Influence of fellowship educational experience on practice patterns for adrenalectomy: A survey of recent AAES fellowship graduates

A natural language processing-informed adrenal gland incidentaloma clinic improves guideline-based care

INTRODUCTION

Adrenal gland incidentalomas (AGIs) are found in up to 5% of cross-sectional images. However, rates of guideline-based workup for AGIs are notoriously low. We sought to determine if a natural language processing (NLP)-informed AGI clinic could improve the rates of indicated biochemical evaluation and adrenal-specific imaging.

METHODS

An NLP algorithm was created to detect clinically significant adrenal nodules from radiology reports of cross-sectional images at an academic institution. The NLP algorithm was applied to scans occurring between June 2020 and July 2021 to form a baseline cohort. The NLP algorithm was re-applied to scans from August 2021 to February 2023 and identified patients were invited to join an outpatient clinic dedicated to AGIs. Patients evaluated in the clinic from March 2022 to February 2023 were included in the intervention cohort. Statistical analysis utilized chi-square, t-test, and a multivariable logistic regression.

RESULTS

The baseline and intervention cohorts included 1784 and 322 unique patients, respectively. Patients in the intervention cohort were more likely to be female (59% vs. 51%, p = 0.01), be younger (60 ± 13.1 vs. 64 ± 13.2 years, p < 0.001), have smaller nodules (1.7 cm, IQR 1.4-2.1 vs. 1.8 cm, IQR 1.4-2.5 cm, p = 0.017), have had biochemical workup (99% vs. 13%, p < 0.001), and have had adrenal-specific imaging (40% vs. 11%, p < 0.001). In a multivariable analysis, intervention cohort patients were significantly more likely to have had biochemical workup (odds ratio ,OR 1209, confidence interval ,CI 434-5117, p < 0.001) and adrenal-specific imaging (OR 8.89, CI 6.42-12.4, p < 0.001).

CONCLUSION

The implementation of an NLP-informed AGI clinic was associated with a seven-fold increase in biochemical workup and a three-fold increase in adrenal-specific imaging in participating patients.

Which factors influence the approach to shared decision-making among surgeons performing complex operations?

BACKGROUND

Shared decision-making (SDM) aims to create a context in which patients and surgeons work together to explore treatment options and goals of care. The objective of the current study was to characterize demographic factors, behaviors, and perceptions of patient involvement among surgeons relative to SDM.

METHODS

Using a cross-sectional survey methodology, surgeon demographics, behaviors, and perceptions of patient involvement were assessed. Surgeon approaches to SDM were measured using a 100-point scale ranging from 'patient-led' (0) to 'surgeon-led' (100).

RESULTS

Among 241 respondents, most were male (n = 123, 67.2%) and White (n = 124, 69.3%); roughly one-half of surgeons had been in practice ≥10 years (n = 120, 52.4%). Surgeon approaches to SDM ranged from 0 to 81.0, with a median rating of 50.0 (IQR: 35.5, 62.0). Reported approaches to SDM were associated with years in practice, sharing information, and perceptions of patient involvement. Surgeons in practice 10 + years most frequently utilized a 'Shared, Patient-led' approach to SDM (27.5%), while individuals with less experience more often employed a 'Shared, Surgeon-led' approach (33.3%, p = 0.031). Surgeons with a 'Patient-led' approach perceived patient involvement as most important (M = 3.82, SD = 0.16), while respondents who had a 'Surgeon-led' approach considered this less important (M = 3.57, SD = 0.38; p < 0.001).

CONCLUSION

Surgeon factors including demographics, behaviors, and perceptions of patient involvement influenced SDM approaches. SDM between patients and surgeons should strive to be more dynamic and tailored to each specific patient's needs to promote optimal patient-centered care.

Open Versus Laparoscopic Surgery in the Management of Adrenocortical Carcinoma: A Systematic Review and Meta-analysis

BACKGROUND

Laparoscopic surgery is considered a standard treatment for benign adrenal tumors; however, no consensus has been reached on the optimal resection technique for adrenocortical carcinomas. This study aims to evaluate the safety and efficacy of laparoscopic surgery and open surgery in the management of adrenocortical carcinoma.

METHODS

The Cochrane, Embase, PubMed, Scopus, and Web of Science databases were searched for articles from inception to May 2022, by two independent reviewers using the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines. The review was registered prospectively on the PROSPERO database (CRD42022316050).

RESULTS

From 183 studies screened, 11 studies met the eligibility criteria, with a total of 1617 patients with adrenocortical carcinoma undergoing either laparoscopic surgery (n = 472) or open surgery (n = 1145). Open surgery demonstrated a lower rate of positive resection margin compared with laparoscopic surgery (odds ratio [OR] 1.52, 95% confidence interval [CI] 1.10-2.10; I² = 0%). Additionally, open surgery had more favorable overall survival (OR 0.56, 95% CI 0.44-0.72; I² = 0%) and recurrence-free rates (OR 0.60, 95% CI 0.42-0.85; I² = 38%) than laparoscopic surgery at 3 years. Hospital stay was shorter for laparoscopic surgery than open surgery (mean difference - 2.49 days, 95% CI - 2.95 to - 2.04; I² = 45%).

CONCLUSIONS

Open surgery should still be considered the standard operative approach; however, laparoscopic surgery could be regarded as an effective and safe operation for selected adrenocortical carcinoma cases with appropriate laparoscopic expertise. Further randomized controlled studies with tumor stage- and resection margin-dependent survival analysis are necessary to ascertain the safety and efficacy of the treatment.

A comparison of robotic and laparoscopic minimally invasive adrenalectomy for adrenal malignancies

BACKGROUND

Although guidelines recommend open adrenalectomy for most resectable adrenal malignancies, minimally invasive adrenalectomies are performed. Robotic adrenalectomies have become more popular recently, but there is a paucity of literature comparing laparoscopic and robotic resections.

METHODS

Patients who underwent a planned minimally invasive adrenalectomy for adrenal malignancies (adrenocortical carcinoma, malignant pheochromocytoma, other carcinoma) were identified in the National Cancer Database. The primary outcome was the conversion rate from minimally invasive to open. Other post-operative outcomes and survival were compared.

RESULTS

416 patients (76.5%) underwent a laparoscopic adrenalectomy and 128 (23.5%) underwent a robotic operation. Demographics and clinical characteristics were similar. Approximately 19% of tumors resected by a minimally invasive approach were > 10 cm. The intra-operative conversion rate was decreased among robotic adrenalectomies relative to laparoscopic on univariate (7.8% vs. 18.3%, p = 0.005) and multivariable (odds ratio 0.39, p = 0.01) analyses. Using marginal standardization, there was a stepwise increase in the conversion rate as tumor size increased (< 5, 5-10, > 10 cm) for laparoscopic (7.5%, 18.0%, 33.2%) and robotic (3.1%, 8.3%, 17.3%) adrenalectomies. Operations which required conversion had a greater margin positivity rate, greater length of stay, and an association with poor overall survival.

CONCLUSION

In contrast to most clinical guidelines, minimally invasive adrenalectomies are being performed on large malignant tumors. A laparoscopic approach was associated with a greater conversion rate and subsequent poor outcomes. If a surgeon is not planning an open adrenalectomy, but adrenal malignancy is a possibility, robotic adrenalectomy may be the preferred approach for resectable adrenal tumors.

Resident self-assessment of common endocrine procedures

BACKGROUND

General surgery residency graduates are expected to be proficient in straightforward endocrine operations. This study aimed to elucidate residents' self-assessment of their ability to perform common endocrine procedures.

METHODS

A fourteen-question survey was emailed to general surgery residents from seven U.S. residency programs regarding their self-assessed ability to perform each step of a straightforward thyroidectomy and parathyroidectomy. Demographics and perceived ability to perform the various procedures were collected.

RESULTS

A minority of respondents (17, 27.9%) agreed they could complete a straightforward thyroidectomy for benign disease, with only 11.7% (n = 7) agreeing they could complete a straightforward thyroidectomy for malignant disease. 26.2% (n = 16) of respondents agreed they could complete a straightforward parathyroidectomy. Completed number of cases was significantly associated with greater self-assessed ability to perform the endocrine operations (p = 0.02).

CONCLUSIONS

Most general surgery residents surveyed did not feel capable of performing common, straightforward endocrine procedures. Although confidence in operative ability increased with PGY-level and number of cases completed, the majority of PGY-5 residents still did not feel able to perform a thyroidectomy for malignant disease unassisted.