Does the surgical approach affect quality of life outcomes? – A comparison of minimally invasive parathyroidectomy with open parathyroidectomy

AbstractBackgroundQuality of life has been shown to improve significantly after successful parathyroid surgery and normalisation of serum calcium levels. What is not known is how much of that effect is related to the patient's perception of their procedure, and whether or not patients may perceive that a minimally invasive operation provides a better outcome than that of an open procedure.MethodsTwo hundred and two consecutive patients who had undergone parathyroid surgery were selected for telephone interview. Of that group, 152 had had an open parathyroidectomy and 50 a minimally invasive approach, either an endoscopic assisted or a direct minimal access approach. Post-operative quality of life was assessed with both the Short Form-36 Health Survey (SF-36) and a disease-specific questionnaire. The SF-36 results were compared with a matched Australian population.ResultsPatients who underwent a direct minimal access parathyroidectomy had significantly better vitality and emotional role limitation scores than those having an open procedure. The health status scores of all patients having surgery for primary hyperparathyroidism were significantly lower in five out of the eight domains than those of a matched Australian population. There was a significantly lower incidence of post-operative symptoms in the minimally invasive group as a whole.ConclusionsMinimally invasive parathyroidectomy is associated with a greater improvement in post-operative quality of life than the open technique despite the fact that both result in equivalent normalisation of serum calcium levels. It is not clear if this is due to differences in the technique itself or is related to the patients' perceptions of having had a “less invasive” surgical procedure

Parathyroidectomy for patients with secondary hyperparathyroidism in a changing landscape for the management of end-stage renal disease

Background: The landscape of patients with end-stage renal disease is changing with the increasing availability of kidney transplantation. In the near future, a less aggressive approach to treat secondary hyperparathyroidism might be beneficial. We report outcomes of parathyroidectomy for end-stage renal disease-related hyperparathyroidism comparing the outcomes of limited, subtotal, and total parathyroidectomy. Methods: We performed a retrospective analysis of prospectively collected data. Patients were divided into 3 parathyroidectomy subgroups: limited ( Results: In total, 195 patients were included for analysis of whom 13.8% underwent limited parathyroidectomy, 46.7% subtotal parathyroidectomy, and 39.5% total parathyroidectomy. Preoperative parathyroid hormone levels (pg/mL) were 471 (210-868), 1,087 (627-1,795), and 1,070 (475-1,632) for the limited, subtotal, and total parathyroidectomy groups, respectively (P < .001). A decrease in serum parathyroid hormone was seen in all groups; however, postoperative levels remained greater in the limited parathyroidectomy group compared to the subtotal and total parathyroidectomy groups (P < .001). Serum calcium, phosphate, and alkaline phosphatase levels decreased in all groups to within the reference range. In the limited parathyroidectomy group, persistent disease and recurrence occurred more frequently (P = .02 and P = .07, respectively). Conclusion: Subtotal parathyroidectomy is the optimal strategy in an era with an increasing availability of kidney transplantation and improved regimens of dialysis. In this changing practice, the approach to parathyroid surgery, however, might shift to a less aggressive and patient-tailored approach. (C) 2020 Elsevier Inc. All rights reserved

Surgery alone for papillary thyroid microcarcinoma is less costly and more effective than long term active surveillance

Background: Papillary thyroid microcarcinoma is a subtype of thyroid cancer that may be managed with active surveillance rather than immediate surgery. Active surveillance decreases complication rates and may decrease health care costs. This study aims to analyze complication rates of thyroid surgery, papillary thyroid microcarcinoma recurrence, and survival rates. Additionally, the costs of surgery versus hypothetic active surveillance for papillary thyroid microcarcinoma are compared in an Australian cohort. Methods: Papillary thyroid microcarcinoma patients were included from a prospectively collected surgical cohort of patients treated for papillary thyroid cancer between 1985 and 2017. The primary outcomes were the complications of thyroid surgery, recurrence-free survival, overall survival, and cost of surgical treatment and active surveillance. Results: In a total of 349 patients with papillary microcarcinoma with a median age of 48 years (range, 18–90 years), the permanent operative complications rate was 3.7%. Postoperative radioactive iodine did not decrease recurrence-free survival (P = .3). The total cost of surgical treatment was $10,226 Australian dollars, whereas hypothetic active surveillance was at a yearly cost of$756 Australian dollars. Estimated cost of surgical papillary thyroid microcarcinoma treatment was equivalent to the cost of 16.2 years of active surveillance. Conclusion: Surgery may have a long-term economic advantage for younger Australian patients with papillary thyroid microcarcinoma who are likely to require more than 16.2 years of follow-up in an active surveillance scheme

Calsequestrin is decreased in the thyroid gland of patients with Graves’ disease – further evidence for a role of autoimmunity against this protein in Graves’ ophthalmopathy

Background: The pathogenesis of Graves’ ophthalmopathy (GO) and the mechanism for its link to thyroid autoimmunity is poorly understood. Our present research focuses on the role of the skeletal muscle calcium binding protein calsequestrin (CASQ1). Earlier studies showed that the CASQ1 gene was up-regulated in thyroid tissue from patients with GO compared to those with Graves’ hyperthyroidism (GH) without eye signs, however, the protein levels remained the same in both groups, raising the possibility that the orbital autoimmune reaction begins in the thyroid gland. Here, we measured the concentration of the CASQ1 protein in normal and Graves’ thyroid tissue, correlating levels with parameters of the eye signs, CASQ1 antibody levels and the CASQ1 gene polymorphism rs3838216, shown previously to be a risk factor for ophthalmopathy. Methods: The CASQ1 protein was measured by quantitative Western blotting. Following electrophoresis, samples were transblotted to polyvinyl difluoride (PVDF) membranes incubated with a 1:1000 dilution of a rabbit anti-CASQ1 antibody and incubated with an horseradish peroxidase (HRP)-conjugated goat anti-rabbit antibody, or anti-mouse antibodies for Glyceraldehyde 3-phosphate dehydrogenase (GAPDH). The protein concentrations were determined from density quantification using the Quantity One 4.4.0 ChemiDoc program and expressed as pmol/mg total protein by reference to CASQ1 standards. Results: Western blot analysis showed the presence of two forms of CASQ1 in the thyroid, of 50 and 60 kDa molecular weight respectively. In thyroid tissues, the mean (± SD) (GO 54.9±86.8 pmol/mg) concentration of the CASQ1 protein (GH 37.1±51.8 pmol/mg) was significantly reduced in patients with Graves’ disease , with or without ophthalmopathy, compared to normal thyroid tissues from control subjects with multi-nodular goitre or thyroid cancer (144.3±162.5 pmol/mg). The difference between GO and GH was not significant. The decreased CASQ1 protein levels in Graves’ thyroid tissues correlated with the homozygous genotype of the rs3838216 CASQ1 polymorphism. A two-fold increase in Levels of CASQ1 protein in toxic nodules compared to Graves’ hyperthyroidism was markedly significant. Conclusions: Decreased CASQ1 in the thyroid tissues of patients with Graves’ disease compared to normal thyroid tissues from control subjects may reflect consumption of the protein in the course of an autoimmune reaction against CASQ1 in the thyroid. Comparing CASQ1 protein levels in thyroid tissue from five patients with toxic nodular goitre (74.5±52.8) to controls showed no significance. The relative two fold increase in CASQ1 levels in toxic nodules compared to Graves’ disease suggests that this is due to the autoimmune reaction rather than the hyperthyroidism.11 page(s

Minimally Invasive Thyroid Surgery for Diagnostic Excision of Solitary Thyroid Nodules

Various techniques for minimally invasive thyroid surgery (MITS), including endoscopic and video-assisted procedures, have now been described. Based on our unit's experience with minimally invasive parathyroidectomy via a lateral incision, a similar technique for minimally invasive thyroid lobectomy has been developed and assessed. METHODS: The last 203 consecutive thyroid procedures using the MITS technique, performed between July 2002 and June 2006, comprised the study group. Inclusion criteria for initial surgery were: initial nodule < 3.0 cm; no preoperative evidence of malignancy; absence of clinical multinodular change. A 2.5- cm lateral incision, using a headlight illumination, provided optimal exposure. RESULTS: A total of 202 patients underwent 203 MITS procedures over the 4-year period, with one patient undergoing bilateral MITS. The procedures included 155 thyroid lobectomies and 48 nodule excisions; 31 of the patients underwent a minimally invasive parathyroidectomy (MIP) during which an ipsilateral thyroid nodule was removed. The mean tumour size was 17.3 mm, but the mean size of the thyroid lobe removed was 39.5 mm. Final diagnoses included benign multinodular goitre (26%), follicular adenoma (22%) and carcinoma (20%). The complication rate was low, with one permanent recurrent laryngeal nerve (RLN) palsy (anterior division only) (0.5%), four RLN neuropraxias which recovered (2%), and one haematoma not requiring re-operation (0.5%). The rate of complications was not significantly different from 819 conventional open hemithyroidectomies performed over the same period. CONCLUSION: MITS is a safe and feasible alternative to open thyroid surgery in appropriately selected cases. It offers a valuable option for diagnostic excision biopsy in patients with thyroid nodules demonstrating an “atypical” fine-needle biopsy whilst avoiding the need for a standard cervical “collar” incision