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Puchi C, Raval MV, Tian Y, Josefson J, Samis J, Johnston DR, Maddalozzo J, Rastatter J, Hazkani I. Assessing national trends in indications for pediatric total thyroidectomy. Am J Otolaryngol 2024; 45:104440. [PMID: 39059161 DOI: 10.1016/j.amjoto.2024.104440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 07/21/2024] [Indexed: 07/28/2024]
Abstract
PURPOSE The most common indications for total thyroidectomy (TT) in children are malignancy and thyrotoxicosis due to Graves' disease (GD). However, the incidence of patients with GD among patients undergoing TT is unknown. This study aims to examine trends in pediatric TT. MATERIALS AND METHODS The US Agency for Health Research and Quality Healthcare Cost and Utilization Project (HCUP) Kids' Inpatient Database (KID) was queried to identify patients who underwent TT between 1997 and 2019. Weighted national estimates were obtained. Statistical analysis was completed using univariate logistic regression and one-sided Mann-Kendall Test. RESULTS An estimated 4803 pediatric patients underwent TT within the study years. GD was the indication in 25 % of cases. Mann-Kendall testing showed a trend toward an increasing proportion of TT for GD without reaching statistical significance (z = 1.3609, S = 12, p = 0.0688). Statistically significant univariate associations were found among those who underwent thyroidectomy for GD compared to other indications, as they were more likely to be female (β = 0.286, 95 % CI [0.058, 0.514], p = 0.014), Black, or Hispanic (β = 1.392 [1.064, 1.721], p < 0.001; and β = 0.562 [0.311, 0.814], p < 0.001, respectively). Additionally, they were less likely to have private insurance (β = -0.308 [-1.076, -0.753], p = 0.002) and more likely to live in a ZIP code associated with a median household income below the 50th percentile (β = 0.190 [0.012, 0.369], p = 0.036). The associations with the female sex, Black race, and Hispanic race persisted in multivariate analysis. CONCLUSION GD appears to be an increasingly prevalent indication for TT. Patient characteristics differ from those who undergo TT for other diagnoses.
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Affiliation(s)
- Christopher Puchi
- Northwestern University Feinberg School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Chicago, IL, United States of America
| | - Mehul V Raval
- Northwestern University Feinberg School of Medicine, Division of Pediatric Surgery, Chicago, IL, United States of America; Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Surgery, Chicago, IL, United States of America
| | - Yao Tian
- Northwestern Feinberg School of Medicine, Division of Surgical Oncology, United States of America
| | - Jami Josefson
- Northwestern University Feinberg School of Medicine, Department of Pediatrics, Chicago, IL, United States of America; Ann & Robert H. Lurie Children's Hospital of Chicago, Division of Endocrinology, Chicago, IL, United States of America
| | - Jill Samis
- Northwestern University Feinberg School of Medicine, Department of Pediatrics, Chicago, IL, United States of America; Ann & Robert H. Lurie Children's Hospital of Chicago, Division of Endocrinology, Chicago, IL, United States of America
| | - Douglas R Johnston
- Northwestern University Feinberg School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Chicago, IL, United States of America; Ann & Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Otolaryngology-Head and Neck Surgery, Chicago, IL, United States of America
| | - John Maddalozzo
- Northwestern University Feinberg School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Chicago, IL, United States of America; Ann & Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Otolaryngology-Head and Neck Surgery, Chicago, IL, United States of America
| | - Jeffrey Rastatter
- Northwestern University Feinberg School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Chicago, IL, United States of America; Ann & Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Otolaryngology-Head and Neck Surgery, Chicago, IL, United States of America
| | - Inbal Hazkani
- Northwestern University Feinberg School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Chicago, IL, United States of America; Ann & Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Otolaryngology-Head and Neck Surgery, Chicago, IL, United States of America.
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Hazkani I, Stein E, Edwards E, Maddalozzo J, Johnston D, Samis J, Josefson J, Rastatter J. Abnormal TSH Prior to Surgery in Children with Graves' Disease Predicts Abnormal TSH Following Thyroidectomy. Laryngoscope 2023; 133:2402-2406. [PMID: 36370147 DOI: 10.1002/lary.30485] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 10/20/2022] [Accepted: 10/30/2022] [Indexed: 08/11/2023]
Abstract
OBJECTIVE To identify variables that are associated with poor compliance to thyroid hormone replacement therapy in children after total thyroidectomy. METHOD A retrospective cohort study of children who underwent total thyroidectomy by high-volume pediatric otolaryngologists between 1/2014 and 9/2021. Postoperative poor compliance was characterized by at least three separate measurements of high TSH levels not associated with radioactive iodine treatment. RESULTS There were 100 patients, ages 3-20 years old who met inclusion criteria; 44 patients underwent thyroidectomy for cancer diagnosis, and 56 for Graves' disease. The mean follow-up time was 36.5 months (range 3.0-95.6 months). Overall, 42 patients (42%) were found to have at least three measurements of high TSH during follow-up, and 29 patients (29%) were diagnosed with clinical hypothyroidism. Sex, race, income, insurance type, and benign versus malignant etiology for thyroidectomy were not associated with adherence to therapy. Multivariate regression analysis identified patients with Graves' disease and hyperthyroidism at the time of surgery and Hispanic ethnicity to be associated with postoperative clinical hypothyroidism (OR 9.38, 95% CI 2.16-49.2, p = 0.004 and OR 6.15, 95% CI 1.21-36.0, p = 0.033, respectively). CONCLUSIONS Preoperative hyperthyroidism in patients with Graves' disease and Hispanic ethnicity were predictors of postoperative TSH abnormalities. Preoperative counseling for patients and their families on the implications of total thyroidectomy and the need for life-long medications postoperatively is necessary. Efforts should be made to evaluate and improve adherence to therapy pre-and postoperatively in patients with Graves' disease. LEVEL OF EVIDENCE 4 Laryngoscope, 133:2402-2406, 2023.
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Affiliation(s)
- Inbal Hazkani
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Eli Stein
- Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Evan Edwards
- Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - John Maddalozzo
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Douglas Johnston
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Jill Samis
- Division of Pediatric Endocrinology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Jami Josefson
- Division of Pediatric Endocrinology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Jeffrey Rastatter
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Hazkani I, Stein E, Samis J, Josefson J, Maddalozzo J, Johnston D, Huang A, Rastatter J. The effect of hyperthyroidism at thyroidectomy on complication rates in children with Graves' disease. Int J Pediatr Otorhinolaryngol 2022; 163:111360. [PMID: 36274323 DOI: 10.1016/j.ijporl.2022.111360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 10/10/2022] [Accepted: 10/12/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Graves' disease (GD) is the most common cause of childhood hyperthyroidism. Surgery is often chosen as a treatment modality given the high relapse rates and side effects of antithyroid drugs and has shown to be safe and efficacious. The goal of our study was to evaluate whether hyperthyroidism at time of thyroidectomy is associated with higher intra and postoperative complication rates. METHODS A retrospective cohort study of children who underwent thyroidectomy for GD by high-volume pediatric otolaryngologists between 2014 and 2021. RESULTS 64 patients met inclusion criteria. Patients with hyperthyroidism (defined as free T4≥1.63 ng/dL) were more likely to be treated with beta-blocker preoperatively compared to the euthyroid group (20/24 patients (83%) vs 23/40 patients (58%) respectively, p = 0.035). Twenty (83%) patients with hyperthyroidism and 39 euthyroid patients (98%) were treated with methimazole prior to surgery. Intraoperative tachycardia was noted in 5% of euthyroid patients and 20.8% of patients with hyperthyroidism. The mean peak heart rate intra-operatively and the number of patients with heart rate ≥120bmp were significantly higher for patients with hyperthyroidism (96.5 ± 16.2 vs 87.6 ± 22.1bpm, p = 0.02). Two patients required administration of esmolol during surgery for heart rate control, both with hyperthyroidism. Intra-operative peak systolic blood pressure, operative time, estimated blood loss, persistent hypocalcemia, length of admission and recurrent laryngeal nerve paralysis rates were similar among groups. CONCLUSIONS Hyperthyroidism at surgery is associated with increased heart rate intraoperatively, with no increased risk for other complications. While optimizing thyroid hormone levels before surgery should be pursued in all children, our data suggest that hyperthyroidism should not delay the surgery.
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Affiliation(s)
- Inbal Hazkani
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
| | - Eli Stein
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jill Samis
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; Division of Pediatric Endocrinology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Jami Josefson
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; Division of Pediatric Endocrinology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - John Maddalozzo
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Douglas Johnston
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Andrea Huang
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; Division of Pediatric Anesthesiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Jeffrey Rastatter
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Elgendy A, Shehata EM, Shehata SM. Outcome and complications after surgery for thyroid carcinoma in pediatric age—an evaluation of practice. World J Surg Oncol 2022; 20:293. [PMID: 36104749 PMCID: PMC9472417 DOI: 10.1186/s12957-022-02757-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 08/19/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Objectives
To discuss management protocol, surgical complications, and outcomes of thyroid carcinoma in children.
Methods
We performed a retrospective analysis including all pediatric patients with thyroid carcinoma who were managed at our institution between January 2011 and January 2021. Data were analyzed regarding demographics, clinical features, operative details, postoperative complications, and survival data.
Results
Thirty-two patients were identified; 26 females (81.25%) and 6 males (18.75%). The median age at operation was 14 years (range: 5–18). Twenty-six (81.25%) patients presented with palpable thyroid swelling. Median tumor size was 3 cm (range: 1–7). Metastatic workup did not detect any pulmonary metastases. Total thyroidectomy was performed in 25 patients (78%), and 16 of them underwent additional bilateral neck dissection (16 had central nodal dissection, and 7 had both central and lateral nodal dissection). Seven patients (22%) underwent hemithyroidectomy, and only one of them had a completion thyroidectomy after 2 weeks. Conservative resection was adopted in six children with similar criteria (tumor size < 1.5 cm in one lobe, no extrathyroid extension, differentiated thyroid carcinoma, no detected lymph nodes). Postoperative complications occurred in eight patients (all had total thyroidectomy) with an overall incidence of 25%. Seven patients had transient morbidities that were managed conservatively (chylous leak n = 1, hypoparathyroidism n = 3, and nerve palsy n = 3). At a median follow-up time of 54 months, four patients had relapsed (all underwent total thyroidectomy). The 5-year OS and EFS were 100% and 87.5%, respectively.
Conclusion
Operative resection for pediatric thyroid carcinoma can be performed with average short-term complications and achieving excellent outcomes. Total thyroidectomy remains the standard procedure of choice in the majority of those patients. However, conservative surgery can be successfully adopted in a well-selected group of children with favorable long-term results as per our findings.
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Zaat AS, Derikx JP, Zwaveling-Soonawala N, van Trotsenburg AP, Mooij CF. Thyroidectomy in Pediatric Patients with Graves' Disease: A Systematic Review of Postoperative Morbidity. Eur Thyroid J 2021; 10:39-51. [PMID: 33777818 PMCID: PMC7983567 DOI: 10.1159/000511345] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 08/09/2020] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Graves' disease (GD) is the most common cause of hyperthyroidism. In children, the overall relapse frequency after treatment with antithyroid drugs is high. Therefore, many pediatric GD patients eventually require thyroidectomy as definitive treatment. However, the postoperative complications of thyroidectomy in pediatric GD patients are poorly reported. OBJECTIVE To identify the frequency of short- and long-term postoperative morbidities after thyroidectomy in pediatric GD patients. METHODS A systematic review of the literature (PubMed and Embase) was performed to identify studies reporting short- and long-term postoperative morbidities after thyroidectomy in pediatric GD patients according to the PRISMA guidelines. RESULTS Twenty-two mainly retrospective cohort studies were included in this review evaluating short- and long-term morbidities in 1,424 children and adolescents. The frequency of transient hypocalcemia was 22.2% (269/1,210), with a range of 5.0-50.0%. The frequency of permanent hypocalcemia was 2.5% (36/1,424), with a range of 0-20.0%. Two studies reported high frequencies of permanent hypocalcemia, 20.0 (6/30) and 17.4% (9/52), respectively. The 20% frequency could be explained by low-volume surgeons in poorly controlled GD patients. Only 21 cases of permanent hypocalcemia were reported in the 1,342 patients included in the other 20 studies (1.6%). Transient and permanent recurrent laryngeal nerve injury were reported less frequently, with frequencies between 0-20.0 and 0-7.1%, respectively. Infection, hemorrhage/hematoma, and keloid development were only rarely reported as postoperative complications. CONCLUSION The results of this systematic review suggest that thyroidectomy is a safe treatment option for pediatric GD patients. The minority of patients will experience transient and benign morbidities, with hypocalcemia being the most common transient postoperative morbidity. Permanent postoperative morbidities are relatively rare.
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Affiliation(s)
- Annabel S. Zaat
- Department of Pediatric Endocrinology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Joep P.M. Derikx
- Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit, Amsterdam, The Netherlands
| | - Nitash Zwaveling-Soonawala
- Department of Pediatric Endocrinology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - A.S. Paul van Trotsenburg
- Department of Pediatric Endocrinology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Christiaan F. Mooij
- Department of Pediatric Endocrinology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- *Christiaan F. Mooij, Department of Pediatric Endocrinology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, NL–1105 AZ Amsterdam (The Netherlands),
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Risk factors of post-surgery complications in children with thyroid cancer. Int J Pediatr Otorhinolaryngol 2019; 127:109673. [PMID: 31546062 DOI: 10.1016/j.ijporl.2019.109673] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 09/05/2019] [Accepted: 09/05/2019] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Thyroid cancer in children is a hot topic because of the large clinical heterogeneity and the risk of severe complications. We aimed to study 1. The frequency, 2. Etiology, and 3. Risk factors of post-surgery complications of thyroid cancer. MATERIAL AND METHODS A retrospective analysis including risk factors for post-surgery complications of patients treated for thyroid malignancies in years 2006-2018 was performed. RESULTS Over a period of 12 years 22 patients with thyroid malignancy (68% female; 12.6 ± 4.0 years of age, median follow-up 6 years) were identified. Histologically, 12 (55%) patients had papillary carcinoma. Six patients (27.3%) had multiple endocrine neoplasia type 2 (MEN2) syndrome, 3 (13.7%) patients had medullary carcinoma and 1 patient had follicular carcinoma. Neck lymph node metastases were diagnosed in 8 (36.4%), distant metastases in 6 (27.3%), and both locations were involved in 4 (18.2%) patients. Six (27.3%) children had surgical complications: 1 child had unilateral vocal cord paralysis and transient hypoparathyroidism and 5 had transient hypoparathyroidism. The higher risk of surgery complications in forward stepwise logistic regression was associated in with distant metastases (R2 = 0.584, OR 52.63, p = 0.010). CONCLUSIONS Postoperative complications were significantly associated with presence of distant metastases. Favorable results were observed in with children with MEN2 syndrome.
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Baumgarten HD, Bauer AJ, Isaza A, Mostoufi-Moab S, Kazahaya K, Adzick NS. Surgical management of pediatric thyroid disease: Complication rates after thyroidectomy at the Children's Hospital of Philadelphia high-volume Pediatric Thyroid Center. J Pediatr Surg 2019; 54:1969-1975. [PMID: 30902456 DOI: 10.1016/j.jpedsurg.2019.02.009] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 12/29/2018] [Accepted: 02/03/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Recent studies suggest improved outcomes for children undergoing thyroidectomy at high-volume pediatric surgery centers. We present outcomes after thyroid surgery at a single center and advocate for referral to high-volume centers for multidisciplinary management of these children. METHODS Medical records were reviewed for all pediatric patients undergoing thyroid surgery at a single institution from 2009 through 2017. Routine recurrent laryngeal nerve and parathyroid hormone monitoring was used. Lymph node dissections were performed in appropriately selected cancer patients. Data collection focused on pathologic diagnosis, surgical technique, and surgical complications, including postoperative hematoma, neurapraxia, permanent nerve damage, hypocalcemia, and transient and permanent hypoparathyroidism. RESULTS From 2009 through 2017, 464 patients underwent thyroid surgery. Median age of the cohort was 15 years (range 2-24). Thirty-three percent were diagnosed with benign nodules (n=151), 36% with papillary or follicular thyroid cancer (n=168), 27% with Graves' disease (n=124), 3% with medullary thyroid cancer (n=14), and 1.5% underwent prophylactic thyroidectomy for MEN2a (n=7). Six patients required return to the OR for hematoma evacuation including 5 patients after surgery for Graves' disease (RR 8.7, 95% CI 1.06-71.85). In sixteen cases, concern about neurapraxia resulted in laryngoscopy, revealing eleven patients with vocal cord paresis. Two of these patients demonstrated a persistent deficit at 6 months postoperatively (0.4%). Thirty-seven percent of patients had transient hypoparathyroidism (n=137), and two patients had persistent hypoparathyroidism 6 months after total thyroidectomy (0.6%). There was no significant difference in either hypocalcemia or hypoparathyroidism after total thyroidectomy based on age or diagnosis. CONCLUSIONS Characterizing outcomes for pediatric patients based on diagnosis will assist in preoperative counseling for patients and their families. This high-volume center reports low complication rates after pediatric thyroid surgery, highlighting that referral to high-volume centers should be considered for children and adolescents with thyroid disease requiring surgery. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Heron D Baumgarten
- Department of Surgery, Children's Hospital of Philadelphia, and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Andrew J Bauer
- Department of Pediatrics, and the Pediatric Thyroid Center, Children's Hospital of Philadelphia, and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Amber Isaza
- Department of Pediatrics, and the Pediatric Thyroid Center, Children's Hospital of Philadelphia, and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Sogol Mostoufi-Moab
- Department of Pediatrics, and the Pediatric Thyroid Center, Children's Hospital of Philadelphia, and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Ken Kazahaya
- Department of Surgery, Children's Hospital of Philadelphia, and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Division of Pediatric Otolaryngology, Children's Hospital of Philadelphia, and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - N Scott Adzick
- Department of Surgery, Children's Hospital of Philadelphia, and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
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Comparative analysis of radioactive iodine versus thyroidectomy for definitive treatment of Graves disease. Surgery 2016; 161:147-155. [PMID: 27863789 DOI: 10.1016/j.surg.2016.06.066] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 04/27/2016] [Accepted: 06/03/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND Management of Graves disease includes antithyroid drugs, 131I therapy, or thyroidectomy. Our aim was to review our institutional experience with definitive treatments for Graves disease. METHODS This was a retrospective review of patients undergoing 131I therapy (n = 295) or thyroidectomy (n = 103) for Graves disease (2003-2015). Demographic, clinical, pathology, and outcome data were collected from institutional databases. RESULTS 131I therapy patients were older (39.1 years vs 33.4 years, P = .001). There was no difference in the presence of ophthalmopathy between groups. A larger proportion of children received thyroidectomy than 131I therapy (17.1% vs 9.2%, P = .026). The success rate of the first 131I therapy dose was 81.4%. Overall success rate, including additional doses, was 90.1%. Rapid turnover of iodine correlated with 131I therapy failure (58.3% rapid turnover failure vs 14.9% non-rapid turnover failure, P < .05). All surgical patients underwent total or near-total thyroidectomy. 131I therapy complications included worsening thyrotoxicosis (1%) and deteriorating orbitopathy (0.7%). Operative complications were higher than 131I therapy complications (P < .05) but were transient. There was no worsening orbitopathy or recurrent Graves disease among surgical patients. CONCLUSION A higher proportion of pediatric Graves disease patients underwent thyroidectomy than 131I therapy. Rapid turnover suggested more effective initial management with operation than 131I therapy. Although transient operative complications were high, 131I therapy complications included worsening of Graves orbitopathy among those with pre-existing orbitopathy.
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Elfenbein DM, Katz M, Schneider DF, Chen H, Sippel RS. Thyroidectomy for Graves' disease in children: Indications and complications. J Pediatr Surg 2016; 51:1680-3. [PMID: 27113266 PMCID: PMC5039045 DOI: 10.1016/j.jpedsurg.2016.03.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 03/10/2016] [Accepted: 03/18/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND The utilization of thyroidectomy for Graves' disease remains controversial; we aim to evaluate the indications for and complications of thyroidectomy for Graves' in children. METHODS A retrospective analysis was performed on all Graves' patients who underwent thyroidectomy from 2009 to 2013 at a high volume academic center. Pediatric patients were <18years old, and a comparative analysis of indications for surgery and complications was performed. RESULTS 167 patients underwent thyroidectomy: 31 pediatric patients and 136 adults. Failure of antithyroid medications was the indication for surgery in 55% of the children vs 36% of adults (p=0.05). Mean duration of medications prior to surgery was similar. No children had failed RAI therapy prior to surgery, but 12.5% of the adult population had (p=0.04). Surgical outcomes were similar. CONCLUSION Clinicians may be more likely to refer children who fail medical treatment to surgery over RAI. Thyroidectomy at a high volume hospital should be discussed as a treatment option for children with Graves'.
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Gauthier JM, Mohamed HE, Noureldine SI, Nazari-Shafti TZ, Thethi TK, Kandil E. Impact of thyroidectomy on cardiac manifestations of Graves' disease. Laryngoscope 2016; 126:1256-9. [DOI: 10.1002/lary.25687] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2015] [Indexed: 11/06/2022]
Affiliation(s)
- Jason M. Gauthier
- Department of Surgery; Washington University School of Medicine; St. Louis Missouri
| | - Hossam Eldin Mohamed
- Division of Endocrine and Oncologic Surgery, Department of Surgery; Tulane University School of Medicine; New Orleans Louisiana
| | - Salem I. Noureldine
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery; Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Timo Z. Nazari-Shafti
- Center for Cardiovascular Regeneration; Houston Methodist Research Institute; Houston Texas
| | - Tina K. Thethi
- Division of Endocrinology, Department of Medicine; Tulane University School of Medicine; New Orleans Louisiana
- Southeast Louisiana Veterans Health Care System; New Orleans Louisiana U.S.A
| | - Emad Kandil
- Division of Endocrine and Oncologic Surgery, Department of Surgery; Tulane University School of Medicine; New Orleans Louisiana
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Shakhsheer BA, Bordini B, Abdulrasool L, Grogan R, Kaplan E. Thyroidectomy in a two-year old for graves' disease. Int J Surg Case Rep 2015; 8C:131-3. [PMID: 25661638 PMCID: PMC4354700 DOI: 10.1016/j.ijscr.2015.01.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 01/28/2015] [Indexed: 11/28/2022] Open
Abstract
The most common cause of hyperthyroidism in children is graves’ disease. Surgery is utilized as a therapy for graves’ disease but rarely employed in children. This case report represents the youngest patient to undergo thyroidectomy for graves’ disease.
Introduction The most common cause of hyperthyroidism in children is graves’ disease – an autoimmune disorder in which antibodies stimulate the thyrotropin receptor to signal growth thyroid gland by increasing thyroid hormone synthesis and release. It can be treated with medical therapy, radioactive iodine, or surgery. Presentation of case JD was a two year old male who presented with severe diarrhea and diffuse neck enlargement. Laboratory work up was consistent with graves’ disease. Discussion Despite maximal outpatient and inpatient treatment with methimazole, atenolol, prednisone, and SSKI, he suffered persistent thyrotoxicosis. He underwent near-total thyroidectomy without complication. Conclusion This case is notable as it may represent the youngest patient in the literature who has undergone thyroidectomy for graves’ disease.
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Affiliation(s)
- Baddr A Shakhsheer
- Department of Surgery, Endocrine Surgery Research Program, The University of Chicago, 5841 S Maryland Avenue, MC 6040, Chicago, IL 60637, USA.
| | - Brian Bordini
- Academic Endocrinology, 1315 Macom Drive, Suite 007, Naperville, IL 60564, USA
| | - Layth Abdulrasool
- Department of Surgery, Endocrine Surgery Research Program, The University of Chicago, 5841 S Maryland Avenue, MC 6040, Chicago, IL 60637, USA
| | - Raymon Grogan
- Department of Surgery, Endocrine Surgery Research Program, The University of Chicago, 5841 S Maryland Avenue, MC 6040, Chicago, IL 60637, USA
| | - Edwin Kaplan
- Department of Surgery, Endocrine Surgery Research Program, The University of Chicago, 5841 S Maryland Avenue, MC 6040, Chicago, IL 60637, USA
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12
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Edafe O, Antakia R, Laskar N, Uttley L, Balasubramanian SP. Systematic review and meta-analysis of predictors of post-thyroidectomy hypocalcaemia. Br J Surg 2014; 101:307-20. [PMID: 24402815 DOI: 10.1002/bjs.9384] [Citation(s) in RCA: 409] [Impact Index Per Article: 40.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2013] [Indexed: 01/20/2023]
Abstract
BACKGROUND Hypocalcaemia is common after thyroidectomy. Accurate prediction and appropriate management may help reduce morbidity and hospital stay. The aim of this study was to perform a systematic literature review and meta-analysis of predictors of post-thyroidectomy hypocalcaemia. METHODS A systematic search of PubMed, EMBASE and the Cochrane Library databases was undertaken, and the quality of manuscripts assessed using a modified Newcastle-Ottawa Scale. RESULTS Some 115 observational studies were included. The median (i.q.r.) incidence of transient and permanent hypocalcaemia was 27 (19-38) and 1 (0-3) per cent respectively. Independent predictors of transient hypocalcaemia included levels of preoperative calcium, perioperative parathyroid hormone (PTH), preoperative 25-hydroxyvitamin D and postoperative magnesium. Clinical predictors included surgery for recurrent goitre and reoperation for bleeding. A calcium level lower than 1·88 mmol/l at 24 h after surgery, identification of fewer than two parathyroid glands (PTGs) at surgery, reoperation for bleeding, Graves' disease and heavier thyroid specimens were identified as independent predictors of permanent hypocalcaemia in multivariable analysis. Factors associated with transient hypocalcaemia in meta-analyses were inadvertent PTG excision (odds ratio (OR) 1·90, 95 per cent confidence interval 1·31 to 2·74), PTG autotransplantation (OR 2·03, 1·44 to 2·86), Graves' disease (OR 1·75, 1·34 to 2·28) and female sex (OR 2·28, 1·53 to 3·40). CONCLUSION Perioperative PTH, preoperative vitamin D and postoperative changes in calcium are biochemical predictors of post-thyroidectomy hypocalcaemia. Clinical predictors include female sex, Graves' disease, need for parathyroid autotransplantation and inadvertent excision of PTGs.
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Affiliation(s)
- O Edafe
- Department of Oncology, University of Sheffield, Sheffield, UK
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13
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Enes Romero P, Martín-Frías M, de Jesús M, Caballero Loscos C, Alonso Blanco M, Barrio Castellanos R. [Efficacy of treatment with I(131) in paediatric Graves disease]. An Pediatr (Barc) 2013; 80:16-20. [PMID: 23796613 DOI: 10.1016/j.anpedi.2013.01.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2012] [Revised: 01/29/2013] [Accepted: 01/30/2013] [Indexed: 10/26/2022] Open
Abstract
INTRODUCTION Radioiodine is an important therapeutic option in young patients with Grave's disease (GD). In the United States it is a widespread therapy, but in Europe its use in paediatrics is still controversial. AIM To report our experience in radioiodine therapy of paediatric GD patients and analyse its effectiveness and safety. PATIENTS AND METHODS We retrospectively studied our paediatric population (<18 years of age) with GD, diagnosed from 1982 to 2012. A curative option was offered to patients who did not respond to anti-thyroid drug (AT) at puberty. We analysed, the patient characteristics, TSH, T4, T3 and thyroid antibodies levels, AT response, remission post I(131), side effects, and hypothyroidism rates. RESULTS A total of 50 patients were diagnosed with GD from 1982 to 2012. All patients received AT as initial treatment (mean duration: 35.3±25.9 months). Permanent remission was achieved in 46%. Thyroidectomy was performed in 5 patients, and 14 patients received I(131) (mean dose: 10.9±1.09 mCi). Remission with I(131) was obtained in 100%. The rate of permanent hypothyroidism was 90%. There was no progression of ophthalmopathy or side effects in any patients treated with I(131.) CONCLUSION Radioiodine treatment of paediatric GD patients is safe, leads to complete remission at the expense of hypothyroidism, and does not exacerbate ophthalmopathy. It can be considered in patients older than 5 years, who do no not respond to AT or with significant side effects with this medication.
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Affiliation(s)
- P Enes Romero
- Unidad de Diabetes y Endocrinología Pediátrica, Servicio de Pediatría, Hospital Universitario Ramón y Cajal, Madrid, España.
| | - M Martín-Frías
- Unidad de Diabetes y Endocrinología Pediátrica, Servicio de Pediatría, Hospital Universitario Ramón y Cajal, Madrid, España
| | - M de Jesús
- Servicio de Medicina Nuclear, Hospital Universitario Ramón y Cajal, Madrid, España
| | - C Caballero Loscos
- Servicio de Medicina Nuclear, Hospital Universitario Ramón y Cajal, Madrid, España
| | - M Alonso Blanco
- Unidad de Diabetes y Endocrinología Pediátrica, Servicio de Pediatría, Hospital Universitario Ramón y Cajal, Madrid, España
| | - R Barrio Castellanos
- Unidad de Diabetes y Endocrinología Pediátrica, Servicio de Pediatría, Hospital Universitario Ramón y Cajal, Madrid, España
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14
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Genovese BM, Noureldine SI, Gleeson EM, Tufano RP, Kandil E. What is the best definitive treatment for Graves' disease? A systematic review of the existing literature. Ann Surg Oncol 2012; 20:660-7. [PMID: 22956065 DOI: 10.1245/s10434-012-2606-x] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2012] [Indexed: 11/18/2022]
Abstract
BACKGROUND The management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists for Graves' disease (GD) include any of the following modalities: (131)I therapy, antithyroid medication, or thyroidectomy. No in-depth analysis has been performed comparing the treatment options, even though a single treatment option seems to be universally accepted. METHODS A systematic review of the literature was performed to examine contemporary literature between 2001 and 2011 evaluating the management options of GD. We compiled retrospective and prospective studies analyzing surgery and radioactive iodine. Outcomes of interest included postoperative hypothyroidism, euthyroidism, and persistent or recurrent hyperthyroidism without supplementation. Success was defined as postoperative euthyroidism or hypothyroidism. Failure was defined as persistent or recurrent hyperthyroidism. RESULTS Of the 14,245 patients, 4,546 underwent surgery [3,158 patients had subtotal thyroidectomy (STT) and 1,388 had total thyroidectomy (TT)] and 9,699 had radioactive iodine. The radioactive iodine group consisted of 2,383 patients receiving 1-10 mCi, 1,558 patients receiving 11-15 mCi, 516 patients receiving >15 mCi, and 5,242 patients receiving an unspecified amount. Surgery was found to be 3.44 times more likely to be successful than radioactive iodine (p < 0.001). STT and TT were found to be 2.33 and 94.45 times more likely to be successful than radioactive iodine (p < 0.001), respectively. CONCLUSIONS On the basis of the outcomes analyzed, surgery appears to be the most successful in the management of GD, with TT being the preferred surgical option.
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Affiliation(s)
- Bradley M Genovese
- Division of Endocrine and Oncological Surgery, Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA.
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15
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Burke JF, Sippel RS, Chen H. Evolution of pediatric thyroid surgery at a tertiary medical center. J Surg Res 2012; 177:268-74. [PMID: 22795270 DOI: 10.1016/j.jss.2012.06.044] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2012] [Revised: 04/06/2012] [Accepted: 06/19/2012] [Indexed: 01/16/2023]
Abstract
BACKGROUND Thyroidectomy in the pediatric population is often avoided due to perceived risks in children. With growing subspecialization and establishment of high volume endocrine surgery centers, the indications for thyroid surgery and extent of resection continue to change. We examined the evolution of pediatric thyroid surgery at a high volume tertiary medical center. METHODS From our prospectively collected database, we reviewed medical records of individuals younger than 19 y who underwent thyroidectomy at our institution from 1994 to 2009. Patients were divided into two groups: (1) before establishment of our endocrine surgery center (1994-2001) and (2) since establishment of the center (2002-2009). RESULTS We identified 78 operations performed on 74 patients with a median age of 15 (range 3-18) y. We found that the number of patients doubled in the later time period, with 26 operations in group 1 and 52 in group 2. The age of patients and percentage of females were similar between groups. After establishment of the endocrine surgery center, there was a significant increase in total thyroidectomies for all indications, including significantly more for benign disease. Overall, 9% of the patient population experienced transient complications, with no permanent complications or long-term sequelae. CONCLUSIONS Pediatric thyroid surgery is extremely safe, especially when performed at a high volume endocrine surgery center. We more often select surgical treatment for benign disease and choose total thyroidectomy over limited resection. This may reflect increasing confidence in the safety and efficacy of surgery and reliability of thyroid hormone replacement.
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Affiliation(s)
- Jocelyn F Burke
- Department of Surgery, Section of Endocrine Surgery, University of Wisconsin, Madison, Wisconsin, USA
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