Thyroidectomy with Wu Gaosong's Procedure

Total thyroidectomy versus hemithyroidectomy with intraoperative radiofrequency ablation for unilateral thyroid cancer with contralateral nodules: A propensity score matching study

Background

For unilateral papillary thyroid carcinoma (PTC) patients with contralateral benign nodules, optimal treatment decisions are made according to patient preference and the disease’s pathological features. This study was performed to evaluate the efficacy and complications of hemithyroidectomy with intraoperative radiofrequency ablation (RFA) compared with total thyroidectomy.

Methods

Patients with unilateral PTC and cytologically benign contralateral nodules were enrolled from 2014 to 2018. Total thyroidectomy or hemithyroidectomy with intraoperative RFA of the contralateral nodule was offered to patients who had anxiety regarding their disease. The operation-related parameters, transient or permanent nerve injury, hypocalcemia and disease recurrence, were recorded and compared between the two groups.

Results

After propensity score matching, 191 patients who underwent total thyroidectomy and 224 contralateral nodules in 191 patients underwent hemithyroidectomy with intraoperative RFA (HTRFA) were included. The volume reduction ratios of the contralateral nodules were 67.7% at 12 months and 95.8% at 24 months. The total thyroidectomy group reported significantly higher hypocalcemia than HTRFA within one year (7.8% vs. 2.6%, p = 0.022). Supplemental levothyroxine was not required in 28.3% (54/191) of the patients one year after HTRFA. With a median follow-up of 4.1 years, three recurrences (1.6%) were observed in the HTRFA, and no recurrence occurred in the total thyroidectomy group (p = 0.246).

Conclusions

Hemithyroidectomy for unilateral PTC and intraoperative RFA for contralateral nodules were acceptable and effective treatment approaches and did not increase the risk of complications.

Graphical Abstract

Visual identification and neuromonitoring vs. no sighting the external branch of the superior laryngeal nerve in thyroid surgery: a randomized clinical trial

To evaluate the incidence of external branch of the superior laryngeal nerve (EBSLN) injuries after thyroid surgical procedures with or without the functional and visual identification of the EBSLN before ligation at the superior thyroid pole. Patients with papillary thyroid carcinoma (PTC) enrolled from a single tertiary referral academic medical center were assigned to functional and visual identification of EBSLN group (study group) or no identification of EBSLN group (controlled group). The main outcome measures were the incidence of EBSLN injury detected by the intraoperative neuromonitoring and Voice Handicap Index-10 (VHI-10) and Impairment Index-5 (VII-5) valuation questionnaires. Postoperative complications were recorded. A total of 140 (50.4%) patients were enrolled in study group and 138 (49.6%) in controlled group. In the study group, 110 (39.3%) EBSLNs were direct visual recognized and 170 (60.7%) nerves were visually identified with the help of neuromonitoring. Three patients in the study group and two patients in the controlled group were diagnosed with vocal cord paralysis. Six (4.4%) patients in the identification group and 37 (27.2%) patients in the no identification group presented no response from the stimulation of sternothyroid-laryngeal triangle. The VII-5 scores of the study group were significantly higher than those of the controlled group at one and three months postoperatively (P = 0.024 and P = 0.034). With significant lower scores of VII-5 and VHI-10, functional and visual identification of EBSLN might be necessary during thyroid surgery to protect the structural integrity and motor activity of the nerve.

Lymph node metastasis in suprasternal space and intra-infrahyoid strap muscle space from papillary thyroid carcinoma

Background

This study was performed to evaluate the clinicopathologic characteristics of Lymph Node metastasis between investing layer of Cervical fascia and deep fascia of infrahyoid strap Muscles (LNCM) in papillary thyroid carcinoma (PTC).

Methods

Retrospective review of patients with PTC who underwent thyroidectomy and central compartment neck dissection (CND) from January 2016 to January 2018 was performed in two tertiary referral academic medical centers. A total of 2104 consecutive patients with PTC who underwent thyroidectomy and CND were included in the retrospective review. The LNCM was resected as a separate specimen by the surgeon and the clinicopathologic characteristics of the patients were recorded. Multivariate logistic regression analysis was performed to identify risk factors for LNCM metastasis.

Results

Of 2104 PTC patients, 451 patients (21.4%) had lymph nodes in the LNCM. Among them, 68 (15.1%) cases were confirmed to be positive in the LNCM. In total, the metastasis rate of LNCM in PTC patients was 3.2% (68/2104). Univariate analysis revealed that the metastasis of LNCM were more likely to have a primary site in the inferior pole, extrathyroidal extension (ETE), central cervical metastasis, level III and level IV metastasis. Multivariate analysis further showed tumor location in the inferior pole, ETE, level III and level IV metastasis conferred a significantly increased odds ratio for LNCM metastasis.

Conclusion

Attention should be paid to the lymph tissue in the LNCM for PTC patients, especially in presence of a primary site in the inferior pole, ETE, level III and level IV metastasis.

Selective vagus-recurrent laryngeal nerve anastomosis in thyroidectomy with cancer invasion or iatrogenic transection

PURPOSE

Immediate recurrent laryngeal nerve (RLN) reconstruction at the time of thyroid cancer extirpation can provide excellent postoperative phonatory function. This study is to present our experience with the methods of RLN reconstruction, and to evaluate the role of selective vagus to RLN anastomosis (SVR) in thyroidectomy.

METHODS

Respective review of RLN reconstruction in thyroid surgery from January 2004 to October 2018 was conducted in two tertiary referral academic medical centers. Immediate RLN reconstruction was performed for primary thyroidectomy patients with intraoperative nerve tumor invasion or iatrogenic transection. Laryngofiberoscopic examination, voice evaluation of maximum phonation time, and GRBAS scale were performed preoperatively, on the second day after surgery, and monthly postoperatively for the first year.

RESULTS

A total of 37 patients were enrolled. Twenty-nine RLNs were resected caused by tumor-associated trauma; the other nerves were inadvertently transected. Direct anastomosis (DA) was performed in eight patients, free nerve graft (FNG) was performed in four patients, ansa cervicalis to RLN anastomosis (ARA) was performed in eight patients, and SVR was performed in 17 patients. The mean periods from the reinnervation surgery of DA, SVR, ARA, and FNG to the phonation recovery were 46 ± 19 (days), 41 ± 29 (days), 83 ± 21 (days), and 137 ± 32 (days), respectively. There were improvements in the GRBAS scale of perceptual voice quality at 1 month for DA and SVR, 2months for ARA.

CONCLUSIONS

Intraoperative SVR reinnervation demonstrated voice improvement postoperatively and might be an effective treatment for thyroidectomy-related permanent unilateral vocal cord paralysis.

Correlation Between Electrophysiological Changes and Outcomes of Vocal Cord Function in 1764 Recurrent Laryngeal Nerves with Visual Integrity During Thyroidectomy

Background: The correlation between the injured recurrent laryngeal nerve (RLN) with incomplete loss of signal (LOS) and the outcomes of vocal cord function is still not well understood. This large cohort validation study was aimed to evaluate the effectiveness of the warning criterion, the reduction of the R2p/R2d ratio, in neuromonitoring during thyroidectomy. Methods: A total of 1108 consecutive patients (1764 nerves) with normal vocal cord function undergoing monitored thyroidectomy were included. Standardized intraoperative neuromonitoring procedures were strictly followed, after complete dissection of RLN, the exposed RLN was routinely stimulated at the lowest proximal end (R2p signal) and the most distal end near the laryngeal entry point (R2d signal). If the reduction of the R2p/R2d ratio (([R2d - R2p]/R2d) × 100%) reached >20%, the whole exposed RLN would be checked to pinpoint the injured area of the nerve. Results: Visual anatomical integrity of the RLN was ensured in all 1764 nerves. Eighteen nerves had complete LOS, and the other 97 nerves had incomplete LOS where the reduction of the R2p/R2d ratio ranged from 21% to 84%. Postoperative temporary vocal cord paralysis (VCP) was noted in 11 (61.1%) RLNs with complete LOS and 16 (16.5%) RLNs with incomplete LOS, where the reduction of the R2p/R2d ratio ranged from 63% to 84%. The positive predictive value of a R2p/R2d ratio >63% for postoperative VCP was 79.4%. Conclusions: Testing and comparing the R2p and R2d signals were useful to detect RLN neurophysiologic injury, elucidating the mechanism of nerve injury and predicting vocal cord function. Determining R2p-R2d was found to be essential and can be applied in routine neuromonitoring thyroidectomy.

The Identification, Preservation and Classification of the External Branch of the Superior Laryngeal Nerve in Thyroidectomy

BACKGROUND

Avoiding injury to the external branch of the superior laryngeal nerve is one of the major challenges during thyroid operation. The aim of this study was to propose a practical classification of the external branch of the superior laryngeal nerve.

METHODS

A retrospective study of total thyroidectomy was performed. Totally 240 patients were included, with 480 external branches of the superior laryngeal nerves explored by intraoperative neuromonitoring. The classification of the external branch of the superior laryngeal nerve was determined by the distance between the upper edge of the superior thyroid pole and the lowest point of the nerve when the thyroid lobe was retracted in the lateral and inferior direction. Multinomial logistic regression analysis was run to predict the type of the nerve from several variables.

RESULTS

The identification rate of the external branch of the superior laryngeal nerve was 98.54% (473 of 480 nerves). Higher ratio of longitudinal size of the thyroid lobe to ipsilateral neck length increased the likelihood of that both the type 2 and 3 nerve with respect to type 1 nerve, with OR 2.72, 95% CI = 1.21-6.12 and OR 5.30, 95% CI = 2.09-13.44, respectively. (1a) The nerve whose lowest point (entry into the muscle) was located more than 1 cm above the horizontal plane passing the upper border of superior thyroid pole. (1b) The nerve whose lowest point (the point right above the superior thyroid pole) was located more than 1 cm above the plane. (2a) The nerve whose lowest point (entry into the muscle) was located within 1 cm above the plane. (2b) The nerve whose lowest point (the point right above the superior thyroid pole) was located within 1 cm above the plane. (3a) The nerve whose lowest point (entry into the muscle) was located below the plane. (3b) The nerve whose lowest point (the point right below the superior thyroid pole) was located anterior to the gland. (3c) The nerve whose lowest point (the point right below the superior thyroid pole) was located posterior to the gland.

CONCLUSIONS

Identification rate of the external branch of the superior laryngeal nerve by intraoperative neuromonitoring was significantly high. Understanding the new practical classification of the nerve allows for better identification and function preservation of this nerve during thyroidectomy.

A novel variation of the recurrent laryngeal nerve

BACKGROUND

Injury to the recurrent laryngeal nerve is one of the most severe complications of thyroid surgery. Several anatomic variations of the nerve increase the likelihood of iatrogenic damage.

CASE PRESENTATION

A 50-year-old woman was presented to our department with a nodule in the right thyroid lobe, and she reported no voice changes. She had no history of surgery or radiation to the head or neck. Fine-needle aspiration was recorded as papillary thyroid carcinoma. The preoperative laryngoscopy revealed left vocal cord paralysis. Right thyroid lobectomy was performed. A scarce course of the left recurrent laryngeal nerve was found during the operation that ascended along the medial edge of the superior thyroid pole and finally disappeared beneath the superior cornu of the thyroid cartilage without any tracheal, esophageal, or laryngeal branches. The patient was discharged on the third postoperative day with the diagnoses of papillary thyroid carcinoma and congenital left vocal cord paralysis.

CONCLUSIONS

The novel variation of the recurrent laryngeal nerve may challenge the current concept of the anatomy of the nerve. The vocal folds mobility should be examined routinely before surgery in patients undergoing thyroid operation.