Complications of thyroid surgery: analysis of a multicentric study on 14,934 patients operated on in Italy over 5 years

Risk factors for post-thyroidectomy haemorrhage: a meta-analysis

BACKGROUND

Post-thyroidectomy haemorrhage is a rare but potentially life-threatening and unpredictable complication of thyroid surgery. In this study, we analysed the potential risk factors for the occurrence of post-thyroidectomy haemorrhage.

METHODS

The PubMed and SCIE databases were comprehensively searched for studies published before June 30, 2016. Studies on patients who underwent an open thyroidectomy with or without neck dissection were included, and RevMan 5.3 software was used to analyse the data.

RESULTS

Twenty-five studies and 424 563 patients were included in this meta-analysis, and post-thyroidectomy haemorrhage occurred in 6277 patients (incidence rate = 1.48%). The following variables were associated with an increased risk of post-thyroidectomy haemorrhage: older age (MD = 4.30, 95% CI = 3.09-5.52, P < 0.00001), male sex (OR = 1.73, 95% CI = 1.54-1.94, P < 0.00001), Graves' disease (OR = 1.76, 95% CI = 1.44-2.15, P < 0.00001), antithrombotic agents use (OR = 1.96, 95% CI 1.55-2.49, P < 0.00001), bilateral operation (OR = 1.71, 95% CI = 1.50-1.96, P < 0.00001), neck dissection (OR = 1.53, 95% CI = 1.11-2.11, P = 0.01) and previous thyroid surgery (OR = 1.62, 95% CI = 1.12-2.34, P = 0.01). Malignant tumours (OR = 1.07, 95% CI = 0.89-1.28, P = 0.46) and drainage device use (OR = 1.27, 95% CI = 0.74-2.18, P = 0.4) were not associated with post-thyroidectomy haemorrhage.

CONCLUSION

Our systematic review identified a number of risk factors for post-thyroidectomy haemorrhage, including older age, male sex, Graves' disease, antithrombotic agents use, bilateral operation, neck dissection and previous thyroid surgery. Early control of modifiable risk factors could improve patient outcomes and satisfaction.

Risk factors for postoperative hypocalcemia

Hypocalcaemia is one of the most common complications after thyroidectomy; however, it is still unclear what preoperative factors could predict this event. The aim of this study was to evaluate the role of risk factors for hypocalcaemia after total thyroidectomy (TT). Consecutive patients who underwent total thyroidectomyat our institution between January 2014 and January 2016 were enrolled. The clinical and pathologic characteristics and surgical details of normocalcemic and hypocalcemic patients were compared. Univariate and multivariate analyses to estimate risk ratio were assessed. A total of 328 patients underwent TT; histology revealed benign and malignant disease in 83 and 17% of cases, respectively. Central-compartment neck dissection (CCND) was performed in 36 subjects (10.9%). Parathyroid glands were observed in 23% (76) of specimens. Laboratory asymptomatic hypocalcaemia was observed in 92 (28%) patients; symptomatic hypocalcaemia occurred in 26 (7.9%). Transient hypocalcaemia has been observed in 48 (14.6%) patients; permanent hypocalcaemia occurred in two subjects (0.6%). On univariate analysis, malignant pathology (p < 0.001), CCND (p < 0.05), female gender (p < 0.001), presence of at least two parathyroid glands in specimens (p < 0.002), and operative time longer than 120 min (p < 0.05) were factors that significantly increased the risk of developing asymptomatic and transient hypocalcaemia. After logistic regression analysis, malignant pathology (p < 0.000; p < 0.001) and CCND (p < 0.005; p = 0.013) were the significant factors that affected the development of symptomatic and transient hypocalcaemia. The presence of malignant pathology and CCND was found to be significant risks factors for postoperative hypocalcaemia. In patients in whom this pathological features are present, attention should be paid to rapidly start an adequate therapy.

Can Parathormon Levels after Ipsilateral Lobectomy Predict Postoperative Hypocalcemia in Patients Undergoing Total Thyroidectomy?

The purpose of this study was to investigate the relationship between the serum parathormone (PTH) levels measured after completion of hemithyroidectomy on the first side during total thyroidectomy and the postoperative hypocalcemia. The patients were divided into two groups, as those who demonstrated a decrease in PTH levels measured after completion of hemithyroidectomy of the first side (Group 1, n = 43) and those who did not demonstrate a decrease in PTH levels (Group 2, n = 24). The serum PTH levels were measured just before the incision (PTHi), when the hemithyroidectomy stage had been completed (PTHht), at the end of the operation (PTHtt), and at the postoperative 24th hour (PTH24hr). The serum total calcium (Ca21) levels were also measured. The median percentage differences in PTHtt levels based on basal PTHi levels of Groups 1 and 2 were -60.6 and -15.7 per cent, respectively, P = 0.001. The frequency of postoperative biochemical hypocalcemia was higher in Group 1, P < 0.05. It was determined that a 10 per cent or higher decrease in PTHht levels in Group 1 could predict biochemical hypocalcemia at the postoperative 24th hour. In conclusions, postoperative hypocalcemia is seen more frequent in patients with a decrease of PTHht during total thyroidectomy. A decrease of 10 per cent in PTHht levels measured after ipsilateral lobectomy and a 62 per cent or higher decrease in PTHtt levels measured in the end of the total thyroidectomy could be helpful for prediction of postoperative hypocalcemia in these patients.

Comparative Effectiveness of Treatment Choices for Graves' Hyperthyroidism: A Historical Cohort Study

BACKGROUND

The optimum therapy for Graves' disease (GD) is chosen following discussion between physician and patient regarding benefits, drawbacks, potential side effects, and logistics of the various treatment options, and it takes into account patient values and preferences. This cohort study aimed to provide useful information for this discussion regarding the usage, efficacy, and adverse-effect profile of radioactive iodine (RAI), antithyroid drugs (ATDs), and thyroidectomy in a tertiary healthcare facility.

METHODS

The cohort included consecutive adults diagnosed with GD from January 2002 to December 2008, who had complete follow-up after treatment at the Mayo Clinic, Rochester, Minnesota. Data on treatment modalities, disease relapses, and adverse effects were extracted manually and electronically from the electronic medical records. Kaplan-Meier analyses were performed to evaluate the association of treatments with relapse-free survival.

RESULTS

The cohort included 720 patients with a mean age of 49.3 years followed for a mean of 3.3 years. Of these, 76.7% were women and 17.1% were smokers. The initial therapy was RAI in 75.4%, ATDs in 16.4%, and thyroidectomy in 2.6%, while 5.6% opted for observation. For the duration of follow-up, ATDs had an overall failure rate of 48.3% compared with 8% for RAI (hazard ratio = 7.6; p < 0.0001). Surgery had a 100% success rate; 80% of observed patients ultimately required therapy. Adverse effects developed in 43 (17.3%) patients treated with ATDs, most commonly dysgeusia (4.4%), rash (2.8%), nausea/gastric distress (2.4%), pruritus (1.6%), and urticaria (1.2%). Eight patients treated with RAI experienced radiation thyroiditis (1.2%). Thyroidectomy resulted in one (2.9%) hematoma and one (2.85%) superior laryngeal nerve damage, with no permanent hypocalcemia.

CONCLUSIONS

RAI was the most commonly used modality within the cohort and demonstrated the best efficacy and safety profile. Surgery was also very effective and relatively safe in the hands of experienced surgeons. While ATDs allow preservation of thyroid function, a high relapse rate combined with a significant adverse-effect profile was documented. These data can inform discussion between physician and patient regarding choice of therapy for GD.

Recurrent laryngeal nerve injury after thyroid and parathyroid surgery: Incidence and postoperative evolution assessment

Recurrent laryngeal nerve (RLN) injury is a feared complication after thyroid and parathyroid surgery. It induces important postoperative morbidity. The present study aimed to assess the incidence of transient/permanent postoperative RLN injuries after thyroid and parathyroid surgery in the present cohort, to observe the timing of recovery, and to identify risk factors for permanent RLN injury after thyroidectomy.All consecutive patients operated on at our institution for thyroid and parathyroid pathologies from 2005 to 2013 were reviewed for vocal cord paresis. Vocal cord paresis was defined based on postoperative fiberoptic laryngoscopy. Demographics, intraoperative details, and postoperative outcomes were collected. Treatment types were assessed, and recovery times collected. Patients with vocal cord paresis on preoperative fiberoptic laryngoscopy were excluded from the analysis.The cohort included 451 thyroidectomies (756 nerves at risk) and 197 parathyroidectomies (276 nerves at risk). There were 63 postoperative vocal cord pareses after thyroidectomy and 13 after parathyroidectomy. Sixty-nine were transient (10.6%) and 7 permanent (1.1%). The main performed treatment was speech therapy in 51% (39/76) of the patients. Median recovery time after transient injuries was 8 weeks. In the group with vocal cord paresis, risk factors for permanent injuries after thyroidectomy were previous thyroidectomy and intraoperative RLN injury on univariate analysis. On multivariate analysis, only intraoperative RLN injury remained significant.Most of the patients with transient postoperative RLN injury recovered normal vocal cord mobility within 6 months. The most common performed treatment was in this cohort speech therapy. Permanent RLN injuries remained rare (1.1%).

[The modern approach to the conservative treatment of the patients presenting with postoperative bilateral vocal fold palsy]

The objective of the preset study was to further improve the diagnostics and treatment of unilateral palsies of the laryngeal recurrent nerves associated with transitory reflective spasm of the functionally competent vocal fold. The study included 49 patients (46 women and 3 men) at the age varying from 21 to 75 years presenting with unilateral palsies of the laryngeal recurrent nerves associated with transitory reflective spasm of the functionally competent vocal fold that developed after the surgical intervention on the thyroid gland. The electromyographic test for latent tetany was performed for diagnostics and objective evaluation of the results of the treatmen. In addition, the blood ionized calcium levels were measured and videolaryngostroboscopy was used. The treatment included respiratory gymnastics, reflexotherapy (novocaine blockade of the Zakhar'in - Head's zone for the larynx, auricolotherapy, and pharmacotherapy with the prescription of vitamin-calcium preparations, myorelaxants, sedatives, and phonopedia. A loud enough resounding voice was restored in all the 49 participants of the study with the normalization of respiration and the complete cessation (or reduction to a minimum) of the reflexive coughing spells and laryngeal reflex spasms. None of the patients required tracheotomy during the follow-up period.

Surgical treatment of thyroid follicular neoplasms: results of a retrospective analysis of a large clinical series

The most appropriate surgical management of "follicular neoplasm/suspicious for follicular neoplasm" lesions (FN), considering their low definitive malignancy rate and the limited predictive power of preoperative clinic-diagnostic factors, is still controversial. On behalf of the Italian Association of Endocrine Surgery Units (U.E.C. CLUB), we collected and analyzed the experience of 26 endocrine centers by computerized questionnaire. 1379 patients, surgically treated after a FN diagnosis from January 2012 and December 2103, were evaluated. Histological features, surgical complications, and medium-term outcomes were reported. Total thyroidectomy (TT) was performed in 1055/1379 patients (76.5 %), while hemithyroidectomy (HT) was carried out in 324/1379 cases (23.5 %). Malignancy rate was higher in TT than in HT groups (36.4 vs. 26.2 %), whereas the rates of transient and definitive hypoparathyroidism following TT were higher than after HT. Consensual thyroiditis (16.8 vs. 9.9 %) and patient age (50.9 vs. 47.9 %) also differed between groups. A cytological FN diagnosis was associated to a not negligible malignancy rate (469/1379 patients; 34 %), that was higher in TT than in HT groups. However, a lower morbidity rate was observed in HT, which should be considered the standard of care in solitary lesions in absence of specific risk factors. Malignancy could not be preoperatively assessed and clinical decision-making is still controversial. Further efforts should be spent to more accurately preoperatively classify FN thyroid nodules.

The true cost of thyroid surgery determined by a micro-costing approach

Whether the amount of the current DRG tariff for thyroid surgery covers its actual cost has been questioned. We estimated a reliable cost of thyroid surgery for a large Italian hospital. A micro-costing approach is used with data from the University Hospital "Umberto I," a large facility that conducts a high volume of thyroidectomy surgical procedures in the Lazio region. The direct costs of surgery and hospitalization for a total and a hemi-thyroidectomy were €4956 and €4673, respectively. When compared to the DRG tariff of €3340, total thyroidectomy was €1616 (48 %) more per procedure and hemi-thyroidectomy was €1333 (40 %) more per procedure. This DRG shortfall is calculated to generate an annual procedure-specific deficit of approximately €1.38 million for this hospital. Furthermore, when the costs associated with pre-surgical work-up, post-surgical follow-up, and complications management through 12 months are incorporated, the estimated costs of total and hemi-thyroidectomy rose to €5812 and €5277, respectively. The true cost of thyroid surgery in Italy is significantly higher than what has been reported in the literature or reimbursed by the DRG tariff.

Surgical management of primary thyroid tumours

The majority of patients who present with well differentiated thyroid cancer will require surgery, but decisions on the appropriate primary procedure will depend on information relating to patient, tumour and surgical factors. As the incidence of thyroid cancer continues to rise, it is critical that clinicians involved in the management of these cases understand the factors which underpin surgical decision making for individual patients. Reporting outcomes in well differentiated thyroid cancer (WDTC) has always been challenging due to the low recurrence and mortality rate of the disease. Although early data supported total thyroidectomy for all patients with >1 cm WDTC, more recent evidence has supported lobectomy in selected, low risk patients. As a result we have seen a change in the approach of international guidelines from a blanket statement that total thyroidectomy should be the treatment for all patients towards a more selective approach to therapy. When selecting the most appropriate surgical approach to WDTC, the primary aim is to minimize the chance of death from disease or further recurrence. Additionally the impact of potential side effects of treatment (laryngeal nerve injury and hypocalcaemia) must also be weighed in the balance. In this review of surgical management of WDTC we aim to present a historical perspective on this subject and explore the arguments for and against total thyroidectomy and thyroid lobectomy in the low-risk patient group.

Prophylactic oral calcium supplementation therapy to prevent early post thyroidectomy hypocalcemia and evaluation of postoperative parathyroid hormone levels to detect hypocalcemia: A prospective randomized study

BACKGROUND

Postoperative hypocalcemia is the most common complication after total thyroidectomy. Postoperative parathyroid hormone (PTH) measurement is one of the methods to detect or prevent postoperative hypocalcemia. Prophylactic oral calcium supplementation is another method to prevent early postoperative hypocalcemia. The aim of this study is to detect the accurate timing of PTH and evaluate efficacy of routine oral calcium supplementation for postoperative hypocalcemia.

METHODS

A total of 106 patients were performed total thyroidectomy. Rotuine oral calcium supplementation was given to group 1 and no treatment to group 2 according to randomization. Serum calcium and PTH level of patients in group 2 at postoperative 6, 12 and 24 h and patients in both groups at postoperative day 7 were evaluated. Patients were compared according to age, sex, operation findings, serum calcium and PTH levels and symptomatic hypocalcemia.

RESULTS

Half of the patients (50%) were in group 1. Most of the patients were female (83%). The most common etiology of thyroid disease was multinodular goiter (64.1%). Oral calcium supplementation was given to 18 (33.9%) patients in group 2. Symptomatic hypocalcemia for group 1 and 2 was found to be 1.9 and 33.9% respectively (p < 0.05). No statistical difference can be observed regarding the timing of serum biomarkers.

CONCLUSION

Serum PTH levels at postoperative 12 and 24 h can predict early post-thyroidectomy hypocalcemia. Prophylactic oral calcium supplementation therapy can prevent early post-thyroidectomy hypocalcemia with advantages of being cost effective and safe.

Microwave ablation for thyroid nodules: a new string to the bow for percutaneous treatments?

BACKGROUND

Thyroid nodules are a fairly common finding in general population and, even if most of them are benign, a treatment can be however necessary. In the last years, non surgical minimally invasive techniques have been developed to treat this pathology, starting from percutaneous ethanol injection (PEI), to laser ablation (LA), radiofrequency ablation (RFA) and, most recently, microwave ablation (MWA).

METHODS

We reviewed all medical literature searching in pubmed.gov the terms "microwave" & "thyroid". We found three original studies concerning MWA treatment, for a total of 263 patients (mean age 51.0 years; range, 15-80 years; male to female ratio 2.55) and 522 nodules.

RESULTS

A total of 522 nodules (338 solid, 22 cystic, 162 mixed) in 263 patients were treated. Studies have shown a mean reduction in volume of thyroid nodules ranging from 45.9% to 65%. No study reported a significant and definitive change in laboratory parameters, except for one case (Heck et al.). No studies have reported major complications after procedure.

CONCLUSIONS

MWA is a new, promising technique among the minimally invasive treatments of thyroid nodules. Actually, the larger diameter of MW antenna seems to be the major limiting factor in the use of this technique. More studies are necessary to evaluate feasibility, safety and efficacy of the procedure.

Applicability of rapid intraoperative parathyroid hormone assay through fine needle aspiration to identify parathyroid tissue in thyroid surgery

Hypoparathyroidism is a frequent and serious complication of thyroid surgery. Identification and preservation of the parathyroid glands are key factors in managing hypoparathyroidism. The aim of the present study was to investigate the efficacy of rapid intraoperative parathyroid hormone (rIO-PTH) assay levels through fine needle aspiration (FNA) in identifying parathyroids as a parameter in thyroid surgery. rIO-PTH assay through FNA and frozen section examination were performed on 194 suspected parathyroids anatomical structures from 50 consecutive patients undergoing thyroidectomy (rIO-PTH group). The association between the rIO-PTH values and histological results were analyzed. Clinical effects were compared between the rIO-PTH and control groups from 50 patients undergoing a similar standard surgery. rIO-PTH levels from 93/194 aspirated anatomical structures certified as parathyroid tissues by histological analysis were demonstrated to have a mean of 3,369 pg/ml (range, 145.2-5,000 pg/ml). These values were significantly increased compared with the mean value of 25.7 pg/ml from non-parathyroids tissues significantly (P<0.001). The mean number of 3.76 on the recognized parathyroids was obtained by naked eye measurements combined with rIO-PTH assay through FNA, was significantly higher than compared with only naked eye measurements (P<0.05). Postoperative permanent or transient hypoparathyroidism was not detected in the rIO-PTH groups. The difference between the postoperative serum calcium level and blood PTH values of rIO-PTH and control groups was not statistically significant (P>0.05). The value of rIO-PTH assay through FNA demonstrated that it is a good parameter for differentiating parathyroids and non-parathyroids tissues. The technique is a highly reliable, quick, simple and non-invasive method with a short learning curve in thyroid surgery, which is particularly valuable for inexperienced surgeons. This method may replace frozen section examination, which relies on a surgeon's personal experience on the basis of topographic or morphologic criteria for recognizing parathyroids.

Is it possible to limit the risks of thyroid surgery?

OBJECTIVE

Inferior laryngeal nerve (ILN) palsy and hypocalcemia remain the two most frequent major complications after thyroid surgery. Their occurrences may be explained by the influence of factors related to the patient, the surgical procedure, thyroid pathology, or the surgeon's technique. This study aims To assess whether systematically following a rigorous surgical technique during thyroidectomy affects postoperative complications and long-term patient recovery.

METHODS

We conducted a multicenter, cross-sectional study of prospectively collected data in five high-volume referral centers enrolling all patients who underwent thyroid surgery between April 2008 and December 2009. Inferior laryngeal nerve (ILN) palsy and hypocalcemia were systematically assessed during hospitalization based on objective criteria. A six-month follow-up was conducted in cases of early complications. Multivariate regression models were computed to quantify their relationship with potential risk factors.

RESULTS

A total of 3574 thyroid procedures were completed. Non-visualization of the ILN during dissection and a large thyroid mass were major risk factors for permanent ILN palsy (OR, 4.17 and 2.61, p<0.01) and persistent complications after initial injury (OR, 4.17 and 2.42, p<0.05). The presence of thyroiditis on the surgical specimen was an independent risk factor for permanent hypoparathyroidism and poor recovery after initial dysfunction (OR, 1.76 and 1.88, p<0.05).

CONCLUSIONS

Thorough meticulous technique in thyroid surgery is a determinant of ILN function but fails to prevent persistent hypoparathyroidism.

Chylothorax in thyroid surgery: a very rare case and systematic review of the literature

Background

Chylothorax is a very rare but major complication in thyroid surgery and should be apparent to clinicians in this field.

Case presentation

We report a case with chylothrax after thyroid surgery in our department that drew our attention.

Methods

Systematic review of the literature to evaluate the incidence and the contributing factors of chylothorax after thyroid surgery. Database (PubMed) and hand searches to identify patients with thyroid surgery and postoperative chylothorax. Keywords included chylothorax, thyroidectomy, thyroid surgery and complications. Two independent reviewers screened studies against inclusion and exclusion criteria. Patient characteristics, risk factors, symptoms, treatments and etiopathogenesis were investigated.

Results

We identified 13 articles in the literature describing 19 patients with chylothorax after thyroidectomy and described our own case. Ninety percent of the patients underwent thyroidectomy for thyroid cancer. Sixteen patients (80 %) underwent thyroidectomy with at least a left lateral neck dissection, 2 patients (10 %) underwent thyroidectomy with sternotomy, and in the remaining 2 patients (10 %), thyroidectomy with lateral neck dissection on both sides was performed with partial sternotomy. Our calculated incidence for chylothorax with total thyroidectomy and neck dissection was 1.85 %; for a thoracic approach the calculated incidence was 7.3 %.

Conclusions

There are no reports of chylothorax after thyroidectomy without at least a left lateral neck dissection due to advanced thyroid cancer and/or sternotomy due to the thyroid size. The extension of thyroid surgery seems to be the main risk factor in developing chylothorax either through direct surgical trauma or through increased intraductal pressure after thoracic duct ligation. An early diagnosis of chylothorax may avoid severe metabolic or cardiopulmonary complications.

Comparison between Focus Harmonic scalpel and other hemostatic techniques in open thyroidectomy: A systematic review and meta-analysis

BACKGROUND

The purpose of this review was to compare the efficacy and surgical outcomes of total thyroidectomy between the Focus Harmonic scalpel (Ethicon, Cincinnati, OH) and other hemostatic procedures.

METHODS

An extensive search was conducted using the PubMed and Cochrane databases from January 2008 to October 2014. Operating time, blood loss, pain, complications, and hospital stay were evaluated.

RESULTS

When compared with conventional techniques or LigaSure Precise Vessel Sealing System (Medtronic, Minneapolis, MN), the use of the Focus Harmonic scalpel reduced operative time by 22,428 minutes and blood loss by 13,914 mL. Length of hospital stay was significantly shorter in the Focus Harmonic scalpel group with a mean reduction of 0.410 days.

CONCLUSION

According to our meta-analysis, when comparing the Focus Harmonic scalpel versus conventional techniques, it seems evident that the use of this device in thyroid surgery is associated with a mean reduction in operating time, blood loss, and hospital stay, without any increase in pain and complications. There was no appreciable difference between the Focus Harmonic scalpel and the LigaSure Precise Vessel Sealing System. © 2016 Wiley Periodicals, Inc. Head Neck 38: First-1578, 2016.

Intraoperative nerve monitoring during thyroid surgery

PURPOSE OF REVIEW

Laryngeal nerve injury, resulting in speech and swallowing dysfunction, is a feared complication of thyroid operations. Routine visualization of the recurrent laryngeal nerve (RLN) has decreased the likelihood of nerve injury, and intraoperative nerve monitoring has been applied in the hope of further enhancing safety.

RECENT FINDINGS

There is conflicting evidence about the value of nerve monitoring during thyroid operations, despite ample research. The data favor nerve monitoring in certain situations, such as neck re-explorations, contralateral RLN injury, extensive or challenging dissections, invasive tumors or large goiters, and nonrecurrent or branching recurrent laryngeal nerves. Continuous intraoperative nerve monitoring may reduce the chances of excessive traction, which is the most common mechanism of injury. Nerve monitoring may also identify and protect the external branches of the superior laryngeal nerve.

SUMMARY

Surgeons should routinely identify recurrent laryngeal nerves during thyroid operations, and intraoperative nerve monitoring might be a useful adjunct to prevent injury. As a result of the relatively low probability of permanent recurrent laryngeal nerve injury, it is difficult to establish the absolute value of nerve monitoring. Further research may focus on continuous nerve monitoring and intraoperative monitoring of the external branches of the superior laryngeal nerves.

Partial Thyroidectomy for Papillary Thyroid Microcarcinoma: Is Completion Total Thyroidectomy Indicated?

BACKGROUND

Total thyroidectomy is a well-established surgical approach for the management of papillary thyroid cancer (PTC). However, the best surgical approach for papillary microcarcinoma is nowadays still debated. Both total thyroidectomy and simple lobectomy are used. We report the experience of a single University center in the treatment of thyroid microcarcinoma.

METHODS

A retrospective analysis on all patients who underwent thyroid surgery at our institution over a 24-year period (1991-2015) was performed. Patients were grouped according to whether they received total thyroidectomy (Group 1) or lobectomy (Group 2). Follow-up was made by routine clinical and ultrasound examination. Specific outcomes such as recurrence and need for reoperation as well as complications (transient vocal cord paralysis and hypocalcemia) were analyzed.

RESULTS

During the study period 880 patients underwent surgery for PTC. Group 1 and 2 consisted, respectively, of 756 and 124 patients. A micro PTC (<10 mm) was present in 251 and 69 specimen of Group 1 and 2. No evidence of disease recurrence in the follow-up was reported in patients with microPTC in Group 1 and in 57 patients of Group 2. In the remaining 12 patients completion thyroidectomy was carried out due to ultrasound findings of contralateral nodules (10), lymphadenopathy (1), and capsular invasion (1). Five of these patients had a contralateral papillary carcinoma on final histopathologic examination. Thus recurrence rate for patients of Group 2 was 7.3%. Morbidity rates were, respectively, for Group 1 and 2: transient nerve palsy 81 and 5 (11 vs. 7.3%, p = ns), transient hypoparathyroidism (Calcium <2.00 mmol/L) 137 (18.6%) and 0 (p < 0.0001). Three of the 12 patients of Group 2 undergoing further surgery had a transient hypoparathyroidism.

CONCLUSIONS

Thyroid lobectomy is an effective surgical strategy to manage papillary microcarcinomas with low complications. Routine completion thyroidectomy is not mandatory. Appropriate selection excluding high-risk patients is of paramount importance in order to achieve the best results.

Comparative analysis between a bipolar vessel sealing and cutting device and the tie and suture technique in thyroidectomy: A randomized clinical trial

BACKGROUND

Advanced bipolar and ultrasonic devices have shown significant reduction in the surgical time of thyroid operations. This randomized, controlled trial assessed if operative time and other relevant outcomes are different for thyroidectomies performed either with a second-generation advanced bipolar device or traditional tie and suture technique.

METHODS

Forty-one patients were randomized into 2 groups (advanced bipolar device and traditional tie and suture). Secondary end points included estimated blood loss, postoperative hemorrhage or hematoma requiring operative reintervention, recurrent laryngeal nerve injury, hypoparathyroidism, pain intensity, number of ligatures, analgesia usage, and loss of signal during recurrent laryngeal nerve monitoring.

RESULTS

Preoperative characteristics were similar between both groups. Mean operative time in the advanced bipolar device group was reduced by 32.5 minutes compared with the traditional tie and suture group (P = .006). Intraoperative blood loss was similar in both groups. Four patients presented postoperative vocal cord dysmotility, 3 in the traditional tie and suture group and 1 in the advanced bipolar device group (P = ns). Two of these 4 patients also had a >50% amplitude decrease during continuous intraoperative neuromonitoring, 1 in each group. Pain intensity, 12 hours after operation, was significantly greater in the traditional tie and suture group (P = .015), even though pain medication requirements during the initial 24 hours after operation were similar between groups (P = .97). There were no cases of postoperative hemorrhage or hematoma requiring reintervention. Postoperative, symptomatic hypocalcemia occurred in 6 patients, 4 in the traditional tie and suture, and 2 in the advanced bipolar device group. One of them developed permanent hypocalcemia.

CONCLUSION

The use of an advanced bipolar device in thyroid operation reduces operative time by >30 minutes, with a similar postoperative outcome profile when compared with the traditional tie and suture technique.

Risk of Complications with Energy-Based Surgical Devices in Thyroid Surgery: A National Multicenter Register Study

BACKGROUND

Energy-based surgical devices (EBD) combining cutting and coagulation are increasingly used in thyroid surgery. However, there is a lack of information about potential benefits and risk of complications outside controlled trials. The aims of this national multicenter register study were to describe the use of EDB, their potential effect on complication rates, and on operation time.

MATERIALS AND METHODS

The Scandinavian Quality Register for Thyroid and Parathyroid surgery includes 35 surgical units in Sweden and covered 88% of the thyroid procedures performed during 2008–2009. The use of the EBD was specifically registered for 12 months, and 1297 patients were included. Surgically related complications and operation time were evaluated. The clamp-and-tie group (C-A-T) constituted the control group for comparison with procedures where EBD was used.

RESULTS

The thyroid procedures performed included C-A-T (16.6%), bipolar electrosurgery (ES: 56.5%), electronic vessel sealing (EVS: 12.2%), and ultrasonic dissection (UD: 14.5%). Mean operative time was longer with EVS (p < 0.001) and shorter with UD (p < 0.05) than in the other groups. The bipolar ES group and the EVS group had higher incidence of calcium treatment at discharge and after 6 weeks than the UD group. No significant difference in nerve injury was found between the groups. There was a significant more frequent use of topical hemostatic agents in the EBD group compared to C-A-T.

CONCLUSION

In this national multicenter study, the use of UD shortened and EVS increased operating time. There was a higher risk of calcium treatment at discharge and after 6 weeks after use of EVS and bipolar ES than after UD use. There was a significant more frequent use of topical hemostatic agents in the EBD groups compared to C-A-T.

Diagnostic, therapeutic and health-care management protocol in thyroid surgery: a position statement of the Italian Association of Endocrine Surgery Units (U.E.C. CLUB)

PURPOSE

The diagnostic, therapeutic and health-care management protocol (Protocollo Gestionale Diagnostico-Terapeutico-Assistenziale, PDTA) by the Association of the Italian Endocrine Surgery Units (U.E.C. CLUB) aims to help treat the patient in a topical, rational way that can be shared by health-care professionals.

METHODS

This fourth consensus conference involved: a selected group of experts in the preliminary phase; all members, via e-mail, in the elaboration phase; all the participants of the XI National Congress of the U.E.C. CLUB held in Naples in the final phase. The following were examined: diagnostic pathway and clinical evaluation; mode of admission and waiting time; therapeutic pathway (patient preparation for surgery, surgical treatment, postoperative management, management of major complications); hospital discharge and patient information; outpatient care and follow-up.

RESULTS

A clear and concise style was adopted to illustrate the reasons and scientific rationales behind behaviors and to provide health-care professionals with a guide as complete as possible on who, when, how and why to act. The protocol is meant to help the surgeon to treat the patient in a topical, rational way that can be shared by health-care professionals, but without influencing in any way the physician-patient relationship, which is based on trust and clinical judgment in each individual case.

CONCLUSIONS

The PDTA in thyroid surgery approved by the fourth consensus conference (June 2015) is the official PDTA of U.E.C. CLUB.

Effect of Dissection of the Recurrent Laryngeal Nerves on Parathyroid Insufficiency during Total Thyroidectomy for Multinodular Goitre

INTRODUCTION

Total thyroidectomy is the accepted standard treatment for benign goitrous enlargements. The surgical skill and technique is one of the most important factor which affect the outcome in thyroid surgery. Hypocalcaemia due to parathyroid insufficiency remains a significant postoperative morbidity after total thyroidectomy. The primary cause is unintentional damage to, or devascularization of, one or more parathyroid glands during surgery.

AIM

To study the risk of hypocalcaemia due to recurrent laryngeal nerves (RLNs) dissection during total thyroidectomy for benign multinodular goitre (MNG).

MATERIALS AND METHODS

The study is a non-randomized control trial, where 100 patients with benign MNG were divided into two groups (group A and group B) each consisting of 50 patients. All 100 patients underwent total thyroidectomy by a subcapsular dissection. In patients of group A, both RLNs were clearly dissected for a minimum length of 2cm down from its entry into the larynx before total thyroidectomy was performed. In group B, each patient had total thyroidectomy without making any deliberate attempt to dissect and demonstrate the RLNs. The patients in the two groups were followed up for the incidence of clinically significant hypocalcaemia in the postoperative period.

RESULTS

A total of 30% of patients in group A developed clinical and biochemical manifestations of hypocalcaemia but the incidence of hypocalcaemia was only 6% in the group B. Three (6%) patients out of those who developed hypocalcaemia in group A had a prolonged hypocalcaemia for upto six months. p-value is 0.003 and odds ratio is 6.59.

CONCLUSION

Routine dissection to identify the RLNs could predispose to a higher incidence of postop hypocalcaemia. Subcapsular dissection of the thyroid safely preserves the parathyroid glands.

Differences in Thyroidectomy Outcomes Based on Surgical Method: A Comparison of LigaSure Precise, Harmonic Focus, and Traditional Methods

New surgical devices have been developed to improve haemostatic control and vascular closure in thyroid surgery. Here, we compare the efficacy and clinical outcomes of 3 surgical methods, Harmonic Focus, LigaSure Precise, and the traditional suture-ligation method, in patients undergoing total thyroidectomies. This retrospective study compared total thyroidectomies performed between July 2008 and August 2012. Thyroidectomies were performed in 243 patients using Harmonic Focus (n = 81), LigaSure Precise (n = 81), and traditional suture-ligation (n = 81). No significant differences were observed among groups in terms of patient demographics, thyroid weight, pathological diagnoses, pre- and postoperative calcium levels, postoperative complications, length of hospitalization, and clinical outcomes. The Harmonic Focus approach showed an ∼15% shortening in operating time relative to the suture-ligation group; no statistically significant differences were detected between the LigaSure and traditional suture-ligation groups. All 3 methods were found to be both safe and effective. Operating time was significantly shorter in the Harmonic Focus group; no differences in terms of postoperative complications were observed among groups.

Haemostasis in Thyroid Surgery: Collagen-Fibrinogen-Thrombin Patch versus Cellulose Gauze-Our Experience

Purpose. Postoperative hemorrhage is fortunately uncommon but potentially life-threatening complication of thyroid surgery that increases the postoperative morbidity and the hospital stay. In this study we compare the efficacy of collagen patch coated with human fibrinogen and human thrombin (CFTP) (group C) and oxidized regenerated cellulose gauze (group B) versus traditional hemostatic procedures (group A) in thyroid surgery. Methods. From January 2011 to December 2013, 226 were eligible for our prospective, nonrandomized, comparative study. Patients requiring a video-assisted thyroidectomy without drain, "near total," or hemithyroidectomy were excluded. Other exclusion criteria were a diagnosis of malignancy, substernal goiter, disorders of hemostasis or coagulation, and Graves or hyperfunctioning thyroid diseases. Outcomes included duration of operation, drainage volume, and postoperative complications. Results. Our results show a significant reduction in drainage volume in group C in comparison with the other two groups. In group C there was no bleeding but the limited numbers do not make this result significant. There were no differences in terms of other complications, except for the incidence of seroma in group B. Conclusion. The use of CFTP reduces the drainage volume, potentially the bleeding complications, and the hospital stay. These findings confirm the efficacy of CFTP, encouraging its use in thyroid surgery.

Differentiated thyroid cancer: feasibility of loboisthmectomy in an endemic region

AIM

The aim of the present retrospective study was to assess the feasibility of loboisthmectomy for the treatment of differentiated thyroid cancer in a endemic area, evaluating the histopathological features and the results of a case series of 1154 patients.

PATIENTS AND METHODS

The clinical records of 1154 patients submitted to total thyroidectomy in our Department were retrospectively reviewed to analyze the histopathological characters and the results.

RESULTS

In 1044 cases (90.5%) a papillary cancer was observed, in 110 (9.5%) a follicular carcinoma; microcarcinomas were 399 (34.5%). Multifocality was present in 323 cases (28%), in 142 unilateral (12.3%) and in 181 bilateral (15.7%). Thyroiditis coexisted in 472 patients (40.9%), multinodular goiter in 404 (35%), Graves' disease in 48 (4.1%), and multinodular toxic goiter in 38 (3.3%). Complications were: postoperative bleeding in 20 patients (1.7%), transient unilateral vocal cord paralysis in 20 (1.7%) definitive in 10 (0.86%), a transient bilateral paralysis in 1 (0.08%), a transient hypoparathyroidism in 351 (30.4%), and a definitive in 24 (2.07%). Nodal recurrence occurred in 25 patients (2.16%).

CONCLUSIONS

Total thyroidectomy remains the safest treatment in differentiated thyroid cancer, especially if performed in high volume centers in which complications can be minimized. Loboisthmectomy can be a viable and safe alternative in small (< 1 cm) unifocal tumors in patients at low risk. Loboisthmectomy is limited in endemic areas by the association with other thyroid diseases. A correct and detailed information of the patient is essential before planning surgery.

Completion thyroidectomy and total thyroidectomy for differentiated thyroid cancer: Comparison and prediction of postoperative hypoparathyroidism

BACKGROUND

Consensus regarding the difference of postoperative hypoparathyroidism following completion thyroidectomy (CT) and total thyroidectomy (TT) has yet to be reached. We compare the occurrence of postoperative hypoparathyroidism between CT and TT for differentiated thyroid cancer (DTC), and explore the predictive factors for postoperative hypoparathyroidism.

METHODS

We retrospectively reviewed 221 consecutive patients underwent CT or TT for DTC between February 2012 and March 2014. Patients' demographic and clinical data of the two groups were analyzed.

RESULTS

There were 57 CTs and 164 TTs. Temporary hypoparathyroidism occurred in 12.3% (7 of 57) and 28.0% (46 of 164) of patients in the CT and TT groups, respectively. In univariate analysis, type of surgical procedure (CT or TT) and extent of central lymph node dissection (CND) (unilateral or bilateral) were significantly associated with the postoperative temporary hypoparathyroidism (P < 0.05). Multivariate analysis showed that only the extent of CND was an independent risk factor for temporary hypoparathyroidism.

CONCLUSIONS

Although temporary hypoparathyroidism was lower in the CT group, our analysis indicates the difference is due to the extent of CND rather than type of surgical procedure (CT vs. TT). Only bilateral CND is an independent risk factor for temporary hypoparathyroidism after thyroidectomy. J. Surg. Oncol. 2016;113:522-525. © 2016 Wiley Periodicals, Inc.

Complications in thyroid surgery. Harmonic Scalpel, Harmonic Focus versus Conventional Hemostasis: A meta-analysis

BACKGROUND

To evaluate the incidence of postoperative complications, hemostatic effects and safety of Total Thyroidectomy (TT) performed using the Harmonic Scalpel (HS), the Harmonic Focus (HF) or Conventional Hemostasis (CH).

METHODS

The meta-analysis was performed according to PRISMA guidelines. A literature search was conducted from 2003 to 2014 and stringent criteria were required for inclusion. Thirteen studies concerning an overall population of 1458 compared HS versus CH, whilst 8 studies with 1667 patients compared HF versus CH.

RESULTS

There was a significant reduction of operative time (Mean Difference [MD] = -25.49 min.; 95% CI -32.43 to -18.55), intraoperative blood loss (MD = -30.49 mL; 95% CI -53.01 to -7.97), postoperative drainage volume (MD = -12.90 mL; 95% CI -22.83 to -2.98) and postoperative pain (MD = -0.87; 95% CI -1.27 to -0.46) in patients underwent TT with HS. Regarding HF group, a significant reduction of operative time (MD = -25.99 min., 95% CI -34.56 to -17.41), length of hospital stay (MD = -0.57; 95% CI -0.97 to -0.17), transient hypocalcemia (OR = 0.56; 95% CI 0.39 to 0.81) and postoperative pain (MD = -1.33 days; 95% CI -2.49 to -0.17) resulted.

CONCLUSIONS

HS TT can be a safe, useful and fast alternative to conventional TT. The newer HF can reduce the rate of hypocalcemia. Future RCTs of larger patient cohorts with more detailed data of postoperative complications, cost-effectiveness and cosmetic results, randomization procedures, intention-to-treat analyses and blinding of outcome assessors are needed to draw more meaningful conclusions.

[Bilateral vocal cord paresis after total thyroidectomy]

A 66-year-old female patient complained of hoarseness and dyspnea under exertion following total thyroidectomy. Due to a faulty operating technique both nerves to the vocal cords were damaged. From the operation report it emerged that the dissection was carried out by protecting the border lamellae but the recurrent laryngeal nerve could not be found on both sides. This article presents the external expert opinion, the decision of the arbitration board and the assessment of the case by two specialist physicians.

Surgical approach to mediastinal goiter: An update based on a retrospective cohort study

AIM

Surgery for mediastinal goiters (MG) is indicated for compression symptoms and risk of malignancy. Total thyroidectomy by cervicotomy is universally considered the standard surgical approach to MG. In selected cases sternotomy or a thoracotomy are used. Options of the operative technique and practical surgical problems are analysed.

METHODS

A retrospective analysis of twenty-eight-years on 1767 cases of MG in a referral centre for endocrine surgery was carried out. All patients underwent standard preoperative study and CT based surgical planning. Surgery was performed by an experienced surgical team with standard technique via cervical approach or in selected case via sternotomy or thoracotomy. Clinical records were examined.

RESULTS

Total thyroidectomy was performed in all cases. A cervical approach was used in almost 99% of patients. Significant shorter surgical time was observed for surgery via the cervical approach vs sternotomy and thoracotomy. Benign struma was observed in 1503 patients and a carcinoma in 264. We observed postoperative bleeding in 0.5% of cases, permanent monolateral recurrent laryngeal nerve palsy occurred in 1.3%, bilateral palsy in 0.6%, transient and permanent hypoparathyroidism in 14% and 4.1% respectively.

CONCLUSION

MG may be approached by a cervicotomic access only with a clear knowledge of potential risk and complications of the surgical manoeuvres. Sternotomy or of a thoracotomy are indicated only in selected cases but their inapplicability may be really dangerous in those MG not otherwise resectable. MG should be referred only to specialized centre.

Risk factors for post-thyroidectomy haematoma

Background:

There has been increasing emphasis on performing ‘same-day’ or ‘out-patient’ thyroidectomy to reduce associated costs. However, acceptance has been limited by the risk of potentially life-threatening post-operative bleeding. This study aimed to review current rates of post-operative bleeding in a metropolitan teaching hospital and identify risk factors.

Method:

Medical records of patients undergoing thyroidectomy between January 2007 and March 2012 were reviewed retrospectively. Pre-operative, operative and pathological data, and post-operative complication data, were examined.

Results:

The study comprised 205 thyroidectomy cases. Mean age was 51.6 years (standard deviation = 14.74), with 80 per cent females. Unilateral thyroidectomy was performed in 81 cases (39.5 per cent) and total thyroidectomy was performed in 74 cases (36.1 per cent; 5.3 per cent with concomitant lymph node dissection). Nine patients (4.4 per cent) suffered post-operative bleeding, of which six required re-operation. Analysis showed that post-operative systolic blood pressure of 180 mmHg or greater was associated with post-operative bleeding (p = 0.003, chi-square test).

Conclusion:

Rates of significant post-operative bleeding are consistent with recent literature. Post-operative hypertension, diabetes and high post-operative drain output were identified as independent risk factors on multivariate analysis; when identified, these may be caveats to same-day discharge of thyroidectomy patients.

Terminal or truncal ligation of the inferior thyroid artery during thyroidectomy? A prospective randomized trial

INTRODUCTION

Thyroidectomy is a common procedure in general and endocrine surgery. The technique of ligation of inferior thyroid artery (ITA) has been invoked as a possible cause of appearance of postoperative hypocalcemia.

METHODS

We performed a prospective randomized study involving 184 patients undergoing total thyroidectomy to evaluate the differences of truncal ligation versus distal ligation of ITA in terms of postoperative hypocalcemia, vocal fold palsy, voice and swallowing impairment. The patients were divided into group A (trunk ligation of ITA) and group B (terminal branches ligation of ITA).

RESULTS

We evaluated postoperative PTH and calcemia (immediate, 6 and 12 months after thyroidectomy), postoperative day of discontinuation of calcium and vitamin D supplementation, voice and swallowing complaints, evaluated by mean of two specific tests available in literature, day of hospital discharge.

CONCLUSION

The only significant differences between the two groups were a higher immediate postoperative calcemia and a greater number of patients discharged without calcium and vitamin-D supplementation in the group B. In conclusion, no substantial differences were found between the two groups. The choice depends on the experience of the surgeon.

Bilateral benign multinodular goiter: What is the adequate surgical therapy? A review of literature

BACKGROUND

Benign multinodular goiter (BMNG) is the most common endocrine disease requiring surgery. During the last few years a more aggressive approach has become the trend for bilateral BMNG treatment.

METHOD

Randomized clinical trials of any size that compared bilateral subtotal resection, Dunhill procedure and total thyroidectomy for benign multinodular goiter, published between January 2000 and the end of March 2015, were reviewed.

DISCUSSION

Total thyroidectomy can be considered the most reliable approach in preventing recurrence. The Dunhill procedure is related to a higher rate of recurrence, but rarely recurrences after Dunhill procedure lead to reoperation. Total thyroidectomy avoid completion thyroidectomy for incidental carcinoma and its related risks. Recurrent laryngeal nerve (RLN) palsy becomes less common as surgical experience increases. Transient and permanent hypoparathyroidism is strictly related to the extent of neck dissection. In the risk-cost analysis we must consider the type of patient candidated to surgery and the impact of the surgical protocol we apply. When thyroid surgery is taken in consideration, specific complication rates of different procedures in each hospital must be analyzed accordingly to patient-specific risk factors and local expertise.

CONCLUSION

The Dunhill procedure seems to be a good compromise between radicality and prevention of complications, avoiding reoperation for recurrence or completion thyroidectomy for incidental thyroid carcinoma. More follow-up studies and prospective studies are necessary to better evaluate, definitively, whether to prefer total thyroidectomy or Dunhill procedure in case of benign goiter surgery.

Thoracic duct lesions in thyroid surgery: An update on diagnosis, treatment and prevention based on a cohort study

INTRODUCTION

Thoracic duct fistula at the cervical level is a severe but rare complication following thyroid surgery, particularly associated to lateral dissection of the neck and to mediastinal goiter.

METHODS

we retrospectively analyzed chylous fistulas observed in a cohort of 13.224 patients underwent surgery for thyroid disease since 1986 to 2014, in the Unit of Endocrine Surgery, S. Maria University Hospital, Terni, Italy.

RESULTS

We observed 20 cases of chylous fistula. Thirteen patients underwent primary surgery in our institution while the remaining 7 cases had been referred to our Department from other hospitals for an already diagnosed lymphatic leak. Surgical procedures carried out included total thyroidectomy for mediastinal goiter in 4 patients, total thyroidectomy for cancer in 2 patients, unilateral functional lymphadenectomy in 11 patients and bilateral in 3. Intraoperative repair was carried out in 4 cases. Of the remaining 16 cases, 4 of the 6 fistulas with low flow leakage healed in about 30 days of conservative treatment, 2 cases instead required surgical repair. All 10 patients with "high-flow" fistula underwent surgery. Despite surgery was performed later, postoperative course in patients with late surgical repair is similar to what observed in those patients with early surgical repair. Both groups underwent cervical drainage removal in post-operative day 4.

CONCLUSION

Healing of a cervical chylous fistula can be achieved by conservative medical therapy (nutritional and pharmacological) but in case of therapeutic failure with rapid decrease of general condition, the surgical approach is necessary. In our experience, duct ligation after unsuccessful conservative treatment, is the only resolutive treatment.

Prospective comparative study of endoscopic via unilateral axillobreast approach versus open conventional total thyroidectomy in patients with papillary thyroid carcinoma

BACKGROUND

Total thyroidectomy can be accomplished in one of two ways. The first is an open conventional approach, and the other is an endoscopic unilateral axillobreast approach (UABA). However, the two have not been thoroughly compared. In the study described herein, we compare the technical feasibility, safety, and surgical completeness of open versus endoscopic total thyroidectomy procedures.

METHODS

A total of 152 patients who underwent open (n = 102) or endoscopic (n = 50) total thyroidectomy via UABA for papillary microcarcinoma from January to December 2011 were enrolled in this study. Data were collected prospectively after obtaining informed consent. We analyzed the clinical characteristics, pathologic results, postoperative thyroglobulin (Tg) levels, and results of radioactive iodine treatment between the two groups.

RESULTS

We conclude that endoscopic thyroidectomy resulted in a younger age, lower body mass index, longer operation time and drain maintenance, and larger drain amount. There were no significant differences with respect to gender, hospital stay, tumor size, time for central compartment neck dissection, number of harvested ipsilateral lymph nodes, or bleeding amount between groups. The proportion of extrathyroidal extension, multifocality, and bilaterality did not differ, and the surgical complication rate was similar. In addition, the postoperative stimulated and non-stimulated Tg levels did not differ significantly, nor did the thyroid bed/brain iodine uptake ratio.

CONCLUSIONS

Based on our results, endoscopic total thyroidectomy via UABA is technically feasible and has comparable surgical completeness to open total thyroidectomy for papillary microcarcinoma within 1 cm.

Hypoparathyroidism: Replacement Therapy with Parathyroid Hormone

Hypoparathyroidism (HypoPT) is characterized by low serum calcium levels caused by an insufficient secretion of parathyroid hormone (PTH). Despite normalization of serum calcium levels by treatment with activated vitamin D analogues and calcium supplementation, patients are suffering from impaired quality of life (QoL) and are at increased risk of a number of comorbidities. Thus, despite normalization of calcium levels in response to conventional therapy, this should only be considered as an apparent normalization, as patients are suffering from a number of complications and calcium-phosphate homeostasis is not normalized in a physiological manner. In a number of recent studies, replacement therapy with recombinant human PTH (rhPTH(1-84)) as well as therapy with the N-terminal PTH fragment (rhPTH(1-34)) have been investigated. Both drugs have been shown to normalize serum calcium while reducing needs for activated vitamin D and calcium supplements. However, once a day injections cause large fluctuations in serum calcium. Twice a day injections diminish fluctuations, but don't restore the normal physiology of calcium homeostasis. Recent studies using pump-delivery have shown promising results on maintaining normocalcemia with minimal fluctuations in calcium levels. Further studies are needed to determine whether this may improve QoL and lower risk of complications. Such data are needed before replacement with the missing hormone can be recommended as standard therapy.

The Surgical Approach to Differentiated Thyroid Cancer

The incidence of thyroid cancer is increasing rapidly. A large percentage of new cases identified fall into a low-risk category. As the incidence has increased, clinical experience has confirmed that the majority of patients will have excellent outcomes and that those at risk of doing badly can be reliably identified. Treatment for thyroid cancer is predominantly surgical. The decision about how aggressively this disease should be managed has remained controversial due to the excellent outcomes irrespective of the nature of surgical procedure chosen. This article reviews the developments in our understanding of the biology of thyroid cancer and the evidence that supports the approach to management.

The Clinical Significance of the Right Para-Oesophageal Lymph Nodes in Papillary Thyroid Cancer

PURPOSE

Although guidelines indicate that routine dissection of the central lymph nodes in patients with thyroid carcinoma should include the right para-oesophageal lymph nodes (RPELNs), located between the right recurrent laryngeal nerve and the cervical oesophagus and posterior to the former, RPELN dissection is often omitted due to high risk of injuries to the recurrent laryngeal nerve and the right inferior parathyroid gland.

MATERIALS AND METHODS

We retrospectively identified all patients diagnosed with papillary thyroid carcinoma who underwent total thyroidectomy with central lymph node dissection, including the RPELNs, between January 1, 2009 and December 31, 2013 at the Thyroid Cancer Center of Yonsei University College of Medicine, Seoul, Korea.

RESULTS

Of 5556 patients, 148 were positive for RPELN metastasis; of the latter, 91 had primary tumours greater than 1 cm (p<0.001). Extrathyroidal extension by the primary tumour (81.8%; p<0.001), bilaterality, and multifocality were more common in patients with than without RPELN metastasis; however, there were no significant differences in age and sex between groups. A total of 95.9% of patients with RPELN metastasis had central node (except right para-oesophageal lymph node) metastasis, and the incidence of lateral neck node metastasis was significantly higher in patients with than without RPELN metastasis (63.5% vs. 14.3%, p<0.001). Forty-one patients underwent mediastinal dissection, with 11 patients confirmed as having mediastinal lymph node metastasis with RPELN metastasis on pathological examination.

CONCLUSION

RPELN metastasis is significantly associated with lateral neck and mediastinal lymph node metastasis.

Outpatient Thyroidectomy: Is it Safe?

Outpatient thyroid surgery is controversial because of concerns over life-threatening cervical hematoma. Despite this concern, outpatient thyroidectomy is becoming increasingly common, especially among high-volume endocrine surgeons. Multiple studies have now demonstrated that careful patient selection combined with surgeon experience can result in successful and safe surgery without a full inpatient admission. This article reviews the data on safety and outcomes for outpatient thyroidectomy and discusses several techniques used to minimize risk to patients.

Effect of malignancy rates on cost-effectiveness of routine gene expression classifier testing for indeterminate thyroid nodules

BACKGROUND

The value of gene expression classifier (GEC) testing for cytologically indeterminate thyroid nodules lies in its negative predictive value, which is influenced by the prevalence of malignancy. We incorporated actual GEC test performance data from a tertiary referral center into a cost-effectiveness analysis of GEC testing.

METHODS

We evaluated consecutive patients who underwent GEC testing for Bethesda category III and IV nodules from 2012 to 2014. Routine GEC testing was compared with conventional management by the use of a decision tree model. Additional model variables were determined via literature review. A cost-effectiveness threshold of $100,000 per quality-adjusted life-year (QALY) was used.

RESULTS

The prevalence of malignancy was 24.3% (52/214). Sensitivity and specificity of GEC testing were 96% and 60%. Conventional management cost $11,119 and yielded 22.15 QALYs. Routine GEC testing was more effective and more costly, with an incremental cost-effectiveness ratio of $119,700/QALY, making it not cost-effective. At malignancy rates of 15, 25, or 35%, routine GEC testing became cost-effective when the cost of GEC testing fell below $3,167, $2,595, or $2,023.

CONCLUSION

The cost-effectiveness of routine GEC testing varies inversely with the underlying prevalence of malignancy in the tested population. The value of routine GEC testing should be assessed within the context of institution-specific malignancy rates.

Management of bilateral recurrent laryngeal nerve paresis after thyroidectomy

Bilateral recurrent laryngeal nerve (RLN) injury is rare for benign thyroid lesions (0.2%). After extubation-stridor, respiratory distress, aphonia occurs due to the closure of the glottic aperture necessitating immediate intervention and emergency intubation or tracheostomy. Intra-operative identification and preservation of the RLN minimizes the risk of injury. It is customary to expect RLN problems after thyroid surgery especially if malignancy, big thyroid, distorted anatomical problems and difficult airway that can lead to intubation trauma. Soon after extubating, it is essential to the anesthetist to check the vocal cord movements on phonation and oropharyngeal reflexes competency. But this case is specially mentioned to convey the message that in spite of absence of above mentioned predisposing factors for complications and good recovery profile specific to thyroid, there can be unanticipated airway compromise that if not attended to immediately may cost patient's life. This is a case of postextubation stridor following subtotal thyroidectomy due to bilateral RLN damage and its management.

Anaesthesia for goitre surgery: A review

Goitres are relatively common and, in extreme cases, present unique challenges (particularly in airway management) for the anaesthetist. There are no specific guidelines from the Difficult Airway Society (United Kingdom) or the American Society of Anesthesiologists for the management of the obstructed airway. We therefore present the principles governing the provision of safe anaesthesia for goitre surgery including formulating a plan ABC for patients with a stable airway and for those presenting with acute airway obstruction.