Quality of life is not influenced by the extent of surgery in patients with benign goiter

The Impact of Post-Thyroidectomy Neck Stretching Exercises on Neck Discomfort, Pressure Symptoms, Voice and Quality of Life: A Randomized Controlled Trial

Background

Methods

Results

Conclusions

Quality of Life in Patients with Benign Non-Toxic Goiter After Surgical Intervention: A Systematic Review and Meta-Analysis

BACKGROUND

Prior studies evaluating health-related quality of life (HR-QoL) outcomes in patients undergoing surgery for benign non-toxic goiter have used different instruments and time points, leading to conflicting results. We sought to systematically review the differences in HR-QoL among patients with BNTG at baseline and 6 months after surgery, using exclusively the ThyPRO questionnaire.

METHODS

A systematic search was performed using PubMed, Embase, Web of Science, Cochrane Central, CINAHL, and PsycINFO for papers reporting the assessment of HR-QoL utilizing ThyPRO. Data were meta-analyzed using a random-effects model, and pooled estimates were calculated using weighted mean differences (WMD) between baseline and 6 months after surgery. We assessed the quality and risk of bias of the studies using the Robins-I tool and previously published minimally important change (MIC) values to assess clinical significance.

RESULTS

Six papers met the predefined inclusion criteria, describing a total of 496 patients. Meta-analysis demonstrated improved QoL in all thirteen domains of ThyPRO six months post-surgical intervention compared to baseline. Specifically, the largest improvement in QoL was seen in the domains of overall QoL, WMD -25.84 (95% CI -29.70, -21.98, p < 0.001, I² = 23%), goiter symptoms, 23.96 (95% CI -30.29, -17.64, p < 0.001, I² = 91%), and tiredness, -16.20 (95% CI -19.23, -13.16, p < 0.001, I² = 3%). The differences in scores 9 of 13 domains were clinically significant based on MIC.

CONCLUSIONS

Disease-specific HR-QoL improved in all ThyPRO domains after surgery in patients with BNTG. Future studies of QoL in thyroid surgery patients will benefit from a standard questionnaire and improved reporting of covariates including complications to ensure comparability across studies.

Validity and reliability of the German version of the shortened thyroid-specific quality of life questionnaire (ThyPRO-39de)

OBJECTIVES

Validation of a German version of the ThyPRO-39 questionnaire for quality of life (QoL) in patients with benign thyroid diseases.

DESIGN

Internal consistency, retest reliability, and validity were to be assessed in a test-retest study.

METHODS

The ThyPRO-39 was translated based on standard methodology. A sample of 98 patients with benign thyroid diseases was tested with the ThyPRO-39de and the generic EuroQol 5D-5L. Forty-four patients with stable symptoms after 2 weeks formed the repeated measures sample. Cronbach's alpha was calculated for the ThyPRO-39de composite score and for each disease-specific scale. Intraclass correlations between the original and the repeated measures sample were calculated for each scale as well as Pearson correlations between various ThyPRO scales and the EuroQol. T-tests were used to test for differences in the goiter and hyperthyroid symptom scales between relevant patient groups and other patients.

RESULTS

Internal consistency was between satisfactory and good, except for two scales (tiredness and cosmetic complaints/appearance). The test-retest correlation was between 0.62 and 0.8 for most scales, but below 0.5 for two scales (tiredness and impaired social life). There were significant correlations between the EuroQol index score and most aspects of the ThyPRO-39de. Only the hyperthyroid symptoms scale was specific for the relevant patient group (Graves' disease).

CONCLUSION

The ThyPRO-39de may be recommended for use in clinical and research settings, especially with regards to the composite score. However, the underlying thyroid disease should always be kept in mind when interpreting the test results. A larger sample would be needed to implement further improvements.

Patient-reported outcomes following total thyroidectomy and lobectomy in thyroid cancer survivors: an analysis of the PROFILES Registry data

PURPOSE

Patient-reported outcomes are important in the surgical decision-making process for low-risk, differentiated thyroid cancer. Current study aimed to assess patient-reported outcomes in thyroid cancer survivors comparing total thyroidectomy (TT) and lobectomy (LT) using the Patient Reported Outcomes Following Initial treatment and Long term Evaluation of Survivorship (PROFILES) registry.

METHODS

European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) scales, illness perception questions, Beliefs about Medicines Questionnaire (BMQ) scales and questions about thyroid surgery-related medication use were compared between thyroid cancer patients who underwent TT versus LT using descriptive analyses.

RESULTS

In total, 58 thyroid cancer patients who underwent TT or LT were included in this study. None of the EORTC QLQ-C30 scales or questions regarding illness perception were significantly different between the surgical groups. Patients in the TT group had significantly higher belief in the necessity of their medication (21.0 vs 15.4; p = 0.003) and greater concerns about taking their medicines (14.7 vs 11.1; p = 0.008) versus patients in the LT group.

CONCLUSION

Concerns about post-surgical medication use specifically in the TT group may indicate that clinicians should consider LT in patients with low-risk, differentiated thyroid cancer when LT and TT are viable surgical options. Clinicians should be aware of the impact of post-surgical medication use in particular following TT and use this knowledge to align goals of treatment with the extent of surgery, allowing for a better-informed decision-making process.

Assessment of thyroid-specific quality of life in patients with benign symptomatic thyroid nodules treated with radiofrequency or ethanol ablation: a prospective multicenter study

Purpose

Radiofrequency ablation (RFA) and ethanol ablation (EA) are effective and safe for benign symptomatic thyroid nodules (BSTNs). However, relatively little is known about the effects of these procedures on patients’ quality of life (QoL). This prospective, multicenter study evaluated the effects of RFA and EA on changes in thyroid-specific QoL in patients with BSTNs and assessed the volume reduction and safety of these procedures.

Methods

Eighty-six consecutive patients with 86 BSTNs were prospectively included from two medical centers. RFA was performed for 55 BSTNs with solidity ≥50% and EA was performed for 31 BSTNs with solidity <50%. QoL was evaluated using an 11-scale, multiple-choice thyroid-specific QoL questionnaire. Nodule characteristics and QoL were evaluated at diagnosis and 1, 6, and 12 months after treatment. Overall QoL was rated from 0 (good) to 4 (poor).

Results

The mean longest size and volume of the index nodule were 4.2±1.5 cm and 21.6±22.1 mL, respectively. Patients received 1.1 treatments on average (range, 1 to 2). Significant post-treatment volume reductions were noted; however, the EA group showed a higher volume reduction than the RFA group at 1 (78.7%-16.1% vs. 49.1%-15.8%), 6 (86.3%-21.7% vs. 73.0%-14.5%), and 12 (90.9%-14.9% vs. 80.3%-12.4%) months. The score for each scale of the QoL questionnaire improved significantly during follow-up (all P<0.001). Overall QoL improved significantly, from 1.7±0.9 at diagnosis to 0.6±0.7 at the 12-month follow-up (P<0.001). There were no major complications.

Conclusion

Both RFA and EA are safe and effective in reducing nodule volume and improving thyroid-specific QoL in patients with BSTNs.

Quality of life is not affected by thyroid surgery in nontoxic benign goitre in long-term surveillance-A prospective observational study

OBJECTIVE

Quality of life (QoL) has so far seldom been taken into account by default in decision-making for surgical indication in thyroid surgery. Therefore, we compared pre- and postoperative QoL of patients using the EuroQoL-5D (EQ-5D) questionnaire. The influence of certain socio-economic factors on QoL as a second end-point was considered.

DESIGN

Prospective cohort study.

PATIENTS

About 153 patients with euthyroid symptomatic benign goitre after hemi- and total thyroidectomy (follow-up 83.6%) have been included.

MEASUREMENTS

The EQ-5D questionnaire was used prior to and 1 year after surgery. In addition, a questionnaire for assessment of socio-economic status was collected.

RESULTS

For n = 90 (n = 67 female, n = 23 male), total thyroidectomy (TT) and, for n = 63 (n = 45 female, n = 18 male), hemithyroidectomy (HT) were performed. None permanent dysfunction of the vocal cord was recorded. Transient symptomatic hypocalcaemia was detected in 9% of the thyroidectomy group (8/90 patients). At follow-up, 86% of patients showed either no change or improved QoL. About 14% of patients complained of deteriorated QoL, regardless of the extent of surgery. Socio-economic factors did not influence postoperative QoL.

CONCLUSIONS

Results indicate that in pre-operative consultation of patients with benign goitre, the improvement of QoL should be taken into account for decision-making in cases of ambiguous surgical indication. Contrary to current discussions that too much thyroid surgery is performed in Germany, we can recommend presenting surgery as an equivalent option to watchful waiting as QoL is at least preserved or improved. The extension of the resection should, however, be decided individually.

Postoperative swallowing disorder after thyroid and parathyroid resection

Introduction

Dysphagia is frequently reported after thyroidectomy. Here, we investigated the incidence of postoperative dysphagia after uncomplicated thyroidectomy and parathyroidectomy. Further, we analyzed diagnosis and types of therapy to identify possible patients at risk.

Patients and methods

A questionnaire was sent to 372 consecutive patients whose thyroid or parathyroid glands were operated on between May 2013 and October 2014 at Ulm University Hospital. Patients were questioned at least 6 months postoperatively.

Results

In the evaluation, 219 questionnaires could be included. Fifty-three (21.3%) patients reported that the overall postoperative swallowing process was better or more trouble-free. In 110 (50.2%) patients, dysphagia was reported only immediately postoperative and disappeared later spontaneously. Sixteen patients (7.3%) stated that after a maximum of 3 months after surgery they suffered from dysphagia. One (0.5%) patient stated that up to 3 months postoperatively, swallowing problems had been successfully treated by logopedic therapy. In 39 (17.6%) patients, the complaints persisted for more than 3 months or still existed at the time of the interview. We found no correlation between dysphagia and patients’ age or gender, the specimen volume, and patients’ body mass index. The more invasive the operation was, the more patients suffered from dysphagia. Analyzing the frequency of dysphagia according to different diagnoses, we found a significant risk of postoperative dysphagia in patients with Graves’ disease and carcinoma. Patients operated on for hyperparathyroidism were at significantly decreased risk of dysphagia.

Conclusion

Nearly 20% of patients reported postoperative dysphagia after uncomplicated thyroidectomy and parathyroidectomy, especially after major surgical intervention. We found a significant risk of postoperative dysphagia in patients with Graves’ disease and carcinoma and a decreased risk for patients operated on for hyperparathyroidism.

Quality of life after thyroidectomy in patients with nontoxic nodular goiter: A prospective cohort study

BACKGROUND

Using the thoroughly validated Thyroid-Related Quality-of-Life Patient-Reported Outcome (ThyPRO) questionnaire, the purpose of this study was to investigate changes in disease-specific quality of life (QOL) after surgical treatment in patients with benign nontoxic multinodular goiters.

METHOD

Patients with goiters scheduled for thyroid surgery (n = 106) and individuals from the general population (n = 739) were studied. The ThyPRO data before, 3 months, and 6 months after surgery were compared with normative scores from the general population using a linear mixed model and t tests.

RESULTS

Before surgery, patients with goiters experienced poorer scores on all scales compared to the general population. After surgery, moderate to large improvements were seen in goiter symptoms, tiredness, anxiety, and overall QOL. After surgery, all scales returned to values equal to the general population. The degree of anxiety was, in fact, lower than in the general population.

CONCLUSION

Thyroid surgery leads to significant benefit among patients with benign nontoxic goiters by restoring QOL equal to that in the general population.

The prevalence of post-thyroidectomy chronic asthenia: a prospective cohort study

PURPOSE

Chronic asthenia (CA) is complained by some patients that have undergone thyroid surgery. We evaluate its impact in patients undergoing unilateral or bilateral thyroidectomy, the trend during a 1-year follow-up, and the possible risk factors.

METHODS

A prospective, cohort study was carried out on 263 patients scheduled for thyroidectomy from 2012 and 2014. Exclusion criteria were as follows: Graves' disease, malignancies requiring radioiodine therapy, post-surgical hypoparathyroidism, laryngeal nerve palsy, abnormal pre- and post-operative thyroid hormone levels, and BMI outside the normal range. Demographics; smoking and alcoholism addiction; cardiac, pulmonary, renal, and hepatic failure; diabetes; anxiety; and depression were recorded. The Brief Fatigue Inventory (BFI) was used to evaluate CA and its possible association with these comorbidities 6 and 12 months after thyroidectomy.

RESULTS

One hundred seventy-seven patients underwent total thyroidectomy (TT), 54 hemithyroidectomy (HT). Thirty-two patients were not recorded because of the onset of exclusion criteria. In the 6 months after thyroidectomy, in the TT group, 64 patients (36.16%) reported an impairment in the BFI score and only 1 in the TL group. The mean BFI score changed from 1.663(±1.191) to 2.16 (±11.148) in the TT group, from 1.584 (±1.371) to 1.171 (±1.093) in the TL group (p < 0.001). No further significant variations in BFI were reported 1 year after surgery.

CONCLUSIONS

CA worsened after TT, but not after HT. Apart from operative procedure itself, no other risk factor was found be significantly associated with post-thyroidectomy asthenia. Further investigation is needed to determine the causes of CA.

Retrospective evaluation of the incidental finding of 403 papillary thyroid microcarcinomas in 2466 patients undergoing thyroid surgery for presumed benign thyroid disease

Background

The aim of our study was to investigate the incidence of papillary thyroid microcarcinoma (PTMC) in patients operated for benign thyroid diseases (BTD) and its relation to age, sex, extent of surgery and type of BTD.

Methods

Retrospective study of 2466 patients who underwent thyroid surgery for BTD from 2008 to 2013. To determine independent predictors for PTMC we used three separate multivariate logistic regression models (MLR).

Results

There were 2128 (86.3%) females and 338 (13.7%) males. PTMC was diagnosed in 345 (16.2%) females and 58 (17.2%) males. Age ranged from 14 to 85 years (mean 54 years). Sex and age were not related to the incidence of PTMC. The overall incidence of PTMC was 16.3%. The highest incidence was in Hashimoto thyroiditis (22.7%, χ² = 10.80, p < 0.001); and in patients with total/near-total thyroidectomy (17.7%, χ² = 7.05, p < 0.008). The lowest incidence (6.6%, χ² = 9.96, p < 0.001) was in a solitary hyperfunctional thyroid nodule (SHTN). According to MLR, Hashimoto thyroiditis (OR 1.54, 95% CI 1.15-2.05, p < 0.003) and SHTN (OR 0.43, 95% CI 0.21-0.87, p < 0.019) are independent predictors. Since the extent of surgery was an independent predictor (OR 1.45, 95% CI 1.10-1.92, p = 0.009) for all BTD, and sex and age were not; when the MLR model was adjusted for them, Graves disease (OR 0.72, 95% CI 0.53-0.99, p < 0.041) also proved to be an independent predictor.

Conclusions

Sex and age are not statistically related to the incidence of PTMC in BTD. The incidence of PTMC is higher in Hashimoto thyroiditis and patients with total/near-total thyroidectomy; and lower in patients with a SHTN and Graves disease.

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

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

Assessing health-related quality of life in patients with benign non-toxic goitre

Health-related quality of life (HRQoL) assessments are increasingly used to evaluate treatment effects and to shape the delivery of value based care. Valid generic and disease specific tools are available for quantifying HRQoL in patients with non-toxic goitre. However, few studies have applied these validated instruments to assess HRQoL in patients with benign non-toxic goitre. Limited evidence suggests that patients with non-toxic goitre have HRQoL impairments in multiple HRQoL domains. While the HRQoL-impact of non-toxic goitre may be small relative to other severely disabling medical conditions, treatment is almost exclusively elected for HRQoL indications. Thus better quantification of HRQoL, particularly at better (or more favorable) levels where many patients score, is essential. Web and mobile technologies have eased the ability to deliver surveys to patients. Routine consideration of HRQoL provides the opportunity to monitor the impact of treatment on the outcomes most meaningful for patients and the opportunity to help shape the delivery of value based health care.

Quality of life (QoL) in patients with benign thyroid goiters (pre- and post-thyroidectomy): a prospective study

BACKGROUND

Preservation of quality of life (QoL) seems an important therapeutic goal in patients with benign thyroid diseases. The aim of the present study was to investigate the impact of thyroidectomy on QoL in patients with benign goiters and to assess the significance of various factors affecting the outcome.

METHODS

A prospective study consisting of 100 patients with benign goiters was conducted between November 2009 and March 2011. Patients completed a disease-specific ThyPRO questionnaire to assess QoL before and 6 months after thyroidectomy. Preoperative and postoperative scores were compared; and univariate and multivariate analyses were performed.

RESULTS

Mean age of the patients was 40.5 years (M:F = 1:4.3); 82 % of the patients had nodular goiters, and the remaining 18 % had diffuse disease. None of the patients had overt thyroid dysfunction at the time they completed the questionnaire. Operative treatment for 54 % of the patients involved total thyroidectomy, whereas 46 % underwent hemithyroidectomy. None of these patients developed any permanent morbidity following surgery. Mean scores of QoL in the 12 domains examined were low and improved significantly (p < 0.001) after surgery: symptoms, 19.4 versus 0.7; fatigue, 29.5 versus 1.5; vitality, 44.4 versus 3.0; memory and concentration, 25.7 versus 1.5; nervousness, 29.6 versus 1.8; psychological well-being, 33.9 versus 1.3; mood swings, 34.9 versus 0.8; relationship, 15.4 versus 1.4; daily activity, 18.7 versus 1.3; sex life, 20.9 versus 1.7; appearance, 14.7 versus 1.0; and overall, 27 versus 5.5. On univariate analysis, weight of goiter was found to be significantly associated with improvement in the scores of the memory and concentration domain (p = 0.03). On multivariate analysis, factors significantly associated with improvement in different domains were young age (nervousness, p = 0.009), female gender (fatigue, p = 0.02), and weight of goiter (symptoms, p = <0.001; vitality, p = <0.001; and memory and concentration, p = <0.001).

CONCLUSIONS

Patients with benign goiters experience significant improvement in QoL after thyroidectomy.

Unilateral thyroidectomy for the treatment of benign multinodular goiter

BACKGROUND

Benign multinodular goiter (MNG) is one of the most commonly treated thyroid disorders. Although bilateral resection is the accepted surgical treatment for bilateral MNG, the appropriate surgical resection for unilateral MNG continues to be debated. Bilateral resection generally has lower recurrence rates but higher complication rates than unilateral resection. Therefore, the purpose of this study was to define the recurrence and complication rates of unilateral and bilateral resections to determine the appropriate intervention for patients with unilateral, benign MNG.

METHODS

We reviewed a prospectively maintained database of all patients who underwent a thyroidectomy for treatment of benign MNG at a single institution between May 1994 and December 2011. All patients with bilateral MNG were treated with bilateral resection. Surgical treatment for unilateral MNG was determined by surgeon preference, with all but one surgeon opting for unilateral resection to treat unilateral MNG. Data were reported as means ± standard error of the mean. Chi-squared analysis was used to determine statistical significance at a level of P < 0.05.

RESULTS

A total of 683 patients underwent thyroidectomy for MNG. Of these patients, 420 (61%) underwent unilateral resection and 263 patients (39%) underwent total thyroidectomy. The mean age was 52 ± 17 y, and 542 patients (79%) were female. The mean follow-up time was 46.1 ± 1.9 mo. The rate of recurrent disease was similar between unilateral (2%, n = 10) and bilateral (1%, n = 3) resections (P = 0.248). Unilateral resection patients had a lower total complication rate than patients with bilateral resections (8% versus 26%, P < 0.001); however, there was no difference in the rate of permanent complications (0.2% versus 1%, P = 0.133). Thyroid hormone replacement was rare in unilateral resection patients but necessary in all patients with bilateral resection (19% versus 100%, P < 0.001).

CONCLUSIONS

Patients that had unilateral resections endured less overall morbidities than those who had bilateral resections, and their risk of recurrent disease was similar. They were also significantly less likely to require lifelong hormone replacement therapy postoperatively. Although bilateral resection remains the recommended treatment for bilateral MNG, these data strongly support the use of unilateral thyroidectomy for the treatment of unilateral, benign MNG.

Thyroid surgery for elderly patients: are they at increased operative risks?

An increasing elderly population, a rising incidence of differentiated thyroid carcinoma (DTC), and a rising incidence of benign nodular disease with age are all contributing to a rise in thyroid operations for the elderly. Literature review on the outcome and safety of thyroid surgery in elderly patients has been filled with conflicting results and this subject remains controversial. Although most single-institution studies conducted by high-volume surgeons did not find significant differences of complication rates in elderly when compared with younger cohorts, they often lacked the power necessary to identify subtle differences and suffered from various selection and referral biases. Recent evidence from large population-based studies concluded that thyroid surgery in the elderly was associated with higher complication rates. One of the major contributing factors for the increased complication rate was because most elderly patients suffered from many preexisting comorbidities. Therefore, elderly patients who have abnormal thyroid findings should complete a thorough preoperative workup and better postoperative care after undergoing any thyroid surgery. Furthermore, these high-risk patients would benefit if they could be referred to high-volume, specialized surgical units early. In this systemic review, we aimed to evaluate different issues and controversies in thyroidectomy for elderly patients.

Vascular clips versus ligatures in thyroid surgery--results of a multicenter randomized controlled trial (CLIVIT Trial)

BACKGROUND

New techniques using vascular clips or ultrasonically activated shears have been suggested to shorten operation time without compromising safety. The objective of the CLIVIT Trial was to compare ligatures with vascular clips for hemostasis in elective benign thyroid surgery.

METHODS

This multicenter, randomized, controlled, parallel group superiority trial was conducted in 13 German surgical centers. Patients scheduled for at least subtotal resection bilaterally were intraoperatively randomized. The primary endpoint was resection time. Secondary endpoints were the amount of postoperative bleeding, reoperation due to bleeding, wound infection, temporary (reversal within 12 months) and permanent (over 1 year) recurrent laryngeal nerve (RLN) paralysis, length of hospital stay, and safety.

REGISTRATION

ISRCTN 96901396.

RESULTS

Two hundred fifty patients were treated with ligatures and 241 with vascular clips. No differences in patients' baseline and surgical characteristics were observed. No difference was detected for mean resection time (clip 63.5 min ± 29.6, ligature 66.1 min ± 29.3, P = 0.258). Postoperative bleeding (mean 86 ml ± 93), reoperation due to bleeding (clips 4, ligature 2), wound infections (clips 4, ligature 4), postoperative hospital stay (mean 3.0 ± 1.9), and safety data also did not vary significantly. The rates of temporary and permanent RLN paralysis were 6.9 % (34/491) and 2.9 % (14/491), respectively. Not using a surgical drain (123 patients) was not associated with a higher rate of complications.

CONCLUSION

Vascular clips did not reduce the resection time. However, a 2.9 % rate of permanent RLN paralysis is of concern. Drains in elective surgery may be of no benefit.