Pediatric thyroidectomy in a high volume thyroid surgery center: Risk factors for postoperative hypocalcemia

Risk prediction in children and adults less than 45 years old with papillary thyroid cancer

The incidence of papillary thyroid cancer is increasing faster than any other cancer in young patients. The purpose of this review is to discuss the most recent determinants of risk of recurrence and compromised outcomes in this population. Areas covered: This review discusses the most updated data on patient age, including children and young adults, extent of disease and subsequent dynamic staging over time, molecular markers for disease aggressiveness, adequacy of surgical resection and surgeon volume, and novel therapies for advanced non-resectable disease as predictors of patient outcomes. Expert commentary: Young patients enjoy excellent outcomes, with long-term survivorship, but face higher risks of short-term complications and disease recurrence. Thoughtful evaluation of the extent of disease, tumor features associated with more aggressive behavior, the presence of locoregional or distant metastases, and an understanding of molecular changes in their tumors are important areas of consideration. High-volume surgeons should work collaboratively with endocrinologists, radiologists, and pathologists specializing in thyroid cancer to help patients achieve excellent outcomes. Emerging data challenging the status quo regarding the relative importance of patient age, tumor features, and dynamic risk-adjustment for overall prognosis of these patients will likely impact future care and staging systems.

Does Surgical Volume Influence the Need for Second Surgery? A Pilot Study

Objective

To examine outcomes of pediatric thyroidectomy in the context of training background, institution, and experience of the surgeon.

Study Design

Case series with chart review.

Setting

A tertiary academic medical center and a pediatric hospital.

Subjects and Methods

Eighty-one thyroidectomy patients younger than 18 years. Outcomes were major complications (recurrent laryngeal nerve injury, permanent hypocalcemia, and wound infection), length of stay (LOS), and need for repeat surgery.

Results

Eighty-one patients, 39 from the University of Nebraska Medical Center and 42 from the Children’s Hospital and Medical Center–Omaha, were identified over a 12-year time period. No difference was found in surgeon training (otolaryngology/head and neck surgery vs general/pediatric surgery) for complications (1 vs 1, odds ratio [OR] = 0.76, 95% confidence interval [CI] = [0.05, 13.1]), LOS >1 day (5 vs 13, OR = 0.39, 95% CI = [0.13, 1.24]), or need for second surgery (4 vs 7, OR = 1.47, 95% CI = [0.39, 5.49]). Higher surgeon volume (≥12 surgeries) was found to be significant for decreased need for second surgery (3 vs 8, OR = 6.67, 95% CI = [1.57, 27.17]). Patients of higher-volume surgeons were 4.2 times more likely to stay in the hospital 1 day or less compared with those patients operated on by surgeons with less experience (7 vs 11, 95% CI = [1.59, 15.0]).

Conclusions

Need for second surgery in pediatric thyroidectomy may be predicted by surgical volume.

Perioperative determinants of transient hypocalcemia after pediatric total thyroidectomy

PURPOSE

We seek to identify risk factors associated with hypocalcemia after pediatric total thyroidectomy.

METHODS

We retrospectively reviewed patients younger than 21years undergoing total thyroidectomy between January 2002 and January 2016. We defined hypocalcemia as any serum calcium <8mg/dl or ionized calcium <1.0mmol/L. Perioperative risk factors were identified through multivariate logistic regression.

RESULTS

Ninety-one children underwent total thyroidectomy. The average age was 13.7±4.4years, and 77% were female. Transient hypocalcemia was diagnosed in 34% (n=31) of patients. There was one case of permanent hypoparathyroidism. Predictors of transient hypocalcemia included age (OR 0.87, 95% CI 0.8-0.97, p=0.01), lymphadenectomy (OR 6.6, 95% CI 1.7-31.6, p=0.01), and hyperthyroidism (OR 13.3, 95% CI 1.3-1849, p=0.03). Patients with malignancy undergoing central (OR 7.1, 95% CI 1.5-33.4, p=0.01) or central plus lateral lymphadenectomy (OR 6.33, 95% CI 1.0-40.1, p=0.05) had significantly increased risk for transient hypocalcemia. Malignancy, MEN2A/B, goiter, preoperative calcium supplementation, incidental parathyroid removal, and postoperative PTH <15pg/ml were not associated with transient hypocalcemia.

CONCLUSIONS

Younger age, hyperthyroidism, and concomitant lymphadenectomy during total thyroidectomy increase risk of developing transient hypocalcemia. Malignant cases with central or central plus lateral lymphadenectomy are also at increased risk. Aggressive perioperative management of hypocalcemia should be initiated in patients with these risk factors.

LEVEL OF EVIDENCE

2b.

A Prospective Study Comparing the Efficacy and Surgical Outcomes of Harmonic Focus Scalpel Versus LigaSure Small Jaw in Thyroid and Parathyroid Surgery

Background The use of sealing devices has been established in thyroid surgeries. Recently, LigaSure Small Jaw (LS), a new device that utilizes bipolar energy, was approved by the Food and Drug Administration for use in different head and neck procedures. The purpose of this study is to assess the efficiency and safety of LS use in thyroid surgery compared to Harmonic Focus Scalpel (HS), a well-established device. Methods A prospective study was conducted to compare the efficacy of LS versus the HS. We evaluated 301 patients who underwent surgery at a North American academic institution. Patients were allocated into two groups according to LS or HS use. All patients underwent vocal cord assessment using direct laryngoscopy preoperatively and postoperatively. Analyses were performed to examine the difference in perioperative outcomes resulting from the utilization of either device. Results No difference was seen in operative time between both groups (124.20 ± 68.44 minutes in HS vs 125.20 ± 72.13 minutes in LS, P = .99). Overall complications were similar between both groups (22.86% in HS vs 13.84% in LS, P = .05). However, LS use was also associated with a lower incidence of postoperative transient hypocalcemia as compared to the HS (P = .025). No significant difference was found between both groups regarding the incidence of recurrent laryngeal nerve injury (P = .52). Conclusion The use of the LS is safe, feasible, and is associated with comparable outcomes to HS. Both intraoperative and postoperative variables were similar between both devices. Future larger studies are warranted to further investigate the effect on postoperative transient hypocalcemia.