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Kao KT, Zacharin M, Farrell S, Simm P. Clinical protocol using calcium and calcitriol after paediatric total thyroidectomy decreases postoperative hypocalcaemia and inpatient blood tests. Int J Pediatr Otorhinolaryngol 2024; 182:112021. [PMID: 38959761 DOI: 10.1016/j.ijporl.2024.112021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 06/11/2024] [Accepted: 06/23/2024] [Indexed: 07/05/2024]
Abstract
INTRODUCTION Postoperative hypocalcaemia is common after thyroidectomy. This study aimed to evaluate whether a standardised post-thyroidectomy protocol using prophylactic calcium and calcitriol reduces hypocalcaemia incidence after total thyroidectomy in children and adolescents. METHODS A cohort children and adolescents ≤18 years of age undergoing total thyroidectomy between January 2016 and October 2022 in one institution were retrospectively identified and divided into pre-protocol and post-protocol groups. The primary outcome measure was hypocalcaemia (total serum calcium of <2.0 mmol/L; ionised serum calcium of 0.9 mmol/L). Secondary outcome measures were the occurrence of hypercalcaemia (serum Calcium >2.7 mmol/L; ionised calcium >1.31 mmol/L), length of hospitalisation and number of postoperative blood tests. RESULTS There were 22 patients in each group (mean age 11.8; SD 4.3 years, female 36 %). The rate of hypocalcaemia was significantly higher in the pre-protocol group than the post-protocol group (54 % vs 13.6 %, p = 0.010). Patients in the pre-protocol group had more inpatient blood tests (mean 5.4; SD 3.2) than the post-protocol group (mean 3.3; SD 1.8, p = 0.011), although the total postoperative blood test count was similar between the groups. Six (13.6 %) patients developed hypercalcaemia. The rate of hypercalcaemia was similar between groups (pre-protocol 2, 9.1 %; post-protocol 4, 18.1 %; p = 0.664). Length of hospitalisation was similar between groups. CONCLUSION Our standardized protocol decreased hypocalcemia and inpatient blood tests after total thyroidectomy in children. Future research should explore if incorporating preoperative calcium and calcitriol treatment, along with intraoperative PTH levels for risk management, can further reduce hypocalcemia rates in paediatric patients.
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Affiliation(s)
- Kung-Ting Kao
- Department of Endocrinology and Diabetes, The Royal Children's Hospital, Melbourne, Victoria, Australia; Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.
| | - Margaret Zacharin
- Department of Endocrinology and Diabetes, The Royal Children's Hospital, Melbourne, Victoria, Australia; Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Stephen Farrell
- Department of Paediatric Surgery, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Peter Simm
- Department of Endocrinology and Diabetes, The Royal Children's Hospital, Melbourne, Victoria, Australia; Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
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Banks L, Kelly NA, Onwuka A, Althubaiti A, Damilano C, Hoffman RP, Aldrink JH, Jatana KR, Walz P. Does preoperative calcium and 1, 25 OH vitamin D supplementation impact postoperative hypocalcemia and length of stay following pediatric thyroidectomy? Int J Pediatr Otorhinolaryngol 2024; 178:111895. [PMID: 38422761 DOI: 10.1016/j.ijporl.2024.111895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 01/24/2024] [Accepted: 02/10/2024] [Indexed: 03/02/2024]
Abstract
OBJECTIVE To investigate whether perioperative calcium and 1,25 OH vitamin D supplementation (PCDS) influences the rates of postoperative hypocalcemia and length of stay (LOS) following pediatric thyroidectomy. STUDY DESIGN Retrospective Cohort Review. SETTING Tertiary children's hospital. METHODS 94 patients who underwent completion or total thyroidectomy with or without concomitant neck dissection from 2010 to 2020 at a single institution were included. Patients with pre-existing hypocalcemia or preoperative vitamin D insufficiency were excluded. Rates of postoperative hypocalcemia and LOS were compared for patients receiving PCDS to those receiving no supplementation. RESULTS Thirty percent of patients with PCDS had documented postoperative hypocalcemia compared to 64% of patients without PCDS (p = 0.01). Patients with PCDS had a median LOS of 30 h compared to 36 h (p = 0.002). Multivariable analyses confirmed that patients with PCDS had lower odds of postoperative hypocalcemia (OR: 0.32, CI: 0.11, 0.89) and shorter LOS by 17 h (SE: 8, p = 0.04) after adjustment for confounders. CONCLUSION PCDS is associated with significantly lower risk of hypocalcemia and shorter LOS. Standardizing preoperative care for pediatric patients undergoing thyroidectomy may decrease variability and improve outcomes following surgery.
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Affiliation(s)
- Laura Banks
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Natalie A Kelly
- Ohio University Heritage College of Osteopathic Medicine, Dublin, OH, USA
| | | | - Abdulrahman Althubaiti
- Department of Otolaryngology - Head and Neck Surgery, College of Medicine, University of Jeddah, Jeddah, Saudi Arabia
| | - Cecilia Damilano
- Divison of Endocrinology, Department of Pediatrics, Nationwide Children's Hosp., Columbus, OH, USA
| | - Robert P Hoffman
- Divison of Endocrinology, Department of Pediatrics, Nationwide Children's Hosp., Columbus, OH, USA
| | - Jennifer H Aldrink
- Division of Pediatric Surgery, Department of Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Kris R Jatana
- Department of Pediatric Otolaryngology, Head and Neck Surgery, Nationwide Children's Hosp., Columbus, OH, USA; Department of Otolaryngology-Head & Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Patrick Walz
- Department of Pediatric Otolaryngology, Head and Neck Surgery, Nationwide Children's Hosp., Columbus, OH, USA; Department of Otolaryngology-Head & Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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Sosnowska-Sienkiewicz P, Danielewicz D, Januszkiewicz-Lewandowska D, Rusak P, Anderko I, Rzepecki M, Niedziela M, Harasymczuk J, Mańkowski P. Thyroid diseases in children and adolescents requiring surgical treatment-indications, techniques, results, and complications based on 10 years of the single center's own experience. Front Endocrinol (Lausanne) 2024; 14:1301191. [PMID: 38283745 PMCID: PMC10811211 DOI: 10.3389/fendo.2023.1301191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 12/19/2023] [Indexed: 01/30/2024] Open
Abstract
Introduction Although thyroid abnormalities are observed less frequently in children than in adults, the increased incidence of thyroid cancer makes it mandatory for all pediatric surgeons to be knowledgeable about the disorders of this gland. Thyroid abnormalities can be associated with hyperthyroidism or hypothyroidism and euthyroidism and/or symmetric or asymmetric enlargement of the gland. Aim The present study was undertaken to retrospectively analyze the indications, surgical techniques used, results obtained, and complications found in the surgical treatment of thyroid diseases in children and adolescents in a surgical center for the macro-region of western Poland. Methods The data of 148 patients undergoing total or partial thyroidectomy between 2013 and 2022 were analyzed from the medical records of the Department of Pediatric Surgery, Traumatology, and Urology of the Medical University of Poznan, Poland. Results A total of 95 children underwent subtotal thyroidectomy and 64 underwent total thyroidectomy, of which the procedure was widened to include prophylactic removal of neck lymph nodes in 45 patients. There were 113 girls (76%) in the analyzed group, and the average age of the patients at the time of surgical treatment was 15 years. The average time from the diagnosis of thyroid disease to surgery was 4 months, ranging from 2 weeks to 3 years. Of the 64 patients undergoing total thyroid resection, 35 (54.69%) were diagnosed with thyroid cancer. Conclusions Collaboration within a multidisciplinary team ensures optimal surgical outcomes in children and adolescents with thyroid disease. With extreme caution, thyroid removal is a safe procedure with few complications, but the experience of the surgeon performing thyroid surgery in children remains crucial. Despite the absence of such a diagnosis in the first fine-needle aspiration biopsy, the high percentage of thyroid carcinomas in the analyzed group may be because the initial biopsy was performed in a less experienced center, also in terms of histopathological laboratory. Hence, we point out the necessity of performing a repeat fine-needle aspiration biopsy (according to the Bethesda classification) in a more experienced center before the final decision of thyroidectomy.
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Affiliation(s)
| | - Dajana Danielewicz
- Department of Pediatric Surgery, Traumatology and Urology, Poznan University of Medical Sciences, Poznań, Poland
| | | | - Paulina Rusak
- Student Research Group of Pediatric Surgery, Poznan University of Medical Sciences, Poznań, Poland
| | - Iwona Anderko
- Student Research Group of Pediatric Surgery, Poznan University of Medical Sciences, Poznań, Poland
| | - Maciej Rzepecki
- Student Research Group of Pediatric Surgery, Poznan University of Medical Sciences, Poznań, Poland
| | - Marek Niedziela
- Department of Pediatric Endocrinology and Rheumatology, Poznan University of Medical Sciences, Poznań, Poland
| | - Jerzy Harasymczuk
- Department of Pediatric Surgery, Traumatology and Urology, Poznan University of Medical Sciences, Poznań, Poland
| | - Przemysław Mańkowski
- Department of Pediatric Surgery, Traumatology and Urology, Poznan University of Medical Sciences, Poznań, Poland
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Scholfield DW, Lopez J, Badillo ND, Eagan A, Levyn H, LaQuaglia M, Shaha AR, Shah JP, Wong RJ, Patel SG, Ganly I. Complications of Thyroid Cancer Surgery in Pediatric Patients at a Tertiary Cancer Center. Ann Surg Oncol 2023; 30:7781-7788. [PMID: 37574514 PMCID: PMC11001250 DOI: 10.1245/s10434-023-14079-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 07/18/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND The incidence of complications and risk factors for hypocalcemia after pediatric thyroid cancer surgery has not been clearly defined in the literature because most reports fail to distinguish between benign and malignant disease. The trend away from total thyroidectomy (TT) to thyroid lobectomy in low-risk disease means there is a need to clearly define the complication profile of malignant disease. METHODS After institutional review board (IRB) approval, a retrospective chart review was undertaken at Memorial Sloan Kettering Cancer Center for pediatric patients undergoing surgery for well-differentiated thyroid cancer from 1986 to 2021. Clinicopathologic characteristics and complications were evaluated. Multivariable analysis was performed to identify factors independently associated with postoperative hypocalcemia. RESULTS The study identified 307 pediatric patients with well-differentiated thyroid carcinoma (median follow-up period, 61 months). Of these patients, 69% underwent TT and 31% received a partial thyroidectomy. Among them, 40% had N0 disease, 28% had N1a disease, and 33% had N1b disease. Postoperatively, no patients experienced a neck hematoma, 1.6% had temporary unilateral vocal cord palsy (VCP), and 0.7% had permanent VCP due to recurrent laryngeal nerve (RLN) invasion. Temporary and permanent hypocalcemia occurred in respectively 32.6 % and 5.2 % of the patients. Multivariable analysis identified central neck dissection (CND) (odds ratio [OR] 3.30; p < 0.001) and N1 disease (OR 2.51; p = 0.036) as independent risk factors for temporary hypocalcemia and N stage (OR 3.64; p = 0.018) as a risk factor for permanent hypocalcemia. CONCLUSION Pediatric thyroid cancer surgery results in low complication rates despite nodal metastases. Vocal cord paralysis is rare unless disease is found to be invading the RLN intraoperatively. Both N stage and CND are independent risk factors for hypocalcemia, helping to identify high-risk patients.
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Affiliation(s)
- Daniel W Scholfield
- Department of Surgery, Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Joseph Lopez
- Division of Pediatric Head and Neck Surgery, AdventHealth for Children, Orlando, FL, USA
| | | | - Alana Eagan
- Department of Surgery, Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Helena Levyn
- Department of Surgery, Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michael LaQuaglia
- Department of Surgery, Pediatric Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ashok R Shaha
- Department of Surgery, Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jatin P Shah
- Department of Surgery, Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Richard J Wong
- Department of Surgery, Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Snehal G Patel
- Department of Surgery, Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ian Ganly
- Department of Surgery, Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Belcher RH, Thomas G, Willmon PA, Gallant JN, Baregamian N, Lopez ME, Solόrzano CC, Mahadevan-Jansen A. Identifying Parathyroids in Pediatric Thyroid/Parathyroid Surgery by Near Infrared Autofluorescence. Laryngoscope 2023; 133:3208-3215. [PMID: 36866696 PMCID: PMC10475145 DOI: 10.1002/lary.30633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 02/09/2023] [Accepted: 02/11/2023] [Indexed: 03/04/2023]
Abstract
OBJECTIVES Compared to adult patients undergoing thyroid surgery, pediatric patients have higher rates of hypoparathyroidism often related to parathyroid gland (PG) inadvertent injury or devascularization. Previous studies have shown that near-infrared-autofluorescence (NIRAF) can be reliably used intraoperatively for label-free parathyroid identification, but all prior studies have been performed in adult patients. In this study, we assess the utility and accuracy of NIRAF with a fiber-optic probe-based system to identify PGs in pediatric patients undergoing thyroidectomy or parathyroidectomy. METHODS All pediatric patients (under 18 years of age) undergoing thyroidectomy or parathyroidectomy were enrolled in this IRB-approved study. The surgeon's visual assessment of tissues was first noted and the surgeon's confidence level in the tissue identified was recorded. A fiber-optic probe was then used to illuminate tissues-of-interest with a wavelength of 785 nm and resulting NIRAF intensities from these tissues were measured while the surgeon was blinded to results. RESULTS NIRAF intensities were measured intraoperatively in 19 pediatric patients. Normalized NIRAF intensities for PGs (3.63 ± 2.47) were significantly higher than that of thyroid (0.99 ± 0.36, p < 0.001) and other surrounding soft tissues (0.86 ± 0.40, p < 0.001). Based on the PG identification ratio threshold of 1.2, NIRAF yielded a detection rate of 95.8% (46/48 pediatric PGs). CONCLUSION Our findings indicate that NIRAF detection can potentially be a valuable and non-invasive technique to identify PGs during neck operations in the pediatric population. To our knowledge, this is the first study in children to assess the accuracy of probe-based NIRAF detection for intraoperative parathyroid identification. LEVEL OF EVIDENCE Level 4 Laryngoscope, 133:3208-3215, 2023.
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Affiliation(s)
- Ryan H. Belcher
- Vanderbilt Department of Otolaryngology – Head and Neck Surgery, Vanderbilt University Medical Center
- Division of Pediatric Otolaryngology, Monroe Carrell Jr. Children’s Hospital at Vanderbilt
| | - Giju Thomas
- Department of Biomedical Engineering, Vanderbilt University
- Vanderbilt Biophotonics Center, Vanderbilt University
| | - Parker A. Willmon
- Department of Biomedical Engineering, Vanderbilt University
- Vanderbilt Biophotonics Center, Vanderbilt University
| | - Jean-Nicolas Gallant
- Vanderbilt Department of Otolaryngology – Head and Neck Surgery, Vanderbilt University Medical Center
| | - Naira Baregamian
- Vanderbilt Section of Surgical Sciences – Department of Surgery, Vanderbilt University Medical Center
| | - Monica E. Lopez
- Department of Pediatric Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Monroe Carrell Jr. Children’s Hospital at Vanderbilt
| | - Carmen C. Solόrzano
- Vanderbilt Section of Surgical Sciences – Department of Surgery, Vanderbilt University Medical Center
| | - Anita Mahadevan-Jansen
- Department of Biomedical Engineering, Vanderbilt University
- Vanderbilt Biophotonics Center, Vanderbilt University
- Vanderbilt Section of Surgical Sciences – Department of Surgery, Vanderbilt University Medical Center
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Romera A, Barragán L, Álvarez-Baena L, Sanjuán E, Ordóñez J, García-Casillas MA, Mora M, Sanz M. Management of hypocalcemia following thyroid surgery in children. Front Pediatr 2023; 11:1151537. [PMID: 37215594 PMCID: PMC10193839 DOI: 10.3389/fped.2023.1151537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 04/19/2023] [Indexed: 05/24/2023] Open
Abstract
Introduction Pediatric post-thyroidectomy hypocalcemia management varies significantly from hospital to hospital. The current study has two aims: first, we evaluate demographic data in all pediatric patients submitted to thyroid surgery in our Spanish tertiary hospital over 20 years; secondly, we describe the way that hypocalcemia was diagnosed and treated in that period and present a multidisciplinary protocol for perioperative management of this condition. Methods This is a retrospective and observational study of all patients from 0 to 16 years old who underwent thyroid surgery from 2000 to 2020 at our institution. Demographic, surgical and electrolyte data were recorded from the electronic database. Results From 2000 to 2016, pediatric thyroid surgery at our institution was performed on 33 patients without a consistent approach or standard electrolyte management. A protocol for perioperative management of these patients was introduced in 2017, and applied to 13 patients. In 2019, the protocol was assessed and updated following a case of symptomatic hypocalcemia. From 2000 to 2016, 47 pediatric patients in all underwent thyroid surgery. We registered eight asymptomatic hypocalcemias. One child developed symptomatic hypocalcemia. Two patients have permanent hypoparathyroidism. Discussion Our incidence of general complications following thyroidectomy was low; hypocalcemia was the most prevalent. All the cases of hypocalcemia submitted to the protocol were identified early by iPTH measurements. Intraoperative iPTH levels and percentage drop from baseline could help stratify patients according to their risk of hypocalcemia. High risk patients require immediate postoperative supplementation, including calcitriol and calcium carbonate.
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Affiliation(s)
- Andrea Romera
- Department of Anesthesiology, Pediatric Section, Gregorio Marañón University Hospital, Madrid, Spain
| | - Lourdes Barragán
- Department of Anesthesiology, Pediatric Section, Gregorio Marañón University Hospital, Madrid, Spain
| | - Lucía Álvarez-Baena
- Department of Anesthesiology, Pediatric Section, Gregorio Marañón University Hospital, Madrid, Spain
| | - Erika Sanjuán
- Department of Anesthesiology, Pediatric Section, Gregorio Marañón University Hospital, Madrid, Spain
| | - Javier Ordóñez
- Department of Pediatric Surgery, Gregorio Marañón University Hospital, Madrid, Spain
| | | | - Marina Mora
- Department of Pediatric Endocrinology, Gregorio Marañón University Hospital, Madrid, Spain
| | - María Sanz
- Department of Pediatric Endocrinology, Gregorio Marañón University Hospital, Madrid, Spain
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Quaglino F, Bellocchia AB, Tuli G, Munarin J, Matarazzo P, Cestino L, Festa F, Carbonaro G, Oleandri S, Manini C, Vergano R, De Sanctis L. Pediatric thyroid surgery: Retrospective analysis on the first 25 pediatric thyroidectomies performed in a reference center for adult thyroid diseases. Front Endocrinol (Lausanne) 2023; 14:1126436. [PMID: 36936146 PMCID: PMC10020637 DOI: 10.3389/fendo.2023.1126436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 02/14/2023] [Indexed: 03/06/2023] Open
Abstract
Introduction Pediatric thyroid carcinoma represents about 4-5% of all pediatric carcinoma with an incidence of 0.5 cases/100,000, compared to 2-10/100000 cases in the adult population. The aim of this study is to present the experience of a reference adult endocrine surgery unit in charge of the treatment of pediatric thyroid diseases. Materials and methods From January 2019 to September 2022, 25 patients, aged 5-17, underwent thyroid surgery. We analysed indications for surgery, use of intraoperative nerve monitoring (IONM), definitive histological examination, postoperative outcomes and risk factors related. Results Surgical indication was performed for Graves' disease (27%) and for nodular pathology (73%): of these, four were malignant lesions (TIR4/TIR5), eight with indeterminate characteristics (TIR3A/TIR3B) and four characterized as benign (TIR1/TIR2). Total thyroidectomy (TT) was performed in 76% of cases, three of which were prophylactic for the activation of the RET gene mutation in MEN 2A. IONM was used in eight cases (32%), all patients aged 11 years or less. FNA's accuracy was 100% for lesions typified as benign and malignant (TIR1/TIR2 and TIR4/TIR5). The overall malignancy rate achieved was 40% and in the final histological examination 75% of the TIR 3B lesions were malignant. Six patients (24%) developed hypoparathyroidism in the first postoperative day, with normalization of calcium values within thirty days in 5 patients. Conclusions Pediatric thyroid nodules are rare and distinguished from adult thyroid disease by a worse prognosis and higher malignancy rates. Our work reports a much higher malignancy rate among indeterminate TIR 3B lesions than observed in the adult population and the three patients who underwent prophylactic total thyroidectomy for activating RET gene mutation had all a definitive histological diagnosis of medullary carcinoma. Post-surgical hypoparathyroidism is a common finding in these patients: in most cases the condition is transient and it benefits from supportive therapy. Intraoperative finding of a thinner recurrent laryngeal nerve in younger patients makes nerve isolation more difficult than in adult surgery: IONM is recommended in patients under 12. Pediatric thyroid surgery is challenging, we sustain it requires referral thyroid Centers for thyroid disease with highly skilled general endocrine surgeons.
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Affiliation(s)
| | | | - Gerdi Tuli
- Pediatric Endocrinology Division, Regina Margherita Children’s Hospital, Turin, Italy
| | - Jessica Munarin
- Pediatric Endocrinology Division, Regina Margherita Children’s Hospital, Turin, Italy
| | - Patrizia Matarazzo
- Pediatric Endocrinology Division, Regina Margherita Children’s Hospital, Turin, Italy
| | - Luca Cestino
- General Surgery Division, Maria Vittoria Hospital, Turin, Italy
| | - Federico Festa
- General Surgery Division, Maria Vittoria Hospital, Turin, Italy
| | | | | | - Claudia Manini
- Pathology Division, Maria Vittoria Hospital, Turin, Italy
| | - Riccardo Vergano
- Otorhinolaryngology Division, Maria Vittoria Hospital, Turin, Italy
| | - Luisa De Sanctis
- Pediatric Endocrinology Division, Regina Margherita Children’s Hospital, Turin, Italy
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Hazkani I, Edwards E, Stein E, Maddalozzo J, Johnston DR, Samis J, Josefson J, Rastatter J. Perioperative outcomes in children with Hashimoto's thyroiditis undergoing total thyroidectomy. Am J Otolaryngol 2023; 44:103785. [PMID: 36608381 DOI: 10.1016/j.amjoto.2022.103785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 12/24/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND Hashimoto's thyroiditis (HT) affects 1-2 % of the pediatric population. In adults with HT, thyroidectomy is considered challenging and prone to postoperative complications due to the chronic inflammatory process. However, the complications of thyroidectomy among children with HT have not been established. The objective of our study was to evaluate whether children with HT undergoing total thyroidectomy for presumed thyroid cancer have higher complication rates than children without HT. METHODS A retrospective cohort study of children who underwent total thyroidectomy by high-volume pediatric otolaryngologists between 2014 and 2021. RESULTS 111 patients met inclusion criteria, 15 of these were diagnosed with HT preoperatively. Operative time and length of admission were similar among the groups. Postoperatively, patients with HT were more likely to have low levels of parathyroid hormone (60 % vs 26 %, p = 0.014) and transient hypocalcemia compared to non-HT patients, present with symptomatic hypocalcemia (67 % vs 27 %, p = 0.006), demonstrate EKG changes (20 % vs 6.3 %, p = 0.035) within 24 h of surgery, and to require both oral and intravenous calcium supplements (80 % vs 35 %, p = 0.001 and 60 % vs 22 % p = 0.004 respectively). Persistent hypocalcemia at 6 months follow-up, and recurrent laryngeal nerve paralysis rates were similar between groups. Parathyroid tissue was found in the thyroid specimen of 9 (60 %) HT patients vs 34 (35 %) non-HT patients (p = 0.069). CONCLUSIONS The risk of permanent complications among children with HT following thyroidectomy is low. However, patients with HT are more likely to develop symptomatic transient hypocalcemia and to require oral and intravenous calcium supplements in the immediate post-operative period compared to non-HT patients. Tailoring a perioperative treatment protocol to optimize calcium levels may be considered for children with HT.
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Affiliation(s)
- Inbal Hazkani
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
| | - Evan Edwards
- Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Eli Stein
- Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - John Maddalozzo
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Douglas R Johnston
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jill Samis
- Division of Pediatric Endocrinology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jami Josefson
- Division of Pediatric Endocrinology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jeffrey Rastatter
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Snyder CW, Williams SA, Danielson PD, Chandler NM. Risk factors for prolonged hospitalization and readmission after total thyroidectomy in children: Associations with surgical subspecialty. Am J Surg 2023; 225:66-69. [PMID: 36266137 DOI: 10.1016/j.amjsurg.2022.09.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 09/19/2022] [Accepted: 09/28/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Total thyroidectomy (TT) in children is performed by pediatric general surgeons (P-GS), pediatric otolaryngologists (P-ENT), or adult GS/ENT. This study evaluated short-term pediatric TT outcomes, focusing on surgical subspecialties. METHODS Pediatric (<18 years) TT with/without central limited lymph node dissection (CLND) between 2015 and 2020 were obtained from the National Surgical Quality Improvement Program-Pediatric database. Risk factors for prolonged hospitalization (PH,>2 days) and 30-day readmission were investigated with multivariate logistic regression. RESULTS Of 1535 patients, 14% had PH and 2% were readmitted. PH rates for P-ENT vs. P-GS vs. adult were 21% vs. 11% vs. 10%, respectively. Adjusted risk of PH was higher for P-ENT (OR 1.70, p = 0.003) but similar for P-GS/adult. There was no difference for risk of readmission by subspecialty. CONCLUSION PH is more likely after pediatric TT performed by P-ENT, as compared to P-GS or adult surgeons. While TT may be performed safely by individual subspecialties, collaboration across specialties may further optimize outcomes.
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Affiliation(s)
- Christopher W Snyder
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA.
| | - Sacha A Williams
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA.
| | - Paul D Danielson
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA.
| | - Nicole M Chandler
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA.
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10
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Muacevic A, Adler JR, Santos Monteiro S, De Carvalho Vaz A, da Silva Cardoso J, Ribeiro L, Mendes C, Freitas J, Ribeiro de Castro J, Borges T, Oliveira MJ. Pediatric Thyroidectomy: Experience From a Portuguese Hospital. Cureus 2023; 15:e33259. [PMID: 36741645 PMCID: PMC9891316 DOI: 10.7759/cureus.33259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2023] [Indexed: 01/03/2023] Open
Abstract
Background and objective Pediatric thyroid disease requiring surgery is rare. Thyroid nodules are a frequent indication for surgery and are mostly benign. However, up to 25% of cases can be malignant. In this study, we aimed to describe our center's experience with regard to pediatric thyroid surgery. Methods This was a retrospective transverse study involving pediatric patients who underwent thyroid surgery at a tertiary hospital between January 2010 and December 2021. Results A total of 14 patients underwent 15 surgeries. The main reason for referral to pediatric endocrinology was thyroid nodules (n=10). Thirteen fine needle aspirations (FNAs) were performed, with follicular tumor (n=6) being the most common finding. The median age of patients at surgery was 15.9 years [interquartile range (IQR): 14.0-16.8]. The most common surgical indications were the presence of a follicular tumor on FNA (n=5) and thyroid nodule size causing symptoms (n=5). There was one case of prophylactic thyroidectomy due to the identification of a multiple endocrine neoplasia type 2A (MEN2A) mutation. The most frequently described histopathology results were follicular adenoma (n=6) and colloid nodular goiter (n=6). Three postoperative complications were observed in three different patients: bilateral lesion of the recurrent laryngeal nerve, cervical hematoma, and transient hypoparathyroidism with hypocalcemia. Conclusion In our study, the most frequent surgical indication was a follicular tumor. A good correlation was found between FNA cytology and final histopathology results, which is in accordance with previous studies. This reinforces the importance of FNA in diagnosis and surgical planning. The rate of complications in our study is comparable to that in larger single-center series in the literature.
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11
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Ziai H, Dixon P, Berman G, Campisi P, Wasserman JD. Incidental Parathyroidectomy Among Pediatric Patients Undergoing Thyroid Surgery. Laryngoscope 2022; 132:2262-2269. [PMID: 35191038 DOI: 10.1002/lary.30056] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 01/19/2022] [Accepted: 01/26/2022] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To evaluate rates of incidental parathyroidectomy(IP) and to determine risk factors among children undergoing thyroid surgery. STUDY DESIGN Retrospective case-control study. METHODS Pediatric patients undergoing thyroidectomy with or without neck dissection were included in this retrospective cohort study over a 20 year period. Demographics, clinical features, and surgical outcomes were evaluated. The primary outcome was the presence of parathyroid tissue in the surgical specimen. RESULTS Two hundred and eighty-six patients were included (100 cases with ≥1 parathyroid gland found in the pathology specimen and 186 controls). The most common surgical indication was cancer (49%), followed by benign nodule (25%). Hemithyroidectomy was performed in 119 (42%) patients, total thyroidectomy in 138 (48%), and completion in 29 (10%). Central neck dissection (CND) and lateral neck dissection were performed in 41% and 13%, respectively. 27 (9%) patients had parathyroid reimplantation. On univariable analysis, diagnosis, adenopathy on preoperative ultrasound, extent of thyroidectomy, neck dissection, and parathyroid reimplantation were significant predictors of IP. On multivariate analysis, CND > 5 nodes were the sole predictor of IP. Patients with IP were more likely to require postoperative calcium/vitamin D supplementation compared to those without (44% vs. 16%; P < .001). CONCLUSIONS Incidental parathyroidectomy during pediatric thyroidectomy is relatively common. CND was independently predictive of IP. There were increased rates of postoperative hypocalcemia when 1 or more parathyroid gland was identified in the specimen. Reimplantation of 1 parathyroid gland was predictive of another gland in the specimen. Anticipating outcomes may help optimize patient care by allowing for early supplementation, frequent monitoring, and consideration of ancillary monitoring modalities in high-risk procedures. LEVEL OF EVIDENCE Level 4 Laryngoscope, 132:2262-2269, 2022.
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Affiliation(s)
- Hedyeh Ziai
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Peter Dixon
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Gavriel Berman
- Division of Endocrinology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Paolo Campisi
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada.,Department of Otolaryngology-Head and Neck Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jonathan D Wasserman
- Division of Endocrinology, The Hospital for Sick Children, Toronto, Ontario, Canada
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12
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Howard SR, Freeston S, Harrison B, Izatt L, Natu S, Newbold K, Pomplun S, Spoudeas HA, Wilne S, Kurzawinski TR, Gaze MN. Paediatric differentiated thyroid carcinoma: a UK National Clinical Practice Consensus Guideline. Endocr Relat Cancer 2022; 29:G1-G33. [PMID: 35900783 PMCID: PMC9513650 DOI: 10.1530/erc-22-0035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 06/23/2022] [Indexed: 11/22/2022]
Abstract
This guideline is written as a reference document for clinicians presented with the challenge of managing paediatric patients with differentiated thyroid carcinoma up to the age of 19 years. Care of paediatric patients with differentiated thyroid carcinoma differs in key aspects from that of adults, and there have been several recent developments in the care pathways for this condition; this guideline has sought to identify and attend to these areas. It addresses the presentation, clinical assessment, diagnosis, management (both surgical and medical), genetic counselling, follow-up and prognosis of affected patients. The guideline development group formed of a multi-disciplinary panel of sub-speciality experts carried out a systematic primary literature review and Delphi Consensus exercise. The guideline was developed in accordance with The Appraisal of Guidelines Research and Evaluation Instrument II criteria, with input from stakeholders including charities and patient groups. Based on scientific evidence and expert opinion, 58 recommendations have been collected to produce a clear, pragmatic set of management guidelines. It is intended as an evidence base for future optimal management and to improve the quality of clinical care of paediatric patients with differentiated thyroid carcinoma.
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Affiliation(s)
- Sasha R Howard
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, Charterhouse Square, London, UK
- Department of Paediatric Endocrinology, Barts Health NHS Trust, London, UK
| | - Sarah Freeston
- Whipps Cross Hospital, Barts Health NHS Trust, London, UK
| | | | - Louise Izatt
- Department of Clinical and Cancer Genetics, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Sonali Natu
- Department of Pathology, University Hospital of North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees, UK
| | - Kate Newbold
- Department of Clinical Oncology, Royal Marsden Hospital Foundation Trust, London, UK
| | - Sabine Pomplun
- Department of Pathology, University College London Hospital NHS Foundation Trust, London, UK
| | - Helen A Spoudeas
- Department of Paediatric Endocrinology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Sophie Wilne
- Department of Paediatric Oncology, Nottingham University Hospital’s NHS Trust, Nottingham, UK
| | - Tom R Kurzawinski
- Department of Endocrine Surgery, University College London Hospitals NHS Foundation Trust, London, UK
- Department of Paediatric Endocrine Surgery, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Mark N Gaze
- Department of Clinical Oncology, University College London Hospitals NHS Foundation Trust, London, UK
- Department of Clinical Oncology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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13
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De Napoli L, Matrone A, Ambrosini CE, Becucci C, Pieroni E, Vagelli F, Taddei G, Gjeloshi B, Torregrossa L, Elisei R, Spinelli C, Materazzi G. Impact of energy-based devices in pediatric thyroid surgery. J Pediatr Surg 2022; 57:740-745. [PMID: 35469657 DOI: 10.1016/j.jpedsurg.2022.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 02/20/2022] [Accepted: 03/05/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND Energy-based devices are surgical devices increasingly utilized for thyroid surgery, owing to a reduction of operative time and surgical related complications. The aim of the study is to evaluate whether the use of energy-based devices could improve the complication rate in pediatric thyroid surgery. METHODS This is a retrospective observational study. We identified 177 consecutive pediatric patients (Group A) with thyroid diseases, surgically treated by energy-based devices and 237 patients (Group B) treated by conventional clamp and tie technique and matched for sex, age and indication for surgery. Transient and permanent complications rate, operative time and length of hospital stay were compared between the two groups. RESULTS Patients of Group A experienced a lower complication rate compared to Group B. Particularly, transient (11.3 vs. 19% p < 0.05) and permanent post operative hypoparathyroidism (1.7 vs. 5.5%, p < 0.05) were lower in Group A. Moreover, operative time was also shorter in Group A compared to Group B and this difference was statistically significant in patients who performed total thyroidectomy alone and total thyroidectomy associated with central compartment neck dissection (p < 0.05). Length of hospital stay was lower in Group A than in Group B, but this difference was statistically significant only for microfollicular lesion (p < 0.05). CONCLUSION The use of energy-based devices has a key role in reducing surgical related complications, particularly transient and permanent hypoparathyroidism, operative time and length of hospital stay in pediatric patients treated with thyroid surgery. LEVEL OF EVIDENCE Level III. TYPE OF STUDY Retrospective comparative study.
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Affiliation(s)
- Luigi De Napoli
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy.
| | - Antonio Matrone
- Department of Clinical and Experimental Medicine, Unit of Endocrinology, University of Pisa, Pisa, Italy
| | - Carlo Enrico Ambrosini
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Chiara Becucci
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Erica Pieroni
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Filippo Vagelli
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Giacomo Taddei
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Benard Gjeloshi
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Liborio Torregrossa
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Rossella Elisei
- Department of Clinical and Experimental Medicine, Unit of Endocrinology, University of Pisa, Pisa, Italy
| | - Claudio Spinelli
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Gabriele Materazzi
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
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14
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Olson SL, Ingram MCE, Graffy PM, Murphy PM, Tian Y, Samis JH, Josefson JL, Rastatter JC, Raval MV. Effect of surgeon volume on pediatric thyroid surgery outcomes: A systematic review. J Pediatr Surg 2022; 57:208-215. [PMID: 34980469 DOI: 10.1016/j.jpedsurg.2021.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 11/26/2021] [Accepted: 12/01/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Pediatric thyroidectomy has been identified as a surgical procedure that may benefit from concentrating cases to high-volume surgeons. This systematic review aimed to address the definition of "high-volume surgeon" for pediatric thyroidectomy and to examine the relationship between surgeon volume and outcomes. METHODS PubMed, Embase, Cochrane Library, Scopus, Web of Science, ClinicalTrials.gov, and OpenGrey databases were searched for through February 2020 for studies which reported on pediatric thyroidectomy and specified surgeon volume and surgical outcomes. RESULTS Ten studies, encompassing 6430 patients, were included in the review. Five single-center retrospective studies reported only on high-volume surgeons, one single center retrospective study reported on only low-volume surgeons, and four national database studies (2 cross sectional, 2 retrospective reviews) reported outcomes for both high-volume and low-volume surgeons. Majority of patients underwent total thyroidectomy (54.9%); common indications for surgery were malignancy (41.7%) and hyperthyroidism/thyroiditis (40.5%). Rates of transient hypocalcemia (11.4% - 74.2%), transient recurrent laryngeal nerve injury (0% - 9.7%), and bleeding (0.5% - 4.3%) varied across studies. Definitions for high-volume pediatric thyroid surgeons ranged from ≥9 annual pediatric thyroid operations to >200 annual thyroid operations (with >30 pediatric cases). Four studies reported significantly better outcomes, including lower post-operative complications and shorter length of hospital stay, for patients treated by high-volume surgeons. CONCLUSIONS Despite significant variation in caseloads to define volume, pediatric thyroid patients have generally better outcomes when operated on by higher volume surgeons. Concentration thyroidectomy cases to a smaller cohort of surgeons within pediatric practices may confer improved outcomes. LEVEL OF EVIDENCE Systematic Reviews and Meta-Analyses; Level IV.
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Affiliation(s)
- Sydney L Olson
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Martha-Conley E Ingram
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Peter M Graffy
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Peggy M Murphy
- Pritzker Research Library, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Yao Tian
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Jill H Samis
- Division of Pediatric Endocrinology, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Jami L Josefson
- Division of Pediatric Endocrinology, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Jeffery C Rastatter
- Department of Otorhinolaryngology-Head & Neck Surgery, Northwestern University, Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States.
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15
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Spinelli C, Ghionzoli M, Bertocchini A, Sanna B, Plessi C, Strambi S, De Napoli L, Frustaci G, Materazzi G, Antonelli A, Morganti R, Gennari F, Inserra A, Bisogno G, Gamba P, Ferrari A, Massimino M. Factors associated with postoperative hypocalcemia following thyroidectomy in childhood. Pediatr Blood Cancer 2022; 69:e29576. [PMID: 35129296 DOI: 10.1002/pbc.29576] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 12/19/2021] [Accepted: 12/27/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Postoperative hypocalcemia is a frequent complication after thyroidectomy. Hypoparathyroidism may develop as transient (TtHP), with normalization within six months from surgery, or permanent (PtHP) if the patient requires replacement therapy. We analyzed factors associated with the development of postoperative hypoparathyroidism and in detail PtHP following thyroid surgery in a pediatric population. PROCEDURE A retrospective multicenter study analyzing 326 patients was carried out. We recorded gender, age, tumor size, thyroiditis, extrathyroidal extension, lymph node dissection (central/lateral compartment, unilateral/bilateral), parathyroid autotransplantation, and histology. Additionally, calcium levels were acquired postoperatively. RESULTS We analyzed pediatric patients ≤18 years who underwent thyroidectomy clustered into age groups (≤15 or > 15). Patients' mean follow-up was 5.8 years (1-11 years). Postoperative hypoparathyroidism occurred in 36 (11.0%): 20 cases (6.13%) developed PtHP. Postoperative hypoparathyroidism was more frequent in younger patients (P = 0.014), in larger tumors (P < 0.001), in case of extrathyroidal extension (P = 0.037), and in central compartment (P = 0.020) and bilateral lymph node dissection (P = 0.030). PtHP was more frequent in older patients (P = 0.014), in case of thyroiditis (P < 0.001), and extrathyroidal extension (P < 0.001). Concerning the first postoperative calcium level measurement, in the postoperative hypoparathyroidism group, we registered a 8.17 mg/dL value with 14% pre/postoperative decrease (ΔCa ), whereas in PtHP patient group calcium level was 7.91 mg/dL with 16.7% ΔCa . CONCLUSIONS The risk of postoperative hypoparathyroidism is related to younger age, tumor size, central compartment and bilateral lymph node dissection, extrathyroidal extension, and decrease in postoperative calcium levels. The risk of PtHP is related to older age, thyroiditis, extrathyroidal extension, and decrease in postoperative calcium levels.
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Affiliation(s)
- Claudio Spinelli
- Division of Pediatric Surgery, Department of Surgical Pathology, University of Pisa, Pisa, Italy
| | - Marco Ghionzoli
- Division of Pediatric Surgery, Department of Surgical Pathology, University of Pisa, Pisa, Italy
| | - Alessia Bertocchini
- Division of Pediatric Surgery, Department of Surgical Pathology, University of Pisa, Pisa, Italy
| | - Beatrice Sanna
- Division of Pediatric Surgery, Department of Surgical Pathology, University of Pisa, Pisa, Italy
| | - Carlotta Plessi
- Division of Pediatric Surgery, Department of Surgical Pathology, University of Pisa, Pisa, Italy
| | - Silvia Strambi
- Division of Pediatric Surgery, Department of Surgical Pathology, University of Pisa, Pisa, Italy
| | - Luigi De Napoli
- Department of Surgical Pathology, Endocrine Surgery Division, University of Pisa, Pisa, Italy
| | - Gianluca Frustaci
- Department of Surgical Pathology, Endocrine Surgery Division, University of Pisa, Pisa, Italy
| | - Gabriele Materazzi
- Department of Surgical Pathology, Endocrine Surgery Division, University of Pisa, Pisa, Italy
| | - Alessandro Antonelli
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Riccardo Morganti
- Division of statistical support to clinical studies, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Fabrizio Gennari
- Division of Pediatric Surgery, "Regina Margherita Hospital,", Turin, Italy
| | - Alessandro Inserra
- General Pediatric and Thoracic Surgery, Bambino Gesù Children's Hospital-Research Institute, Rome, Italy
| | - Gianni Bisogno
- Hematology Oncology Division, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Piergiorgio Gamba
- Pediatric Surgery, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Andrea Ferrari
- Department of Pediatrics, National Cancer Institute, Milan, Italy
| | - Maura Massimino
- Department of Pediatrics, National Cancer Institute, Milan, Italy
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16
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Robot-Assisted Total Thyroidectomy with or without Robot-Assisted Neck Dissection in Pediatric Patients with Differentiated Thyroid Cancer. J Clin Med 2022; 11:jcm11123320. [PMID: 35743391 PMCID: PMC9224679 DOI: 10.3390/jcm11123320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 05/27/2022] [Accepted: 05/29/2022] [Indexed: 12/04/2022] Open
Abstract
Pediatric thyroid cancer more frequently develops cervical node metastasis than adult thyroid cancer, even in differentiated thyroid carcinoma (DTC). Thus, cervical neck dissection often needs to be performed simultaneously with thyroidectomy in pediatric patients. Herein, we describe our experience with robot-assisted total thyroidectomy with/without robot-assisted neck dissection in pediatric patients compared with the conventional operated group. A total of 30 pediatric patients who underwent thyroidectomy for DTC between July 2011 and December 2019 were retrospectively reviewed. Among them, 22 underwent robot-assisted operation, whereas 8 underwent conventional operation. There was no statistical difference in the mean operation times, blood loss, drainage amounts, and hospital stay length between the robot-assisted and conventional operation groups; however, the operation time was less in the retroauricular approach subgroup (robot-assisted operation group) with better satisfaction on cosmesis. No postoperative complications, such as seromas, hemorrhages, or hematomas were observed. Our experience suggested that robot-assisted thyroidectomy with or without neck dissection through the retroauricular approach is a feasible and safe alternative treatment, producing outstanding esthetic results compared to the conventional approach, especially in pediatric patients with DTC.
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17
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Van Remortel BJ, Chehab L, Bauer AJ, Isaza A, Yimei L, Baumgarten HD, Franco AT, Laetsch TW, Kazahaya K, Adzick NS, Mostoufi-Moab S. Surgical outcomes in survivors of childhood cancer undergoing thyroidectomy: A single-institution experience. Pediatr Blood Cancer 2022; 69:e29674. [PMID: 35338690 DOI: 10.1002/pbc.29674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 02/22/2022] [Accepted: 03/02/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Childhood cancer survivors (CCS) are at increased risk for thyroid disease, and many require definitive management with thyroid surgery. Despite this, there is limited evidence on surgical outcomes among CCS. We sought to evaluate postoperative outcomes at our institution among CCS undergoing thyroid surgery compared to patients without a history of primary childhood malignancy. PROCEDURE Medical records were reviewed for 638 patients treated at the Children's Hospital of Philadelphia Pediatric Thyroid Center between 2009 and 2020. Rates of surgical complications, including recurrent laryngeal nerve (RLN) paralysis and hypoparathyroidism, among CCS were compared to patients with sporadic/familial thyroid cancer, Graves' disease, and other benign thyroid conditions. Operative time and intraoperative parathyroid hormone levels were also evaluated. RESULTS There were no significant differences in long-term surgical complication rates, such as permanent RLN paralysis and hypoparathyroidism, between CCS and patients without a history of primary childhood malignancy (all p > .05). For all surgical outcomes, there were no significant differences in complication rates when CCS were compared to those undergoing surgery for sporadic/familial thyroid cancer or Graves' disease (all p > .05). CCS with benign final pathology had significantly higher rates of transient hypoparathyroidism compared to patients with benign thyroid conditions (p < .001). CONCLUSIONS Our study suggests that CCS are not at higher risk of long-term complications from thyroid surgery when treated by high-volume surgeons within a multidisciplinary team.
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Affiliation(s)
- B J Van Remortel
- Department of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - L Chehab
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - A J Bauer
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - A Isaza
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Li Yimei
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Heron D Baumgarten
- Department of Surgery, University of Virginia Medical Center, Charlottesville, Virginia, USA
| | - Aime T Franco
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Theodore W Laetsch
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ken Kazahaya
- Division of Pediatric Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Otorhinolaryngology/Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - N Scott Adzick
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sogol Mostoufi-Moab
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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18
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Wesson DE, Johnson BL, Barclay C, Vogel AM, Chelius DC, Dimachkieh AL, Athanassaki ID, Karaviti LP, Sher AC, Hernandez JA, Mahmood NF, Mahajan P, Quintanilla N, Lopez ME. Thyroid surgery outcomes at a children's hospital: The value of a multidisciplinary team approach. J Pediatr Surg 2022; 57:622-629. [PMID: 34301414 DOI: 10.1016/j.jpedsurg.2021.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 05/24/2021] [Accepted: 06/29/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Our purpose is to describe the structure, function and outcomes of our multidisciplinary pediatric thyroid program and to evaluate our experience in comparison to other high-volume centers. METHODS We reviewed all thyroid operations performed 10/2012 through 09/2019, and examined number of cases per year, patient demographics, procedures, final diagnoses and results. Primary outcomes were hypoparathyroidism and recurrent laryngeal nerve (RLN) injury at 12 months. Data were analyzed using descriptive statistics and univariate analyses. RESULTS We performed 294 thyroid operations on 279 patients. Seventy-nine percent were female. Median age was 15 years (IQR: 12-17). Operations included total thyroidectomy (65%), lobectomy (30%) and completion thyroidectomy (5%). Most common diagnoses were Graves' disease (35%), malignancy (29%), and benign nodule (20%). We developed an evidence-based clinical pathway and conducted weekly multidisciplinary meetings. A clinical data specialist reviewed process and outcome measures routinely. Overall, 6 patients (2.0%) had hypoparathyroidism and 2 (0.7%) had unilateral RLN injury at 12 months. Two of the patients with clinical suspicion of permanent hypoparathyroidism were ultimately weaned off calcium. Both patients with RLN injury had extensive locally advanced malignant disease involving the nerve. CONCLUSIONS Our multidisciplinary team achieved excellent long-term outcomes for pediatric thyroid surgery comparable to other high-volume pediatric and adult centers.
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Affiliation(s)
- David E Wesson
- Division of Pediatric Surgery, Department of Surgery, Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin Street, Suite 1210, Houston, TX 77030, United States
| | - Brittany L Johnson
- Division of Pediatric Surgery, Department of Surgery, Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin Street, Suite 1210, Houston, TX 77030, United States
| | - Charlene Barclay
- Outcomes and Impact Service, Texas Children's Hospital, Houston, TX, United States
| | - Adam M Vogel
- Division of Pediatric Surgery, Department of Surgery, Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin Street, Suite 1210, Houston, TX 77030, United States
| | - Daniel C Chelius
- Division of Pediatric Otolaryngology, Department of Surgery, Texas Children's Hospital, Houston, TX, United States
| | - Amy L Dimachkieh
- Division of Pediatric Otolaryngology, Department of Surgery, Texas Children's Hospital, Houston, TX, United States
| | - Ioanna D Athanassaki
- Division of Pediatric Endocrinology, Department of Pediatrics, Texas Children's Hospital, Houston, TX, United States
| | - Lefkothea P Karaviti
- Division of Pediatric Endocrinology, Department of Pediatrics, Texas Children's Hospital, Houston, TX, United States
| | - Andrew C Sher
- Department of Radiology, Texas Children's Hospital, Houston, TX, United States
| | - Jose A Hernandez
- Department of Radiology, Texas Children's Hospital, Houston, TX, United States
| | - Nadia F Mahmood
- Department of Radiology, Texas Children's Hospital, Houston, TX, United States
| | - Priya Mahajan
- Division of Pediatric Oncology, Department of Pediatrics, Texas Children's Hospital, Houston, TX, United States
| | - Norma Quintanilla
- Department of Pathology, Texas Children's Hospital, Houston, TX, United States
| | - Monica E Lopez
- Division of Pediatric Surgery, Department of Surgery, Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin Street, Suite 1210, Houston, TX 77030, United States.
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19
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Maksimoski M, Bauer AJ, Kazahaya K, Manning SC, Parikh SR, Simons JP, D'Souza J, Maddalozzo J, Purkey MR, Rychlik K, Ho B, Rutter MJ, Jiang W, Prager JD, Diercks G, Propst EJ, Miyamoto RC, Stack BC, Randolph GW, Rastatter JC. Outcomes in Pediatric Thyroidectomy: Results From a Multinational, Multi-institutional Database. Otolaryngol Head Neck Surg 2022; 167:869-876. [PMID: 35133903 DOI: 10.1177/01945998221076065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Traditionally, data regarding thyroidectomy were extracted from billing databases, but information may be missed. In this study, a multi-institutional pediatric thyroidectomy database was used to evaluate recurrent laryngeal nerve (RLN) injury and hypoparathyroidism. STUDY DESIGN Retrospective multi-institutional cohort study. SETTING Tertiary care pediatric hospital systems throughout North America. METHODS Data were individually collected for thyroidectomies, then entered into a centralized database and analyzed using univariate and multivariable regression models. RESULTS In total, 1025 thyroidectomies from 10 institutions were included. Average age was 13.9 years, and 77.8% were female. Average hospital stay was 1.9 nights and 13.5% of patients spent at least 1 night in the pediatric intensive care unit. The most frequent pathology was papillary thyroid carcinoma (42%), followed by Graves' disease (20.1%) and follicular adenoma (18.2%). Overall, 1.1% of patients experienced RLN injury (0.8% permanent), and 7.2% experienced hypoparathyroidism (3.3% permanent). Lower institutional volume (odds ratio [OR], 3.57; 95% CI, 1.72-7.14) and concurrent hypoparathyroidism (OR, 3.51; 95% CI, 1.64-7.53) correlated with RLN injury on multivariable analysis. Graves' disease (OR, 2.27; 95% CI, 1.35-3.80), Hashimoto's thyroiditis (OR, 4.67; 95% CI, 2.39-9.09), central neck dissection (OR, 3.60; 95% CI, 2.36-5.49), and total vs partial thyroidectomy (OR, 7.14; 95% CI, 4.55-11.11) correlated with hypoparathyroidism. CONCLUSION These data present thyroidectomy information and complications pertinent to surgeons, along with preoperative risk factor assessment. Multivariable analysis showed institutional volume and hypoparathyroidism associated with RLN injury, while hypoparathyroidism associated with surgical indication, central neck dissection, and extent of surgery. Low complication rates support the safety of thyroidectomy in pediatric tertiary care centers.
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Affiliation(s)
- Matthew Maksimoski
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Andrew J Bauer
- The Thyroid Center, Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Ken Kazahaya
- Division of Pediatric Otolaryngology, Children's Hospital of Philadelphia, Department of Otolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Scott C Manning
- Department of Otolaryngology, University of Washington, Seattle Children's Hospital, Seattle, Washington, USA
| | - Sanjay R Parikh
- Department of Otolaryngology, University of Washington, Seattle Children's Hospital, Seattle, Washington, USA
| | - Jeffrey P Simons
- Division of Pediatric Otolaryngology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jill D'Souza
- Division of Pediatric Otolaryngology, Children's Hospital of New Orleans and Louisiana State University, New Orleans, Louisiana, USA
| | - John Maddalozzo
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Division of Pediatric Otolaryngology, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Matthew R Purkey
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Karen Rychlik
- Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Brian Ho
- Division of Pediatric Otolaryngology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Michael J Rutter
- Division of Pediatric Otolaryngology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Wen Jiang
- Department of Surgery, University of California, San Diego, Division of Otolaryngology, Rady Children's Hospital, San Diego, California, USA
| | - Jeremy D Prager
- Division of Pediatric Otolaryngology, University of Colorado School of Medicine, Children's Hospital of Colorado, Denver, Colorado, USA
| | - Gillian Diercks
- Division of Pediatric Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Evan J Propst
- Department of Otolaryngology-Head & Neck Surgery, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - R Christopher Miyamoto
- Division of Pediatric Otolaryngology, Peyton Manning Children's Hospital at Ascension St. Vincent, Indianapolis, Indiana, USA
| | - Brendan C Stack
- Department of Otolaryngology-Head and Neck Surgery, SIU School of Medicine, Springfield, Illinois, USA
| | - Gregory W Randolph
- Division of Pediatric Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Jeffrey C Rastatter
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Division of Pediatric Otolaryngology, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
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20
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García-García E, Gómez-Gila AL, Romero-Lluch AR, Conde-Sánchez M, Domínguez-Pascual I, Fernández Pineda I, Cabello-Laureano R. Hypoparathyroidism after thyroidectomy: A 20-year experience at a children's hospital. ENDOCRINOL DIAB NUTR 2022; 69:92-97. [PMID: 35256064 DOI: 10.1016/j.endien.2022.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 03/09/2021] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Hypoparathyroidism (HP) is the most common complication of total thyroidectomy and can be an emergency. OBJECTIVES To describe the prevalence of HP after total thyroidectomy in children under 14 years of age, the variables related to its appearance and its clinical expression. PATIENTS AND METHODS Retrospective study at a children's hospital in the last 20 years. HP was defined by the need to supplement calcium after the intervention and was considered permanent if it could not be suspended within 12 months. Fisher's statistical method of comparison of proportions. RESULTS Thirty-nine children and adolescents (26 females) with an age range of 3.67-14.00 years. In 25 patients, the intervention was prophylactic and in 14 it was therapeutic; 14 suffered accidental excision of some parathyroid gland, but none more than two of them; 12 presented HP, of which 3 were permanent; 5 presented clinical symptoms; 1 of them was an emergency. The frequency of HP was 4/4 when 2 parathyroids were dissected, 2/10 when one was dissected, and 6/25 when none were dissected (p = 0.02). In the prophylactic interventions, it was 6/25 compared to 6/14 in the therapeutic ones (p = 0.29). The three cases of permanent HP were in children under 6 years of age, and it did not occur in any older children (p = 0.09). CONCLUSIONS HP is a common and sometimes serious complication in children after total thyroidectomy. It can occur, and even be permanent, even if the intervention is prophylactic and parathyroid glands remain in situ. Younger age could be a risk factor.
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Affiliation(s)
| | - Ana L Gómez-Gila
- Unidad de Endocrinología Pediátrica, Hospital Virgen del Rocío, Sevilla, Spain
| | - Ana R Romero-Lluch
- Servicio de Endocrinología y Nutrición, Hospital Virgen del Rocío, Sevilla, Spain
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21
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Abstract
The term 'hyperthyroidism' refers to a form of thyrotoxicosis due to inappropriate high synthesis and secretion of thyroid hormone(s) by the thyroid. The leading cause of hyperthyroidism in adolescents is Graves' disease (GD); however, one should also consider other potential causes, such as toxic nodular goitre (single or multinodular), and other rare disorders leading to excessive production and release of thyroid hormones. The term 'thyrotoxicosis' refers to a clinical state resulting from inappropriate high thyroid hormone action in tissues, generally due to inappropriate high tissue thyroid hormone levels. Thyrotoxicosis is a condition with multiple aetiologies, manifestations, and potential modes of therapy. By definition, the extrathyroidal sources of excessive amounts of thyroid hormones, such as iatrogenic thyrotoxicosis, factitious ingestion of thyroid hormone, or struma ovarii, do not include hyperthyroidism. The aetiology of hyperthyroidism/and thyrotoxicosis should be determined. Although the diagnosis is apparent based on the clinical presentation and initial biochemical evaluation, additional diagnostic testing is indicated. This testing should include: (1) measurement of thyroid-stimulating hormone receptor (TSHR) antibodies (TRAb); (2) analysis of thyroidal echogenicity and blood flow on ultrasonography; or (3) determination of radioactive iodine uptake (RAIU). A 123I or 99mTc pertechnetate scan is recommended when the clinical presentation suggests toxic nodular goitre. A question arises regarding whether diagnostic workup and treatment (antithyroid drugs, radioiodine, surgery, and others) should be the same in children and adolescents as in adults, as well as whether there are the same goals of treatment in adolescents as in adults, in female patients vs in male patients, and in reproductive or in postreproductive age. In this aspect, different treatment modalities might be preferred to achieve euthyroidism and to avoid potential risks from the treatment. The vast majority of patients with thyroid disorders require life-long treatment; therefore, the collaboration of different specialists is warranted to achieve these goals and improve patients' quality of life.
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Affiliation(s)
- Marek Niedziela
- Department of Pediatric Endocrinology and Rheumatology, Institute of Pediatrics, Karol Jonscher’s Clinical Hospital, Poznan University of Medical Sciences, Poznan, Poland
- Correspondence should be addressed to M Niedziela:
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22
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Quintanilla-Dieck L, Khalatbari HK, Dinauer CA, Rastatter JC, Chelius DC, Katowitz WR, Shindo ML, Parisi MT, Kazahaya K. Management of Pediatric Graves Disease: A Review. JAMA Otolaryngol Head Neck Surg 2021; 147:1110-1118. [PMID: 34647991 DOI: 10.1001/jamaoto.2021.2715] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance The incidence of Graves disease (GD) is rising in children, and adequate care of these patients requires a multidisciplinary approach. Whether patients are seen in the context of endocrinology, nuclear medicine, or surgery, it is important to know the nuances of the therapeutic options in children. Observations Given the rarity of GD in children, it is important to recognize its various clinical presenting signs and symptoms, as well as the tests that may be important for diagnosis. The diagnosis is typically suspected clinically and then confirmed biochemically. Imaging tests, including thyroid ultrasonography and/or nuclear scintigraphy, may also be used as indicated during care. It is important to understand the indications for and interpretation of laboratory and imaging tools so that a diagnosis is made efficiently and unnecessary tests are not ordered. Clinicians should be well-versed in treatment options to appropriately counsel families. There are specific scenarios in which medical therapy, radioactive iodine therapy, or surgery should be offered. Conclusions and Relevance The diagnosis and treatment of pediatric patients with GD requires a multidisciplinary approach, involving pediatric specialists in the fields of endocrinology, ophthalmology, radiology, nuclear medicine, and surgery/otolaryngology. Antithyroid drugs are typically the first-line treatment, but sustained remission rates with medical management are low in the pediatric population. Consequently, definitive treatment is often necessary, either with radioactive iodine or with surgery, ideally performed by experienced, high-volume pediatric experts. Specific clinical characteristics, such as patients younger than 5 years or the presence of a thyroid nodule, may make surgery the optimal treatment for certain patients.
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Affiliation(s)
| | - Hedieh K Khalatbari
- Department of Radiology, University of Washington School of Medicine and Seattle Children's Hospital, Seattle.,Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital, Seattle
| | - Catherine A Dinauer
- Department of Pediatrics, Section of Pediatric Endocrinology, Yale University School of Medicine, New Haven, Connecticut
| | - Jeffrey C Rastatter
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.,Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Daniel C Chelius
- Department of Otolaryngology-Head and Neck Surgery, Pediatric Thyroid Tumor Program, Baylor College of Medicine, Texas Children's Hospital, Houston.,Pediatric Head and Neck Tumor Program, Baylor College of Medicine, Texas Children's Hospital, Houston
| | - William R Katowitz
- Department of Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Maisie L Shindo
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland
| | - Marguerite T Parisi
- Department of Radiology, University of Washington School of Medicine and Seattle Children's Hospital, Seattle.,Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital, Seattle
| | - Ken Kazahaya
- Division of Pediatric Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia
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23
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Pediatric Thyroid Cancer: To Whom Do You Send the Referral? Cancers (Basel) 2021; 13:cancers13174416. [PMID: 34503225 PMCID: PMC8430721 DOI: 10.3390/cancers13174416] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 08/26/2021] [Accepted: 08/28/2021] [Indexed: 11/23/2022] Open
Abstract
Simple Summary Pediatric thyroidectomies are performed by pediatric and adult general surgeons as well as pediatric and adult otolaryngologists. Surgeons may be high or low-volume thyroid surgeons. In this review, we discuss the roles of surgical subspecialty, surgeon volume, and institution volume as they relate to pediatric thyroidectomy outcomes. We also present institutional approaches to multidisciplinary treatment of pediatric thyroid cancer. Abstract Pediatric thyroid cancer is rare, but increasing in annual incidence. Differentiated thyroid cancer in pediatric patients is treated surgically. Pediatric thyroidectomies are performed by general surgeons, otolaryngologists, general pediatric surgeons, and pediatric otolaryngologists. In a comprehensive literature review, we discuss the evidence supporting the importance of surgeon subspecialty and surgeon volume on outcomes for pediatric thyroid cancer patients. Pediatric general surgeons and pediatric otolaryngologists perform most pediatric thyroidectomies. Certain subpopulations specifically benefit from a combined approach of a pediatric surgeon and a high-volume thyroid surgeon. The correlation between high-volume surgeons and lower complication rates in adult thyroid surgery applies to the pediatric population; however, the definition of high-volume for pediatric thyroidectomies requires further investigation. The development of dedicated pediatric thyroid malignancy centers and multidisciplinary or dual-surgeon approaches are advantageous.
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24
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García-García E, Gómez-Gila AL, Romero-Lluch AR, Conde-Sánchez M, Domínguez-Pascual I, Fernández Pineda I, Cabello-Laureano R. Hypoparathyroidism after thyroidectomy: A 20-year experience at a children's hospital. ENDOCRINOL DIAB NUTR 2021; 69:S2530-0164(21)00157-9. [PMID: 34272207 DOI: 10.1016/j.endinu.2021.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 03/08/2021] [Accepted: 03/09/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Hypoparathyroidism (HP) is the most common complication of total thyroidectomy and can be an emergency. OBJECTIVES To describe the prevalence of HP after total thyroidectomy in children under 14 years of age, the variables related to its appearance and its clinical expression. PATIENTS AND METHODS Retrospective study at a children's hospital in the last 20 years. HP was defined by the need to supplement calcium after the intervention and was considered permanent if it could not be suspended within 12 months. Fisher's statistical method of comparison of proportions. RESULTS Thirty-nine children and adolescents (26 females) with an age range of 3.67 to 14.00 years. In 25 patients, the intervention was prophylactic and in 14 it was therapeutic. Fourteen suffered accidental excision of some parathyroid gland, but none more than t2 of them. Twelve presented HP, of which 3 were permanent; 5 presented clinical symptoms; one of them was an emergency. The frequency of HP was 4/4 when 2 parathyroids were dissected, 2/10 when one was dissected, and 6/25 when none were dissected (P=.02). In the prophylactic interventions, it was 6/25 compared to 6/14 in the therapeutic ones (P=.29). The 3 cases of permanent HP were in children under 6 years of age, and it did not occur in any older children (P=.09). CONCLUSIONS HP is a common and sometimes serious complication in children after total thyroidectomy. It can occur, and even be permanent, even if the intervention is prophylactic and parathyroid glands remain in situ. Younger age could be a risk factor.
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Affiliation(s)
- Emilio García-García
- Unidad de Endocrinología Pediátrica, Hospital Virgen del Rocío, Sevilla, España.
| | - Ana L Gómez-Gila
- Unidad de Endocrinología Pediátrica, Hospital Virgen del Rocío, Sevilla, España
| | - Ana R Romero-Lluch
- Servicio de Endocrinología y Nutrición, Hospital Virgen del Rocío, Sevilla, España
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25
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Trans-oral endoscopic thyroidectomy vestibular approach (TOETVA) for the pediatric population: a multicenter, large case series. Surg Endosc 2021; 36:2507-2513. [PMID: 34031742 DOI: 10.1007/s00464-021-08537-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 04/30/2021] [Indexed: 12/16/2022]
Abstract
INTRODUCTION A cervical scar has been shown to have an impact on the quality of life of children undergoing thyroid surgery. Transoral endoscopic vestibular thyroidectomy via the vestibular approach (TOETVA) offers the absence of a cutaneous incision, and has not been described to date in the pediatric population. OBJECTIVE To describe the first series of TOETVA in a pediatric population. PATIENTS AND METHODS A retrospective, multicenter study, including all patients > 18 years old who underwent TOETVA. Data was prospectively collected and included demographics, preoperative ultrasound, cytology and indications for surgery. Intraoperative parameters included length of surgery and complications, with final pathology and postoperative course also reviewed. TOETVA surgical success was defined as completion of surgery via this approach. RESULTS Forty-eight children were included. Of these, 43 (89.5%) were girls. The median age was 16 years (range 10-17). The most common indication for surgery was a benign thyroid nodule (n = 26, 54.1%). Eleven patients (22.9%) had papillary thyroid carcinoma on final pathology, of which 90.9% (10/11) were diagnosed pre-operatively based on FNA cytology. Hemithyroidectomy was performed in 36 patients (75%). All surgeries were completed endoscopically. The mean malignant tumor size was 1.4 ± 0.4 cm and all tumors were completely excised with clean margins. No permanent complications were documented. A single patient (2.1%) had transient RLN injury (1.6%, 1/60 nerves at risk). Transient hypocalcemia was documented in 4 of the 12 patients undergoing total thyroidectomy (33.3%). Transient mental nerve injury/chin hypoesthesia was documented in 2 patients (4.2%). CONCLUSIONS TOETVA appears to be a feasible and safe approach for thyroidectomy in the pediatric population in carefully selected cases, and may be discussed with patients and parents as an alternative for the trans-cervical approach.
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Memeh K, Ruhle B, Alsafran S, Vaghaiwalla T, Kaplan E, Angelos P, Keutgen XM. Total Thyroidectomy vs Thyroid Lobectomy for Localized Papillary Thyroid Cancer in Children: A Propensity-Matched Survival Analysis. J Am Coll Surg 2021; 233:39-49. [PMID: 33887483 DOI: 10.1016/j.jamcollsurg.2021.03.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 03/16/2021] [Accepted: 03/16/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Current guidelines recommend total thyroidectomy (TT) and radioablation for most papillary thyroid cancer (PTC) in children. These guidelines have been criticized as aggressive, especially for early-stage PTC, as it likely does not influence patient survival and results in life-long thyroid hormone replacement. We sought to study whether the extent of thyroidectomy (TT vs thyroid lobectomy [TL]) influences overall and disease-specific survival in children with localized PTC. METHODS The National Cancer Database and the Surveillance, Epidemiology, and End Results registries were queried. Patients 18 years or younger with low-risk PTC between 2004 and 2016 were included. Using a 1:1 propensity score matching, patients who underwent TT were matched for age, sex, race, year of diagnosis, and tumor size with a similar cohort of patients who underwent TL. Primary end points were overall survival and disease-specific survival. RESULTS There were 3,500 patients identified as surgically treated for PTC, of which 1,325 patients met inclusion criteria for matching. Three hundred and twenty-six patients were matched. One hundred and sixty-three patients had TT; 140 were female and mean age was 16 years (interquartile range [IQR] 13 to 17 years). One hundred and sixty-three patients had TL; 140 were female and mean age was 16 years (IQR 14 to 17 years). Median follow-up was 5.0 years (IQR 2.8 to 8 years) and 8.3 years (IQR 3.6 to 14.4 years) in the National Cancer Database and Surveillance, Epidemiology, and End Results cohorts, respectively. There was no statistically significant difference in overall survival or disease-specific survival in patients with PTC < 4 cm, regardless of whether patients underwent TT or TL (p = 0.32 for National Cancer Database registry and p = 0.67 for Surveillance, Epidemiology, and End Results registry). CONCLUSIONS This study suggests that the extent of thyroidectomy does not influence survival for pediatric patients with early-stage PTC and that TL might be adequate in this patient population.
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Affiliation(s)
- Kelvin Memeh
- Section of Endocrine Surgery, Department of Surgery, University of Chicago Medicine, Chicago, IL.
| | - Brian Ruhle
- Section of Endocrine Surgery, Department of Surgery, University of Chicago Medicine, Chicago, IL
| | - Salman Alsafran
- Faculty of Medicine, Kuwait University Health Science Center, Kuwait
| | - Tanaz Vaghaiwalla
- Section of Endocrine Surgery, Department of Surgery, University of Chicago Medicine, Chicago, IL
| | - Edwin Kaplan
- Section of Endocrine Surgery, Department of Surgery, University of Chicago Medicine, Chicago, IL
| | - Peter Angelos
- Section of Endocrine Surgery, Department of Surgery, University of Chicago Medicine, Chicago, IL
| | - Xavier M Keutgen
- Section of Endocrine Surgery, Department of Surgery, University of Chicago Medicine, Chicago, IL
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Kao KT, Ferguson EC, Blair G, Chadha NK, Chanoine JP. Risk factors for the development of hypocalcemia in pediatric patients after total thyroidectomy - A systematic review. Int J Pediatr Otorhinolaryngol 2021; 143:110666. [PMID: 33706109 DOI: 10.1016/j.ijporl.2021.110666] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 02/22/2021] [Accepted: 02/28/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Post-thyroidectomy hypocalcemia is a common complication that causes increased morbidity. This review aims to identify the factors that predict occurrence of hypocalcemia after total thyroidectomy in children and adolescents. METHODS Comprehensive searches of English language pediatric (≤18 years of age) articles were performed in Medline, CINAHL, EMBASE, Web of Science and the Cochrane Library. Studies published between January 1, 1970 to August 20, 2020 regarding risk factors and strategies to prevent hypocalcemia were included if the study: 1. included only pediatric patients who were ≤18 years of age, 2. included only patients who had total, subtotal or completion thyroidectomy, 3. defined hypocalcemia as serum total calcium of <2.0 mmol/L (8 mg/dL) or ionized calcium of <1.0 mmol/L. The quality of included papers was assessed using the Newcastle-Ottawa scale. Results of all included studies were summarised. Meta-analyses were performed if appropriate. RESULTS Five studies with a total of 477 patients between 0 and 18 years, who had total/subtotal/completion thyroidectomy, were included. Overall rates of transient hypocalcemia were higher than permanent hypocalcemia (transient n = 104, 22%; permanent n = 48, 10%). Two studies found intraoperative parathyroid hormone (PTH) useful in predicting hypocalcemia. While two single institution cohort studies reported that neck dissection, male sex and a lower Parathyroid Gland Remaining In Situ score were associated with hypocalcemia, two other studies, including one population-based cohort study, reported that age at surgery, patient sex, hospital volume, type of thyroid disease, number of identified parathyroid glands, parathyroid auto-transplantation, operation time, thyroid specimen weight, and lymph node dissection were not risk factors for hypocalcemia. CONCLUSION Intraoperative PTH may be useful in predicting hypocalcemia in children after total thyroidectomy. No consistent clinical risk factors or preventative methods were identified in the pediatric literature. High-quality pediatric research is urgently required to address this knowledge gap.
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Affiliation(s)
- Kung-Ting Kao
- Department of Endocrinology and Diabetes, The Royal Children's Hospital Melbourne, 50 Flemington Road, Parkville, VIC, 3052, Australia; Murdoch Childrens Research Institute, 50 Flemington Road, Parkville, VIC, 3052, Australia; Department of Paediatrics, University of Melbourne, 50 Flemington Road, Parkville, VIC, 3052, Australia.
| | - Elspeth C Ferguson
- Murdoch Childrens Research Institute, 50 Flemington Road, Parkville, VIC, 3052, Australia; Department of Endocrinology, Sheffield Children's NHS Foundation Trust, Western Bank, Sheffield S10 2TH, UK
| | - Geoff Blair
- Divisions of Pediatric Surgery, British Columbia Children's Hospital, 4500 Oak St, Vancouver, BC V6H 3N1, Canada; University of British Columbia, 4480 Oak Street, Vancouver, BC V6H 3V4, Canada
| | - Neil K Chadha
- University of British Columbia, 4480 Oak Street, Vancouver, BC V6H 3V4, Canada; Pediatric Otolaryngology-Head and Neck Surgery, British Columbia Children's Hospital, 4500 Oak St, Vancouver, BC V6H 3N1, Canada
| | - Jean-Pierre Chanoine
- University of British Columbia, 4480 Oak Street, Vancouver, BC V6H 3V4, Canada; Endocrinology and Diabetes Unit, British Columbia Children's Hospital, 4500 Oak St, Vancouver, BC V6H 3N1, Canada
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28
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Zaat AS, Derikx JP, Zwaveling-Soonawala N, van Trotsenburg AP, Mooij CF. Thyroidectomy in Pediatric Patients with Graves' Disease: A Systematic Review of Postoperative Morbidity. Eur Thyroid J 2021; 10:39-51. [PMID: 33777818 PMCID: PMC7983567 DOI: 10.1159/000511345] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 08/09/2020] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Graves' disease (GD) is the most common cause of hyperthyroidism. In children, the overall relapse frequency after treatment with antithyroid drugs is high. Therefore, many pediatric GD patients eventually require thyroidectomy as definitive treatment. However, the postoperative complications of thyroidectomy in pediatric GD patients are poorly reported. OBJECTIVE To identify the frequency of short- and long-term postoperative morbidities after thyroidectomy in pediatric GD patients. METHODS A systematic review of the literature (PubMed and Embase) was performed to identify studies reporting short- and long-term postoperative morbidities after thyroidectomy in pediatric GD patients according to the PRISMA guidelines. RESULTS Twenty-two mainly retrospective cohort studies were included in this review evaluating short- and long-term morbidities in 1,424 children and adolescents. The frequency of transient hypocalcemia was 22.2% (269/1,210), with a range of 5.0-50.0%. The frequency of permanent hypocalcemia was 2.5% (36/1,424), with a range of 0-20.0%. Two studies reported high frequencies of permanent hypocalcemia, 20.0 (6/30) and 17.4% (9/52), respectively. The 20% frequency could be explained by low-volume surgeons in poorly controlled GD patients. Only 21 cases of permanent hypocalcemia were reported in the 1,342 patients included in the other 20 studies (1.6%). Transient and permanent recurrent laryngeal nerve injury were reported less frequently, with frequencies between 0-20.0 and 0-7.1%, respectively. Infection, hemorrhage/hematoma, and keloid development were only rarely reported as postoperative complications. CONCLUSION The results of this systematic review suggest that thyroidectomy is a safe treatment option for pediatric GD patients. The minority of patients will experience transient and benign morbidities, with hypocalcemia being the most common transient postoperative morbidity. Permanent postoperative morbidities are relatively rare.
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Affiliation(s)
- Annabel S. Zaat
- Department of Pediatric Endocrinology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Joep P.M. Derikx
- Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit, Amsterdam, The Netherlands
| | - Nitash Zwaveling-Soonawala
- Department of Pediatric Endocrinology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - A.S. Paul van Trotsenburg
- Department of Pediatric Endocrinology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Christiaan F. Mooij
- Department of Pediatric Endocrinology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- *Christiaan F. Mooij, Department of Pediatric Endocrinology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, NL–1105 AZ Amsterdam (The Netherlands),
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Radakrishnan A, Reddy AT, Dalal P, Rastatter JC, Josefson JL, Samis JH, Beestrum M, Tian Y, Raval MV. Hypocalcemia prevention and management after thyroidectomy in children: A systematic review. J Pediatr Surg 2021; 56:526-533. [PMID: 33004188 DOI: 10.1016/j.jpedsurg.2020.08.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 08/10/2020] [Accepted: 08/27/2020] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Hypocalcemia is the most common complication following thyroidectomy in children. Guidelines to manage post-thyroidectomy hypocalcemia are available for adults, but not children. The objective of this review was to identify practices related to hypocalcemia prevention and management in pediatric patients. METHODS We identified studies examining the prevention and management of hypocalcemia in pediatric patients post-thyroidectomy within PubMed, EMBASE, Web of Science and Cochrane databases. Three independent reviewers screened citations and reviewed full-text papers. RESULTS A total of 15 studies were included, representing 1552 patients. The overall study quality was weak with lack of randomization and inconsistent outcome reporting. The pooled incidence of hypocalcemia from the 15 studies was 35.5% for transient hypocalcemia and 4.2% for permanent hypocalcemia. All studies discussed post-operative hypocalcemia treatment, with most patients requiring admission for intra-venous calcium therapy. One study described a protocol discharging asymptomatic patients on calcitriol and calcium. Three studies discussed preoperative calcium supplementation in patients at risk of hypocalcemia. No studies examined routine use of calcium and/or vitamin D supplementation to prevent post-operative hypocalcemia. CONCLUSION A significant number of children undergoing thyroidectomy develop hypocalcemia. Despite this high incidence, our systematic review demonstrates significant practice variation surrounding post-thyroidectomy hypocalcemia prevention and management in children. LEVEL OF EVIDENCE III (systematic review of studies of which some were case-control studies (III) and some were case series (IV)).
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Affiliation(s)
- Ankitha Radakrishnan
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Abhita T Reddy
- Department of Otorhinolaryngology-Head & Neck Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Prarthana Dalal
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Jeffrey C Rastatter
- Department of Otorhinolaryngology-Head & Neck Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Jami L Josefson
- Division of Endocrinology, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Jill H Samis
- Division of Endocrinology, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Molly Beestrum
- Galter Health Sciences Library & Learning Center, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Yao Tian
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL.
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Christison-Lagay E, Baertschiger RM. Management of Differentiated Thyroid Carcinoma in Pediatric Patients. Surg Oncol Clin N Am 2021; 30:235-251. [PMID: 33706898 DOI: 10.1016/j.soc.2020.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Differentiated thyroid carcinomas are rare in young children but represent almost 10% of all malignancies diagnosed in older adolescents. Differentiated thyroid carcinoma in children is more likely to demonstrate nodal involvement and is associated with higher recurrence rates than seen in adults. Decisions regarding extent of surgical resection are based on clinical and radiologic features, cytology, and risk assessment. Total thyroidectomy and compartment-based resection of involved lymph node basins form the cornerstone of treatment. The use of molecular genetics to inform treatment strategies and the use of targeted therapies to unresectable progressive disease is evolving.
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Affiliation(s)
- Emily Christison-Lagay
- Division of Pediatric Surgery, Department of Surgery, Yale University School of Medicine, 330 Cedar Street, PO Box 208062, New Haven, CT, USA.
| | - Reto M Baertschiger
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Room 1524, 555 University Ave, Toronto, ON M5G 1X8, Canada
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31
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Gonsalves R, Jamshidi R, Newbern D, Shaibi G, Olson M, Chawla R, Gnagi SH, Oatman OJ. A quality improvement project for managing hypocalcemia after pediatric total thyroidectomy. J Pediatr Endocrinol Metab 2020; 33:1443-1448. [PMID: 33027054 DOI: 10.1515/jpem-2020-0376] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 09/21/2020] [Indexed: 11/15/2022]
Abstract
Objectives Hypocalcemia following total thyroidectomy (TT) is relatively common. It may result in significant morbidity, prolonged hospital stay, and increased costs. Treatment with intravenous (IV) calcium gluconate may also carry significant risks. In pediatrics, management consensus guidelines are lacking. Methods At Phoenix Children's Hospital, a team of pediatric endocrinologists, surgeons and otolaryngologists developed a clinical pathway for patients undergoing TT. It was a Quality Improvement (QI) project with the primary aim of decreasing IV calcium gluconate use from a baseline of 68% to less than 40% over 15 months. Secondary aims included reducing hypocalcemia and length of hospitalization. Interventions included sending weekly pathway reminder emails, starting pre-operative calcium, and pathway implementation into the electronic health record. Results Twenty-seven patients underwent TT over 15 months. IV calcium gluconate use dropped to 48%. Hypocalcemia and length of hospitalization were 96% and 52.7 h (range 21.1-115.7) respectively. Pathway adherence improved after targeted interventions. Eleven (73%) of the 15 patients whose post-operative parathyroid hormone (PTH) nadir was below 15 pg/mL required IV calcium gluconate vs. two (17%) out of 12 with levels above this threshold. Conclusions Standardizing care allowed for objective outcome analysis. We learned that post-operative serum PTH level was the main risk factor for requiring IV calcium gluconate. Implementing the pathway as a QI project allows for revisions based on outcomes, ultimately resulting in a pathway that best utilizes our infrastructure to optimize care. Other pediatric institutions may face similar challenges and can potentially learn from our experience.
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Affiliation(s)
- Rob Gonsalves
- Phoenix Children's Hospital, Division of Endocrinology and Diabetes, Phoenix, AZ, USA
| | - Ramin Jamshidi
- Phoenix Children's Hospital, Division of Pediatric Surgery, Phoenix, AZ, USA
| | - Dorothee Newbern
- Phoenix Children's Hospital, Division of Endocrinology and Diabetes, Phoenix, AZ, USA
| | - Gabriel Shaibi
- Arizona State University College of Nursing and Health Innovation, Center for Health Promotion and Disease Prevention, Phoenix, AZ, USA
| | - Micah Olson
- Phoenix Children's Hospital, Division of Endocrinology and Diabetes, Phoenix, AZ, USA
| | - Reeti Chawla
- Phoenix Children's Hospital, Division of Endocrinology and Diabetes, Phoenix, AZ, USA
| | - Sharon H Gnagi
- Phoenix Children's Hospital, Department of Otolaryngology, Phoenix, AZ, USA
| | - Oliver J Oatman
- Phoenix Children's Hospital, Division of Endocrinology and Diabetes, Phoenix, AZ, USA
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Pediatric differentiated thyroid carcinoma: An update from the APSA Cancer Committee. J Pediatr Surg 2020; 55:2273-2283. [PMID: 32553450 DOI: 10.1016/j.jpedsurg.2020.05.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 04/04/2020] [Accepted: 05/03/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Differentiated thyroid carcinomas (DTCs) are rare in young children but represent almost 10% of all malignancies diagnosed in older adolescents. METHODS This article reviews the recent literature describing surgical therapeutic approaches to pediatric DTC, associated complications, and long-term recurrence and survival outcomes. RESULTS Similar to adult thyroid cancers, pediatric DTCs are more common in females and are associated with thyroid nodules, family history of thyroid cancer, radiation exposure, iodine deficiency, autoimmune thyroid disease, and genetic syndromes. Management of thyroid cancers in children involves ultrasound imaging, fine needle aspiration, and surgical resection with treatment decisions based on clinical and radiological features, cytology and risk assessment. CONCLUSIONS Total thyroidectomy and compartment based resection of clinically involved lymph node basins form the cornerstone of treatment of DTC. There is an evolving literature regarding the use of molecular genetics to inform treatment strategies and the use of targeted therapies to treat iodine refractory and surgically unresectable progressive disease. TYPE OF STUDY Summary review. LEVEL OF EVIDENCE This is a review article of previously published Level 1-5 articles that includes expert opinion (Level 5).
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Gorbea E, Goldrich DY, Agarwal J, Nayak R, Iloreta AM. The impact of surgeon volume on total thyroidectomy outcomes among otolaryngologists. Am J Otolaryngol 2020; 41:102726. [PMID: 32979668 DOI: 10.1016/j.amjoto.2020.102726] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 08/21/2020] [Accepted: 09/08/2020] [Indexed: 12/30/2022]
Abstract
PURPOSE To evaluate the impact of surgeon volume on total thyroidectomy complications and outcomes among otolaryngologists. MATERIALS AND METHODS This state-wide, multi-hospital retrospective review identified patients who underwent total thyroidectomy (TT) (ICD9-06.4) through the Statewide Planning and Research Cooperative System (SPARCS) between 1995 and 2015. Surgeons were categorized into high (>100), medium (10-99), and low (<10) volume groups and differences in complication rates were analyzed. Statistical analysis employed Spearman's rank correlation, Kruskal-Wallis testing, and chi-squared testing. RESULTS 32,133 TT performed by 1032 otolaryngologists were identified. Overall complication rate in our cohort was 9.83% (CI: 9.48-10.18). The most common complication identified overall was hypocalcemia occurring in 3.85% of cases. Surgeons in the high volume group had a complication rate of 9.6%, compared to 10.0% and 11.6% in the medium and low volume groups. This represents a moderate, but statistically significant difference (rho: -0.4, p < 0.0001; KW p ≤0.0001). When looking at individual complications, temporary tracheostomy rate was higher in the low volume group (5.1%, p = 0.001). Other variables such as advanced age, sex, non-white race, or thyroid malignancy were not predictors of increased complication rates for TT. CONCLUSIONS Otolaryngologists who perform a high volume of total thyroidectomy were found to have overall less perioperative complications than those with less volume. In particular, the risk of temporary tracheostomy is higher among low volume surgeons. These findings are consistent with previous studies of the effect of thyroidectomy volume on surgical complications.
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Thomas JK, Kurian JJ, Cherian AJ, Hephzibah J, Paul MJ, Abraham DT. Papillary Thyroid Carcinoma in Children: Clinicopathological Profile and Outcomes of Management. World J Surg 2020; 45:496-506. [PMID: 33078217 DOI: 10.1007/s00268-020-05817-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND We aim to analyze the clinicopathological profile and outcomes of management for children with papillary thyroid carcinoma (PTC). METHODS Relevant clinical data of children ≤ 18 years of age managed for PTC between January 2006 and July 2018 as well as details of their follow-up till December 2019 were retrospectively collected and analyzed. RESULTS There were 82 children with PTC that were managed during the study period. At presentation, 39 (47.6%) had cervical lymphadenopathy, while 9 (11%) had systemic metastasis. Majority of patients 39 (47.6%) underwent total thyroidectomy with a selective neck dissection, while total thyroidectomy alone was performed in 26 (31.7%). Following surgery, hypocalcemia was seen in 39 (47.6%): 28 (34.1%) were temporary, while 11 (13.4%) were permanent. Twenty-eight (34%) developed persistent disease after surgery and 131I therapy. Significant risk factors for persistence and metastatic disease were metastatic cervical lymph node at presentation (p = 0.002) and tumor size (p = 0.014), respectively. The mean duration of follow-up was 60.3 (range 12-150) months with a mean overall disease-free survival of 60 months (95% CI 57.11, 77.95). CONCLUSION Children with papillary thyroid cancers present with aggressive disease, 47.6% with cervical nodal metastasis and 11% with distant metastasis in this cohort. The rate of post-thyroidectomy hypocalcemia in this study is substantial, and efforts to reduce it are actively being pursued. The presence of metastatic cervical lymph node at presentation (p = 0.002) and tumor size (p = 0.014) were the only significant risk factors for persistent and metastatic disease, respectively, in this study.
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Affiliation(s)
- John K Thomas
- Dept of Pediatric Surgery, Christian Medical College, Vellore, India
| | | | - Anish Jacob Cherian
- Dept of Endocrine Surgery, Christian Medical College and Hospital, Vellore, India.
| | - Julie Hephzibah
- Dept of Nuclear Medicine, Christian Medical College, Vellore, India
| | - M J Paul
- Dept of Endocrine Surgery, Christian Medical College and Hospital, Vellore, India
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Children are at a high risk of hypocalcaemia and hypoparathyroidism after total thyroidectomy. J Pediatr Surg 2020; 55:1260-1264. [PMID: 31383578 DOI: 10.1016/j.jpedsurg.2019.06.027] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 05/25/2019] [Accepted: 06/22/2019] [Indexed: 12/20/2022]
Abstract
PURPOSE Disruption of calcium homeostasis is the most common complication after total thyroidectomy in adults. We explored the incidence and risk factors of hypocalcaemia and hypoparathyroidism after total thyroidectomy in children (≤18 years of age). METHODS One hundred six children underwent total thyroidectomy. Patient, operative and outcome data were collected and analyzed. RESULTS The indication for surgery was Graves' disease in 52 children (49.1%), Multiple Endocrine Neoplasia type-2 in 36 (33.9%), multinodular goiter in 3 (2.8%) and follicular/papillary thyroid carcinoma in 15 (14.2%). Neck dissection was performed in 23 children (18.9%). In 14 children (13.2%), autotransplantation was performed; in 31 (29.2%), ≥1 glands were found in the specimen. Hypocalcaemia within 24 h of thyroidectomy was observed in 63 children (59.4%) and 52 (49.3%) were discharged on supplements. Hypoparathyroidism at 6 months persisted in 23 children (21.7%). The ratios of all forms of calcium-related-morbidity were larger among children with less than four parathyroid glands remaining in situ: hypocalcaemia within 24 h of thyroidectomy (54.0% versus 47.5%; p = 0.01), hypoparathyroidism on discharge (64.4% versus 37.7%; p = 0.004) and long-term hypoparathyroidism (31.1% versus 14.8%; p = 0.04). CONCLUSION The incidence of postoperative hypocalcaemia and hypoparathyroidism among children undergoing total thyroidectomy is considerable. The inability to preserve the parathyroid glands in situ during surgery seems an important factor. For optimal outcomes, the parathyroid glands should be preserved in situ. TYPE OF STUDY Prognosis Study. LEVEL OF EVIDENCE Level IV.
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Almosallam OI, Aseeri A, Alhumaid A, AlZahrani AS, Alsobhi S, AlShanafey S. Thyroid surgery in 103 children in a single institution from 2000-2014. Ann Saudi Med 2020; 40:316-320. [PMID: 32757990 PMCID: PMC7410218 DOI: 10.5144/0256-4947.2020.316] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Data on thyroid surgery in children are scarce. OBJECTIVE Analyze outcome data on thyroid surgery in a pediatric population. DESIGN Medical record review. SETTING Tertiary health care institution. PATIENTS AND METHODS We collected demographic and clinical data on patients 18 years or younger who had thyroid surgery in the period 2000 to 2014. Descriptive data are presented. MAIN OUTCOME MEASURES Indications for thyroidectomy, thyroid pathology, complications, length of stay, and radioactive iodine treatment and recurrences. SAMPLE SIZE 103. RESULTS Of 103 patients who underwent 112 thyroidectomy procedures, 80 (78%) were females and the mean age at operation was 13.2 years. and 17 (16%) were associated with multiple endocrine neoplasia type 2. There was no history of radiation exposure. Eighty-one patients (78%) had fine needle aspiration (FNA) which correlated with the final histopathology in 94% of cases. Sixty-six patients (64%) had malignant cancer (61 papillary), 44 (74.6%) of 59 patients who had neck dissection had lymph node metastasis and 7 (11%) had distant metastases to the lung. Procedures included total thyroidectomy (50%), hemithyroidectomy (17%), completion (31%), and subtotal thyroidectomy (2%). Twenty-three patients (22%) developed hypocalcemia (3 permanent) and 6 (5.8%) had unilateral recurrent laryngeal nerve injury (3 permanent). Patients were followed up for a mean duration of 71.7 months (median 60 months). Of 66 patients with thyroid cancer, 43 (65%) received radioactive iodine, and 10 (15%) had recurrence. CONCLUSION Malignancy is the commonest indication for thyroid surgery in children and FNA is highly diagnostic. Hypocalcemia and recurrent laryngeal nerve injury are significant complications. The recurrence rate in thyroid cancer is 15%. LIMITATIONS Retrospective. CONFLICT OF INTEREST None.
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Affiliation(s)
- Osama Ibrahim Almosallam
- From the Department of Surgery, College of Medicine, Qassim University, Buraidah, Al Qassim, Saudi Arabia
| | - Ali Aseeri
- From the Department of Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Ahmed Alhumaid
- From the Department of Surgery, College of Medicine, Qassim University, Buraidah, Al Qassim, Saudi Arabia
| | - Ali S AlZahrani
- From the Department of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Saif Alsobhi
- From the Department of Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Saud AlShanafey
- From the Department of Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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Overman RE, Hsieh LB, Menon R, Thomas IH, Bruch SW. 4-Hour postoperative PTH level predicts hypocalcemia after thyroidectomy in children. J Pediatr Surg 2020; 55:1265-1269. [PMID: 31892477 DOI: 10.1016/j.jpedsurg.2019.11.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 10/31/2019] [Accepted: 11/30/2019] [Indexed: 01/26/2023]
Abstract
BACKGROUND Hypocalcemia occurs frequently after a total thyroidectomy in pediatric patients. Four hour postoperative PTH monitoring predicts the need for calcium supplementation in the adult thyroidectomy population. We evaluated the role of the 4 h postoperative PTH level in determining the need for calcium supplementation after thyroidectomy in the pediatric population. METHODS This is a retrospective review of children undergoing total thyroidectomy by a single pediatric surgeon from July 2011 through July 2018. Intact PTH obtained four hours postoperatively determined the need for calcium supplementation for patients beginning in November 2014 onward. Serum total calcium levels were monitored concurrently with serum intact PTH levels. Serum calcium levels were followed in our Multispecialty Pediatric Endocrine Surgery clinic within the month following thyroidectomy. RESULTS From July 2011 through July 2018, there were a total of 56 total thyroidectomies at our institution. Prior to November 2014, all pediatric total thyroidectomies received calcium supplementation per our institutional protocol. Based on ionized calcium levels, 26.3% (5/19) of children developed hypocalcemia. From November 2014 to July 2018, 37 pediatric patients required total thyroidectomies. 29.7% (11/37) had low 4-h postoperative PTH levels. 72.7% (8/11) patients with low 4-h postoperative PTH levels had corresponding postoperative day 1 total calcium levels less than 8.5 or ionized calcium levels less than 1.12, and five children (45.5%) developed symptomatic hypocalcemia. 70% (26/37) of children had normal 4-h postop PTH levels, with only 5 (19%) ever developing hypocalcemia. No patients with a normal postop PTH level developed symptomatic hypocalcemia or required IV calcium repletion. A single 4-h postoperative PTH <10 pg/dl for identifying hypocalcemia has a sensitivity of 81% and specificity of 91%, with AUC 0.81. CONCLUSION The 4-h postoperative serum PTH level can help determine the need for calcium supplementation in pediatric patients undergoing total thyroidectomy, thereby reducing unnecessary calcium supplementation and serial lab draws to monitor for postoperative hypocalcemia. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- R Elliott Overman
- Division of Pediatric Surgery, Department of Surgery, University of Michigan, 1540 E Hospital Dr. Rm 4972, Ann Arbor, MI 48109.
| | - Lily B Hsieh
- Division of Pediatric Surgery, Department of Surgery, University of Michigan, 1540 E Hospital Dr. Rm 4972, Ann Arbor, MI 48109.
| | - Ram Menon
- Division of Pediatric Endocrinology, Diabetes, and Metabolism, Department of Pediatrics, University of Michigan, 1500 E Medical Center Dr, D1205 MPB, Ann Arbor, MI 48109.
| | - Inas H Thomas
- Division of Pediatric Endocrinology, Diabetes, and Metabolism, Department of Pediatrics, University of Michigan, 1500 E Medical Center Dr, D1205 MPB, Ann Arbor, MI 48109.
| | - Steven W Bruch
- Division of Pediatric Surgery, Department of Surgery, University of Michigan, 1540 E Hospital Dr. Rm 4972, Ann Arbor, MI 48109.
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Abstract
Benign thyroid disease in children represents a wide spectrum of disease. While most benign thyroid disorders may be either monitored or managed medically, surgery is an important treatment, particularly for Graves' disease or large multinodular goiters. Multidisciplinary teams including specialists in pediatric endocrinology, genetics, radiology, pathology and surgery at high volume centers offer the safest and most effective management.
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Affiliation(s)
- Michael J Zobel
- Department of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, AZ
| | - Benjamin E Padilla
- Department of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, AZ.
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Torabi SJ, Avery JM, Salehi PP, Lee Y. Risk factors and effects of hypocalcemia prior to discharge following thyroidectomy. Am J Otolaryngol 2020; 41:102420. [PMID: 32139087 DOI: 10.1016/j.amjoto.2020.102420] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 02/09/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE To find patient and surgical characteristics associated with hypocalcemia prior to discharge (HPTD) in thyroidectomy patients. MATERIALS AND METHODS In a retrospective analysis of the 2016-2017 National Surgical Quality Improvement Program, eligible total thyroidectomy patients were stratified into cohorts based on development of HPTD. We identified demographic and surgical risk factors for the development of hypocalcemia via binary logistic regression and identified the negative sequelae of HPTD utilizing univariate and multivariate methods. RESULTS We identified a total of 6519 patients who underwent total thyroidectomy, of which 450 (6.9%) had HPTD. Predictors associated with an increased incidence of HPTD included female sex (OR: 1.737 [95% CI: 1.319-2.288]; p < .001), increased operative time (OR: 1.003 [1.002-1.004]; p < .001), and central neck dissection (OR: 1.484 [1.190-1.850]; p < .001). However, factors that decreased incidence of HPTD included increased age, obesity (OR: 0.648 [0.501-0.837]; p = .001), and the use of vessel sealant devices (VSD) (OR: 0.650 [0.527-0.803]; p < .001). Multivariate analysis further revealed that HPTD independently led to an increased hospitalization length after surgery (B: 0.708 [0.607-0.809]; p < .001) and an increased 30-day readmission rate (OR: 2.429 [1.594-3.704]; p < .001). CONCLUSION Obesity, increased age, and intra-operative VSD use were significantly associated with decreased rates of HPTD after total thyroidectomy. Female sex, longer operations, and central neck dissections were associated with HPTD. Delineating risk factors and protective factors for HPTD in total thyroidectomy patients is important as patients with HPTD were found to be at a significantly higher risk for longer post-operative stays, increased odds of 30-day readmission, and increased hypocalcemia-related event.
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Affiliation(s)
- Sina J Torabi
- Department of Surgery, Division of Otolaryngology, Yale School of Medicine, New Haven, CT, United States of America.
| | - Jonathan M Avery
- Department of Surgery, Division of Otolaryngology, Yale School of Medicine, New Haven, CT, United States of America.
| | - Parsa P Salehi
- Department of Surgery, Division of Otolaryngology, Yale School of Medicine, New Haven, CT, United States of America.
| | - Yan Lee
- Department of Surgery, Division of Otolaryngology, Yale School of Medicine, New Haven, CT, United States of America.
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Zobel MJ, Long R, Gosnell J, Sosa JA, Padilla BE. Postoperative Hypoparathyroidism After Total Thyroidectomy in Children. J Surg Res 2020; 252:63-68. [PMID: 32234570 DOI: 10.1016/j.jss.2020.02.018] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 01/17/2020] [Accepted: 02/16/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Postoperative hypocalcemia because of hypoparathyroidism is the most common complication of total thyroidectomy in children. We hypothesized that most children with postoperative hypocalcemia would be eucalcemic by 12 mo and sought to define risk factors for permanent hypoparathyroidism. METHODS We retrospectively reviewed children who underwent total thyroidectomy at a single children's hospital from 2012 to 2019. Patients with prior neck surgery were excluded. Indication for operation, final pathologic diagnosis, and postoperative serum calcium up to 12 mo were recorded. Permanent hypoparathyroidism was defined as supplemental calcium requirement beyond 1 y postoperatively. RESULTS Sixty-eight patients underwent total thyroidectomy. Graves' disease was the most common benign indication for surgery (38 patients). Twenty-six patients (38%) had cancer on final pathology. Central lymph node dissection (CLND) was performed in 12 cancer patients. Twenty-eight patients (41%) had postoperative hypocalcemia. Eight patients (12%) had hypocalcemia at 6 mo. Risk factors for hypoparathyroidism at 6 mo were a cancer diagnosis (odds ratio [OR] 6.7; P = 0.02), CLND (OR 12.6; P < 0.01), and parathyroid tissue in the surgical specimen on pathologic analysis (OR 19.5; P < 0.01). Only two patients (3%) developed permanent hypoparathyroidism, both of whom had thyroidectomy for cancer and underwent CLND. CONCLUSIONS Children with thyroid cancer are at high risk for postoperative hypocalcemia after total thyroidectomy. The risk is further increased by CLND, which should be performed selectively. A majority of patients with hypoparathyroidism at 6 mo postoperatively regain normal parathyroid function by 1 y. Permanent hypoparathyroidism in children after total thyroidectomy at a pediatric endocrine surgery center is rare.
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Affiliation(s)
- Michael J Zobel
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Roger Long
- Division of Pediatric Endocrinology, Department of Pediatrics, University of California San Francisco, San Francisco, California
| | - Jessica Gosnell
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Julie Ann Sosa
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Benjamin E Padilla
- Department of Surgery, University of California San Francisco, San Francisco, California.
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Wu SY, Chiang YJ, Fisher SB, Sturgis EM, Zafereo ME, Nguyen S, Grubbs EG, Graham PH, Lee JE, Waguespack SG, Perrier ND. Risks of Hypoparathyroidism After Total Thyroidectomy in Children: A 21-Year Experience in a High-Volume Cancer Center. World J Surg 2020; 44:442-451. [PMID: 31686157 DOI: 10.1007/s00268-019-05231-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Hypoparathyroidism occurs relatively frequently after thyroid surgery in children. However, few studies have reported risk factors. We aimed to identify risk factors for hypoparathyroidism that occurred after total thyroidectomy for proven or suspected malignancy in children. METHODS Children (aged ≤ 18 years) who underwent total thyroidectomy for neoplasm or RET germline mutation at our institution between 1997 and 2018 were included. We retrospectively reviewed demographics, surgical indications, perioperative and follow-up laboratory results, pathologic results, and duration of calcium/calcitriol supplementation. Risk factors for hypoparathyroidism were identified by multivariate analysis. RESULTS Of 184 consecutive patients, 111 had undergone surgery for neoplasm; these diseases were primarily malignancies (106, 95.5%), predominantly papillary carcinoma (103, 92.8%). The remaining 73 patients had undergone early thyroidectomy for RET germline mutation. Among all patients, 67 (36.4%) had hypoparathyroidism: 61 transient and 6 permanent. In a multivariate analysis, central neck dissection (odds ratio 4.3, 95% confidence interval 2.0-9.1) and gross extrathyroidal extension (odds ratio 4.9, 95% confidence interval 2.0-12.1) predicted overall hypoparathyroidism; however, no significant factors were associated with permanent hypoparathyroidism. Most patients with permanent hypoparathyroidism (5 of 6) had undergone therapeutic central neck dissection. When central neck dissection was performed, younger children had a higher risk of overall hypoparathyroidism. CONCLUSIONS In pediatric total thyroidectomies, central neck dissection and gross extrathyroidal extension were major predictors for overall hypoparathyroidism. Surgeons performing thyroidectomy in such patients should be aware of the relatively high risk, preserve parathyroid tissue to the extent possible, and be conscientious regarding postoperative calcium monitoring and replacement.
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Affiliation(s)
- Si-Yuan Wu
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1484, Houston, TX, 77030-4095, USA
- Division of General Surgery, Departments of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yi-Ju Chiang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1484, Houston, TX, 77030-4095, USA
| | - Sarah B Fisher
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1484, Houston, TX, 77030-4095, USA
| | - Erich M Sturgis
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mark E Zafereo
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sa Nguyen
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1484, Houston, TX, 77030-4095, USA
| | - Elizabeth G Grubbs
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1484, Houston, TX, 77030-4095, USA
| | - Paul H Graham
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1484, Houston, TX, 77030-4095, USA
| | - Jeffrey E Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1484, Houston, TX, 77030-4095, USA
| | - Steven G Waguespack
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nancy D Perrier
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1484, Houston, TX, 77030-4095, USA.
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Risk factors of post-surgery complications in children with thyroid cancer. Int J Pediatr Otorhinolaryngol 2019; 127:109673. [PMID: 31546062 DOI: 10.1016/j.ijporl.2019.109673] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 09/05/2019] [Accepted: 09/05/2019] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Thyroid cancer in children is a hot topic because of the large clinical heterogeneity and the risk of severe complications. We aimed to study 1. The frequency, 2. Etiology, and 3. Risk factors of post-surgery complications of thyroid cancer. MATERIAL AND METHODS A retrospective analysis including risk factors for post-surgery complications of patients treated for thyroid malignancies in years 2006-2018 was performed. RESULTS Over a period of 12 years 22 patients with thyroid malignancy (68% female; 12.6 ± 4.0 years of age, median follow-up 6 years) were identified. Histologically, 12 (55%) patients had papillary carcinoma. Six patients (27.3%) had multiple endocrine neoplasia type 2 (MEN2) syndrome, 3 (13.7%) patients had medullary carcinoma and 1 patient had follicular carcinoma. Neck lymph node metastases were diagnosed in 8 (36.4%), distant metastases in 6 (27.3%), and both locations were involved in 4 (18.2%) patients. Six (27.3%) children had surgical complications: 1 child had unilateral vocal cord paralysis and transient hypoparathyroidism and 5 had transient hypoparathyroidism. The higher risk of surgery complications in forward stepwise logistic regression was associated in with distant metastases (R2 = 0.584, OR 52.63, p = 0.010). CONCLUSIONS Postoperative complications were significantly associated with presence of distant metastases. Favorable results were observed in with children with MEN2 syndrome.
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Baumgarten HD, Bauer AJ, Isaza A, Mostoufi-Moab S, Kazahaya K, Adzick NS. Surgical management of pediatric thyroid disease: Complication rates after thyroidectomy at the Children's Hospital of Philadelphia high-volume Pediatric Thyroid Center. J Pediatr Surg 2019; 54:1969-1975. [PMID: 30902456 DOI: 10.1016/j.jpedsurg.2019.02.009] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 12/29/2018] [Accepted: 02/03/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Recent studies suggest improved outcomes for children undergoing thyroidectomy at high-volume pediatric surgery centers. We present outcomes after thyroid surgery at a single center and advocate for referral to high-volume centers for multidisciplinary management of these children. METHODS Medical records were reviewed for all pediatric patients undergoing thyroid surgery at a single institution from 2009 through 2017. Routine recurrent laryngeal nerve and parathyroid hormone monitoring was used. Lymph node dissections were performed in appropriately selected cancer patients. Data collection focused on pathologic diagnosis, surgical technique, and surgical complications, including postoperative hematoma, neurapraxia, permanent nerve damage, hypocalcemia, and transient and permanent hypoparathyroidism. RESULTS From 2009 through 2017, 464 patients underwent thyroid surgery. Median age of the cohort was 15 years (range 2-24). Thirty-three percent were diagnosed with benign nodules (n=151), 36% with papillary or follicular thyroid cancer (n=168), 27% with Graves' disease (n=124), 3% with medullary thyroid cancer (n=14), and 1.5% underwent prophylactic thyroidectomy for MEN2a (n=7). Six patients required return to the OR for hematoma evacuation including 5 patients after surgery for Graves' disease (RR 8.7, 95% CI 1.06-71.85). In sixteen cases, concern about neurapraxia resulted in laryngoscopy, revealing eleven patients with vocal cord paresis. Two of these patients demonstrated a persistent deficit at 6 months postoperatively (0.4%). Thirty-seven percent of patients had transient hypoparathyroidism (n=137), and two patients had persistent hypoparathyroidism 6 months after total thyroidectomy (0.6%). There was no significant difference in either hypocalcemia or hypoparathyroidism after total thyroidectomy based on age or diagnosis. CONCLUSIONS Characterizing outcomes for pediatric patients based on diagnosis will assist in preoperative counseling for patients and their families. This high-volume center reports low complication rates after pediatric thyroid surgery, highlighting that referral to high-volume centers should be considered for children and adolescents with thyroid disease requiring surgery. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Heron D Baumgarten
- Department of Surgery, Children's Hospital of Philadelphia, and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Andrew J Bauer
- Department of Pediatrics, and the Pediatric Thyroid Center, Children's Hospital of Philadelphia, and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Amber Isaza
- Department of Pediatrics, and the Pediatric Thyroid Center, Children's Hospital of Philadelphia, and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Sogol Mostoufi-Moab
- Department of Pediatrics, and the Pediatric Thyroid Center, Children's Hospital of Philadelphia, and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Ken Kazahaya
- Department of Surgery, Children's Hospital of Philadelphia, and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Division of Pediatric Otolaryngology, Children's Hospital of Philadelphia, and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - N Scott Adzick
- Department of Surgery, Children's Hospital of Philadelphia, and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
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Dimachkieh AL, Kazahaya K, Chelius DC. Assessment and Management of Thyroid Disease in Children. Otolaryngol Clin North Am 2019; 52:957-967. [DOI: 10.1016/j.otc.2019.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Maizlin II, Chen H, Russell RT. RETRACTED: Factors Affecting Readmission After Pediatric Thyroid Resection: A National Surgical Quality Improvement Program-Pediatric Evaluation. J Surg Res 2019; 243:33-40. [PMID: 31153014 DOI: 10.1016/j.jss.2019.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 04/16/2019] [Accepted: 05/01/2019] [Indexed: 11/18/2022]
Abstract
This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). This article has been retracted at the request of the authors because of an error involving the dataset which doubled the reported sample size, thereby invalidating the analysis. The authors reported this error immediately upon discovering the problem. The authors regret the error.
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Affiliation(s)
- Ilan I Maizlin
- Division of Pediatric Surgery, Children's Hospital of Alabama, University of Alabama, Birmingham, Alabama
| | - Herbert Chen
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Robert T Russell
- Division of Pediatric Surgery, Children's Hospital of Alabama, University of Alabama, Birmingham, Alabama
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Tsai SD, Mostoufi-Moab S, Bauer S, Kazahaya K, Hawkes CP, Adzick NS, Bauer AJ. Clinical Utility of Intraoperative Parathyroid Hormone Measurement in Children and Adolescents Undergoing Total Thyroidectomy. Front Endocrinol (Lausanne) 2019; 10:760. [PMID: 31781035 PMCID: PMC6851192 DOI: 10.3389/fendo.2019.00760] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 10/21/2019] [Indexed: 01/10/2023] Open
Abstract
Background: Hypoparathyroidism is one of the most common complications for patients undergoing total thyroidectomy. Our study's primary objective was to assess if intraoperative PTH levels correlate with parathyroid gland function recovery time in pediatric patients following total thyroidectomy. Methods: Retrospective review of pediatric patients who underwent thyroid surgery at CHOP for demographics and laboratory test values (calcium, phosphorus, and parathyroid hormone). We defined Time of Recovery (TOR) as the time difference from first intra-operative parathyroid hormone level (ioPTH) timepoint until normalization of PTH (> 10 pg/mL) post-thyroidectomy. Calcium and vitamin D supplements were weaned following normalization of calcium and phosphorous levels postoperatively. Patients were excluded if they lacked three intraoperative PTH timepoints or were missing postoperative follow-up PTH data. Results: 65 patients (54 female), median age 15 (range 5-23 years), underwent thyroid surgery and met study inclusion criteria. The correlations of 2nd and 3rd ioPTHs with TOR were statistically significant (p < 0.05): the lower the ioPTH, the greater the recovery time. Stratifying patients into high-risk (2nd ioPTH ≤ 10 pg/mL), moderate-risk (2nd ioPTH between 10 and 20 pg/mL), and low-risk (2nd ioPTH ≥ 20 pg/mL) tertiles, the TOR decreased by orders of magnitudes from an average of 43.13 ± 76.00 to 6.10 ± 17.44 to 1.85 ± 6.20 days. These differences were statistically significant (p < 0.05). Conclusions: Our study results confirm the usefulness of intraoperative PTH levels to predict pediatric patient recovery post-surgery and provides useful anticipatory guidance to optimize timing and frequency of postoperative laboratory surveillance.
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Affiliation(s)
- Steven D. Tsai
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Sogol Mostoufi-Moab
- Division of Pediatric Oncology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Samantha Bauer
- Orthopaedic Institute for Children, Los Angeles, CA, United States
| | - Ken Kazahaya
- Division of Pediatric Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Colin P. Hawkes
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - N. Scott Adzick
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Andrew J. Bauer
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA, United States
- *Correspondence: Andrew J. Bauer
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Abstract
Surgical hypoparathyroidism is the most common cause of hypoparathyroidism and the result of intentional or inadvertent extirpation, trauma, or devascularization of the parathyroid glands. Surgical hypoparathyroidism may present as a medical emergency. Pediatric patients, those with Graves disease, and those undergoing extensive neck dissections or reoperative neck surgery are at particular risk for this complication. Extensive surgical expertise, immediate or delayed autotransplantation, and prophylactic and postoperative calcium/vitamin D supplementation in select patients are associated with a reduction in the risk of surgical hypoparathyroidism. Intraoperative parathyroid imaging is among novel strategies being investigated to mitigate surgical hypoparathyroidism in the intraoperative setting.
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Affiliation(s)
- Hadiza S Kazaure
- Section of Endocrine Surgery, Department of Surgery, Duke Cancer Institute, Duke University Medical Center, Box 2945, Durham, NC 27710, USA
| | - Julie Ann Sosa
- Department of Surgery, University of California, San Francisco, 513 Parnassus Avenue, Suite S320, Box 0104, San Francisco, CA 94143, USA.
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Machens A, Elwerr M, Schneider R, Lorenz K, Dralle H. Disease impacts more than age on operative morbidity in children with Graves' disease after total thyroidectomy. Surgery 2018; 164:993-997. [PMID: 30174139 DOI: 10.1016/j.surg.2018.07.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 07/02/2018] [Accepted: 07/18/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND In pediatric Graves' disease, operative morbidity after total thyroidectomy remains ill defined. The present study aimed to clarify whether total thyroidectomy entails greater operative morbidity in children with Graves' disease, in particular when they are very young, as compared with an age-matched reference group of children with hereditary C-cell disease who underwent total thyroidectomy at the same time. METHODS Operative morbidity after total thyroidectomy for Graves' disease was determined in relation to the child's age and in comparison with a reference group of age-matched children with hereditary C-cell disease. RESULTS Included in the study were 58 children with Graves' disease (51 girls and 7 boys) and 108 children with hereditary C-cell disease (59 girls and 49 boys). When children with Graves' disease and children with hereditary C-cell disease were compared across and within the 4 age increments (≤ 3, 4-6, 7-12, and 13-18 years), operative mortality did not differ significantly among and within age increments. Children with Graves' disease had a 1.7-fold greater overall risk of transient hypoparathyroidism (29% versus 17%; P = .073) than children with hereditary C-cell disease. Permanent hypoparathyroidism was nil in either group. Transient recurrent laryngeal nerve palsy, wound hemorrhage, and wound infections were infrequent (≤ 3% each), resolving spontaneously and after reoperation, respectively. CONCLUSION Disease impacts more than age on operative morbidity in children with Graves' disease after total thyroidectomy but is fairly low overall and rarely permanent in experienced hands.
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Affiliation(s)
- Andreas Machens
- Medical Faculty, Department of General, Visceral and Vascular Surgery, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany.
| | - Malik Elwerr
- Medical Faculty, Department of General, Visceral and Vascular Surgery, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Rick Schneider
- Medical Faculty, Department of General, Visceral and Vascular Surgery, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Kerstin Lorenz
- Medical Faculty, Department of General, Visceral and Vascular Surgery, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Henning Dralle
- Medical Faculty, Department of General, Visceral and Vascular Surgery, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany; Department of General, Visceral and Transplantation Surgery, Section of Endocrine Surgery, University of Duisburg-Essen, Essen, Germany
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Patel NA, Bly RA, Adams S, Carlin K, Parikh SR, Dahl JP, Manning S. A clinical pathway for the postoperative management of hypocalcemia after pediatric thyroidectomy reduces blood draws. Int J Pediatr Otorhinolaryngol 2018; 105:132-137. [PMID: 29447801 DOI: 10.1016/j.ijporl.2017.12.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 11/23/2017] [Accepted: 12/10/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Postoperative calcium management is challenging following pediatric thyroidectomy given potential limitations in self-reporting symptoms and compliance with phlebotomy. A protocol was created at our tertiary children's institution utilizing intraoperative parathyroid hormone (PTH) levels to guide electrolyte management during hospitalization. The objective of this study was to determine the effect of a new thyroidectomy postoperative management protocol on two primary outcomes: (1) the number of postoperative calcium blood draws and (2) the length of hospital stay. STUDY DESIGN Institutional review board approved retrospective study (2010-2016). METHODS Consecutive pediatric total thyroidectomy and completion thyroidectomy ± neck dissection cases from 1/1/2010 through 8/5/2016 at a single tertiary children's institution were retrospectively reviewed before and after initiation of a new management protocol. All cases after 2/1/2014 comprised the experimental group (post-protocol implementation). The pre-protocol control group consisted of cases prior to 2/1/2014. Multivariable linear and Poisson regression models were used to compare the control and experimental groups for outcome measure of number of calcium lab draws and hospital length of stay. RESULTS 53 patients were included (n = 23, control group; n = 30 experimental group). The median age was 15 years. 41 patients (77.4%) were female. Postoperative calcium draws decreased from a mean of 5.2 to 3.6 per day post-protocol implementation (Rate Ratio = 0.70, p < .001), adjusting for covariates. The mean number of total inpatient calcium draws before protocol initiation was 13.3 (±13.20) compared to 7.2 (±4.25) in the post-protocol implementation group. Length of stay was 2.1 days in the control group and 1.8 days post-protocol implementation (p = .29). Patients who underwent concurrent neck dissection had a longer mean length of stay of 2.32 days compared to 1.66 days in those patients who did not undergo a neck dissection (p = .02). Hypocalcemia was also associated with a longer mean length of stay of 2.41 days compared to 1.60 days in patients who did not develop hypocalcemia (p < .01). CONCLUSIONS The number of calcium blood draws was significantly reduced after introduction of a standardized protocol based on intraoperative PTH levels. The hospital length of stay did not change. Adoption of a standardized postoperative protocol based on intraoperative PTH levels may reduce the number of blood draws in children undergoing thyroidectomy.
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Affiliation(s)
- Neha A Patel
- Cohen Children's Medical Center, Division of Pediatric Otolaryngology, New Hyde Park, NY, USA; Hofstra Northwell School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Hempstead, NY, USA; Seattle Children's Hospital, Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle, WA, USA; University of Washington, Department of Otolaryngology-Head and Neck Surgery, Seattle, WA, USA.
| | - Randall A Bly
- Seattle Children's Hospital, Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle, WA, USA; University of Washington, Department of Otolaryngology-Head and Neck Surgery, Seattle, WA, USA.
| | - Seth Adams
- University of Washington, Department of Pediatrics and Hospital Medicine, Seattle, WA, USA.
| | - Kristen Carlin
- Seattle Children's Research Institute, Center for Clinical and Transitional Research, Seattle, WA, USA.
| | - Sanjay R Parikh
- Seattle Children's Hospital, Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle, WA, USA; University of Washington, Department of Otolaryngology-Head and Neck Surgery, Seattle, WA, USA.
| | - John P Dahl
- Indiana University School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Indianapolis, IN, USA; Riley Hospital for Children at IU Health, Indianapolis, IN, USA.
| | - Scott Manning
- Seattle Children's Hospital, Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle, WA, USA; University of Washington, Department of Otolaryngology-Head and Neck Surgery, Seattle, WA, USA.
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Medas F, Erdas E, Canu GL, Longheu A, Pisano G, Tuveri M, Calò PG. Does hyperthyroidism worsen prognosis of thyroid carcinoma? A retrospective analysis on 2820 consecutive thyroidectomies. J Otolaryngol Head Neck Surg 2018; 47:6. [PMID: 29357932 PMCID: PMC5778700 DOI: 10.1186/s40463-018-0254-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Accepted: 01/08/2018] [Indexed: 12/04/2022] Open
Abstract
Background Hyperthyroidism is associated with high incidence of thyroid carcinoma; furthermore, tumors arisen in hyperthyroid tissue show an aggressive behavior. Thyroid Stimulating Hormone (TSH) and Thyroid-stimulating antibodies, present in Graves’s disease, seem to play a key role in carcinogenesis and tumoral growth. Methods We retrospectively reviewed our series of patients who underwent thyroidectomy for thyroid carcinoma. We compared pathological features and surgical outcomes of hyperthyroid versus euthyroid patients. Results From 2007 to 2015, 909 thyroidectomies were performed at our institution for thyroid cancer: 87 patients were hyperthyroid and 822 euthyroid. We observed, in hyperthyroid patients, a higher rate of transient hypoparathyroidism (28.1% vs 13.2%; p < 0.01) and of node metastases (12.6% vs 6.1%; p = 0.03); also local recurrence rate was higher (5.7% vs 2.5%) even if not statistically significant (p = 0.17). Five-year disease free survival rate was significant lower in the same group (89.1% vs 96.6%; p = 0.03). Conclusion Thyroid cancers in hyperthyroid patients have an aggressive behavior, with high incidence of local invasion and a worse prognosis than euthyroid patients. All hyperthyroid patients should undergo a careful evaluation with ultrasound and scintigraphy; in case of suspicious nodules, an aggressive approach, including thyroidectomy and lymphectomy, is justified. In patients with toxic adenoma, thyroid cancer is uncommon, thus a loboisthmectomy can be safely performed. Trial registration number Research registry n. 2670 registered 19 June 2017 (retrospectively registered).
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Affiliation(s)
- Fabio Medas
- Department of Surgical Sciences, University of Cagliari, Cittadella Universitaria, SS554, Bivio Sestu, 09042, Monserrato (CA), Italy.
| | - Ernico Erdas
- Department of Surgical Sciences, University of Cagliari, Cittadella Universitaria, SS554, Bivio Sestu, 09042, Monserrato (CA), Italy
| | - Gian Luigi Canu
- Department of Surgical Sciences, University of Cagliari, Cittadella Universitaria, SS554, Bivio Sestu, 09042, Monserrato (CA), Italy
| | - Alessandro Longheu
- Department of Surgical Sciences, University of Cagliari, Cittadella Universitaria, SS554, Bivio Sestu, 09042, Monserrato (CA), Italy
| | - Giuseppe Pisano
- Department of Surgical Sciences, University of Cagliari, Cittadella Universitaria, SS554, Bivio Sestu, 09042, Monserrato (CA), Italy
| | - Massimiliano Tuveri
- Istituto Pancreas, Policlinico Borgo Roma, AOUI Verona, Piazzale L.A. Scuro, 10, 37134, Verona, Italy
| | - Pietro Giorgio Calò
- Department of Surgical Sciences, University of Cagliari, Cittadella Universitaria, SS554, Bivio Sestu, 09042, Monserrato (CA), Italy
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