Influence of Experience on Performance of Individual Surgeons in Thyroid Surgery: Prospective Cross Sectional Multicentre Study

Objective: To determine the association between surgeons’ experience and postoperative complications in thyroid surgery. Design: Prospective cross sectional multicentre study. Setting: High volume referral centres in five academic hospitals in France. Participants: All patients who underwent a thyroidectomy undertaken by every surgeon in these hospitals from 1 April 2008 to 31 December 2009. Main outcome measures: Presence of two permanent major complications (recurrent laryngeal nerve palsy or hypoparathyroidism), six months after thyroid surgery. We used mixed effects logistic regression to determine the association between length of experience and postoperative complications. Results: 28 surgeons completed 3574 thyroid procedures during a one year period. Overall rates of recurrent laryngeal nerve palsy and hypoparathyroidism were 2.08% (95% confidence interval 1.53% to 2.67%) and 2.69% (2.10% to 3.31%), respectively. In a multivariate analysis, 20 years or more of practice was associated with increased probability of both recurrent laryngeal nerve palsy (odds ratio 3.06 (1.07 to 8.80), P=0.04) and hypoparathyroidism (7.56 (1.79 to 31.99), P=0.01). Surgeons’ performance had a concave association with their length of experience (P=0.036) and age (P=0.035); surgeons aged 35 to 50 years had better outcomes than their younger and older colleagues. Conclusions: Optimum individual performance in thyroid surgery cannot be passively achieved or maintained by accumulating experience. Factors contributing to poor performance in very experienced surgeons should be explored further

Detection of recurrent nerve paralysis: Development of a Computer Aided Diagnosis system

International audienceRecurrent nerve paralysis (RP) is one of the most frequent complications of thyroid surgery. It reduces vocal fold mobility. Nasal endoscopy, a mini-invasive procedure, is the reference procedure to detect RP, and is based on the examination of vocal fold mobility. A new approach based on laryngeal ultrasound acquisition and using a dedicated data analysis was designed to help with the automated detection of RP. One hundred and fifty subjects were enrolled for this feasibility study: 50 controls, 50 patients with RP and 50 patients without RP, according to nasal endoscopy. The ultrasound protocol was based on a ten seconds B-mode acquisition in an axial plane during normal breathing. Image processing included three steps: 1) the detection of two consecutive closing and opening images corresponding to extreme positions of vocal folds in the sequence of B-mode images; 2) the positioning of three landmarks and the robust tracking of these points using multi-pyramidal refined optical flow approaches; 3) the estimation of quantitative parameters indicating left and right fractions of mobility and motion symmetry. Results provided by the first two image processing steps were compared to those obtained by an expert. Motion symmetry and fraction of mobility indices were systematically computed using the automated procedures. Associated sensitivity and specificity values for detecting RP were then calculated. To optimize the performances of the system, a mixed CAD system, which integrates the automatic steps of image processing and a possible correction of its results by a trained operator was developed. Laryngeal ultrasound combined with appropriate image processing helped in the diagnosis of recurrent nerve paralysis and could be proposed as a first–line method

Diagnostic des lésions du tube digestif dans les traumatismes fermés de l'abdomen

PARIS6-Bibl.Pitié-Salpêtrie (751132101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Are oxyphil cells responsible for the ineffectiveness of cinacalcet hydrochloride in haemodialysis patients?

International audienceParathyroid glands consist primarily of chief cells. In some cases, the proportion of parathyroid oxyphil cells increases in patients with chronic kidney disease. We describe a case of secondary hyperparathyroidism (SHPT) in a patient treated with haemodialysis who initially received large doses of vitamin D and calcium (Ca) supplements, as well as high doses of cinacalcet hydrochloride (C-HCl), but without any effect on parathyroid hormone levels. Following a successful parathyroidectomy, histopathological examination revealed that two of the parathyroid glands consisted of 40% of oxyphil cells. Oxyphil cells have significantly more Ca-sensing receptors (CaSRs) than chief cells, suggesting that CaSRs are involved in the transdifferentiation of chief cells to oxyphil cells. C-HCl treatment leads to a significant increase in parathyroid oxyphil cell content. This case suggests that C-HCl may induce specific phenotypic alterations in hyperplastic parathyroid glands in patients with severe SHPT

Incidental parathyroidectomy during total thyroidectomy and functional parathyroid preservation: a retrospective cohort study

Abstract Background The published rate of incidental parathyroidectomy (IP) during thyroid surgery varies between 5.8% and 29%. The risk factors and clinical significance of postoperative transient hypocalcemia and permanent hypoparathyroidism are still debated. The aims of this study were to assess the clinical relevance of avoidable IP for transient hypocalcemia and permanent hypoparathyroidism, and to describe the risk factors for IP. Methods This retrospective cohort study included 1,537 patients who had a one-step total thyroidectomy in a high-volume endocrine surgery center between 2018 and 2019. Pathology reports were reviewed for incidentally removed parathyroid glands. Intrathyroidal parathyroid glands were excluded from the study. Demographic characteristics, potential risk factors, and postoperative calcium and PTH levels were compared between IP and control groups. Results Avoidable IP occurred in 234 (15.2%) patients. Patients with IP had a higher risk of transient hypocalcemia (17.9% vs. 11.5%, p = 0.006; odds ratio [OR] 1.68, 95% confidence interval [95% CI]1.16–2.45) and permanent hypoparathyroidism (4.7% vs. 1.6%, p = 0.002; OR 3.01, 95% CI 1.29–6.63) than patients without IP. Multivariate analysis showed that central lymph node dissection (CLND) and incidental removal of thymus tissue were independent risk factors for IP (OR 4.83, 95% CI 2.71–8.86, p < 0.001 and OR 1.72, 95% CI 1.02–2.82, p = 0.038). Conclusions Patients with IP were more likely to develop transient hypocalcemia and permanent hypoparathyroidism, indicating the clinical significance of avoidable IP for patients and the need for raising awareness among surgeons. Patients undergoing CLND are at a higher risk for IP, and should be adequately informed and treated. Any removal of thymus tissue should be avoided during CLND

Feasibility and safety of ambulatory transoral endoscopic thyroidectomy via vestibular approach (TOETVA)

BACKGROUND: In search of an ideal cosmesis, transoral endoscopic thyroidectomy via vestibular approach (TOETVA) has recently been introduced to avoid a visible scar. Although ambulatory thyroid surgery is considered safe in carefully selected patients, this remains unclear for TOETVA. METHODS: All consecutive adult patients who underwent ambulatory TOETVA or open thyroid surgery at a French university hospital were prospectively enrolled from 12/2020 until 11/2021. The primary outcome was postoperative morbidity (recurrent laryngeal nerve (RLN) palsy, re-intervention for bleeding, wound morbidity, or hospital readmission). The secondary outcome was quality of life (QoL), measured by a survey including a validated questionnaire (SF-12) and a modified thyroid surgery questionnaire six weeks after surgery. RESULTS: Throughout the study period, 374 patients underwent a unilateral lobectomy or isthmectomy in ambulatory setting, of which 34 (9%) as TOETVA (including 21 (62%) for a possible malignancy). In the TOETVA group, younger age (median 40 (IQR 35–50) vs. 51 (40–60) years, P < 0.001) and lower BMI (median 23.1 (20.9–25.4) vs. 24.9 (22.1–28.9) kg/m(2), P = 0.001) were noted. No cases were converted to open cervicotomy. TOETVA was at least as good as open cervicotomy with nil versus four (1%) re-interventions for bleeding, one temporary (5%) versus 13 (4%) (temporary) RLN palsies, and one (<1%) wound infection (open cervicotomy group). No hospital readmissions occurred in all ambulatory surgery patients. No differences were found in physical (P = 0.280) and mental (P = 0.569) QoL between TOETVA and open surgery. CONCLUSIONS: In carefully selected patients, the feasibility and safety of ambulatory TOETVA are comparable to open surgery. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s00268-022-06666-y

Prognostic impact of lymph node characteristics after therapeutic neck dissection for classic N1 papillary thyroid cancer

Abstract: Background The impact of lymph node characteristics on mortality and recurrence remains controversial. This study evaluated the prognostic impact of lymph node characteristics in a large, homogenous cohort of patients with therapeutic neck dissection for clinically N1 classic papillary thyroid cancer (PTC).Methods All consecutive adult patients with therapeutic central and lateral neck dissection for PTC at a French referral centre were prospectively enrolled from January 2000 until June 2021. The primary outcome was the impact of lymph node characteristics in predicting a disease event (persistence or recurrence), using univariable and multivariable logistic regression modelling.Results A total of 462 patients were included. Lymph node capsular rupture was seen in 260 patients (56.3 per cent). Median maximum lymph node size was 15 (i.q.r. 9-23) mm. The median central, lateral, and total lymph node ratio (LNR) was 0.50 (i.q.r. 0.22-0.75), 0.15 (i.q.r. 0.07-0.29), and 0.26 (i.q.r. 0.14-0.41), respectively. After a median follow-up of 93 (i.q.r. 50-149) months, 182 (39.4 per cent) patients had a disease event. After multivariable analysis, the number of harvested lymph node >35 (OR 2.33 (95 per cent c.i. 1.10-4.95)), presence of lymph node capsular rupture (OR 1.92 (1.17-3.14)), and total LNR >0.20 (OR 2.37 (1.08-5.19)) and >0.40 (OR 4.92 (1.61-15.03)) predicted a disease event. An LNR of 0.20 predicted a disease event with a sensitivity of 80.8 per cent and a specificity of 50.4 per cent.Conclusion Disease persistence or recurrence after thyroidectomy with therapeutic neck dissection for classic PTC with preoperative nodal disease appears to depend on number of harvested lymph node, presence of lymph node capsular rupture, and total LNR

Extensive thyroidectomy in Graves' disease.

BACKGROUND: The best surgical treatment for hyperthyroidism caused by Graves' disease remains a controversial subject. METHODS: Seven hundred fourteen consecutive patients underwent total or near-total thyroidectomy for Graves' disease in a 13-year period. In a first analysis, postoperative rates of suffocating hematoma, wound infection, recurrent laryngeal nerve (RLN) palsy, hypoparathyroidism, and persistence or recurrence of hyperthyroidism, were studied and compared with the same parameters in 4,426 patients who underwent bilateral thyroid gland resection for other conditions. A second analysis identified factors associated with postoperative complications among Graves' disease patients. RESULTS: Comparing Graves' disease patients with patients who had bilateral thyroid resection for other conditions, the transient morbidity rate was 13.3% versus 8.2% (p < 0.0001), with 10.2% versus 5.0% (p < 0.0001) hypoparathyroidism, 2.2% versus 1.7% (p = 0.35) RLN palsy, 1.7% versus 0.9% (p < 0.05) suffocating hematoma, and 0.3% versus 0.4% (p = 0.67) wound infection, respectively. Permanent morbidity rate was 2% versus 2.2% (p = 0.72), including 0.4% versus 0.6% RLN palsy and 1.5% versus 1.7% hypoparathyroidism. Among the Graves' disease patients, univariate analysis revealed that those who experienced postoperative complications had a higher weight resected thyroid gland (odds ratio = 1.5; 95% CI, 1.0-2.3) and a higher rate of total thyroidectomy (24.4% versus 19.5%, odds ratio = 2.2; 95% CI, 1.4-3.4) than patients without complications. In the multivariable model, these two factors remained independent. There was no recurrence of hyperthyroidism with a median followup of 6.7 years (interquartile range 4.1 to 10.1 years). Persistent hyperthyroidism developed in three patients. CONCLUSIONS: Total or near-total thyroidectomy is an effective and safe treatment for Graves' disease when performed by an experienced surgeon

Medios de comunicación y gobernanza turística en Mar del Plata

Se propone el desarrollo de un proyecto de investigación a través del cual observar el vínculo medios de comunicación local - turismo local, a partir de la indagación del contenido de la información relacionada con el turismo presente en medios de prensa gráfica local, a fin de determinar el papel específico que los mismos juegan en los procesos de gobernanza turística local, como así también, realizar una evaluación integral de la gobernanza turística en Mar del Plata.Fil: Cacciutto, Mariangel. Universidad Nacional de Mar del Plata. Facultad de Ciencias Económicas y Sociales; Argentina.Fil: Roldán, Nadia G. Universidad Nacional de Mar del Plata. Facultad de Ciencias Económicas y Sociales; Argentina.Fil: Castellucci, Daniela I. Universidad Nacional de Mar del Plata. Facultad de Ciencias Económicas y Sociales; Argentina.Fil: Corbo, Yanina A. Universidad Nacional de Mar del Plata. Facultad de Ciencias Económicas y Sociales; Argentina.Fil: Cruz, Gonzalo. Universidad Nacional de Mar del Plata. Facultad de Ciencias Económicas y Sociales; Argentina.Fil: Barbini, Bernarda. Universidad Nacional de Mar del Plata. Facultad de Ciencias Económicas y Sociales; Argentina.Fil: Navarro, Viviana Mariel. Universidad Nacional de la Patagonia Austral; Argentina.Fil: Ferrari, Silvia Noemí. Universidad Nacional de la Patagonia Austral; Argentina