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

Bilateral Truncal Ligation of the Inferior Thyroid Artery during Bilateral Subtotal Thyroidectomy Causes a Decrease in Parathormone without Clinically Manifest Hypoparathyroidism: A Randomized Clinical Trial

BACKGROUND

Bilateral truncal ligation (BTL) of the inferior thyroid artery (ITA) is frequently used during subtotal thyroidectomy to reduce the risk of post-operative bleeding as well as to reduce the blood loss intra-operatively. However, its effect on parathyroid function has not been evaluated in relation to age, residual and resected thyroid volume.

METHODS

A total of 83 patients were randomized to receive non-BTL or BTL. After bilateral resection, the residual thyroid tissue on each side was measured by intra-operative ultrasonography. Laboratory and clinical examinations were performed the day before operation, intra-operatively and on post-operative days 2 and 5. The primary outcome measure was the difference in intact parathormone (PTHi) on post-operative day 5. Secondary outcomes were laboratory-diagnosed hypocalcaemia or hypoparathyroidism and clinically manifest hypoparathyroidism, respectively.

RESULTS

PTHi on post-operative day 5 was significantly lower in the BTL group (29.4 vs. 34.7 ng/l in the non-BTL group, p = 0.033), especially in 61- to 80-year-old patients (0 vs. -7.91 ng/l, p = 0.029). The biggest decline in PTHi was found in the BTL group (-14.067 ng/l PTH, p = 0.018) with a residual thyroid volume of 0.5-1.9 ml. There were two cases of asymptomatic hypoparathyroidism in each group (5.1 vs. 4.8%, respectively, p = 1.000). The only case of clinically manifest hypoparathyroidism was in a BTL group patient aged 64 years (2.4%, p = 1.000).

CONCLUSION

BTL of the ITA during subtotal thyroidectomy causes a larger decrease in PTH but does not lead to a significantly higher rate of clinically manifest hypoparathyroidism. BTL of the ITA, age >61 years, and a very small thyroid remnant (<2 ml) may be risk factors for post-operative hypoparathyroidism.

Surgical morbidity of cervical lymphadenectomy for thyroid cancer: A retrospective cohort study over 25 years

INTRODUCTION

Prognosis of thyroid cancer is strictly related to loco-regional metastases. Cervical lymphadenectomy has a specific oncologic role but may lead to significant increase of morbidity. Aim of the study is the analysis of surgical morbidity in cervical lymphadenectomy for thyroid cancer.

METHODS

We retrospectively analyzed 1.765 thyroid cancers operated over a period of 25 years at S. Maria University Hospital, Terni, University of Perugia, Italy. Type of lymphadenectomy, histology and complications were analysed.

RESULTS

A prevalence of differentiated and medullary cancers was observed (respectively 88% and 7.2%). Central lymphadenectomy was carried out in 425 patients, lateral modified and radical lymphadenectomy respectively in 651 and 17 cases. Following central neck dissection we observed: bilateral and unilateral temporary recurrent nerves palsy respectively of 0.7% and 3.5%, unilateral permanent palsy in 1.6% of cases, temporary and permanent hypoparathyroidism respectively in 17.6% and 4.4%. After lateral neck dissection we observed: intra and post-operative haemorrhage respectively in 2% and 0.29%, respiratory distress in 0.29%, lesions of facial nerve in 0.44%, of vagus in 0.14%, of phrenic nerve in 0.14%, of hypoglossal nerve in 0.29%, of the accessory nerve, transient in 1.34% and permanent in 0.29%, permanent lesion of cervical plexus in 0.29%, salivary fistula in 0.14% and chylous fistula in 1.04% of patients. Student's t test was used to compare groups when appliable.

CONCLUSION

Central and lateral cervical lymph node dissection are associated to severe morbidity. Correct indication, surgical expertise, high volume of patients and early multidisciplinary management of complications is the key of an acceptable balance between oncologic benefits and surgical morbidity.

Efficacy and Safety of Radiofrequency Ablation Versus Observation for Nonfunctioning Benign Thyroid Nodules: A Randomized Controlled International Collaborative Trial

BACKGROUND

Percutaneous radiofrequency thermal ablation (RFA) has been reported as an effective tool for the management of benign thyroid nodules (BTN). However, large, randomized controlled trials (RCTs) are lacking.

OBJECTIVE

The aims of this study were to assess the volume reduction of BTN after a single RFA performed using the moving-shot technique and to compare the volume reduction obtained in patients treated in two centers with different experience of the moving-shot technique.

METHOD

This study was an international prospective RCT. It was carried out at the Mauriziano Hospital (Turin, Italy) and the Asan Medical Center (Seoul, Korea). Eighty patients harboring solid, compressive, nonfunctioning BTN (volume 10-20 mL) were enrolled. Twenty patients in each country were treated by RFA using a 18-Gauge internally cooled electrode (group A); 20 nontreated patients in each country were followed as controls (group B).

RESULTS

At six months, BTN volume significantly decreased in group A (15.1±3.1 mL vs. 4.2±2.7 mL; p<0.0001), whereas it remained unchanged in group B (14.4±3.3 mL vs. 15.2±3.5 mL). The baseline volume was larger in the Italian series (16.4±2.5 mL vs. 13.9±3.3 mL, p=0.009). However, at six months, there was no significant difference between the Korean group and the Italian group (3.7±2.9 mL vs. 5.5±2.2 mL). Both cosmetic and compressive symptoms significantly improved (3.6±0.5 vs. 1.7±0.4 and 3.6±1.9 vs. 0.4±0.7, respectively; p<0.001). No side effects occurred.

CONCLUSIONS

RFA was effective in reducing the volume of BTN. The outcome was similar in centers with different experience in the moving-shot technique.

Thyroid surgery performed on an overnight basis: a 17 years of experience

OBJECTIVE

This study aimed to evaluate the results of thyroid surgeries with hospitalization periods shorter than 18 hours performed in a surgical endocrinology service, correlating these results with type of procedure, the definitive diagnosis and complications associated with the procedure.

SUBJECTS AND METHODS

The procedures performed, complications associated, hospitalization period, and relationships among these variables were assessed in consecutive patients subjected to different types of thyroid surgeries from January 1997 to March 2014 by the same group of surgeons. Data were analyzed by frequency, and the associations between the hospitalization period and other variables were analyzed using the Pearson chi-square test and Fisher's exact test, using a multiple comparisons test with Bonferroni correction.

RESULTS

Among the 3,411 surgeries performed, 799 of them were malignant neoplasia, 2,505 were benign tumors and 107 were Graves' disease. The following procedures were performed: total thyroidectomy (1597 patients); total thyroidectomy with neck exploration (369 patients); lobectomy plus isthmectomy (1084 patients); total thyroidectomy complementation (145 patients); total thyroidectomy with neck dissection (84 patients); modified radical total thyroidectomy (13 patients); nodulectomy (11 patients); unresectable (9 patients); central neck dissection (48 patients); lateral neck dissection (38 patients); and others (13 patients). The following surgical complications, characteristic of the procedure: hemorrhage in 41 (1.2%) patients, hypoparathyroidism in 10 (0.3%) patients and recurrent laryngeal nerve (RLN) injury in 23 (0.7%) patients. Hospitalization shorter than 18 hours was observed in 97% of patients.

CONCLUSION

Thyroid surgery can be safely performed in virtually all patients on an overnight basis in specialized services.

Effect of injection augmentation on need for framework surgery in unilateral vocal fold paralysis

OBJECTIVES/HYPOTHESIS

To determine whether injection augmentation reduces the likelihood of ultimately needing definitive framework surgery in unilateral vocal fold paralysis (UVFP) patients.

STUDY DESIGN

Retrospective cohort study.

METHODS

All patients diagnosed with UVFP (2008-2012) at the academic center were identified. The time from symptom onset to presentation to either community otolaryngologist and/or academic center, as well as any directed treatment(s), were recorded. Stepwise, multivariate logistic regression analysis was used to determine whether injection augmentation independently affected odds of needing definitive, framework surgery among patients who were seen within 9 months of symptom onset and had not undergone any prior rehabilitative procedures.

RESULTS

Cohort consisted of 633 patients (55% female, 80% Caucasian, median age 60 years) with UVFP. The majority of etiologies were either surgery (48%) or idiopathic (37%). Duration to presentation at community otolaryngologist was shorter than to the academic center (median 2 vs. 6 months). Overall, less than half of UVFP patients had any operation (46%). Multivariate logistic regression found that earlier injection augmentation did not affect odds of ultimately undergoing framework surgery (odds ratio 1.13; confidence interval, 0.92-1.40; P = 0.23).

CONCLUSION

Nearly half of UVFP patients do not require any rehabilitative procedure. When indicated, early injection augmentation is effective at temporarily alleviating associated symptoms but does not reduce likelihood of needing a definitive framework operation in patients with UVFP. Understanding practice patterns and fostering early detection and treatment may improve quality of life in this patient population.

Postoperative Complications After Prophylactic Thyroidectomy for Very Young Patients With Multiple Endocrine Neoplasia Type 2: Retrospective Cohort Analysis

The aim of this study was to investigate whether younger age at surgery is associated with the increased incidence of postoperative complications after prophylactic thyroidectomy in pediatric patients with multiple endocrine neoplasia (MEN) 2. The shift toward earlier thyroidectomy has resulted in significantly less medullary thyroid carcinoma (MTC)-related morbidity and mortality. However, very young pediatric patients might have a higher morbidity rate compared with older patients. Hardly any literature exists on complications in the very young. A retrospective single-center analysis was performed on the outcomes of MEN2 patients undergoing a prophylactic total thyroidectomy at the age of 17 or younger. Forty-one MEN2A and 3 MEN2B patients with thyroidectomy after January 1993 and at least 6 months of follow-up were included, subdivided in 9 patients younger than 3 years, 15 patients 3 to 6 years, and 20 patients older than 6 years. Postoperative hypocalcemia and other complications were registered. Twelve (27%) patients developed transient hypocalcemia and 9 (20%) patients suffered from permanent hypocalcemia, with a nonsignificant trend toward higher incidence with decreasing age. Three (7%) patients had other complications, of whom 2 were younger than 3 years. For patients younger than 3 years, the average length of stay (LOS) was 6.7 days, versus 1.7 and 3.5 days, respectively, for the older patient groups (P < 0.05). Patients with complications had a longer LOS compared with patients without (5.0 vs 2.0, P < 0.01). None of the patients had clinical signs of recurrent MTC after a mean follow-up of 10.5 years. Prophylactic thyroidectomy in very young children is associated with a higher rate of complications, causing a significant increased LOS. Irrespective age of surgery, MTC did not recur in any patient. In planning optimal timing of surgery, clinicians should take the risk of complications into account. We advise not to perform total thyroidectomy before the age of 3 for patients defined high risk by the American Thyroid Association guideline.

Endocrinopathies: The current and changing perspectives in anesthesia practice

The gateways to advancements in medical fields have always been accessed through the coalition between various specialties. It is almost impossible for any specialty to make rapid strides of its own. However, the understanding of deeper perspectives of each specialty or super specialty is essential to take initiatives for the progress of the other specialty. Endocrinology and anesthesiology are two such examples which have made rapid progress in the last three decades. Somehow the interaction and relationship among these medical streams have been only scarcely studied. Diabetes and thyroid pathophysiologies have been the most researched endocrine disorders so far in anesthesia practice but even their management strategies have undergone significant metamorphosis over the last three decades. As such, anesthesia practice has been influenced vastly by these advancements in endocrinology. However, a comprehensive understanding of the relationship between these two partially related specialties is considered to be an essential cornerstone for further progress in anesthesia and surgical sciences. The current review is an attempt to imbibe the current and the changing perspectives so as to make the understanding of the relationship between these two medical streams a little simple and clearer.

Videoendoscopic Evaluation of Swallowing After Thyroidectomy: 7 and 60 Days

Deglutition complaints are frequent after thyroidectomy. The purpose of this study was to follow-up on patients with thyroidectomy indication to compare the videoendoscopic evaluation of swallowing on the seventh day (early postoperative, EPO) and on the 60th day after thyroidectomy, (late postoperative, LPO) and to compare patients that evolved with normal laryngeal mobility (NLM) and abnormal laryngeal mobility (ALM). Nasofibroscopic evaluation was performed preoperatively (PRE), on the EPO and LPO. Two groups were compared: ALM and NLM. The majority of people were women, age bracket 46-65, who underwent total thyroidectomy and with high frequency of carcinoma. 30 out of the 54 patients in the study had change in swallowing (55 %). Dysphagia occurred in 87 % (13/15) of patients with ALM in the EPO and remained in 67 % of them in the LPO. In the NLM group, dysphagia occurred in 44 % (17/39) in EPO and 25 % in LPO. There was a statistical difference between PRE and EPO, and PRE and LPO (P < 0,001). In the ALM group, liquid penetration and aspiration were identified in 33 % of the cases during EPO (P = 0,014); retention of food occurred in 87 % in EPO and in 60 % in LPO (P < 0,001). Dysphagia occurs in patients after thyroid surgery (regardless of larynx mobility alteration) and characterized by stasis of food in the oro and hypopharynx, which is also noticed in LPO, though more frequently in EPO.

The use of a biologic topical haemostatic agent (TachoSil(®)) for the prevention of postoperative bleeding in patients on antithrombotic therapy undergoing thyroid surgery: A randomised controlled pilot trial

INTRODUCTION

Anticoagulants and antiplatelet agents are well-known risk factors for post-operative bleeding. The aim of this prospective, randomized pilot study was to evaluate the effectiveness of a topical haemostatic agent, namely TachoSil, for the prevention of postoperative bleeding in patients on antithrombotic therapy undergoing thyroidectomy. Perioperative management and some distinctive aspects of cervical haematomas were also discussed.

METHODS

Between January 2012 and May 2014, all patients taking vitamin K antagonists (VKAs) or acetyl salicylic acid (ASA) scheduled for total thyroidectomy were enrolled and randomly allocated to group 1 (standard haemostasis) and group 2 (standard haemostasis + TachoSil). Antithrombotic drugs were always suspended prior to surgery and, when indicated, replaced by bridging anticoagulation with low-molecular-weight heparin. The primary endpoint was the incidence of postoperative cervical haematomas.

RESULTS

A total of 70 patients were included in the study, representing 8.5% (70/820) of all patients who underwent thyroidectomies in the same period. The overall rate of post-operative cervical haematoma was 7.1% (5/70) and reached 14.8% (4/27) in patients on VKA therapy. All but one occurred more than 24 h after surgery (32nd hour, 8th, 10th, and 13th days). Group 1 (37 patients) and group 2 (33 patients) were well-matched according to clinical and demographic features. Postoperative haematoma was observed in 2/37 patients (5.4%) recruited in the Group 1 and 3/33 patients (9.1%) recruited in the Group 2 (P = 0.661).

CONCLUSIONS

Patients taking antithrombotic drugs represent a major problem in thyroid surgery. The incidence of bleeding after thyroidectomy is significantly high and the use of TachoSil do not seem effective in preventing its occurrence. However, larger multicenter study is needed to confirm these results.

Six-Year Experience With Endoscopic Thyroidectomy: Outcomes and Safety Profile

BACKGROUND

Though minimally invasive video-assisted thyroidectomy (MIVAT) offers many advantages over traditional thyroid surgery, its adoption in North America has been limited. This study analyzes the largest series of MIVAT in North America to explore its safety.

METHODS

A prospectively maintained database of all patients undergoing thyroid surgery by a single surgeon from 2003 to 2011 at an academic tertiary care medical center was evaluated. Demographic information, surgical and pathologic data, and postoperative outcomes were analyzed.

RESULTS

Beginning in 2005, a total of 260 MIVATs were performed during the study period. Outpatient surgery was accomplished in 234 MIVATs (90%). MIVAT patients were predominantly young (46.8±14.8 years vs 52.4±14.6 years for conventional thyroidectomy) and female (88.5% vs 75.5% for conventional thyroidectomy). There were no cases of permanent hypoparathyroidism or permanent recurrent laryngeal nerve dysfunction. Observed complications included transient recurrent laryngeal nerve dysfunction (n=10; 3.8%), cellulitis (n=1; 0.4%), and temporary hypocalcemia (n=6; 2.3%). The overall complication rate for MIVAT (6.5%) was lower than the overall complication rate in conventional thyroidectomy (18.5%, P<.0001).

CONCLUSION

MIVAT can be performed safely with a low complication profile in a high-volume practice. The safety of MIVAT represented by this experience supports broader adoption across surgical practices.

Clinico-Epidemiological Study and Treatment Outcome of Multinodular Goitre at A Tertiary Care Hospital

BACKGROUND

Thyroid enlargement has been a common problem encountered in general surgical practice. Thyroid being an endocrine gland, its involvement has a diverse issue from a meagre cosmetic problem to a more concerned malignancy.

AIM

This study was conducted to study the age and sex distribution along with the mode of presentation of Multinodular Goitre (MNG). The incidence of malignancy and the surgical complications in the study population were also studied.

MATERIALS AND METHODS

In this descriptive study, patients diagnosed with MNG from January 2011 to July 2012 were chosen from the in-patient of our teaching hospital. One hundred such patients who qualified to undergo surgery were included in the study after a detailed history and clinical examination. Patients underwent Fine needle aspiration cytology (FNAC) for preoperative pathological diagnosis and the goitre was confirmed to be benign. Patients diagnosed with malignancy were excluded from the study. Following thyroidectomy, the thyroid specimens were subjected to histopathological examination.

RESULTS

Among the 100 cases of MNG, 59% patients belonged to 3rd and 4th decade of life, 90% patients were females, 82% presented before 5yrs. The most common symptom at presentation was swelling (100%). Among the patients 80% were in euthyroid state, 19% were hyperthyroid and 1% hypothyroid. Most of the patients were treated with sub-total thyroidectomy (59%), followed by total (20%), near total (11%), and Hemithyroidectomy (10%). Following surgery complications like stridor and laryngeal oedema (3%), wound infection (2%), hypocalcemia (2%), haemorrhage (1%) and seroma (1%) were noted. On Histopathological examination (HPE) of the surgical specimen, 3% were reported to be malignant.

CONCLUSION

As noted by this study, Multinodular Goitre is more common among females in the third and fourth decades. Patients can present with various complaints. MNG can present as hyperthyroid, hypothyroid but mostly in euthyroid state. The indication for surgery in patients with MNG includes cosmesis, hyperthyroidism, local compressive symptoms and most importantly malignancy. Subtotal thyroidectomy is the preferred surgery, but a trend towards total and near total thyroidectomy is noticeably replacing the old belief in subtotal thyroidectomy.

Frequency and severity of globus pharyngeus symptoms in patients undergoing thyroidectomy: a pre-post short term cross-sectional study

Background

Globus pharyngeus is a sensation of a lump or foreign body in the throat, sometimes associated with thyroid diseases and surgery. Previous studies investigated this condition with contradictory results, mainly because not standardized instruments of measure were used. The aim of this study was to evaluate the prevalence and severity of globus pattern symptoms in a population of patients three months after a thyroidectomy, and the reduction or increase of pre-existing symptoms or the onset of new symptoms.

Methods

Ninety-five patients (65 women, 30 men, mean age 56.03 ± 12.45) were assessed for globus pattern symptoms before and three months after thyroid surgery (72 patients: benign goiter, 23 patients: papillary cancer). The Glasgow-Edinburgh Throat Scale (GETS) was translated into Italian and used as a validated instrument of measure of the severity of globus pattern symptoms.

Results

The Italian version of the GETS was reliable (Cronbach alpha = 0.85) and valid. Normative data were used to classify patients into 4 groups of severity. A significant decrease of the mean GETS score was observed at the postoperative assessment (13.02 ± 11.84 vs 8.00 ± 11.26; p < 0.01), but beside symptomatic patients who improved we could observe also two other significant groups of patients: asymptomatic patients who developed symptoms and symptomatic patients who remained symptomatic.

Conclusions

The significant decrease of the mean GETS postoperative score was mainly due to the improvement of strongly symptomatic patients. Two other significant outcomes exist and further studies are needed to understand their pathophysiological mechanism.

Horner's syndrome subsequent to minimally invasive video-assisted thyroidectomy in two patients

Horner's syndrome (HS), characterized by a combination of ptosis and miosis, is an uncommon complication of thyroid surgery, particularly in minimally invasive thyroid surgery. Two cases of HS were observed secondary to minimally invasive video-assisted thyroidectomy in the Department of Thyroid Breast Surgery of Zhejiang Provincial People's Hospital between August 2012 and July 2014. The two patients developed miosis and ptosis following total thyroidectomy; all symptoms had resolved at 1 and 11 months subsequent to surgery, respectively. HS has currently been reported secondary to numerous types of minimally invasive thyroid procedures. The literature was reviewed to identify cases of this iatrogenic complication secondary to each type of thyroidectomy and the possible injury mechanisms underlying the syndrome were summarized in the present study. In addition, factors that were associated with minimally invasive thyroidectomy, such as the limited endoscopic vision during the procedure, the retraction effect and the occurrence of thermal damage from the use of the harmonic scalpel, were emphasized. The present study concluded that close attention is required during minimally invasive thyroid surgery in order to avoid HS as a complication of the procedure.

Post-thyroidectomy hypocalcemia exacerbated by chyle leak

Transient hypocalcemia after thyroidectomy is not uncommon and the risk increases with the extent of neck surgery. We report a case of severe and prolonged hypocalcemia after total thyroidectomy complicated by thoracic duct injury. Hypoparathyroidism and thoracic duct injury are potential complications following total thyroidectomy with extensive lymph node dissection. This case suggested that having both conditions may complicate treatment of hypoparathyroid-induced hypocalcemia by way of losses of calcium and vitamin D in the chyle leak.

Risk factors for and occurrence of postoperative cervical hematoma after thyroid surgery: A single-institution study based on 5156 cases from the past 2 years

BACKGROUND

The occurrence of and risk factors for postoperative cervical hematoma remain unclear.

METHODS

We conducted a retrospective analysis of 5156 patients treated at a single institution.

RESULTS

The occurrence of postoperative cervical hematoma was 0.85% (44 of 5156 patients). The multivariate analysis showed that male sex, benign pathology, hypertension, and previous thyroid surgery are individual risk factors with odds ratios of 1.906, 2.004, 7.962, and 4.407, respectively. The majority (88.7%) of hematomas occurred within 12 hours after surgery. Obvious bleeding points were detected in 28 cases (73.6%) during reexploration, surface of the strap muscle, superior thyroid vessel, and end of the recurrent laryngeal nerve were the most frequent bleeding sources.

CONCLUSION

Hematoma often occurs within 12 hours after thyroid surgery. Hypertension, previous thyroid surgery, male sex, and benign pathology may increase the risk of hematoma.

Minimally invasive video-assisted thyroidectomy for papillary thyroid cancer: a prospective 5-year follow-up study

BACKGROUND

Minimally invasive video-assisted thyroidectomy (MIVAT) was initially introduced for the treatment of selected patients who met certain thyroid volume, nodule size and pathological criteria. Recent studies indicate that the completeness of resection of malignant nodules is comparable to that obtained with conventional thyroidectomy.

AIMS

To compare the 5-year outcomes in patients with papillary thyroid carcinoma (PTC) treated with MIVAT versus conventional thyroidectomy.

METHODS

In this prospective cohort study conducted over 2 years (July 2005-June 2007), 172 patients with node-negative, nonmetastatic PTC underwent either MIVAT (n = 67) or conventional thyroidectomy (n = 105). Study outcomes were 1) the cumulative dose of radioactive iodine (RAI) to achieve a disease-free state, defined as a stimulated serum thyroglobulin (Tg) level &lt;2 ng/mL with negative Tg antibody and no tumor on a whole-body scan or cross-sectional imaging, and 2) the 5-year serum Tg level.

RESULTS

The clinical parameters of the MIVAT and conventional thyroidectomy groups were comparable except for age (mean 43 ± 12 vs. 59 ± 17 years, respectively; p = 0.03) and operative time (mean 69 ± 24 vs. 53 ± 16 minutes, p = 0.02); the mean tumor size was similar between groups (1.3 ± 0.7 vs. 1.6 ± 0.9 cm, p = 0.14). Surgical morbidity was similar in both groups. Median follow-up was 5 years. RAI dose (mean 72 ± 38 vs. 96 ± 47 mCu, p = 0.34) and serum Tg at 5 years (mean 0.3 ± 0.2 vs. 0.5 ± 0.3 ng/mL, p = 0.30) were not significantly different between the MIVAT and conventional thyroidectomy groups.

CONCLUSIONS

MIVAT can be safely utilized in patients with localized PTC, providing comparable completeness of resection and oncological outcome to conventional thyroidectomy.

Post-thyroidectomy chronic asthenia: self-deception or disease?

There is clinical evidence that post-total thyroidectomy (TT) patients can present persistent asthenia. The aim of this study was to evaluate the prevalence of asthenia symptoms in such patients, assess whether a chronic asthenia syndrome could be caused by TT or become evident after it. An observational study was carried out comparing two groups of 100 patients each, all with homogeneous characteristics. Group A was treated with total lobectomy (TL), Group B with TT. All patients presented normal thyroid hormone levels. The patients were interviewed in order to identify the ones affected by post-operative asthenia persisting for at least six months, with reduced ability to perform physical and mental work, not showing improvement with rest. The severity of the symptoms has been measured by means of the brief fatigue inventory (BFI). Statistical analysis was performed to evaluate statistically significative differences between groups and prognostic factors in TT group. The incidence of post-operative asthenia was 0 % after TL and 25 % after TT, with the operation being the only significant variable. Asthenia is well known as symptom of post-thyroidectomy, but it has not been adequately investigated as consequence of surgery. We demonstrated that the complete removal of the thyroid gland could determine chronic post-thyroidectomy asthenia, although with intensity limited to low/moderate. Post-thyroidectomy asthenia is a relevant sequela interfering with quality of life of at least 25 % of patients operated, suggesting the need to identify its real causes and limit the indication to TT only when strictly required.

Perioperative kinetics of parathyroid hormone in unilateral, primary thyroid surgery

Dysfunction of the parathyroid glands is an important cause of complications after thyroid surgery. Intraoperative monitoring of the function of the parathyroid glands can be performed using parathyroid hormone (PTH) kinetics. Unilateral thyroid surgery is associated with a decreased risk for postoperative hypocalcemia (POH) and permanent hypoparathyroidism (PEH). We focused on unilateral thyroid surgery by monitoring the functionality of the parathyroid glands and comparing the perioperative PTH kinetics of patients with and without POH. In a prospective study, 143 patients scheduled for unilateral thyroid surgery underwent monitoring of perioperative changes in serum PTH and serum calcium levels, and of clinical symptoms of hypocalcemia. The rates of POH and PEH were 18.2 and 0%, respectively. In patients without POH, PTH significantly increased from the time of skin incision to the end of the operation and after the operation (20.1 pg/ml, IQR 15.5-26.8 vs. 21.4 pg/ml, IQR 16.4-29.5; p=0.005), which was not the case in patients who developed POH. In a multivariate analysis of predictive factors for POH, two parameters became significant, namely female gender (odds ratio 6.87, 95% confidence interval 0.92-51.01) and lower initial serum calcium levels (odds ratio 3.54*e(-8), 95% confidence interval 3.63*e(-12); 0.00). The rate of POH was unexpectedly high. Rather than intraoperative PTH declines, an unstable balance of factors that influence calcium metabolism likely is the major contributor to POH after unilateral thyroid surgery. There was no case of PEH after unilateral, primary thyroid surgery, which underlines the need for an individualized approach to the extent of resection.

The management of thyroid nodules: a retrospective analysis of health insurance data

BACKGROUND

In Germany, about 59 000 thyroid operations are performed each year for uni- or multinodular goiter, most of them for diagnostic purposes. The rate of detection of thyroid cancer in such operations is relatively low, at 1:15. Evidence suggests that the preoperative tests recommended in guidelines for estimating the risk of cancer are not being performed as often as they should. In the present study, we determined the measures that were actually taken to diagnose and treat thyroid nodules and compared the findings with the guideline recommendations.

METHOD

We retrospectively analyzed data from a single, large statutory healthinsurance carrier in Germany (AOK), determining the diagnostic and therapeutic measures that were reimbursed for 25 600 patients in whom a uni- or multinodular goiter was newly diagnosed in the second quarter of 2006 (none of these patients had carried such a diagnosis 1 year previously). We recorded the diagnostic measures performed in the preceding 9 months and all other tests and treatments, including surgery and radioactive iodine treatment, in the 2 years thereafter.

RESULTS

Among patients who underwent surgery for uninodular goiter, the preoperative diagnostic studies included ultrasonography (in 100% of patients), scintigraphy (94%), measurement of thyroid-stimulating hormone (95%), measurement of calcitonin (9%), and fine-needle aspiration cytology (FNAC)(21%). An ultrasonographic examination was billed for only 28% of patients with uninodular goiter in the two years after the diagnosis was made. 13% of patients with uninodular goiter who were not operated on were given L-thyroxine, even though this is against guideline recommendations.

CONCLUSION

Inadequate preoperative risk stratification of thyroid nodules may explain the large number of thyroid operations that are performed for diagnostic purposes, resulting in a low percentage of malignancies detected. Preoperative FNAC and calcitonin measurement should be used in the diagnostic evaluation of thyroid nodules far more often than this is now done. As a rule, follow-up ultrasonography should be performed for all thyroid nodules that are not operated on. Patients with non-operated thyroid nodules should not be given thyroxine. A limitation of this study is that diagnostic measures were only recorded if they were performed in the 9 months before surgery, with earlier diagnostic measures (if any) being missed.

Factors affecting hypocalcaemia following total thyroidectomy: a prospective study

OBJECTIVE

After thyroidectomy hypocalcaemia is the most significant complication for clinicians. In this study, we investigated the factors associated with development of hypocalcaemia after thyroidectomy.

MATERIALS AND METHODS

We investigated the patients prospectively for age, gender, preoperative diagnosis, hormonal status, operative time, operating surgeon, existence of parathyroid gland injury at the operation, parathyroid gland auto-transplantation, preoperative use of anti-thyroid drugs and amount of bleeding at the operation. After operation in 1 and 2 days, serum calcium and phosphor, and in the 1 day parathyroid hormone values were evaluated. The chi-square test was applied in the analysis of categorical variables. Logistic regression model was used to determine the risk of hypocalcaemia in the univariate analysis.

RESULTS

Hypocalcaemia developed in 47 of 196 patients. Female gender, preoperative diagnosis of thyroid cancer and toxic nodular goitre, <3cm nodule size, parathyroid injury and auto-transplantation and low vitamin D levels were factors found to be associated with hypocalcaemia in the Logistic regression analysis.

CONCLUSION

The factors associated with hypocalcaemia were defined to be "gender, preoperative diagnosis, parathyroid gland injury, nodule size and vitamin D deficiency", it is a multifactorial problem and it would not be proper to define a few etiological factors.

Surgical management of hyperthyroidism

AIMS

Hyperthyroidism includes several clinical and histopathological situations. Surgery is commonly indicated after failure of medical treatment. The aim of this study was to analyze the indications and complications of surgery as well as endocrine results.

MATERIALS AND METHODS

Patients operated on for hyperthyroidism between 2004 and 2012 were included in a retrospective study. Total thyroidectomy was performed for Graves' disease, toxic multinodular goiter and amiodarone-associated thyrotoxicosis; patients with toxic nodule underwent hemithyroidectomy. Pathologic analysis assessed surgical specimens; postoperative complications and resolution of hyperthyroidism were noted.

RESULTS

Two hundred patients from 15 to 83 years old were included. One hundred and eighty-eight underwent primary surgery and 12 were re-operated for recurrent goiter (6 with subtotal thyroidectomy for multinodular goiter 25 years previously; 6 with hemithyroidectomy for solitary nodule 15 years previously). Eighty-two patients suffered from toxic multinodular goiter, 78 from Graves' disease, 35 from solitary toxic nodules and 5 from amiodarone-associated thyrotoxicosis. Fourteen papillary carcinomas (including 11 papillary microcarcinomas) and 34 healthy parathyroid glands (17%) were identified in the pathological specimens. Postoperative complications comprised 4% permanent recurrent laryngeal nerve palsy (1 year follow-up), 9% hematoma requiring surgical revision, and 3% definitive hypocalcemia. Normalization of thyroid hormone levels was observed in 198 patients. Two recurrences occurred due to incomplete resection (1 case of Graves' disease and 1 intrathoracic toxic goiter that occurred respectively 18 and 5 months after resection). Postoperative complications were more frequent in multinodular goiter (23%) than in Graves' disease (13%) (ns: P>0.05).

CONCLUSION

Surgical management of hyperthyroidism enables good endocrinal control if surgery is complete. Patients need to be fully informed of all possible postoperative complications that could occur, especially vocal ones. Long-term follow-up is necessary to detect recurrence, which can occur more than 20 years after partial thyroidectomy surgery. Surgery allows early diagnosis of 12.5% of papillary carcinomas.

Esophageal fistula complicating thyroid lobectomy

Thyroidectomy is associated with low morbidity and mortality. Esophageal perforation following thyroidectomy has been reported only three times previously, with subsequent fistulization occurring in two of these cases. The authors present the first such case report in the English-speaking literature.

Risk factors for neck hematoma after thyroid or parathyroid surgery: ten-year analysis of the nationwide inpatient sample database

CONTEXT

Postoperative neck hematoma is a well-known complication of thyroid and parathyroid surgery. Better understanding of risk factors for hematoma formation will help define high-risk populations.

OBJECTIVE

To examine possible risk factors for neck hematoma after thyroid or parathyroid surgery.

DESIGN

Retrospective analysis of hospital discharge data from the Nationwide Inpatient Sample database.

METHODS

Using the International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis and procedures codes, we identified adults who underwent thyroid or parathyroid surgery and in whom neck hematoma subsequently developed. Information about demographic, clinical, and hospital characteristics was collected. Multivariate regression analyses were used to predict independent risk factors for neck hematoma.

RESULTS

We identified 147,344 thyroid and parathyroid operations performed nationwide between 2000 and 2009. Overall incidence of postoperative neck hematoma was 1.5% (n = 2210). In multivariate analysis, age 65 years and older (odds ratio [OR] = 1.8, 95% confidence interval [CI] = 1.4-2.1), male sex (OR = 1.3, 95% CI = 1.2-1.4), African-American race (OR = 1.5, 95% CI = 1.2-1.7), being from the South (OR = 1.3, 95% CI = 1-1.4), comorbidity score of 3 or more (OR = 2, 95% CI = 1.6-2.6), history of alcohol abuse (OR = 2.7, 95% CI = 1.6-2.5), Graves disease (OR = 3, 95% CI = 2.1-4.1), and substernal thyroidectomy (OR = 3.3, 95% CI = 2.8-3.9) were associated with a higher risk of neck hematoma.

CONCLUSION

We identified demographic and clinical factors associated with increased risk of neck hematoma after thyroid or parathyroid surgery.

The Cost of Prolonged Hospitalization due to Postthyroidectomy Hypocalcemia: A Case-Control Study

The aim of this study is to evaluate the additional costs associated with calcium monitoring and treatment as well as evaluate the incidence and predictors of postthyroidectomy hypocalcemia. Methods. This case-control study involved thyroidectomy and completion thyroidectomy patients operated on between January 2012 and August 2013. Cases were defined as requiring calcitriol supplementation, and controls did not require supplementation. Patient (age, sex), nodule (cytology, pathology), surgical data (neck dissection, parathyroid identification, and reimplantation), and hospital stay (days hospitalized in total and after drain removal) were compared. Comparisons were made using t-tests and chi-square tests with an alpha of 0.05. The estimated cost associated with the extended stay was then compared with the cost of supplementation. Results. A total of 191 patients were evaluated (61 cases and 130 controls). Predictors of hypocalcemia include female age, neck dissection, and parathyroid reimplantation. Hypocalcemic patients were hospitalized for a longer period of time after drain removal (2.5 versus 0.8 days, P<0.001), and hospitalization costs after neck drain removal were higher in this group as well (8,367.32$ versus 2,534.32$, P<0.001). Conclusion. Postoperative hypocalcemia incurs significant additional health care costs at both the local and health care system levels.

Severe Vitamin D Deficiency

Objective

To assess the role of preoperative serum 25 hydroxyvitamin D as predictor of hypocalcemia after total thyroidectomy.

Study Design

Retrospective cohort study.

Setting

University teaching hospital.

Subjects and Methods

All consecutively performed total and completion thyroidectomies from February 2007 to December 2013 were reviewed through a hospital database and patient charts. The relationship between postthyroidectomy laboratory hypocalcemia (serum calcium ≤2 mmol/L), clinical hypocalcemia, and preoperative serum 25 hydroxyvitamin D level was evaluated.

Results

Two hundred thirteen patients were analyzed. The incidence of postoperative laboratory and clinical hypocalcemia was 19.7% and 17.8%, respectively. The incidence of laboratory and clinical hypocalcemia among severely deficient (<25 nmol/L), deficient (<50 nmol/L), insufficient (<75 nmol/L), and sufficient (≥75 nmol/L) serum 25 hydroxyvitamin D levels was 54% versus 33.9%, 10% versus 18%, 2.9% versus 11.6%, and 3.1% versus 0%, respectively. Multiple logistic regression analysis revealed preoperative severe vitamin D deficiency as a significant independent predictor of postoperative hypocalcemia (odds ratio [OR], 7.3; 95% confidence interval [CI], 2.3-22.9; P = .001). Parathyroid hormone level was also found to be an independent predictor of postoperative hypocalcemia (OR, 0.6; 95% CI, 0.5-0.8; P = .002).

Conclusion

Postoperative clinical and laboratory hypocalcemia is significantly associated with low levels of serum 25 hydroxyvitamin D. Our findings identify severe vitamin D deficiency (<25 nmol/L) as an independent predictor of postoperative laboratory hypocalcemia. Early identification and management of patients at risk may reduce morbidity and costs.

Routine prophylactic central neck dissection for low-risk papillary thyroid cancer is not cost-effective

BACKGROUND

The role of routine prophylactic central neck dissection (CND) in papillary thyroid cancer (PTC) remains controversial. The aim of this study was to evaluate the cost utility of the addition of routine CND in patients with low-risk PTC compared with total thyroidectomy (TT) alone.

METHODS

A Markov model for low-risk PTC was constructed with a treatment algorithm based on the American Thyroid Association guidelines for well-differentiated thyroid carcinoma. Utilities and outcome probabilities were derived from published medical literature. US 2010 costs were examined from a society perspective using Medicare reimbursement rates and opportunity loss based on published US government data. Monte Carlo simulation and sensitivity analysis were used to examine the uncertainty of probability, cost and utility estimates.

RESULTS

Initial TT alone is more cost-effective than TT with CND, resulting in a cost savings of US $5763 per patient with slightly higher effectiveness per patient (0·03 QALY) for a cost savings of $285 per QALY. Sensitivity analysis shows that TT alone offers no advantage when radioactive iodine (RAI) becomes more detrimental to a patient's state of health, when the incidence of non-neck recurrence increases above 5% in patients undergoing TT alone or decreases below 3·9% in patients undergoing TT with CND or when the rate of permanent hypocalcaemia rises above 4%.

CONCLUSIONS

TT with CND is not a cost-effective strategy in low-risk PTC. Initial TT alone is favourable because of the low complication rates and low recurrence rates associated with the initial surgery. Alternative strategies such as unilateral prophylactic neck dissection require additional study to assess their cost-effectiveness.

The role of surgery in the current management of differentiated thyroid cancer

In the last decades, a surprising increased incidence of differentiated thyroid cancer (DTC), along with a precocious diagnosis of "small" tumors and microcarcinomas have been observed. In these cases, better oncological outcomes are expected, and a "tailored" and "less aggressive" multimodal therapeutic protocol should be considered, avoiding an unfavorable even if minimal morbidity following an "overtreatment." In order to better define the most suitable surgical approach, its benefits and risks, we discuss the role of surgery in the current management of DTCs in the light of data appeared in the literature. Even if lymph node metastases are commonly observed, and in up to 90 % of DTC cases micrometastases are reported, the impact of lymphatic involvement on long-term survival is still argument of intensive research, and indications and extension of lymph node dissection (LD) are still under debate. In particular, endocrine and neck surgeons are still divided between proponents and opponents of routine central LD (RCLD). Considering the available evidence, there is agreement about total thyroidectomy, therapeutic LD in clinically node-positive DTC patients, and RCLD in "high risk" cases. Nevertheless, indications to the best surgical treatment of clinically node-negative "low risk" patients are still subject of research. Considering on the one hand, the recent trend toward routine central lymphadenectomy, avoiding radioactive treatment, and on the other hand, the satisfactory results obtained reserving prophylactic LD to "high risk" patients, we think that further prospective randomized trials are needed to evaluate the best choice between the different surgical approaches.

Hypocalcemia following thyroid surgery: incidence and risk factors. A longitudinal multicenter study comprising 2,631 patients

Postoperative hypocalcemia is the most frequent complication of total thyroidectomy. It may have a delayed onset, and therefore delays the discharge from the hospital, requiring calcium replacement therapy to alleviate clinical symptoms. During a 7-month period, 2,631 consecutive patients undergoing primary or completion thyroidectomy were prospectively followed up and underwent analysis regarding postoperative hypoparathyroidism. Data were prospectively collected by questionnaires from 39 Italian endocrine surgery units affiliated to the Italian Endocrine Surgery Units Association (Club delle Unità di EndocrinoChirurgia-UEC), where thyroid surgery is routinely performed. The incidence of hypoparathyroidism was 28.8 % (757 patients), including transient hypocalcemia (27.9 %-734 patients) and permanent hypocalcemia (0.9 %-23 patients). The rate of asymptomatic hypocalcemia was 70.80 %. The incidence of permanent hypocalcemia was higher in the symptomatic hypocalcemia group (7.5 %) than in asymptomatic one (1.5 %). Female patients experienced a transient postoperative hypocalcemia more frequently than male patients (29.7 and 21.2 %, respectively; p < 0.0001). The percentage developing hypocalcemia in patients in which parathyroid glands were intraoperatively identified and preserved was higher than in the patients in which the identification of parathyroid glands was not achieved (29.2 vs. 18.7 %, p < 0.01). This prospective study confirmed the main risk factors for postoperative hypocalcemia: thyroid cancer, nodal dissection, and female gender. It farther showed that identifying parathyroids has an important role to prevent permanent hypocalcemia though with a higher risk of transient hypocalcemia. A suitable informed consent should especially emphasize the importance of some primary factors in increasing the risk of hypocalcemia after thyroid surgery.

Postoperative PTH monitoring of hypocalcemia expedites discharge after thyroidectomy

PURPOSE

Hypocalcemia is the most common complication after total thyroidectomy. Some patients need to stay in the hospital for monitoring of hypocalcemic symptoms and serum calcium levels for several days. We investigated the efficacy and safety of using early postoperative parathyroid hormone (PTH) results for early discharge after thyroidectomy.

MATERIALS AND METHODS

A retrospective cohort study of 2 sequential groups of patients undergoing total thyroidectomy between January 2010 and March 2013 was undertaken. Patients were divided into 2 groups. In Group 1 (before June 2011), patients had daily monitoring of serum calcium level and hypocalcemic symptoms. They were discharged when calcium level was static and asymptomatic. Postoperative PTH was not utilized for discharge plan. In Group 2 (after June 2011), postoperative PTH and calcium level on day 1 were utilized to dictate subsequent management and discharge plan.

RESULTS

Of the 107 patients reviewed, 54 (50.5%) were in Group 1 and 53 (49.5%) were in Group 2. A total of 51 (47.7%) patients developed hypocalcemia. The two groups were comparable in demographic data, early postoperative PTH value, rate of hypocalcemia, the need for oral calcium and vitamin D supplements and rate of permanent hypoparathyroidism. Fewer patients in Group 2 experienced hypocalcemic symptoms, p=0.005. None of the patients in Group 2 needed intravenous calcium supplement (p=0.003). The median postoperative hospital stay for Group 1 was 4 days and for Group 2 was 1 day (p<0.0001).

CONCLUSIONS

Postoperative PTH level after total thyroidectomy facilitates early supplementation therapy and abates symptomatic hypocalcemia. It also allows early and safe patient discharge.

Comparison of the incidence of postoperative hypocalcemia following total thyroidectomy vs completion thyroidectomy

OBJECTIVE

To study the rate of postoperative hypocalcemia following completion thyroidectomy (CT), in comparison with the hypocalcemia rate following total thyroidectomy (TT).

STUDY DESIGN AND SETTING

A retrospective study, performed at the McGill University Thyroid Cancer Center, Montreal, Quebec, Canada, from 2007 to 2012.

SUBJECTS AND METHODS

Medical records of adult patients undergoing CT and TT operated by a single surgeon were reviewed. Data were extracted for demographics, postoperative calcium levels, surgical logs, and final surgical pathology. Hypocalcemia was defined as corrected serum calcium level ≤ 1.90 mmol/L, with concurrent serum parathyroid hormone <8 ng/L, and/or any signs or symptoms of hypocalcemia.

RESULTS

There were 68 CTs and 146 TTs. Transient hypocalcemia occurred in 1 of 68 (1.5%) and 18 of 146 (12.5%) patients in the CT and TT groups, respectively. The rate of hypocalcemia was significantly lower in the CT compared with the TT group (P = .02). In both groups, there were no cases of permanent hypocalcemia.

CONCLUSION

The risk of transient of hypocalcemia in patients undergoing CT is significantly lower than the rate of hypocalcemia in patients undergoing TT.

The use of FOCUS Harmonic scalpel compared to conventional haemostasis (knot and tie ligation) for thyroid surgery: a prospective randomized study

Haemostasis is crucial in thyroid surgery to avoid intraoperative and postoperative complications. In the present study, we evaluated the efficiency and the safety of Harmonic scalpel when compared to conventional suture ligation in open total thyroidectomy. We enrolled 265 patients who underwent total thyroidectomy for multinodular disease since October 2011 up to October 2013. They were randomized into two groups: 141 in group HS (Harmonic Scalpel), 124 in group CT (Conventional tecnique). We recorded the following data: operative time, post-operative blood loss, length of hospital stay and complications. The patients were monitored for 48 hours after surgery. Several differences were observed between the two groups (HS vs CT): the use of Harmonic scalpel was associated to a significant reduction of surgical operative time (110 min in CT vs 79.36 min in HS, p = 0.00001) and also associated to a lower blood loss (97.38 ml in CT vs 68.72 ml in HS, p = 0.00001). The length of stay was significantly shorter in the HS group (2.75 days in CT vs 1.93 days in HS) Complication rate was similar in the two groups. According to our experience, the Harmonic scalpel represents a safe alternative to conventional haemostasis in thyroid surgery, allowing for a significant reduction of operative time, blood loss and hospitalization. The rate of complication demonstrated no significant difference among the two groups.

Rare complication after thyroidectomy-cervical esophageal stenosis: a case report and literature review

The most common complications after thyroidectomy are injuries associated with the recurrent laryngeal nerve and parathyroid gland. Cervical esophagus perforation is an exceptionally rare complication after thyroidectomy; it can usually be resolved by conservative care. Cervical esophageal stenosis secondary to intraoperative esophageal injury during thyroidectomy is much rarer and has not been reported in the literature to date. We report a case of esophageal stenosis following thyroidectomy performed at a peripheral hospital. The patient initially underwent a thyroidectomy for papillary thyroid carcinoma involving the cervical esophagus; esophageal perforation was noted intraoperatively, and closed using three number 4 silk sutures. Cervical esophageal stenosis subsequently developed after conservative care. The patient was successfully treated with cervical esophagectomy and reconstruction using a tubed forearm free flap after a failed attempt at endoscopic recanalization. This case is discussed in conjunction with a review of the literature.

Total thyroidectomy is associated with increased prevalence of permanent hypoparathyroidism

Background

Thyroid disorders are very common in adults. Despite advances in conservative management, surgery remains a treatment modality of choice in many cases. The mortality and morbidity of thyroidectomy are low, but long-term postoperative hypoparathyroidism (HPT) remains a prominent complication of the procedure.

The aim of this study was to assess the incidence of permanent HPT and identify the risk factors for this complication in a cohort of post-thyroidectomy patients followed at a District Endocrine Clinic.

Material/Methods

This was a retrospective analysis of 401 patients followed up at a Regional/District Endocrine Clinic, who had undergone thyroid surgery in the years 1993–2011. The percentage of patients with permanent (>12 months) HPT was the primary endpoint of the study. The statistically analyzed data of patients with permanent HPT versus the remaining patients free from postoperative complications included their demographic data, indications for surgical treatment of their thyroid disorder, and extent of the thyroid resection. The risk factors for postoperative hypoparathyroidism were assessed using logistic regression analysis.

Results

Permanent HPT following surgery on the thyroid gland occurred in 8.5% of the patients. It was more frequent following total thyroidectomy (20.2%) than near-total thyroidectomy (6.7%) or subtotal thyroidectomy (4.2%); p<0.0001. A multivariate statistical regression analysis demonstrated that primary total thyroidectomy was a significant risk factor for permanent HPT (OR 6.5; 95% CI: 2.9–14.4; p<0.0001).

Conclusions

Total thyroidectomy was associated with increased prevalence of permanent hypoparathyroidism when compared to less extensive thyroid resection modes in patients with benign thyroid diseases.

Complications in thyroid resurgery: a single institutional experience on 233 patients from a whole series of 4,752 homogeneously treated patients

The aim of this study was to examine a homogeneous, consecutive recent series of patients who underwent reoperation on the thyroid bed to assess the incidence of the complications commonly correlated with resurgery. We reviewed clinical charts of 233 patients who underwent resurgery taken from a total of 4,752 patients previously operated on for benign and malignant thyroid diseases from 2006 to 2010 by the same surgical team. We evaluated the incidence of postoperative hemorrhage, hypoparathyroidism, and recurrent laryngeal nerve (RLN) palsy. Analyses were done separately in relation to the type of the type of resurgery adopted: (A) monolateral completion; (B) bilateral completion, after monolateral (B1) or bilateral prior surgery (B2); and (C) lymph node dissection. We also separately analyzed patients according to their final histological diagnosis of benign or malignant disease. Regarding hemorrhage, 6/233 patients (2.5 %) underwent surgical revision of the thyroid within 12 h for postoperative hemorrhage. They included 2 (1.5 %) of the 129 monolateral reoperations (A), 3 (4 %) of the 74 bilateral reoperations (B), and 1 (3.3 %) of the 30 central dissections for nodal relapse (C). Transient and definitive postoperative hypoparathyroidism was recorded in 78 (36.4 %) and 7 (3.3 %) of the 214 eligible patients. Transient RLN palsy occurred in 21 RLNs at risk (7 %) and definitive RLN palsy in 5 (1.7 %). Elective total thyroidectomy cannot always be supported as an effective policy for preventing recurrences in patients with a single, benign node: lobectomy, preferably with extemporaneous histological examination, unquestionably represents the best minimal approach to thyroid resection.

Cost-effectiveness of FDG-PET/CT for cytologically indeterminate thyroid nodules: a decision analytic approach

CONTEXT

Patients with thyroid nodules of indeterminate cytology undergo diagnostic surgery according to current guidelines. In 75% of patients, the nodule is benign. In these patients, surgery was unnecessary and unbeneficial because complications may occur. Preoperative fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) was found to have a very high negative predictive value (96%) and might therefore avoid futile surgery, complications, and costs. In the United States, two molecular tests of cytology material are routinely used for this purpose.

OBJECTIVE

Five-year cost-effectiveness for routine implementation of FDG-PET/CT was evaluated in adult patients with indeterminate fine-needle aspiration cytology and compared with surgery in all patients and both molecular tests.

DESIGN

A Markov decision model was developed to synthesize the evidence on cost-effectiveness about the four alternative strategies. The model was probabilistically analyzed. One-way sensitivity analyses of deterministic input variables likely to influence outcome were performed.

SETTING AND SUBJECTS

The model was representative for adult patients with cytologically indeterminate thyroid nodules.

MAIN OUTCOME MEASURES

The discounted incremental net monetary benefit (iNMB), the efficiency decision rule containing outcomes as quality-adjusted life-years and (direct) medical cost, of implementation of FDG-PET/CT is displayed.

RESULTS

Full implementation of FDG-PET/CT resulted in 40% surgery for benign nodules, compared with 75% in the conventional approach, without a difference in recurrence free and overall survival. The FDG-PET/CT modality is the more efficient technology, with a mean iNMB of €3684 compared with surgery in all. Also, compared with a gene expression classifier test and a molecular marker panel, the mean iNMB of FDG-PET/CT was €1030 and €3851, respectively, and consequently the more efficient alternative.

CONCLUSION

Full implementation of preoperative FDG-PET/CT in patients with indeterminate thyroid nodules could prevent up to 47% of current unnecessary surgery leading to lower costs and a modest increase of health-related quality of life. Compared with an approach with diagnostic surgery in all patients and both molecular tests, it is the least expensive alternative with similar effectiveness as the gene-expression classifier.

Radiofrequency dissection versus 'knot tying' in conventional total thyroidectomy

OBJECTIVE

To evaluate the safety and effectiveness of radiofrequency dissection in conventional 'open' total thyroidectomy.

METHODS

Thirty-nine patients scheduled for conventional total thyroidectomy were included in a prospective randomised study. Patients were randomly assigned to one of two groups: a radiofrequency dissection method was used in one group, and a knot tying technique was used in the other.

RESULTS

Significantly fewer surgical instruments and materials were required for the radiofrequency dissection group than the knot tying group (p < 0.01). There were no significant differences between the two groups in mean operative time, blood loss, post-operative drainage and pain, recurrent palsy, and hypocalcaemia (p > 0.05).

CONCLUSION

Radiofrequency dissection is a safe alternative to the knot tying technique, and enables a significant reduction in the number of surgical instruments required for the operation.

Parathyroid Hormone Levels Predict Posttotal Thyroidectomy Hypoparathyroidism

We hypothesized that parathyroid hormone (PTH) determination would be the most effective strategy to identify posttotal thyroidectomy hypoparathyroidism (PTTHP) compared with other clinical and laboratory parameters. We retrospectively reviewed our recent experience with total thyroidectomy. We recorded demographics, malignancy, thyroid weight, parathyroid autotransplantation, hospital stay, use of postoperative calcium and hormonally active vitamin D3 (calcitriol), and postoperative serum calcium and PTH levels. Patients were divided into two groups depending on whether supplemental calcitriol was required to maintain eucalcemia and therefore reflecting the diagnosis of PTTHP. From October 2010 to June 2013, a total of 202 total thyroidectomies were performed. Twenty-four patients (12%) developed PTTHP and required calcitriol replacement. Logistic regression analysis revealed that only postoperative calcium levels ( P = 0.02) and PTH levels ( P < 0.0001) statistically significantly predicted PTTHP. Twenty-two of 29 patients with PTH 13 pg/mL or less had PTTHP. Only two of 173 patients with a PTH level greater than 13 pg/mL were diagnosed with PTTHP. We recommend using PTH levels after total thyroidectomy to determine which patients will have hypoparathyroidism requiring calcitriol therapy. An early determination of PTTHP allows for prompt management that can shorten hospital stay and improve outcomes.

Cost-effectiveness of molecular testing for thyroid nodules with atypia of undetermined significance cytology

CONTEXT

Novel molecular diagnostics, such as the gene expression classifier (GEC) and gene mutation panel (GMP) testing, may improve the management for thyroid nodules with atypia of undetermined significance (AUS) cytology. The cost-effectiveness of an approach combining both tests in different practice settings in North America is unknown.

OBJECTIVE

The aim of the study was to determine the cost-effectiveness of two diagnostic molecular tests, singly or in combination, for AUS thyroid nodules.

DESIGN AND SETTING

We constructed a microsimulation model to investigate cost-effectiveness from US (Medicare) and Canadian healthcare system perspectives.

PATIENTS

Low-risk patients with AUS thyroid nodules were simulated.

INTERVENTIONS

We examined five management strategies: 1) routine GEC; 2) routine GEC + selective GMP; 3) routine GMP; 4) routine GMP + selective GEC; and 5) standard management.

MAIN OUTCOME MEASURES

Lifetime costs and quality-adjusted life-years were measured.

RESULTS

From the US perspective, the routine GEC + selective GMP strategy was the dominant strategy. From the Canadian perspective, routine GEC + selective GMP cost and additional CAN$24 030 per quality-adjusted life-year gained over standard management, and was dominant over the other strategies. Sensitivity analyses reported that the decisions from both perspectives were sensitive to variations in the probability of malignancy in the nodule and the costs of the GEC and GMP. The probability of cost-effectiveness for routine GEC + selective GMP was low.

CONCLUSIONS

In the US setting, the most cost-effective strategy was routine GEC + selective GMP. In the Canadian setting, standard management was most likely to be cost effective. The cost of these molecular diagnostics will need to be reduced to increase their cost-effectiveness for practice settings outside the United States.

Ruling in or ruling out thyroid malignancy by molecular diagnostics of thyroid nodules

Routine morphologic cytology is the basis for any kind of (integrated) molecular FNA diagnostics. The rule out (gene expression classifier) approach requires confirmation by independent studies, whereas the rule in approach (detection of BRAF, NRAS, HRAS, and KRAS and PAX8/PPARG- and RET/PTC rearrangements) has been investigated by several groups with overall reproducible results. Moreover, molecular screening for point mutations and rearrangements is feasible in routine air-dried FNA smears, offering several advantages over obtaining additional fresh FNA material. The current panel of somatic mutations (rule in approach) for indeterminate FNAs clarifies only a subgroup of indeterminate FNAs. Therefore, further markers are urgently needed that can reliably identify the malignant, but mutation negative and especially the many benign nodules, among the indeterminate FNAs. miRNA markers and the targeted next generation sequencing (NGS) technology do have the potential to identify those nodules that are mutation negative by current approaches.