46.20 Parathyroidectomy in Primary vs Secondary/Tertiary Hyperparathyroidism Patients: Different Outcomes?

Posted on January 18, 2018

S. K. Chung1, A. A. Asban1, C. Balentine1, H. Chen1  1University Of Alabama At Birmingham,Department Of Surgery,Birmingham, AL, USA

Introduction:
Surgical treatment is the definitive therapy for primary, secondary and tertiary hyperparathyroidism (HPT). However, each type of hyperparathyroidism has a different etiology and differing patient populations. We hypothesize that despite these differences, parathyroidectomy is equally effective in treating all types of HPT and result in similar outcomes.

Methods:
We retrospectively reviewed the records of patients with primary, secondary or tertiary HPT referred for parathyroidectomy to one surgeon at a tertiary care center between November 2015 and June 2017. We used Chi Square test for categorical variables and Student T-test for difference between means to identify differences between the two groups.

Results:
We identified 221 patients with primary (181, 82%), or secondary/tertiary HPT (40, 18%) who underwent parathyroidectomy. The mean ages for patients with primary and secondary/tertiary HPT were 60 years (SD 13.6 ) and 52.5 years (SD 11.7), respectively (p<0.001). There was a statistically significant difference in gender: 79% females with primary HPT and 53% females with secondary/tertiary HPT (p=0.001). Racial distribution was also significantly different (p=0.001) with 16% African Americans with primary HPT and 45% African Americans with secondary/tertiary HPT. High cure rates with no statistical difference (p=0.49) were seen between the two groups: 99% for primary HPT and 97% for secondary/tertiary HPT. There was no statistically significant difference between groups in length of stay (0.2 days), rates of transient or permanent hoarseness, transient or permanent hypocalcemia, or wound complications.

Conclusion:
Despite the difference in comorbidities and pathology in patients with primary versus secondary/tertiary HPT, there were no differences in cure rate, complications, or hospital length of stay. Patients with all types of HPT can be managed with outpatient parathyroidectomy.
 

46.15 Incidental Thyroid Carcinoma in Patients Undergoing Surgery for Benign Thyroid Disease

Posted on January 18, 2018

M. Manasa1, O. Picado1, M. L. Mao1, R. Minami1, J. C. Farra1, J. I. Lew1  1University Of Miami Leonard M. Miller School Of Medicine,Division Of Endocrine Surgery, DeWitt Daughtry Family, Department Of Surgery,Miami, FL, USA

Introduction: Patients with benign thyroid disease undergo thyroidectomy for a variety of reasons including compressive symptoms, hyperthyroidism and cosmesis. Although patients are referred for benign disease, underlying thyroid malignancy may be incidentally discovered on final pathology. This study examines the association between benign indication for thyroid surgery and incidental thyroid cancer.

Methods: A retrospective review of 1,040 patients undergoing thyroid surgery at a tertiary referral center was performed. Surgical indications for benign thyroid disease (n=357) included compressive symptoms, hyperthyroidism, goiter size >4 cm, substernal goiter, cosmesis, and patient preference. A dominant or “index” thyroid nodule was defined as a nodule >1 cm or the largest/most suspicious thyroid nodule in a multinodular goiter (MNG). An “incidental” thyroid carcinoma was defined as any cancer incidentally discovered outside the index nodule. Patients with previous thyroid surgery, indeterminate or malignant preoperative FNA results were excluded.

Results: Of 916 patients who underwent thyroidectomy, 559 were referred for malignancy and 357 for benign disease. Patients with benign disease were referred most commonly for non-toxic MNG (n=223, 63%) followed by Graves’ disease (n=46, 13%), non-toxic solitary nodule (n=40, 11%), toxic MNG (n=32, 9%), and substernal goiter (n=16, 4%). Final pathology demonstrated incidental thyroid carcinoma in 97 patients (27%): 39 (40%) had a malignant index nodule, 36 (37%) had incidental thyroid carcinoma, and 23 (23%) had both index and incidental malignancy. The median size of malignant index nodules was 2 cm (range: 0.1-6 cm) and the median size of incidental carcinomas was 0.4 cm (range: 0.1-5.8 cm). Lymphovascular invasion was present in 20% (19/97) and extrathyroidal extension was present in 8% (8/97) of patients. Patients with non-toxic solitary nodule (n=18, 45%) most commonly had incidental carcinoma followed by non-toxic MNG (n=69, 31%), substernal goiter (n=4, 25%), toxic MNG (n=5, 16%) and Graves’ disease (n=4, 9%). The most common malignancy found on final pathology was papillary thyroid carcinoma (PTC, n=93, 96%) followed by follicular (n=2, 2%), medullary (n=1, 1%), and anaplastic (n=1, 1%) thyroid cancer. The majority of PTC were follicular variant (n=69, 74%) followed by classical (n=20, 22%), tall cell (n=2, 2%), and diffuse sclerosing (n=2, 2%) variants.

Conclusion: Patients undergoing surgery for benign thyroid disease have significant rates of occult malignancy on final pathology. Despite these high rates of underlying malignancy, the majority of these tumors are low risk thyroid malignancies based on American Thyroid Association risk stratification and thus do not warrant further extensive surgical or clinical management. Nevertheless, careful evaluation and counseling by a surgeon may be necessary in managing patients with benign thyroid disease.

46.16 Understanding Nationwide Readmissions After Thyroid Surgery

Posted on January 18, 2018

A. Rios-Diaz1, R. Zheng1, D. P. Thibault2, J. A. Crispo2, A. W. Willis2, A. I. Willis1  1Thomas Jefferson University,Department Of Surgery,Philadelphia, PA, USA 2University Of Pennsylvania,Department Of Biostatistics And Epidemiology,Philadelphia, PA, USA

Introduction:  The 30-day readmission rate is increasingly utilized as a metric of quality impacting reimbursement. To date, there are no national data on readmission rates after thyroid surgery. We aimed to determine national readmission rates and associated clinical factors for patients with thyroidectomy operations at a national level.

Methods:  Using the 2014 Nationwide Readmission Database, we identified patients undergoing thyroid surgery as defined by International Classification of Diseases, Ninth Revision, procedure codes for thyroid lobectomy, partial thyroidectomy, complete thyroidectomy and substernal thyroidectomy. Descriptive statistics were used to examine readmission rates, most common causes for readmission and timing of presentation after discharge. Adjusted multivariable logistic regression models controlling for potential confounders were used to determine factors associated with increased 30-day readmission. Statistical significance was set at P < 0.05.

Results: A total of 22,654 patients underwent thyroid surgery in the study period and 990 (4.37%) were readmitted within 30 days. Among these, the most common diagnoses for readmission were "disorders of mineral metabolism" accounting for 36% and "hypocalcemia" for 26.6%. This held true regardless of the indication for surgery (goiter, cancer or thyroid function disorder) or timing of readmission after discharge. Most readmissions (54.6%) occurred within seven days of discharge, with 24.6% within the first 48 hours. Factors associated with increased readmission odds included Medicare insurance (Adjusted Odds Ratio 1.47 [95% Confidence Interval 1.03-2.11]), Medicaid insurance (AOR 1.44 [CI 1.04-1.99]), discharge to inpatient post acute care (AOR 2.31 [CI 1.48-3.62]) or home with home healthcare (AOR 1.78 [CI 1.21-2.63]), Elixhauser comorbidity score ≥ 4 (AOR 2.04 [CI 1.27-3.26]), length of stay ≥  2 days (AOR 2.7 [CI 1.9-3.82]). Hypocalcemia was the only complication during the index admission that was associated with increased odds of readmission (AOR 1.5 [CI 1.1-2.06]). (All AOR P<0.01). There was no association of diagnosis indication for surgery or type of procedure with odds of readmissions.

Conclusion: A considerable proportion of thyroidectomy patients are readmitted early after thyroid surgery. The most common diagnosis for readmission is hypocalcemia/mineral metabolism disorder. Socioeconomic factors, comorbidities and complications during index admissions are significantly associated with increased readmissions. Recognition of these risk factors may decrease readmission rates as well as guide further policy discussions regarding readmissions.

 

46.17 Early Intraoperative PTH Values Can Help Guide Surgical Decision Making

Posted on January 18, 2018

N. C. Luehmann1, J. A. Cirino1, P. F. Czako1, S. Nagar1  1William Beaumont Hospital,Department Of Surgery,Royal Oak, MI, USA

Introduction:  The advent of intraoperative parathyroid hormone (ioPTH) monitoring has enhanced the efficacy of parathyroidectomy by allowing surgeons to ensure that all abnormal parathyroid tissue is excised in the operating room. Although ioPTH monitoring has been a revolutionary development, limitations are faced when initial ioPTH values do not meet accepted criteria. Surgeons must decide whether to proceed with further dissection or wait for additional ioPTH levels to return. The purpose of our study was to review our 5-minute post-gland excision ioPTH (5-min ioPTH) data to determine if there are trends that identify patients at risk for multigland disease, thereby allowing further dissection to begin sooner.

Methods:  A retrospective chart review was performed for all patients who underwent parathyroidectomy with ioPTH monitoring from January 2001 through March 2015 at Beaumont Hospital’s Royal Oak campus. We specifically studied patients who had a 5-min ioPTH level drawn. Patients were excluded if they were less than 18 years old, had surgery for secondary or tertiary hyperparathyroidism, re-operative parathyroidectomy, concomitant thyroid procedures, other prior neck operations, or a thoracic procedure to remove an intrathoracic parathyroid gland. Methodology used in previous studies looking at this idea was employed in our study. Patient’s charts were reviewed to document baseline pre-excision PTH level, 5-min ioPTH level, final pathology with respect to single adenoma (SA), double adenomas (DA), or four gland hyperplasia (4G), and post-operative calcium levels to determine cure, persistence, or recurrence. 

Results: In total, 621 patients had a 5-min ioPTH level and were included. The median baseline ioPTH for the cured, persistence, and recurrence groups was similar at 134, 119, and 136 pg/mL, respectively (p=0.18). However, the median 5-min ioPTH was lower in the cured group compared to the persistence and recurrence groups (37, 58 and 58 pg/mL, respectively) (p=0.002). Similarly, the percent decline in PTH from baseline to 5-min ioPTH was significantly greater in the cured group at 74% versus 47% in the persistence and 51% in the recurrence groups (p<0.001). Within the subset of patients cured from the index operation, median 5-min ioPTH between those with SA, DA, and 4G was 36, 51, and 93 pg/mL, respectively (p<0.001). Percent decline in PTH from baseline to 5-min ioPTH was 74% for the SA group and decreased to 60% in the DA group and 17% in the 4G group (p<0.001). Finally, a ROC analysis conducted using the same subset of patients indicated that a 35% decline from baseline to the 5-min ioPTH is needed to best distinguish a SA from DA or 4G (sensitivity 49.4% and specificity 98.9%).

Conclusion: Our results indicate that 5min-ioPTH values are lower in SA versus DA and 4G. Additionally, we found that if a decline of >35% between baseline and ioPTH is not achieved, consideration for further dissection is warranted. 

 

46.13 Factors Affecting Readmission Following Pediatric Thyroid Resection: A NSQIP-P Evaluation

Posted on January 18, 2018

I. I. Maizlin1, H. Chen2, R. T. Russell1  1University Of Alabama at Birmingham,Pediatric Surgery,Birmingham, Alabama, USA 2University Of Alabama at Birmingham,General Surgery,Birmingham, Alabama, USA

Introduction: Thyroid neoplasms are among the most common endocrine pathologies in the pediatric population and their incidence has increased over the last several decades. Many of these conditions require surgical resection. We aimed to determine pre-operative and intraoperative factors that affect unplanned post-operative readmission (UPOR) among pediatric patients undergoing thyroidectomy.

Methods: Utilizing the 2015 NSQIP-P Public-Use-File (first year to include these procedures), pediatric thyroidectomy patients were collated. We evaluated demographics, comorbidities, peri-operative variables and post-operative morbidities, performing a multivariate analysis comparing individuals that required UPOR within 30 days of surgery to those that did not.

Results: 658 pediatric thyroidectomies were identified, of whom 2.6% required UPOR. Following multivariate analysis, male gender (3.7%, p=0.027), African American race (5.7%, p=0.038) and pre-operative inpatient status (3.1%, p=0.015) were associated with increased rates of UPOR. Patients with thyroiditis were significantly more likely to have UPOR (4.4%, p=0.023). Similarly, higher UPOR rates were seen in patients with a history of asthma (8.3%, p=0.030), cardiac comorbidities (7.1%, p=0.001), developmental delay (3.6%, p=0.047) and hematological disorders (9.1%, p=0.021).  In addition, figure 1 demonstrates that patients operated by general surgeons had a lower rate of UPOR (0.5%) when compared to otolaryngology surgeons (4.3%) (p=0.019), as well as lower rates of surgical site infections (p=0.041) and shorter operative times (p<0.001).

Conclusion: The number of children readmitted after thyroid surgery is low.  Several factors, however, including underlying etiology of thyroid disease and surgeon subspecialty, highly determine the rate of unplanned post-operative readmission after thyroid surgery in children. 

 

46.14 Mixed-methods Evaluation of Patient-Surgeon Decision Making about Thyroid Microcarcinoma Treatment

Posted on January 18, 2018

M. F. Bates1, M. C. Saucke1, J. L. Jennings1, H. J. Khokhar1, C. I. Voils1, S. C. Pitt1  1University Of Wisconsin,Madison, WI, USA

Introduction:

Papillary thyroid microcarcinoma (PTMC) is an overtreated disease where achieving value-concordant care is critical.  Patients have three treatment options with equivalent survival outcomes, yet widely varying risks.  We aimed to better understand patients’ and surgeons’ decision making about PTMC treatment.

Methods:

This cross-sectional, mixed-methods study of 10 patients with PTMC post-thyroidectomy and 12 surgeons, used semi-structured interviews and a survey that included validated measures of decision control and involvement.  We utilized qualitative content analysis to characterize decision-making preferences.

Results: 

The majority of patients were white (90%) and female (80%), with a median age of 46 years.  Most surgeons were white (91.7%), male (83.3%), endocrine surgeons (83.3%) who worked at university/academic institutions (91.7%). Patients and surgeons both preferred the patient to make the final treatment decision after considering the surgeon’s opinion. They least preferred to leave the final decision to the surgeon.

Examination of patient decision-making showed that 20% of patients did not have as much input as they wanted in their treatment choice and their decision was not consistent with their personal values. Patient experiences ranged from deciding on their treatment prior to surgical consultation, to a perceived lack of a choice because the surgeon only discussed one option.  When asked what was most important in choosing a treatment, patients frequently discussed getting the cancer out and trust in the surgeon. The survey demonstrated that 70% of patients felt the surgeon’s recommendation was the most important factor in their decision. 

Multiple factors influenced surgeons’ treatment recommendations – most commonly clinical data and patients’ anxiety.  Surgeons described tailoring their recommendation based on their own perception of patients’ level of fear and tolerance of risk without explicit discussion. When surveyed, only 58% of surgeons assessed patients’ preferred treatment, and just 42% elicited patients’ preferred level of involvement in decision-making

Conclusion:

When making decisions about PTMC treatment, patients and surgeons prefer a shared model with the patient controlling the final decision.  Surgeons’ recommendations appear to heavily influence the decision, but are based on the surgeon’s own perceptions of patients’ preferences, which may not be accurate.  To achieve value-concordant patient-centered care, explicit discussion of patients’ preferences in relation to all treatment options and outcomes will be key.
 

46.12 Influence of Concurrent Thyroid Pathology on Parathyroidectomy for Primary Hyperparathyroidism

Posted on January 18, 2018

B. Sunkara1, M. Cohen2, B. Miller2, P. Gauger2, D. Hughes2  1University Of Michigan,Medical School,Ann Arbor, MI, USA 2University Of Michigan,Department Of General Surgery,Ann Arbor, MI, USA

Introduction: The influence of concurrent thyroid pathology on parathyroidectomy for primary hyperparathyroidism (PHPT) has not been established. The hypothesis of this study is that concurrence of thyroid pathology and PHPT will influence various factors in parathyroidectomy. 

Methods: This is retrospective cohort study of consecutive parathyroidectomy patients for PHPT. Patients were stratified according to presence or absence of thyroid pathology and then analyzed for effect of specific thyroid pathology on preoperative imaging, intraoperative factors and outcomes of parathyroidectomy. 

Results: Of the 1001 patients:  534 (53.4%) had no thyroid pathology, 266 (26.6%) had thyroid nodules, 240 (24.0%) had hypothyroidism, 83 (8.3%) had Hashimoto’s thyroiditis, 39 (3.9 %) had previous thyroid surgery, and 21 (2.1%) had thyroid cancer (some had >1 pathology). The presence of thyroid pathology did not significantly influence intraoperative PTH results or rates of persistent PHPT.   The localization accuracy of ultrasound was greater than sestamibi when any thyroid pathology was present (63% vs 50%; p<0.02).  Sestamibi was used more frequently in patients with history of thyroidectomy (74% vs 56%; p=0.03) and hypothyroidism (68% vs 56%; p<0.02); however sestamibi was least accurate when hypothyroidism was present (41% vs 52%; p=0.03). Patients without thyroid pathology had a higher rate of successful focused parathyroidectomy (63%) compared to patients with hypothyroidism (53%; p<0.02) and nodules (48%; p<0.02).  A bilateral exploration (planned or converted) was performed in 37% of patients without thyroid pathology compared to hypothyroidism (47%; p<0.02), Hashimoto’s (48%; p=0.04) and thyroid nodules (51%; p<0.02). The correlation between thyroid pathology and the total weight of the excised glands is less pronounced with the only significant difference being found in the group with a history of thyroid cancer (0.485gm vs no pathology 0.845gm; p<0.02). 

Conclusion: Concurrent thyroid pathology influences use and accuracy of preoperative imaging for PHPT as well as the need for bilateral exploration, but does not affect the overall success rates of parathyroidectomy. 

 

46.09 Timely Evaluation and Management of Primary Hyperparathyroidism in Patients with Kidney Stones

Posted on January 18, 2018

A. A. Perez1, D. F. Schneider1, S. C. Pitt1, K. L. Long1, A. Chu1, R. S. Sippel1  1University Of Wisconsin,Endocrine Surgery,Madison, WI, USA

Introduction:

Kidney stones are a common manifestation of primary hyperparathyroidism (PHPT), and a strong indicator for surgical treatment of PHPT. Effective detection and treatment of PHPT is critical for managing the risk of recurrent stone disease and other complications of unmanaged PHPT. In this study, we examined predictors of kidney stones in PHPT patients and determined how effectively the diagnosis of PHPT is made in patients who first present with stones.

Methods:

We performed a retrospective analysis of surgically treated PHPT patients, comparing 247 patients who were kidney stone-formers (SF) and 1,047 patients with no stones (NS). We identified 51 SF patients who presented with a stone before their PHPT diagnosis, and whose stone evaluation and treatment was completed entirely within our health system for further analysis. Extracted data included clinical assessment and treatment of stones as well as timing of PHPT evaluation.

Results:

Compared to NS patients, SF patients were more likely to be male (28.6% vs 19.7%, p=0.002) and to be normocalcemic (26.6% vs. 16.9%, p=0.001) than the NS patients. SF patients also had higher alkaline phosphatase (92 IU/L vs. 85 IU/L, p=0.012) and higher 24-hour urinary calcium levels (342 mg/day vs 304 mg/day, p=0.005). On multivariate analysis, being male and having a higher 24-hour urine calcium and alkaline phosphatase were independently associated with a greater incidence of kidney stone formation. Despite these differences, 52.7% of SF had 24-hour urinary calcium levels within the normal range at the time of surgery. Of the 51 SF patients with full chart available for review, 72.5% (n=37) had a serum calcium drawn within 6 months of the first stone episode. Hypercalcemia was present in 43.2% of these patients (n=16), but only 10 (62.5%) of these patients had a serum PTH ordered within 3 months of their elevated calcium. Patients that had both a calcium and PTH drawn within 9 months of their first episode of kidney stones had a significantly shorter time from their first stone to surgical treatment than the other patients (median 8.5 months vs. 49.1 months, p=0.001).

Conclusion:

SF patients were found to be stronger excreters of calcium, but elevated urinary calcium and serum alkaline phosphatase levels did not identify the majority of PHPT patients at risk of forming kidney stones. Many patients with kidney stones had normal serum calcium levels and normal urinary calcium levels highlighting the need to carefully evaluate all SF for the possible treatable cause of hyperparathyroidism. Timely consideration of PHPT as well as prompt serum calcium and PTH evaluation significantly reduces time to treatment and minimize the risks of complications of longstanding PHPT.

46.10 Hypervascular Pancreatic Lesions: Neuroendocrine Tumor Cannot Be Assumed

Posted on January 18, 2018

S. M. Wcislak1, Z. E. Stiles1, J. L. Deneve1, E. S. Glazer1, S. W. Behrman1, M. Ismail2, F. T. Farees3, P. V. Dickson1  1University Of Tennessee Health Science Center,Division Of Surgical Oncology, Department Of Surgery,Memphis, TN, USA 2University Of Tennessee Health Science Center,Division Of Gastroenterology, Department Of Medicine,Memphis, TN, USA 3Gastro One,Gasteroenterology,Memphis, TN, USA

Introduction: Although pancreatic neuroendocrine tumors (PNETs) typically have a solid, hypervascular appearance on contrast-enhanced imaging, other non-PNET lesions may have a similar appearance.  Preoperative recognition of non-PNET diagnoses may alter further staging and treatment plans.

Methods:  Patients from our institutional pancreatic surgery database who underwent pancreatectomy for suspected PNET were identified.  Demographics as well as results of pre-operative contrast-enhanced CT and/or MRI, endoscopic ultrasound-fine needle aspiration (EUS-FNA), and pathology data were collected.  Patients with documented distant metastases, functional tumors, and hereditary PNET syndromes were excluded.

Results:  From 2007-2017, 55 patients with pre-operative contrast-enhanced CT and/or MRI had pancreatectomy for a suspected diagnosis of sporadic, localized, non-functional PNET.  Final pathology revealed PNET in 42 (76%) and a non-PNET diagnosis in 13 (24%).  Of patients with a diagnosis of PNET, the lesion on CT/MRI was solid in 31 (74%) and cystic in 11 (26%).  Solid PNETs were hypervascular in 26 (84%), hypodense in 4 (13%), and isodense in 1(3%) on contrast-enhanced imaging.  Hypervascular solid lesions were appreciated in 13 non-PNET patients with a final diagnosis of intrapancreatic splenule (4), metastatic renal cell carcinoma (2), solid pseudopapillary tumor (2), serous cystadenoma (1), duodenal GIST (1), adenocarcinoma (1), focal pancreatitis (1), and no tumor present (1). There were no significant differences in age, gender, race, tumor size, tumor location, pancreatic or biliary duct dilation, or contrast enhancement patterns (homogenous vs heterogeneous) between patients with PNET vs non-PNET diagnoses.  Patients with a non-PNET diagnosis on final pathology were significantly less likely to have undergone EUS-FNA than patients with a final diagnosis of PNET (15% vs 79%, p<0.001).  EUS-FNA was found to have a sensitivity of 79%.  Accurate pre-operative diagnosis would have spared pancreatectomy in 7(13%) patients with benign pathology and may have altered the staging or preoperative treatment plan in 4(7%) with non-PNET malignancies.

Conclusion:  Although typically hypervascular, PNETs may appear isodense, hypodense, or cystic on contrast-enhanced imaging.  Importantly, a number of other benign and malignant non-PNET diagnoses may have a solid, hypervascular appearance.  EUS-FNA and additional diagnostic modalities should be routinely performed to confirm a diagnosis prior to pancreatectomy. 

 

46.11 High Rate of Incidental Thyroid Carcinoma found in Contralateral Thyroid Lobes

Posted on January 18, 2018

R. Minami1, O. Picado1, M. Mao1, M. Manasa1, J. Lew1, J. C. Farrá1  1University Of Miami Leonard M. Miller School Of Medicine,Division Of Endocrine Surgery, DeWitt Daughtry Family Department Of Surgery,Miami, FL, USA

Background: Current American Thyroid Association (ATA) guidelines recommend thyroid lobectomy (TL) alone for low risk papillary thyroid carcinomas up to 4cm. This represents a paradigm shift from completion thyroidectomy (CT) to allow for radioactive iodine ablation and use of thyroglobulin levels for surveillance. However, little data is available on rates of incidental and multifocal malignancy in contralateral thyroid lobes and its clinical significance. This study examines the rate of underlying malignancy in index thyroid nodules and incidental cancers in contralateral lobes of patients who undergo initial or staged total thyroidectomy (TT).

Method: A retrospective review of 1048 patients who underwent thyroidectomy at a single institution from 2010-2017 was performed. An “index” thyroid nodule was defined as either a solitary nodule >1 cm or the largest/most suspicious nodule in a multinodular goiter. An “incidental” thyroid cancer was defined as incidentally discovered outside of the index nodule. CT was performed at least 3 months after initial lobectomy. In patients with staged TT, pathology reports were reviewed for cancer in TL and correlated to reports from subsequent CT. Overall rate of malignancy in index thyroid nodules was determined and rates of incidental carcinoma within the contralateral lobe to the index nodule were established.

Results: Of 1048 patients who underwent thyroidectomy, 567 (54%) had malignant index thyroid nodules. Of patients with malignant index nodules, 35% (196/567) had incidental cancers on the contralateral lobe. In these patients the breakdown of pathology for the index nodule was as follows: 91% papillary thyroid cancer (n=179), 6% follicular thyroid cancer (n=11) 2% medullary thyroid cancer (n=4) 1% microcarcinoma (n=2). Lymphovascular invasion was found in 36% (70/196) of these patients, extrathyroidal extension in 15% (30/196), and multifocality in 58% (114/196). Initial total thyroidectomy was performed in 470 (83%) of patients with thyroid cancer: 60% (283/470) had a malignant index nodule only and 28% (131/470) had incidental carcinoma in the contralateral lobe to the index malignancy. Initial thyroid lobectomy was performed in 97 (17%) of patients with thyroid cancer, of which 66 underwent CT and 98% (65/66) had an incidental cancer in the contralateral lobe on final pathology.

Conclusion: There is a clinically significant rate of malignancy in the contralateral lobes of index malignant thyroid nodules in both patients who undergo initial and staged TT. Although current ATA guidelines recommend no further surgery for patients who undergo TL with thyroid cancer, the long-term significance of these remaining multifocal microcarcinomas in retained contralateral lobes remains unknown, and further active surveillance and evaluation is warranted.

46.06 An Additional 20 Minute ioPTH Measurement Minimizes Bilateral Neck Exploration

Posted on January 18, 2018

Z. F. Khan1, R. Teo1, M. L. Mao1, J. C. Farrá1, J. I. Lew1  1University Of Miami,Division Of Endocrine Surgery, DeWitt Daughtry Family Department Of Surgery, University Of Miami Leonard M. Miller School Of Medicine,Miami, FL, USA

Introduction:
Parathyroidectomy (PTX) guided by intraoperative parathormone (ioPTH) monitoring for primary hyperparathyroidism (pHPT) confirms removal of all hyperfunctioning parathyroid glands. A >50% ioPTH drop criterion at 10 minutes after abnormal parathyroid gland excision predicts operative success in 98% of patients. However, ioPTH levels may be influenced by gland manipulation and PTH half-life variability between patients. This study evaluates the utility of an additional 20 minute ioPTH measurement when a 10 minute value has not dropped by >50% during PTX in patients with pHPT.

Methods:
A retrospective review of prospectively collected data of 739 patients with pHPT confirmed by elevated serum calcium and PTH levels who underwent ioPTH monitoring guided PTX at a single institution was performed. When a >50% ioPTH drop from the highest either pre-incision or pre-excision level was achieved after 10 minutes, PTX was completed. If this >50% ioPTH drop criterion was not met, however, bilateral neck exploration (BNE) was performed, or an additional 20 minute ioPTH measurement was obtained. Operative success was defined as eucalcemia ≥6 months whereas recurrence was defined as calcium and PTH levels above normal range >6 months after successful PTX. Multiglandular disease (MGD) was defined as persistently elevated PTH and calcium levels despite removal of one hypersecreting gland at the initial operation, or when removal of a single gland resulted in operative failure.

Results:
Of 739 patients with a mean follow up of 41 months, overall operative success was 98.5% with a recurrence rate of 1.1%. Within this group, 79 (11%) patients did not meet the >50% ioPTH drop at 10 minutes criterion. Of these patients, 63% (50/79) patients underwent immediate further exploration, while a 20 minute ioPTH measurement was drawn in 37% (29/79). There were no significant differences in preoperative calcium, PTH or creatinine in these two groups. Of patients with a 20 minute ioPTH level with no further exploration, 38% (11/29) had a >50% ioPTH drop at 20 minutes, and 62% (18/29) did not. There were no significant differences between operative success, failure, recurrence or MGD between patients who had a 20 minute ioPTH measurement and those who underwent immediate further exploration. Of the 79 patients that did not meet the >50% ioPTH drop criterion at 10 minutes, there was a statistically significant lower rate of BNE in the group with a 20 minute ioPTH level measured compared to the group that underwent immediate further exploration (38% 11/29 vs. 64% 32/50, p<0.05). By obtaining a 20 minute ioPTH level, BNE was avoided in 38% (11/29) of patients that had a ≤50% ioPTH drop at 10 minutes. 

Conclusion:
A 20 minute ioPTH measurement is useful in preventing unnecessary BNE and its associated risk for complications in patients with a delayed >50% ioPTH drop due to parathyroid gland manipulation and PTH half-life variability during PTX. 
 

46.07 The Posterior Adiposity Index: A Quantitative Selection Tool for Adrenalectomy Approach

Posted on January 18, 2018

B. M. Lindeman1,2, A. A. Gawande2, F. D. Moore2, N. L. Cho2, G. M. Doherty2, M. A. Nehs2  1University Of Alabama At Birmingham,Surgery,Birmingham, AL, USA 2Brigham And Women’s Hospital,Surgery,Boston, MA, USA

Introduction:
No objective criteria exist to guide surgeons about which minimally invasive approach (laparoscopic transabdominal [LA] or retroperitoneoscopic [RP]) to adrenalectomy is optimal.  We aimed to determine whether anthropometric imaging characteristics could predict optimal adrenalectomy approach based on operative time and estimated blood loss (EBL). 

Methods:
A retrospective cohort study was conducted for all adult patients undergoing minimally-invasive adrenalectomy between 2014-2016 (n=113) at one tertiary-care hospital where both LA and RP adrenalectomy are performed.  Anthropometric measurements included distances between the skin and Gerota’s fascia at the 12th rib tip (S-GF), the adrenal and upper border of the kidney (A-K), the adrenal and tip of 12th rib (A-R), the 12th rib and top of the iliac crest (R-IC), and perinephric fat thickness (PNF) on CT or MRI. The effect of these characteristics as well as patient BMI, gender, age, tumor size, and diagnosis on operative time and estimated blood loss (EBL) were analyzed independently with Pearson’s correlation or ANOVA, as appropriate.  A multivariable linear regression model was also constructed to identify independent predictors of operative time after adjustment.  

Results:
Half of patients underwent LA (n=56) while half had an RP approach (n=57).  Median age was 57 years; 60% were female.  Endocrine disorders were the most common adrenalectomy indication (51%) and mean tumor size was 3.2cm. Only 36% of patients had a BMI <25; 39% had a BMI >30. Patients with a higher BMI were significantly more likely to undergo LA (p=0.03).  Increasing lesion size was modestly correlated with longer operative time (r=0.296) independent of operative approach.  Bivariate analysis demonstrated that S-GF distance and PNF were moderately correlated with operative time (r=0.464 and 0.494, respectively) for RP procedures.  The product of the S-GF and PNF variables was used to generate a Posterior Adiposity Index (PAI), and the PAI demonstrated a strong correlation with operative time for RP procedures (r=0.608).  No other demographic or anthropometric variables were associated with increased operative time or EBL on bivariate analyses.  Multivariate analysis revealed that larger lesions (p=0.025) and increasing PAI (p=0.019) were associated with longer operative time, with PAI ≥12 conferring the greatest risk (p=0.004).  

Conclusion:
Patients undergoing RP adrenalectomy for smaller lesions and with body habitus conferring a PAI <12 had significantly shorter operative times.  Surgeons can utilize data from preoperative imaging to calculate the Posterior Adiposity Index to determine whether an RP or LA approach would be optimal.  
 

46.08 Gene Expression Classification has Limited Utility in the Evaluation of AUS/FLUS Thyroid Nodules

Posted on January 18, 2018

K. D. Klingbeil1, R. L. Deitz1, M. L. Mao1, J. C. Farrá1, J. I. Lew1  1University Of Miami Miller School Of Medicine,Division Of Endocrine Surgery, DeWitt Daughtry Family Department Of Surgery,Miami, FL, USA

Introduction: The current management for thyroid nodules remains a challenge for physicians due to the underlying risk of malignancy. With the Bethesda System for Reporting Thyroid Cytopathology (BSRTC), atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS), known as Bethesda III, has an unclear rate of malignancy. Gene expression classification (GEC) testing was developed to further stratify patients with AUS/FLUS nodules. Given its known variability between institutions, this study examines the utility of GEC testing in predicting malignancy in patients with AUS/FLUS thyroid nodules. 

Methods:  A retrospective review of prospectively collected data for patients with index thyroid nodules who underwent FNA and thyroidectomy at a single institution was performed. GEC testing utilized in patients with AUS/FLUS by FNA was reported as benign or suspicious for malignancy. Patients with AUS/FLUS nodules underwent initial thyroid lobectomy for definitive diagnosis unless there was a history of known risk factors and/or patient preference for which total thyroidectomy was performed. AUS/FLUS nodules were subdivided into malignant or benign groups based on final pathology. Among patients who underwent GEC testing, final pathology was compared to initial GEC results.

Results: Of 863 patients who underwent FNA and thyroidectomy, 224 patients (26%) were found to have AUS/FLUS nodules. Following thyroidectomy, 120 patients (54%) were shown to have thyroid cancer (Papillary, n=110; Follicular, n=8; Medullary, n=2) on final pathology. The remaining 104 patients had benign final pathology, most commonly presenting as multinodular hyperplasia, n=31. GEC testing was performed in 102 patients with AUS/FLUS testing, of which 96 had suspicious results. The rate of malignancy for patients with AUS/FLUS nodules and suspicious GEC results was 51% (49/96) whereas the rate of malignancy for AUS/FLUS nodules without GEC testing was 55% (67/122). Of the 6 patients with benign GEC results, 4 were found to be malignant (66%). The positive predictive value (PPV) for GEC testing in AUS/FLUS nodules was 51%.  

Conclusion: Surgical patients with AUS/FLUS nodules had a high malignancy rate compared to the general population. GEC testing demonstrated a high frequency of suspicious results in AUS/FLUS thyroid nodules, yet had limited utility of predicting malignancy. There was no significant difference in malignancy rates when comparing AUS/FLUS nodules without GEC testing to those with suspicious GEC results. In addition, GEC testing failed to rule out malignancy in AUS/FLUS nodules with benign results. Thus, the application of GEC testing has limited utility in surgical decision-making. Surgeons should assess their local institutional experience to determine if there is added utility of GEC testing for AUS/FLUS nodules in their everyday clinical practice. 

46.05 Lowest Intraoperative Parathyroid Hormone Level As a Predictor of Cure Following Parathyroidectomy

Posted on January 18, 2018

J. Claflin1, A. Dhir1, N. M. Espinosa1, A. G. Antunez1, D. T. Hughes1,2  1University Of Michigan,Medical School,Ann Arbor, MI, USA 2University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA

Introduction:

Intraoperative parathyroid hormone (IOPTH) monitoring is used to predict biochemical cure during parathyroidectomy. However, there is variability in the IOPTH criteria used to define biochemical cure during surgery. We hypothesize that using a lowest IOPTH value that is more restrictive than the typical criteria of 50% drop from pre-excision and into the normal range will better predict post-operative normocalcemia.

Methods:

This is a retrospective study of 2,706 patients with primary hyperparathyroidism who underwent parathyroidectomy with IOPTH monitoring at a single-center from 1999 to 2014. We used multivariate logistic regression analysis to measure associations between the lowest IOPTH level and persistence of primary hyperparathyroidism following parathyroidectomy in order to define the optimal IOPTH level to best predict cure after surgery.

Results:

Forty-eight (1.8 %) patients had persistent hyperparathyroidism after parathyroidectomy. After adjusting for patient factors and disease severity the lowest IOPTH was a significant predictor of post-operative normocalcemia  (OR= 1.18 per 10 pg/mL increase, 95% CI = 1.11-1.25, p < 0.01). Patients with a lowest IOPTH above the normal range (>65 pg/mL) had significantly higher persistence rates compared to patients with an IOPTH in or below the normal range (6.3% vs 1.4%, p < 0.01) (Figure 1). Furthermore, patients with a lowest IOPTH from 20-40 pg/mL had reduced incidence of persistence compared to patients with lowest IOPTH 40-65 pg/mL (1.4% vs 3.4%, p <0.01). Patients with lowest IOPTH 0-20 pg/mL did not have significantly reduced incidence of persistence compared to patients with lowest IOPTH 20-40 pg/mL (0.7% vs 1.4%, p = 0.09). 

Conclusion:

During parathyroidectomy for primary hyperparathyroidism, patients with a 50% drop from pre-excision PTH and a lowest IOPTH level below 40 pg/mL had lower rates of persistent primary hyperparathyroidism than patients who met only the traditional criteria of a 50% drop from pre-excision PTH and a final IOPTH level in the normal range (<65 pg/mL). Our analysis shows no additional benefit to achieving an IOPTH level below 20 pg/mL.

46.03 Sub-classification of thyroid nodules with atypia of undetermined significance: Does it matter?

Posted on January 18, 2018

N. Eisa2, A. Khan3, M. Fensterwald3, S. Saleem3, M. A. Akhter3, M. J. Campbell1  1University Of California – Davis,Department Of Surgery,Sacramento, CA, USA 2University Of California – Davis,Department Of Internal Medicine,Sacramento, CA, USA 3University Of California – Davis,School Of Medicine,Sacramento, CA, USA

Introduction:  Ultrasound with fine needle aspiration (FNA) is the most reliable diagnostic procedure for evaluation of thyroid nodules. Most FNA cytology is evaluated according to the Bethesda System for Reporting Thyroid Cytopathology, which uses six diagnostic categories to stratify the risk of malignancy. Bethesda category III, atypia of underdetermined significance (AUS), is a heterogeneous category with an anticipated risk of malignancy between 5 – 15%. It has been suggested AUS should be further sub-classified into categories describing the type of neoplasm of concern to allow for a better assessment of the risk of malignancy. The purpose of this study is to evaluate the association between the sub-classification of AUS thyroid nodules and risk of thyroid cancer.

Methods: We performed a review all patients with a thyroid nodule who underwent a FNA between January 2012 and October 2015 at a tertiary referral center. Patients with a cytologic diagnosis of AUS were sub-classified into the following four categories based on review of the cytology reports: 1) AUS-PTC (atypia with concern for papillary thyroid carcinoma), 2) AUS-FN (atypia with concern for a follicular neoplasm) 3) AUS – HCN (atypia with concern for a Hurthle cell neoplasm) and AUS-NOS where the nodule did not fall into the previous three categories or had mixed features.   Continuous variables were evaluated using the student T-test and categorical variables were analyzed using the Fischer exact test.  A multivariable logistic model was constructed to evaluate for independent associations with malignancy. 

Results:

1,460 patients with 2,155 thyroid nodules underwent a FNA during our study period. 191 (8.8%) nodules had a cytologic diagnosis of AUS.  Of the 163 nodules with AUS on their initial FNA, 27(17%) had AUS-PTC, 62 (38%) had AUS-FN, 57 (35%) had AUS-HCN, and 17 (10%) had AUS-NOS.

62(38%) nodules went on to have a repeat FNA and 24 (39%) came back benign.  The frequency of benign cytology on the second FNA was similar between AUS subgroups [5/10 (50%) for AUS-PTC vs. 12/28 (43%) for AUS-FN vs. 5/19 (26%) for AUS-HCN vs. 2/5 (40%) for AUS-NOS, p= 0.189].

 

73 patients with 78 (48%) nodules went on to have a thyroidectomy. The overall malignancy rate for all nodules with AUS was 36%.  The risk of malignancy differed between AUS sub-types as follows: 10/14(71%) for AUS-PTC vs. 7/25 (28%) for AUS-FN vs. 8/32 (25%) AUS-HCN vs. 3/7 (42%) AUS-NOS (p=0.033).

On univariate analysis AUS-PTC (p=0.004) was associated with a thyroid cancer on surgical pathology; however, on multivariable analysis AUS sub-type was not independently associated with risk of malignancy.

Conclusion:The risk of malignancy in nodules with AUS may be influenced by the type of atypia found by the cytopathologist, but the independent contribution of AUS subtype is unclear.  
 

46.04 Well-Differentiated Thyroid Cancer and Robotic-Assisted Surgery: Experience at a Single Institution

Posted on January 18, 2018

M. E. Garstka1, K. Moshin1, D. Bu Ali1, H. Shalaby1, K. Ibraheem1, M. Abdulgawad Farag1, L. Saparova1, S. Kang1, E. Kandil1  1Tulane University School Of Medicine,Department Of Surgery,New Orleans, LA, USA

Introduction:
Many recent studies report the safety and feasibility of robotic-assisted thyroid surgery, but most of these studies were performed in Asia.  In the United States, several small series and case reports have been published regarding treatment of benign disease. The aim of our study is to report the safety and feasibility of robot-assisted thyroid surgery for well-differentiated thyroid cancer patients at a Western institution.

Methods:

We performed a retrospective cohort study using a prospectively collected single-center clinical database at an academic medical center. We included all well-differentiated thyroid cancer patients who underwent robotic–assisted or conventional cervical approach thyroid surgery at our institution from January 2015 to June 2017. Patient demographics and perioperative data were collected and analyzed. The primary outcomes evaluated in this initial analysis included operating times, estimated blood loss, hospital length of stay, and complications.  Patient demographics included sex, race, and BMI.  Pathology characteristics including specimen size, microscopic margin status, and number of lymph nodes removed were also analyzed, as was duration of patient follow-up and episodes of clinical recurrence of disease. 

Results:

A total of 144 surgeries for thyroid cancer were performed; 35 (24.3%) were performed with robotic-assisted technique.  The majority of patients in the sample were female (113 patients, 78.5%) and Caucasian (81, 59.1%).  Mean age of the patients undergoing robotic-assisted surgery was 42.1±12.5 years, which was significantly less than those undergoing the conventional cervical approach at 52.7±15.6 years (p = 0.003), and mean BMI of 25.0±4.3 kg/m2 for robotic-assisted patients was significantly less than that for cervical approach, at 32.5±8.1kg/m2 (p = <0.0001).  There were no significant differences in estimated blood loss, operative times, complication rates, specimen sizes, positive microscopic margins, number of lymph nodes removed with associated lymph node dissections, patient follow-up duration, or clinical recurrence rates between the two groups.  However, overall length of stay was shorter for robotic-assisted surgical patients, at 0.6±0.9 days, versus 1.1±1.2 days for conventional cervical approach surgical patients (p=0.0087).  Of note, for robotic-assisted surgical patients, 54.3% were discharged on the day of surgery (19 patients), and only one patient was admitted as inpatient to the hospital for greater than 23 hours (2.9%). 

Conclusion:

Robot-assisted thyroid surgery is a safe and feasible approach for a select group of well-differentiated thyroid cancer patients with regards to the short-term outcomes analyzed in this study.  Future multi-institutional studies and long-term oncologic follow-up studies are needed to further evaluate the outcomes of this technique. 

 

46.02 Indocyanine Green Lymphangiography For Thoracic Duct Identification During Neck Dissection

Posted on January 18, 2018

J. M. Chakedis1, L. A. Shirley1, A. M. Terando1, R. Skoracki2, J. Phay1  1The Ohio State University Wexner Medical Center And James Cancer Hospital And Solove Research Institute,Division Of Surgical Oncology, Department Of Surgery,Columbus, OH, USA 2The Ohio State University Wexner Medical Center And James Cancer Hospital And Solove Research Institute,Division Of Oncologic Plastic Surgery, Department Of Plastic Surgery,Columbus, OH, USA

Introduction:
Injury to the thoracic duct causing a chyle leak is a common complication following a left modified radical neck dissection, and carries a high degree of morbidity when it occurs.  There are no interventions or diagnostics which are routinely used to assist with thoracic duct identification intra-operatively. Lymphangiography using Indocyanine Green (ICG) has previously been described for sentinel lymph node biopsy and for the evaluation and management of lymphedema.  To our knowledge, there have been no reports of the use of ICG lymphangiography for mapping the thoracic duct during neck dissection.  Here we present the first clinical experience with this technique.

Methods:
In 5 patients undergoing left modified radical neck dissection for either thyroid cancer or melanoma, Indocyanine Green (2.5 mg/mL) 1mL was injected subcutaneously on the dorsum of the left foot 15-50 minutes before imaging.  The neck dissection was performed until either the thoracic duct was identified or the suspected area was dissected clean.  At this point, intraoperative imaging of the neck was performed with a hand-held Near InfraRed (NIR) camera (Hamamatsu PDE-Neo).

Results:
In 4 out of 5 patients the thoracic duct was visualized using the NIR camera. The thoracic duct was identified with dissection alone in 1 out of 4 patients, and the area around the normal anatomical location was cleared in the other 3. Time from injection to identification of the thoracic duct was variable at 15 to 90 minutes. Imaging was optimized by positioning the camera at the angle of the mandible and pointing down the neck into the space below the clavicle in a caudal direction (Figure 1).  There were no adverse reactions from ICG injection; and the total time required to perform imaging was 5-15 minutes. No leakage from the thoracic duct was identified in any patient, and all patients’ postoperative courses were uncomplicated.  In the 1 patient in whom the duct was not identified, it is unclear if non-visualization was related to the timing of the injection, duct obliteration due to a prior dissection in this area, or another factor.

Conclusion:
This is the first description of using ICG lymphangiography for identification of the thoracic duct during left modified radical neck dissection.  Identification with ICG is technically feasible, simple to perform with NIR imaging, and safe.  This technique can be a helpful adjunct to the surgeon to facilitate identification of the thoracic duct and thereby reduce post-operative complications.
 

46.01 Quality of Life in Patients with MEN-2 Compared to US Normative and Chronic Disease Populations

Posted on January 18, 2018

M. N. Mongelli1, I. Helenowski1, S. Yount1, C. Sturgeon1  1Feinberg School Of Medicine – Northwestern University,Chicago, IL, USA

Introduction:  Patient-Reported Outcomes (PROs) are being measured in many chronic disease states to inform decisions about intervention and management of disease while minimizing patient suffering and side effects. There is a paucity of data on health-related quality of life (HRQOL) and PROs in patients with Multiple Endocrine Neoplasia Type-2 (MEN-2). We hypothesized that HRQOL in MEN-2 patients would be lower than that of the general United States (US) population, but similar to that of patients suffering from other chronic diseases.

Methods:  Adults ≥ 18 years were recruited from an online MEN support group and completed the PROMIS-29 questionnaire (n=46). Responses were converted into t-scores for each of the seven health domains. T-scores of PROMIS domains were compared to US normative data using a one-sample t-test. PROMIS scores for other conditions, including low back pain, cancer, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), major depressive disorder, rheumatoid arthritis (RA), neuroendocrine tumors (NET), primary hyperparathyroidism (PHPT), and MEN-1 were obtained through literature review. T-scores for health domains were compared to other conditions using a Wilcoxon signed-rank test.

Results: The mean age was 46.1 years and the average time since diagnosis was 14.1 years. Compared to the US normative population, MEN-2 patients reported statistically significantly more anxiety (56.1±11.2, p=.001), depression (54.6±11.2, p=.008), fatigue (61.0±10.4, p<.001), pain interference (55.2±11.1, p =.003), and sleep disturbance (57.0±3.7, p<.001), as well as significantly decreased physical functioning (44.6±9.5, p<.001) and ability to participate in social roles (45.8±9.7, p=.005). MEN-2 patients reported statistically significantly greater fatigue than patients with cancer (p<.0001), COPD (p=.01), RA (p=.0001), NET (p=.0007), and PHPT (p<.0001), greater pain interference than patients with PHPT (p<.0001), and improved physical functioning compared to patients with low back pain (p<.0001), CHF (p<.0001), and COPD (p=.0002).

Conclusion: PROs may be a valuable tool to inform the management of patients with MEN-2. Our study is the first to use the PROMIS-29 metric to directly compare PROs between MEN-2 and other chronic conditions. Individuals with MEN-2 reported worse HRQOL in all 7 domains compared to normative data. There is a pattern of increased fatigue among MEN-2 patients compared to many other chronic conditions, even though MEN-2 patients report greater physical functioning than other chronic diseases.  Prospective longitudinal evaluation of PROs in MEN-2 should be conducted in order to identify treatments associated with the highest HRQOL.

 

45.18 Strategies to Maximize the Detection and Treatment of Perioperative Hyperglycemia

Posted on January 18, 2018

V. N. O’Reilly-Shah1,2, E. W. Duggan1, G. C. Lynde1  1Emory University School Of Medicine,Anesthesiology,Atlanta, GA, USA 2Children’s Healthcare Of Atlanta,Pediatric Anesthesiology,Atlanta, GA, USA

Introduction: The association between perioperative hyperglycemia and adverse clinical outcomes is well established [1-3]. Evidence indicates that improved glycemic control reduces hospital complications and decreases mortality in general surgery patients [4,5]. To promote inpatient glycemic control in non-cardiac surgical patients, a screening/treatment algorithm was developed at a tertiary-care academic hospital.

Methods: Several tools were advanced to increase clinician adherence to the algorithm including screening order sets and an mHealth clinical decision tool for Android and iOS (Figure 1). Preoperative screening began in May 2016. After beta testing and review, the mHealth tool was launched November 2016. The cloud-integrated Survalytics platform was integrated into the app, collecting in-app analytics and user demographics. Statistical analysis was performed in R [6].

 

Results: Screening was completed for 2858 patients; 691 with diagnosed diabetes. Of those considered at-risk, 32.8% were identified with undiagnosed diabetes or prediabetes. Prevalence of BG > 180mg/dL increased with higher HgbA1C. Adherence to insulin treatment for BG > 180mg/dL was 81% for diagnosed diabetics and 48% in undiagnosed disease. Growing use of the app provides more facile access to treatment recommendations based on patient diagnosis and risk. Further exploration between app use, inpatient glycemic control and provider behaviors will be followed.

 

Conclusion: This work demonstrates an evidence-based algorithm to identify surgical patients at risk for perioperative hyperglycemia .The mHealth tool provides up-to-date screening and treatment recommendations, and provides rapid feedback to improve inpatient glycemic control and positively impact clinician decision-making.

45.19 Opioid Prescribing for Acute Pain: Surgeons vs. Emergency Medicine Physicians

Posted on January 18, 2018

J. S. Lee1, C. M. Brummett2, J. F. Waljee1, M. J. Englesbe1  1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA 2University Of Michigan,Department Of Anesthesiology,Ann Arbor, MI, USA

Introduction:
Although recent studies have suggested opioid prescribing is declining, opioid-related mortality continues to rise. Opioid prescriptions for acute pain play a crucial role, serving as a gateway to chronic use and a source of unused opioids for diversion. To identify potential opportunities to reduce excess opioid prescriptions for acute pain, we evaluated trends in opioid prescribing over time between surgeons and Emergency Medicine physicians. We hypothesized that opioid prescribing would increase in surgical specialties due to a lack of effective strategies for changing practice.

Methods:
Using the Medicare Part D Prescriber Public Use File, we identified surgeons and Emergency Medicine physicians with claims for opioid prescriptions from 2013 – 2015. Prescriber specialty was identified by National Provider Identifier codes. Our primary outcome measure was the number of days supplied for an individual opioid prescription, a parameter frequently restricted by legislation targeting opioid prescriptions for acute pain. We then calculated the average days supplied each year for surgeons and Emergency Medicine physicians. Differences in mean days supplied were evaluated using t-tests. We also calculated the percent change in mean days supplied compared to 2013 levels.

Results:
Between 2013 and 2015, 20.7 million opioid prescriptions were provided by surgeons, while 7.5 million opioid prescriptions were provided by Emergency Medicine physicians. For opioid prescriptions provided by surgeons, the number of days supplied per prescription rose by 3% (Figure 1) from 2013 to 2015 (7.7 vs. 7.9 days, p < 0.001). In contrast, for prescriptions provided by Emergency Medicine physicians, days supplied decreased by 5% (5.0 vs 4.7 days, p <0.001).

Conclusion:
In recent years, the average days supplied for opioid prescriptions provided by surgeons has increased by 3%, but has declined by 5% for Emergency Medicine physicians. This may be due to earlier implementation of strategies in Emergency Medicine, such as the American College of Emergency Physicians Clinical Policy on Opioid Prescribing in 2012. With recent studies showing surgical opioid prescriptions far exceed patient needs, surgeons must develop more effective strategies to change practice for opioid prescribing.

 

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