Effect of the COVID-19 pandemic on surgery for indeterminate thyroid nodules (THYCOVID): a retrospective, international, multicentre, cross-sectional study

BACKGROUND

Since its outbreak in early 2020, the COVID-19 pandemic has diverted resources from non-urgent and elective procedures, leading to diagnosis and treatment delays, with an increased number of neoplasms at advanced stages worldwide. The aims of this study were to quantify the reduction in surgical activity for indeterminate thyroid nodules during the COVID-19 pandemic; and to evaluate whether delays in surgery led to an increased occurrence of aggressive tumours.

METHODS

In this retrospective, international, cross-sectional study, centres were invited to participate in June 22, 2022; each centre joining the study was asked to provide data from medical records on all surgical thyroidectomies consecutively performed from Jan 1, 2019, to Dec 31, 2021. Patients with indeterminate thyroid nodules were divided into three groups according to when they underwent surgery: from Jan 1, 2019, to Feb 29, 2020 (global prepandemic phase), from March 1, 2020, to May 31, 2021 (pandemic escalation phase), and from June 1 to Dec 31, 2021 (pandemic decrease phase). The main outcomes were, for each phase, the number of surgeries for indeterminate thyroid nodules, and in patients with a postoperative diagnosis of thyroid cancers, the occurrence of tumours larger than 10 mm, extrathyroidal extension, lymph node metastases, vascular invasion, distant metastases, and tumours at high risk of structural disease recurrence. Univariate analysis was used to compare the probability of aggressive thyroid features between the first and third study phases. The study was registered on ClinicalTrials.gov, NCT05178186.

FINDINGS

Data from 157 centres (n=49 countries) on 87 467 patients who underwent surgery for benign and malignant thyroid disease were collected, of whom 22 974 patients (18 052 [78·6%] female patients and 4922 [21·4%] male patients) received surgery for indeterminate thyroid nodules. We observed a significant reduction in surgery for indeterminate thyroid nodules during the pandemic escalation phase (median monthly surgeries per centre, 1·4 [IQR 0·6-3·4]) compared with the prepandemic phase (2·0 [0·9-3·7]; p<0·0001) and pandemic decrease phase (2·3 [1·0-5·0]; p<0·0001). Compared with the prepandemic phase, in the pandemic decrease phase we observed an increased occurrence of thyroid tumours larger than 10 mm (2554 [69·0%] of 3704 vs 1515 [71·5%] of 2119; OR 1·1 [95% CI 1·0-1·3]; p=0·042), lymph node metastases (343 [9·3%] vs 264 [12·5%]; OR 1·4 [1·2-1·7]; p=0·0001), and tumours at high risk of structural disease recurrence (203 [5·7%] of 3584 vs 155 [7·7%] of 2006; OR 1·4 [1·1-1·7]; p=0·0039).

INTERPRETATION

Our study suggests that the reduction in surgical activity for indeterminate thyroid nodules during the COVID-19 pandemic period could have led to an increased occurrence of aggressive thyroid tumours. However, other compelling hypotheses, including increased selection of patients with aggressive malignancies during this period, should be considered. We suggest that surgery for indeterminate thyroid nodules should no longer be postponed even in future instances of pandemic escalation.

FUNDING

None.

WhatsApp-Based virtual consultation in clinical practice during COVID times: A prospective institutional study

Background:

As the novel coronavirus disease 2019 (COVID-19) continues its pandemic surge globally, the attention toward the treatment of non-COVID diseases has become difficult. Software-based systems and social media platforms could provide alternatives for ensuring regular health-care non-COVID diseases. In this context, we evaluated our own experience with virtual consultation (VC) for the management of endocrine surgical patients during the current COVID pandemic.

Materials and Methods:

This prospective study was conducted in the endocrine surgery department spanning 4 months from April to July 2020. We employed WhatsApp-based group video conferencing for VC with both new and follow-up outpatients. We evaluated the satisfaction quotient of patients, regarding the three types of consultations (no consultation, VC, and direct consultation) on an ordinal scale of three modes of consultation.

Results:

Virtual consultation was performed with 102 new and 285 follow-up patients. Goiters, clinical findings, and wounds/scars (in post-operative cases) were evaluated virtually. Dosage of thyroxine replacement, calcium supplementation, and other medications was prescribed based on findings and history. Patients who needed surgery (25/102 cases) were given appropriate appointment. More than 82% of the patients in both groups preferred VC during this COVID pandemic.

Conclusions:

More than 82% of both new and follow-up patients preferred VC over direct or no consultation during this COVID pandemic. Our findings suggest that VC through social media platforms is capable of ensuring appropriate treatment and follow-up for endocrine diseases.

Prognostic Impact of Focal Poorly Differentiated Areas in Follicular Differentiated Thyroid Cancer: Is It a Distinct Entity from Poorly Differentiated Thyroid Cancer?

Poorly differentiated thyroid cancer (PDC) and especially poorly differentiated areas (PDA) within follicular cell-derived differentiated thyroid cancer are ill-defined clinicopathological entities. We report our experience on their comparative prognostic outcomes This is a retrospective study of 61 patients (PDC = 29; PDA = 32) from Endocrine and Metabolic Surgery Department (2009 to 2017). Clinical and follow-up details are collected and digitally tabulated from departmental database. Gender ratio was M:F = 1:1.3 and 1:1.6. Mean age was 51 ± 12 years (16-76) and 54 ± 10.5 years (36-81) in PDA and PDC, respectively. Mean tumour size (4.6 ± 0.9 cm; 4.9 ± 1.2 cm), extrathyroidal invasion (59%; 73%) and regional lymphadenopathy were 50% and 55% in PDA and PDC, respectively. Total thyroidectomy was possible in 94% of PDA and in only 77% of PDC. Radioiodine ablation was utilised in 65% (PDA); 29% (PDC). With mean follow-up of 64 ± 23.5 months (12-103) in PDA and 37 ± 22 months (6-94) in PDC, nodal recurrence (PDC = 29%; PDA = 22%) and systemic metastasis was 41% in PDC (synchronous = 24%; metachronous = 17%); 19% in PDA (synchronous = 16%; metachronous = 3%). Five-year event-free survival (EFS) and overall survival (OS) was 90% and 93% in PDA, and 42% and 44% in PDC, respectively. Our study shows that PDA is a separate clinicopathological entity with significantly positive prognosis compared to PDC.

Selfie-driven thyroid disease leads: A study on a unique sign and its utility in clinical practice

Introduction

Taking a photograph of self alone or with a group called selfie, has become modern-day rage with spurt in smartphone technology. It has catapulted from a hobby into psychiatric ailment, especially among teens and young adults. Although it is considered a psychiatric ailment keeping them aloof from social interactions, we observed an inadvertent advantage in this process. In this context, we present some intriguing findings in this study.

Materials and Methods

This retrospective study was based on compilation of 14 cases from endocrine surgery outpatient cum inpatient database collected over 2 years' period. The inclusion criteria are the chief complaint (CC) was noted only after watching the selfie picture and not otherwise; the CC leads them to consult physician; the picture was captured by oneself or other person who was also part of that image; and the CC leads to definitive diagnosis of thyroid disease requiring treatment. All other clinical, investigative, and treatment (medical and surgical) were studied.

Results

In all, we had 14/5820 (0.0024%) cases meeting the above criteria. CC and later confirmed in pictures were four cases of Grave's disease associated ophthalmopathic exophthalmos, eight cases of goiter, and two cases of facial puffiness (myxedema related). All these CC helped in investigating for the diagnosis of Graves' disease (4), nodular goiter (8), and hypothyroidism (2) confirmed by appropriate investigations. Ten cases underwent thyroidectomy (two of the nodular goiter cases were papillary thyroid cancer) and four cases took conservative medical treatment.

Conclusions

Although selfie is considered a modern-day lifestyle-induced psychiatric illness, it can inadvertently help in picking up thyroid diseases in earlier stages.

Analysis of Weight-Loss Outcomes Following Laparoscopic One Anastomosis Duodenal Switch

Background: Laparoscopic one anastomosis duodenal switch (OADS) is one of the most effective bariatric surgeries aimed at simplifying duodenal switch procedure and reducing malabsorption without compromising weight-loss efficacy. This study analyzed weight-loss outcomes following OADS surgery with a common channel 300 cm. Methodology: Between June 2016 and November 2020, 150 patients who underwent OADS surgery with a common channel 300 cm were included in the study. The weight-loss outcomes of these patients at six months and one year after surgery were retrospectively studied with respect to various perioperative variables including biliopancreatic limb (BPL) and common channel lengths. Results: At six months and one year after surgery, %TWL was 30%, 39.4%, and %EWL was 75%, 98.8%, respectively. The BMI loss, weight loss and %TWL were directly proportional to preoperative BMI and weight, while the %EWL was inversely proportional to these variables. Preoperative BMI was found to be an independent predictor of BMI loss and %EWL. The BMI loss, and weight loss were also directly proportional to BPL length. The %TWL was directly proportional to BPL length at one year after surgery. Age, gender and diabetes did not have significant effects on the weight-loss outcomes. The success rate (%TWL 25%) was 88.9% and 99.2% at six months and one year after surgery, respectively. Conclusions: OADS surgery using a common channel 300 cm appears to be highly effective for weight loss. Preoperative BMI, weight and BPL length were found to be significant predictors of weight-loss outcomes following this surgery.

What is the impact of thyroidectomy on autoimmune features associated with Hashimoto's thyroiditis?-Institutional experience

Background

Hashimoto's thyroiditis (HT) is one of the commonest endocrine disorders, globally. Often, HT presents a protean range of associated autoimmune features (AAI) such as vitiligo, rheumatoid arthritis, pernicious anemia, skin allergy/atopy, thrombocytopenia, Addison's disease, type 1 diabetes, celiac disease, eosinophilia, etc., The usual treatment of HT is symptomatic with no curative option. In this context, we report our experience on the impact of surgical thyroidectomy on remission of AAI in HT.

Aims

To report our experience on the impact of surgical thyroidectomy on remission of AAI in patients with HT.

Material and Methods

This is a retrospective study conducted in the Endocrine Surgery department of a tertiary care hospital. A total of 61 patients with HT and various AAI combinations were included in this study. All the clinicoinvestigative and operative data were systematically analyzed. The most frequent indication for surgery was nodular goiter followed by associated malignancy, persistent goiter, and painful thyroiditis. Others were cosmetic/pressure symptoms and not AAI per se. The mean follow-up after surgery was 55.6 ± 11.8 months.

Results

The gender ratio was 5.8:1 in favor of women and the mean age was 41.5 ± 5.4 years. The mean preoperative and postoperative serum anti-thyroperoxidase antibody (Anti-TPO Ab) levels were 339 ± 98.2 and 58.75 ± 25 IU/L at the last follow-up visit. A total of 60% AAI manifestations had resolution or significant alleviation. The major improvements in AAI were skin allergy, eosinophilia, rheumatoid arthritis, vitiligo, thrombocytopenia, celiac disease symptomatic episodes; but, type 1 diabetes and Addison's disease showed static response.

Conclusions

Surgical total thyroidectomy and anti-TPO Ab-related autoimmunity appear to play a beneficial role and definitive role in the remission of AAI in HT.

Metabolic efficacy following laparoscopic sleeve gastrectomy with loop duodenal switch surgery for type 2 diabetes in Indian patients with severe obesity

BACKGROUND AND AIMS

Metabolic surgery improves glycemic control in patients with type 2 diabetes (T2DM) and severe obesity. Sleeve gastrectomy with loop duodenal switch (SLDS), a loop modification of biliopancreatic diversion with duodenal switch, is aimed to reduce the malabsorption, without compromising the efficacy. This study was designed to analyze the metabolic efficacy following SLDS.

METHODS

Eighty patients, who underwent SLDS for T2DM and severe obesity between January 2014 and February 2020 were retrospectively analyzed. Complete T2DM remission was defined as HbA1_C < 6% in the absence of anti-diabetic medications. T2DM remission was analyzed at the 6-month and 1-year follow-ups in terms of various predictors. Prediction of T2DM remission by ABCD, DiaRem and IMS scores was analyzed. Lower ABCD scores and higher DiaRem and IMS scores indicate severe T2DM.

RESULTS

Following SLDS, HbA1_C significantly reduced from 8.7% to 5.5% at the 6-month and 5.1% at the 1-year follow-ups. T2DM remission was 82.5% at the 6-month and 90.8% at the 1-year follow-ups. Preoperative glycemic control positively predicted, while T2DM duration and preoperative insulin use negatively predicted T2DM remission. Higher ABCD score, lower DiaRem and IMS scores predicted higher T2DM remission. Severe hypoalbuminemia was 20% in patients with 250 cm common channel and 02% in patients with ≥300 cm common channel at the 1-year follow-up.

CONCLUSIONS

SLDS is an effective surgery to treat T2DM with severe obesity. Shorter T2DM duration, better preoperative glycemic control and the absence of insulin use were associated with better T2DM remission. Malabsorption was significantly lesser, when common channel was ≥300 versus 250 cm.

Is there adenoma-carcinoma sequence between benign adenoma and papillary cancer of thyroid: A genomic linkage study

BACKGROUND

The adenoma-carcinoma sequence in thyroid nodules is an enigmatic phenomenon. Genomics is the only definitive modality to resolve this hypothesis. Adenomas and papillary carcinomas tend to have mutations in RAS and highly specific BRAF gene respectively. In this context, we set out study the prevalence and clinical significance of these somatic mutations in surgical tissue samples.

MATERIAL AND METHODS

This retrospective study was conducted on surgically managed thyroid nodule patients. Institutional ethical committee approval was obtained. Diagnosis was based on biochemical confirmation, imaging, fine needle aspiration cytology and later confirmed by histopathology. We selected 100 benign thyroid adenomas (BTA) and 100 papillary thyroid carcinoma (PTC) cases. Archived tumour tissue samples of selected cases were retrieved. After appropriate processing of samples, DNA extraction, cDNA preparation, PCR amplification, application of 4 sets of Primers were performed as part of mutational analysis of RAS (H-,K-,N-) and BRAF genes.

RESULTS

Homozygous mutations in N-RAS were found in 36/100 (36%) of BTA and 7/100 (7%) of PTC cases. No H-RAS or K-RAS mutations were found in both groups. Homozygous mutations were found in BRAF gene in 4/100 (4%) of BTA cases and 52/100 (52%) of PTC cases. The differences were statistically significant.

CONCLUSIONS

Similar N-RAS and BRAF mutations were prevalent in both benign and malignant thyroid nodules giving some evidence for linkage between them. Though not robust, we opine that there is possibility of adenoma-carcinoma sequence in thyroid nodules.

Metabolic Efficacy and Diabetes Remission Predictors Following 'Sleeve Gastrectomy with Loop Duodenojejunal Bypass' Surgery

PURPOSE

Laparoscopic sleeve gastrectomy with loop duodenojejunal bypass (SLDJB) is a novel metabolic surgery that is a modification of the single anastomosis duodenoileal bypass with sleeve. Compared to conventional surgeries, SLDJB is highly effective in inducing diabetes remission. This study analyzed the metabolic efficacy of SLDJB.

MATERIALS AND METHODS

Seventy-eight patients with obesity and diabetes who underwent SLDJB between May 2013 and October 2017 were retrospectively analyzed to investigate the efficacy of their surgery and diabetes remission predictors. Complete diabetes remission was defined as an HbA1_c level <6% with cessation of insulin and oral hypoglycemic agents.

RESULTS

Complete diabetes remission occurred in 80.52% and 76.71% of patients at 1- and 3-year follow-ups, respectively. There was no significant difference in the rates of complete diabetes remission between the groups based on gender, preoperative body mass index (BMI), diabetes duration or preoperative insulin use. There was a significantly higher rate of complete remission in patients <50 years of age at the 1-year follow-up. Additionally, the rate of complete remission was significantly less when preoperative glycemic control was poor. Preoperative HbA1_c levels negatively predicted complete remission, but was significant only at the 3-year follow-up.

CONCLUSION

SLDJB is highly effective in treating obesity with type 2 diabetes, and preoperative glycemic control was found to predict complete remission. Patients under 50 years of age had a better short-term response rate; however, the surgery was effective regardless of gender, preoperative BMI, duration of diabetes or preoperative insulin use.

Factors Predicting Weight Loss after "Sleeve Gastrectomy with Loop Duodenojejunal Bypass" Surgery for Obesity

Background

Laparoscopic sleeve gastrectomy with loop duodenojejunal bypass (SG LDJB) is a loop modification of biliopancreatic diversion with duodenal switch. The aim of this study was to analyze weight loss response and factors predicting weight loss outcomes after SG LDJB.

Methods

This was a retrospective study analyzing SG LDJB surgeries performed between May 2013 and December 2017 in 126 Indians suffering from obesity. The collected data was analyzed to understand weight loss efficacy and the factors predicting weight loss. Surgery was considered successful when percentage excess weight loss (%EWL) was ≥50% or percentage total weight loss (%TWL) was ≥25%.

Results

%EWL was 95.77% and 83.84% and %TWL was 34.64% and 30.32% at the 1-year and 3-year follow-up, respectively. %EWL ≥50% was 99.04% and 96.47% and %TWL ≥25% was 91.35% and 75.29% at the 1-year and 3-year follow-up, respectively. Patient age and sex did not independently predict %EWL or %TWL. Preoperative body mass index (BMI), weight, and excess weight negatively predicted %EWL and positively predicted %TWL at the 1-year and 3-year follow-up. Multiple regression analysis showed that these parameters were independent predictors of %EWL and %TWL at 1 year, while preoperative weight and excess weight also independently predicted %EWL at the 3-year follow-up. In diabetic patients, %EWL was significantly lower at the 3-year follow-up and %TWL was significantly lower at the 1-year and 3-year follow-up.

Conclusion

SG LDJB was an effective bariatric surgery to treat obesity. Preoperative BMI, weight, excess weight, and the presence of diabetes were the significant factors associated with the weight loss outcomes.

Pre-surgical road map for thyroid cancer and large goiters: Practical benefits of detailed radiological evaluation by surgeon

INTRODUCTION

Pre-surgical radiological evaluation of neck is often mandatory for surgical planning in high risk thyroid cancer and large goiters. Frequently, surgeons are overdependent on radiologist's report. In this context, we analysed the practical benefits of surgeon's independent radiological evaluation in our institutional experience.

MATERIAL AND METHODS

This prospective study was conducted in Endocrine Surgery department of a teaching hospital in South India. Cases operated between January 2011 and June 2012 (18 months) were included. Films of cross-sectional imaging were read in detail by primary and assistant surgeons in correlation with stepwise operative planning and documented. Cases with additional radiological signs on surgeon's evaluation, which were missing in radiologist's report are discussed in detail.

RESULTS

F: M ratio is 67:24. Mean age was 45.3 ± 9.8 years (37 - 76). Forty-seven cases of thyroid cancer and 44 cases of large goiters were analysed. Surgeon read additional signs such as obliterated fat plane between goiter and subcutaneous plane; level I lymph nodes; bilateral cervical lymphadenopathy, internal jugular vein thrombus, and pharyngeal invasion helped in pre-operatively planned modification of operative steps for optimal R0 resection and total thyroidectomy. A mean of 1.42 ± 0.83 (1 - 6), additional signs were detected on surgeon's radiological evaluation compared to radiologist's report in 41.7% of cases. These findings modified the pre-operative plan, facilitating better surgical outcome in 28.6% of cases.

CONCLUSION

In high-risk thyroid cancer and large goiters, detailed radiological evaluation by surgeon facilitates optimal surgical resection and superior outcome compared to radiologist report-guided surgery.