Abstract The future of surgical progress depends on surgeons finding innovative solutions to their patients' problems. Surgical innovation is critical to advances in surgery. However, surgical ...innovation also raises a series of ethical issues that challenge the professionalism of surgeons. The very criteria for defining surgical progress have changed as patients may value more than simply reductions in morbidity and mortality. The requirement for informed consent prior to surgery is difficult when an innovative surgical procedure is planned since the risks of the novel operation may not be known. In addition, even if the risks are known in the hands of the innovator, the actual risks to patients when surgeons are learning the new technique are unknown. New techniques often depend on new technology which may be significantly more expensive than traditional techniques. There are no clear criteria to decide which new innovative techniques are going to turn out to be truly beneficial to patients. Many surgical innovations depend on new products which may have been developed as collaborative efforts between surgical device companies and surgeons. Although many currently accepted therapies were developed in this fashion, the collaboration of surgeons and device companies raises the potential for significant harmful conflicts of interest. In the decades to come, careful attention to these and other ethical issues will help to define the future professional standing of surgeons.
Abstract Surgical ethics as a specific discipline is relatively new to many. Surgical ethics focuses on the ethical issues that are particularly important to the care of surgical patients. Informed ...consent for surgical procedures, the level of responsibility that surgeons feel for their patients' outcomes, and the management of surgical innovation are specific issues that are important in surgical ethics and are different from other areas of medicine. The future of surgical progress is dependent on surgical innovation, yet the nature of surgical innovation raises specific concerns that challenge the professionalism of surgeons. These concerns will be considered in the following pages.
Background
The use of neuromonitoring in thyroid surgery is controversial. Attitudes about neuromonitoring, usage patterns, and predictors of use have not been formally studied. We hypothesized that ...attitudes would predict usage patterns and that the predominant strategy among endocrine surgeons would be no neuromonitoring during thyroid surgery.
Methods
Members of the American Association of Endocrine Surgeons and registrants of the 2006 annual meeting were surveyed by e-mail. An Internet-based survey composed of simple answer and Likert questions was used. Central tendency was evaluated by modal response. Significance was analyzed by the chi-squared test, and strength of association was calculated by Cramér’s V.
Results
A total of 117 surveys were completed (41%). Respondents were placed into two groups based on use (37.1%), or nonuse (62.9%) of neuromonitoring. The use category was composed of routine (13.8%) and selective (23.3%) users. The nonuse category was composed of those who have never used neuromonitoring (49.1%) and those who have abandoned its use (13.8%). Nonusers were older (
p
= 0.023) and reported a lower case volume (
p
= 0.003), less familiarity with the technology (
p
< 0.001), and less access to the equipment (
p
< 0.001). Nonusers reported a lower frequency of patient-initiated discussions about neuromonitoring (
p
< 0.001) and were less likely to initiate a discussion with patients (
p
< 0.001). In total, 56% of users and 90% of nonusers believed neuromonitoring does not improve the safety of thyroidectomy (
p
< 0.01). There was no difference in perceived nerve injury rate between users and nonusers. Users agreed that benefits include facilitating identification of the recurrent laryngeal nerve, facilitating resident education, improving patient outcomes, and decreasing liability risk, whereas nonusers disagreed with these statements. Nonusers believed that neuromonitoring can lead to reliance on technology and loss of surgical technique or judgment, but users disagreed. There was consensus of opinion that neuromonitoring allows identification of an intact nerve, can lead to a false sense of security, drives up costs, is beneficial in <10% of cases, does not shorten the length of the procedure, and does not prevent nerve injury.
Conclusions
Usage is associated with surgeon age, case volume, equipment availability and familiarity, beliefs about the degree of benefit, and frequency of patient or doctor initiated discussions.
Thyroidectomy may be performed for clinical indications that include malignancy, benign nodules or cysts, suspicious findings on fine needle aspiration biopsy, dysphagia from cervical esophageal ...compression, or dyspnea from airway compression. About 1 in 10 patients experience temporary laryngeal nerve injury after surgery, with longer lasting voice problems in up to 1 in 25. Reduced quality of life after thyroid surgery is multifactorial and may include the need for lifelong medication, thyroid suppression, radioactive scanning/treatment, temporary and permanent hypoparathyroidism, temporary or permanent dysphonia postoperatively, and dysphagia. This clinical practice guideline provides evidence-based recommendations for management of the patient's voice when undergoing thyroid surgery during the preoperative, intraoperative, and postoperative period.
The purpose of this guideline is to optimize voice outcomes for adult patients aged 18 years or older after thyroid surgery. The target audience is any clinician involved in managing such patients, which includes but may not be limited to otolaryngologists, general surgeons, endocrinologists, internists, speech-language pathologists, family physicians and other primary care providers, anesthesiologists, nurses, and others who manage patients with thyroid/voice issues. The guideline applies to any setting in which clinicians may interact with patients before, during, or after thyroid surgery. Children under age 18 years are specifically excluded from the target population; however, the panel understands that many of the findings may be applicable to this population. Also excluded are patients undergoing concurrent laryngectomy. Although this guideline is limited to thyroidectomy, some of the recommendations may extrapolate to parathyroidectomy as well.
The guideline development group made a strong recommendation that the surgeon should identify the recurrent laryngeal nerve(s) during thyroid surgery. The group made recommendations that the clinician or surgeon should (1) document assessment of the patient's voice once a decision has been made to proceed with thyroid surgery; (2) examine vocal fold mobility, or refer the patient to a clinician who can examine vocal fold mobility, if the patient's voice is impaired and a decision has been made to proceed with thyroid surgery; (3) examine vocal fold mobility, or refer the patient to a clinician who can examine vocal fold mobility, once a decision has been made to proceed with thyroid surgery if the patient's voice is normal and the patient has (a) thyroid cancer with suspected extrathyroidal extension, or (b) prior neck surgery that increases the risk of laryngeal nerve injury (carotid endarterectomy, anterior approach to the cervical spine, cervical esophagectomy, and prior thyroid or parathyroid surgery), or (c) both; (4) educate the patient about the potential impact of thyroid surgery on voice once a decision has been made to proceed with thyroid surgery; (5) inform the anesthesiologist of the results of abnormal preoperative laryngeal assessment in patients who have had laryngoscopy prior to thyroid surgery; (6) take steps to preserve the external branch of the surperior laryngeal nerve(s) when performing thyroid surgery; (7) document whether there has been a change in voice between 2 weeks and 2 months following thyroid surgery; (8) examine vocal fold mobility or refer the patient for examination of vocal fold mobility in patients with a change in voice following thyroid surgery; (9) refer a patient to an otolaryngologist when abnormal vocal fold mobility is identified after thyroid surgery; (10) counsel patients with voice change or abnormal vocal fold mobility after thyroid surgery on options for voice rehabilitation. The group made an option that the surgeon or his or her designee may monitor laryngeal electromyography during thyroid surgery. The group made no recommendation regarding the impact of a single intraoperative dose of intravenous corticosteroid on voice outcomes in patients undergoing thyroid surgery.
Background Although recurrence and death can occur in patients with papillary thyroid cancer (PTC) several years after being diagnosed, the necessary duration of follow-up for these patients remains ...unclear. Methods This was a single-institution, retrospective review of 269 patients with PTC. Cox proportional hazards model and Kaplan-Meier curves were used to identify risk factors for recurrence and death. Risk predictors included age, sex, radiation exposure history, extent of operation, radioactive iodine treatment, follicular variant of PTC (FVPTC), extrathyroidal invasion, multifocality, TNM status, and stage. Results Median follow-up was 27 years. Of 269 patients, 180 (66%) were female, and 196 (73%) were ≤45 years of age. Recurrence and cancer-specific death rates were 28% and 9%, respectively. Time to recurrence (±SD) was 8.1 (± 8.3) years and to cancer-specific death was 9.0 (± 11.0) years; however, 11% of recurrences and 17% of deaths occurred after 20 years. Risk factors for recurrence were older age, FVPTC, T4 tumors, cervical lymph node involvement, metastases, and stage ≥ 4a. Predictors of death from PTC were older age, metastases, and stage ≥ 3. Conclusion Both recurrences and death from PTC can occur more than 30 years after being treated, thus lifelong follow-up of patients with PTC is necessary.
Although ethics is not a new concept in the surgical care of patients, the focused attention to ethics education in surgical education is a recent phenomenon. As more options have become available in ...the treatment armamentarium of surgery, the central question of surgical care has changed from "What can be done for this patient?" to the more modern question, "What should be done for this patient?" To answer this question, surgeons must attend to patients' values and preferences. Surgical residents also spend much less time in the hospital today than they did several decades ago, increasing the necessity of focused attention to ethics education. Finally, with the shift to more outpatient care, surgical residents have fewer opportunities to engage in many of the important discussions about diagnosis and prognosis with patients. These factors have made ethics education in surgical training programs more important today than in previous decades.
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