Total thyroidectomy for non-toxic multinodular goiter with versus without the use of harmonic FOCUS dissecting shears - a prospective randomized study

Energy-based devices for hemostasis in thyroid surgery

The evolution of operative techniques in thyroid surgery that has taken place over the past several decades would not have been possible if not for a sui generis revolution in surgery at the turn of the 19th and 20th centuries. The three most important events of the end of the 19th century, i.e., the introduction of anesthesia, the use of artery forceps and ligation of blood vessels, as well as prophylactic management of perioperative infections decidedly affected the improvement of therapeutic results of thyroid surgery. Surgical treatment of thyroid diseases is associated with the possibility of complications developing, of which bleeding is among the most serious ones, starting from the need for an immediate reoperation and ending at a considerable damage to functionally important structures: the laryngeal nerves and parathyroid glands. The consensus reached between the development of science and progress in modern technologies has provided the basis for introducing and popularizing minimally invasive procedures, including operations using the approach through natural body openings. Such an unprecedented development of surgical techniques would not be possible without devices for closing blood vessels. Given the mechanism of hemostasis, current vascular sealing devices can generally be divided into three groups: ultrasonic, bipolar-radiofrequency and hybrid systems combining both energy modalities. While analyzing the innovative, advanced technology of all the energy-based devices, it should be stated that only if they are used in a safe manner, quality of life of patients with various thyroid conditions is improved. The employment of such devices fully confirms their usefulness; nevertheless, all the advantages should never release the surgeon from the obligation to appropriately and safely identify the surrounding structures and let him uncritically use the new device.

Procedure costs associated with the use of Harmonic devices compared to conventional techniques in various surgeries: a systematic review and meta-analysis

Background

As compared to conventional techniques, recent meta-analyses have reported cost savings with Harmonic devices; however, only in thyroidectomy. Thus, the aim of this study was to evaluate the costs associated with Harmonic devices versus conventional techniques across a range of surgical procedures.

Methods

A systematic search of MEDLINE, EMBASE, and Cochrane Library was conducted from inception to October 01, 2016 without language restrictions to identify randomized controlled trials comparing Harmonic devices to conventional techniques and reporting procedure costs (operating time plus operating equipment/consumables/device costs). Costs were pooled using the ratio of geometric means, and a random effects model was applied. Sensitivity analyses varying statistical methods, number of included studies, and cost outcomes were completed to test the robustness of the results.

Results

Thirteen studies met the inclusion criteria. A total of 561 and 540 participants had procedures performed with Harmonic devices and conventional methods, respectively, with procedures including gastrectomy, thyroidectomy, colectomy, cholecystectomy, Nissen fundoplication, and pancreaticoduodenectomy. As compared to conventional methods, Harmonic devices reduced total procedure costs by 8.7% (p=0.029), resulting in an absolute reduction of US$227.77 from mean conventional technique costs, derived primarily from a reduction in operating time costs. When operating time costs, excluding operating equipment/consumables/device costs, were analyzed, costs were reduced by $544 per procedure with the use of Harmonic devices. The results from all sensitivity analyses demonstrated cost reductions with Harmonic devices.

Conclusion

This systematic review and meta-analysis showed that despite a higher device cost, Harmonic devices provide a statistically significant reduction in procedure costs, derived primarily from a reduction in operating time costs, across surgical procedures. In addition to functionality benefits, Harmonic devices may represent a potentially cost saving method to reduce overall hospital resource use. Future research should focus on potential costs and benefits from use of Harmonic devices in procedures not covered here.

Comparison of surgical outcomes and complications between the Harmonic FOCUS and conventional surgery for open thyroidectomy

The aim of the present study was to evaluate the potential advantages of the ultrasonic scalpel compared with the conventional technique in thyroid surgery. Patients with resectable thyroid cancer and Basedow's disease were assigned to ultrasonic scalpel or conventional technique (knot-tying and electrocoagulation). The present study used the Harmonic FOCUS^® (HF) as an ultrasonic scalpel. Between February 2013 and May 2016, 45 patients were enrolled into the study. Duration of the surgery was significantly decreased in the HF group compared with the conventional surgery (CS) group (median 142 vs. 151 min; P=0.0406). Intraoperative blood loss and total volume of drainage fluid were significantly decreased in the HF group compared with the CS group (median 40 vs. 125 ml; P=0.0054, and median 120 vs. 175.5 ml; P=0.0490). Duration of drain placement and length of hospitalization stay were similar in the two groups. Furthermore, the overall incidence of postoperative complications did not differ between the two groups. Overall, the present study suggests that open thyroidectomy using the HF is safe and effective and not associated with any increase in complications.

Randomized clinical trial of ultrasonic scissors versus conventional haemostasis to compare complications and economics after total thyroidectomy (FOThyr)

Background

The benefits of single‐use ultrasonic scissors in thyroid surgery are still debated. Although this device has been shown to reduce operating time compared with conventional haemostasis, its cost‐effectiveness has never been demonstrated. The aim of this study was to evaluate the efficacy, cost‐effectiveness and safety of ultrasonic scissors for total thyroidectomy.

Methods

This was a prospective, randomized, multicentre trial conducted at 13 hospital sites. The primary endpoint was the percentage of patients with hypocalcaemia (serum calcium level below 2 mmol/l) on day 2. Secondary endpoints included postoperative complications and costs, with calculation of incremental cost differences and cost‐effectiveness ratios.

Results

In total, 1329 patients who underwent total thyroidectomy were included in the analysis: 670 were randomized to treatment with ultrasonic scissors and 659 to conventional haemostasis. There was no difference between groups in the rate of complications, including hypocalcaemia on day 2 (19^.7 per cent in ultrasonic scissors group versus 20^.3 per cent in conventional haemostasis group; P = 0·743). Median operating times were significantly shorter with ultrasonic scissors (90 versus 100 min with conventional haemostasis; P < 0·001). Total mean(s.d.) direct costs at 6 months were €4311(1547) and €4011(1596) respectively (P < 0·001).

Conclusion

Ultrasonic scissors were no more clinically effective than conventional haemostasis, but use of these devices was more costly. Registration number: NCT01551914 (http://www.clinicaltrials.gov).

A systematic review and meta-analysis of Harmonic Focus in thyroidectomy compared to conventional techniques

Introduction

Several meta-analyses have been performed comparing the use of a variety of ultrasonic devices in thyroidectomy to conventional procedures. These studies have shown the superiority of ultrasonic devices for most outcomes studied including faster operative time and less blood loss, and equivalent or better safety for recurrent laryngeal nerve paresis and hypocalcemia. The current work is the first to examine a single ultrasonic device specifically designed for thyroid surgery, the Harmonic Focus, in order to confirm its efficacy and safety in thyroidectomy.

Methods

A comprehensive literature search without language restrictions was performed for randomized clinical trials comparing Harmonic Focus and conventional clamp, cut and tie in thyroidectomy. Outcome measures included operating time, blood loss, post-operative pain, length of hospital stay, hypocalcemia and recurrent laryngeal nerve paresis. Risk of bias was analyzed for all studies. Meta-analysis was performed using random effects models with the inverse-variance method for mean differences of continuous variables and the Mantel-Haenszel method for risk ratios of dichotomous variables.

Results

A total of 14 studies met the inclusion criteria. Harmonic Focus reduced operative time by 29 min, a 31 % decrease (p < 0.001), intra-operative blood loss by 45 ml (p < 0.001), post-operative pain (p < 0.001), length of hospital stay by 0.68 days (p = 0.005), drainage volume by 29 ml (p = 0.01), and occurrence of transient hypocalcemia by 40 % (p = 0.001). There were no significant differences between Harmonic Focus and conventional procedures in rate of persistent hypocalcemia, or rates of transient and persistent recurrent laryngeal nerve paresis.

Conclusion

This is the first meta-analysis of Harmonic Focus in thyroid surgery. In agreement with meta-analyses previously performed on ultrasonic devices, use of the Harmonic Focus has been shown to be a more effective surgical procedure compared to conventional methods in thyroidectomy. The low occurrence of hypocalcemia and recurrent laryngeal nerve paresis confirms that Harmonic Focus can improve thyroidectomy efficiency without increasing the risk of complications.

Minimally invasive video-assisted thyroidectomy: experience of 200 cases in a single center

Introduction

Minimally invasive techniques in thyroid surgery including video-assisted technique originally described by Miccoli have been accepted in several continents for more than 10 years.

Aim

To analyze our preliminary results from minimally invasive video-assisted thyroidectomy (MIVAT) and to evaluate the feasibility and effects of this method in a general department over a 4-year period.

Material and methods

Initial experience was presented based on a series of 200 patients selected for MIVAT at the General Surgery Department of Yantai Yuhuangding Hospital affiliated with Qingdao University during the period from May 2008 to June 2012. The enrolling criteria were rigorously observed. An above sternal incision with average length of 2.5 cm (1.5–3.0 cm) was made. Clinicopathologic characteristics, postoperative pain, length of hospital stay, cosmetic results and complications were retrospectively analyzed.

Results

All patients received general anesthesia. Thyroid unilateral lobectomy was successfully accomplished in 108 cases, total thyroidectomy in 84, and partial lobectomy in 8. Conversion to standard conventional thyroidectomy was required in 6 patients (3%) because of thyroiditis and bleeding. The mean lymph node yield of the cancer specimens was 3.6 per patient. Permanent unilateral recurrent laryngeal nerve (RLN) palsy occurred in 1 case (0.5%), transient unilateral RLN palsy in 6 patients (3.0%, complete recovery after 1–6 months), and transient hypocalcemia in 7 patients (3.5%). No definitive hypocalcemia was observed. No postoperative hematomas occurred. Postoperative pain was endurable. The cosmetic result was excellent in most cases.

Conclusions

The MIVAT is feasible and safe in selected patients, with better results comparable to conventional thyroidectomy. The MIVAT can also be performed in a general surgery department.

A retrospective case-controlled study of video-assisted versus open minimally invasive parathyroidectomy

INTRODUCTION

Minimally invasive parathyroidectomy (MIP) with intraoperative parathyroid hormone assay (IOPTH) has successfully replaced conventional neck exploration in most patients with primary hyperparathyroidism (pHPT) and preoperatively localized parathyroid adenoma.

AIM

To compare outcomes of video-assisted MIP (MIVAP) to open MIP (OMIP).

MATERIAL AND METHODS

A retrospective case-controlled study of 455 patients with sporadic pHPT undergoing MIP with IOPTH at our institution in 2003-2012 was undertaken. The primary outcome measure was postoperative pain. Secondary outcome measures were: duration of surgery, recurrent laryngeal nerve (RLN) identification rate, conversion rate, length of hospital stay, cure rate, patients' satisfaction with cosmetic outcome, morbidity, costs, and diagnostic accuracy of IOPTH.

RESULTS

Of 455 patients with pHPT and a solitary parathyroid adenoma on preoperative imaging, 151 underwent MIVAP and 304 had OMIP. The following outcomes were favourable for MIVAP vs. OMIP: lower pain intensity during 24 h postoperatively (p < 0.001), lower analgesia request rate (p < 0.001), lower analgesics consumption (p < 0.001), higher recurrent laryngeal nerve identification rate (p < 0.001), shorter scar length (p < 0.001), and better cosmetic satisfaction at 1 month (p = 0.013) and at 6 months (p = 0.024) after surgery. However, MIVAP vs. OMIP had longer duration of surgery (p < 0.001), and was more expensive (p < 0.001). No differences were noted in the conversion rate, length of hospital stay, and morbidity.

CONCLUSIONS

Both MIVAP and OMIP approaches were equally safe and effective. However, the outcomes of MIVAP operations were superior to OMIP in terms of lesser postoperative pain, lower analgesics consumption, and better cosmetic satisfaction resulting from a smaller scar.

Lessons learned from the first 50 thyroidectomies with Harmonic Focus Curved Shears - technical note

Precise and safe hemostasis is necessary for successful thyroid surgery. In this respect, the advent of the ultrasonic surgical device Harmonic Focus Curved Shears (HFCS) from Ethicon Endo-Surgery constituted a major progress in the domain by its multiple capabilities of dissection, grasping, vessel sealing and transecting. The paper presents the initial experience of 50 cases with this device of a surgical team with special interest in endocrine surgery, mostly thyroid and parathyroid. The thyroid conditions for which surgery was indicated were: diffuse toxic goiter in 8 patients; multinodular toxic and nontoxic goiter in 30 patients; autonomous nodule in 2 patients; 2 patients with benign nodules at fine needle aspiration biopsy (FNAB); 4 patients with nodules positive for carcinoma at FNAB, among them 2 with unilateral cervical lymph nodes enlargement; 4 patients with highly suspect nodule on FNAB. The types of surgery performed were 4 hemithyroidectomies and 46 total thyroidectomies, 2 in association with unilateral functional neck dissections. We had 4 intraoperative hemorrhagic incidents, all in the first 15 cases and imputable to lack of expertise and improper usage of the device. We registered the following noticeable postoperative complications: 1 cervical hematoma from an arteriolar source in sternothyroid muscle demanding prompt reintervention; 8 hypocalcemias and 2 vocal cord paresis, none of which permanent. We remarked several advantages with HFCS: no necessity of changing instruments, fluentness of the intervention and more comfort for the operating team, reduced operating time, safe hemostasis. Some important tips and tricks with the usage of the instrument are presented.