The use of “harmonic scalpel” versus “knot tying” for conventional “open” thyroidectomy: results of a prospective randomized study

Improving Operating Room Efficiency in Otolaryngology-Head and Neck Surgery: A Scoping Review

OBJECTIVE

One minute of operating room (OR) time costs $36 to 37. However, ORs are notoriously inefficient. There is growing literature on improving OR efficiency, but no formal review of this topic within otolaryngology has been performed. This study reviews and synthesizes the current literature on improving OR efficiency within otolaryngology.

DATA SOURCES

MEDLINE, EMBASE, Web of Science, CINAHL, Cochrane Library, preprints.org, and medRxiv were searched on November 4, 2022.

REVIEW METHODS

Published English studies were included if they reported on metrics for improving OR efficiency within otolaryngology. There were no publication date restrictions. Articles were screened by 2 reviewers. Preferred Reporting Items for Systematic Reviews and Meta-analysis reporting for scoping reviews was followed.

RESULTS

The search yielded 9316 no-duplicate articles; 129 articles were included. Most of the studies reported on head and neck procedures (n = 52/129). The main tactics included surgical considerations: hemostatic devices, techniques, and team/simultaneous approaches; anesthetic considerations: local anesthetic and laryngeal mask airways; procedure location considerations: procedures outside of the OR and remote technologies; standardization: equipment, checklists, and personnel; scheduling considerations: use of machine learning for booking, considering patient/surgeon factors, and utilizing dedicated OR time/multidisciplinary teams for on-call cases.

CONCLUSION

The current literature brings to attention numerous strategies for improving OR efficiency within otolaryngology. Applying these strategies and implementing novel techniques to manage surgical cases may assist in offloading overloaded health care systems and improving access to care while facilitating patient safety and outcomes. Anticipated barriers to implementation include resistance to change, funding, and the current strain on health care systems and providers.

Systematic review and meta-analysis of the use of high-energy devices for thyroid surgery

BACKGROUND

We conducted a systematic review and meta-analysis to evaluate the role of High Energy Devices (HEDs) versus conventional clamp and tie technique in thyroidectomy. This work is endorsed by the Italian Society of Surgical Endoscopy (Italian Society of Endoscopic Surgery and new technologies-SICE) in the broader project on the evaluation of the role of HEDs in different surgical settings with the full health technology assessment report.

MEHODS

Inclusion criteria were adult patients (≥ 18 years old) undergoing Thyroidectomy/Parathyroidectomy conducted with High Energy Devices (as ultrasonic (US), radiofrequency (RF), and hybrid energy (H-US/RF)) in the setting of thyroid surgery (both partial and total) for benign and malign diseases. However, some variability was found in included studies and described in the text. This systematic review and meta-analysis were performed according to the Cochrane handbook for systematic reviews, and the recommendations of the 2020 updated Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) guidelines were pursuit. Selection of abstracts was performed in Ryyan system by 2 independent reviewers, and doubts were solved by another independent reviewer. At the end of literature research, Randomized controlled trials and observational studies were included. Risk of Bias was assessed with ROB2 for RCTs, and New Castle Ottawa Scale for Observational studies.

RESULTS

The literature search yielded 47 studies, including 29 RCTs and 18 observational studies. Meta-analysis was performed for 29 randomized clinical trials. Outcomes included in the comparison between High Energy Devise and conventional technique groups were operative time, operative blood loss, overall post-operative drainage volume, length of stay, complications, and costs. HED significantly reduced operative time (28 studies, 3097patients; MD -128.8; 95% CI -34.4 to -23.20; I2 = 96%, p < 0.00001, Random-effect), intra-operative blood loss (13 studies, 642 vs 519 patients; SMD -0.82; 95% CI -1.33 to -0.32; I2 = 93%, p < 0.00001, Random-effect), LOS (22 studies, 2808 vs 2789 patients; MD -0.38, 95% CI -0.59 to -0.17; I2 = 98%, p < 0.00001 Random-effect), and healthcare costs (8 studies, 1138 vs 1129 patients, SMD 1.05; 95% CI -0.06 to 2.16; I2 = 99%, p < 0.00001 Random-effect). The rate of overall intraoperative complications was significantly different between both groups (25 studies, 2804 vs 2775 patients; RR 0.88, 95% CI 0.80 to 0.97; I2 = 38%, p = 0.03 Random-effect), but the sensitivity analysis did not find a statistically significant difference (6 studies, 605 vs 594 patients, RR; 95% CI to; I2 = 0%, p = 0.50, Random-effect). There was no difference in the subgroup analysis for the occurrence of transient and permanent RLN palsy, nor hematoma formation and hypocalcaemia.

DISCUSSION

Though findings of our systematic review and metanalysis are limited by heterogeneous data, surgeons, hospital managers, and policymakers should note that the use of High Energy Devices compared to conventional clamp and tie technique have reduced operative times, intra-operative blood loss, length of stay, and hospital costs in patients underwent to tyroid surgery. Future work must explore issues of equity to mitigate barriers to patient access to safe thyroid surgical care and define better this initial results.

High-energy devices in different surgical settings: lessons learnt from a full health technology assessment report developed by SICE (Società Italiana di Chirurgia Endoscopica)

BACKGROUND

The present paper aims at evaluating the potential benefits of high-energy devices (HEDs) in the Italian surgical practice, defining the comparative efficacy and safety profiles, as well as the potential economic and organizational advantages for hospitals and patients, with respect to standard monopolar or bipolar devices.

METHODS

A Health Technology Assessment was conducted in 2021 assuming the hospital perspective, comparing HEDs and standard monopolar/bipolar devices, within eleven surgical settings: appendectomy, hepatic resections, colorectal resections, cholecystectomy, splenectomy, hemorrhoidectomy, thyroidectomy, esophago-gastrectomy, breast surgery, adrenalectomy, and pancreatectomy. The nine EUnetHTA Core Model dimensions were deployed considering a multi-methods approach. Both qualitative and quantitative methods were used: (1) a systematic literature review for the definition of the comparative efficacy and safety data; (2) administration of qualitative questionnaires, completed by 23 healthcare professionals (according to 7-item Likert scale, ranging from - 3 to + 3); and (3) health-economics tools, useful for the economic evaluation of the clinical pathway and budget impact analysis, and for the definition of the organizational and accessibility advantages, in terms of time or procedures' savings.

RESULTS

The literature declared a decrease in operating time and length of stay in using HEDs in most surgical settings. While HEDs would lead to a marginal investment for the conduction of 178,619 surgeries on annual basis, their routinely implementation would generate significant organizational savings. A decrease equal to - 5.25/-9.02% of operating room time and to - 5.03/-30.73% of length of stay emerged. An advantage in accessibility to surgery could be hypothesized in a 9% of increase, due to the gaining in operatory slots. Professionals' perceptions crystallized and confirmed literature evidence, declaring a better safety and effectiveness profile. An improvement in both patients and caregivers' quality-of-life emerged.

CONCLUSIONS

The results have demonstrated the strategic relevance related to HEDs introduction, their economic sustainability, and feasibility, as well as the potentialities in process improvement.

Tension-free thyroidectomy (TFT): initial report

The safety of thyroid surgery in terms of recurrent laryngeal nerve palsy and hypoparathyroidism has increased over the last decade. In this study, we present a new method of tension-free thyroidectomy (TFT), which could be used to further decrease the complication rate after a thyroidectomy. The procedure is based on the medial approach to the recurrent laryngeal nerve and the parathyroid glands after the division of the isthmus and successive complete dissection of Berry's ligament. In total, 92 patients (127 nerves at risk) underwent "tension-free thyroidectomy" (TFT) between August and November 2021. All the procedures were performed by a single surgeon at Saint Petersburg State University Hospital. There were 74 females and 18 male patients (ratio 4.1:1) with a mean age of 46.9 (range from 17 to 74). A lobectomy was carried out in 57 (62%) patients and a total thyroidectomy in 35 (38%). In 27 cases, patients additionally underwent central and/or lateral neck dissection. Indications for surgery were papillary carcinoma (N = 34), medullary cancer (N = 2), follicular neoplasia (N = 43), Grave's disease (N = 9), multinodular toxic goiter (N = 3), and multinodular nontoxic goiter (N = 1). Mean thyroid volume was 24.6 ml (ranged 12-70 ml). Intraoperative neuromonitoring was used in all the cases (5 mA). Translaryngeal ultrasound (TLUS) or direct laryngoscopy were routinely used prior and after surgery to evaluate vocal cords mobility. Calcium and parathormone levels were measured in patients after thyroidectomy on the first, 14th and 30th postoperative days. No recurrent laryngeal nerve palsy was observed. One patient exhibited hypoparathyroidism which was resolved in 2 weeks using substitution therapy with calcium and alfacalcidol. The mean operating time for lobectomy was 54 ± 14 min (range: 30-95 min) and for total thyroidectomy 99 ± 28 min (range: 55-158 min). There was no conversion to the conventional lateral-to-medial approach. TFT can be considered a safe and feasible operation. Comparative (randomized studies) with conventional dissection technique should be performed to investigate the hypothesis that this approach can provide a lower complication rate.

Vessel Sealant Devices in Thyroidectomies: An ACS-NSQIP Study

OBJECTIVES

Thyroidectomies involve meticulous dissection of a highly vascularized organ and complications may develop, such as hematoma, hypocalcemia, and even hypoparathyroidism. Because some of these complications may be fatal, we sought to identify the differences in postthyroidectomy outcomes when the use of a vessel sealant device (VSD) such, as LigaSure or Harmonic scalpel, is compared with more traditional techniques, such as ligatures and clips.

METHODS

Using the 2016 American College of Surgeons National Surgical Quality Improvement Program Targeted Thyroidectomy database, we compared patients who underwent a thyroidectomy using a VSD with patients without a VSD for differences in postoperative complications.

RESULTS

A total of 5146 cases were identified and 3452 of those cases used a VSD, whose use was associated with significantly lower rates of hematoma, deep vein thrombosis, and hypocalcemia before discharge, as well as a shorter length of stay and longer operation time. Multivariate logistic regression showed that VSD was associated with 32.27% and 39.15% lower odds of hypocalcemia and hematoma, respectively. VSDs also were used more frequently in cases that had multinodular, severe, or substernal goiter or Graves disease as the primary indication for surgery and in patients with a higher body mass index. There was no significant difference in the incidence of recurrent laryngeal nerve injury between the two groups.

CONCLUSIONS

Analysis of the American College of Surgeons National Surgical Quality Improvement Program data indicates that VSDs are associated with a lower risk of complications, such as hypocalcemia, hematoma, and deep vein thrombosis, suggesting that VSDs may be a more effective method of hemostasis than traditional techniques.

Tension-free thyroidectomy — results of the initial 77 operations

BACKGROUND: Surgeons from all over the world make considerable efforts to reduce thyroid intraoperative complications such as recurrent laryngeal nerves trauma and parathyroid vascular supply damage.

AIM: The aim of the study was improving thyroidectomy technique to reduce the rate of postoperative complications.

MATERIALS AND METHODS: Inclusion criteria were primary thyroid operation in cases of papillary or medullary cancer, follicular tumours (Bethesda IV) and Grave’s disease. Thyroid volume ranged from 12–70 ml. Tension-free technique of thyroidectomy (TFT) was suggested by the authors of this study. Key points of TFT are the following: the first step is the complete dissection of Berry ligament fibers and terminal branches of lower thyroid arteries and vein. There is only lateral traction while medial traction is not applied at all. Mobilization of the upper parathyroid gland is performed at the medial thyroid surface. Thyroid lobe is extracted out of its bed beginning with the lower pole only after complete dissection of Berry’s ligament, vessels and parathyroid glands. The last step of the operation is the dissection of the upper pole thyroid vessels. The mobilized lobe is easily withdrawn downwards, that leads to space increase between external branch of the superior laryngeal nerve and the upper pole of the lobe. Transient and continuous neuromonitoring as well as optical magnification and headlamps were used during operations. Vocal cords function was controlled before and after surgery (on the first day) by means of ultrasound or endoscopic laryngoscopy. Ionized calcium and parathyroid hormone levels were checked in cases of total thyroidectomy group on the day of surgery, on the 1st and 14th postoperative days.

RESULTS: 77 consecutive patients were included into the study (continuous sampling of patients). 33 hemithyroidectomies, 13 hemithyroidectomies with central ipsilateral neck dissection, 21 thyroidectomies, 8 thyroidectomies with central neck dissection, 2 thyroidectomies with central and lateral neck dissection were performed by the same surgeon. All the operations were performed by tension-free technique (TFT). There were no cases of loss of signal from the recurrent laryngeal nerves function during all the operations. One case of postoperative transient hypoparathyroidism finished with normalization of parathyroid hormone and calcium levels in 2 weeks after the operation.

CONCLUSION: initial experience in TFT allows to recommend this procedure for further practicing and examination.

The role of LigaSure™ and Harmonic Scalpel in the preservation of recurrent laryngeal nerve during thyroidectomy

INTRODUCTION

Transient or permanent damage to the recurrent laryngeal nerve (RLN) during thyroidectomy is of paramount importance for patient quality of life. The aim of this study is to systematically review the literature concerning the role of the most popular energy-based vessel-sealing devices (LigaSure™ (LS) and Harmonic Scalpel (HS)) in preservation of the RLN during thyroidectomy. The safety and inferiority or superiority of LS and HS compared with conventional haemostatic techniques are highlighted.

METHODS

A systematic search of the literature was performed. Clinical trials, prospective and retrospective studies that significantly compared the use of LS and HS with conventional haemostasis regarding the postoperative incidence of RLN palsy were included.

FINDINGS

The search resulted in 43 studies, including 17,953 patients treated using energy-based devices or conventional haemostatic methods. Concerning the incidence of RLN palsy, 40 studies showed no significant difference between the energy-based device and conventional groups, whereas two studies demonstrated a significant superiority in performance for LS and HS compared with conventional haemostasis. Only one study exhibited significant inferiority of LS and HS compared with conventional methods. No statistical relationship was observed between energy-based devices and conventional techniques regarding permanent damage to the RLN.

CONCLUSION

The performance of both LS and HS shows no inferiority compared with conventional haemostatic techniques, regarding damage to the laryngeal nerve. Further well-designed studies are needed to investigate their potential benefit in preservation of the RLN.

Effect of energy-based devices on post-operative parathyroid function and blood calcium levels after total thyroidectomy

Introduction: Energy-based devices are widely used in thyroid surgery in order to achieve optimal hemostasis, while their role in the incidence of hypocalcemia and hypoparathyroidism comprises a topic evaluated in numerous studies.Areas covered: The aim of this systematic review is to investigate the potential benefit of Ultrasonic Shears and Electrothermal Bipolar (Radiofrequency) System in thyroid surgery regarding the incidence of post-operative hypocalcemia and hypoparathyroidism. A systematic review of the literature in PubMed/Medline and Scopus databases was conducted. Forty-nine studies met the inclusion criteria and were analyzed. A statistically decreased rate of transient hypocalcemia and hypoparathyroidism was reported in 15 studies and 4 studies, respectively, when using energy-based devices. However, 18 and 13 surveys examined transient hypocalcemia and hypoparathyroidism, respectively, and demonstrated no statistical difference between energy-based devices and conventional hemostasis. No difference was observed between the groups concerning permanent hypocalcemia. Out of 13 studies, only 2 showed a significant reduction in the occurrence of permanent hypoparathyroidism in the energy-based device group.Expert opinion: Energy-based devices reduced the rate of transient hypocalcemia and hypoparathyroidism after thyroid surgeries in 42.8% and 23.5% of the included studies, respectively. Further studies are needed to evaluate their impact on permanent post-operative hypocalcemia and hypoparathyroidism.

Energy Based Vessel Sealing Devices in Thyroid Surgery: A Systematic Review to Clarify the Relationship with Recurrent Laryngeal Nerve Injuries

Background and objectives: The principal complications associated with thyroid surgery consist in postoperative recurrent laryngeal nerve (RLN) palsy, hypoparathyroidism, intra-operative and post-operative hemorrhage. In this paper, structured as a literature review, we describe the current knowledge and the technical improvements currently employed in the field of thyroid surgery, focusing on the contribution of energy based devices in relation with the reduction of the operating time and the odds of possible complication. Materials and methods: a relevant systematic literature search on Pubmed was carried out including works from 2004 through 2019, selecting studies providing information on the energy based devices employed in surgeries and statistic data concerning RNL (transient and permanent) injury and operative time. Results: Nineteen studies were reviewed, dealing with 4468 patients in total. The operative variables considered in this study are: employed device, number of patients, pathological conditions affecting the patients, surgical treatment, RNL injury percentage and the operating time, offering an insight on different patient conditions and their relative operative outcomes. A total of 1843 patients, accounting to the 41.2% of the total pool, underwent the traditional technique operation, while 2605 patients (58.3%) were treated employing the energy based devices techniques. Thyroidectomy performed by approaches different from traditional (for example robotic, MIVAT (Mini Invasive Video Assisted thyroidectomy)) were excluded from this study. Conclusions: The energy-based vessel sealing devices in study, represent a safe and efficient alternative to the traditional clamp-and-tie hand technique in the thyroidal surgery scenario, granting a reduction in operating time while not increasing RNL injury rates. According to this information, a preference for energy based devices techniques might be expressed, furthermore, a progressively higher usage rate for these devices is expected in the near future.

The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults

OBJECTIVE

To develop evidence-based recommendations for safe, effective, and appropriate thyroidectomy.

BACKGROUND

Surgical management of thyroid disease has evolved considerably over several decades leading to variability in rendered care. Over 100,000 thyroid operations are performed annually in the US.

METHODS

The medical literature from 1/1/1985 to 11/9/2018 was reviewed by a panel of 19 experts in thyroid disorders representing multiple disciplines. The authors used the best available evidence to construct surgical management recommendations. Levels of evidence were determined using the American College of Physicians grading system, and management recommendations were discussed to consensus. Members of the American Association of Endocrine Surgeons reviewed and commented on preliminary drafts of the content.

RESULTS

These clinical guidelines analyze the indications for thyroidectomy as well as its definitions, technique, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Fine Needle Aspiration Biopsy Diagnosis, Molecular Testing, Indications, Extent and Outcomes of Surgery, Preoperative Care, Initial Thyroidectomy, Perioperative Tissue Diagnosis, Nodal Dissection, Concurrent Parathyroidectomy, Hyperthyroid Conditions, Goiter, Adjuncts and Approaches to Thyroidectomy, Laryngology, Familial Thyroid Cancer, Postoperative Care and Complications, Cancer Management, and Reoperation.

CONCLUSIONS

Evidence-based guidelines were created to assist clinicians in the optimal surgical management of thyroid disease.

Association of Vessel-Sealant Devices vs Conventional Hemostasis With Postoperative Neck Hematoma After Thyroid Operations

Importance

Vessel-sealant devices (VSDs) have been popularized for use in thyroid operations; however, the association of their use with postoperative neck hematoma, a rare but potentially fatal complication, has not been well studied.

Objective

To examine the association of VSDs vs conventional hemostasis (CH) in thyroid operations with the development of neck hematoma.

Design, Setting, and Participants

This retrospective cohort study evaluated 10 903 patients in the Thyroid Procedure-Targeted Database of the National Surgical Quality Improvement Program from January 1, 2016, to December 31, 2017. One-to-one nearest-neighbor propensity score matching was conducted to adjust for differences in baseline covariates, including demographics, comorbidities, indications for thyroid procedure (goiter, Graves disease, malignant and benign thyroid nodule), and several other thyroid-specific characteristics, between the VSD and CH groups.

Main Outcomes and Measures

The primary outcome was postoperative hematoma requiring intervention with open evacuation, return to the operating room, tracheostomy, additional observation, or extended length of stay. Secondary outcomes include recurrent laryngeal nerve injury, operative duration, and hospital length of stay.

Results

One-to-one propensity score matching yielded 6522 patients (mean [SD] age, 52 [15] years; 8544 [78.4%] female) with 3261 in each exposure group such that distribution of observed baseline covariates was not different between groups of the same propensity score. Within the matched cohort, CH was associated with higher odds of neck hematoma compared with VSD (odds ratio, 2.33; 95% CI, 1.55-3.49; P < .001), with 34 (1.0%) hematomas in the VSD group and 78 (2.4%) in the CH group. On the basis of this analysis, the number needed to treat with a VSD to prevent 1 postoperative hematoma was 74. Secondary outcomes included longer length of hospital stay (incidence rate ratio, 1.29; 95% CI, 1.23-1.36; P < .001]) in the CH group compared with the VSD group but no difference in the odds of recurrent laryngeal nerve injury (odds ratio, 0.90; 95% CI, 0.73-1.11; P = .32) or operative duration (incidence rate ratio, 0.99; 95% CI, 0.96-1.01; P = .24).

Conclusions and Relevance

Use of VSDs during thyroid operations was associated with reduced odds of neck hematoma compared with CH techniques without increasing odds of nerve injury. The results suggest that postoperative neck hematoma rates after thyroid surgery may differ based on the hemostasis technique and that these differences should be considered when developing strategies for quality improvement of postoperative outcomes.

Comparing Hematoma Incidence between Hemostatic Devices in Total Thyroidectomy: A Systematic Review and Meta-analysis

OBJECTIVE

Alternative energy devices have become a popular alternative to conventional hemostasis in thyroid surgery. These devices have been shown to reduce operative time and thermal nerve injury. As hemostasis is paramount in thyroid surgery, we sought to examine the relative efficacy of 2 alternate energy devices compared to conventional hemostasis in preventing postoperative hematoma following total thyroidectomy.

DATA SOURCES

Ovid MEDLINE, EMBASE, PubMed, and Cochrane Central Register of Controlled Trials.

REVIEW METHODS

A systematic literature search was performed for all relevant English-language studies published between 1946 and July 2018. Two authors independently extracted data and analyzed articles for quality using the National Institute of Health Quality Assessment Scale. Our primary outcome of interest was hematoma requiring reoperation.

RESULTS

A total of 348 studies were screened, with 23 meeting the inclusion criteria. We found no significant difference in postoperative hematoma rates using alternate energy devices compared to conventional hemostasis (P = .370, .317). Network meta-analysis echoed the results of conventional meta-analysis, demonstrating no significant difference in hematoma rates.

CONCLUSIONS

We found no significant difference in postoperative hematoma rates following total thyroidectomy for any indication with the use of alternate energy devices compared to conventional hemostatic techniques. This suggests that hematoma occurrence does not necessarily need to be considered when choosing between these hemostatic devices. This information may help guide surgeons' decisions regarding choice of hemostatic technique during thyroid surgery.

Procedure costs associated with the use of Harmonic devices compared to conventional techniques in various surgeries: a systematic review and meta-analysis

Background

As compared to conventional techniques, recent meta-analyses have reported cost savings with Harmonic devices; however, only in thyroidectomy. Thus, the aim of this study was to evaluate the costs associated with Harmonic devices versus conventional techniques across a range of surgical procedures.

Methods

A systematic search of MEDLINE, EMBASE, and Cochrane Library was conducted from inception to October 01, 2016 without language restrictions to identify randomized controlled trials comparing Harmonic devices to conventional techniques and reporting procedure costs (operating time plus operating equipment/consumables/device costs). Costs were pooled using the ratio of geometric means, and a random effects model was applied. Sensitivity analyses varying statistical methods, number of included studies, and cost outcomes were completed to test the robustness of the results.

Results

Thirteen studies met the inclusion criteria. A total of 561 and 540 participants had procedures performed with Harmonic devices and conventional methods, respectively, with procedures including gastrectomy, thyroidectomy, colectomy, cholecystectomy, Nissen fundoplication, and pancreaticoduodenectomy. As compared to conventional methods, Harmonic devices reduced total procedure costs by 8.7% (p=0.029), resulting in an absolute reduction of US$227.77 from mean conventional technique costs, derived primarily from a reduction in operating time costs. When operating time costs, excluding operating equipment/consumables/device costs, were analyzed, costs were reduced by $544 per procedure with the use of Harmonic devices. The results from all sensitivity analyses demonstrated cost reductions with Harmonic devices.

Conclusion

This systematic review and meta-analysis showed that despite a higher device cost, Harmonic devices provide a statistically significant reduction in procedure costs, derived primarily from a reduction in operating time costs, across surgical procedures. In addition to functionality benefits, Harmonic devices may represent a potentially cost saving method to reduce overall hospital resource use. Future research should focus on potential costs and benefits from use of Harmonic devices in procedures not covered here.

Update on sutureless thyroidectomy

INTRODUCTION

The Harmonic scalpel ("Focus" and the new version "Focus+") is one of the first devices for surgical simultaneous cutting and tissue coagulation which allows to obtain dissection and hemostasis by direct application of ultrasound and allows minimally invasive surgical procedures with minimal lateral thermal spread and, thus, minimal adjacent tissue destruction. The aim of the study is to complete the previous study that we made in 2014, based on the TT performed between January 2008 and December 2013, with new data about TT performed in our Surgical Division between January 2014 and December 2016 and compare the outcome using the Ultrasonic scalpel versus the device Ligasure in term of safety, operative time, overall drainage volume, complications, hospital stay.

PATIENTS AND METHODS

250 patients were randomized into two groups: Group A where Ultracision were used and Group B where the Ligasure device was used.

RESULTS

The results of the group A and of the Group B 2014-2016 have been compared with the results of the previous study and we found that they are similar, but asymptomatic hypocalcaemia increased in the patients of the new study.

CONCLUSIONS

We found that the use of Ultrasonic scalpel and Ligasure is effective both in the hemostasis of all vessels and in dissection of tissues and confirm the results of our first study without significant difference in the rate of post-operative morbidity with these two different energy based devices used.

Use of ultrasonic scalpel and monopolar electrocautery for skin incisions in neck dissection: a prospective randomized trial

PURPOSE

Ultrasonic scalpel (UC) and monopolar electrocautery (ME) are standard equipment for soft tissue surgery. The aim of the present study was to compare intraoperative and postoperative patterns of patients using either UC or ME for skin incisions in neck dissection.

MATERIAL AND METHODS

In a prospective randomized study of 30 patients, the thermal effects of UC (n = 15) and ME (n = 15) were examined using real-time infrared thermographic imaging. Additionally, tissue damage was evaluated histopathologically. The other measured variables were operation and bleeding time, postoperative pain score (only neck incision area), in-patient time, and complications.

RESULTS

UC significantly reduces the thermal effects, compared to ME (p < 0.001). The mean depth of tissue damage (i.e., necrosis) was 272.7 μm for UC and 284.7 μm for ME with no significant difference (p = 0.285). From the third postoperative day, patients treated using UC had noticeably less pain in the neck incision area (t3 p = 0.010; t4 p < 0.001; t5 p < 0.005). Cutting time was reduced for ME by 36.1 s (p < 0.001) and the bleeding time was decreased by 40.9 s for UC (p < 0.001). The total preparation time was the same (p = 0.402). When comparing in-patient time (p = 0.723), as well as complications, no significant differences were seen.

CONCLUSION

UC results in less postoperative pain and less bleeding in the neck incision area. Accordingly, UC is superior to ME for skin incisions in neck dissection.

New generation cut-and-seal devices in oral and oropharyngeal cancer resection: clinical and cost-effectiveness study

OBJECTIVES

To evaluate the clinical efficacy and cost-effectiveness of ultrasonic shears and the electrothermal bipolar vessel sealing system, in comparison to the traditional cold knife and bipolar forceps, in oral and oropharyngeal cancer surgery.

METHODS

Patients who underwent oral or oropharyngeal cancer resection and neck dissection with either ultrasonic shears (n = 36) or electrothermal bipolar vessel sealing (n = 32) were enrolled. Surgical time, intra-operative bleeding, blood drainage, post-operative pain, neck oedema, complications and hospitalisation duration were compared to those of an historical cohort of 36 patients treated using a cold knife and bipolar forceps. Additionally, a cost-effectiveness evaluation was performed.

RESULTS

Ultrasonic shears and, in particular, electrothermal bipolar vessel sealing, were advantageous compared to the traditional techniques. The cost of ultrasonic shears and electrothermal bipolar vessel sealing was completely offset by declining time-driven costs for the surgical team and operating theatre.

CONCLUSION

Ultrasonic shears and, in particular, electrothermal bipolar vessel sealing, are more advantageous compared to the traditional techniques, from both a clinical and economic point of view.

Randomized clinical trial of ultrasonic scissors versus conventional haemostasis to compare complications and economics after total thyroidectomy (FOThyr)

Background

The benefits of single‐use ultrasonic scissors in thyroid surgery are still debated. Although this device has been shown to reduce operating time compared with conventional haemostasis, its cost‐effectiveness has never been demonstrated. The aim of this study was to evaluate the efficacy, cost‐effectiveness and safety of ultrasonic scissors for total thyroidectomy.

Methods

This was a prospective, randomized, multicentre trial conducted at 13 hospital sites. The primary endpoint was the percentage of patients with hypocalcaemia (serum calcium level below 2 mmol/l) on day 2. Secondary endpoints included postoperative complications and costs, with calculation of incremental cost differences and cost‐effectiveness ratios.

Results

In total, 1329 patients who underwent total thyroidectomy were included in the analysis: 670 were randomized to treatment with ultrasonic scissors and 659 to conventional haemostasis. There was no difference between groups in the rate of complications, including hypocalcaemia on day 2 (19^.7 per cent in ultrasonic scissors group versus 20^.3 per cent in conventional haemostasis group; P = 0·743). Median operating times were significantly shorter with ultrasonic scissors (90 versus 100 min with conventional haemostasis; P < 0·001). Total mean(s.d.) direct costs at 6 months were €4311(1547) and €4011(1596) respectively (P < 0·001).

Conclusion

Ultrasonic scissors were no more clinically effective than conventional haemostasis, but use of these devices was more costly. Registration number: NCT01551914 (http://www.clinicaltrials.gov).

Is the superior laryngeal nerve really safe when using harmonic focus in total thyroidectomy? A prospective randomized study

BACKGROUND

Harmonic focus (HF) was introduced in thyroid surgery in an effort to reduce operation time and complications.

OBJECTIVE

The present study aimed to compare function of superior laryngeal nerve and incidence of other postoperative complications in total thyroidectomies using HF and conventional ligation (CL).

METHODS

The trial is a randomized single-center, single-blinded study. Patients aged ≥ 18 years scheduled for total thyroidectomy were considered for participation. An ultrasonic dissector was used for coagulation and cutting in the HF group, while the standard technique was used in the CL group. Demographic, surgical data, and complications were recorded. Data were analyzed using SPSS for Windows.

RESULTS

Of 244 eligible patients, data of 206 patients who completed the study were analyzed. The groups were similar in terms of age, sex, and indication for operation. The mean operative time in the HF group was significantly shorter than that in CL group (p=0.01). Drain necessity, duration of drainage, duration of postoperative hospitalization, and the incidence of postoperative complications was similar in the groups (p>0.05). The external branch of the superior laryngeal nerve and recurrent laryngeal nerve palsy were noted in three and two patients in the HF group and in two and one patients in the CL group at 6 months.

CONCLUSION

To the best of our knowledge, this is the first study comparing conventional technique with HF in total thyroidectomy, focusing on the function of the external branch of the superior laryngeal nerve using laryngostroboscopy; results showed that HF is as safe as the conventional technique.

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

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

Hospital costs associated with thyroidectomy performed with a Harmonic device compared to conventional techniques: a systematic review and meta-analysis

OBJECTIVES

Harmonic devices have become a world-wide standard for dissection and hemostasis in thyroidectomy. Numerous systematic reviews have reported superior operating times, blood loss, post-operative pain, length of stay, and overall safety outcomes. What has not been extensively evaluated in a robust manner is their economic impact. The purpose of this study is to evaluate the hospital costs associated with open thyroidectomy using Harmonic devices compared with conventional techniques for hemostasis.

METHODS

A systematic review of Medline, Scopus, and CENTRAL was performed from January 1, 2000 to May 23, 2014 without language restrictions for randomized clinical trials comparing Harmonic surgical devices to conventional methods in thyroidectomy. The main outcome measure was total reported costs. Costs were pooled using the ratio of means and a random effects model. Sensitivity analyses assessed whether differences in patient and trial characteristics, healthcare setting, or choice of statistical model affected outcomes.

RESULTS

Seven studies met the inclusion criteria. A total of 476 participants had procedures performed with Harmonic devices and 478 with conventional monopolar electrosurgery and clamp, cut and tie techniques. Compared with conventional techniques, Harmonic devices reduced total reported costs by 10% (p = 0.007), resulting in a $229 US dollars (USD) absolute reduction from mean baseline costs. Results remained relatively robust to additional sensitivity analyses.

CONCLUSIONS

This systematic review and meta-analysis demonstrates that the Harmonic family of surgical devices is associated with a reduction in total reported costs in thyroidectomy compared with conventional techniques. A large portion of the overall savings derives from a reduction in operative costs.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Effectiveness of preventative and other surgical measures on hypocalcemia following bilateral thyroid surgery: a systematic review and meta-analysis

BACKGROUND

A variety of measures have been proposed to reduce the incidence of post-thyroidectomy hypocalcemia. The aim of this study was to perform a systematic review and meta-analysis of preventive and other surgical measures on post-thyroidectomy hypocalcemia as reported in the literature.

METHODS

Comprehensive searches of the PubMed, EMBASE, and Cochrane databases were performed, and the quality of included papers was assessed using the Cochrane risk of bias tool or a modified Newcastle-Ottawa Scale (NOS). The results of all included studies were summarized, and meta-analyses were performed where appropriate.

RESULTS

Thirty-nine randomized controlled trials (RCTs) and 37 observational studies were included. Measures studied included hemostatic techniques, extent of thyroidectomy and central neck dissection, surgical approach, calcium/vitamin D/thiazide diuretic supplements, parathyroid gland autotransplantation (PGAT) and intraoperative parathyroid gland (PG) identification, truncal ligation of inferior thyroid artery (ITA), preoperative magnesium infusion, and use of magnification loupes and Surgicel. Measures associated with significantly lower rates of transient hypocalcemia in meta-analysis were postoperative calcium and vitamin D supplementation compared to either calcium supplements alone (odds ratio (OR) 0.66; p=0.04) or no supplements (OR 0.34; p=0.007), and bilateral subtotal thyroidectomy (BST) compared to Hartley Dunhill (HD) procedure (OR 0.35; p=0.01). Meta-analyses did not demonstrate any measure to be significantly associated with a reduction in permanent hypocalcemia.

CONCLUSION

This review identified postoperative calcium and vitamin D supplementation and bilateral subtotal thyroidectomy (over HD) as being effective in prevention of transient hypocalcemia. However, the majority of RCTs were of low quality, primarily due to a lack of blinding. The wide variability in study design, definitions of hypocalcemia, and methods of assessment prevented meaningful summation of results for permanent hypocalcemia.

The safety of the Harmonic® FOCUS in open thyroidectomy: a prospective, randomized study comparing the Harmonic® FOCUS and traditional suture ligation (knot and tie) technique

Since Kocher and Billroth refined an acceptable technique, the thyroidectomy has become one of the most frequent procedures in endocrine surgery and bilateral total thyroidectomy is performed in the majority of thyroid diseases. This work evaluated the use of the Harmonic(®) FOCUS and traditional suture ligation (knot and tie) technique in a prospective, randomized study of open thyroidectomy. Eighty two patients were randomized and divided into two similarly sized groups: the Harmonic(®) FOCUS group (F group) and traditional group (T group). The use of the harmonic FOCUS shows some statistically significant advantages limited to a few intraoperative parameters: surgical time and volume of blood loss. The surgical time was significantly shorter in F group than in the T group (105 ± 27 min vs 143 ± 32 respectively; p < 0.05). Intraoperative volume blood loss was significantly more in the T group than in the F group (36 ± 23 ml vs. 24 ± 18; p < 0.05). The postoperative parameters (volume of drainage fluid, serum calcium at 12 and 48 h, hypocalcemia, wound complication, RLN palsy, postoperative pain and length of hospital stay) showed no statistical difference. The Harmonic Focus may provide a cost-effective option only in high volume centers where reducing operative time may balance the number of daily procedures.

Sutureless thyroidectomy

OBJECTIVE

The ultrasonic scalpel is a surgical shear that uses high-frequency mechanical energy to enable simultaneous vessel sealing and tissue coagulation at the same time. We conducted a prospective study to compare the outcome of total thyroidectomy using the ultrasonic scalpel versus the device Ligasure in terms of safety, operative time, overall drainage volume, complications, hospital stay.

METHODS

Between January 2008 and December 2013,400 patients (260 women, 140 men; mean age 46 years) undergoing thyroidectomy were randomized into two groups: group A, where Ultracision were used, and group B, where the Ligasure device was used.

RESULTS

There was no significant differences between the two groups in terms of age, gender, indication for thyroidectomy, thyroid gland weight and diameter, histopathologic diagnosis, preoperative and postoperative serum calcium levels, postoperative complications and reoperative thyroid surgery, time of operation and amount of drainage.

CONCLUSIONS

The ultrasonic scalpel and the Ligasure ares safe, effective, useful, and time-saving alternative to the traditional suture ligation technique for thyroid surgery. They simplified total thyroidectomy, eliminating the need for clamp-and-tie maneuvers while achieving efficient hemostasis.

Harmonic scalpel versus conventional haemostasis in neck dissection: a prospective randomized study

PURPOSE

The aim of this prospective randomized trial was to compare operative factors, postoperative outcomes, and surgical complications of neck dissection (ND) when using the harmonic scalpel (HS) versus conventional haemostasis (CH) (classic technique of tying and knots, resorbable ligature, and bipolar diathermy).

MATERIALS AND METHODS

Sixty-one patients who underwent ND with primary head and neck cancer (HNSCC) resection were enrolled in this study and were randomized into two homogeneous groups: CH (conventional haemostasis with classic technique of tying and knots, resorbable ligature, and bipolar diathermy) and HS (haemostasis with harmonic scalpel). Outcomes of the study included operative time, intraoperative blood loss, drainage volume, postoperative pain, hospital stay, and incidence of intraoperative and postoperative complications.

RESULTS

The use of the HS reduced significantly the operating time, the intraoperative blood loss, the postoperative pain, and the volume of drainage. No significant difference was observed in mean hospital stay and perioperative, and postoperative complications.

CONCLUSION

The HS is a reliable and safe tool for reducing intraoperative blood loss, operative time, volume of drainage and postoperative pain in patients undergoing ND for HNSCC. Multicenter randomized studies need to be done to confirm the advantages of this technique and to evaluate the cost-benefit ratio.

ENERgized vessel sealing systems versus CONventional hemostasis techniques in thyroid surgery--the ENERCON systematic review and network meta-analysis

PURPOSE

Energized vessel-sealing systems have been proposed to save operation time and reduce post-operative complications. The aim of the present systematic review was to compare operation time and postoperative morbidity for ultrasonic and electrothermal bipolar-activated devices with conventional hemostasis techniques and with each other in open thyroidectomy.

METHODS

A systematic literature search (MEDLINE, Cochrane Library, EMBASE and ISI Web of Science) was performed to identify randomised controlled trials (RCTs) comparing conventional hemostasis techniques, ultrasonic devices (Harmonic® scalpel) and/or electrothermal bipolar-activated vessel sealing systems (Ligasure®) during open thyroidectomy. For the primary endpoint (operation time), a network meta-analysis with Bayesian random effects model was performed. Pairwise meta-analyses with random effects were calculated for primary and secondary endpoints.

RESULTS

One hundred sixteen publications were evaluated for eligibility; 35 RCTs (4,061 patients) were included. There was considerable methodological and clinical heterogeneity of included trials. The Harmonic scalpel significantly reduced operation time compared with conventional techniques (22.26 min, 22.7 min in the inconsistency model). The use of Ligasure significantly reduced operation time in total thyroidectomy (13.84 min in the consistency model, 12.18 min in the inconsistency model). In direct comparison, operations with the Harmonic scalpel were faster than with Ligasure (8.42 min in the consistency model, 2.45 min in the inconsistency model). The rates of recurrent nerve palsy and postoperative hypocalcaemia did not significantly differ in the intervention groups.

CONCLUSIONS

This meta-analysis shows superiority of ultrasonic devices in terms of operation time compared with conventional hemostasis techniques in thyroid surgery, with no detriment to safety outcomes.

Which hemostatic device in thyroid surgery? A network meta-analysis of surgical technologies

BACKGROUND

Energy-based hemostatic devices are increasingly being used in thyroid surgery. However, there are several limitations with regard to the existing evidence and a paucity of guidelines on the subject. The goal of this review is to employ the novel evidence synthesis technique of a network meta-analysis to assess the comparative effectiveness of surgical technologies in thyroid surgery and contribute to enhanced governance in the field of thyroid surgery.

METHODS

Articles published between January 2000 and June 2012 were identified from Embase, Medline, Cochrane Library, and PubMed databases. Randomized controlled trials of any size comparing the use of ultrasonic coagulation (harmonic scalpel) or Ligasure either head-to-head or against the "clamp-and-tie" technique were included. Two reviewers independently critically appraised and extracted the data from each study. The number of patients who experienced postoperative events was extracted in dichotomous format or continuous outcomes. Odds ratios were calculated by a Bayesian network meta-analysis, and metaregression was used for pair-wise comparisons. Indirect and direct comparisons were performed and inconsistency was assessed.

RESULTS

Thirty-five randomized controlled trials with 2856 patients were included. Ultrasonic coagulation ranked first (followed by Ligasure and then clamp-and-tie) with the lowest risk of postoperative hypoparathyroidism (odds ratio 1.43 [95% confidence interval (CI) 0.77-2.67] and 0.70 [CI 0.43-1.13], ultrasonic coagulation vs. Ligasure and ultrasonic coagulation vs. clamp-and-tie, respectively), least blood loss (-0.25 [CI -0.84 to -0.35] and -1.22 [CI -1.85 to -0.59]), and drain output (0.28 [CI -0.35 to -0.91] and -0.36 [CI -0.70 to -0.03]). From a health technology viewpoint, ultrasonic coagulation was associated with the shortest operative time (-0.66 [CI -1.17 to -0.14] and -1.29 [CI -1.59 to -1.00]) and hospital stay (-0.28 [CI -0.78 to 0.22] and -0.56 [CI -1.28 to 0.15]). The only exception occurs with the clinically important complication of recurrent laryngeal nerve paralysis, where the reverse trend applies (1.36 [CI 0.25-7.46] and 1.74 [CI 0.94-3.26]).

CONCLUSIONS

The comparative effectiveness of ultrasonic coagulation in thyroid surgery outcomes seems superior to other techniques with the exception of recurrent laryngeal nerve injury. This network meta-analysis, one of a handful in a surgical field, offers preliminary and robust evidence to guide clinical decisions and policy makers to adopt safer thyroid operations.

Sutureless thyroidectomy with energy-based devices: Cerrahpasa experience

Total thyroidectomy makes up the majority of all thyroidectomy cases. Energy-based advanced vessel-sealing devices which were developed in recent years for the control of vascular pedicles allowed significant progress in thyroid surgery. This study is designed to compare the efficiency and safety of the two energy-based vessel-sealing devices (Ligasure™ LF1212 and Harmonic FOCUS(®)) in sutureless thyroidectomy. Two hundred and forty-five consecutive patients underwent sutureless total thyroidectomy. Patients were randomized for the Ligasure™ LF1212 (n = 126) or Harmonic FOCUS(®) (n = 119). The parameters of demographics, surgical indications, morbidity, incision length, duration of operation, weight of specimen, amount of drainage, postoperative pain, hospital stay, and histopathology of specimen were recorded. Mean duration of operation was 37.98 ± 14.98 min (16-92 min) and was significantly shorter for Harmonic FOCUS(®) (p < 0.001). Mean hospital stay was 1.09 ± 0.3 (1-3) days. Morbidity rate was 9.8 % in total, whereas no mortality was observed. In terms of morbidity rates, no significant difference was determined between the two groups (p = 0.476). In both groups, there was no need for extra analgesic application other than the routine given after surgery. According to our experience, sutureless thyroidectomy can be performed with low morbidity rates in secure and efficient way.

[Efficacy and budget impact of the Focus harmonic scalpel compared to the ACS-14C device in total thyroidectomy due to multinodular goitre. A prospective randomised study]

OBJECTIVE

To analyse the potential advantages and outcomes of the new Harmonic Focus™ (Focus) device compared to the Harmonic Scalpel™ ACS-14C in benign thyroid surgery.

METHODS

A controlled randomised study was conducted in which the Focus was compared to former ACS-14C device in patients undergoing total thyroidectomy for multinodular goitre. The primary endpoint was time of surgery. The secondary endpoints were time of use of the device, number of ligatures, blood loss, hypocalcaemia, laryngeal nerve impairment, postoperative pain and quality of life.

RESULTS

Two groups of patients were included, 26 patients in group i (ACS-14C) and 28 in group ii (Focus). There was a 16% reduction in surgical time (78.7 ± 22.01 vs. 66 ± 17.0 min; P<.05) between group i and ii respectively. The Focus was used longer than ACE-14S, both in absolute time (26.0 ± 7.7 vs. 10.0 ± 3.5 minutes; P<.05), as well as in relative time (40.7 ± 11.8% vs. 13.1 ± 4.1%; P<.05), respectively. A significant reduction in number of ligatures in Focus patients was also observed (0,3 ± 0,8 vs. 2.9 ± 3.6; P<.05). Budget impact analysis showed an additional average savings per procedure of 179.74 €.

CONCLUSIONS

Focus ergonomics significantly improved the operation time in thyroidectomy causing a positive impact on the budget. Focus also adds further benefits to those previously achieved by Harmonic technology, and it is by itself more cost-effective in total thyroidectomy than ACS-14C.

Total thyroidectomy for non-toxic multinodular goiter with versus without the use of harmonic FOCUS dissecting shears - a prospective randomized study

INTRODUCTION

Thyroidectomy is among the most commonly performed procedures involving the endocrine glands and the development of advanced surgical methods combined with a strife for performing the operation in a manner that is minimally invasive for the patient has considerably increased the need for instruments that would limit surgical trauma.

AIM

To compare of the outcomes of total thyroidectomy operations with and without the use of ultrasonic harmonic FOCUS dissecting shears.

MATERIAL AND METHODS

Eighty-two patients with a bilateral, non-toxic multinodular goiter were randomized to two groups of 41 patients each. Total thyroidectomy was performed in each patient. In the clip-ligation group (CL-G), during thyroidectomy, the superior thyroid vessels were clipped and bipolar coagulation was used to secure smaller vessels, whereas in the harmonic FOCUS group (HF-G), a harmonic device was used to dissect and divide all the thyroid vessels. The statistical analysis included the mean operative time, blood loss, postoperative morbidity and cost-effectiveness.

RESULTS

HF-G vs. CL-G operations were shorter (45.4 ±8.7 min vs. 64.5 ±14.2 min; p < 0.001), characterized by a lower mean blood loss (29.9 ±9.8 ml vs. 56.8 ±11.0 ml; p < 0.001) and appeared to be more cost-effective (666.2 ±37.5 EUR vs. 718.0 ±69.2 EUR; p < 0.01). No major complications were observed in both groups.

CONCLUSIONS

In total thyroidectomy operations, the harmonic FOCUS is safe and facilitates dissection, allowing for a significant decrease in operative time. Other benefits include lower blood loss and a slightly decreased cost of the procedure.

THE HARMONIC STUDY: COST-EFFECTIVENESS EVALUATION OF THE USE OF THE ULTRASONIC SCALPEL IN TOTAL THYROIDECTOMY

Background: Total thyroidectomy (TT) can be performed either with the traditional technique or using the ultrasound scalpel. Here, the use of the ultrasound scalpel is investigated in order to assess cost-effectiveness from an hospital, third party payer and societal perspective.

Methods: A randomized controlled trial was conducted at the University Hospital A. Gemelli in Rome. Data refer to 198 patients, randomized to either surgery with the ultrasound scalpel (n = 96) or traditional (n = 102) and followed for 3 months after hospital discharge. Operation time (OT) and resource consumption were recorded. Main clinical outcome investigated was quality of life (evaluated with EQ-5D).

Results: A shorter operation time (traditional: 76.36 vs ultrasound: 54.16 minutes, p < 0.001) was observed. 3 months after surgery, differences in QoL were significant (0.91 vs 0.84, p = 0.002). Concerning the hospital perspective, ultrasound scalpel allows savings of 119 EUR per patient. From a societal perspective, ultrasound scalpel is also related to lower medical resource consumption during a 3 month follow-up after discharge (traditional: 129.03 EUR vs ultrasound: 107.82 EUR) and lower non-medical resource utilization (transport/hotels costs traditional:535.51 EUR vs ultrasound: 342.77 EUR. No statistical difference was found in productivity losses up to 3 months (traditional: 377.71 EUR vs ultrasound: 385.51 EUR).

Conclusion: Allowing an overall saving of 325.36 EUR per patient, Ultrasound scalpel should be adopted for TT procedures in the “A.Gemelli” University hospital.

Efficacy of fibrin sealant for drainage reduction in total thyroidectomy with bilateral central neck dissection

OBJECTIVE

To investigate the efficacy of fibrin sealant (FS) for reducing postoperative drainage in patients who underwent total thyroidectomy (TT) with bilateral central neck dissection (CND) for papillary thyroid cancer.

STUDY DESIGN

Prospective randomized trial.

SETTING

Tertiary care institution.

SUBJECTS AND METHODS

Seventy-eight patients with papillary thyroid cancer were enrolled and randomized to either the FS application group (FS+, 38 patients) or no FS application group (FS-, 40 patients). In both groups, postoperative drainage amounts were measured by a negative suction system until the criterion of drain removal was met. Drainage amounts as well as the time to drain removal, postoperative complications, and chemical profile assay of drain fluids between the 2 groups were performed.

RESULTS

Drainage amounts at the initial 24 hours as well as total amounts of the FS+ group tended to be lower than those of the FS- group; however, they were not statistically different (at initial 24 hours, 64.3 ± 17.5 mL vs 73.0 ± 18.0 mL, P = .06; total amounts, 93.5 ± 30.7 mL vs 105.7 ± 31.2 mL, P = .05). The FS application did not shorten the time to drain removal even when different criteria for drain removal were applied (criteria of <20 mL/d or <30 mL/d). When chemistry profiles of collected drain fluids were analyzed in patient subgroups, the level of triglycerides in the FS+ group was significantly lower than in the FS- group.

CONCLUSION

Fibrin sealant has no additional advantage in terms of drainage reduction and early discharge despite the additional medical cost.

The use of the harmonic scalpel versus knot tying for modified radical neck dissection

BACKGROUND

Although the utility of the harmonic scalpel (HS) in thyroidectomy has been extensively demonstrated, there is little experience regarding its use for neck dissections.

METHODS

Within 10 years, 119 patients underwent modified radical neck dissection (MRND) for thyroid cancer. In 51 patients, MRND was performed using conventional knot tying and in 68 using the HS. The number of lymph nodes (LNs) removed, operative time, estimated blood loss (EBL), drain output, duration of the drainage, and complications were compared for 47 patients undergoing first-time unilateral MRND without concomitant additional surgical procedures.

RESULTS

The number of LNs removed, operative time, duration of drainage, and rate of lymphatic leak were similar between groups. For the HS group, EBL (5 ± 3 vs 32 ± 10; P = .006) and drain output on postoperative day 1 (51.7 ± 6.2 vs 78.9 ± 11.9; P = .02) and at 1 week (6.1 ± 1.2 vs 10.2 ± 1.8, respectively; P = .03) were significantly less.

CONCLUSION

Despite the limitations of its retrospective nature, this study shows that the HS reduces EBL and the amount of lymphatic drainage compared to knot tying after MRND.

Postoperative functional voice changes after conventional open or robotic thyroidectomy: a prospective trial

PURPOSE

To use objective and subjective voice function analysis to compare outcomes in patients who had undergone conventional open thyroidectomy or robotic thyroidectomy.

METHODS

The study involved 88 consecutive patients who underwent thyroid surgery between May 2009 and December 2009; 46 patients underwent a conventional open thyroidectomy, and 42 underwent a robotic thyroidectomy. Auditory perceptual evaluation was used to make subjective assessments of voice function, and videolaryngostroboscopy, acoustic voice analysis with aerodynamic study, electroglottography, and voice range profile were used to make objective assessments. Each assessment was made before surgery, and at 1 week and 3 months after surgery.

RESULTS

The conventional open and robotic thyroidectomy groups were similar in terms of age, gender ratio, and disease profile. We found that 18 (20.5%) of the 88 patients showed some level of voice dysfunction at 1 week after surgery; that the dysfunction resolved by 3 months after surgery in all cases; and that it was not permanent according to postoperative videolaryngostroboscopy. The conventional open and robotic thyroidectomy groups were found to have similar levels of dysfunction at 1 week after surgery, except for jitter, which was greater in the robotic group. For both groups, any such dysfunction spontaneously resolved by 3 months after surgery, and there were no significant differences between the groups in terms of any voice function parameter.

CONCLUSIONS

Voice dysfunction was present after both open and robotic thyroidectomy (without any evident laryngeal nerve injury). However, function subsequently normalized to preoperative levels at 3 months after surgery in both groups. Voice function outcomes after robotic thyroidectomy are similar to those after conventional open thyroidectomy.

Initial experience using a bipolar radiofrequency ablation device for hemostasis during thyroidectomy

BACKGROUND

The purpose of this study was to evaluate a novel bipolar radiofrequency ablation (BRFA) device using nanotechnology for division of all named vessels during thyroidectomy.

METHODS

All thyroidectomies from January 2008 to July 2010 at a single institution used the BRFA device (EnSeal, Ethicon Endo-Surgery, Cincinnati, OH) for hemostasis. Clinicopathologic data and complications were recorded and compared with existing literature using other energy devices.

RESULTS

Fifty-eight thyroidectomies were performed. Mean age was 54.7 years, and mean operating room time was 81 minutes. The average estimated blood loss was 46 mL. Ninety percent of patients were discharged in <23 hours. There were no hemorrhages. There was 1 recurrent laryngeal nerve (RLN) injury, and 1 case of transient hypocalcemia.

CONCLUSION

This first small series using the BRFA device reveals initial safety and effectiveness for thyroid hemostasis, and warrants further study. The minimal thermal spread inherent in this device may make it an attractive option when structures such as the RLN may be near the zone of hemostasis.

Harmonic focus in total thyroidectomy plus level III-IV and VI dissection: a prospective randomized study

The aim of this study was to compare operating time, postoperative outcomes, and surgical complications of total thyroidectomy plus level III-IV and VI dissection between the no-tie technique using the Harmonic Focus and classic suture ligation for hemostasis. Fifty-four patients underwent total thyroidectomy plus level III-IV and VI dissection by classic suture ligation and 51 patients by the Harmonic Focus. There was obvious distinction as to the operating time between the Focus and classic group (102.8 and 150.1 minutes, respectively, P < 0.05). Drainage volume (202.7 ± 187.0 mL vs 299.7 ± 201.4 mL, P < 0.05) were significantly lower in the Focus group. Transient hypoparathyroidism had no statistically significant difference between the groups (17.6% vs 18.5%, P > 0 .05). No patient experienced nerve injury or permanent hypocalcemia. The use of Harmonic Focus for the control of thyroid vessels during thyroid surgery is reliable and safe. The device can offer extraordinary capabilities for delicate tissue grasping and dissection.

Randomized clinical trial on Harmonic Focus shears versus clamp-and-tie technique for total thyroidectomy

BACKGROUND

The Harmonic Focus is the last ultrasonic device designed for thyroid surgery. The aim is to assess its efficacy and safety compared with traditional dissection in a prospective randomized trial of total thyroidectomy procedures.

METHODS

Total thyroidectomy was performed in 34 patients using the Harmonic Focus, and in 34 patients using the clamp-and-tie technique.

RESULTS

In the Harmonic Focus group, relative reductions of 29% and 46% were observed in surgical time and blood loss, respectively. The number of intraoperative instrument exchanges also decreased by 70%, and use of specific materials required to achieve hemostasis decreased significantly. Safety was found to be similar in both patient groups.

CONCLUSIONS

Our study showed beneficial effects of Harmonic Focus use in thyroid surgery. Further studies therefore are needed to evaluate cost in the light of savings made in surgical time, materials needed for hemostasis, and human resources.