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Lang BHH, Wong CKH. Validation and Comparison of Nomograms in Predicting Disease-Specific Survival for Papillary Thyroid Carcinoma. World J Surg 2015; 39:1951-8. [DOI: 10.1007/s00268-015-3044-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Brauner E, Lang BHH, Wong KP, Burns JA, Phitayakorn R, Parangi S. Learning Laryngeal Ultrasound. VideoEndocrinology 2015. [DOI: 10.1089/ve.2014.0032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Wong KP, Woo JW, Youn YK, Chow FCL, Lee KE, Lang BHH. The importance of sonographic landmarks by transcutaneous laryngeal ultrasonography in post-thyroidectomy vocal cord assessment. Surgery 2014; 156:1590-6; discussion 1596. [DOI: 10.1016/j.surg.2014.08.061] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 08/20/2014] [Indexed: 10/24/2022]
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Tsang YP, Lang BHH, Shek TWH. Assessing the short- and long-term outcomes after resection of benign insulinoma. ANZ J Surg 2014; 86:706-10. [PMID: 25345822 DOI: 10.1111/ans.12891] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2014] [Indexed: 12/14/2022]
Abstract
BACKGROUND Insulinoma is a rare functional pancreatic neuroendocrine tumour (NET) believed to have an excellent long-term outcome, but few studies have solely focused on this issue after apparently curative resection. This study aimed to assess post-operative and long-term outcomes after resection of benign insulinomas. METHODS From 1998 to 2013, 36 consecutive patients with insulinomas underwent surgery. Three patients had multiple endocrine neoplasia type-1 (MEN-1). Demographics, operative findings, tumour grade (2010 World Health Organization (WHO) NET classification), post-operative pancreatic fistula (POPF) grade (International Study Group of Pancreatic Fistula (ISGPF)), complications and recurrence were analysed. RESULTS Eighteen (50%) had enucleation while the rest underwent pancreatic resection. The majority (86.1%) of insulinomas belonged to WHO NET grade G1. POPF occurred in 58.3% of patients while clinical fistula (ISGPF grades B and C) occurred in 19.4%. One (2.8%) patient required reoperation. The occurrence of POPF was not related to type of resection or surgical approach. There was no perioperative mortality. After a mean follow-up of 83.6 months, two patients (5.7%) developed disease recurrence at 34.4 and 131.9 months after initial surgery. No patients developed distant metastasis. The 10- and 15-year disease-free rates were 95.6 and 85.4%, respectively. CONCLUSION POPF occurred frequently and posed a significant morbidity after resection of insulinoma. However, it occurred independently of type of resection or surgical approach. Although the immediate cure rate after resection was high (100%), long-term disease recurrence in sporadic (non-MEN-1) cases was not insignificant. Regular long-term follow-up is recommended.
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Wong KP, Lang BHH, Chang YK, Wong KC, Chow FCL. Assessing the Validity of Transcutaneous Laryngeal Ultrasonography (TLUSG) After Thyroidectomy: What Factors Matter? Ann Surg Oncol 2014; 22:1774-80. [DOI: 10.1245/s10434-014-4162-z] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2014] [Indexed: 11/18/2022]
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Lang BHH, Wong CKH, Tsang JS, Wong KP, Wan KY. A systematic review and meta-analysis evaluating completeness and outcomes of robotic thyroidectomy. Laryngoscope 2014; 125:509-18. [PMID: 25236330 DOI: 10.1002/lary.24946] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Revised: 08/06/2014] [Accepted: 09/04/2014] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS Despite immense interest, robotic-assisted thyroidectomy (RT) remains controversial in differentiated thyroid carcinoma (DTC). This systematic review and meta-analysis compared surgical completeness and/or oncological outcomes between RT and open thyroidectomy (OT) in low-risk DTC. STUDY DESIGN Systematic review. METHODS A systematic review was performed to identify studies that compared surgical completeness and/or oncological outcomes between RT and OT in DTC. Any study that compared at least one parameter relating to surgical completeness and/or oncological outcome for DTC was considered. Number of central lymph nodes (CLNs) retrieved during central neck dissection (CND), preablation stimulated thyroglobulin (sTg) level, radioiodine uptake on post-therapy scan, and locoregional recurrence (LRR) were examined. Meta-analysis was performed using a fixed or random-effects model depending on heterogeneity between studies. RESULTS Ten studies were eligible. Of the 2,205 DTCs, 752 (34.1%) had RT, whereas 1,453 (65.9%) had OT. Relative to OT, RT had significantly fewer CLNs retrieved during CND (4.7 ± 3.2 vs. 5.5 ± 3.8, standardized mean difference [SMD] = -0.240, 95% confidence interval [CI]: -0.364 to -0.116, P < .001) and higher preablation sTg level (3.6 ± 6.7 ng/mL vs. 2.0 ± 5.0 ng/mL, SMD = 0.272, 95% CI: 0.022 to 0.522, P = .033). Interestingly, these differences were more evident in the robotic transaxillary approach (RTAA) than the robotic bilateral axillo-breast approach. After a mean follow-up of 17.7 months, no LRR was found in RT, whereas after 18.6 months, one LRR was found in OT. CONCLUSIONS Relative to OT, total thyroidectomy by RTAA was associated with fewer CLNs retrieved and less-complete thyroid resection. However, using RTAA is unlikely to compromise the outcomes of low-risk DTC because of its inherently good prognosis.
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Lang BHH, Lo CY, Wong KP, Wan KY. Long-Term Outcomes for Older Patients with Papillary Thyroid Carcinoma: Should Another Age Cutoff Beyond 45 Years Be Added? Ann Surg Oncol 2014; 22:446-53. [DOI: 10.1245/s10434-014-4055-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Indexed: 01/15/2023]
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Lang BHH, Chan DTY, Wong KP, Wong KKC, Wan KY. Predictive Factors and Pattern of Locoregional Recurrence After Prophylactic Central Neck Dissection in Papillary Thyroid Carcinoma. Ann Surg Oncol 2014; 21:4181-7. [DOI: 10.1245/s10434-014-3872-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2014] [Indexed: 01/28/2023]
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Lang BHH, Wong KP. How useful are perioperative biochemical parameters in predicting the duration of calcium and/or vitamin D supplementation after total thyroidectomy? World J Surg 2014; 37:2581-8. [PMID: 23982779 DOI: 10.1007/s00268-013-2195-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Oral calcium and calcitriol are often prescribed after total thyroidectomy to avoid biochemical and/or symptomatic hypocalcemia. We aimed to identify independent perioperative factors that correlated with the duration of calcium and/or calcitriol supplementation after total thyroidectomy. METHODS Of 271 eligible patients, 48 (17.7 %) required calcium and/or calcitriol supplements on discharge. Patients were gradually weaned from the supplementation by one surgeon according to a biweekly algorithm based on serum calcium (Ca). Duration of supplementation was calculated from the date of operation to the date of ceasing all supplementation without biochemical hypocalcemia (i.e., serum adjusted Ca ≥ 8.44 mg/dL). The Cox regression analysis was performed to identify independent perioperative factors for duration of supplementation. The best cut-off value for these independent factors was determined by the receiver characteristic curve. RESULTS In the multivariate analysis, parathyroid hormone (PTH) at skin closure (PTH-SC) (RR 1.742, 95 % CI 1.080-2.810) and on postoperative day 1 adjusted Ca (Ca-D1) (RR 77.526, 95 % CI 3.600-1669.57) were the only two independent determinants for shorter duration before ceasing all supplementation. The best cut-off values in predicting supplementation ≥ 6 months for PTH-SC and Ca-D1 were 7.08 pg/mL (sensitivity = 100 %, specificity = 60.5 %, PPV = 40.0 % and NPV = 100 %) and 7.88 mg/dL (sensitivity = 90.0 %, specificity = 55.3 %, PPV = 34.6 % and NPV = 95.5 %), respectively. CONCLUSIONS Both PTH-SC and Ca-D1 were independently associated with the duration of supplementation after total thyroidectomy. Almost all patients with PTH-SC ≥ 7.08 pg/mL or Ca-D1 ≥ 7.88 mg/dL did not require supplementation ≥ 6 months whereas about one third of patients with PTH-SC <7.08 pg/mL or Ca-D1 <7.88 mg/dL required supplementation ≥ 6 months.
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Lang BHH, Wong CKH, Tsang RKY, Wong KP, Wong BYH. Evaluating the Cost-Effectiveness of Laryngeal Examination after Elective Total Thyroidectomy. Ann Surg Oncol 2014; 21:3548-56. [DOI: 10.1245/s10434-014-3770-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Indexed: 12/16/2022]
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Lang BHH, Ng SH, Wong KP. Pain and surgical outcomes with and without neck extension in standard open thyroidectomy: A prospective randomized trial. Head Neck 2014; 37:407-12. [DOI: 10.1002/hed.23611] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Revised: 11/09/2013] [Accepted: 01/09/2014] [Indexed: 12/26/2022] Open
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Lang BHH, Wong CKH, Tsang JS, Wong KP. A systematic review and meta-analysis comparing outcomes between robotic-assisted thyroidectomy and non-robotic endoscopic thyroidectomy. J Surg Res 2014; 191:389-98. [PMID: 24814766 DOI: 10.1016/j.jss.2014.04.023] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Revised: 02/19/2014] [Accepted: 04/09/2014] [Indexed: 12/23/2022]
Abstract
BACKGROUND Despite its feasibility, using the da Vinci robot in remote-access thyroidectomy remains controversial. This meta-analysis compared surgical and oncological outcomes between robotic-assisted thyroidectomy (RT) and non-robotic endoscopic thyroidectomy (ET). METHODS A systematic review was performed to identify studies comparing outcomes between RT and ET. Outcomes included operating time, drain output, complications, number of central lymph nodes retrieved, and preablation stimulated thyroglobulin level. A random-effects model was used. RESULTS Six studies were eligible. Of the 3510 patients, 2167 (61.7%) underwent RT whereas 1343 (38.3%) underwent ET. Despite a higher drain output (185.8 mLs versus 173.3 mLs, P = 0.019), RT had fewer temporary recurrent laryngeal nerve injury (2.6% versus 3.3%, P = 0.035) and shorter length of hospital stay (3.4 d versus 3.5 d, P = 0.030). In terms of oncological outcomes, despite higher incidence of multicentricity and larger tumors, the number of central lymph nodes retrieved during unilateral central neck dissection in RT was significantly greater than ET (4.5 ± 2.6 and 3.4 ± 2.5, P < 0.001) whereas the preablation stimulated thyroglobulin was comparable (0.8 ng/mL versus 1.1 ng/mL, P = 0.456). However, follow-up data were relatively scarce. CONCLUSIONS Adding the robot in remote-access thyroidectomy was associated with a significantly lower risk of temporary recurrent laryngeal nerve injury and shorter length of hospital stay. However, despite achieving a comparable level of surgical completeness for low-risk differentiated thyroid carcinoma between RT and ET, this study highlighted the limitations with the current literature and the need for more prospective studies with adequate follow-up.
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Lang BHH, Chai YJ, Cowling BJ, Min HS, Lee KE, Youn YK. Is BRAFV600E mutation a marker for central nodal metastasis in small papillary thyroid carcinoma? Endocr Relat Cancer 2014; 21:285-95. [PMID: 24402044 DOI: 10.1530/erc-13-0291] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Utilizing BRAF(V600E) mutation as a marker may reduce unnecessary prophylactic central neck dissection (pCND) in clinically nodal negative (cN0) neck for small (≤2 cm) classical papillary thyroid carcinoma (PTC). We aimed to assess whether BRAF is a significant independent predictor of occult central nodal metastasis (CNM) and its contribution to the overall prediction after adjusting for other significant preoperative clinical factors in small PTC. Primary tumor tissue (paraffin-embedded) from 845 patients with small classical cN0 PTC who underwent pCND was tested for BRAF mutation. Clinicopathologic factors were compared between those with and without BRAF. BRAF was evaluated to see if it was an independent factor for CNM. Prediction scores were generated using logistic regression models and their predictability was measured by the area under the ROC curve (AUC). The prevalence of BRAF was 628/845 (74.3%) while the rate of CNM was 285/845 (33.7%). Male sex (odds ratio (OR): 2.68, 95% CI: 1.71-4.20), large tumor size (OR: 2.68, 95% CI: 1.80-4.00), multifocality (OR: 1.49, 95% CI: 1.07-2.09), lymphovascular permeation (OR: 10.40, 95% CI: 5.18-20.88), and BRAF (OR: 1.65, 95% CI: 1.10-2.46) were significant independent predictors of CNM, while coexisting Hashimoto's thyroiditis (OR: 0.56, 95% CI: 0.40-0.80) was an independent protective factor. The AUC for prediction score based on tumor size and male sex was similar to that of prediction score based on tumor size, male sex, and BRAF status (0.68 vs 0.69, P=0.60). Although BRAF was an independent predictor of CNM, knowing its status did not substantially improve the overall prediction. A simpler prediction score based on male sex and tumor size might be sufficient.
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Chang RYK, Lang BHH, Chan AC, Wong KP. Evaluating the efficacy of primary treatment for graves' disease complicated by thyrotoxic periodic paralysis. Int J Endocrinol 2014; 2014:949068. [PMID: 25147568 PMCID: PMC4131447 DOI: 10.1155/2014/949068] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2014] [Revised: 06/22/2014] [Accepted: 07/14/2014] [Indexed: 12/18/2022] Open
Abstract
Objective. Thyrotoxic periodic paralysis (TPP) is a potentially life-threatening complication of Graves' disease (GD). The present study compared the long-term efficacy of antithyroid drugs (ATD), radioactive iodine (RAI), and surgery in GD/TPP. Methods. Sixteen patients with GD/TPP were followed over a 14-year period. ATD was generally prescribed upfront for 12-18 months before RAI or surgery was considered. Outcomes such as thyrotoxic or TPP relapses were compared between the three modalities. Results. Eight (50.0%) patients had ATD alone, 4 (25.0%) had RAI, and 4 (25.0%) had surgery as primary treatment. Despite being able to withdraw ATD in all 8 patients for 37.5 (22-247) months, all subsequently developed thyrotoxic relapses and 4 (50.0%) had ≥1 TPP relapses. Of the four patients who had RAI, two (50%) developed thyrotoxic relapse after 12 and 29 months, respectively, and two (50.0%) became hypothyroid. The median required RAI dose to render hypothyroidism was 550 (350-700) MBq. Of the 4 patients who underwent surgery, none developed relapses but all became hypothyroid. Conclusion. To minimize future relapses, more definitive primary treatment such as RAI or surgery is preferred over ATD alone. If RAI is chosen over surgery, a higher dose (>550 MBq) is recommended.
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Wong CKH, Lang BHH. A Cost-Utility Analysis for Prophylactic Central Neck Dissection in Clinically Nodal-Negative Papillary Thyroid Carcinoma. Ann Surg Oncol 2013; 21:767-77. [DOI: 10.1245/s10434-013-3398-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Indexed: 01/08/2023]
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Wong KP, Lang BHH, Ng SH, Cheung CY, Chan CTY, Chan MY. Is Vocal Cord Asymmetry Seen on Transcutaneous Laryngeal Ultrasonography a Significant Predictor of Voice Quality Changes After Thyroidectomy? World J Surg 2013; 38:607-13. [DOI: 10.1007/s00268-013-2337-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Lang BHH, Wong CKH, Tsang JS, Wong KP, Wan KY. A systematic review and meta-analysis comparing surgically-related complications between robotic-assisted thyroidectomy and conventional open thyroidectomy. Ann Surg Oncol 2013; 21:850-61. [PMID: 24271160 DOI: 10.1245/s10434-013-3406-7] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND Despite gaining popularity, robotic-assisted thyroidectomy (RT) remains controversial. This systematic review and meta-analysis is aimed at comparing surgically-related complications between RT and conventional open thyroidectomy (OT). METHODS A systematic review of the literature was performed to identify studies comparing surgically-related outcomes between RT and OT. Studies that compared ≥ 1 surgically-related outcomes between RT and OT were included. Outcomes included operating time, blood loss, complications, and hospital stay. Meta-analysis was performed using a fixed-effects model. RESULTS Eleven studies were eligible but none were randomized controlled trials. Of the 2,375 patients, 839 (35.3 %) underwent RT, while 1,536 (64.7 %) underwent OT. RT was significantly associated with longer operating time (p < 0.001), hospital stay (p = 0.023) and higher temporary recurrent laryngeal nerve (RLN) injury (p = 0.016). Although there was no correlation between the number of RTs reported in the study and the rate of temporary RLN injury (p = -0.486, p = 0.328, respectively), routine perioperative laryngoscopy was performed in only 2 of 11 studies. Blood loss (p = 0.485), temporary (p = 0.333) and permanent (p = 0.599) hypocalcemia, hematoma (p = 0.602), and overall morbidity (p = 0.880) appeared comparable. Two (0.2 %) brachial plexus injuries in RT were reported in one study. CONCLUSIONS Relative to OT, RT was associated with significantly longer operating time, longer hospital stay, and higher temporary RLN injury rate but comparable permanent complications and overall morbidity. Given some of the limitations with the literature and the potential added surgical risks and morbidity in RT, application of the robot in thyroid surgery should be carefully and thoroughly discussed before one decides on the procedure.
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Lang BHH, Ng SH, Lau LLH, Cowling BJ, Wong KP, Wan KY. A systematic review and meta-analysis of prophylactic central neck dissection on short-term locoregional recurrence in papillary thyroid carcinoma after total thyroidectomy. Thyroid 2013; 23:1087-98. [PMID: 23402640 DOI: 10.1089/thy.2012.0608] [Citation(s) in RCA: 149] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Prophylactic central neck dissection (pCND) at the time of total thyroidectomy (TT) remains controversial in clinically node-negative (cN0) papillary thyroid carcinoma (PTC). Despite occult central lymph node metastases being common, it is unclear if removing these metastases initially would reduce future locoregional recurrence (LRR). This systematic review and meta-analysis aimed at comparing the short-term LRR between patients who underwent TT with pCND and those who underwent TT alone. METHODS A systematic review of the literature was performed to identify studies comparing LRR between patients with PTC who underwent TT + pCND (group A) and those who underwent TT alone (group B). Inclusion criteria were cN0 patients, with each comparative group containing > 10 patients, and with the number of LRR and mean follow-up duration available. The pooled incidence rate ratio (IRR) was used for calculating the LRR rate between the two groups. Other parameters evaluated included postoperative radioiodine (RAI) ablation, surgically related complications, and overall morbidity. Meta-analysis was performed using a fixed-effects model. RESULTS Fourteen studies matched the selection criteria. Of the 3331 patients, 1592 (47.8%) belonged to group A, while 1739 (52.2%) belonged to group B. Relative to group B, group A was significantly more likely to have postoperative RAI ablation (71.7% vs. 53.1%; odds ratio [OR] = 2.60 [95% confidence interval (CI) = 2.12-3.18]), temporary hypocalcemia (26.0% vs. 10.8%; OR = 2.56 [CI = 2.04-3.21]), and overall morbidity (33.2% vs. 17.7%; OR = 2.12 [CI = 1.75-2.57]). When temporary hypocalcemia was excluded, overall morbidity was similar between the two groups (7.3% vs. 6.8%; OR = 1.07 [CI = 0.78-1.47]). Group A had a significantly lower risk of LRR than group B (4.7% vs. 8.6%; IRR = 0.65 [CI = 0.48-0.86]). CONCLUSIONS Group A was more likely to have postoperative RAI ablation, temporary hypocalcemia, and overall morbidity than group B. Temporary hypocalcemia was the major surgical morbidity in pCND and, when excluded, the overall morbidity appeared similar between the two groups. Although our meta-analysis would suggest that those who undergo TT + pCND may have a 35% reduction in risk of LRR than those who undergo TT alone in the short term (< 5 years), it remains unclear how much of this risk reduction is related to increased use of RAI ablation and potential selection bias in some of the studies examined.
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Lang BHH, Wong CKH. A cost-minimization analysis comparing total thyroidectomy alone and total thyroidectomy with prophylactic central neck dissection in clinically nodal-negative papillary thyroid carcinoma. Ann Surg Oncol 2013; 21:416-25. [PMID: 23982258 DOI: 10.1245/s10434-013-3234-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Indexed: 01/13/2023]
Abstract
BACKGROUND Total thyroidectomy (TT) with prophylactic central neck dissection (pCND) remains controversial for clinically nodal-negative (cN0) papillary thyroid carcinoma (PTC), and the issue of cost rarely has been examined. We evaluated whether pCND at the time of TT is more cost-saving than TT alone in the medium- to long-term. METHODS For a hypothetical group of 50-year-old females with a 1.5-cm cN0 PTC, a decision-tree model using TreeAge Software was developed to simulate outcomes and compare the 20-year accumulative direct cost between TT alone and TT+pCND strategies. Baseline values and ranges were determined from a systematic review of the literature. Sensitivity analyses were conducted to test model strength. Cost estimate of surgical procedures, complications, and radioiodine (RAI) ablation was based on government gazette. RESULTS The cost accrued per patient for the primary operation under TT alone and TT+pCND strategies were USD 6,702.81 and USD 10,062.35, respectively, whereas the cost for the reoperative procedure were USD 12,981.40 and USD 12,509.09, respectively. The 20-year accumulative cost for TT alone and TT+pCND strategies were USD 19,888.36 and USD 22,760.86, respectively. The incremental cost per patient was USD 2,872.50. In the univariate and bivariate sensitivity analyses, no change in conclusion was seen by varying the rates of complications, annualized locoregional recurrences and RAI, or by extending the model to 50 years. CONCLUSIONS From a pure economic institution's perspective, TT+pCND is more expensive in the medium- and long-term and seems less justified compared with TT alone for cN0 PTC.
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Lang BHH, Lo CY, Wong KP, Wan KY. Should an Involved but Functioning Recurrent Laryngeal Nerve be Shaved or Resected in a Locally Advanced Papillary Thyroid Carcinoma? Ann Surg Oncol 2013; 20:2951-7. [DOI: 10.1245/s10434-013-2984-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2013] [Indexed: 11/18/2022]
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Lang BHH, Yih PCL, Hung GKY. Does using an energized device in open thyroidectomy reduce complications? J Surg Res 2013; 181:e23-9. [DOI: 10.1016/j.jss.2012.06.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Revised: 05/12/2012] [Accepted: 06/04/2012] [Indexed: 01/03/2023]
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Ng SH, Lang BHH. Parathyroid carcinoma in a 30-year-old man: a diagnostic and management challenge. World J Surg Oncol 2013; 11:83. [PMID: 23566353 PMCID: PMC3623658 DOI: 10.1186/1477-7819-11-83] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Accepted: 03/23/2013] [Indexed: 11/16/2022] Open
Abstract
Parathyroid carcinoma is a rare endocrine malignancy, accounting for less than 1% of cases of primary hyperparathyroidism. Patient-related factors such as age and sex, as well as the biological features and management of the cancer, influence mid-term and long-term survival. We report a case of a young man with an unusual presentation of parathyroid carcinoma. The patient presented with left thigh swelling, which had been present for 6 months without other symptoms of hypercalcemia. On computed tomography scan a hypodense lesion, 30 × 20 × 20 mm in size, was seen in the posterior thyroid. There was no evidence of cervical lymphadenopathy or local infiltration. On a Sestamibi scan, a hot spot was seen in the lower pole of left thyroid lobe. Cervical neck exploration was performed. The patient subsequently underwent surgery and a parathyroid tumor was excised. The tumor was adherent to the thyroid capsule, but there was no evidence of invasion. After surgery, the patient’s calcium and parathyroid hormone levels normalized, but histology confirmed parathyroid carcinoma with capsular and vascular invasion. The patient was offered reoperation, but declined, and developed recurrent parathyroid carcinoma 2 years later. In this report, we aim to present the challenges in managing parathyroid carcinoma and discuss factors that might contribute to future locoregional recurrences. This case also highlighted several issues, including the challenge of ascertaining the diagnosis before surgery and the dilemma of reoperation after simple excision.
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Lang BHH, Yih PCL, Lo CY. A review of risk factors and timing for postoperative hematoma after thyroidectomy: is outpatient thyroidectomy really safe? World J Surg 2013; 36:2497-502. [PMID: 22714575 PMCID: PMC3465547 DOI: 10.1007/s00268-012-1682-1] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Background Although postoperative hematoma after thyroidectomy is uncommon, patients traditionally have been advised to stay overnight in the hospital for monitoring. With the growing demand for outpatient thyroidectomy, we assessed its safety and feasibility by evaluating the potential risk factors and timing of postoperative hematoma after thyroidectomy. Methods From 1995–2011, 3,086 consecutive patients underwent thyroidectomy at our institution; of these, 22 (0.7 %) developed a postoperative hematoma that required surgical reexploration (group I). Potential risk factors were compared between group I and those without hematoma (n = 3,045) or with hematoma but not requiring reexploration (n = 19; group II). Variables that were significant in the univariate analysis were entered into multivariate analysis by binary logistic regression analysis. Results Group I was significantly more likely to have undergone previous thyroid operation than group II (27.3 vs. 8.2 %, p = 0.007). The median weight of excised thyroid gland (71.8 vs. 40 g, p = 0.018) and the median size of the dominant nodule (4.1 vs. 3 cm, p = 0.004) were significantly greater in group I than group II. Previous thyroid operation (odds ratio (OR) = 4.084; 95 % confidence interval (CI), 1.105–15.098; p = 0.035) and size of dominant nodule (OR = 1.315; 95 % CI, 1.024–1.687; p = 0.032) were independent factors for hematoma. Sixteen (72.7 %) had hematoma within 6 h, whereas the other 6 (27.3 %) had hematoma at 6–24 h. Conclusions Previous thyroid operation and large dominant nodule were independent risk factors for hematoma requiring surgical reexploration. Given that a quarter of hematoma occurred between 6 to 24 h after surgery, routine outpatient thyroidectomy could not be recommended.
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Lang BHH, Wong KP, Cheung CY, Fong YK, Chan DKK, Hung GKY. Does Preoperative 25-Hydroxyvitamin D Status Significantly Affect the Calcium Kinetics after Total Thyroidectomy? World J Surg 2013; 37:1592-8. [DOI: 10.1007/s00268-013-2015-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Lang BHH, Ng SH, Lau LL, Cowling BJ, Wong KP. A Systematic Review and Meta-analysis Comparing the Efficacy and Surgical Outcomes of Total Thyroidectomy Between Harmonic Scalpel Versus Ligasure. Ann Surg Oncol 2013; 20:1918-26. [DOI: 10.1245/s10434-012-2849-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2012] [Indexed: 11/18/2022]
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