How Useful Are Perioperative Biochemical Parameters in Predicting the Duration of Calcium and/or Vitamin D Supplementation After Total Thyroidectomy?

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Feasibility on the use of intraoperative vagal nerve stimulation in gasless, transaxillary endoscopic, and robotic-assisted thyroidectomy

BACKGROUND: Intraoperative nerve stimulation (IONS) could potentially reduce the incidence of recurrent laryngeal nerve (RLN) injury in thyroidectomy. The current study aimed at demonstrating the technical feasibility of using IONS in gasless, transaxillary endoscopic thyroidectomy (GTET) and robotic-assisted thyroidectomy (RAT) with conventional nerve stimulator probe and comparing the overall accuracy between two different nerve stimulation techniques, namely the direct RLN stimulation and the indirect stimulation via the vagus nerve (VN group), in predicting postoperative RLN function. METHODS: From 2009 to 2010, 60 (17.1%) patients underwent endoscopic thyroidectomy using IONS. Thirty-three (55.0%) patients had direct intraoperative RLN stimulation (RLN group), whereas 27 (45.0%) patients had stimulation to the VN (VN group). Total number of nerves at risk was 76. The results of IONS were confirmed by the postoperative vocal cord movement on laryngoscopy. RESULTS: Patient demographics, surgical indications, resection type, size of dominant nodule, excised gland weight, and final pathology were similar between the two groups. The number of vocal cord palsies in the RLN and VN groups was 3 (7.3%) and 2 (5.7%), respectively. Compared with the VN group, the RLN group had a significantly lower percentage of true negatives (78.0% vs. 94.3%, P=.045) and higher percentage of false positives (14.6% vs. 0.0%, P=.018). Overall accuracy was higher in the VN group. CONCLUSIONS: The current study demonstrated the technical feasibility of using conventional open-nerve stimulator probe in both GTET and RAT. Indirect stimulation via the VN produced more reliable and accurate IONS test results than direct RLN stimulation.published_or_final_versio

Endoscopic thyroidectomy: a literature review and update

Since the first report of endoscopic subtotal parathyroidectomy in 1996, a variety of endoscopic surgical approaches has been reported. These endoscopic approaches include the minimally-invasive video-assisted thyroidectomy (MIVAT), the endoscopic lateral approach, the lateral mini-incision approach, the anterior/chest (hybrid) approach, the transaxillary approach, the axillobreast approach, the post-auricular and axillary approach, and other novel experimental approaches. Some of these approaches could be done with the assistance of the da Vinci robot (i.e. robotic-assisted thyroidectomy). For simplification, these approaches could be categorized into the cervical/direct approach and the extra-cervical/indirect approach. Each technique or approach has its own benefits and weaknesses. Currently, there is no preferred approach in the literature and the choice seems to be determined by the surgeon’s own experience and the patient’s preference. In our experience, the transaxillary approach was a technically more challenging procedure and was associated with longer hospital stay, longer operating time, more immediate pain, and increased overall RLN injury and morbidity than MIVAT. The 6-month scar appearance and patient satisfaction were similar between the two procedures.postprin

New molecular targeted therapy and redifferentiation therapy for radioiodine-refractory advanced papillary thyroid carcinoma: Literature review

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Graves’ Ophthalmopathy as an Indication Increased the Risk of Hypoparathyroidism After Bilateral Thyroidectomy

BACKGROUND: Studies have evaluated the effect of thyroidectomy on the course of Graves' ophthalmopathy (GO) but it is unclear how GO as an indication might affect surgical outcomes. We aimed to evaluate the impact of this indication on surgical outcomes in Graves' disease (GD). METHODS: From 1995 to 2008, 329 patients with GD underwent thyroidectomy. Patients were stratified into two groups, namely, those with GO as indication (GO) and those with non-GO indication (non-GO). Outcomes were compared between the groups and outcomes with significance were further analyzed by multivariate analyses to determine independent factors. RESULTS: The GO group was significantly older (P < 0.001), had more males (P < 0.001), and fewer relapses (P < 0.001) than the non-GO group. It also had a higher proportion of total/near-total thyroidectomy (P < 0.001), despite a shorter operating time (P = 0.024) and less blood loss (P = 0.010). When only total/near-total thyroidectomy was considered, the GO group had significantly more permanent hypoparathyroidism than the non-GO group (9.2 vs. 1.6%, P = 0.038), but the rate of permanent hypoparathyroidism was similar in the two groups when only those with parathyroid autotransplantation were considered. Other complications were similar between the two groups. By multivariate analysis, GO as indication was an independent risk factor for temporary (OR 1.97, P = 0.033) and permanent hypoparathyroidism (OR 4.76, P = 0.007). CONCLUSION: GO as a surgical indication (i.e., unstable or active GO requiring ophthalmic treatment or follow-up) was associated with increased risk of temporary and permanent hypoparathyroidism after bilateral thyroidectomy. Routine parathyroid autotransplantation may reduce the risk of permanent hypoparathyroidism in this select patient group.published_or_final_versionSpringer Open Choice, 21 Feb 201

A comparison of surgical morbidity and scar appearance between gasless, transaxillary endoscopic thyroidectomy (GTET) and minimally invasive video-assisted thyroidectomy (VAT)

BACKGROUND: The gasless, transaxillary endoscopic thyroidectomy (GTET) and minimally invasive video-assisted thyroidectomy (VAT) are both well-recognized endoscopic thyroid procedures, but how their postoperative outcomes are compared remains unclear. The present study was designed to compare surgical morbidities/complications and scar appearance between GTET and VAT at our institution. METHODS: Of the 141 patients eligible for endoscopic thyroidectomy, 96 (68.1 %) underwent GTET and 45 (31.9 %) underwent VAT. Patient demographics, indications, operative findings, pain scores on days 0 and 1, and surgical morbidities were compared between the two groups. At 6 months after surgery, all patients were asked about their satisfaction on the cosmetic result by giving a score (Patient Satisfaction Score or PSS) and their scar appearance was assessed by the 11 domains in the Patient and Observer Scar Assessment Scale (POSAS). RESULTS: GTET was associated with a significantly longer operating time (84 vs. 148 min, p = 0.005), higher pain scores on days 0 and 1 (2.9 vs. 2.3, p = 0.042 and 2.2 vs. 1.7, p = 0.033, respectively), overall recurrent laryngeal nerve (RLN) injury (6.3 vs. 0 %, p = 0.043), and overall morbidity rates (12.5 vs. 2.2 %, p = 0.049) than VAT. The actual individual score for the 11 domains in POSAS and for PSS remained similar between the two groups. They remained similar even when patients with morbidity were excluded. CONCLUSIONS: GTET was a technically more challenging procedure and was associated with longer hospital stay, longer operating time, more immediate pain, and increased overall RLN injury and morbidity than VAT. The 6-month POSAS and PSS were similar between the two procedures.published_or_final_versio

A systematic review and meta-analysis on acoustic voice parameters after uncomplicated thyroidectomy

BACKGROUND: Postthyroidectomy voice changes are common even without apparent laryngeal nerve injury. Our study evaluated the impact of open cervical thyroidectomy on five acoustic voice parameters in the early (< 3 months) and late (≥ 3 months) postoperative periods. METHODS: A systematic review was performed to identify studies that quantitatively assessed voice quality by acoustic voice analysis before and after thyroidectomy. Parameters included average fundamental frequency (F0 , Hz), jitter (%), shimmer (%), noise-to-harmonic ratio (NHR), and maximum phonation time (MPT) (in secs). Meta-analysis was performed using both fixed- and random-effects models. RESULTS: A total of 896 patients were analyzed. Relative to baseline, F0 significantly worsened in the early period (from 194.9 ± 34.9 Hz to 188.0 ± 34.0 Hz, P = 0.001). This was equivalent to a quarter-tone loss (P = 0.004). Shimmer (from 3.15 ± 1.59% to 3.19 ± 1.70%, P = 0.040) and MPT (from 17.9 secs to 16.7 secs, P = 0.046) also worsened in the early period, whereas jitter and NHR remained unchanged in the early and late periods. Males suffered greater deterioration in F0 (from 120.6 ± 18.8 Hz to 111.0 ± 18.5 Hz, P = 0.048) and in NHR (from 0.12 ± 0.02 to 0.16 ± 0.03, P = 0.019) than females in the early period. Four of the five acoustic parameters (F0 , jitter, shimmer, and NHR) significantly worsened after total thyroidectomy (TT) and not after lesser resection. CONCLUSION: F0 , shimmer, and MPT significantly worsened in the early and not in the late postoperative period. F0 impairment was perceptually significant. Males and those undergoing TT suffered greater voice impairment than their counterparts during the early period.postprin

Postablation stimulated thyroglobulin level is an important predictor of biochemical complete remission after reoperative cervical neck dissection in persistent/recurrent papillary thyroid carcinoma

BACKGROUND: The efficacy of reoperative cervical neck dissection (RND) in achieving biochemical complete remission (BCR) (or postreoperation stimulated thyroglobulin [sTg] of 2 ng/mL) were correlated with the postreoperation sTg levels after RNDs. Patients' clinicopathological characteristics, operative findings, and subsequent RNDs were compared between those with BCR after RNDs and those without. RESULTS: Those with postablation sTg levels of 2 ng/mL. Overall BCR gradually decreased after each subsequent RND. Postablation sTg significantly correlated with postreoperation sTg (rho = 0.509, p < 0.001). After adjusting for the number of metastatic lymph nodes excised at first RND and presence of extranodal extension, postablation sTg of </= 0.2 ng/mL was the only independent factor for BCR after one or more RNDs (odds ratio 37.0, 95 % confidence interval 5.68-250.0, p = 0.001). CONCLUSIONS: Only a third of patients who underwent one or more RNDs for persistent/recurrent PTC had BCR afterward. Postablation sTg level was an independent factor for BCR. Completeness of the initial operation is important for the subsequent success of RND.published_or_final_versio

A review of risk factors and timing for postoperative hematoma after thyroidectomy: is outpatient thyroidectomy really safe?

BACKGROUND: Although postoperative hematoma after thyroidectomy is uncommon, patients traditionally have been advised to stay overnight in the hospital for monitoring. With the growing demand for outpatient thyroidectomy, we assessed its safety and feasibility by evaluating the potential risk factors and timing of postoperative hematoma after thyroidectomy. METHODS: From 1995-2011, 3,086 consecutive patients underwent thyroidectomy at our institution; of these, 22 (0.7 %) developed a postoperative hematoma that required surgical reexploration (group I). Potential risk factors were compared between group I and those without hematoma (n = 3,045) or with hematoma but not requiring reexploration (n = 19; group II). Variables that were significant in the univariate analysis were entered into multivariate analysis by binary logistic regression analysis. RESULTS: Group I was significantly more likely to have undergone previous thyroid operation than group II (27.3 vs. 8.2 %, p = 0.007). The median weight of excised thyroid gland (71.8 vs. 40 g, p = 0.018) and the median size of the dominant nodule (4.1 vs. 3 cm, p = 0.004) were significantly greater in group I than group II. Previous thyroid operation (odds ratio (OR) = 4.084; 95 % confidence interval (CI), 1.105-15.098; p = 0.035) and size of dominant nodule (OR = 1.315; 95 % CI, 1.024-1.687; p = 0.032) were independent factors for hematoma. Sixteen (72.7 %) had hematoma within 6 h, whereas the other 6 (27.3 %) had hematoma at 6-24 h. CONCLUSIONS: Previous thyroid operation and large dominant nodule were independent risk factors for hematoma requiring surgical reexploration. Given that a quarter of hematoma occurred between 6 to 24 h after surgery, routine outpatient thyroidectomy could not be recommended.published_or_final_versio

Thyroid surgery for elderly patients: Are they at increased operative risks?

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