Prospective study of postoperative complications after total thyroidectomy for multinodular goiters by surgeons with experience in endocrine surgery

Do extremely large goiters carry a higher risk of malignancy or complications? A case control study

INTRODUCTION

The definition of thyroid goiter remains ambiguous, yet size may impact both malignancy rate and surgical complications' rate.

METHODS

All patients with thyroid goiter who underwent thyroidectomy between 1/2015-1/2023 were included. Goiter was defined as lobe ≥4 cm. For analysis purpose, goiters measuring 4-8 cm and ≥8 cm were defined as large and extremely large goiters, respectively. For malignancy definition, tumor<1 cm in their largest diameter were excluded from study. Collected data included demographics, cytology, histology and postoperative complication.

RESULTS

144 goiters from 111 patients were included. The most common indication for surgery was symptoms (55 %). Compared with large goiter, extremely large goiters demonstrated a trend for tracheal narrowing on pre-operative CT findings (23 % vs. 45 %, p = 0.07 respectively). Overall differentiated thyroid carcinoma (DTC) rate was 17 % (25/144) without statistical difference between groups (p = 0.89). Within goiters with pre-operative benign cytology, the DTC rate was 17 % (7/43). Follicular variant of papillary thyroid cancer was the most common type for both groups. Nodular hyperplasia was significantly associated with extremely large goiters (53 % vs. 73 %, p = 0.03). No significant difference was found in transient hypocalcemia (48 % [15/31] vs. 41 % [5/12], p = 0.6) and other complications' rate between extremely large goiters and the control group.

CONCLUSION

When discussing management options for patients with goiters, the size of the goiter should not regarded as a higher risk for complications or malignancy, yet the relatively high malignancy rate found should be taken under consideration for resection.

Incidence of Post-Thyroidectomy Hypoparathyroidism and Associated Preoperative and Intraoperative Risk Factors

INTRODUCTION

Thyroidectomy technique and extent are related to parathyroid injury and hypoparathyroidism. Total thyroidectomy is one of the most commonly performed endocrine surgeries, and the majority of patients recover completely without any complications. However, persistent hypoparathyroidism is the most prevalent long-term consequence following total thyroidectomy. While it is seldom deadly, it can cause severe morbidity for the patient and raise healthcare expenses.

METHODS

This retrospective cohort study was conducted at King Abdulaziz Medical City, Jeddah, Saudi Arabia. We included all confirmed thyroid cancer cases that underwent thyroidectomy with or without neck dissection between July 2016 and August 2022. The data was collected from a chart review of the electronic medical record system (BEST-care), and a data collection sheet was utilized. SPSS version 26 was used to analyze the data.

RESULTS

A total of 192 patients undergoing thyroid surgery were enrolled. One hundred forty-three (74.5%) were females and the mean age of participants was 45.29 ± 16.88 years. Most patients, 170 (88.5%), had a papillary histological type, and total thyroidectomy was performed in 150 (78.1%). A significant association was found between the type of surgery and postoperative hypoparathyroidism (p=<0.05*). In addition, hypocalcemia was seen in 147 (76.6%) of the patients. Postoperative hypoparathyroidism was significantly higher among patients who had asymptomatic postoperative hypocalcemia and those who received IV calcium gluconate (p=<0.05*). Moreover, postoperative hypocalcemia, hypomagnesemia, and hyperphosphatemia were significantly associated with postoperative hypoparathyroidism (p=<0.05*).

CONCLUSION

The incidence of postoperative hypoparathyroidism is significantly higher among patients who underwent total thyroidectomy and had a normal level of preoperative parathyroid hormone (PTH) and magnesium (Mg) levels. Identifying these factors is a crucial step to minimize the occurrence of such complications.

Outcomes and predictors of complications of thyroidectomy in a scarce resource setting: Retrospective cross-sectional study

BACKGROUND

Outcomes and predictors of complications of thyroidectomy are diverse and have been extensively studied, but data from our country and other African countries with high disease burdens are limited.

OBJECTIVE

To evaluate the outcomes and predictors of complications of thyroidectomy among operated patients.

METHOD

Single institution retrospective cross-sectional study was conducted by reviewing charts from 365 patients who had undergone thyroidectomy on an elective basis between March 2018-February 2022. All patients who were admitted and underwent thyroidectomy were included in this study. Bivariate and multivariate logistic regressions were used to identify risk factors. P-value <0.05 was considered statistically significant.

RESULT

Overall, post-thyroidectomy complications occurred in 17 % of the cases. The two most common complications were hypocalcemia and voice change; the latter being due to injury of either external branch of superior laryngeal nerve or recurrent laryngeal nerve with an incidence of 4.9 % and 2.5 % respectively. Thyroidectomy performed by surgical residents and having total thyroidectomy were significantly associated with overall complications of thyroidectomy. Total thyroidectomy was found to be a risk factor for postoperative hypocalcemia (AOR = 12.24 (95%CI: 4.53, 19.65); P = 0.02). Younger age of the patient (AOR =0.3(95%CI, 0.12,0.51)) and prolonged duration of presentation (AOR = 2.53(95%CI, 1.17,7.76)) were detected predictors of voice change due to injury of either external branch of superior laryngeal nerve or recurrent laryngeal nerve.

CONCLUSION

The rate of thyroidectomy complications is relatively similar to other studies. In this study demographic and clinical factors associated with increased risk of complications after thyroid surgery were identified. This information will be useful for educating patients about the risks of thyroid surgery.

Comparison of indocyanine green angiography vs intraoperative parathyroid hormone in early prediction of risk of post-thyroidectomy hypocalcemia: a prospective cohort study

Introduction

Indocyanine green (ICG) angiography is the 'real-time intraoperative imaging' technique used to reduce the chances of hypoparathyroidism in post-thyroidectomy patients. In our study, the authors predicted the risk of early post-thyroidectomy hypocalcemia by intraoperative evaluation of parathyroid gland perfusion by ICG angiography.

Materials and methods

In patients who underwent total thyroidectomy, ICG angiography was done using the SPY PHI imaging system (Stryker). Post-thyroid specimen removal, scoring of parathyroids was done in spy contrast mode. All 4 or <4 visualized parathyroids were scored for vascularity with the highest score of 8. Serum ionized calcium was done 6 h postsurgery and on the morning and evening of postoperative days 1 and 2. Calcium supplements were given to only those who developed clinical or severe biochemical hypocalcemia.

Results

Out of 60, postoperative hypocalcemia was noted in 41 patients. Total ICG score ≤5 was seen in 34 patients, out of which 28 developed postoperative hypocalcemia showing PPV 82.3% and diagnostic accuracy of 68.3% while iPTH (4.28 pmol/l) showed PPV 76.7 and diagnostic accuracy 70 %. In eight patients, none of the glands was scored as 2 (White) and all these patients developed hypocalcemia requiring calcium infusion.

Conclusion

The absence of visualization of at least 1 well-perfused (score 2) gland on ICG angiography is highly predictive of hypocalcemia and the majority of patients with total ICG score ≤5 developed hypocalcemia in the immediate postoperative period. ICG is a good predictor of the absence of hypoparathyroidism after thyroidectomy and is comparable to iPTH in the prediction of post-thyroidectomy hypocalcemia.

Total Number of Identified Parathyroid Glands During Total Thyroidectomy and Its Relation to Postoperative Hypoparathyroidism

OBJECTIVES

To evaluate the correlation between the intraoperative number of identified parathyroid glands (PGs) and the risk of developing hypoparathyroidism postoperatively. Also, to determine the risks and prognostic factors in patients with postoperative hypoparathyroidism.

METHODS

A retrospective study of 499 patients who underwent total thyroidectomy at two tertiary care institutions, King Saud University Medical City (KSUMC) and King Fahad Medical City (KFMC) in Riyadh, Saudi Arabia was included. Individual demographic characteristics with detailed clinical information were recorded, focusing mainly on operative reports for a total number of identified PGs intraoperatively and investigating the risk of developing hypoparathyroidism postoperatively. Factors such as age, gender, comorbidity, and number of excised and reimplanted parathyroid glands were investigated to determine the risks and prognostic factors in patients with postoperative hypoparathyroidism.

RESULTS

The findings from the analysis showed that the number of identified PGs intraoperatively had a positive correlation with a higher postoperative risk of developing hypoparathyroidism. For zero, one, two, three, and four identified PGs, the risk of hypoparathyroidism in one-hour parathyroid hormone level postoperative was 6.6%, 7.3%, 34.4%, 34.4%, and 17.2% respectively.

CONCLUSION

The greater the number of identified PGs intraoperatively, the less likely it was to prevent inadvertent hypoparathyroidism post-total thyroidectomy.

Thyroidectomy With or Without Nerve Identification: A Personal Experience and Technique

INTRODUCTION

Careful and precise dissection of the gland, away from the typical trajectory of the recurrent and external laryngeal nerves, poses a minimal or similar risk of nerve injuries compared to directly visualizing and identifying the nerves.

MATERIALS AND METHODS

In a randomized controlled study involving 150 patients with various thyroid disorders who underwent different surgical procedures (total, near total, and hemi thyroidectomy), the patients were randomly assigned into two groups using a coin toss. The first group (G1) consisted of 75 patients who underwent thyroidectomy with nerve visual identification, while the second group (G2) comprised 75 patients without the requirement of nerve visualization. The aim was to determine the method with a lower risk of complications.

RESULTS

The incidence of external laryngeal nerve palsy (ELNP) was found to be higher in G1 patients compared to G2 patients (5.3% vs 2%), while no cases of permanent recurrent laryngeal nerve (RLN) palsy were observed in either group. The frequency of total nerve injury was higher in G1, with 14 patients (10.2%), compared to G2, with eight patients (5.3%). However, there was no significant association between nerve identification and the rate of nerve injury (P value = 0.452). Among the different surgical procedures, total thyroidectomy for toxic goiter was the most common operation associated with transient external laryngeal nerve (TELN) injury and permanent external laryngeal nerve (PELN) injury.

CONCLUSION

 By employing meticulous dissection techniques in proximity to the thyroid capsule, experienced surgeons can effectively reduce the risk of nerve injury, even in the absence of direct nerve visualization.

US Features of the Parathyroid Glands: An Intraoperative Surgical Specimen Study

Purpose

This study aimed to evaluate the US features of the parathyroid glands (PTGs) using surgical specimens of normal PTGs obtained during thyroid surgery.

Materials and Methods

This study included 34 normal PTGs from 17 consecutive patients who underwent thyroid surgery between December 2020 and March 2021. All normal PTGs were histologically confirmed by intraoperative frozen-section biopsy for autotransplantation. Surgically resected parathyroid specimens were scanned in sterile normal saline using high-resolution US prior to autotransplantation. The US features of echogenicity (hyperechogenicity or hypoechogenicity), echotexture (homogeneous or heterogeneous), size, and shape (ovoid or round) were retrospectively evaluated. The echogenicity of the three PTGs was compared with that of the thyroid parenchyma of the resected thyroid specimens in two patients.

Results

All PTGs showed hyperechogenicity similar to that of gauze soaked in normal saline. Homogeneous hyperechogenicity was observed in 32/34 (94.1%) patients, and the echogenicity of the three PTGs was hyperechoic compared with that of the thyroid parenchyma. The long diameter of the PTGs ranged from 5.1 mm to 9.8 mm (mean, 7.1 mm) and the shape of the PTGs was ovoid in 33/34 (97.1%) patients.

Conclusion

The echogenicity of normal PTG specimens was consistently hyperechoic, and the small ovoid homogeneously hyperechoic structure was a characteristic US feature of the PTGs.

Biological behavior of familial papillary thyroid microcarcinoma: Spanish multicenter study

PURPOSE

Familial papillary thyroid microcarcinoma (FPTMC) can present a more aggressive behavior than the sporadic microcarcinoma. However, few studies have analyzed this situation. The objective is to analyze the recurrence rate of FPTMC and the prognostic factors which determine that recurrence in Spain.

METHODS

Spanish multicenter longitudinal analytical observational study was conducted. Patients with FPTMC received treatment with curative intent and presented cure criteria 6 months after treatment. Recurrence rate and disease-free survival (DFS) were analyzed. Two groups were analyzed: group A (no tumor recurrence) vs. group B (tumor recurrence).

RESULTS

Ninety-four patients were analyzed. During a mean follow-up of 73.3 ± 59.3 months, 13 recurrences of FPTMC (13.83%) were detected and mean DFS was 207.9 ± 11.5 months. There were multifocality in 56%, bilateral thyroid involvement in 30%, and vascular invasion in 7.5%; that is to say, they are tumors with histological factors of poor prognosis in a high percentage of cases. The main risk factors for recurrence obtained in the multivariate analysis were the tumor size (OR: 2.574, 95% CI 1.210-5.473; p = 0.014) and the assessment of the risk of recurrence of the American Thyroid Association (ATA), both intermediate risk versus low risk (OR: 125, 95% CI 10.638-1000; p < 0.001) and high risk versus low risk (OR: 45.454, 95% CI 5.405-333.333; p < 0.001).

CONCLUSION

FPTMC has a recurrence rate higher than sporadic cases. Poor prognosis is mainly associated with the tumor size and the risk of recurrence of the ATA.

Analysis of Risk Factors for Phonation Disorders after Thyroid Surgery

Phonation disorders after thyroidectomy are among the most common complications and occur as a result of recurrent laryngeal nerve (RLN) injury. The multivariate analysis of risk factors for phonation disorders after thyroidectomy was assessed. A group of 830 patients with 1500 RLNs at risk of injury during thyroidectomy were analyzed retrospectively. The impact of the method of RLN identification, age, sex, BMI, kind of thyroid surgery, pathology, surgeon’s experience and thyroid volume on vocal cord paralysis was analyzed. We found that the retrosternal goiter and the volume above 100 mL were the most important risk factors for both transient and permanent paralysis. Thyroid cancer had a statistically significant impact on the increase in permanent paralysis, while this indication had practically no impact on transient paralysis. Among patients over 65 years with obesity, the probability of transient complications approximately doubled, with no effect on the permanent paralysis. Men were approximately 1.7 times more likely to develop any type of phonation disorder. Secondary operations more than doubled the risk of transient and permanent vocal cord paralysis. Thyroidectomy with only visual RLN identification was associated with a risk of both transient and permanent vocal cord paralysis almost two times higher, compared to neuromonitoring.

Case Control Study of Risk Factors for Occurrence of Postoperative Hematoma After Thyroid Surgery: Ten Year Analysis of 6938 Operations in a Tertiary Center in Serbia

BACKGROUND

Post-thyroidectomy bleeding is rare, but potentially life-threatening complication. Early recognition with immediate intervention is crucial for the management of this complication. Therefore, it is very important to identify possible risk factors of postoperative hemorrhage as well as timing of postoperative hematoma occurrence.

METHODS

Retrospective review of 6938 patients undergoing thyroidectomy in a tertiary center in a ten year period (2009-2019) revealed 72 patients with postoperative hemorrhage requiring reoperation. Each patient who developed postoperative hematoma was matched with four control patients that did not develop postoperative hematoma after thyroidectomy. The patients and controls were matched by the date of operation and surgeon performing thyroidectomy.

RESULTS

The incidence of postoperative bleeding was 1.04%. On univariate analysis older age, male sex, higher BMI, higher ASA score, preoperative use of anticoagulant therapy, thyroidectomy for retrosternal goiter, larger thyroid specimens, larger dominant nodules, longer operative time, higher postoperative blood pressure and the use of postoperative subcutaneous heparin were identified as risk factors for postoperative bleeding. Sixty-nine patients (95.8%) bled within first 24 h after surgery.

CONCLUSION

The rate of postoperative bleeding in our study is consistent with recent literature. Male sex, the use of preoperative anticoagulant therapy, thyroidectomy for retrosternal goiter and the use of postoperative subcutaneous heparin remained statistically significant on multivariate analysis (p < 0.001). When identified, these risk factors may be an obstacle to the outpatient thyroidectomy in our settings.

Indocyanine Green Angiography of Parathyroid Glands versus Intraoperative Parathyroid Hormone Assay as a Reliable Predictor for Post Thyroidectomy Transient Hypocalcemia

BACKGROUND

Prediction of postoperative hypocalcemia is a fundamental issue in thyroidectomy. Indocyanine green (ICG) angiography of parathyroid glands is a feasible method to detect the perfusion of parathyroid glands and predict postoperative hypocalcemia.

MATERIALS AND METHODS

A prospective observational study was conducted at Ain Shams University Hospitals between April 2018 and April 2021. The included cases of total thyroidectomy underwent intraoperative ICG fluorescence angiography to identify the four parathyroid glands and score each gland according to the viability. Patients in which less than four glands were identified were excluded. Intraoperative intact parathyroid hormone (ioPTH) level assay was also measured to compare with ICG in predicting postoperative transient hypocalcemia.

RESULTS

A total of 134 cases underwent total thyroidectomy during the study period. We could identify the four parathyroid glands in 90 patients, including them in the study. We had postoperative hypocalcemia in 28 cases (31.1%). The diagnostic accuracy of ICG angiography and ioPTH level assay was high and almost similar (82.22% versus 87.78%). Both were higher than the surgeons' diagnostic accuracy of visual inspection (62.22%).

CONCLUSIONS

ICG angiography of the parathyroid gland is a safe, reliable predictor for postoperative transient hypocalcemia with a high and almost similar accuracy compared to intraoperative parathyroid hormone level.

Left Nonrecurrent Laryngeal Nerve with Situs Inversus Totalis

The recurrent laryngeal nerve (RLN), a branch of the vagus nerve, supplies the motor and sensation function of the larynx. Generally, RLN detours around the right subclavian artery on the right side and the aortic arch on the left side. In a rare anatomical variant, called nonrecurrent laryngeal nerve (NRLN), the nerve takes an aberrant path rather than descending into the thorax as usual. First reported in 1823, NRLN is a rare anomaly arising almost exclusively on the right side, reported in 0.3–0.8% of people, and associated with vascular anomalies of embryonic aortic arch development. The atypical vascular pattern of aberrant subclavian artery (arteria lusoria) running behind the trachea and esophagus allows the vagus nerve to pass freely, which then directly branches out as NRLN at the level of the larynx. On the other hand, cases of left NRLN, only reported in 0.004% of people, are all accompanied by significant pathologies such as situs inversus totalis with opposite vascular pattern of left aberrant subclavian artery. This rare anatomical variation is clinically important, as NLRN is a major risk factor for iatrogenic injury during thyroidectomy, parathyroidectomy, and other invasive procedures in the head and neck region.

Ultrasound Identification of Normal Parathyroid Glands

Ultrasound has become indispensable for identification of thyroid and parathyroid pathology, but normal parathyroid glands have historically been considered too subtle to accurately detect. Inability to identify and protect parathyroid glands can result in hypoparathyroidism and hypocalcemia during thyroidectomy surgery as well as misinterpretation of central neck structures in the postoperative neck. Advances in ultrasound resolution have opened the door to novel applications for this technology. In this study, we report the first surgeon-performed ultrasound identification of normal parathyroid glands in a series of 6 patients, confirmed by parathyroid tissue aspirate or parathyroid autofluorescence. Recognition of normal parathyroid glands using ultrasound can be valuable for preventing postoperative hypoparathyroidism and in increasing the accuracy of postsurgical ultrasound surveillance.

Varied Recurrent Laryngeal Nerve Course Is Associated with Increased Risk of Nerve Dysfunction During Thyroidectomy: Results of the Surgical Anatomy of the Recurrent Laryngeal Nerve in Thyroid Surgery Study, an International Multicenter Prospective Anatomic and Electrophysiologic Study of 1000 Monitored Nerves at Risk from the International Neural Monitoring Study Group

Background: The recurrent laryngeal nerve (RLN) can be injured during thyroid surgery, which can negatively affect a patient's quality of life. The impact of intraoperative anatomic variations of the RLN on nerve injury remains unclear. Objectives of this study were to (1) better understand the detailed surgical anatomic variability of the RLN with a worldwide perspective; (2) establish potential correlates between intraoperative RLN anatomy and electrophysiologic responses; and (3) use the information to minimize complications and assure accurate and safe intraoperative neuromonitoring (IONM). Methods: A large international registry database study with prospectively collected data was conducted through the International Neural Monitoring Study Group (INMSG) evaluating 1000 RLNs at risk during thyroid surgery using a specially designed online data repository. Monitored thyroid surgeries following standardized IONM guidelines were included. Cases with bulky lymphadenopathy, IONM failure, and failed RLN visualization were excluded. Systematic evaluation of the surgical anatomy of the RLN was performed using the International RLN Anatomic Classification System. In cases of loss of signal (LOS), the mechanism of neural injury was identified, and functional evaluation of the vocal cord was performed. Results: A total of 1000 nerves at risk (NARs) were evaluated from 574 patients undergoing thyroid surgery at 17 centers from 12 countries and 5 continents. A higher than expected percentage of nerves followed an abnormal intraoperative trajectory (23%). LOS was identified in 3.5% of NARs, with 34% of LOS nerves following an abnormal intraoperative trajectory. LOS was more likely in cases of abnormal nerve trajectory, fixed splayed or entrapped nerves (including at the ligament of Berry), extensive neural dissection, cases of cancer invasion, or when lateral lymph node dissection was needed. Traction injury was found to be the most common form of RLN injury and to be less recoverable than previous reports. Conclusions: Multicenter international studies enrolling diverse patient populations can help reshape our understanding of surgical anatomy during thyroid surgery. There can be significant variability in the anatomic and intraoperative characteristics of the RLN, which can impact the risk of neural injury.

Changes in Thyrotropin Receptor Antibody Levels Following Total Thyroidectomy or Radioiodine Therapy in Patients with Refractory Graves' Disease

Background: The actions of thyrotropin-binding inhibitory immunoglobulins (TBIIs) against thyrotropin receptors in thyroid follicular cells have been studied as important etiological factors in Graves' disease (GD). The purpose of this study was to investigate changes in the TBII levels of patients undergoing total thyroidectomy (TTx) or radioactive iodine (RAI) therapy for GD refractory to antithyroid drugs (ATDs). Methods: We enrolled patients who underwent TTx or RAI for GD with previous ATD use between January 2011 and December 2017 at the Samsung Medical Center in Seoul, Korea. Thorough retrospective reviews of medical records were performed in 130 patients. Results: Patients with goiter, ophthalmopathy, high levels of TBIIs, and high doses of ATDs received TTx. Elderly patients with arrhythmia received RAI. We observed that TBII levels continued to decrease after TTx. On the contrary, TBIIs initially increased for 138 days (estimated median time) and then decreased slowly after RAI. A faster decline in TBII levels was observed in the TTx group than in the RAI group (p < 0.001). The estimated median time for TBIIs to decrease below 4.5 IU (3 × upper normal limit, which is known to be a risk factor for fetal hyperthyroidism) was 318 days in the TTx group and 659 days in the RAI group, respectively. In the RAI group, high levels of TBII (>4.5 IU/L) were present in 70 (82%) at 6 months, 57 (67%) at 1 year, and 3 (3%) at 2 years. In the TTx group, rapid decreases in TBII levels were observed in younger patients and those with lower baseline TBII levels. In the RAI group, smaller thyroid volume was correlated with more rapid decrease in TBII levels. Conclusions: The changes in TBII levels following TTx or RAI were different in patients with refractory GD. When deciding on TTx or RAI, this difference should be considered with patient age, severity of hyperthyroidism, goiter, ophthalmopathy, and future pregnancy plans (for young female patients).

Proposal of New Key Step in Lateral Approach Thyroidectomy in Light of Comparison of Surgical Outcomes of Medial versus Lateral Approach Thyroidectomy: A Randomised Controlled Study

Objective

Thyroid surgery has travelled a long path, from a surgery which once was considered deemed to fail and even led to death, to the current time when newer techniques are being tested to make the incision smaller and smaller. The aim of our study is to give a precise detailed stepwise description of medial and lateral surgical approach with the anatomical basis and to compare their feasibility and safety.

Methods

104 cases presenting with thyroid swelling in the Department of Otorhinolaryngology, Assam Medical College Dibrugarh from January 1, 2019, to December 31, 2019, were selected and randomisation was done based on day of admission from OPD. Basic demographic data, preoperative diagnosis, operative time, blood loss, need for transection of strap muscles, and complications were recorded.

Result

The distribution of thyroid cases according to age ranged from 17 to 81 years. The prevalence of thyroid disorders was the highest (37.5%) in the age group of 31-40 yrs. Of a total of 104 thyroid cases, 49 were colloid goitre, 24 were multinodular goitre, 9 were follicular neoplasm category 4, 4 were papillary thyroid carcinoma, 2 were follicular neoplasm category 3, and 3 were follicular neoplasm category 5.

Conclusion

Out of the two approaches, lateral approach thyroidectomy showed better results with fewer complications. A single structure (superior belly of omohyoid) can be used as a guide to preserving all vital structures related to the thyroid gland.

Feasibility and Safety of Outpatient Thyroidectomy: A Narrative Scoping Review

BACKGROUND

Outpatient thyroid surgery is gaining popularity as it can reduce length of hospital stay, decrease costs of care, and increase patient satisfaction. There remains a significant variation in the use of this practice including a perceived knowledge gap with regards to the safety of outpatient thyroidectomies and how to go about implementing standardized institutional protocols to ensure safe same-day discharge. This review summarizes the information available on the subject based on existing published studies and guidelines.

METHODS

This is a scoping review of the literature focused on the safety, efficacy and patient satisfaction associated with outpatient thyroidectomies. The review also summarizes and editorializes the most recent American Thyroid Association guidelines.

RESULTS

In total, 11 studies were included in the analysis: 6 studies were retrospective analyses, 3 were retrospective reviews of prospective data, and 2 were prospective studies. The relative contraindications to outpatient thyroidectomy have been highlighted, including: complex medical conditions, anticipated difficult surgical dissection, patients on anticoagulation, lack of home support, and patient anxiety toward an outpatient procedure. Utilizing these identified features, an outpatient protocol has been proposed.

CONCLUSION

The salient features regarding patient safety and selection criteria and how to develop a protocol implementing ambulatory thyroidectomies have been identified and reviewed. In conclusion, outpatient thyroidectomy is safe, associated with high patient satisfaction and decreased health costs when rigorous institutional protocols are established and implemented. Successful outpatient thyroidectomies require standardized preoperative selection, clear discharge criteria and instructions, and interprofessional collaboration between the surgeon, anesthetist and same-day nursing staff.

Methylene Blue Spray for Identification of Parathyroid Glands During Thyroidectomy

Background: Hypocalcaemia is a common delayed complication after thyroidectomy. Several studies have identified risk factors and possible ways to prevent post-thyroidectomy hypocalcemia. The purpose of our study is to evaluate the effectiveness of an intraoperative methylene blue spray to identify parathyroid glands during thyroidectomy.

Materials and methods: We have conducted a prospective non-randomised cohort study with 50 patients who underwent hemithyroidectomy or total thyroidectomy between January 2019 and January 2020. During thyroidectomy, 1 ml (10 mg) of 1% methylene blue was sprayed over the parathyroid glands, the inferior thyroid artery, and the recurrent laryngeal nerve.

Results: Our study included 50 patients with ages ranging from 18 to 80 years old (43.0±9.7). We were able to identify the parathyroid glands with the intraoperative methylene blue spray in 82% of cases, with no significant postoperative complications.

Conclusion: Our study concludes that the methylene blue spray is a safe, feasible, and effective technique to identify parathyroid glands.

To explore the risk factors and preventive measures affecting the treatment of retrosternal goiter: An observational study

The definition of substernal goiter (SG) is based on variable criteria, leading to considerable variations in the reported incidence (from 0.2% to 45%). The peri- and postoperative complications are higher in total thyroidectomy (TT) for SG than that for cervical goiter. This study aimed to evaluate the preoperative risk factors associated with postoperative complications.From 2002 to 2014, 142 (8.5%; 98 women and 44 men) of the 1690 patients who underwent TT had a SG. We retrospectively evaluated the following parameters: sex, age, histology, pre- and retro-vascular position, recurrence, and extension beyond the carina. These parameters were then related to the postoperative complications: seroma/hematoma, transient and permanent hypocalcemia, transient and permanent laryngeal nerve palsy, and the length of surgery. The results were further compared with a control group of 120 patients operated on in the same period with TT for cervical goiter (CG).Statistical analysis (Student t test and Fisher exact test) indicated an association between recurrence and extension beyond the carina with all postoperative complications. The group that underwent TT of SG showed a statistically significant higher risk for transient hypocalcemia (relative risk = 1.767 with 95% confidence interval: 1.131-2.7605, P = .0124, and need to treat = 7.1) and a trend toward significance for transient recurrent laryngeal nerve palsy (relative risk = 6.7806 with 95% confidence interval: 0.8577-53.2898, P = .0696, and need to treat = 20.8) compared with the group that underwent TT of cervical goiter. The major risk factors associated with postoperative complications are recurrence and extension beyond the carina.TT is the procedure to perform in SG even if the incidence of complications is higher than cervical goiters. The major risk factors associated with postoperative complications are recurrence and extension beyond the carina.

EARLIER PREDICTION OF HYPOCALCEMIA BY POSTOPERATIVE SECOND HOUR PARATHYROID HORMONE LEVEL AFTER TOTAL THYROIDECTOMY

Context

Thyroidectomy is becoming an ambulatory surgical procedure. By predicting hypocalcemia,duration of hospital stay might decline. We tried to determine whether measuring parathormone two hours after total thyroidectomy predicts hypocalcemia.

Objective

We aimed to design a protocol for early prediction of hypocalcemia by defining PTH measurement time and cut-off value of our center.

Design

One hundred and six patients undergoing total thyroidectomy between November 2017 and October 2018 were prospectively studied.

Methods

Pregnant women, patients with renal failure, parathyroid disease, previous neck operation and thyroid malignancy requiring neck dissection were excluded from the study. Parathormone (PTH) and calcium measurement was done preoperatively and in the postoperative second hour.

Results

Group 1 consisted of 75 normocalcemic patients while group 2 had 31 hypocalcemic patients. Mean age was 45±13.1 (age range: 18-76). Female/male ratio was 82/24. While with a 8.36 pg/mL postoperative second hour PTH, hypocalcemia can be predicted with a 51.5% sensitivity and 90.7% specificity while with a PTH decline of 40.8% hypocalcemia can be diagnosed with a 83.9% sensitivity and 52% specificity.

Conclusion

Postoperative second hour PTH and PTH percentage decline can predict postoperative hypocalcemia in total thyroidectomies. Preoperative Dual-energy X-ray absorptiometry (DXA) was not found useful in hypocalcemia prediction.

Results of a randomised controlled trial between an ORC collagen hemostatic agent and a carrier-bound fibrin sealant

INTRODUCTION

Despite ongoing optimisation of surgical techniques, hemostasis continues to be a fundamental challenge in many operations today. This randomised controlled trial compared the efficacy of a new hemostatic agent made of oxidised regenerated cellulose and collagen (ORC-Coll) with that of a conventional carrier-bound fibrin sealant (CBFS).

METHODS

Hemostasis was investigated representatively in the case of post-thyroidectomy bleeding from the resection surface. To demonstrate that ORC-Coll (mediCipio® A) has at least the same hemostatic efficacy as CBFS (Tachosil®), the volume of drainage fluid at the time of drain removal was used as the primary endpoint in a non-inferiority test with a significance level of 5%. The secondary endpoints included number and size of hemostatic agents required, adhesion of the hemostatic agent to the bleeding surface, intraoperative hemostatic effect, duration of drainage and adverse events during a six-month follow-up period.

RESULTS

A total of 150 patients (ORC-Coll: 75; CBFS: 75) were included. After operation, total volume of drainage fluid was 68.20±44.56mL in the ORC group and 68.21±40.20mL in the CBFS group. The non-inferiority of ORC-Coll compared to CBFS with regard to hemostatic efficacy was shown at a significance level of 5%. The results demonstrated effectiveness in achieving hemostasis without adverse events.

CONCLUSIONS

ORC-Coll is an effective hemostatic agent and barrier sealant without blood components, which ensures reliable prevention of intra- and postoperative bleeding. With use of the new technique, any risks associated with the use of human blood components are a priori eliminated.

Outcomes After Urgent Thyroidectomy Following Rapid Control of Thyrotoxicosis in Graves' Disease are Similar to Those After Elective Surgery in Well-Controlled Disease

BACKGROUND

Surgery for Graves' disease (GD) is usually performed after adequate control with medical treatment. Occasionally, rapid pre-operative optimization is required. The primary objective was to compare the outcomes of patients undergoing elective surgery for well-controlled GD with those undergoing rapid pre-operative treatment. We also propose a formal treatment protocol for future use.

METHODS

A retrospective cohort study in a tertiary referral centre included 247 patients with well-controlled GD undergoing elective surgery and 19 patients with poorly controlled disease undergoing surgery after rapid optimization. The latter group did not respond well to thionamides (carbimazole and/or propylthiouracil) or had intolerance or side effects to thionamides and were treated with a range of non-thionamide drugs, including Lugol's iodine, cholestyramine, beta blockers and steroids (with or without thionamides), and closely monitored for 1-2 weeks before surgery. Outcome measures included thyroid storm, hypoparathyroidism and recurrent laryngeal nerve palsy.

RESULTS

In total, 266 patients with male-to-female ratio of 1:6 and median (interquartile range) age of 39 (31-51) were included. Overall, long-term recurrent laryngeal palsy and hypoparathyroidism occurred in 1 (0.38%) and 13 (4.9%) patients, respectively. No patient had thyroid storm. There was no significant difference in hypoparathyroidism (p = 1), vocal cord palsy (p = 0.803) and post-operative bleeding (p = 0.362), between elective surgery and rapid optimization groups.

CONCLUSION

Rapid pre-operative treatment is effective, safe and is associated with similar outcomes compared to usual treatment. A rapid pre-operative optimization protocol is proposed.

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

OBJECTIVE

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Energy vessel sealant devices are associated with decreased risk of neck hematoma after thyroid surgery

Postoperative neck hematomas following thyroidectomy occur in up to 6.5% of cases. It is unclear whether the use of energy vessel sealant devices effects the rate of PNH. We hypothesized use of an EVSD to be associated with decreased risk of PNH in patients undergoing thyroidectomy. The 2016-2017 American College of Surgeons Thyroidectomy database was queried for patients undergoing thyroidectomy with and without EVSDs. A multivariable logistic regression analysis was performed to evaluate for risk of PNH. From 11,355 patients undergoing thyroidectomy, an EVSD was used for 7460 (65.7%) patients. Age distribution was similar between the two groups (52 vs. 53-years old, p = 0.467). Compared to patients without EVSD used, patients with EVSD used had higher rates of comorbid hypertension (40.6% vs. 34.8%, p < 0.001) and diabetes (14.2% vs. 11.5%, p < 0.001); however, a lower rate of PNH (1.4% vs. 2.4%, p < 0.001). After adjusting for known risk factors for PNH including age, prior neck surgery, and comorbidities, EVSD use was associated with a decreased risk of PNH (OR 0.453, 95% CI 0.330-0.620, p < 0.001). The strongest associated risk factors for PNH were hypertension (OR 1.823, 95% CI 1.283-2.591, p = 0.001) and toxic goiter (OR 1.837, 95% CI 1.144-2.949, p = 0.012). When compared to standard vessel ligation, EVSD use was associated with a lower risk of PNH in patients undergoing thyroidectomy. The strongest associated risk factor for PNH was toxic goiter. Future prospective research is needed to confirm these findings and if corroborated, then increased use of an EVSD should be employed.

Positive central lymph-nodes are underdiagnosed in patients with Bethesda V cytology in an endemic goiter region

Background

Fine needle aspiration (FNA) is a significant diagnostic procedure for detecting malignancy in patients with nodular thyroid disease. A high proportion of patients with cytological diagnosed follicular neoplasia (Bethesda IV and V) ultimately have thyroid cancer. The aim of this study was to evaluate the incidence of preoperatively undiagnosed central lymph node metastasis in patients with multinodular goiter (MNG).

Methods

Patients who underwent FNA and were classified as Bethesda IV/V were included. Applying a radical approach, all patients underwent (hemi)thyroidectomy and prophylactic unilateral central neck dissection.

Results

During our study period 2009-2013, 60 patients (19.7%) were classified as Bethesda IV and 21 (6.9%) Bethesda V. Final histopathological results revealed malignancy in 35 (43.2%) of 81 Bethesda IV/V nodules. Of the nodules classified as Bethesda IV, 20 (33.3%) showed malignancy in the final histology. Ten patients (16.7%) had papillary micro-carcinoma (mPTC, <10 mm), 4 (6.6%) PTC and 6 (10%) follicular thyroid cancer. Fifteen of 21 (71.4%) Bethesda V nodules were revealed as PTC of whom seven (33.3%) patients also had lymph-node metastases.

Conclusions

While 33.3% of the patients with PTC, preoperatively classified as Bethesda V, had previously undetected positive lymph-nodes, only one patient with Bethesda IV had lymph-node metastasis.

Early detection of recurrent laryngeal nerve damage using intraoperative nerve monitoring during thyroidectomy

Objective

This study aimed to investigate risk factors for early recurrent laryngeal nerve (RLN) damage during thyroid surgery with intraoperative nerve monitoring (IONM) technology to avoid RLN damage during surgery.

Methods

Data were retrospectively collected from 93 patients who underwent thyroidectomy at Beijing Hospital. All operations were performed by the same surgeon. A four-step procedure of IONM was used during the operation to determine the amplitude and latency of the RLN.

Results

The majority (51.6%) of patients who underwent surgery had thyroid carcinoma. Lymphadenectomy was carried out in 55 (59.1%) patients. A strong association was observed between temporary injury of the RLN and the extent of resection. The risk of temporary injury of the RLN during total thyroidectomy was three times that during right thyroid lobectomy (odds ratio = 3.13). The results of left lobectomy were also different from those of right lobectomy because the RLN was more likely to be damaged during left lobectomy.

Conclusions

Assessment of the amplitude and latency of the RLN can help to assess the integrity of the RLN. The extent of resection affects the functional integrity of the RLN.

[Update of the S2k guidelines : Surgical treatment of benign thyroid diseases]

Thyroid resections represent one of the most common operations with 76,140 interventions in the year 2016 in Germany (source Destatis). These are predominantly benign thyroid gland diseases. Recommendations for the operative treatment of benign thyroid diseases were last published by the CAEK in 2010 as S2k guidelines (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e.V. [AWMF] 003/002) against the background of increasingly more radical resection procedures. Hemithyroidectomy and thyroidectomy are routinely performed for benign thyroid disease in practice. The operation-specific risks show a clear increase with the extent of the resection. Therefore, weighing-up of the risk-indications ratio between unilateral lobectomy or thyroidectomy necessitates an independent evaluation of the indications for both sides. This principle in particular has been used to update the guidelines. In addition, the previously published recommendations of the CAEK for correct execution and consequences of intraoperative neuromonitoring were included into the guidelines, which in particular serve the aim to avoid bilateral recurrent laryngeal nerve paralysis. Moreover, the recommendations for the treatment of postoperative complications, such as hypoparathyroidism and postoperative infections were revised. The updated guidelines therefore represent the current state of the science as well as the resulting surgical practice.

TOTAL THYROIDECTOMY FOR MALIGNANCY - IS CENTRAL NECK DISSECTION A RISK FACTOR FOR RECURRENT NERVE INJURY AND POSTOPERATIVE HYPOCALCEMIA? A TERTIARY CENTER EXPERIENCE IN ROMANIA

Introduction

Surgery for thyroid cancer carries a higher risk of morbidity given the region's complicated anatomy, the setting of malignancy and extent of the surgery.

Aim

To investigate the rate of complications related to the recurrent nerve and parathyroid glands lesions in patients with thyroid carcinoma that undergo thyroid surgery and lymph node dissection.

Patients and Methods

The data of 71 patients who underwent total thyroidectomy and 19 patients who underwent total thyroidectomy and central neck dissection with various associated neck dissection techniques were investigated using appropriate statistical tests.

Results

As expected, the rate of recurrent nerve injury observed in the neck dissection group was higher than in the total thyroidectomy group (15.7% vs. 2.8%, p=0.05). As for postoperative hypocalcemia, the rate observed in the neck dissection group, both for postoperative day 1 (p<0.0001) and day 30 (p=0.0003) was higher than in the total thyroidectomy group (68.4% vs. 19.7% postoperative day 1, 31.5% vs. 4.2% postoperative day 30).

Conclusions

The risk of morbidity concerning the recurrent nerve injury and postoperative hypoparathyroidism increases with the extent of surgery. Extensive surgery may achieve proper oncologic outcomes but increases the risk of postoperative morbidity and decreases quality of life. In deciding for extensive surgery, both patient and medical team need to understand these risks.

Postoperative hypocalcemia: analysis of factors influencing early hypocalcemia development following thyroid surgery

BACKGROUND

Early Hypocalcemia is the most frequent complication after thyroid surgery. Several studies have tried to identify factors (patient caracteristics or surgical technique variations) affecting hypocalcemia following thyroid surgery. This studiy evaluates the role of several factors in postoperative hypocalcemia development.

METHODS

A retrospective study conducted on 2108 patients that underwent thyroid surgery in a single center (1669 women and 439 men). Postoperative early hypocalcemia was defined as serum calcium levels lower than 8,0 mg/dl measured 24 h after surgery. Following factors were evaluated in the study: sex, age, glandular hyperfunction, preoperative diagnosis, preoperative serum calcium levels, preoperative serum PTH levels, type of surgery performed (total thyroidectomy vs. lobectomy); minimally invasive video assisted thyroidectomy (MIVAT); number of parathyroid preserved in situ, postoperative serum calcium levels, changes in perioperative calcium levels (difference between preoperative values ​​and postoperative calcium levels), presence of carcinoma in the surgical specimen, presence of thyroiditis based on histopatology reports.

RESULTS

Among evaluated factors only gender and surgical procedure revealed to be significantly correlated to early hypocalcemia development. In fact female patients experienced postoperative hypocalcemia in 42% (701/1669) of cases, which was signicantly higher than the 21.4% (94/439) identified in men. We also noticed a greater hypocalcemia incidence in patient undergoing total thyroidectomy (38.8%) than in patient undergoing lobectomy group (13.8%). Early hypocalcemia development didn't appear to be related to preoperative serum calcium levels but it showed a statistically significant correlation with perioperative serum calcium level drop.

CONCLUSION

This findings suggest that sex (female gender is a strong risk factor),surgical procedure and perioperative changes in serum calcium are the only factors (among all variables examined) that influence early hypocalcemia development.

Preventive Effect of Dexamethasone Therapy on the Transient Hypoparathyroidism through Total Thyroidectomy

INTRODUCTION

This study aimed to investigate whether pre-operative dexamethasone could ameliorate transient hypoparathyroidism outcome through total thyroidectomy.

MATERIALS AND METHODS

This randomized clinical trial study was conducted on 128 patients underwent total thyroidectomy from March 2014 to April 2015. Patients were randomly assigned to two groups of experimental receiving 8 mg IV of intravenous dexamethasone (n=45) 45 min before skin incision treatment and control (n=83). After the surgery, all patients were evaluated for clinical and laboratory hypocalcaemia.

RESULTS

Post-operative transient biochemical hypoparathyroidism and hypocalcaemia did not occur more often in the control group, compared to the dexamethasone group while controlling for the baseline variables. However, there was a significant difference in phosphorus level between the dexamethasone and control groups (P=0.028). A total of 50 (39.1%) patients developed hypocalcaemia after surgery. Moreover, post-operative symptomatic hypocalcemia occurred more frequently in the control group (68%) compared to the dexamethasone group (32%); however, this difference was not statistically significant (P=0.54).

CONCLUSION

The pre-operative administration of dexamethasone reduced post-operative hypocalcemia rate. It is essential to conduct future studies with validated means for better results.

One-Hour Postoperative Parathyroid Hormone Levels Do Not Reliably Predict Hypocalcemia After Thyroidectomy

INTRODUCTION

Hypocalcemia is a well-known complication after total thyroidectomy. Studies have indicated that the presence of low postoperative parathyroid hormone (PTH) levels can predict hypocalcemia. However, definitive study designs are lacking. The aim of this study was to determine whether postoperative PTH alone can accurately predict postoperative biochemical hypocalcemia.

METHODS

Under IRB approval, a prospective study of 218 consecutive patients who underwent total or completion thyroidectomy by two surgeons between June 2014 and June 2016 was performed. Biochemical hypocalcemia was defined as ionized calcium <1.13 mmol/L or serum calcium <8.4 mg/dL at any time postoperatively. Three PTH thresholds, <10, <20 pg/mL, and >50% drop in PTH 1 h postoperatively from baseline were examined.

RESULTS

Postoperative PTH < 10 pg/mL had a sensitivity of 36.5% (95% CI 27.4-46.3%) and a specificity of 89.2% (95% CI 81.9-94.3%). Postoperative PTH < 20 pg/mL had a sensitivity of 66.4% (95% CI 56.6-75.2%) and a specificity of 67.6% (95% CI 58.0-76.2%). Postoperative PTH decrease >50% had a sensitivity of 63.4% (95% CI 53.2-72.7%) and a specificity of 72.5% (95% CI 62.5-81.0%). Across all PTH thresholds, the false-negative rate was 33.6-63.5% indicating that up to 64% of patients with a normal PTH level could have been discharged without appropriate calcium supplementation. The false-positive rate was 10.8-32.4% indicating that up to 32.4% of patients with low PTH could have been treated with calcium supplementation unnecessarily.

CONCLUSION

Following total thyroidectomy, PTH levels are unreliable in predicting hypocalcemia. Additional prospective studies are needed to understand the true utility of PTH levels post-thyroidectomy.

Network meta-analysis of topical haemostatic agents in thyroid surgery

Background

The objective of this study was to investigate the potential benefit of local haemostatic agents for the prevention of postoperative bleeding after thyroidectomy.

Methods

A systematic literature search was performed, and RCTs involving adult patients who underwent thyroid surgery using either active (AHA) or passive (PHA) haemostatic agents were included in the review. The main outcome was the rate of cervical haematoma that required reoperation. A Bayesian random-effects model was used for network meta-analysis with minimally informative prior distributions.

Results

Thirteen RCTs were included. The rate of cervical haematoma requiring reoperation ranged from 0 to 9·1 per cent, and was not reduced by haemostatic agents: AHA versus control (odds ratio (OR) 1·53, 95 per cent credibility interval 0·21 to 10·77); PHA versus control (OR 2·74, 0·41 to 16·62) and AHA versus PHA (OR 1·77, 0·12 to 25·06). No difference was observed in the time required for drain removal, duration of hospital stay, and the rate of postoperative hypocalcaemia or recurrent nerve palsy. AHA led to a significantly lower total postoperative blood loss and reduced operating time in comparison with both the control and PHA groups.

Conclusion

The general use of local haemostatic agents has not been shown to reduce the rate of clinically relevant bleeding.

Evaluation of the thyroid nodule with high-resolution ultrasonography and elastography without fine needle aspiration biopsy

INTRODUCTION

Fine needle aspiration biopsy (FNAB) is the gold standard screening technique used in the diagnostic protocol for thyroid nodules. However, it is not free of complications.

OBJECTIVE

To identify thyroid nodules in which FNAB could be avoided during the diagnostic process by means of the use of a high-resolution ultrasonography or elastography.

MATERIAL AND METHOD

A prospective, non-randomized study was carried out. Single thyroid nodules and dominant nodules of multinodular goiter were included. Patients who had undergone thyroid surgery in the past were excluded. All patients underwent a high-resolution ultrasound and elastography, and, subsequently, a FNAB. We analyzed the ultrasound variables in 2D and Doppler, followed by the elastographic variables, and the results of the FNAB according to Bethesda. To correlate the data, the nodules were classified as benign or malignant. Student's t test, the Chi-square test and a logistic regression analysis were applied for the statistical analysis.

RESULTS

A total of 221 thyroid nodules were analyzed, 32 of which were malignant (14%). The most predictive ultrasound findings of malignancy (P<.05) were a hypoechoic or complex echostructure (OR=11.832), the presence of microcalcifications (OR=9.637) and chaotic vascularization observed in the Doppler (OR=46.464). With regard to the elastography, elastographic patterns i and ii were seen to be associated with benignity (P=.0004 and P<.0001, respectively). When type i or ii elastography was combined with an ultrasound showing a non-hypoechoic nor complex echostructure, without microcalcifications nor chaotic vascularization in the Doppler ultrasound, 100% of the cases were benign with a specificity of 100% and a sensitivity of 14%.

CONCLUSIONS

The combination of a high-resolution ultrasound with an elastography makes it possible to select cases where a FNAB does not have to be performed. Cases susceptible to a periodic follow-up without the use of a FNAB are those without a hypoechoic nor complex structure, no microcalcifications, non-chaotic vascularization and a type i or ii elastography.

Hemostatic agent use in thyroid surgery: a meta-analysis

Background

The use of hemostatic agents in thyroid surgery has been widely reported in the literature. The aim of this study is to assess the safety and efficacy of hemostatic agents in comparison to conventional techniques for hemostasis by meta-analysis of the current literature.

Methods

Articles were identified from PubMed and EMBASE using the following keyword searches: "hemostatic agent and thyroid surgery" and "hemostatic agent and thyroidectomy". Outcomes included total operative time, estimated blood loss, length of hospital stay, and intraoperative and postoperative complications. Data were extracted following review of appropriate studies by two independent authors and outcome differences were calculated using analysis of variance and the Bonferroni method.

Results

Thirty-four publications were identified and 10 studies met our inclusion criteria, totaling 941 patients, 519 (55.1%) of which received a hemostatic agent during thyroid surgery. Of these patients who had hemostatic agents, 369 (71%) received a hemostatic gel and 150 (29%) received an oxidized cellulose patch. Outcome measures in each of these groups were compared with the patients receiving only conventional methods of hemostasis. The risk of hematoma formation in the hemostatic gel group was comparable to conventional hemostatic methods (95% CI: 0.33, 2.59). This was also true when comparing conventional hemostasis to the patch (95% CI: 0.64, 15.24). No difference in the risk for seroma formation was found between the conventional and hemostatic gel groups (95% CI: 0.26, 3.95). Drain output was significantly less in the gel group 40.75±35.6 mL compared to 66.26±31.2 mL in the conventional group (95% CI: -23.422, -7.460). Patients who received hemostatic agents had shorter hospital stays when compared to the conventional group (95% CI: -1.057, -0.203).

Conclusions

Our meta-analysis suggests that the use of a hemostatic agent in thyroid surgery yields minimal advantages for the management of perioperative bleeding risk.

Babu MJ, Menon R, Jacob P. Preoperative Preparation of Hyperthyroidism for Thyroidectomy - Role of Supersaturated Iodine and Lithium Carbonate

INTRODUCTION

Thyroidectomy is effective and safe procedure for permanent cure of hyperthyroidism (HT). Iodine preparations are widely used before operation to prevent excess blood loss. Ideal regimen for refractory HT is debated. This retrospective case-control study is designed to study the efficacy of various regimens of preoperative preparations.

MATERIALS AND METHODS

Case records, anesthesia charts, and follow-up details of hyperthyroid patients undergoing thyroidectomy were reviewed and compared with an age- and sex-matched euthyroid patients operated during the same period. Iodine preparations were not used for preoperative preparation. Study group was subdivided based on preoperative regimens of anti-thyroid medications.

RESULTS

Of the 168 patients in the study group, procedure time, duration of hospital stay, and overall complication rate were high compared to euthyroid group. Operative blood loss was not high in the study group. There was no difference in rate of complications in the subgroups of the study cohort.

CONCLUSION

Iodine preparations are not mandatory in preoperative preparation of HT. Lithium carbonate is effective in preoperative preparation of refractory HT. Rate of postthyroidectomy complications is not different in patients receiving thionamides alone or in combination with β-blocker.

Medial Approach for the Resection of Goiters with Suprahyoid, Retropharyngeal, or Substernal Extension

BACKGROUND

Resection of massive goiters with suprahyoid, retropharyngeal, and substernal extension may not be amenable to standard approaches. This study evaluates a surgical approach allowing resection of massive goiters with minimal substernal and deep neck dissection.

METHODS

Cases of thyroidectomy for goiters with substernal, retropharyngeal, or suprahyoid extension at a single institution from 2006 to 2017 were reviewed. The technique involves initial complete division of the medial thyroid tracheal attachments after identification of the RLN medial-inferiorly or superiorly. Deep components are then delivered into the superficial paratracheal region of the neck.

RESULTS

Sixty patients were included, 46 of which had substernal and 14 had only suprahyoid or retropharyngeal extension. Mean substernal extension was 3.7 cm (range 1.5-7.5 cm). The medial approach was successful in identifying the RLN in 70 (83%) of 84 goiter sides (71% medial-inferiorly and 29% superiorly). Standard inferior/lateral approaches were used in 12 (14%) nerves or not found until after goiter removal in 2 (2.5%). No patients required sternotomy or tracheotomy. Complications included postoperative seroma/hematoma (n = 9, 15%) with one re-exploration, transient RLN injury (n = 4, 4% of all lobectomies), transient hypocalcemia (n = 6, 16% of total thyroidectomies), permanent hypocalcemia (n = 2, 5% of total thyroidectomies), and permanent RLN paralysis (n = 1, 1% of all lobectomies).

CONCLUSION

Large suprahyoid, retropharyngeal, and substernal goiters were resected transcervically with low morbidity. Early complete division of Berry's ligament after medial-inferior RLN identification was achieved in a high proportion of patients, facilitating goiter delivery with minimal mediastinal and deep neck dissection.

Randomized clinical trial of intraoperative parathyroid gland angiography with indocyanine green fluorescence predicting parathyroid function after thyroid surgery

BACKGROUND

Hypoparathyroidism, the most common complication after thyroid surgery, leads to hypocalcaemia and significant medical problems. An RCT was undertaken to determine whether intraoperative parathyroid gland angiography with indocyanine green (ICG) could predict postoperative hypoparathyroidism, and obviate the need for systematic blood tests and oral calcium supplementation.

METHODS

Between September 2014 and February 2016, patients who had at least one well perfused parathyroid gland on ICG angiography were randomized to receive standard follow-up (measurement of calcium and parathyroid hormone (PTH) on postoperative day (POD) 1 and systematic supplementation with calcium and vitamin D; control group) or no supplementation and no blood test on POD 1 (intervention group). In all patients, calcium and PTH levels were measured 10-15 days after thyroidectomy. The primary endpoint was hypocalcaemia on POD 10-15.

RESULTS

A total of 196 patients underwent ICG angiography during thyroid surgery, of whom 146 had at least one well perfused parathyroid gland on ICG angiography and were randomized. None of these patients presented with hypoparathyroidism, including those who did not receive calcium supplementation. The intervention group was statistically non-inferior to the control group (exact 95 per cent c.i. of the difference in proportion of patients with hypocalcaemia -0·053 to 0·053; P = 0·012). Eleven of the 50 excluded patients, in whom no well perfused parathyroid gland could be identified by angiography, presented with hypoparathyroidism on POD 1, and six on POD 10-15, which was significantly different from the findings in randomized patients (P = 0·007).

CONCLUSION

ICG angiography reliably predicts the vascularization of the parathyroid glands and obviates the need for postoperative measurement of calcium and PTH, and supplementation with calcium in patients with at least one well perfused parathyroid gland. Registration number: NCT02249780 (http://www.clinicaltrials.gov).

Consequences of bleeding after thyroid surgery - analysis of 7805 operations performed in a single center

INTRODUCTION

Surgical treatment of thyroid gland diseases is associated with the possibility of severe complications. The most dangerous of them is bleeding. Current studies focus on its risk factors, rather than reoperation-related consequences.

MATERIAL AND METHODS

We analyzed 7805 thyroid operations performed from 1996 to 2014 in the Clinic of General, Gastroenterological and Endocrine Surgery of Wroclaw Medical University. Typical risk factors, symptoms and consequences of bleeding were analyzed.

RESULTS

Among operated patients 88.2% were female and 11.8% male. Bleeding occurred in 84 (1.08%) patients. Sex (p = 0.006), preoperative thyroid pathology (p = 0.03), and type of operation (p < 0.001) are significant risk factors for bleeding, while retrosternal goiter and surgeon's experience are not. Risk of bleeding is highest in the case of male sex, toxic goiter and total resection of the thyroid gland. Most reoperations took place within 6 h. In 88.8% of cases of this kind of complication the surgeon indicated the exact source of bleeding; most commonly it was the neck muscles, skin and subcutaneous tissue, or the thyroid stump. Three patients required a second reoperation, 24 suffered further complications, and 8 required transfer to the Intensive Care Unit (ICU). Cardiac arrest occurred in 3 patients and 2 suffered bilateral vocal cord palsy.

CONCLUSIONS

Bleeding after thyroid operations is a direct life threat that requires immediate intervention. As a result death may occur, half of patients suffer other complications and some require intensive care. The risk is highest in the case of male sex, toxic goiter and total resection of the thyroid gland. Each patient after thyroid surgery needs to be closely observed. An operating theatre and ICU should be available at all times.

Unintentional recurrent laryngeal nerve injuries following thyroidectomy: Is it the surgeon who pays the bill?

BACKGROUND

Thyroidectomy is one of the most common intervention in general surgery and, after the turn of the century, its rate has sharply increased, along with a worldwide increased incidence of differentiated thyroid cancers. Therefore, injuries of the recurrent laryngeal nerve have become one of the most frequent cause of surgical malpractice claims, mostly following surgery for benign pathology.

MAIN BODY

Even if the incidence of definitive paralysis is generally lower than 3%, during the last 20 years in Italy, the number of claims for damages has sharply raised. As a consequence, a lot of defensive medicine has been caused by this issue, and a witch-hunt has been accordingly triggered, so determining mostly a painful and lasting frustration for the surgeons, who sometimes are compelled to pay a lot of money for increasing insurance premiums and lawyers fees. Recurrent laryngeal nerve injury should be considered as a potentially catastrophic predictable but not preventable event, rather than the result of a surgical mistake.

CONCLUSION

Purposes of the Authors are analyzing incidence, conditions of risk, and mechanisms of recurrent laryngeal nerve injuries, underlining notes of surgical technique and defining medical practice recommendations useful to reduce the risk of malpractice lawsuits and judgments against surgeons.

How many parathyroid glands can be identified during thyroidectomy?: Evidence-based data for medical experts

Background

The purpose of this study is to provide guidance for medical experts regarding malpractice claims on permanent hypoparathyroidism by analyzing the number of parathyroid glands (PGs) identified during thyroidectomy and the clinical outcome.

Methods

Parathyroid findings were documented in a standardized protocol for 357 patients undergoing thyroidectomy and treated by a single specialized surgeon. The resected thyroid was routinely dissected for accidentally removed PGs with consecutive autotransplantation and the pathological report also described unintentionally resected PGs. Follow-up was performed for 6 months.

Results

The mean number of identified PGs was 2.28. No PGs were found in 20 (5.6%), one in 56 (15.7%), two in 126 (35.3%), three in 114 (31.9%), and four in 41 (11.5%) cases. One patient (0.28%) had manifest permanent hypoparathyroidism, while ten patients (2.8%) had latent permanent hypoparathyroidism (hypocalcemia and normoparathyroidism). The risk factors identified for postoperative hypoparathyroidism were an increasing number of visualized PGs, autotransplantation, central neck dissection, and PGs in the histopathological work-up. For permanent hypoparathyroidism, PGs in the histology examination and neck dissection were significant, but the number of identified PGs was not.

Conclusion

Even an experienced surgeon is not always able to find all four PGs during thyroidectomy and occasionally identifies none. Rather than focusing on identifying a minimum number of PGs, it is more important not to miss them in risky positions. A documented awareness of PGs, i. e., knowledge of variable parathyroid positions and their saving, is a prerequisite for surgical quality and to protect surgeons from claims.

A reappraisal of vascular anatomy of the parathyroid gland based on fluorescence techniques

Identification of the parathyroid glands (PGs) during thyroid surgery may prevent their inadvertent surgical removal and prevent postoperative hypoparathyroidism. However, identification of the PGs does not guarantee their function, and their vascular supply needs to be preserved as well. The recent introduction of intraoperative indocyanine green (ICG) fluorescent angiography of the PGs during thyroid surgery allows for the appraisal of the vascular anatomy and evaluation of PG function. The use of this tool could lead to a significant reduction in the rate of postoperative hypoparathyroidism, as it allows surgeons to adapt their surgical technique for the preservation of the PGs. ICG fluorescent angiography is currently the only available real-time tool to assess the vascular blood supply of each individual PG intraoperatively and can thus assist surgeons in their decision-making. Herein, we review the relevant literature.

Less than total thyroidectomy for goiter: when and how?

Benign goiter is the most common endocrine disease that requires surgery, especially in endemic areas suffering from iodine-deficiency. Recent European and American guidelines recommended total thyroidectomy for the surgical treatment of multinodular goiter. Total thyroidectomy has now become the technique of choice and is widely considered the most reliable approach in preventing recurrence. Nevertheless, total thyroidectomy carries a substantial risk in terms of hypoparathyroidism and the morbidity associated with injury to the inferior laryngeal nerve. In this context, partial/less-than-total thyroidectomy is being considered once again as a viable alternative. This review will discuss the extent of thyroid surgery for benign disease and the impact of the surgical protocol on the patient- and surgeon-specific risk factors for specific complication rates.