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Balbaloglu H, Tasdoven I, Buyukuysal MC, Karadeniz E, Comert M, Cakmak GK. Predicting coexisting thyroid cancer with primary hyperparathyroidism in an endemic region of multinodular goiter: evaluating the effectiveness of preoperative inflammatory markers. Ann Surg Treat Res 2023; 105:290-296. [PMID: 38023432 PMCID: PMC10648613 DOI: 10.4174/astr.2023.105.5.290] [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: 06/05/2023] [Revised: 08/30/2023] [Accepted: 09/07/2023] [Indexed: 12/01/2023] Open
Abstract
Purpose The aim is to examine the efficacy of inflammatory indicators to predict thyroid cancer in patients with primary hyperparathyroidism (PHPT) in an endemic region of nodular goiter. Methods The prospective database was reviewed to identify patients operated on with the diagnosis of PHPT and thyroid disease between April 2015 and June 2021. Permanent pathologic reports were used as the gold standard for diagnosis. Detailed imaging data with peripheral blood inflammation indices were analyzed to assess their predictive values for concomitant PHPT with thyroid cancer. Postoperative complications and the duration of hospitalization were also reviewed. Results Thyroid malignancy accompanying PHPT was found in 13 patients (26.0%) out of 50 who had concurrent surgery. The analysis regarding inflammatory indexes revealed nothing significant between thyroid cancer and preoperative blood biochemistry (P > 0.05). In the concurrent surgery group, recurrent laryngeal nerve injury was observed in 1 patient (2.0%) and the mean hospital stay was longer. Conclusion In endemic regions of nodular thyroid disease, thyroid cancer might accompany PHPT. The value of inflammatory indexes to predict thyroid malignancy in PHPT is controversial and should not be employed in the surgical decision-making process.
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Affiliation(s)
- Hakan Balbaloglu
- Department of General Surgery, Bülent Ecevit University School of Medicine, Zonguldak, Turkey
| | - Ilhan Tasdoven
- Department of General Surgery, Bülent Ecevit University School of Medicine, Zonguldak, Turkey
| | | | - Emre Karadeniz
- Department of General Surgery, Bülent Ecevit University School of Medicine, Zonguldak, Turkey
| | - Mustafa Comert
- Department of General Surgery, Bülent Ecevit University School of Medicine, Zonguldak, Turkey
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Cisco R, Arnow K, Barreto N, Lin D, Kebebew E, Seib C. Increased Risk of Complications Associated With Concurrent Parathyroidectomy in Patients Undergoing Total Thyroidectomy. J Surg Res 2023; 288:275-281. [PMID: 37043874 DOI: 10.1016/j.jss.2023.02.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 01/03/2023] [Accepted: 02/17/2023] [Indexed: 04/14/2023]
Abstract
INTRODUCTION We sought to investigate the association of concurrent parathyroidectomy (PTX) with risks of total thyroidectomy (TTX) through analysis of Collaborative Endocrine Surgery Quality Improvement Program data. TTXis a common operation with complications including recurrent laryngeal nerve injury, neck hematoma, and hypoparathyroidism. A subset of patients undergoing thyroidectomy undergoes planned concurrent PTX for treatment of primary hyperparathyroidism. There are limited data on the risk profile of TTX with concurrent PTX (TTX + PTX). METHODS We queried the Collaborative Endocrine Surgery Quality Improvement Program database for patients who underwent TTX or TTX + PTX from January 2014 through April 2020. Multivariable logistic regression was performed to predict hypoparathyroidism, vocal cord dysfunction, neck hematoma, and postoperative emergency department visit. Covariates included patient demographics, patient body mass index, indication for surgery, central neck dissection, anticoagulation use, and surgeon volume. RESULTS Thirteen thousand six hundred forty seven patients underwent TTX and 654 patients underwent TTX + PTX. Unadjusted rates of hypoparathyroidism were higher in TTX + PTX patients at 30 d (9.6% versus 7.4%, P = 0.04) and 6 mo (7.9% versus 3.1%, P < 0.001). On multivariable regression, TTX + PTX was associated with an increased risk of hypoparathyroidism at 30 d (odds ratio [OR] 2.09, 95% confidence interval [CI] 1.57-2.79) and 6 mo (OR 4.63, 95% CI 3.06-7.00) and an increased risk of postoperative emergency department visit (OR 1.66, 95% CI 1.20-2.31). TTX + PTX was not associated with recurrent laryngeal nerve injury or neck hematoma. CONCLUSIONS Concurrent PTX in patients undergoing TTX is associated with increased risk of immediate and long-term hypoparathyroidism, which should be considered in informed consent discussions and operative decision-making.
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Affiliation(s)
- Robin Cisco
- Division of General Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California.
| | - Katherine Arnow
- Stanford-Surgery Policy Improvement Research & Education Center (S-SPIRE), Stanford, California
| | - Nicolas Barreto
- Stanford-Surgery Policy Improvement Research & Education Center (S-SPIRE), Stanford, California
| | - Dana Lin
- Division of General Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Electron Kebebew
- Division of General Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Carolyn Seib
- Division of General Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California; Stanford-Surgery Policy Improvement Research & Education Center (S-SPIRE), Stanford, California
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Pastoricchio M, Bernardi S, Bortul M, de Manzini N, Dobrinja C. Autofluorescence of parathyroid glands during endocrine surgery with minimally invasive technique. J Endocrinol Invest 2022; 45:1393-1403. [PMID: 35262861 DOI: 10.1007/s40618-022-01774-x] [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: 11/02/2021] [Accepted: 02/18/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Accidental injury to the parathyroid glands (PTGs) is common during thyroid and parathyroid surgery. To overcome the limitation of naked eye in identifying the PTGs, intraoperative autofluorescence imaging has been embraced by an increasing number of surgeons. The aim of our study was to describe the technique and assess its utility in clinical practice. METHODS Near-infrared (NIR) autofluorescence imaging was carried out during open parathyroid and thyroid surgery in 25 patients (NIR group), while other 26 patients underwent traditional PTG detection based on naked eye alone (NO-NIR group). Primary variables assessed for correlation between traditional approach and autofluorescence were number of PTGs identified and incidence of postoperative hypoparathyroidism (hypoPT). RESULTS 81.9% of PTGs were detected by means of fluorescence imaging and 74.5% with visual inspection alone, with an average of 2.72 PTGs visualized per patient using NIR imaging versus approximately 2.4 per patient using naked eye (p = 0.38). Considering only the more complex total thyroidectomies (TTs), the difference was almost statistically significant (p = 0.06). Although not statistically significant, the observed postoperative hypoPT rate was lower in the NIR group. CONCLUSION Despite the limitations and technical aspects still to be investigated, fluorescence seems to reduce this complication rate by improving the intraoperative detection of the PTGs.
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Affiliation(s)
- M Pastoricchio
- Division of General Surgery, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), Gorizia, Italy
| | - S Bernardi
- Department of Medical, Surgical, and Health Sciences, University of Trieste, Cattinara Teaching Hospital UCO Medicina Clinica, 34100, Trieste, Italy
| | - M Bortul
- Division of General Surgery, Department of Medical, Surgical, and Health Sciences, Cattinara Teaching Hospital, University of Trieste, Trieste, Italy
| | - N de Manzini
- Division of General Surgery, Department of Medical, Surgical, and Health Sciences, Cattinara Teaching Hospital, University of Trieste, Trieste, Italy
| | - C Dobrinja
- Division of General Surgery, Department of Medical, Surgical, and Health Sciences, Cattinara Teaching Hospital, University of Trieste, Trieste, Italy.
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Outcomes of concurrent parathyroidectomy and thyroidectomy among CESQIP surgeons. Am J Surg 2022; 224:1190-1196. [DOI: 10.1016/j.amjsurg.2022.03.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 02/26/2022] [Accepted: 03/23/2022] [Indexed: 11/01/2022]
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Weber T, Dotzenrath C, Trupka A, Schabram P, Lorenz K, Dralle H. [Medicolegal aspects of primary and renal hyperparathyroidism]. Chirurg 2021; 93:596-603. [PMID: 34874460 DOI: 10.1007/s00104-021-01535-1] [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] [Accepted: 10/25/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Compared with malpractice claims in thyroid surgery, expert medico-legal reviews of surgery performed for hyperparathyroidism (HPT) that aim to prove or rebut surgical malpractice are rare. The aim of this analysis was to describe typical risk patterns for possible treatment errors and to generate recommendations for avoiding these treatment errors. MATERIAL AND METHODS A total of 12 surgical expert medico-legal reviews, which were carried out by order of 9 arbitration boards and 3 courts between 1997 and 2020 were evaluated. RESULTS If the indications for surgical treatment of hyperparathyroidism were present, the failure to identify a parathyroid adenoma or hyperplastic parathyroid glands was in the majority of cases not rated as a surgical treatment error, especially in atypical localizations. Unilateral recurrent laryngeal nerve palsy and postoperative bleeding cannot always be prevented, despite maximum diligence. In contrast, bilateral recurrent laryngeal nerve palsy can be prevented when intraoperative neuromonitoring is correctly applied. A lack of patient information regarding postoperatively persistent HPT, postoperative hypoparathyroidism following the removal of inconspicuous parathyroid glands and nonindicated lobectomy or total thyroidectomy, mostly performed under the assumption of an intrathyroid parathyroid adenoma, represented avoidable malpractice issues. CONCLUSION Advanced knowledge of the pathophysiology of the disease and the anatomy of the parathyroid glands as well as the establishment of intraoperative and perioperative standards can prospectively greatly reduce avoidable errors in the surgical treatment and postoperative care of HPT.
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Affiliation(s)
- T Weber
- Klinik für Endokrine Chirurgie, Marienhaus Klinikum Mainz, An der Goldgrube 11, 55131, Mainz, Deutschland.
| | - C Dotzenrath
- Helios Universitätsklinikum Wuppertal, Wuppertal, Deutschland
| | - A Trupka
- Klinikum Starnberg, Starnberg, Deutschland
| | - P Schabram
- Kanzlei Ratajczak & Partner, Freiburg, Deutschland
| | - K Lorenz
- Universitätsklinikum Halle, Halle, Deutschland
| | - H Dralle
- Universitätsklinikum Essen, Essen, Deutschland
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Management of primary and renal hyperparathyroidism: guidelines from the German Association of Endocrine Surgeons (CAEK). Langenbecks Arch Surg 2021; 406:571-585. [PMID: 33880642 DOI: 10.1007/s00423-021-02173-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 04/06/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIMS The purpose of this review is to provide updated recommendations for the surgical management of primary (pHPT) and renal (rHPT) hyperparathyroidism, formulating a new guideline of the German Association of Endocrine Surgeons (CAEK). METHODS Evidence-based recommendations for the diagnosis and therapy of pHPT and rHPT were assessed by a multidisciplinary panel using PubMed for a comprehensive literature search together with a structured consensus dialogue (S2k guideline of the Association of the German Scientific Medical Societies, AWMF). RESULTS During the last 20 years, a variety of new preoperative localization procedures, such as sestamibi-SPECT, 4D-CT, and various PET/CT procedures, were established for pHPT. High-resolution imaging, together with intraoperative parathyroid hormone (IOPTH) measurement, enabled focused or minimally invasive surgery to become the most favored surgical technique. Patients with pHPT and nonlocalizing imaging have a higher risk of multiglandular disease. Surgical therapy provides very high cure rates, with a clear relation to the surgeon's experience in parathyroid procedures. Reoperative parathyroidectomy, children with pHPT or familial forms, and parathyroid carcinoma are addressed and require special surgical expertise. A multidisciplinary team of experienced nephrologists, transplant, and endocrine surgeons should assess the diagnosis and treatment of renal HPT. CONCLUSION Surgery is the only curative treatment for pHPT and should be considered for all patients with pHPT. For rHPT, a more selective approach is required, and parathyroidectomy is indicated only when conservative treatment options fail. In parathyroid carcinoma, the adequacy of local resection influences local disease control.
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The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults. Ann Surg 2020; 271:e21-e93. [PMID: 32079830 DOI: 10.1097/sla.0000000000003580] [Citation(s) in RCA: 231] [Impact Index Per Article: 57.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To develop evidence-based recommendations for safe, effective, and appropriate thyroidectomy. BACKGROUND Surgical management of thyroid disease has evolved considerably over several decades leading to variability in rendered care. Over 100,000 thyroid operations are performed annually in the US. METHODS The medical literature from 1/1/1985 to 11/9/2018 was reviewed by a panel of 19 experts in thyroid disorders representing multiple disciplines. The authors used the best available evidence to construct surgical management recommendations. Levels of evidence were determined using the American College of Physicians grading system, and management recommendations were discussed to consensus. Members of the American Association of Endocrine Surgeons reviewed and commented on preliminary drafts of the content. RESULTS These clinical guidelines analyze the indications for thyroidectomy as well as its definitions, technique, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Fine Needle Aspiration Biopsy Diagnosis, Molecular Testing, Indications, Extent and Outcomes of Surgery, Preoperative Care, Initial Thyroidectomy, Perioperative Tissue Diagnosis, Nodal Dissection, Concurrent Parathyroidectomy, Hyperthyroid Conditions, Goiter, Adjuncts and Approaches to Thyroidectomy, Laryngology, Familial Thyroid Cancer, Postoperative Care and Complications, Cancer Management, and Reoperation. CONCLUSIONS Evidence-based guidelines were created to assist clinicians in the optimal surgical management of thyroid disease.
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Özden S, Saylam B, Daglar G, Yuksek YN, Tez M. ARE THYROID NODULES AN OBSTACLE TO MINIMAL INVASIVE PARATHYROID SURGERY? A SINGLE-CENTER STUDY FROM AN ENDEMIC GOITER REGION. ACTA ENDOCRINOLOGICA-BUCHAREST 2020; 15:531-536. [PMID: 32377254 DOI: 10.4183/aeb.2019.531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Context Minimally invasive parathyroidectomy (MIP) procedure has become a widely accepted alternative to the standard four-gland exploration nowadays. Objective The aim of this study was to evaluate patients with primary hyperparathyroidism (PHPT), who had been treated with thyroidectomy and bilateral neck exploration (BNE), rather than MIP alone, due to coexisting thyroid nodules and to determine the benefits of simultaneous thyroidectomy and the possible negative outcomes of not performing this additional procedure. Design There were 185 patients who were operated for PHPT at our clinic from January 2014 to November 2016. Subjects and Methods 50 patients meet inclusion criteria: have thyroidectomy at the same time of parathyroid surgery, have concordant findings of parathyroid adenoma localization at preoperative MIBI-SPECT and the cervical US and have not had malignancy on fine needle aspiration biopsy (FNAB). Results The mean age of the patients was 55.3±10.4, and female to male ratio was 7:1. All patients had parathyroidectomy with BNE and thyroidectomy: 11 (22%) patients had micropapillary thyroid cancer (mPTC), 2 (4%) had papillary thyroid cancer (PTC). Conclusion The results were inconclusive in clearly demonstrating which patients presenting with coexisted thyroid nodules should undergo thyroidectomy, rather than MIP, and which should be monitored for thyroid nodules after MIP. However, we consider that in cases who are not clearly indicated for thyroidectomy, MIP followed by monitoring of thyroid nodules can be the treatment approach.
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Affiliation(s)
- S Özden
- TC Saglik Bakanligi, Ankara Numune Training and Research Hospital - Surgery, Altindag, Ankara, Turkey
| | - B Saylam
- TC Saglik Bakanligi, Ankara Numune Training and Research Hospital - Surgery, Altindag, Ankara, Turkey
| | - G Daglar
- TC Saglik Bakanligi, Ankara Numune Training and Research Hospital - Surgery, Altindag, Ankara, Turkey
| | - Y N Yuksek
- TC Saglik Bakanligi, Ankara Numune Training and Research Hospital - Surgery, Altindag, Ankara, Turkey
| | - M Tez
- TC Saglik Bakanligi, Ankara Numune Training and Research Hospital - Surgery, Altindag, Ankara, Turkey
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Orloff LA, Wiseman SM, Bernet VJ, Fahey TJ, Shaha AR, Shindo ML, Snyder SK, Stack BC, Sunwoo JB, Wang MB. American Thyroid Association Statement on Postoperative Hypoparathyroidism: Diagnosis, Prevention, and Management in Adults. Thyroid 2018; 28:830-841. [PMID: 29848235 DOI: 10.1089/thy.2017.0309] [Citation(s) in RCA: 222] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Hypoparathyroidism (hypoPT) is the most common complication following bilateral thyroid operations. Thyroid surgeons must employ strategies for minimizing and preventing post-thyroidectomy hypoPT. The objective of this American Thyroid Association Surgical Affairs Committee Statement is to provide an overview of its diagnosis, prevention, and treatment. SUMMARY HypoPT occurs when a low intact parathyroid hormone (PTH) level is accompanied by hypocalcemia. Risk factors for post-thyroidectomy hypoPT include bilateral thyroid operations, autoimmune thyroid disease, central neck dissection, substernal goiter, surgeon inexperience, and malabsorptive conditions. Medical and surgical strategies to minimize perioperative hypoPT include optimizing vitamin D levels, preserving parathyroid blood supply, and autotransplanting ischemic parathyroid glands. Measurement of intraoperative or early postoperative intact PTH levels following thyroidectomy can help guide patient management. In general, a postoperative PTH level <15 pg/mL indicates increased risk for acute hypoPT. Effective management of mild to moderate potential or actual postoperative hypoPT can be achieved by administering either empiric/prophylactic oral calcium and vitamin D, selective oral calcium, and vitamin D based on rapid postoperative PTH level(s), or serial serum calcium levels as a guide. Monitoring for rebound hypercalcemia is necessary to avoid metabolic and renal complications. For more severe hypocalcemia, inpatient management may be necessary. Permanent hypoPT has long-term consequences for both objective and subjective well-being, and should be prevented whenever possible.
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Affiliation(s)
- Lisa A Orloff
- 1 Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine , Stanford, California
| | - Sam M Wiseman
- 2 Department of Surgery, University of British Columbia , Vancouver, Canada
| | - Victor J Bernet
- 3 Division of Endocrinology, Mayo Clinic College of Medicine , Jacksonville, Florida
| | - Thomas J Fahey
- 4 Department of Surgery, The New York Presbyterian Hospital-Weill Cornell Medical Center , New York, New York
| | - Ashok R Shaha
- 5 Head and Neck Service, Memorial Sloan Kettering Cancer Center , New York, New York
| | - Maisie L Shindo
- 6 Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University , Portland, Oregon
| | - Samuel K Snyder
- 7 Department of Surgery, University of Texas Rio Grande Valley School of Medicine , Harlingen, Texas
| | - Brendan C Stack
- 8 Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences , Little Rock, Arkansas
| | - John B Sunwoo
- 1 Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine , Stanford, California
| | - Marilene B Wang
- 9 Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA , Los Angeles, California
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