included 64 patients, with a median age of 51.5 y. Primary care providers referred most patients (51.6%), followed by endocrinologists (40.6%), and other specialists (7.8%). In total, 35.9% of evaluations did not include a TSH value, which is vital to any thyroid nodule evaluation. Most evaluations (95.3%) included a dedicated ultrasound, but only 12.3% of ultrasound reports commented on nodule size in three dimensions, structure, echogenicity, and lymph nodes, which we considered the minimum commentary indicative of a high-quality ultrasound. Only 51.5% of evaluations included both a TSH and a thyroid ultrasound. If patients receiving low-quality ultrasound reports were excluded, 9.4% of the entire cohort received a guideline-concordant, high-quality evaluation.

Conclusions: Great variation exists in the quality of thyroid nodule evaluations before surgical referral. Two necessary components of thyroid nodule evaluations that contribute most to the observed deviation from guidelines are obtaining a TSH value and obtaining an ultrasound with enough information to risk stratify the nodule.
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http://dx.doi.org/10.1016/j.jss.2019.06.024DOI Listing
December 2019

The Role of Surgery in Autoimmune Conditions of the Thyroid.

Surg Clin North Am 2019 Aug 9;99(4):633-648. Epub 2019 May 9.

Department of Surgery, University of Kentucky, 125 East Maxwell Street, Suite 302, Lexington, KY 40508, USA. Electronic address:

The two most common autoimmune conditions of the thyroid include chronic lymphocytic (Hashimoto's) thyroiditis and Graves' disease. Both conditions can be treated medically, but surgery plays an important role. Hashimoto's thyroiditis and Graves' disease are mediated by autoantibodies that interact directly with the thyroid, creating inflammation and impacting thyroid function. Patients may develop large goiters with compressive symptoms or malignancy requiring surgical intervention. In addition, there are several surgical indications specific to Hashimoto's and Graves' Disease.
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http://dx.doi.org/10.1016/j.suc.2019.04.005DOI Listing
August 2019

Risk of Recurrence in Differentiated Thyroid Cancer: A Population-Based Comparison of the 7th and 8th Editions of the American Joint Committee on Cancer Staging Systems.

Ann Surg Oncol 2019 Sep 4;26(9):2703-2710. Epub 2019 Mar 4.

Department of Surgery, College of Medicine, University of Kentucky, Lexington, KY, USA.

Background: Differentiated thyroid cancer (DTC) survival is excellent, making recurrence a more clinically relevant prognosticator. We hypothesized that the new American Joint Committee on Cancer (AJCC) 8th edition improves on the utility of the 7th edition in predicting the risk of recurrence in DTC.

Methods: A population-based retrospective review compared the risk of recurrence in patients with DTC according to the AJCC 7th and 8th editions using the Surveillance, Epidemiology, and End Results-based Kentucky Cancer Registry from 2004 to 2012.

Results: A total of 3248 patients with DTC were considered disease-free after treatment. Twenty percent of patients were downstaged from the 7th edition to the 8th edition. Most patients had stage I disease (80% in the 7th edition and 94% in the 8th edition). A total of 110 (3%) patients recurred after a median of 27 months. The risk of recurrence was significantly associated with stage for both editions (p < 0.001). In the 7th edition, there was poor differentiation between lower stages and better differentiation between higher stages (stage II hazard ratio [HR] 0.91, 95% confidence interval [CI] 0.39-2.11; stage III HR 3.72, 95% CI 2.29-6.07; stage IV HR 11.66, 95% CI 7.10-19.15; all compared with stage I). The 8th edition better differentiated lower stages (stage II HR 4.06, 95% CI 2.38-6.93; stage III HR 13.07, 95% CI 5.30-32.22; stage IV 11.88, 95% CI 3.76-37.59; all compared with stage I).

Conclusions: The AJCC 8th edition better differentiates the risk of DTC recurrence for early stages of disease compared with the 7th edition. However, limitations remain, emphasizing the importance of adjunctive strategies to estimate the risk of recurrence.
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http://dx.doi.org/10.1245/s10434-019-07275-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6684465PMC
September 2019

Should the duration of primary hyperparathyroidism impact guidelines for evaluation and treatment?

Surgery 2019 01 22;165(1):105-106. Epub 2018 Sep 22.

Department of Surgery, Section of Endocrine Surgery, University of Kentucky, Lexington, Kentucky.

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http://dx.doi.org/10.1016/j.surg.2018.07.044DOI Listing
January 2019

Survival in patients with medullary thyroid cancer after less than the recommended initial operation.

J Surg Oncol 2018 May 19;117(6):1211-1216. Epub 2017 Dec 19.

Department of General Surgery, Section of Endocrine Surgery, University of Wisconsin, Madison, Wisconsin.

Background And Objectives: We aimed to evaluate the disease specific-survival (DSS) of patients with Medullary Thyroid Cancer (MTC) confined to the central neck based on the extent of the initial operation.

Methods: This retrospective review of patients with MTC from the SEER registry from 2004 to 2012 excluded patients with lateral neck involvement or distant metastases.

Results: The cohort (n = 766) included 85(11%) less than total thyroidectomies (TT), 212(28%) TT alone, and 469(61%) TT with lymph node excision. Mean tumor size was similar (2.2cm for
Conclusion: According to population-based SEER registry data, the extent of initial resection may not significantly change DSS in patients with MTC confined to the central neck.
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http://dx.doi.org/10.1002/jso.24954DOI Listing
May 2018

Back so soon? Is early recurrence of papillary thyroid cancer really just persistent disease?

Surgery 2018 01 8;163(1):118-123. Epub 2017 Nov 8.

Division of Endocrine Surgery, Department of Surgery, University of Wisconsin, Madison, WI.

Background: Papillary thyroid carcinoma has excellent survival, yet recurrence remains a challenge. We sought to determine the proportion of reoperations performed for persistent, rather than truly recurrent, disease.

Methods: We conducted a retrospective review of a prospectively maintained database. Patients with papillary thyroid carcinoma who underwent reoperation for disease from 2000-2016 were included. We defined recurrence as disease that developed after a patient had an undetectable thyroglobulin and a negative ultrasonography within 1 year of operation.

Results: A total of 69 patients underwent 92 reoperations. On initial pathology, mean tumor size was 2.6 cm, 51% were multifocal, and 42% had extrathyroidal extension. Half (46%) of the patients underwent a central/lateral neck dissection at the initial operation, and 77% were treated with postoperative radioactive iodine. The median time to first reoperation was 21 months (range, 1-292), and 42% occurred within 1 year. Only 3 operations met criteria for true "recurrence," while 71 operations were categorized as persistent disease.

Conclusion: Many reoperations for papillary thyroid carcinoma are for management of persistent disease. More than half of the patients required reoperation within the first 2 years, which suggests strongly that improvements in the preoperative assessment and adequacy of initial operative therapy need to be made to improve the care of patients with thyroid cancer.
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http://dx.doi.org/10.1016/j.surg.2017.05.028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5736421PMC
January 2018

Editorial: Implications of implementing NIFTP terminology in the management of patients with thyroid tumors.

Surgery 2018 01 3;163(1):66-67. Epub 2017 Nov 3.

Department of Surgery, University of Virginia, Charlottesville, VA.

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http://dx.doi.org/10.1016/j.surg.2017.06.024DOI Listing
January 2018

Impact of potassium iodide on thyroidectomy for Graves' disease: Implications for safety and operative difficulty.

Surgery 2018 01 3;163(1):68-72. Epub 2017 Nov 3.

Department of Surgery, University of Wisconsin, Madison, WI.

Background: Potassium iodide often is prescribed prior to thyroidectomy for Graves' disease, but the effect of potassium iodide on the ease and safety of thyroidectomy for Graves' is largely unknown.

Methods: We conducted a prospective, cohort study of patients with Graves' disease undergoing thyroidectomy. For the first 8 months, no patients received potassium iodide; for the next 8 months, potassium iodide was added to the preoperative protocol for all patients. Outcomes included operative difficulty (based on the Thyroidectomy Difficulty Scale) and complications.

Results: We included a total of 31 patients in the no potassium iodide group and 28 in the potassium iodide group. According to the Thyroidectomy Difficulty Scale, gland vascularity decreased in the potassium iodide group (mean score 2.6 vs 3.3, P = .04), but there were no differences in friability, fibrosis, or size of the thyroid or in overall difficulty of operation (P = not significant for all). Despite similar operative difficulty, patients prescribed potassium iodide were less likely to experience transient hypoparathyroidism (7% vs 26%, P = .018) and transient hoarseness (0% vs 16%, P = .009) compared with the no potassium iodide group.

Conclusion: Potassium iodide administration decreases gland vascularity, but does not change the overall difficulty of thyroidectomy. Preoperative use of potassium iodide solution was, however, associated with less transient hypoparathyroidism and transient hoarseness, suggesting that potassium iodide improves the safety of thyroidectomy for Graves' disease.
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http://dx.doi.org/10.1016/j.surg.2017.03.030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5736456PMC
January 2018

Machine learning to identify multigland disease in primary hyperparathyroidism.

J Surg Res 2017 11 29;219:173-179. Epub 2017 Jun 29.

Department of Surgery, University of Wisconsin, Madison, Wisconsin.

Background: 20%-25% of patients with primary hyperparathyroidism will have multigland disease (MGD). Preoperatative imaging can be inaccurate or unnecessary in MGD. Identification of MGD could direct the need for imaging and inform operative approach. The purpose of this study is to use machine learning (ML) methods to predict MGD.

Methods: Retrospective review of a prospective database. The ML platform, Waikato Environment for Knowledge Analysis, was used, and we selected models for (1) overall accuracy and (2) preferential identification of MGD. A review of imaging studies was performed on a cohort predicted to have MGD.

Results: 2010 patients met inclusion criteria: 1532 patients had single adenoma (SA) (76%) and 478 had MGD (24%). After testing many algorithms, we selected two different models for potential integration as clinical decision-support tools. The best overall accuracy was achieved using a boosted tree classifier, RandomTree: 94.1% accuracy; 94.1% sensitivity, 83.8% specificity, 94.1% positive predictive value, and 0.984 area under the receiver operating characteristics curve. To maximize positive predictive value of MGD prediction, a rule-based classifier, JRip, with cost-sensitive learning was used and achieved 100% positive predictive value for MGD. Imaging reviewed from the cohort of 34 patients predicted to have MGD by the cost-sensitive model revealed 39 total studies performed: 28 sestamibi scans and 11 ultrasounds. Only 8 (29%) sestamibi scans and 4 (36%) ultrasounds were correct.

Conclusions: ML methods can help distinguish MGD early in the clinical evaluation of primary hyperparathyroidism, guiding further workup and surgical planning.
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http://dx.doi.org/10.1016/j.jss.2017.05.117DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5661967PMC
November 2017

Papillary thyroid microcarcinoma: decision-making, extent of surgery, and outcomes.

J Surg Res 2017 10 21;218:237-245. Epub 2017 Jun 21.

Division of Endocrine Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. Electronic address:

Background: The optimal extent of surgery for patients with papillary thyroid microcarcinoma (PTMC), tumors ≤1 cm, is controversial because survival is excellent regardless of approach. The objective of this study was to investigate patient and surgeon decision-making about the extent of surgery for PTMC.

Materials And Methods: We conducted a retrospective review of thyroid cancer patients operated on at a single institution from 2008-2016. To examine decision-making about the extent of surgery, we performed a discourse analysis on all available documentation looking for patient or surgeon reasons.

Results: Of the 853 thyroid cancer patients, 125 (14.7%) had a PTMC as their largest tumor. Overall, 27.2% of the PTMC patients underwent a thyroid lobectomy, whereas 72.8% had a total thyroidectomy (TT). Of those patients diagnosed with PTMC preoperatively (19/125), a significantly higher proportion underwent a TT (94.7% versus 68.9%, P = 0.02). In all cases, documentation indicated that these preoperatively diagnosed patients followed the surgeon's recommendation regarding the extent of surgery. Reasons surgeons cited for recommending a TT included patient and disease factors (34.6%), belief that TT was the standard treatment (21.7%), ease of follow-up (8.7%), and referring provider preference (4.3%). Of the 19 patients diagnosed preoperatively, four (21.1%) patients had a complication, one (5.3%) of which was permanent and potentially avoidable with less extensive surgery.

Conclusions: These data suggest that surgeons drive decision-making about the extent of thyroidectomy in patients with preoperatively diagnosed PTMC. With recent guidelines recommending thyroid lobectomy, closer examination of decision-making is needed to ensure that patients make well-informed, preference-based decisions.
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http://dx.doi.org/10.1016/j.jss.2017.05.054DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5703188PMC
October 2017

Assessing the risk of hypercalcemic crisis in patients with primary hyperparathyroidism.

J Surg Res 2017 09 12;217:252-257. Epub 2017 Jul 12.

Department of Surgery, University of Wisconsin, Madison, Wisconsin. Electronic address:

Background: Hypercalcemic crisis (HC) is a potentially life-threatening manifestation of primary hyperparathyroidism (PHPT). This study aimed to identify patients with PHPT at greatest risk for developing HC.

Methods: This retrospective cohort study included patients with a preoperative calcium of at least 12 mg/dL undergoing initial parathyroidectomy for PHPT from 11/2000 to 03/2016. We compared those with HC, defined as needing hospitalization for hypercalcemia, to those without HC.

Results: The study cohort included 29 patients (15.8%) with HC and 154 patients (84.2%) without HC. Demographics and comorbidities were similar between the groups. Patients with HC were more likely to have a history of kidney stones (31.0% versus 14.3%, P = 0.039), higher preoperative calcium (median 13.8 versus 12.4 mg/dL, P < 0.001), higher parathyroid hormone (PTH) (median 318 versus 160 pg/mL, P = 0.001), and lower vitamin D (median 16 versus 26 ng/mL, P < 0.001) than patients without HC. Cure rates with parathyroidectomy were similar, but nearly double the proportion of patients with HC had multigland disease (24.1 versus 12.3%, P = 0.12). In multivariable analysis, higher preoperative calcium (odds ratio [OR] 1.7, 95% confidence interval [CI] 1.1-2.5), higher PTH (OR 1.0, 95% CI 1.0-1.0), and kidney stones (OR 3.0, 95% CI 1.1-8.2) were independently associated with HC. A Classification and Regression Tree revealed that HC developed in 91% of patients with a calcium ≥13.25 mg/dL and a Charlson Comorbidity Index ≥4.

Conclusions: These data indicate that calcium, PTH, and kidney stones are important in predicting who are at greatest risk of HC. The Classification and Regression Tree can further help stratify risk for developing HC and allow surgeons to expedite parathyroidectomy accordingly.
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http://dx.doi.org/10.1016/j.jss.2017.06.041DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5603402PMC
September 2017

Papillary Thyroid Cancer: The Good and Bad of the "Good Cancer".

Thyroid 2017 07 12;27(7):902-907. Epub 2017 Jun 12.

1 Department of General Surgery, University of Wisconsin , Madison, Wisconsin.

Background: Papillary thyroid cancer is often described as the "good cancer" because of its treatability and relatively favorable survival rates. This study sought to characterize the thoughts of papillary thyroid cancer patients as they relate to having the "good cancer."

Methods: This qualitative study included 31 papillary thyroid cancer patients enrolled in an ongoing randomized trial. Semi-structured interviews were conducted with participants at the preoperative visit and two weeks, six weeks, six months, and one year after thyroidectomy. Grounded theory was used, inductively coding the first 113 interview transcripts with NVivo 11.

Results: The concept of thyroid cancer as "good cancer" emerged unprompted from 94% (n = 29) of participants, mostly concentrated around the time of diagnosis. Patients encountered this perception from healthcare providers, Internet research, friends, and preconceived ideas about other cancers. While patients generally appreciated optimism, this perspective also generated negative feelings. It eased the diagnosis of cancer but created confusion when individual experiences varied from expectations. Despite initially feeling reassured, participants described feeling the "good cancer" characterization invalidated their fears of having cancer. Thyroid cancer patients expressed that they did not want to hear that it's "only thyroid cancer" and that it's "no big deal," because "cancer is cancer," and it is significant.

Conclusions: Patients with papillary thyroid cancer commonly confront the perception that their malignancy is "good," but the favorable prognosis and treatability of the disease do not comprehensively represent their cancer fight. The "good cancer" perception is at the root of many mixed and confusing emotions. Clinicians emphasize optimistic outcomes, hoping to comfort, but they might inadvertently invalidate the impact thyroid cancer has on patients' lives.
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http://dx.doi.org/10.1089/thy.2016.0632DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5561445PMC
July 2017

Trends in the presentation, treatment, and survival of patients with medullary thyroid cancer over the past 30 years.

Surgery 2017 01 11;161(1):137-146. Epub 2016 Nov 11.

Department of Surgery, University of Wisconsin, Madison, WI.

Background: The impact of recent medical advances on disease presentation, extent of operation, and disease-specific survival for patients with medullary thyroid cancer is unclear.

Methods: We used the Surveillance, Epidemiology, and End Results registry to compare trends over 3 time periods, 1983-1992, 1993-2002, and 2003-2012.

Results: There were 2,940 patients diagnosed with medullary thyroid cancer between 1983 and 2012. The incidence of medullary thyroid cancer increased during this time period from 0.14 to 0.21 per 100,000 population, and mean age at diagnosis increased from 49.8 to 53.8 (P < .001). The proportion of tumors ≤1 cm also increased from 11.4% in 1983-1992, 19.6% in 1993-2002, to 25.1% in 2003-2012 (P < .001), but stage at diagnosis remained constant (P = .57). In addition, the proportion of patients undergoing a total thyroidectomy and lymph node dissection increased from 58.2% to 76.5% during the study period (P < .001). In the most recent time interval, 5-year, disease-specific survival improved from 86% to 89% in all patients (P < .001) but especially for patients with regional (82% to 91%, P = .003) and distant (40% to 51%, P = .02) disease.

Conclusion: These data demonstrate that the extent of operation is increasing for patients with medullary thyroid cancer. Disease-specific survival is also improving, primarily in patients with regional and distant disease.
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http://dx.doi.org/10.1016/j.surg.2016.04.053DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5164945PMC
January 2017

Selective Versus Non-selective α-Blockade Prior to Laparoscopic Adrenalectomy for Pheochromocytoma.

Ann Surg Oncol 2017 Jan 25;24(1):244-250. Epub 2016 Aug 25.

Department of Surgery, University of Wisconsin, Madison, WI, USA.

Background: The optimal preoperative α-blockade strategy is debated for patients undergoing laparoscopic adrenalectomy for pheochromocytomas. We evaluated the impact of selective versus non-selective α-blockade on intraoperative hemodynamics and postoperative outcomes.

Methods: We identified patients having laparoscopic adrenalectomy for pheochromocytomas from 2001 to 2015. As a marker of overall intraoperative hemodynamics, we combined systolic blood pressure (SBP) > 200, SBP < 80, SBP < 80 and >200, pulse > 120, vasopressor infusion, and vasodilator infusion into a single variable. Similarly, the combination of vasopressor infusion in the post-anesthesia care unit (PACU) and the need for intensive care unit (ICU) admission provided an overview of postoperative support.

Results: We identified 52 patients undergoing unilateral laparoscopic adrenalectomy for pheochromocytoma. Selective α-blockade (i.e. doxazosin) was performed in 35 % (n = 18) of patients, and non-selective blockade with phenoxybenzamine was performed in 65 % (n = 34) of patients. Demographics and tumor characteristics were similar between groups. Patients blocked selectively were more likely to have an SBP < 80 (67 %) than those blocked with phenoxybenzamine (35 %) (p = 0.03), but we found no significant difference in overall intraoperative hemodynamics between patients blocked selectively and non-selectively (p = 0.09). However, postoperatively, patients blocked selectively were more likely to require additional support with vasopressor infusions in the PACU or ICU admission (p = 0.02). Hospital stay and complication rates were similar.

Conclusion: Laparoscopic adrenalectomy for pheochromocytoma is safe regardless of the preoperative α-blockade strategy employed, but patients blocked selectively may have a higher incidence of transient hypotension during surgery and a greater need for postoperative support. These differences did not result in longer hospital stay or increased complications.
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http://dx.doi.org/10.1245/s10434-016-5514-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5182141PMC
January 2017

Ovarian Thyroid Cancer.

Am Surg 2016 07;82(7):e160-1

Department of Plastic and Reconstructive Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.

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July 2016

Should vitamin D deficiency be corrected before parathyroidectomy?

J Surg Res 2016 07 22;204(1):94-100. Epub 2016 Apr 22.

Department of Surgery, University of Wisconsin, Madison, Wisconsin.

Background: Vitamin D deficiency is common in patients with hyperparathyroidism, but the importance of replacement before surgery is controversial. We aimed to evaluate the impact of vitamin D deficiency on the extent of resection and risk of postoperative hypocalcemia for patients undergoing parathyroidectomy for primary hyperparathyroidism.

Methods: We identified patients with primary hyperparathyroidism undergoing parathyroid surgery between 2000 and 2015 using a prospectively maintained database. Patients with normal (≥30 ng/mL) vitamin D were compared to those with levels less than 30 ng/mL.

Results: There were 1015 (54%) patients with normal vitamin D and 872 (46%) patients with vitamin D deficiency undergoing parathyroidectomy for primary hyperparathyroidism. Vitamin D deficiency was associated with higher preoperative parathyroid hormone (median 90 versus 77 pg/mL, P < 0.001) and calcium (median 10.5 versus 10.4 mg/dL, P < 0.001) compared with normal vitamin D. To achieve similar cure rates, patients with vitamin D deficiency were less likely to require removal of more than one gland (20% versus 30%, P < 0.001) than patients with normal vitamin D. Patients with vitamin D deficiency had similar rates of persistent (1.5% versus 2.0%, P = 0.43) and recurrent (1.7% versus 2.6%, P = 0.21) hyperparathyroidism. Postoperatively, both groups had equivalent rates of transient (2.3% versus 2.3%, P = 0.97) and permanent (0.2% versus 0.4%, P = 0.52) hypocalcemia.

Conclusions: Restoring vitamin D in deficient patients should not delay the appropriate surgical treatment of primary hyperparathyroidism. Deficient patients are more likely to be cured with the excision of a single adenoma and no more likely to suffer persistence, recurrence, or hypocalcemia than patients with normal vitamin D.
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http://dx.doi.org/10.1016/j.jss.2016.04.022DOI Listing
July 2016

Optimal extent of lymphadenectomy for gastric adenocarcinoma: A 7-institution study of the U.S. gastric cancer collaborative.

J Surg Oncol 2016 Jun 21;113(7):750-5. Epub 2016 Mar 21.

Surgical Oncology Service, Department of Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina.

Background And Objectives: The optimal extent of lymphadenectomy in the treatment of gastric adenocarcinoma is debated. We compared gastrectomy outcomes following limited (D1) or extended (D2) lymphadenectomy.

Methods: Using the multi-institutional US Gastric Cancer Collaborative database, we reviewed the morbidity, mortality, recurrence, and overall survival (OS) of patients receiving D1 or D2 lymphadenectomies.

Results: Between 2000 and 2012, 266 and 461 patients received a D1 and D2 lymphadenectomy, respectively. ASA class, mean number of comorbidities, grade, and stage were similar between groups. While major morbidity was similar (P = 0.85), mortality was worse for those receiving a D1 lymphadenectomy (4.9% vs. 1.3%, P = 0.004). D2 lymphadenectomy was associated with improved median OS in stage I (4.7 years for D1 vs. not reached for D2, P = 0.003), stage II (3.6 years for D1 vs. 6.3 for D2, P = 0.42), and stage III patients (1.3 years for D1 vs. 2.1 for D2, P = 0.01). After adjusting for predictors of OS, D2 lymphadenectomy remained a significant predictor of improved survival (HR 1.5, 95%CI 1.1-2.0, P = 0.008).

Conclusions: D2 lymphadenectomy can be performed without increased risk of morbidity and mortality. Additionally, D2 lymphadenectomy is associated with improved survival especially in early stages, and should be considered for gastric adenocarcinoma patients. J. Surg. Oncol. 2016;113:750-755. © 2016 Wiley Periodicals, Inc.
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http://dx.doi.org/10.1002/jso.24227DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4874863PMC
June 2016

Biliary Duplication Cyst.

Am Surg 2015 Jul;81(7):E291-3

Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.

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July 2015

Appendiceal goblet cell carcinomatosis treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.

J Surg Res 2015 Jun 24;196(2):229-34. Epub 2015 Mar 24.

Section of Surgical Oncology, Department of General Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina. Electronic address:

Background: Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is a treatment commonly applied to peritoneal surface disease from low-grade mucinous tumors of the appendix. Some centers have extended this therapy to carcinomatosis from more aggressive malignancies. Therefore, we reviewed our experience with CRS/HIPEC for patients with goblet cell carcinomatosis.

Methods: Patients with carcinomatosis from appendiceal primaries with goblet cell features were identified in a prospectively maintained database of 1198 CRS/HIPEC procedures performed between 1991 and 2014. Patient demographics, disease characteristics, morbidity, mortality, and survival were reviewed.

Results: A total of 31 patients with carcinomatosis originating from appendiceal goblet cell tumors underwent CRS/HIPEC during the study period. Patients were generally young (mean age, 53 y) and otherwise healthy (84% without comorbidities) with good performance status (94% Eastern Cooperative Oncology Group 0 or 1). The mean number of visceral resections was 3.5, and complete cytoreduction of macroscopic disease was accomplished in 36%. Major 90-d morbidity and mortality rates were 38.7% and 9.7%, respectively. Median overall survival (OS) for all patients was 18.4 mo. Patients with negative nodes had better survival than those with positive nodes (median OS, 29.2 versus 10.2 mo), respectively (P = 0.002). Although complete cytoreduction was associated with longer median OS after CRS/HIPEC (R0/R1 28.6 versus R2 17.2 mo, P = 0.47), the observed difference did not reach statistical significance.

Conclusions: CRS/HIPEC may improve survival in patients with node negative goblet cell carcinomatosis when a complete cytoreduction is achieved. Patients with disease not amenable to complete cytoreduction should not be offered CRS/HIPEC.
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http://dx.doi.org/10.1016/j.jss.2015.03.051DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4514020PMC
June 2015

Significance of diabetes on morbidity and mortality following cytoreductive surgery with hyperthermic intraperitoneal chemotherapy.

J Surg Oncol 2015 May 29;111(6):740-5. Epub 2014 Dec 29.

Section of Surgical Oncology, Department of General Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina.

Background And Objectives: Patients with diabetes suffering from peritoneal surface disease represent a challenge to treat due to the effects of both processes on multiple organ systems. We sought to define the impact of diabetes on outcomes following cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC).

Methods: A retrospective analysis of a prospective database of 1065 CRS/HIPEC procedures was conducted. Patient demographics, comorbidities, and tumor characteristics were reviewed.

Results: CRS/HIPEC was performed in 91 diabetic and 844 non-diabetic patients with peritoneal surface disease from 1991 to 2013. Diabetics and non-diabetics spent 6.8 and 3.1 (P = 0.009) days in the ICU, respectively. Diabetics were more likely to suffer major complications (P < 0.001) including infectious (P < 0.001) and thrombotic (P = 0.05) complications, arrhythmias (P = 0.007), renal insufficiency (P = 0.002) and respiratory failure (P = 0.002) than non-diabetics. Mortality was significantly worse for diabetic patients at 30-days (8.8% vs. 2.7%, P = 0.007) and at 90-days (13.2% vs. 5.2%, P = 0.008). Even after adjusting for other significant predictors of morbidity, diabetes predicted more major complications and increased mortality following CRS/HIPEC.

Conclusions: Diabetes predicts major complications and specific complication patterns associated with increased ICU stay and worse mortality in patients undergoing CRS/HIPEC. Diabetic patients deemed to be appropriate candidates for CRS/HIPEC should be treated with caution.
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http://dx.doi.org/10.1002/jso.23865DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4406797PMC
May 2015

Peritoneal surface disease (PSD) from appendiceal cancer treated with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC): overview of 481 cases.

Ann Surg Oncol 2015 Apr 16;22(4):1274-9. Epub 2014 Oct 16.

Section of Surgical Oncology, Department of General Surgery, Wake Forest Baptist Health, Winston-Salem, NC, USA,

Background: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) used to treat peritoneal surface disease (PSD) from appendiceal cancer have shown variability in survival outcomes. The primary goal of this study was to determine predictors of surgical morbidity and overall survival. The secondary goal was to describe the impact of nodal status on survival after CRS/HIPEC for PSD from low-grade appendiceal (LGA) and high-grade appendiceal (HGA) primary lesions.

Methods: A retrospective analysis of 1,069 procedures from a prospective database was performed. Patient characteristics, tumor grade, nodal status, performance status, resection status, morbidity, mortality, and survival were reviewed.

Results: The study identified 481 CRS/HIPEC procedures: 317 (77.3 %) for LGA and 93 (22.7 %) for HGA lesions. The median follow-up period was 44.4 months, and the 30-day major morbidity and mortality rates were respectively 27.8 and 2.7 %. Major morbidity was jointly predicted by incomplete cytoreduction (p = 0.0037), involved nodes (p < 0.0001), and comorbidities (p = 0.003). Multivariate negative predictors of survival included positive nodal status (p = 0.003), incomplete cytoreduction (p < 0.0001), and preoperative chemotherapy (p = 0.04) in LGA patients and incomplete cytoreduction (p = 0.0003) and preoperative chemotherapy (p = 0.0064) in HGA patients. After complete cytoreduction, median survival was worse for patients with positive nodes than for those with negative nodes in LGA (85 months vs not reached [82 % alive at 90 months]; p = 0.002) and HGA (30 vs 153 months; p < 0.0001).

Conclusions: Positive nodes are associated with decreased survival not only for HGA patients but also for LGA patients even after complete cytoreduction. Nodal status further stratifies histologic grade as a prognostic indicator of survival. Patients with node-negative HGA primary lesions who receive a complete cytoreduction may experience survival comparable with that for LGA patients.
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http://dx.doi.org/10.1245/s10434-014-4147-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4346452PMC
April 2015

Peritoneal surface disease with synchronous hepatic involvement treated with Cytoreductive Surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC).

Ann Surg Oncol 2015 May 14;22(5):1634-8. Epub 2014 Aug 14.

Surgical Oncology Service, Department of General Surgery, Wake Forest Baptist Health, Winston-Salem, NC, USA.

Background: Patients with peritoneal surface disease (PSD) often present with synchronous hepatic involvement (HI). The impact of addressing the hepatic component during CRS/HIPEC on operative and survival outcomes is not clearly defined.

Methods: A prospective database of 1,067 procedures was reviewed based on primary tumor, performance status, resection status, type of liver involvement (superficial or parenchymal) and hepatic resection, morbidity, mortality, and overall survival.

Results: There were 108 (10 %) CRS/HIPEC procedures performed with synchronous liver debulking in 99 patients with PSD from 27 (33 %) appendiceal and 32 (39 %) colorectal primary lesions. Ninety percent of patients underwent subsegmental hepatic resection, whereas 22 % had disease with hepatic parenchymal involvement. Median intensive care unit (ICU) and hospital stay were 3.5 and 13.6 days, respectively. Clavien grade III/IV morbidity was similar for patients with or without resected HI (18.9 vs. 22.5 %; p = 0.39). The 30-day mortality rate was 6.5 and 2.8 % (p = 0.07) for patients with and without resected HI, respectively. The median survival for all patients with low-grade appendiceal cancer was 42.1 months with resected HI and 95.5 months without HI (p = 0.03). Median survival for colorectal cancer patients after complete cytoreduction was 21.2 months with HI versus 33.6 months without HI (p = 0.03).

Conclusions: Synchronous resection of limited HI does not increase the morbidity or mortality of CRS/HIPEC procedures. The survival benefit, although still meaningful, was less for patients with HI. Resectable low volume HI in patients with PSD from colon and appendiceal primary lesions should not be considered a contraindication for CRS/HIPEC procedures.
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http://dx.doi.org/10.1245/s10434-014-3987-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4329114PMC
May 2015

Impact of distal pancreatectomy on outcomes of peritoneal surface disease treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.

Ann Surg Oncol 2015 May 14;22(5):1645-50. Epub 2014 Aug 14.

Surgical Oncology Service, Department of General Surgery, Wake Forest University, Winston-Salem, NC, USA.

Background: Left upper quadrant involvement by peritoneal surface disease (PSD) may require distal pancreatectomy (DP) to obtain complete cytoreduction. Herein, we study the impact of DP on outcomes of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC).

Methods: Analysis of a prospective database of 1,019 procedures was performed. Malignancy type, performance status, resection status, comorbidities, Clavien-graded morbidity, mortality, and overall survival were reviewed.

Results: DP was a component of 63 CRS/HIPEC procedures, of which 63.3 % had an appendiceal primary. While 30-day mortality between patients with and without DP was no different (2.6 vs. 3.2 %; p = 0.790), 30-day major morbidity was worse in patients receiving a DP (30.2 vs. 18.8 %; p = 0.031). Pancreatic leak rate was 20.6 %. Intensive care unit days and length of stay were longer in DP versus non-DP patients (4.6 vs. 3.5 days, p = 0.007; and 22 vs. 14 days, p < 0.001, respectively). Thirty-day readmission was similar for patients with and without DP (29.2 vs. 21.1 %; p = 0.205). Median survival for low-grade appendiceal cancer (LGA) patients requiring DP was 106.9 months versus 84.3 months when DP was not required (p = 0.864). All seven LGA patients undergoing complete cytoreduction inclusive of DP were alive at the conclusion of the study (median follow-up 11.8 years).

Conclusions: CRS/HIPEC including DP is associated with a significant increase in postoperative morbidity but not mortality. Survival was similar for patients with LGA whether or not DP was performed. Thus, the need for a DP should not be considered a contraindication for CRS/HIPEC procedures in LGA patients when complete cytoreduction can be achieved.
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http://dx.doi.org/10.1245/s10434-014-3976-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4329108PMC
May 2015