Truncal ligation of the inferior thyroid arteries does not affect the incidence of hypocalcaemia after thyroidectomy.

OBJECTIVE: To assess the effect of truncal ligation of the inferior thyroid arteries during bilateral subtotal thyroidectomy on the incidence of hypocalcaemia after thyroidectomy. DESIGN: Prospective non-randomised study. SETTING: Teaching hospital, Turkey. SUBJECTS: 216 patients who had bilateral subtotal thyroidectomy for non-toxic nodular goitre between 1990 and 1996. INTERVENTIONS: The trunk of the each inferior thyroid artery was simply ligated during bilateral subtotal thyroidectomy. MAIN OUTCOME MEASURES: Clinical examination, and measurement of serum calcium, ionised calcium, and inorganic phosphate concentrations before and after operation. RESULTS: Four patients (2%) had low concentrations of total and ionised calcium during the postoperative period. On physical examination three of them had spasms of the facial nerve, as seen in tetany. They were given calcium supplements orally and their laboratory results returned to reference ranges within 180 days. No patients developed permanent hypocalcaemia. CONCLUSION: Truncal ligation of the inferior thyroid arteries during bilateral subtotal thyroidectomy has no effect on the incidence of hypocalcaemia after thyroidectomy.     

Total thyroidectomy: the procedure of choice for toxic goitre

OBJECTIVE: Over the years, subtotal thyroidectomy has been the mainstay of treatment for toxic goitre; however, total thyroidectomy is increasingly being considered as the procedure of choice. This study aimed to review our experience with total thyroidectomy in toxic goitre and evaluate the outcome of this procedure. METHODS: A total of 67 consecutive patients who were diagnosed with toxic goitres and had total thyroidectomy from January 2003 to February 2005 were included in this prospective open study. The preoperative diagnosis in all patients was benign goitre. The surgical outcomes were reviewed with regard to mortality and morbidity. RESULTS: A standardized operative technique was adopted and practiced among all surgeons in our department. Of the 67 patients with toxic goitre, 36 (53.7%) patients had toxic multinodular goitre (Plummer's disease) and 31 (46.3%) patients had diffuse goitre (Graves' disease). Although there were no documented injuries to the recurrent laryngeal nerves, one patient had temporary hoarseness of voice. In our series of total thyroidectomy, 18 patients (26.8%) developed transient hypocalcaemia but only one patient (1.5%) had persistent hypocalcaemia. Four (5.9%) patients had occult papillary thyroid cancer and one patient (1.5%) had Hashimoto's thyroiditis discovered on histological examination. There were no other postoperative complications except for wound infection in one patient (1.5%). CONCLUSION: Total thyroidectomy should be considered as the procedure of choice for toxic goitres. It is paramount that sufficient attention be paid to the preservation of the laryngeal nerves and the parathyroid glands.     

Safety of total thyroidectomy

BACKGROUND: Total thyroidectomy is the preferred operation for multinodular goitre, Graves' disease and thyroid cancer. This study reviewed prospectively collected data on a personal consecutive series of 336 total thyroidectomies to assess whether results reported in world centres of excellence could also be achieved elsewhere. METHODS: Between 1991 and 2004, 336 total thyroidectomies (85% over the last 6 years) of median age 53 years (13-86 years) and male : female ratio of 1:4.3 were undertaken for multinodular goitre 232 (69%), Graves' disease 26 (7.7%), thyroid cancer 60 (17.9%) and other benign conditions 17 (5.4%). Thirty-nine patients had 2-stage procedures. No patient required median sternotomy. Parathyroid autotransplantation was carried out in 43 (12.8%). RESULTS: Permanent unilateral recurrent laryngeal nerve palsy occurred in 0.3% and permanent hypoparathyroidism in 1.8%. Significant temporary hypocalcaemia occurred in 13.4%. Non-significant temporary hypocalcaemia occurred in 23.8%, resulting in an overall rate of hypocalcaemia of 38.9% for the total series. Hypocalcaemia was more common after 1-stage compared with 2-stage surgeries (P < 0.001). Temporary hypocalcaemia was commoner after surgery for Graves' disease than surgery for other conditions. The rate of postoperative haemorrhage was 0.9% and wound infection, 1.5%. There was no postoperative mortality. CONCLUSION: Total thyroidectomy removes the disease process completely, lowers local recurrence rates and avoids the substantial risks of reoperative surgery. Total thyroidectomy is safe and can be carried out with low complication rates that are equal to world centres of excellence.     

甲状腺癌患者甲状腺全切手术安全性探讨

目的 探讨甲状腺癌患者行甲状腺全切除手术的安全性.方法 回顾性分析1986年1月至2006年12月因甲状腺癌行甲状腺全切除(全切组)以及次全或近全切除术(双叶手术组)的患者资料,比较两组间喉返神经损伤和继发性甲状旁腺功能低下的发生率.结果 双叶切除手术组433例:13例发生暂时性单侧喉返神经损伤,5例发生永久性单侧喉返神经损伤;11例发生暂时性甲状旁腺功能低下,无永久性甲状旁腺功能下病例.甲状腺全切手术组共70例:4例发生暂时性单侧喉返神经损伤(P>0.05),1例发生永久性单侧喉返神经损伤(P>0.05);7例发生暂时性甲状旁腺功能低下(P<0.01),2例永久性甲状旁腺功能低下(P<0.05).结论 甲状腺全切除术并不增加喉返神经损伤的概率,但手术后甲状旁腺功能低下发生率增加,因此应该有选择的施行甲状腺全切除手术.     

The Change in Surgical Practice from Subtotal to Near-Total or Total Thyroidectomy in the Treatment of Patients with Benign Multinodular Goiter

Background  Although total thyroidectomy is the procedure of choice in patients with thyroid carcinoma, this surgical approach has emerged as a surgical option to treat patients with benign multinodular goiter (BMNG), especially in endemically iodine-deficient regions. The aim of this study was to review our experience with patients with BMNG in an endemically iodine-deficient region treated by either subtotal or total/near-total thyroidectomy, and to document whether total or near-total thyroidectomy decreased the rate of completion thyroidectomy for incidentally diagnosed thyroid carcinoma in comparison to the patients with BMNG treated initially by subtotal thyroidectomy. Methods  Two thousand five hundred ninety-two patients with BMNG were included. There were 1695 bilateral subtotal thyroidectomies (group 1) and 1211 total or near-total thyroidectomies (group 2) for BMNG during this period. All patients were euthyroid and had no history of hyperthyroidism, radiation exposure, or familial thyroid carcinoma. Any patient with preoperative or perioperative suspicion of malignancy or hyperthyroidism was excluded. Results  Bilateral subtotal thyroidectomy was performed in 1695 patients (58.3%) in group 1 and total or near-total thyroidectomy in 1211 patients (41.7%), in group 2, respectively. The incidence of incidental thyroid carcinoma was found to be 7.2% (n = 210/2906). Although the rate of permanent hypoparathyroidim and transient or permanent unilateral recurrent laryngeal nerve (RLN) palsy were not significantly different between the two groups, transient hypoparathyroidism was significantly higher in group 2 than in group 1 (8.4% vs. 1.42%; p < 0.001, odds ratio [OR] = 52.98). The incidence of thyroid carcinoma was significantly higher in group 2 (10.7%, n = 129/1211) than in group 1 (4.68%, n = 81/1695) (p < 0.001; OR = 39.1).Thirty-eight patients in group 1 (2.24%) underwent completion thyroidectomy, whereas completion thyroidectomy has been not indicated in group 2 (p = 0.007). Two of 38 patients (5.26%) had thyroid papillary microcarcinoma on their remnant thyroid tissue. The rate of recurrent goiter was 7.1% in group 1. The average time to recurrence in group 1 was 14.9 ± 8.7 years. Six of 121 patients with recurrent disease (4.95%) has been operated on. Conclusions  Subtotal thyroidectomy resulted in a significantly higher rate of completion thyroidectomy for incidentally diagnosed thyroid carcinoma compared with total or near-total thyroidectomy in patients with BMNG. The extent of surgical resection had no significant effect on the rate of permanent complications. We recommend total or near-total thyroidectomy in BMNG to prevent recurrence and to eliminate the necessity for early completion thyroidectomy in case of a final diagnosis of thyroid carcinoma.     

Surgical treatment of Graves' disease

The surgical treatment of the Graves' disease is no longer a final solution but the main option, as for all the benign thyroid diseases. Between January 1994 and December 2003 in the 3rd Surgical Unit of the Sf. Spiridon Hospital of Ia?i 805 operations were performed for benign thyroid disorders, 78 of which were performed for the Graves' disease. All the patients had been investigated and diagnosed in the Endocrinology Unit of the same hospital, where the necessary medical treatments had been administered. The patients transferred to Surgery had a medium age of 38 (extremes 17-79 years). Women had a greater proportion, as expected (sex ratio F: M = 4.57:1). Some patient had concurrent diseases (5 cases with atrial fibrillation and 3 with chronic hypocalcaemia). 58 total and 20 subtotal thyroidectomy were performed. There were few immediate (3 bleedings which needed reoperation for haemostasis) and late complications (2 cases of postoperative hypocalcaemia which received medical treatment). 4 relapses after previously performed subtotal thyroidectomy were diagnosed and treated. Total thyroidectomy is the treatment of choice for the Graves' disease. The frequency of complications is similar to that occurred after subtotal thyroidectomy, the functional results are immediate, predictable and stable, and the substitutive treatment is very efficient and easy to administer.     

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??Total or near-total bilateral thyroidectomy after subtotal bilateral thyroidectomy YANG Wei-ping, SHAO Tang-lei,CHEN Wei-gou, et al.Department of General Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200025, China. Corresponding author:SHAO Tang-lei,E-mail:shaotl_03@hotmail.com Abstract Objective To evaluate the safety of total or near-total bilateral thyroidectomy after subtotal bilateral thyroidectomy. Methods Thirty-four cases of subtotal bilateral thyroidectomy because of benign thyroid disease were performed total or near-total bilateral thyroidectomy because of the recurrence of nodules between June 1995 and June 2008 at Ruijin Hospital of Shanghai Jiaotong University School of Medicine. The clinical data of all the cases were analyzed. Results Partial fibers of right recurrent laryngeal nerves were cut at their entrance to the larynges in 2 cases.But the mobility of the vocal cord return to normal and the hoarseness were disappeared 6 months after operation. Hypocalcaemia was occurred in 6 cases.The hypocalcaemia disappeared by calcium supplementing through oral or/and intravenously in 5 of 6 cases 2 weeks after operation. But the righr superior parathyroid was cut inadvertently in one thyroid papillary cancer case, and the case underwent parathyroid autotransplantation. Hypocalcaemia was alleviated gradually 1 year after operation in the case. The levels of calcaemia and PTH were still under the normal until 14 months after operation. Conclusion If choosing the right way to expose the remnant gland and being familiar with the anatomical position of bilateral recurrent laryngeal nerves and parathyroids, it is safety to perform total or near-total bilateral thyroidectomy after subtotal bilateral thyroidectomy.     

Changes in the choice of thyroidectomy for benign thyroid disease

Purposes

There is an increasing trend towards performing more radical resections instead of a subtotal resection for benign thyroid disease. The aim of this study was to examine the effect of this change in practice on the surgical treatment of bilateral thyroid diseases in this unit.

Methods

The data on 367 patients that underwent a bilateral thyroidectomy were categorized by dividing the operation types into 4 groups: (1) total thyroidectomy (TT), (2) near-total thyroidectomy, (3) Dunhill procedure, and (4) bilateral subtotal thyroidectomy.

Results

A statistically significant change in the choice of thyroidectomy occured during the study period (p < 0.001). TT has replaced subtotal thyroidectomy (STT; bilateral subtotal thyroidectomy and Dunhill procedure) as the preferred routine surgical procedure for bilateral benign thyroid diseases in this clinic. The permanent complication rates were similar for all surgical procedures. The rate of secondary thyroidectomy for both recurrence of multinodular goiter and incidental thyroid carcinoma were significantly higher in the STT groups, than the total in the TT and near-total thyroidectomy patients.

Conclusions

Total or near total thyroidectomy procedures are now being increasingly employed to treat bilateral benign thyroid disease, and are as safe as the sub-total thyroidectomy procedures, which are more conservative and associated with significantly higher recurrence rates.     

LigaSure versus clamp-and-tie thyroidectomy for benign nodular disease

BACKGROUND: LigaSure is an alternative bipolar diathermy system (BDS) combining vessel sealing with reduced thermal spread, which has been successfully used in many abdominal operations; however, there is a little experience in open thyroidectomy. This study compares the efficacy and the advantages of the LigaSure BDS when used for total thyroidectomy for benign thyroid disease with the conventional clamp-and-tie technique. METHODS: Between May 1998 and October 2002, 517 patients underwent total thyroidectomy for benign thyroid multinodular goiter. Among them, from May 1998 until May 2000, 247 patients (group I) were operated on with the conventional clamp-and-tie technique, whereas from May 2000 until October 2003, 270 patients (group II) underwent total thyroidectomy for benign multinodular goiter with LigaSure BDS through a 4-cm transverse suprasternal incision. Demographics, pathologic characteristics, gland mass, operative time, blood loss, and complications were assessed. RESULTS: There were no intraoperative complications. Thyroid mass was similar in both groups, but the operative time was shorter in group II than in group I (mean +/- standard deviation, 71 +/- 14 minutes vs 86 +/- 22 minutes; p < .01). Intraoperative total blood loss was similar between the two groups, but postoperative drain volume was less in group II than in group I (21 +/- 15 mL; p < .01). Major post-thyroidectomy complications (ie, laryngeal nerve palsy, hematoma, and hypocalcemia) occurred less frequently in the LigaSure group than in the clamp-and-tie group (0.7%, 0.4%, 1.1% vs 4%, 2%, 4.8%, respectively; p < .05). The mean +/- standard deviation postoperative hospital stay was significantly less for the patients in group II than for those in group I (2.3 +/- 1.7 days vs 2.8 +/- 1.3 days; p < .05). CONCLUSIONS: The use of the LigaSure vessel sealer for thyroid surgery is an effective and safe alternative that reduces the overall operative time and could be successfully applied through a narrow surgical incision.     

Early results after minimal lobectomy for benign nodular goiter

Following traditional operations (enucleation and subtotal resection) for benign nodular goiters recurrences may develop. Reoperations for this condition can cause complications, such as hypoparathyroidism and damage of the recurrent laryngeal nerve. That is why total thyroidectomy is recommended by many specialists in benign thyroid disease. We performed lobectomy on one side, and, if necessary, partial resection on the other side. Lobectomy was performed on one side in 31 cases, with partial resections on the other side in 73 patients. We tried to identify the parathyroid glands and both recurrent laryngeal nerves. Postoperative complications were evaluated. Temporary dysfunction of the recurrent laryngeal nerve was detected in 2.3%, permanent damage in 1.1%. Temporary hypocalcaemia developed in 16.4%, permanent hypocalcemia in 1.9%. Two reoperations were necessary for bleeding. Because of the low postoperative complication rate we recommend this method as an alternative to thyroidectomy for benign nodular goiters. We know that our favourable results can be compared with traditional subtotal resection and thyroidectomy when long term results of thyroid function and data about nodular recurrences will be collected.     

Serum levels of the interferon-gamma-inducible alpha chemokine CXCL10 in patients with active Graves' disease, and modulation by methimazole therapy and thyroidectomy

BACKGROUND: The interferon-gamma-inducible chemokine CXCL10 is highly expressed in infiltrating inflammatory cells, and in thyrocytes in patients with Graves' disease. The aim of this study was to measure serum levels of CXCL10 in relation to thyroid function and treatment. METHODS: Serum levels of CXCL10 were measured in 22 patients with Graves' disease when hyperthyroid, when euthyroid under methimazole therapy, and 3 days after near-total thyroidectomy. They were compared with levels in three groups of age- and sex-matched controls: 44 subjects with no thyroid disorder, 44 patients with euthyroid autoimmune thyroiditis and 20 with toxic nodular goitre. RESULTS: Basal serum levels of CXCL10 in patients with Graves' disease were higher than levels in patients with toxic nodular goitre or no thyroid disorder, and similar to levels in patients with autoimmune thyroiditis (mean(s.d.) 167(121), 100(24), 78(46) and 142(107) pg/ml respectively; P < 0.010). Among patients with Graves' disease, serum levels of CXCL10 were significantly higher in those aged over 50 years (P = 0.010), with a hypoechoic pattern at thyroid ultrasonography (P < 0.001) or with hypervascularity (P = 0.001). CXCL10 levels in patients with Graves' disease decreased significantly when euthyroidism was achieved by methimazole therapy (P < 0.010), and a further decrease was observed after thyroidectomy (P < 0.010). CONCLUSION: Serum levels of CXCL10 are higher in newly diagnosed hyperthyroid patients with Graves' disease than in those with toxic nodular goitre, and decrease when euthyroidism is achieved with antithyroid therapy. This high level may be related to the active inflammatory phase of Graves' disease. A further reduction of CXCL10 levels after thyroidectomy indicates that it is produced mainly in the thyroid in patients with autoimmune thyroid disease.     

Video-assisted subtotal or near-total thyroidectomy for Graves' disease

BACKGROUND: Surgery remains the treatment of choice for patients with Graves' disease. The purpose of the present study was to assess the usefulness and efficacy of video-assisted subtotal or near-total thyroidectomy in patients with Graves' disease. METHODS: Between March 2000 and December 2004, 63 patients with Graves' disease underwent video-assisted subtotal, near-total or total thyroidectomy. Fifty-three patients (84 per cent) were considered for surgery after failure of antithyroid drug and radioiodine therapy, whereas the other ten patients were initially selected for surgical treatment based on their own preference. Treatment outcome was evaluated, including surgical complications, thyroid function, quality of life and patient satisfaction with the surgical result. RESULTS: All patients were operated on using a video-assisted technique, with some modifications depending on time and experience. There were no conversions to open surgery. Three patients (5 per cent) had temporary recurrent laryngeal nerve palsy that recovered spontaneously. Most patients were satisfied with the surgical results, particularly regarding the placement of the surgical scars. CONCLUSION: Video-assisted subtotal or near-total thyroidectomy is a safe and effective procedure for treatment of Graves' disease.     

Near-total thyroidectomy could be the best treatment for thyroid disease in endemic regions

HYPOTHESIS: Near-total thyroidectomy, on the basis of its low morbidity rate, is an appropriate treatment option in the surgical management of various thyroid diseases in an endemic region in Turkey. DESIGN: Single-institution study of patients with various thyroid diseases treated by means of near-total thyroidectomy within 2 years in an endemic region, with comparison of the results vs the complication rates of bilateral subtotal and total thyroidectomy reported in the literature. SETTING: Tertiary academic referral center. PATIENTS: One hundred fifty-two patients who underwent near-total thyroidectomy for various thyroid diseases. MAIN OUTCOME MEASURES: Surgical treatments of various benign thyroid diseases were compared according to the complication rates and the achievable benefits of the procedures. RESULTS: In our clinic, near-total thyroidectomy was the principal surgical procedure performed for benign thyroid disease. The temporary recurrent laryngeal nerve palsy rate with respect to the nerves at risk was 3.3% (10 of 304 nerves), whereas temporary hypoparathyroidism was 7.2% (11 of 152 patients). Neither permanent recurrent laryngeal nerve palsy nor permanent hypoparathyroidism occurred. In 1 patient, wound hematoma developed and required re-exploration. Seroma in another patient needed no medical or surgical intervention. Neither wound infection nor mortality were noted. CONCLUSIONS: Near-total thyroidectomy achieves a lower complication rate of hypoparathyroidism and a similar complication rate of recurrent laryngeal nerve palsy and recurrence when compared with the rates reported in the literature for total thyroidectomy. It is an effective and safe surgical treatment option for various benign thyroid diseases.     

SURGICAL THYROID DISEASE IN PAPUA NEW GUINEA

A clinical and histopathological analysis was carried out on 376 thyroid specimens removed under various diagnoses from the surgical clinics of Papua New Guinea over a period of 11 years (1980–90). Solitary nodular goitre (solid and cystic) was the most common clinical diagnosis. Nineteen per cent of the solid and 35% of the cystic solitary nodular goitres were found to be malignant. Malignant goitres were confirmed histologically in 73.3% of the clinically diagnosed cases of malignancy. The presence of amyloid goitre (1.9%) posed a significant diagnostic and therapeutic problem due to its clinical features resembling that of malignant goitre. Hemithyroidectomy (lobectomy) was the most common surgical procedure employed for all unilateral thyroid lesions and partial or subtotal thyroidectomy was performed for benign and most malignant lesions.     

Benign nodular goitre presenting as acute airway obstruction

BACKGROUND: Although rare in non-endemic areas, benign nodular goitre may cause acute airway obstruction and the clinical management of this condition remains a challenge. METHODS: From 1996 to 2005, a total of 1115 patients underwent thyroid surgery at our institution and of these, 7 patients were identified to have a benign nodular goitre leading to acute airway obstruction. They were retrospectively reviewed with reference to the aetiology, presentation, perioperative management and postoperative outcome. RESULTS: All seven patients were elderly women with a history of symptomatic goitre and concomitant medical problems. Five patients required emergency tracheal intubation, whereas two patients underwent urgent tracheostomy. Total thyroidectomy was successfully carried out for all patients and there was no hospital death. Perioperative complications included three patients with pneumonia, two with renal failure and one with perforated duodenal ulcer. Surgically related complications included transient recurrent nerve palsy in one patient and transient hypocalcaemia in four. After a median follow up of 22 months (range, 4-53 months), two patients died of cerebrovascular accident. CONCLUSION: Prompt airway protection followed by total thyroidectomy within the same hospital admission should be recommended and can be associated with favourable outcome.     

Benign diseases of the thyroid: indications for surgical treatment and the current role of total thyroidectomy

Total thyroidectomy is the most popular surgical option in a wide range of indications for the treatment of benign disease of the thyroid. The preference for the procedure derives from a long period of observation and clinical experience dating as far back as the early 'seventies and confirms its safety and efficiency. Nevertheless, many doubts still exist as to the indications in the context of benign thyroid disease, as well as the incidence and seriousness of the complications which, though not frequent, are often invalidating. On the basis of the experience gained over the period from January 1994 to November 2002 in 697 patients undergoing surgery for benign disease of the thyroid, the authors analyse the indications for the various different therapeutic options and evaluate the results of total thyroidectomy in terms of therapeutic efficiency, relapse rates and complications. The latter are analysed on the basis of dividing the patients into 2 groups, one comprising 545 patients treated with total thyroidectomy as first-line treatment and the second consisting of 34 patients treated with total thyroidectomy for relapsing goitre after subtotal thyroidectomy. Comparison of the respective incidences of complications reveals a significant difference between the two groups of patients. Total thyroidectomy after subtotal thyroidectomy presented a significantly higher percentage of complications than initial total thyroidectomy. The authors come out in favour of total thyroidectomy with its low incidence of complications and the radical control of the disease it affords, reserving lobectomy-isthmectomy for selected cases of patients with monolateral disease which does not expose the patient to any risk of relapse.     

Incidence and risk factors for injuries to the recurrent laryngeal nerve during neck surgery in the moderate-volume setting

Purpose

Total lobectomy is currently recommended also in benign thyroid disease in order to reduce the risk of goitre recurrence, an approach claimed not to increase post-operative morbidity. The aim of the study was to analyse risk factors for recurrent laryngeal nerve (RLN) palsy during neck surgery, with particular interest in complications after total lobectomy and subtotal resection, respectively.

Methods

All consecutive patients operated for thyroid and parathyroid diseases at one institution between 1984 and 2011 were prospectively recorded, and 1,322 patients were included. Patients with permanent post-operative RLN palsy were re-examined in 2011.

Results

The risk of permanent RLN palsy after parathyroid surgery was 0.3 %. Patients operated for thyroid cancer had a 5.9 % risk of permanent nerve injury, higher than that of patients with benign thyroid disease (1.4 %; P?=?0.029). Independent risk factors for RLN paralysis after benign thyroid surgery were intrathoracic goitre (odds ratio (OR), 3.57; 95 % confidence interval, 1.70–7.48), ipsilateral redo-surgery (OR, 3.64; 1.00–13.28) and total lobectomy (OR, 2.41; 1.05–5.55). At long-time follow-up (median, 10 years), 7 of 12 patients with permanent RLN palsy still suffered moderate or severe symptoms.

Conclusions

RLN paralysis is an infrequent complication after neck surgery, but with major negative impact on patients’ well-being when permanent. Hemithyroidectomy/total thyroidectomy is increasingly preferred over subtotal resection in multinodular goitre. This is supported by an increased risk of RLN injury during redo-surgery for recurrency but should be carefully weighed against individual risk factors for nerve palsy, including surgical experience and volume.     

Local recurrence in papillary thyroid carcinoma: is extent of surgical resection important?

From a multivariate analysis of more than 20,600 patient-years' experience with papillary thyroid carcinoma (PTC), we devised a prognostic scoring system based on patient age, tumor grade, extent, and size (AGES). This scoring system was used as an adjustment variable for analyzing the role of different types of surgical treatment in the development of local recurrence (LR) in 963 PTC patients who underwent unilateral (15%), bilateral subtotal/near-total (69%), or total thyroidectomies (16%) from 1946 through 1975 at the Mayo Clinic. In 866 patients with AGES scores of 3.99 or less, the risk of LR developing at 10, 20, and 30 years was 7%, 14%, and 14% after unilateral resection and 1.5%, 2%, and 4% after bilateral resection (p less than 0.001). In 97 patients with AGES scores of 4 or more, the comparable rates were 26%, 45%, and 59% after unilateral resection and 13%, 20%, and 20% after bilateral resection (p less than 0.001). In neither the low- nor the high-risk group was there a significant difference in the frequency of LR comparing total thyroidectomy with bilateral subtotal/near-total thyroidectomy. At 30 years after diagnosis of LR, mortality from PTC was 48%; the risk of cancer death with an LR located outside the thyroid remnant was much greater than with a remnant recurrence alone. In this series of 52 patients, followed up for as many as 41 years, no patient with tumor recurrence limited to the thyroid remnant died of thyroid cancer.     

Quality assurance study of benign and malignant goiter. Prospective multicenter data collection regarding 7,617 patients]

A quality control study was undertaken on 7,265 patients with benign goitre and 352 patients with malignant goitre who were surgically treated between 1.1.98 and 31.12.98. 3 hospital groups were defined according to surgical workload: Group 1: < 50 operations/yr; Group 2: 50-150 operations/yr; Group 3: > 150 operations/yr. The temporary rate of recurrent laryngeal nerve (RLN) palsies for benign goitre was 3.9% and the permanent 1.1%. For malignant goitre the rates were 12.8% and 6.8% respectively. The rate of temporary (p < 0.040) and permanent (0.003) palsies after surgery for benign goitre was lower in group 3 compared to group 1 and 2. There were too few cases for statistical analysis of the malignant goitres. After benign goitre surgery a transient hypocalcaemia rate of 6.3% and a permanent of 1.1% were observed. For malignant goitre the incidence was 23.8% and 7.1%, respectively. A significantly increased rate of permanent hypocalcaemia (p < 0.003) was demonstrated in group 3 after surgery for multinodular goitre. Centres in group 3 made more extended (smaller thyroid remnants) resections (p < 0.01) with the equivalent rate of general complications. The average inpatient stay for malignant goitres was 13.1 days and for benign goitres 8.7 days. On average, patients with bilateral resections for benign goitre stayed 0.4 days longer in hospital than those with unilateral procedures. Prophylactic antibiotics were administered to 2.1% of patients and 94.6% received thrombosis prophylaxis.     

A comparative study of cytological and histological studies of the thyroid gland

We compare the results of fine-needle aspiration cytology of the thyroid gland with postoperative histological findings in 533 patients with thyroidectomy operated on between 1987 and 1994. The classification of the cytological preparations followed the proposal of Weiss and Pilz [35] with the groups 0-IV. In group 0 the most frequent findings were cystic changes in multinodular goitre or malpuncture, respectively. The groups I and II contained cases with multinodular goitre, thyroiditis and follicular adenomas, but 4 carcinomas too. The group III comprised particularly follicular adenomas and carcinomas (8 cases). Both cases in group IV were carcinomas. In group III (cytologic group with suspicious findings) there were 65 cases with false positive results of the cytologic investigation resulting in a specificity of 86.4%. 4 out of 14 thyroid carcinomas could not be detected by cytologic preparations corresponding to a sensitivity of 71.4% for carcinomas. The false negative rate for thyroid carcinomas in group II was caused by regression areas in the center of the tumors (3 cases) as well as one microcarcinoma. Preoperative fine-needle aspiration cytology of the thyroid gland reduces the number of patients operated on for multinodular goitre or cold nodules especially in cases suspicious of carcinoma.