The overwhelming majority but not all motor fibers of the bifid recurrent laryngeal nerve are located in the anterior extralaryngeal branch

BACKGROUND: Few small studies reported that motor fibers are located exclusively in the anterior branch of the bifid recurrent laryngeal nerve (RLN). The aim of this study was to investigate the location of the motor fibers to the intrinsic muscles of the larynx among the bifid RLNs, and assess the prevalence of RLN injury with respect to nerve branching in a pragmatic trial. METHODS: This was a prospective cohort study of 1250 patients who underwent total thyroidectomy with intraoperative neural monitoring. The primary outcome was the position of the motor fibers in the bifid nerves. Adduction of the vocal folds was detected by the endotracheal tube electromyography and abduction by finger palpation of muscle contraction in the posterior cricoarytenoid. The secondary outcomes were the prevalence of the RLN branching and the prevalence of RLN injury in bifid versus non-bifid nerves. RESULTS: The bifid RLNs were identified in 613/2500 (24.5 %) nerves at risk, including 92 (7.4 %) patients with bilateral bifurcations. The motor fibers were present exclusively in the anterior branch in 605/613 (98.7 %) bifid nerves, and in both the RLN branches in 8/613 (1.3 %) bifid nerves. Prevalence of RLN injury was 5.2 versus 1.6 % for the bifid versus non-bifid nerves (p < 0.001), odds ratio 2.98 (95 % confidence interval 1.79–4.95; p < 0.001). CONCLUSIONS: The motor fibers of the RLN are located in the anterior extralaryngeal branch in the vast majority of but not in all patients. In rare cases, the motor fibers for adduction or abduction are located in the posterior branch of the RLN. As the bifid nerves are more prone to injury than non-branched nerves, meticulous dissection is recommended to assure preservation of all the branches of the RLN during thyroidectomy

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

INTRODUCTION: Thyroidectomy is among the most commonly performed procedures involving the endocrine glands and the development of advanced surgical methods combined with a strife for performing the operation in a manner that is minimally invasive for the patient has considerably increased the need for instruments that would limit surgical trauma. AIM: To compare of the outcomes of total thyroidectomy operations with and without the use of ultrasonic harmonic FOCUS dissecting shears. MATERIAL AND METHODS: Eighty-two patients with a bilateral, non-toxic multinodular goiter were randomized to two groups of 41 patients each. Total thyroidectomy was performed in each patient. In the clip-ligation group (CL-G), during thyroidectomy, the superior thyroid vessels were clipped and bipolar coagulation was used to secure smaller vessels, whereas in the harmonic FOCUS group (HF-G), a harmonic device was used to dissect and divide all the thyroid vessels. The statistical analysis included the mean operative time, blood loss, postoperative morbidity and cost-effectiveness. RESULTS: HF-G vs. CL-G operations were shorter (45.4 ±8.7 min vs. 64.5 ±14.2 min; p < 0.001), characterized by a lower mean blood loss (29.9 ±9.8 ml vs. 56.8 ±11.0 ml; p < 0.001) and appeared to be more cost-effective (666.2 ±37.5 EUR vs. 718.0 ±69.2 EUR; p < 0.01). No major complications were observed in both groups. CONCLUSIONS: In total thyroidectomy operations, the harmonic FOCUS is safe and facilitates dissection, allowing for a significant decrease in operative time. Other benefits include lower blood loss and a slightly decreased cost of the procedure

Nodal recurrence in the lateral neck after total thyroidectomy with prophylactic central neck dissection for papillary thyroid cancer

PURPOSE: The aim of this study was to examine risk factors for nodal recurrence in the lateral neck (NRLN) in patients with papillary thyroid cancer (PTC) who underwent total thyroidectomy with prophylactic central neck dissection (TT + pCND). METHODS: This was a retrospective cohort study of patients with PTC who underwent TT + pCND. Data of all patients treated over a 10-year period (between 1998 and 2007) were analysed. The primary outcome was prevalence of NRLN within the 5-year follow-up after initial surgery. Predictors of NRLN were determined in the univariable and multivariable analysis. RESULTS: Of 760 patients with PTC included in this study, 44 (6.0 %) developed NRLN. In the univariable analysis, the following factors were identified to be associated with an increased risk of NRLN: positive/negative lymph node ratio ≥0.3 (odds ratio (OR) 14.50, 95 % confidence interval (CI) 7.21 to 29.13; p < 0.001), central lymph node metastases (OR 7.47, 95 % CI 3.63 to 15.38; p < 0.001), number of level VI lymph nodes <6 in the specimen (OR 2.88, 95 % CI 1.21 to 6.83; p = 0.016), extension through the thyroid capsule (OR 2.55, 95 % CI 1.21 to 5.37; p = 0.013), localization of the tumour within the upper third of the thyroid lobe (OR 2.35, 95 % CI 1.27 to 4.34; p = 0.006) and multifocal lesions (OR 1.85, 95 % CI 1.01 to 3.41; p = 0.048). CONCLUSIONS: Central lymph node metastases together with positive to negative lymph node ratio ≥0.3 represent the strongest independent prognostic factors for the PTC recurrence in the lateral neck

Subtotal parathyroidectomy for secondary renal hyperparathyroidism : a 20-year surgical outcome study

AIM: The aim of this study was to evaluate the outcomes of surgery for patients with secondary renal hyperparathyroidism (rHPT). METHODS: This is a retrospective cohort study. Our institutional database was searched for eligible patients treated in 1995–2014. The inclusion criterion was initial parathyroidectomy for rHPT. Clinical and follow-up data were analyzed to estimate the cure rate (primary outcome), and morbidity (secondary outcome). RESULTS: The study group comprised 297 patients (154 females, age 44.5 ± 13.7 years, follow-up 24.6 ± 10.5 months), including 268 (90.2 %) patients who had underwent subtotal parathyroidectomy, and 29 (9.8 %) who had had incomplete parathyroidectomy. Intraoperative iPTH assay was utilized in 207 (69.7 %) explorations. Persistent rHPT occurred in 12/268 (4.5 %) patients after subtotal parathyroidectomy and 5/29 (17.2 %) subjects after incomplete parathyroidectomy (p = 0.005). The patients operated on with intraoperative iPTH assay had a higher cure rate than non-monitored individuals, 201/207 (97.1 %) vs. 79/90 (87.8 %), respectively (p = 0.001). In-hospital mortality occurred in 1/297 (0.3 %) patient. The hungry bone syndrome occurred in 84/268 (31.3 %) patients after subtotal parathyroidectomy and 2/29 (6.9 %) subjects after incomplete parathyroidectomy (p = 0.006). Transient recurrent laryngeal nerve paresis occurred in 14/594 (2.4 %) and permanent in 5/594 (0.8 %) nerves at risk. CONCLUSIONS: Subtotal parathyroidectomy is a safe and efficacious treatment for patients with rHPT. Utilization of intraoperative iPTH assay can guide surgical exploration and improve the cure rate

Trends in prevalence of thyroid cancer over three decades : a retrospective cohort study of 17,526 surgical patients

INTRODUCTION: Thyroid cancer (TC) incidence has been increasing in recent years. The aim of this study was to investigate our institution-based estimates of operative volumes for TC over the last three decades. MATERIALS AND METHODS: This was a retrospective cohort study of patients undergoing thyroid surgery at our institution. Patient characteristics were reviewed in three subgroups: Group I (treated in 1981–1986), Group II (treated in 1987–2002), and Group III (treated in 2003–2012). RESULTS: TC was diagnosed in 1578/17,526 (9.0 %) thyroid operations. Incidence of TC increased from 3.7 % in Group I to 10.4 % in Group III (p < 0.001). Incidence of papillary TC increased form 40.6 % in Group I to 81.3 % in Group III (p < 0.001). In the latter group, 23.5 % of all papillary TCs were diagnosed in patients with Hashimoto’s disease. Meanwhile, incidence of anaplastic TC decreased from 16.2 % in Group I to 2.1 % in Group III patients (p < 0.001). pT1 tumors were diagnosed in 8.1 % Group I and 54.8 % Group III (p < 0.001), whereas pT4 tumors were identified in 40.5 % Group I, 2.4 % Group II, and 0.84 % Group III subjects (p < 0.001). pT3 tumors were found in 51.6 % Group I, whereas multifocal papillary TCs were found in 15.7 % Group III patients, the latter with a higher prevalence of pN1 stage (p < 0.001). CONCLUSIONS: The following trends in surgical volume for TC were identified throughout the study period: a fivefold increase of thyroid operations for TC, a threefold increase in incidence of papillary TC, and an eightfold decrease in incidence of anaplastic TC. It is of interest that a significant increase in incidence of multifocal papillary TC in young female patients with Hashimoto’s disease was found over time

Coexistence of papillary thyroid cancer with Hashimoto thyroiditis

AIMS: Conflicting data have been reported with regard to Hashimoto thyroiditis (HT) and risk of malignancy. The aim of this study was to evaluate coexistence of papillary thyroid cancer (PTC) with HT. PATIENTS AND METHODS: This is a retrospective cohort study in which HT was diagnosed in 452 (F/M ratio = 405:47, median age 53.5 ± 12.1 years) of 7,545 patients qualified for thyroidectomy throughout the years 2002 to 2010. Pathological reports were reviewed to identify prevalence of PTC in HT vs. non-HT patients. RESULTS: PTC was diagnosed in 106 of 452 (23.5 %) HT patients vs. 530 of 7,093 (7.5 %) non-HT patients (p < 0.001). Metastases to level VI lymph nodes were observed in 81 of 106 (76.4 %) patients with PTC in HT vs. 121 of 530 (22.8 %) patients with PTC in non-HT disease (p < 0.001). CONCLUSIONS: HT was associated with a threefold increase of PTC prevalence as compared to other non-HT thyroid diseases, and the spread of PTC to level VI lymph nodes was four times more frequent in HT than in non-HT patients

Randomized controlled trial of visualization versus neuromonitoring of the external branch of the superior laryngeal nerve during thyroidectomy

BACKGROUND: Injury to the external branch of the superior laryngeal nerve (EBSLN) during thyroidectomy results in a lowered fundamental frequency of the voice and deteriorated voice performance in producing high-frequency sounds. It remains unclear if the use of intraoperative nerve monitoring (IONM) can improve the clinical outcome of thyroidectomy in terms of preserved individual voice performance. This study was designed to test that hypothesis. METHODS: A total of 210 consenting female patients planned for total thyroidectomy were randomly assigned to two groups equal in size (n = 105): visual inspection of the EBSLN and RLN vs. this plus additional EBSLN and RLN monitoring. The primary outcome was the identification rate of the EBSLN. The secondary outcomes included: anatomical variability of the EBSLN according to the Cernea classification and changes in postoperative voice performance. Voice assessment included pre- and postoperative videostrobolaryngoscopy and an analysis of maximum phonation time (MPT), voice level (VL), fundamental frequency (Fo), and voice quality rating on the GRBAS scale. RESULTS: The following differences were found for operations without vs. with IONM: identification rate of the EBSLN was 34.3 % vs. 83.8 % (p < 0.001), whereas a 10 % or higher decrease in phonation parameters was found in 10 % vs. 2 % patients for MPT (p = 0.018), 13 % vs. 2 % for VL (p = 0.003), and 9 % vs. 1 % for Fo (p = 0.03), a change in the GRBAS scale > 4 points in 7 % vs. 1 % (p = 0.03), and temporary RLN injury was found in 2 % vs. 1 % (p = 0.56), respectively. CONCLUSIONS: The use of IONM significantly improved the identification rate of the EBSLN during thyroidectomy, as well as reduced the risk of early phonation changes after thyroidectomy

Clinical validation of S-DetectTM mode in semi-automated ultrasound classification of thyroid lesions in surgical office

Background: In recent years well-recognized scientific societies introduced guidelines for ultrasound (US) malignancy risk stratification of thyroid nodules. These guidelines categorize the risk of malignancy in relation to a combination of several US features. Based on these US image lexicons an US-based computer-aided diagnosis (CAD) systems were developed. Nevertheless, their clinical utility has not been evaluated in any study of surgeon-performed office US of the thyroid. Hence, the aim of this pilot study was to validate s-DetectTM mode in semi-automated US classification of thyroid lesions during surgeon-performed office US. Methods: This is a prospective study of 50 patients who underwent surgeon-performed thyroid US (basic US skills without CAD vs. with CAD vs. expert US skills without CAD) in the out-patient office as part of the preoperative workup. The real-time CAD system software using artificial intelligence (S-DetectTM for Thyroid; Samsung Medison Co.) was integrated into the RS85 US system. Primary outcome was CAD system added-value to the surgeon-performed office US evaluation. Secondary outcomes were: diagnostic accuracy of CAD system, intra and interobserver variability in the US assessment of thyroid nodules. Surgical pathology report was used to validate the pre-surgical diagnosis. Results: CAD system added-value to thyroid assessment by a surgeon with basic US skills was equal to 6% (overall accuracy of 82% for evaluation with CAD vs. 76% for evaluation without CAD system; P<0.001), and final diagnosis was different than predicted by US assessment in 3 patients (1 more true-positive and 2 more true-negative results). However, CAD system was inferior to thyroid assessment by a surgeon with expert US skills in 6 patients who had false-positive results (P<0.001). Conclusions: The sensitivity and negative predictive value of CAD system for US classification of thyroid lesions were similar as surgeon with expert US skills whereas specificity and positive predictive value were significantly inferior but markedly better than judgement of a surgeon with basic US skills alone

Intraoperative nerve monitoring can reduce prevalence of recurrent laryngeal nerve injury in thyroid reoperations : results of a retrospective cohort study

BACKGROUND: The prevalence of recurrent laryngeal nerve (RLN) injury is higher in repeat than in primary thyroid operations. The use of intraoperative nerve monitoring (IONM) as an aid in dissection of the scar tissue is believed to minimize the risk of nerve injury. The aim of this study was to examine whether the use of IONM in thyroid reoperations can reduce the prevalence of RLN injury. METHODS: This was a retrospective cohort study of patients who underwent thyroid reoperations with IONM versus with RLN visualization, but without IONM. The database of thyroid surgery was searched for eligible patients (treated in the years 1993–2012). The primary outcomes were transient and permanent RLN injury. Laryngoscopy was used to evaluate and follow RLN injury. RESULTS: The study group comprised 854 patients (139 men, 715 women) operated for recurrent goiter (n = 576), recurrent hyperthyroidism (n = 36), completion thyroidectomy for cancer (n = 194) or recurrent thyroid cancer (n = 48), including 472 bilateral and 382 unilateral reoperations; 1,326 nerves at risk (NAR). A group of 306 patients (500 NAR) underwent reoperations with IONM and 548 patients (826 NAR) had reoperations with RLN visualization, but without IONM. Transient and permanent RLN injuries were found respectively in 13 (2.6 %) and seven (1.4 %) nerves with IONM versus 52 (6.3 %) and 20 (2.4 %) nerves without IONM (p = 0.003 and p = 0.202, respectively). CONCLUSIONS: IONM decreased the incidence of transient RLN paresis in repeat thyroid operations compared with nerve visualization alone. The prevalence of permanent RLN injury tended to be lower in thyroid reoperations with IONM, but statistical validation of the observed differences requires a sample size of 920 NAR per arm