[Surgical procedures and risk factors in therapy of benign multinodular goiter. A statistical comparison of the incidence of complications]

A comparison of the efficacy of three different peak airway pressures on intraoperative bleeding point detection in patients undergoing thyroidectomy: a randomized, controlled, clinical trial

BACKGROUND

Various techniques are used to detect intraoperative bleeding points in thyroid surgery. We aimed to assess the effect of increasing peak airway pressure to 30, 40 and 50 cm H₂O manually in detecting intraoperative bleeding points.

METHODS

One hundred and 34 patients scheduled for total thyroidectomy were included to this prospective randomised controlled clinical study. We randomly assigned patients to increase peak airway pressure to 30, 40 and 50 cm H₂O manually intraoperatively just before surgical closure during hemostasis control. The primary endpoint was the rate of bleeding points detected by the surgeon during peak airway pressure increase.

RESULTS

The rate of detection of the bleeding points was higher in 50 cm H₂O Group than the other two groups (15.9 vs 25.5 vs 40%, P = 0.030), after pressure administration, the HR, SpO₂, and P peak were similar between groups (P = 0.125, 0.196, 0.187, respectively). The median duration of the bleeding point detection after the pressure application was 21.82 s in 30 cm H₂O, 25 s in 40 cm H₂O, and 22.50 s in 50 cm H₂O groups. Postoperative subcutaneous hematomas or hemorrhages requiring surgery were not seen in any patient.

CONCLUSIONS

Manually increasing peak airway pressure to 50 cm H₂O during at least 22.50 s may be used as an alternative way to detect intraoperative bleeding points in thyroid surgery.

CLINICAL TRIAL REGISTRATION

NCT03547648. Registered 6 June2018.

Compartment Pressure Monitoring After Thyroid Surgery: A Possible Method to Detect a Rebleeding

BACKGROUND

Postoperative rebleeding after thyroid surgery is a rare but a serious complication. The aim of this study was to ascertain the extent to which postoperative pressure could be used as detector for rebleeding after thyroid surgery.

METHODS

Thirty-two patients with thyroidectomy or hemithyroidectomy were considered prospectively. In the course of surgery, a pressure microsensor (3PN Probe Spiegelberg) was implanted into the postoperative cavity and data were collected for special activities and stress situations over the first 48 h postoperatively. Additional endpoint was the influence of drains on the determined values.

RESULTS

The overall mean pressure (MP) at rest on both postoperative days for all patients with and without drain was 0.36 ± 2.84 mmHg (range -6.7 to 6.7). The MP in all activity and stress situations on the first day was with 0.23 ± 3.71 mmHg, and on the second day, the MP was 1.33 ± 4.50. 92.13% of our values were below 7 mmHg. One patient had a hemorrhage. The pressure increases continuously up to 36 mmHg, before the patient was transferred to the operating theater.

CONCLUSIONS

This is the first pilot study to consider continuous pressure measurement to be a potential tool for early detection of a postoperative rebleeding in thyroid surgery. In the strictest sense, postoperative intra-cervical pressure at rest ranges from subatmospheric to 7 mmHg. The elevation of pressure in case of a rebleeding up to 36 mmHg differs dramatically from normal postoperative pressure. The collected data will warrant further validation to be able to recommend threshold values for an early treatment decisions in rebleeding.

The surgical treatment of bilateral benign nodular goiter: balancing invasiveness with complications

BACKGROUND

About 100,000 thyroid operations are performed in Germany each year. There is a current trend toward more radical surgery for bilateral euthyroid nodular goiter. In recent years, thyroid specialists and specialty guidelines have recommended total thyroidectomy, because it ensures that nodules will not recur and already provides an adequately radical excision in case an incidental carcinoma is found postoperatively on histological study of the specimen. An alternative method is unilateral hemithyroidectomy with contralateral subtotal resection (the Dunhill procedure).

METHOD

Selective literature review.

RESULTS

Three randomized controlled trials (RCTs) have compared the longterm outcomes of different surgical methods. In addition, retrospective studies have been published, but their findings must be interpreted with caution because of limitations of method. When all of the data are considered, it appears that radical procedures are often not justified. According to the RCTs, nodules arose during long-term follow-up in 4.7-14% of patients who had undergone subtotal resection; yet, in the two more recent and methodologically more valid RCTs, surgery for recurrent goiter was needed in only 0-0.5% of patients treated with a Dunhill procedure and given adequate hormone supplementation. Most incidental carcinomas are papillary microcarcinomas; this entity is usually adequately treated with hemithyroidectomy. The reported complication rates of total thyroidectomy for permanent hypoparathyroidism in particular range from 0.5% (in specialized centers) to 10% (in a cross-sectional study) and thus seem higher than the corresponding rate for a Dunhill procedure (1-2%).

CONCLUSION

Total thyroidectomy has significant risks and should only be performed if the indication has been critically assessed. Alternative methods such as the Dunhill procedure are often radical enough with a much lower rate of postoperative hypoparathyroidism; they remain an important option in thyroid surgery. Further RCTs with sufficient long-term follow-up are needed so that the different surgical methods can be reliably compared in detail.

Differentiated Operative Strategy in Minimally invasive, Video-assisted Thyroid Surgery Results in 196 Patients

To date, experience in minimally invasive thyroid surgery has been limited to unilateral lobectomy and total thyroidectomy. There are no reports regarding selective operative strategy, guided by morphology and function, which is widely accepted in endemic goiter regions. To analyze the efficiency and outcome of tissue-preserving thyroid surgery using a minimally invasive video-assisted technique (MIVA-T), a total of 196 patients were operated on for thyroid nodules between February 1999 and October 2003. Concurrent primary hyperthyroidism was treated in 22 (11%) cases. Indications for operation were solitary, multiple unilateral, or bilateral nodules with a maximum diameter of 30 mm and a maximum lobe volume of 15 ml. Contraindications for minimally invasive operation were thyroid malignancy diagnosed by fine-needle aspiration (FNA), recurrent goiter, and Hashimoto's thyroiditis. Nodule excision was performed in 6% of these cases; subtotal lobectomy, in 6%; selective resection, in 48%; and total lobectomy, in 39%. Histological examination revealed follicular adenoma in 82%, colloid and cystic lesions in 11%, thyroiditis in 1%, and differentiated thyroid carcinoma in 6%. Conversion to open surgery was necessary in 7.7% of the patients (secondary to malignancy demonstrated on frozen section in 3% and to technical difficulties in 4.7%). Transient and permanent laryngeal nerve palsy occurred in 2.0% and 0.5% of patients, respectively. Temporary hypoparathyroidism occurred in 5.6% of patients exclusively after conversion to open total thyroidectomy or in those patients ( n = 22) with additional primary hyperparathyroidism. Given a correct indication, MIVA-T technique can be performed with low conversion and complication rates. Selective operative strategy, guided by morphology and thyroid function, with a variety of operative procedures fitting the individual situation may be performed by this minimally invasive technique.