American Association of Endocrine Surgeons (AAES): Annual Meeting

BOSTON – A proposed system for staging adrenocortical carcinomas appears to more accurately predict prognoses across all age and stage groups, but the system is not quite ready for prime time, investigators say.

The system combines information on patient age, tumor stage, and nodal and metastatic (TNM) status. In a retrospective study, the TNM-age system was better at predicting 5-year overall survival than was the European Network for the Study of Adrenal Tumors (ENSAT) staging system, which was in turn a modification of another system, said Dr. Elliot Asare, a research resident in the department of surgical education at the Medical College of Wisconsin in Milwaukee.

The improved predictive power of the TNM-age system may be due to differences in tumor biology between older and younger patients, Dr. Asare noted.

"Improved staging allows for a more accurate assessment of the natural history of the disease," he said at the annual meeting of the American Association of Endocrine Surgeons.

The two main staging systems currently used for adrenocortical carcinoma (ACC) are the American Joint Committee on Cancer/International Union Against Cancer (AJCC/UICC) system, and ENSAT, which was proposed in 2009 as a modified version of the AJCC/UICC staging system. Under the ENSAT modification, stage IV disease would be limited to patients with distant metastases.

However, the ENSAT criteria were not good at discriminating between stage I and stage II disease, and failed to show a significant survival difference, Dr. Asare noted.

The investigators undertook to see whether the ENSAT’s prognostic accuracy might improve with a larger data set, and to determine whether adding age as a variable to staging ACC could improve the accuracy of survival predictions.

They drew data on patients with a histologic diagnosis of ACC from 1985 through 2006 in the National Cancer Database, and used Surveillance, Epidemiology and End Results (SEER) summary stage information to establish TNM stage according to ENSAT criteria.

They considered tumor size, resection margin status, histologic grade, lymph node status, SEER summary stage, vital status, and age of diagnosis.

Out of a total of 3,263 patients with ACC, sufficient data were available on 1,597.

When they applied the staging criteria, they were able to validate the ENSAT system for stage III vs. stage IV (P less than .0001), and for stage II vs. state III (P less than .0001), but no significant differences between I and II (P =.04). The 5-year overall survival rates under ENSAT were 68% for stage I and 61% for stage II.

They then developed their alternative staging system by adding age to the mix, as follows:

• Stage 1: T1-T2, N0, M0, age 55 or younger.

• Stage II: T1-T2, N0, M0, age over 55.

• Stage III: T1-T2, N1, M0, any age, or T3-T4, any N, M0, any age.

• Stage IV: any T, any N, M1.

By using this system applied to the same cohort, they found that the respective 5-year overall survival rates (stage I-IV) were 70%, 53%, 37%, and 9.7%, respectively. In addition, the survival rates were significantly different between stages I and II (P less than .0001), stages II and III (P = .0004), and stages III and IV (P less than .0001).

Significant predictors of death under the TNM-age staging were stage II and above, positive tumor resection margins, and grade.

Dr. Asare noted that the study was limited by the lack of some variables in the database and an absence of information on cause-specific mortality, and by the fact that age cannot be used as a continuous variable in a classification system.

The staging system needs to be tested in a validation study with information from an independent database, he added.

Dr. Asare disclosed receiving support from the American College of Surgeons Clinical Scholars in Residence fellowship, partially supported by an unrestricted education grant from Genentech.

BOSTON – A proposed system for staging adrenocortical carcinomas appears to more accurately predict prognoses across all age and stage groups, but the system is not quite ready for prime time, investigators say.

The system combines information on patient age, tumor stage, and nodal and metastatic (TNM) status. In a retrospective study, the TNM-age system was better at predicting 5-year overall survival than was the European Network for the Study of Adrenal Tumors (ENSAT) staging system, which was in turn a modification of another system, said Dr. Elliot Asare, a research resident in the department of surgical education at the Medical College of Wisconsin in Milwaukee.

The improved predictive power of the TNM-age system may be due to differences in tumor biology between older and younger patients, Dr. Asare noted.

"Improved staging allows for a more accurate assessment of the natural history of the disease," he said at the annual meeting of the American Association of Endocrine Surgeons.

The two main staging systems currently used for adrenocortical carcinoma (ACC) are the American Joint Committee on Cancer/International Union Against Cancer (AJCC/UICC) system, and ENSAT, which was proposed in 2009 as a modified version of the AJCC/UICC staging system. Under the ENSAT modification, stage IV disease would be limited to patients with distant metastases.

However, the ENSAT criteria were not good at discriminating between stage I and stage II disease, and failed to show a significant survival difference, Dr. Asare noted.

The investigators undertook to see whether the ENSAT’s prognostic accuracy might improve with a larger data set, and to determine whether adding age as a variable to staging ACC could improve the accuracy of survival predictions.

They drew data on patients with a histologic diagnosis of ACC from 1985 through 2006 in the National Cancer Database, and used Surveillance, Epidemiology and End Results (SEER) summary stage information to establish TNM stage according to ENSAT criteria.

They considered tumor size, resection margin status, histologic grade, lymph node status, SEER summary stage, vital status, and age of diagnosis.

Out of a total of 3,263 patients with ACC, sufficient data were available on 1,597.

When they applied the staging criteria, they were able to validate the ENSAT system for stage III vs. stage IV (P less than .0001), and for stage II vs. state III (P less than .0001), but no significant differences between I and II (P =.04). The 5-year overall survival rates under ENSAT were 68% for stage I and 61% for stage II.

They then developed their alternative staging system by adding age to the mix, as follows:

• Stage 1: T1-T2, N0, M0, age 55 or younger.

• Stage II: T1-T2, N0, M0, age over 55.

• Stage III: T1-T2, N1, M0, any age, or T3-T4, any N, M0, any age.

• Stage IV: any T, any N, M1.

By using this system applied to the same cohort, they found that the respective 5-year overall survival rates (stage I-IV) were 70%, 53%, 37%, and 9.7%, respectively. In addition, the survival rates were significantly different between stages I and II (P less than .0001), stages II and III (P = .0004), and stages III and IV (P less than .0001).

Significant predictors of death under the TNM-age staging were stage II and above, positive tumor resection margins, and grade.

Dr. Asare noted that the study was limited by the lack of some variables in the database and an absence of information on cause-specific mortality, and by the fact that age cannot be used as a continuous variable in a classification system.

The staging system needs to be tested in a validation study with information from an independent database, he added.

Dr. Asare disclosed receiving support from the American College of Surgeons Clinical Scholars in Residence fellowship, partially supported by an unrestricted education grant from Genentech.

BOSTON – A proposed system for staging adrenocortical carcinomas appears to more accurately predict prognoses across all age and stage groups, but the system is not quite ready for prime time, investigators say.

The system combines information on patient age, tumor stage, and nodal and metastatic (TNM) status. In a retrospective study, the TNM-age system was better at predicting 5-year overall survival than was the European Network for the Study of Adrenal Tumors (ENSAT) staging system, which was in turn a modification of another system, said Dr. Elliot Asare, a research resident in the department of surgical education at the Medical College of Wisconsin in Milwaukee.

The improved predictive power of the TNM-age system may be due to differences in tumor biology between older and younger patients, Dr. Asare noted.

"Improved staging allows for a more accurate assessment of the natural history of the disease," he said at the annual meeting of the American Association of Endocrine Surgeons.

The two main staging systems currently used for adrenocortical carcinoma (ACC) are the American Joint Committee on Cancer/International Union Against Cancer (AJCC/UICC) system, and ENSAT, which was proposed in 2009 as a modified version of the AJCC/UICC staging system. Under the ENSAT modification, stage IV disease would be limited to patients with distant metastases.

However, the ENSAT criteria were not good at discriminating between stage I and stage II disease, and failed to show a significant survival difference, Dr. Asare noted.

The investigators undertook to see whether the ENSAT’s prognostic accuracy might improve with a larger data set, and to determine whether adding age as a variable to staging ACC could improve the accuracy of survival predictions.

They drew data on patients with a histologic diagnosis of ACC from 1985 through 2006 in the National Cancer Database, and used Surveillance, Epidemiology and End Results (SEER) summary stage information to establish TNM stage according to ENSAT criteria.

They considered tumor size, resection margin status, histologic grade, lymph node status, SEER summary stage, vital status, and age of diagnosis.

Out of a total of 3,263 patients with ACC, sufficient data were available on 1,597.

When they applied the staging criteria, they were able to validate the ENSAT system for stage III vs. stage IV (P less than .0001), and for stage II vs. state III (P less than .0001), but no significant differences between I and II (P =.04). The 5-year overall survival rates under ENSAT were 68% for stage I and 61% for stage II.

They then developed their alternative staging system by adding age to the mix, as follows:

• Stage 1: T1-T2, N0, M0, age 55 or younger.

• Stage II: T1-T2, N0, M0, age over 55.

• Stage III: T1-T2, N1, M0, any age, or T3-T4, any N, M0, any age.

• Stage IV: any T, any N, M1.

By using this system applied to the same cohort, they found that the respective 5-year overall survival rates (stage I-IV) were 70%, 53%, 37%, and 9.7%, respectively. In addition, the survival rates were significantly different between stages I and II (P less than .0001), stages II and III (P = .0004), and stages III and IV (P less than .0001).

Significant predictors of death under the TNM-age staging were stage II and above, positive tumor resection margins, and grade.

Dr. Asare noted that the study was limited by the lack of some variables in the database and an absence of information on cause-specific mortality, and by the fact that age cannot be used as a continuous variable in a classification system.

The staging system needs to be tested in a validation study with information from an independent database, he added.

Dr. Asare disclosed receiving support from the American College of Surgeons Clinical Scholars in Residence fellowship, partially supported by an unrestricted education grant from Genentech.

BOSTON – Preoperative comorbidities and postoperative complications are the most common reasons that patients are readmitted to a hospital within 30 days of thyroid or parathyroid surgery, but outpatient surgery was associated with a lower likelihood of readmission, investigators have found.

A review of data on more than 7,000 patients who underwent cervical endocrine resections showed that 4% were readmitted within a month of surgery, reported Dr. Matthew G. Mullen, a surgery resident at the University of Virginia Health System in Charlottesville.

"Identifying best practice patterns to avoid major postoperative complications will help reduce hospital readmission rates and improve the quality of patient care," Dr. Mullen said at the annual meeting of the American Association of Endocrine Surgeons.

Previous single-institution studies have shown readmission rates for patients undergoing thyroidectomy of 0.3%-3.9%. A 2010 study of readmission rates among elderly patients undergoing thyroidectomy for thyroid cancer found that 8% required readmission within a month of surgery, Dr. Mullen noted.

To see whether, as they suspected, patients with more medical comorbidities and postoperative complications are more likely to be back in the hospital within 30 days of surgery, the investigators reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) participant use data file, which includes records on 442,149 elective surgery cases from 315 U.S. hospitals. Data on a total of 7,069 total elective cases, including 3,711 thyroidectomies and 3,358 parathyroidectomies were reviewed.

They found an overall readmission rate of 4.0%, with a rate of 4.1% for patients undergoing thyroidectomy, and 3.8% for those undergoing parathyroidectomy.

Demographic factors significantly associated with a greater likelihood of readmission included diabetes (present in 18.6% of readmitted patients, vs. 12.5% of not readmitted patients; P = .003), severe chronic obstructive pulmonary disease (4.6% vs. 2.0%; P = .002), hemodialysis (11.8% vs. 2.2%; P = .001), and weight loss of more than 10% (1.8% vs. 0.5%; P = .005). Younger and heavier patients were more likely to be readmitted within 30 days than were slightly older and lighter-weight patients.

Complications predict readmission

Postoperative complications associated with readmission included wound complications (5% vs. 0.3%; P less than .001 for all following comparisons, unless noted), respiratory complications 5.4 vs. 0.2%), renal complications (2.1% vs. 0.3%), neurologic complications (0.7% vs. 0.1%; P = .008), and cardiovascular complications (4.6% vs. 0.2%).

In multivariate analysis, factors that were significantly associated with readmission were reoperation within 30 days (P less than .001), American Society of Anesthesiologists physical status class (P = .024), patient functional status (independent vs. partially or fully dependent, P = .007), renal insufficiency (P = .004), and hemodialysis (P = .005).

In contrast, patients who were discharged within 24 hours of surgery were significantly less likely to be readmitted (odds ratio, 0.63; P = .006).

The researchers also found that 63% of patients had a longer than 24-hour stay after surgery – a finding that Dr. Mullen said was surprising – and that patients undergoing surgery for malignant disease were significantly more likely to be readmitted than were patients with benign disease (11% vs. 2.6%, P less than .001). There was no difference in readmission rates of patients treated by general surgeons, compared with those treated by surgeons trained in otolaryngologic procedures.

Dr. Mullen noted that the study was limited by the lack of data on the reasons for each readmission and by a lack of information on many complications that are specific to endocrine surgery.

In the discussion, Dr. Samuel K. Snyder of Texas A & M University in Temple, commented on the lack of study specifics about the reasons for readmission making it hard to draw conclusions about how best to prevent readmissions.

Dr. Mullen responded that because some of the patients had treatable comorbidities such as renal insufficiency, medical augmentation could be a reasonable approach to reducing postoperative complications and risk of readmission.

The authors did not disclose the study funding source. Dr. Mullen and Dr. Snyder reported having no financial disclosures.

BOSTON – Preoperative comorbidities and postoperative complications are the most common reasons that patients are readmitted to a hospital within 30 days of thyroid or parathyroid surgery, but outpatient surgery was associated with a lower likelihood of readmission, investigators have found.

A review of data on more than 7,000 patients who underwent cervical endocrine resections showed that 4% were readmitted within a month of surgery, reported Dr. Matthew G. Mullen, a surgery resident at the University of Virginia Health System in Charlottesville.

"Identifying best practice patterns to avoid major postoperative complications will help reduce hospital readmission rates and improve the quality of patient care," Dr. Mullen said at the annual meeting of the American Association of Endocrine Surgeons.

Previous single-institution studies have shown readmission rates for patients undergoing thyroidectomy of 0.3%-3.9%. A 2010 study of readmission rates among elderly patients undergoing thyroidectomy for thyroid cancer found that 8% required readmission within a month of surgery, Dr. Mullen noted.

To see whether, as they suspected, patients with more medical comorbidities and postoperative complications are more likely to be back in the hospital within 30 days of surgery, the investigators reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) participant use data file, which includes records on 442,149 elective surgery cases from 315 U.S. hospitals. Data on a total of 7,069 total elective cases, including 3,711 thyroidectomies and 3,358 parathyroidectomies were reviewed.

They found an overall readmission rate of 4.0%, with a rate of 4.1% for patients undergoing thyroidectomy, and 3.8% for those undergoing parathyroidectomy.

Demographic factors significantly associated with a greater likelihood of readmission included diabetes (present in 18.6% of readmitted patients, vs. 12.5% of not readmitted patients; P = .003), severe chronic obstructive pulmonary disease (4.6% vs. 2.0%; P = .002), hemodialysis (11.8% vs. 2.2%; P = .001), and weight loss of more than 10% (1.8% vs. 0.5%; P = .005). Younger and heavier patients were more likely to be readmitted within 30 days than were slightly older and lighter-weight patients.

Complications predict readmission

Postoperative complications associated with readmission included wound complications (5% vs. 0.3%; P less than .001 for all following comparisons, unless noted), respiratory complications 5.4 vs. 0.2%), renal complications (2.1% vs. 0.3%), neurologic complications (0.7% vs. 0.1%; P = .008), and cardiovascular complications (4.6% vs. 0.2%).

In multivariate analysis, factors that were significantly associated with readmission were reoperation within 30 days (P less than .001), American Society of Anesthesiologists physical status class (P = .024), patient functional status (independent vs. partially or fully dependent, P = .007), renal insufficiency (P = .004), and hemodialysis (P = .005).

In contrast, patients who were discharged within 24 hours of surgery were significantly less likely to be readmitted (odds ratio, 0.63; P = .006).

The researchers also found that 63% of patients had a longer than 24-hour stay after surgery – a finding that Dr. Mullen said was surprising – and that patients undergoing surgery for malignant disease were significantly more likely to be readmitted than were patients with benign disease (11% vs. 2.6%, P less than .001). There was no difference in readmission rates of patients treated by general surgeons, compared with those treated by surgeons trained in otolaryngologic procedures.

Dr. Mullen noted that the study was limited by the lack of data on the reasons for each readmission and by a lack of information on many complications that are specific to endocrine surgery.

In the discussion, Dr. Samuel K. Snyder of Texas A & M University in Temple, commented on the lack of study specifics about the reasons for readmission making it hard to draw conclusions about how best to prevent readmissions.

Dr. Mullen responded that because some of the patients had treatable comorbidities such as renal insufficiency, medical augmentation could be a reasonable approach to reducing postoperative complications and risk of readmission.

The authors did not disclose the study funding source. Dr. Mullen and Dr. Snyder reported having no financial disclosures.

BOSTON – Preoperative comorbidities and postoperative complications are the most common reasons that patients are readmitted to a hospital within 30 days of thyroid or parathyroid surgery, but outpatient surgery was associated with a lower likelihood of readmission, investigators have found.

A review of data on more than 7,000 patients who underwent cervical endocrine resections showed that 4% were readmitted within a month of surgery, reported Dr. Matthew G. Mullen, a surgery resident at the University of Virginia Health System in Charlottesville.

"Identifying best practice patterns to avoid major postoperative complications will help reduce hospital readmission rates and improve the quality of patient care," Dr. Mullen said at the annual meeting of the American Association of Endocrine Surgeons.

Previous single-institution studies have shown readmission rates for patients undergoing thyroidectomy of 0.3%-3.9%. A 2010 study of readmission rates among elderly patients undergoing thyroidectomy for thyroid cancer found that 8% required readmission within a month of surgery, Dr. Mullen noted.

To see whether, as they suspected, patients with more medical comorbidities and postoperative complications are more likely to be back in the hospital within 30 days of surgery, the investigators reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) participant use data file, which includes records on 442,149 elective surgery cases from 315 U.S. hospitals. Data on a total of 7,069 total elective cases, including 3,711 thyroidectomies and 3,358 parathyroidectomies were reviewed.

They found an overall readmission rate of 4.0%, with a rate of 4.1% for patients undergoing thyroidectomy, and 3.8% for those undergoing parathyroidectomy.

Demographic factors significantly associated with a greater likelihood of readmission included diabetes (present in 18.6% of readmitted patients, vs. 12.5% of not readmitted patients; P = .003), severe chronic obstructive pulmonary disease (4.6% vs. 2.0%; P = .002), hemodialysis (11.8% vs. 2.2%; P = .001), and weight loss of more than 10% (1.8% vs. 0.5%; P = .005). Younger and heavier patients were more likely to be readmitted within 30 days than were slightly older and lighter-weight patients.

Complications predict readmission

Postoperative complications associated with readmission included wound complications (5% vs. 0.3%; P less than .001 for all following comparisons, unless noted), respiratory complications 5.4 vs. 0.2%), renal complications (2.1% vs. 0.3%), neurologic complications (0.7% vs. 0.1%; P = .008), and cardiovascular complications (4.6% vs. 0.2%).

In multivariate analysis, factors that were significantly associated with readmission were reoperation within 30 days (P less than .001), American Society of Anesthesiologists physical status class (P = .024), patient functional status (independent vs. partially or fully dependent, P = .007), renal insufficiency (P = .004), and hemodialysis (P = .005).

In contrast, patients who were discharged within 24 hours of surgery were significantly less likely to be readmitted (odds ratio, 0.63; P = .006).

The researchers also found that 63% of patients had a longer than 24-hour stay after surgery – a finding that Dr. Mullen said was surprising – and that patients undergoing surgery for malignant disease were significantly more likely to be readmitted than were patients with benign disease (11% vs. 2.6%, P less than .001). There was no difference in readmission rates of patients treated by general surgeons, compared with those treated by surgeons trained in otolaryngologic procedures.

Dr. Mullen noted that the study was limited by the lack of data on the reasons for each readmission and by a lack of information on many complications that are specific to endocrine surgery.

In the discussion, Dr. Samuel K. Snyder of Texas A & M University in Temple, commented on the lack of study specifics about the reasons for readmission making it hard to draw conclusions about how best to prevent readmissions.

Dr. Mullen responded that because some of the patients had treatable comorbidities such as renal insufficiency, medical augmentation could be a reasonable approach to reducing postoperative complications and risk of readmission.

The authors did not disclose the study funding source. Dr. Mullen and Dr. Snyder reported having no financial disclosures.

BOSTON – Preoperative comorbidities and postoperative complications are the most common reasons that patients are readmitted to a hospital within 30 days of thyroid or parathyroid surgery, but outpatient surgery was associated with a lower likelihood of readmission, investigators have found.

A review of data on more than 7,000 patients who underwent cervical endocrine resections showed that 4% were readmitted within a month of surgery, reported Dr. Matthew G. Mullen, a surgery resident at the University of Virginia Health System in Charlottesville.

"Identifying best practice patterns to avoid major postoperative complications will help reduce hospital readmission rates and improve the quality of patient care," Dr. Mullen said at the annual meeting of the American Association of Endocrine Surgeons.

Previous single-institution studies have shown readmission rates for patients undergoing thyroidectomy of 0.3%-3.9%. A 2010 study of readmission rates among elderly patients undergoing thyroidectomy for thyroid cancer found that 8% required readmission within a month of surgery, Dr. Mullen noted.

To see whether, as they suspected, patients with more medical comorbidities and postoperative complications are more likely to be back in the hospital within 30 days of surgery, the investigators reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) participant use data file, which includes records on 442,149 elective surgery cases from 315 U.S. hospitals. Data on a total of 7,069 total elective cases, including 3,711 thyroidectomies and 3,358 parathyroidectomies were reviewed.

They found an overall readmission rate of 4.0%, with a rate of 4.1% for patients undergoing thyroidectomy, and 3.8% for those undergoing parathyroidectomy.

Demographic factors significantly associated with a greater likelihood of readmission included diabetes (present in 18.6% of readmitted patients, vs. 12.5% of not readmitted patients; P = .003), severe chronic obstructive pulmonary disease (4.6% vs. 2.0%; P = .002), hemodialysis (11.8% vs. 2.2%; P = .001), and weight loss of more than 10% (1.8% vs. 0.5%; P = .005). Younger and heavier patients were more likely to be readmitted within 30 days than were slightly older and lighter-weight patients.

Complications predict readmission

Postoperative complications associated with readmission included wound complications (5% vs. 0.3%; P less than .001 for all following comparisons, unless noted), respiratory complications 5.4 vs. 0.2%), renal complications (2.1% vs. 0.3%), neurologic complications (0.7% vs. 0.1%; P = .008), and cardiovascular complications (4.6% vs. 0.2%).

In multivariate analysis, factors that were significantly associated with readmission were reoperation within 30 days (P less than .001), American Society of Anesthesiologists physical status class (P = .024), patient functional status (independent vs. partially or fully dependent, P = .007), renal insufficiency (P = .004), and hemodialysis (P = .005).

In contrast, patients who were discharged within 24 hours of surgery were significantly less likely to be readmitted (odds ratio, 0.63; P = .006).

The researchers also found that 63% of patients had a longer than 24-hour stay after surgery – a finding that Dr. Mullen said was surprising – and that patients undergoing surgery for malignant disease were significantly more likely to be readmitted than were patients with benign disease (11% vs. 2.6%, P less than .001). There was no difference in readmission rates of patients treated by general surgeons, compared with those treated by surgeons trained in otolaryngologic procedures.

Dr. Mullen noted that the study was limited by the lack of data on the reasons for each readmission and by a lack of information on many complications that are specific to endocrine surgery.

In the discussion, Dr. Samuel K. Snyder of Texas A & M University in Temple, commented on the lack of study specifics about the reasons for readmission making it hard to draw conclusions about how best to prevent readmissions.

Dr. Mullen responded that because some of the patients had treatable comorbidities such as renal insufficiency, medical augmentation could be a reasonable approach to reducing postoperative complications and risk of readmission.

The authors did not disclose the study funding source. Dr. Mullen and Dr. Snyder reported having no financial disclosures.

BOSTON – Preoperative comorbidities and postoperative complications are the most common reasons that patients are readmitted to a hospital within 30 days of thyroid or parathyroid surgery, but outpatient surgery was associated with a lower likelihood of readmission, investigators have found.

A review of data on more than 7,000 patients who underwent cervical endocrine resections showed that 4% were readmitted within a month of surgery, reported Dr. Matthew G. Mullen, a surgery resident at the University of Virginia Health System in Charlottesville.

"Identifying best practice patterns to avoid major postoperative complications will help reduce hospital readmission rates and improve the quality of patient care," Dr. Mullen said at the annual meeting of the American Association of Endocrine Surgeons.

Previous single-institution studies have shown readmission rates for patients undergoing thyroidectomy of 0.3%-3.9%. A 2010 study of readmission rates among elderly patients undergoing thyroidectomy for thyroid cancer found that 8% required readmission within a month of surgery, Dr. Mullen noted.

To see whether, as they suspected, patients with more medical comorbidities and postoperative complications are more likely to be back in the hospital within 30 days of surgery, the investigators reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) participant use data file, which includes records on 442,149 elective surgery cases from 315 U.S. hospitals. Data on a total of 7,069 total elective cases, including 3,711 thyroidectomies and 3,358 parathyroidectomies were reviewed.

They found an overall readmission rate of 4.0%, with a rate of 4.1% for patients undergoing thyroidectomy, and 3.8% for those undergoing parathyroidectomy.

Demographic factors significantly associated with a greater likelihood of readmission included diabetes (present in 18.6% of readmitted patients, vs. 12.5% of not readmitted patients; P = .003), severe chronic obstructive pulmonary disease (4.6% vs. 2.0%; P = .002), hemodialysis (11.8% vs. 2.2%; P = .001), and weight loss of more than 10% (1.8% vs. 0.5%; P = .005). Younger and heavier patients were more likely to be readmitted within 30 days than were slightly older and lighter-weight patients.

Complications predict readmission

Postoperative complications associated with readmission included wound complications (5% vs. 0.3%; P less than .001 for all following comparisons, unless noted), respiratory complications 5.4 vs. 0.2%), renal complications (2.1% vs. 0.3%), neurologic complications (0.7% vs. 0.1%; P = .008), and cardiovascular complications (4.6% vs. 0.2%).

In multivariate analysis, factors that were significantly associated with readmission were reoperation within 30 days (P less than .001), American Society of Anesthesiologists physical status class (P = .024), patient functional status (independent vs. partially or fully dependent, P = .007), renal insufficiency (P = .004), and hemodialysis (P = .005).

In contrast, patients who were discharged within 24 hours of surgery were significantly less likely to be readmitted (odds ratio, 0.63; P = .006).

The researchers also found that 63% of patients had a longer than 24-hour stay after surgery – a finding that Dr. Mullen said was surprising – and that patients undergoing surgery for malignant disease were significantly more likely to be readmitted than were patients with benign disease (11% vs. 2.6%, P less than .001). There was no difference in readmission rates of patients treated by general surgeons, compared with those treated by surgeons trained in otolaryngologic procedures.

Dr. Mullen noted that the study was limited by the lack of data on the reasons for each readmission and by a lack of information on many complications that are specific to endocrine surgery.

In the discussion, Dr. Samuel K. Snyder of Texas A & M University in Temple, commented on the lack of study specifics about the reasons for readmission making it hard to draw conclusions about how best to prevent readmissions.

Dr. Mullen responded that because some of the patients had treatable comorbidities such as renal insufficiency, medical augmentation could be a reasonable approach to reducing postoperative complications and risk of readmission.

The authors did not disclose the study funding source. Dr. Mullen and Dr. Snyder reported having no financial disclosures.

BOSTON – Preoperative comorbidities and postoperative complications are the most common reasons that patients are readmitted to a hospital within 30 days of thyroid or parathyroid surgery, but outpatient surgery was associated with a lower likelihood of readmission, investigators have found.

A review of data on more than 7,000 patients who underwent cervical endocrine resections showed that 4% were readmitted within a month of surgery, reported Dr. Matthew G. Mullen, a surgery resident at the University of Virginia Health System in Charlottesville.

"Identifying best practice patterns to avoid major postoperative complications will help reduce hospital readmission rates and improve the quality of patient care," Dr. Mullen said at the annual meeting of the American Association of Endocrine Surgeons.

Previous single-institution studies have shown readmission rates for patients undergoing thyroidectomy of 0.3%-3.9%. A 2010 study of readmission rates among elderly patients undergoing thyroidectomy for thyroid cancer found that 8% required readmission within a month of surgery, Dr. Mullen noted.

To see whether, as they suspected, patients with more medical comorbidities and postoperative complications are more likely to be back in the hospital within 30 days of surgery, the investigators reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) participant use data file, which includes records on 442,149 elective surgery cases from 315 U.S. hospitals. Data on a total of 7,069 total elective cases, including 3,711 thyroidectomies and 3,358 parathyroidectomies were reviewed.

They found an overall readmission rate of 4.0%, with a rate of 4.1% for patients undergoing thyroidectomy, and 3.8% for those undergoing parathyroidectomy.

Demographic factors significantly associated with a greater likelihood of readmission included diabetes (present in 18.6% of readmitted patients, vs. 12.5% of not readmitted patients; P = .003), severe chronic obstructive pulmonary disease (4.6% vs. 2.0%; P = .002), hemodialysis (11.8% vs. 2.2%; P = .001), and weight loss of more than 10% (1.8% vs. 0.5%; P = .005). Younger and heavier patients were more likely to be readmitted within 30 days than were slightly older and lighter-weight patients.

Complications predict readmission

Postoperative complications associated with readmission included wound complications (5% vs. 0.3%; P less than .001 for all following comparisons, unless noted), respiratory complications 5.4 vs. 0.2%), renal complications (2.1% vs. 0.3%), neurologic complications (0.7% vs. 0.1%; P = .008), and cardiovascular complications (4.6% vs. 0.2%).

In multivariate analysis, factors that were significantly associated with readmission were reoperation within 30 days (P less than .001), American Society of Anesthesiologists physical status class (P = .024), patient functional status (independent vs. partially or fully dependent, P = .007), renal insufficiency (P = .004), and hemodialysis (P = .005).

In contrast, patients who were discharged within 24 hours of surgery were significantly less likely to be readmitted (odds ratio, 0.63; P = .006).

The researchers also found that 63% of patients had a longer than 24-hour stay after surgery – a finding that Dr. Mullen said was surprising – and that patients undergoing surgery for malignant disease were significantly more likely to be readmitted than were patients with benign disease (11% vs. 2.6%, P less than .001). There was no difference in readmission rates of patients treated by general surgeons, compared with those treated by surgeons trained in otolaryngologic procedures.

Dr. Mullen noted that the study was limited by the lack of data on the reasons for each readmission and by a lack of information on many complications that are specific to endocrine surgery.

In the discussion, Dr. Samuel K. Snyder of Texas A & M University in Temple, commented on the lack of study specifics about the reasons for readmission making it hard to draw conclusions about how best to prevent readmissions.

Dr. Mullen responded that because some of the patients had treatable comorbidities such as renal insufficiency, medical augmentation could be a reasonable approach to reducing postoperative complications and risk of readmission.

The authors did not disclose the study funding source. Dr. Mullen and Dr. Snyder reported having no financial disclosures.

BOSTON – Relaxing eligibility criteria for cytoreductive surgery may improve overall survival among patients with carcinoid metastases to the liver, investigators report.

Lowering the debulking threshold from 90% to 70% and including patients with intermediate-grade disease and/or extrahepatic disease resulted in 5-year overall survival rates of 90%, compared with 61%-74% rates reported by other treatment centers, said Dr. Amanda N. Graff-Baker, a surgical oncology resident at the Oregon Health and Science University (OHSU), Portland.

Neil Osterweil/Frontline Medical News

"The use of expanded criteria would substantially increase the number of patients eligible for debulking without compromising survival," she reported at the annual meeting of the American Association of Endocrine Surgeons.

Carcinoid tumors, a subset of neuroendocrine tumors, originate in the enterochromaffin cells of the aerodigestive tract. Approximately 60% of these tumors occur in the gastrointestinal tract, most commonly in the small intestine.

Approximately 60%-80% of patients with small bowel carcinoid tumors will have metastases to the liver, with liver failure from hepatic replacement by tumor being the most common cause of death, she explained.

Although there are no standardized patient selection criteria for liver debulking surgery in these patients, many U.S. centers follow NANETS (North American Neuroendocrine Tumor Society) treatment guidelines, which recommend surgical excision of at least 90% of all visible tumor. In addition, many centers choose not to offer cytoreductive surgery to patients with extrahepatic disease, Dr. Graff-Baker said.

Using these criteria, centers have reported 5-year survival rates ranging from 61% to 74%, but only about 20% of patients with carcinoid metastases to the liver are eligible for resection.

The investigators hypothesized that expanded eligibility criteria used at OHSU for several years could improve both liver progression-free and disease-specific survival rates. The criteria include a lower liver debulking threshold (70% or greater) and allow inclusion of patients with extrahepatic disease and/or intermediate-grade tumors.

They tested this idea by reviewing records of patients with metastatic carcinoid tumors who underwent liver debulking procedures at their center from 2007 to 2011. A single pathologist rated the grade of primary and metastatic tumors, and investigators correlated clinical factors with outcomes.

They identified a total of 52 patients, ranging in age from 29 to 77 years. Of this group, 32 (62%) had carcinoid syndrome, and 34 (65%) had extrahepatic disease.

The patients underwent a total of 51 wedge resections and 16 anatomic resections.

The mean number of metastases resected was 22 (range, 1-131). The mean size of metastases was 3 cm (range, 0.3-16 cm).

On pathologic review, all primary tumors were found to be low grade, but one-third of patients had one or more intermediate-grade metastases, suggesting a significant degree of tumor heterogeneity, Dr. Graff-Baker said.

The median liver progression-free survival was 72 months. A comparison between patients with liver progression and those with stable liver disease showed that there were no significant differences between the groups in either the percentage of tumor resected, number of resections, tumor size, presence of one or more intermediate-grade metastases, or extrahepatic disease. The only factor associated with a significant difference between groups was age. The mean age of patients with stable disease was 60.1 years, compared with 52 years for patients with liver progression (P = .016).

A separate analysis by age confirmed the last finding, with patients 50 years and older having significantly better liver progression-free survival than patients under age 50 (P = .001).

The 5-year disease-specific survival rate among all patients was 90%. All deaths were due to liver failure caused by tumor progression.

An analysis of factors predicting disease-specific survival showed once again that older patients for a change fared better than their more youthful counterparts (P = .03).

"The number, size, grade, extent of resection, and presence of extrahepatic disease did not have an adverse impact on outcomes," Dr. Graff-Baker said.

The study was internally funded. Dr. Graff-Baker reported having no financial disclosures.

BOSTON – Relaxing eligibility criteria for cytoreductive surgery may improve overall survival among patients with carcinoid metastases to the liver, investigators report.

Lowering the debulking threshold from 90% to 70% and including patients with intermediate-grade disease and/or extrahepatic disease resulted in 5-year overall survival rates of 90%, compared with 61%-74% rates reported by other treatment centers, said Dr. Amanda N. Graff-Baker, a surgical oncology resident at the Oregon Health and Science University (OHSU), Portland.

Neil Osterweil/Frontline Medical News

"The use of expanded criteria would substantially increase the number of patients eligible for debulking without compromising survival," she reported at the annual meeting of the American Association of Endocrine Surgeons.

Carcinoid tumors, a subset of neuroendocrine tumors, originate in the enterochromaffin cells of the aerodigestive tract. Approximately 60% of these tumors occur in the gastrointestinal tract, most commonly in the small intestine.

Approximately 60%-80% of patients with small bowel carcinoid tumors will have metastases to the liver, with liver failure from hepatic replacement by tumor being the most common cause of death, she explained.

Although there are no standardized patient selection criteria for liver debulking surgery in these patients, many U.S. centers follow NANETS (North American Neuroendocrine Tumor Society) treatment guidelines, which recommend surgical excision of at least 90% of all visible tumor. In addition, many centers choose not to offer cytoreductive surgery to patients with extrahepatic disease, Dr. Graff-Baker said.

Using these criteria, centers have reported 5-year survival rates ranging from 61% to 74%, but only about 20% of patients with carcinoid metastases to the liver are eligible for resection.

The investigators hypothesized that expanded eligibility criteria used at OHSU for several years could improve both liver progression-free and disease-specific survival rates. The criteria include a lower liver debulking threshold (70% or greater) and allow inclusion of patients with extrahepatic disease and/or intermediate-grade tumors.

They tested this idea by reviewing records of patients with metastatic carcinoid tumors who underwent liver debulking procedures at their center from 2007 to 2011. A single pathologist rated the grade of primary and metastatic tumors, and investigators correlated clinical factors with outcomes.

They identified a total of 52 patients, ranging in age from 29 to 77 years. Of this group, 32 (62%) had carcinoid syndrome, and 34 (65%) had extrahepatic disease.

The patients underwent a total of 51 wedge resections and 16 anatomic resections.

The mean number of metastases resected was 22 (range, 1-131). The mean size of metastases was 3 cm (range, 0.3-16 cm).

On pathologic review, all primary tumors were found to be low grade, but one-third of patients had one or more intermediate-grade metastases, suggesting a significant degree of tumor heterogeneity, Dr. Graff-Baker said.

The median liver progression-free survival was 72 months. A comparison between patients with liver progression and those with stable liver disease showed that there were no significant differences between the groups in either the percentage of tumor resected, number of resections, tumor size, presence of one or more intermediate-grade metastases, or extrahepatic disease. The only factor associated with a significant difference between groups was age. The mean age of patients with stable disease was 60.1 years, compared with 52 years for patients with liver progression (P = .016).

A separate analysis by age confirmed the last finding, with patients 50 years and older having significantly better liver progression-free survival than patients under age 50 (P = .001).

The 5-year disease-specific survival rate among all patients was 90%. All deaths were due to liver failure caused by tumor progression.

An analysis of factors predicting disease-specific survival showed once again that older patients for a change fared better than their more youthful counterparts (P = .03).

"The number, size, grade, extent of resection, and presence of extrahepatic disease did not have an adverse impact on outcomes," Dr. Graff-Baker said.

The study was internally funded. Dr. Graff-Baker reported having no financial disclosures.

BOSTON – Relaxing eligibility criteria for cytoreductive surgery may improve overall survival among patients with carcinoid metastases to the liver, investigators report.

Lowering the debulking threshold from 90% to 70% and including patients with intermediate-grade disease and/or extrahepatic disease resulted in 5-year overall survival rates of 90%, compared with 61%-74% rates reported by other treatment centers, said Dr. Amanda N. Graff-Baker, a surgical oncology resident at the Oregon Health and Science University (OHSU), Portland.

Neil Osterweil/Frontline Medical News

"The use of expanded criteria would substantially increase the number of patients eligible for debulking without compromising survival," she reported at the annual meeting of the American Association of Endocrine Surgeons.

Carcinoid tumors, a subset of neuroendocrine tumors, originate in the enterochromaffin cells of the aerodigestive tract. Approximately 60% of these tumors occur in the gastrointestinal tract, most commonly in the small intestine.

Approximately 60%-80% of patients with small bowel carcinoid tumors will have metastases to the liver, with liver failure from hepatic replacement by tumor being the most common cause of death, she explained.

Although there are no standardized patient selection criteria for liver debulking surgery in these patients, many U.S. centers follow NANETS (North American Neuroendocrine Tumor Society) treatment guidelines, which recommend surgical excision of at least 90% of all visible tumor. In addition, many centers choose not to offer cytoreductive surgery to patients with extrahepatic disease, Dr. Graff-Baker said.

Using these criteria, centers have reported 5-year survival rates ranging from 61% to 74%, but only about 20% of patients with carcinoid metastases to the liver are eligible for resection.

The investigators hypothesized that expanded eligibility criteria used at OHSU for several years could improve both liver progression-free and disease-specific survival rates. The criteria include a lower liver debulking threshold (70% or greater) and allow inclusion of patients with extrahepatic disease and/or intermediate-grade tumors.

They tested this idea by reviewing records of patients with metastatic carcinoid tumors who underwent liver debulking procedures at their center from 2007 to 2011. A single pathologist rated the grade of primary and metastatic tumors, and investigators correlated clinical factors with outcomes.

They identified a total of 52 patients, ranging in age from 29 to 77 years. Of this group, 32 (62%) had carcinoid syndrome, and 34 (65%) had extrahepatic disease.

The patients underwent a total of 51 wedge resections and 16 anatomic resections.

The mean number of metastases resected was 22 (range, 1-131). The mean size of metastases was 3 cm (range, 0.3-16 cm).

On pathologic review, all primary tumors were found to be low grade, but one-third of patients had one or more intermediate-grade metastases, suggesting a significant degree of tumor heterogeneity, Dr. Graff-Baker said.

The median liver progression-free survival was 72 months. A comparison between patients with liver progression and those with stable liver disease showed that there were no significant differences between the groups in either the percentage of tumor resected, number of resections, tumor size, presence of one or more intermediate-grade metastases, or extrahepatic disease. The only factor associated with a significant difference between groups was age. The mean age of patients with stable disease was 60.1 years, compared with 52 years for patients with liver progression (P = .016).

A separate analysis by age confirmed the last finding, with patients 50 years and older having significantly better liver progression-free survival than patients under age 50 (P = .001).

The 5-year disease-specific survival rate among all patients was 90%. All deaths were due to liver failure caused by tumor progression.

An analysis of factors predicting disease-specific survival showed once again that older patients for a change fared better than their more youthful counterparts (P = .03).

"The number, size, grade, extent of resection, and presence of extrahepatic disease did not have an adverse impact on outcomes," Dr. Graff-Baker said.

The study was internally funded. Dr. Graff-Baker reported having no financial disclosures.