LigaSure vs clamp-and-tie technique to achieve hemostasis in total thyroidectomy for benign multinodular goiter: a prospective randomized study

HYPOTHESIS: Occurrence of adverse effects and advantages of the LigaSure diathermy system (or LigaSure vessel sealing system) in total thyroidectomy have not been tested in prospective randomized studies comparing its use with that of the time-saving clamp-and-tie technique to ligate and divide thyroid vessels. The effectiveness of LigaSure in achieving vessel division and hemostasis remains dependent on vessel diameter, and the risk of damage to adjacent structures cannot be completely excluded. We tested the hypothesis that use of LigaSure compared with the clamp-and-tie technique can significantly and conveniently reduce operative time without increasing postoperative complications in patients undergoing total thyroidectomy for benign multinodular goiter. DESIGN: Prospective randomized study. SETTING: Regional hospital. PATIENTS: Two hundred consecutive patients with benign multinodular goiter undergoing total thyroidectomy performed by 1 of 3 surgeons. INTERVENTIONS: According to a randomized sequence, total thyroidectomy was performed in 100 patients using LigaSure and in 100 patients using the clamp-and-tie technique. MAIN OUTCOME MEASURES: End points of the study included the comparative evaluation of postoperative complications, need for parathyroid gland autotransplantation, operative time, and time to hospital discharge. Preoperative, postoperative (24 hours), and 6-week follow-up serum Ca(++) levels are also reported and compared. RESULTS: The postoperative complication rate was 35% overall, including all transient postoperative disturbances. The incidence of cervical hematomas was 2%, but 3 patients (1.5%), 1 in the LigaSure group and 2 in the clamp-and-tie group, required repeat operations because of respiratory tract obstruction. The incidence of permanent complications was 2.5% overall, including 3 patients (1.5%) with permanent hypocalcemia and 2 patients (1%) with permanent recurrent nerve lesions. No statistical difference in the incidence of complications was found between the 2 study groups. Similarly, no difference was found in mean hospitalization time and need for parathyroid gland autotransplantation. Preoperative, postoperative, and 6-week follow-up mean serum Ca(++) levels were not statistically different in the 2 study groups and in the subset of patients undergoing parathyroid gland autotransplantation. Mean operative time was significantly shorter in the LigaSure group, although the mean difference between the 2 study groups was minimal (7.4 minutes). Concomitantly, there was an additional cost of 45euro (US $57.40) per operation using LigaSure. CONCLUSION: The use of LigaSure is equally as safe and effective at vessel division and homeostasis as the clamp-and-tie technique, with a statistically significant (although minimal) decrease in mean operative time. Because of this minimal decrease in operative time, use of LigaSure would allow more patients to undergo total thyroidectomy each year, which would eventually help to offset its higher cost.     

Treatment and Prevention of Recurrence of Multinodular Goiter: An Evidence-based Review of the Literature

BACKGROUND: Reportedly, 10-15% of patients with goiters ultimately require operative intervention, and recurrences of multinodular goiter (MNG) account for up to 12% of all thyroid operations. METHODS: We performed an evidence-based review of articles published in the English language between January 1987 and October 2007 relevant to the subject. RESULTS: Medical treatment with T4 appears to be associated with a greater proportion of patients whose nodules decreased in size by more than 50% (22% vs. 10%; range = 14-39% vs. 0-20%). Recurrence rates of benign nodular goiter after total thyroidectomy were essentially nonexistent (range = 0-0.3%) compared with those after subtotal thyroidectomy (range = 2.5-42%) and more limited resections (range = 8-34%). There was no difference between total and less-than-total thyroidectomy with respect to temporary recurrent laryngeal nerve (RLN) injury (1-10% vs. 0.9-6%, respectively) or permanent RLN palsy (0-1.4%). There was, however, a significantly higher rate of transient hypocalcemia after total thyroidectomy than less extensive operations (9-35% vs. 0-18%, respectively). In relation to redo surgery, permanent hypoparathyroidism appeared to be far more common in the redo group (0-22% vs. 0-4%) Moreover; the redo group had more frequent RLN injury, both temporary (0-22% vs. 0.5-18%) and permanent (0-13% vs. 0-4%). About half the studies examined conclude that postoperative TSH suppression is effective in reducing recurrences, while the other half state that it is not. CONCLUSION: The definitive management and prevention of recurrence of benign nodular goiter is primarily surgical. Total thyroidectomy essentially eliminates the risk of recurrence without an accompanying increased risk of permanent hypoparathyroidism or RLN injury. Therefore, total thyroidectomy should be considered the procedure of choice for benign multinodular goiter whenever possible, especially considering that reoperations for goiter are significantly more morbid than any initial operation.     

Total versus subtotal thyroidectomy for the management of benign multinodular goiter in an endemic region

BACKGROUND: Because controversy still continuous to surround use of total thyroidectomy for the management of benign multinodular goiter, the present study aims to prospectively compare the safety and efficacy of total thyroidectomy with subtotal thyroidectomy. METHODS: A total of 200 consecutive patients with benign multinodular goiter were assigned to have either total thyroidectomy (n = 105) or subtotal thyroidectomy (n = 95) based on preoperative evaluation, intraoperative macroscopic findings and nodular dissemination. The patients with no healthy tissue or nodules localized in the dorsal part of the gland, which are usually left during normal subtotal resection, were assigned to the total thyroidectomy group. Demographic details, biochemical findings, indications for operation, operating time, specimen weight, complications and hospital stay were noted. RESULTS: There was no significant difference in the sex, hormonal status or duration of goiter between the two groups (P = 0.74, P = 0.59 and P = 0.59, respectively). The mean operating time was longer (148.52 min +/- 51.10 vs 135.10 min +/- 32.47, P = 0.03), and the mean weight of the specimens was greater (228.40 g +/- 229.91 vs 157.01 g +/- 151.23, P = 0.01) for total rather than subtotal thyroidectomy. Either temporary recurrent laryngeal nerve (RLN) palsy or hypoparathyroidism occurred in 10 (9.3%) or 12 (11.4%) of the patients undergoing total compared with six (6.3%) or nine (9.5%) of the patients undergoing subtotal thyroidectomy (P = 0.40 and P = 0.65, respectively). Either permanent RLN palsy or hypoparathyroidism was observed in one patient undergoing total thyroidectomy (P = 0.34 for each comparison). The mean hospital stay was longer in the total thyroidectomy group (2.24 days +/- 1.18 vs 1.89 days +/- 0.72 for subtotal thyroidectomy, P = 0.01). CONCLUSIONS: The present study shows that total thyroidectomy can be performed without increasing risk of complication, and it is an acceptable alternative for benign multinodular goiter, especially in endemic regions, where patients present with a huge multinodular goiter.     

Use of a diathermy system in thyroid surgery

HYPOTHESIS: New hemostatic methods have been widely used in open and laparoscopic surgery. The LigaSure Precise diathermy system (Valleylab, Boulder, Colo) has been recently used in thyroid surgery. We hypothesized that its use could lead to reduced operative time and fewer complications compared with conventional knot tying in total or near-total thyroidectomy. DESIGN: Prospective case-controlled study. SETTING: Tertiary care private hospital. PATIENTS: Eighty patients underwent total or near-total thyroidectomy by 1 surgeon. INTERVENTIONS: Forty patients underwent thyroidectomy with the conventional knot tying technique and 40 patients with the LigaSure diathermy system. MAIN OUTCOME MEASURES: Demographics, histopathological diagnosis, operative time, intraoperative blood loss, complications, and cost, using chi2 test and Wilcoxon rank sum test. RESULTS: The study groups had similar demographic and histopathological characteristics. The mean +/- SD operative time was nonsignificantly reduced in the LigaSure group compared with the conventional knot tying group (84 +/- 6 vs 89 +/- 7 minutes, P = .60). The mean +/- SD intraoperative blood loss was less for the LigaSure group (30 +/- 5 vs 35 +/- 8 mL, P = .36). There was 1 case of transient recurrent laryngeal nerve palsy in the LigaSure group. One patient from this group and 2 patients from the other group exhibited transient hypocalcemia; permanent postoperative hypocalcemia was not encountered in either group. The cost of the LigaSure diathermy system was significantly greater than that of conventional knot tying. CONCLUSION: Use of the LigaSure in thyroid surgery did not significantly reduce operative time, blood loss, or complication rates compared with conventional knot tying, but it increased operative cost.     

The use of LigaSure in patients with hyperthyroidism

Background Thyroidectomies of hyperthyroidic patients are known to be more blood-spattered than the operations performed for euthyroid nodular diseases and require careful hemostasis. Our purpose was to evaluate the efficacy of the use of LigaSure in patients with hyperthyroidism.Materials and methods Between January 2004 and October 2005, 100 patients underwent total or near-total thyroidectomy. Bipolar vessel ligation system (LigaSure) was the choice of modality for hemostasis in half of these patients, and the conventional suture ligation technique was used for the rest. The following data were evaluated non-randomized and prospectively in this study: patients demographics, thyroid pathology, operative duration, presence of complications, and the duration of the hospital stay. Comparisons of the data were evaluated by the Wilcoxon and chi-square tests.Results Among the patients of the LigaSure group, 14 patients were detected to have hyperthyroidism (seven patients with Graves’ disease and another seven patients with multinodular toxic goiter), while 36 patients were found to be euthyroidic. The durations of the operation time and of the hospital stay of the patients in the LigaSure group were significantly lower than the conventional thyroidectomy group (p<0.05). The complication rates of the LigaSure and conventional thyroidectomy groups were 4 and 6%, respectively (p>0.05).Conclusions The use of LigaSure as an operative technique in the treatment of Graves’ disease and toxic goiter is a safe and effective modality that provides a shorter hospital stay and a shorter operation time as well.Presented at the International Symposium “Modern Technologies in Thyroid Surgery”, 10–11 February 2006, Halle/Saale, Germany     

The impact of the Harmonic FOCUS™ on complications in thyroid surgery: a prospective multicenter study

In recent years, newer tools have been developed and used in thyroid surgery. This study compared patients with multinodular goiter undergoing thyroidectomy using the Harmonic FOCUS? with patients undergoing the clamp-and-tie technique. Medical records of 268 patients with multinodular goiter undergoing thyroidectomy from December 2006 to July 2011 in two centers in Italy, the Department of Surgery of Pisa and the General Surgery Unit of Grosseto, were prospectively evaluated. Patients were divided into group A (Harmonic FOCUS? Shear), and group B (clamp-and-tie technique). Patient demographics and specific end points analyzed included age, sex, diagnosis, thyroid gland volume, operative time, complications, need for clips and hemostatic agents, need for suction balloon, postoperative blood loss, and postoperative hospital length of stay. 141 patients were included in group A, and 127 patients were included in group B. The two groups were similar in age, sex ratio, indication for surgery, and thyroid volume. Mean operative time was significantly shorter with the Harmonic FOCUS? Shear (51.8 min) than with the clamp-and-tie technique (70.9 min). The mean postoperative amount obtained from the suction balloon was similar. Vascular clips were needed significantly more frequently in group A (26.2 %) than in group B (12.5 %), whereas the need for hemostatic agents was significantly reduced in group A (4.2 %) compared with group B (14.9 %). The decision to leave a suction drain at the end of the operation occurred significantly more frequently in group B (96 %) than in group A (78 %). Mean postoperative hospital length of stay was 2.02 days in group A compared with 3.1 days in group B, which was significant. No definitive postoperative complications were documented in either group, except a higher rate, but not statistically significant, of permanent hypoparathyroidism in group B versus Group A. Transient laryngeal nerve injury was similar in both groups, whereas transient hypoparathyroidism occurred more frequently in Group B (4.7 %) than in Group A (2.4 %). Harmonic FOCUS device was significantly associated with lower rate of postoperative transient hypocalcemia, decreased operative time, shorter hospitalization, and lesser need for hemostatic agents and postoperative drain balloon. These results might be considered “indirect” money-saving factors, despite the cost of the device, especially in countries where the cost of thyroidectomy is influenced also by the hospital length of stay.     

The use of the harmonic scalpel vs conventional knot tying for vessel ligation in thyroid surgery

HYPOTHESIS: The technique of thyroidectomy has undergone little change in several decades. The harmonic scalpel, using ultrasonic frictional heating to ligate vessels, is widely used in laparoscopic surgery, but there is little experience in open thyroidectomy. We hypothesized that the use of the harmonic scalpel could lead to a significant reduction in operative time as compared with knot tying in thyroid surgery. DESIGN: Retrospective case-controlled study. SETTING: Teaching institution. PATIENTS: One hundred seventy-one consecutive patients undergoing lobectomy or total thyroidectomy by one surgeon (A.E.S.). INTERVENTIONS: Eighty-six patients underwent thyroid surgery with the conventional clamp-and-tie technique (lobectomy, n = 49; total thyroidectomy, n = 36) and 85 with the harmonic scalpel (lobectomy, n = 38; total thyroidectomy, n = 47). MAIN OUTCOME MEASURES: Demographics, pathological characteristics, thyroid size, operative time, blood loss, and complications using a 2-tailed t test, chi(2)test, and Wilcoxon rank sum test. RESULTS: The 2 groups were similar regarding age and sex. There were no intraoperative complications. Mean +/- SD thyroid size tended to be larger in the harmonic scalpel group for both lobectomy (5.1 +/- 2.6 cm vs 4.2 +/- 2.2 cm; P =.06) and total thyroidectomy specimens (6.3 +/- 3.8 cm vs 4.8 +/- 2.9 cm; P =.08) compared with the conventional technique. Mean +/- SD operative time was shorter in the harmonic scalpel group compared with the conventional technique group for both lobectomy (89 +/- 20 minutes vs 115 +/- 25 minutes; P<.01) and total thyroidectomy (132 +/- 39 minutes vs 161 +/- 42 minutes; P<.01) procedures. There was no difference between the 2 techniques regarding the amount of blood loss for different procedures. There was no effect of tumor size on operative time (Pearson correlation factors: 0.14 for total, 0.21 for unilateral thyroidectomy). CONCLUSIONS: The use of the harmonic scalpel for the control of thyroid vessels during thyroid surgery is safe, and it shortens the operative time by almost 30 minutes compared with the conventional technique for both unilateral lobectomy or total thyroidectomy procedures.     

Symptomatic benign multinodular goiter: unilateral or bilateral thyroidectomy?

BACKGROUND: Symptomatic benign multinodular goiter (MNG) is extremely common in the north central United States. The extent of surgery for unilateral or bilateral disease is controversial. Bilateral resection should be associated with low recurrence rates, but potentially a higher technical morbidity. The long-term outcomes of patients with obvious unilateral MNG who had unilateral resection only is not commonly reported. To determine the optimal operation for patients with symptomatic MNG, we reviewed our single institutional results. METHODS: From May 1994 through November 2004, 883 patients underwent a thyroid operation at our institution. Of these, 237 (27%) underwent thyroidectomy for MNG. One hundred forty patients underwent unilateral lobectomy and 97 underwent total thyroidectomy. RESULTS: The mean age was 51 +/- 1 years and 196 (83%) were female. With up to 145 months' follow-up, there was a higher recurrence rate in the lobectomy group (11% vs 3%; P = .029). However, patients in the lobectomy group had a much lower complication rate (2% vs 9%; P = .007). Importantly, in patients who underwent reoperation for recurrent MNG after lobectomy, the complication rate was low (5.5%) and not significantly higher than the initial surgery. CONCLUSIONS: In patients with symptomatic MNG, 89% of those who underwent unilateral resection did not require further surgery. Unilateral thyroidectomy was associated with lower morbidity than bilateral resection. Furthermore, those patients who required operation for contralateral recurrence did not experience a significantly higher operative morbidity. Therefore, these data convincingly support recommending unilateral thyroid lobectomy as the procedure of choice for patients with symptomatic unilateral MNG.     

Safely increasing the efficiency of thyroidectomy using a new bipolar electrosealing device (LigaSure) versus conventional clamp-and-tie technique

Operative time in thyroid surgery can be safely reduced through use of a new bipolar electrosealing device (LigaSure). We evaluated consecutive patients undergoing thyroid surgery from January 2003 through January 2005 (n=155). During the first half of the study, hemostasis was obtained using silk ties (conventional group, n=70). During the second half of the study period, hemostasis was obtained with a bipolar electrosealing device (LigaSure group, n=85). The mean operative time was 130 +/- 37 minutes in the conventional group and 110 +/- 33 minutes (P < 0.001) in the LigaSure group. EBL in the LigaSure group was statistically significantly less (43 +/- 53 vs 33 +/- 33 mL; P < 0.05). Postoperative calcium level was statistically significantly higher in the LigaSure group (8.2 +/- 0.5 vs 8.4 +/- 0.6 mg/dL, P < 0.05). Hospital length of stay (LOS) did not differ significantly. One patient in each group developed neck hematoma requiring reoperation. One permanent recurrent nerve injury occurred in the conventional group and one transient bilateral recurrent nerve injury occurred in the LigaSure group. The occurrence of symptomatic hypocalcemia was similar between the two groups. The training level of the surgical resident had no significant impact on the operative time, estimated blood loss (EBL), LOS, or complication rate. LigaSure bipolar electrosealer as the primary means of hemostasis during thyroidectomy significantly reduces mean operative times. Rates of operative complications were unchanged. LigaSure use in thyroid surgery can safely increase efficiency.     

The advantage of total thyroidectomy to avoid reoperation for incidental thyroid cancer in multinodular goiter

HYPOTHESIS: To investigate the impact of total thyroidectomy on the rate of completion thyroidectomy for incidentally found thyroid cancer in euthyroid multinodular goiter. DESIGN: A randomized, prospective clinical trial. SETTING: A tertiary referral center. PATIENTS: Patients with euthyroid multinodular goiter without any preoperative suspicion of malignancy, history of familial thyroid cancer, or previous exposure to radiation were randomized (according to a random table) to total or near-total thyroidectomy leaving no remnant tissue or less than 1 g (group 1; n = 109) or bilateral subtotal thyroidectomy leaving 5 g or more of remnant tissue (group 2; n = 109). Patients with preoperative or perioperative suspicion of malignancy were excluded. MAIN OUTCOME MEASURES: We compared the complication rates and the incidence of thyroid cancer requiring radioactive iodine ablation and completion thyroidectomy between groups. RESULTS: There were no permanent complications. The rates of temporary unilateral vocal cord dysfunction and hypoparathyroidism showed no significant difference between groups 1 and 2 (0.9% vs 0.9% and 1.8% vs 0.9%, respectively; P>.05). Papillary cancer was found in 10 group 1 patients (9.2%) and 8 group 2 patients (7.3%) (P =.80). Of the 9 patients requiring radioactive iodine ablation, reoperation was avoided in 5 group 1 patients; the remaining 4 group 2 patients underwent completion thyroidectomy (P =.007). CONCLUSION: We recommend total or near-total thyroidectomy in multinodular goiter to eliminate the necessity for early completion thyroidectomy in case of a final diagnosis of thyroid cancer.     

Is Total Thyroidectomy the Surgical Procedure of Choice for Benign Multinodular Goiter? An Evidence-Based Review

BACKGROUND: Benign multinodular goiter is one of the most common endocrine surgical problems. The appropriate surgical procedure for its effective and safe management is a matter of debate. Though seen by some as an overly hazardous procedure because of the risk of recurrent laryngeal nerve injury and damage to parathyroid function, total thyroidectomy has replaced subtotal thyroidectomy as the procedure of choice, as the latter is associated with significant recurrences. METHODS: A systemic literature review was undertaken of all available medical literature to evaluate whether total thyroidectomy is the appropriate, safe and effective surgical procedure for benign multinodular goiter. RESULTS: There is consistent level II-IV evidence that subtotal thyroidectomy results in recurrence in up to 50% patients. Incidental thyroid cancers are detected in 3%-16.6% of apparently benign goiters in numerous studies, mostly providing level IV evidence, one third of which would need further surgical treatment after subtotal thyroidectomy. Studies comparing subtotal thyroidectomy and total thyroidectomy, including two each of prospective randomized and prospective nonrandomized ones, provide level II-IV evidence that permanent complication rates associated with subtotal thyroidectomy and total thyroidectomy are not different, although the rate of transient hypocalcemia is higher with total thyroidectomy. On basis of these findings, a grade B recommendation can be made that subtotal thyroidectomy is associated with significant recurrence of goiter, leaves a small number of incidentally detected thyroid cancers inadequately treated, and provides little significant safety advantage over total thyroidectomy. Grade C recommendations can also be made about total thyroidectomy being a safe and effective procedure for benign multinodular goiters in the hands of expert surgeons, based on the extensive level IV evidence, and limited level II and level III evidence, which show that the risk of permanent vocal cord palsy and hypoparathyroidism associated with total thyroidectomy is below the acceptable 2% rate, but not without exceptions. CONCLUSION: Total thyroidectomy is the procedure of choice for the surgical management of benign multinodular goiter.     

Benign thyroid disease: 20-year experience in surgical therapy

This retrospective study compares recurrence and postoperative complication rates after isthmo-lobectomy and subtotal thyroidectomy (group I) vs near-total and total thyroidectomy (group II) for benign thyroid disease. Seven hundred and forty-three patients were operated on for thyroid diseases over the period from 1977 to 1998. We considered 202 patients operated on for benign thyroid disease from 1988 to 1998. The follow-up ranged from 1 to 10 years (mean: 3.4 yrs). One hundred and thirty-two patients (65.3%) were operated on for bilateral nodular goitre, 35 (17.3%) for unilateral nodular goitre, 14 (6.9%) for toxic goitre and 21 (10.4%) for thyroiditis. Over the period 1988-1992, 19 patients underwent isthmo-lobectomy and 71 subtotal thyroidectomy (group I). From 1993 to 1998, 39 patients underwent near-total thyroidectomy and 61 total thyroidectomy (group II). The relapse rate was 14.4% in group I, while there were no recurrences in group II (p = 0.000064). Temporary hypocalcaemia was significantly higher (p = 0.000001) in group II (29%) than in group I (2.2%). Within group II, the rate was significantly higher (p = 0.0013) after total thyroidectomy (37.7%) than after near-total thyroidectomy (15.4%). In our experience, near-total and total thyroidectomy are an appropriate approach for preventing recurrence in patients with benign thyroid disease despite the fact that the risk of temporary hypocalcaemia is higher than after less radical surgery. Near-total thyroidectomy and the exercise of all due care in the surgical technique may help to reduce its incidence.     

Thyroidectomy with LigaSure versus traditional thyroidectomy: our experience

Over the past few decades the surgical strategy for both benign and malignant thyroid diseases has undergone several changes. In particular, total thyroidectomy today has become the routine operation for most thyroid diseases. The complications of this surgical procedure, though of multifactorial aetiopathogenesis, are often related to the efficacy of the haemostasis. Our aim in this study was to verify whether the use of the new LigaSure haemostatic system is capable of reducing the incidence of these complications as well as operative times and length of hospital stay as compared to the conventional haemostatic procedures. Twenty-five patients were randomly assigned to thyroidectomy with LigaSureTM (group A), and 25 to total thyroidectomy using the conventional haemostasis procedures (group B). Of these, 39 were women and 11 men, with a mean age +/- standard deviation of 52.26 +/- 13.57 years. In both groups the thyroidectomy was performed according to the standard total thyroidectomy surgical technique entailing the placement of two aspiration drainages at the end of the operation. As regards the assessment of operative times, these were significantly lower in thyroidectomy with LigaSureTM compared to traditional thyroidectomy (duration: 60 +/- 14.8 min [range: 60-105) in group A versus 92.4 +/- 27.5 min [range: 70-150] in group B, p = 0.02). The total amount of fluid drained postoperatively was substantially similar in the two groups (145 +/- 80 cc in group A versus 140 +/- 64.1 cc in group B). The incidence of postoperative complications was also similar in the two groups. We had only one case of haemorrhage in a patient submitted to thyroidectomy with LigaSureTM, 8 cases of transitory hypocalcaemia, 3 of which in patients with LigaSure thyroidectomy and 5 in patients treated with traditional thyroidectomy (p = 0.42), 2 cases of stupor of the recurrent nerve (1 in group A and 1 in group B) and a single definitive recurrent lesion in a group B patient with carcinoma, in which the tumour infiltrated the recurrent nerve. We observed no cases of definitive hypocalcaemia. The mean postoperative hospital stay of the patients in group A was 1.88 +/- 0.44 days as against 2.2 +/- 0.41 days in group B. The statistical analysis revealed a significant difference between the two groups (p = 0.01).     

Total Thyroidectomy for Benign Thyroid Disorders in an Endemic Region

Total thyroidectomy is increasingly being accepted as a treatment of choice for differentiated thyroid cancer. However, because of presumed increased morbidity associated with this procedure, it is still not considered a viable option for management of benign thyroid disorders. To assess the safety and efficacy of total thyroidectomy for management of benign thyroid disorders, we analyzed our data from 127 total thyroidectomies performed for benign thyroid disorders. Demographic details, biochemical findings, indications for operation, specimen weight, and complications were noted. Among these patients, 52 had a toxic goiter and 75 had a nontoxic goiter. The mean duration of the goiters being present was 6.08 ± 6.06 years (0.9–26.0 years), and the mean weight of the specimens was 136.88 ± 120.68 g. The incidence of occult malignancy was 6.3% (n= 8), and those of permanent hypothyroidism and permanent recurrent laryngeal nerve palsy were 1.6% and 0.8%, respectively. Total thyroidectomy should be considered a treatment of choice for multinodular goiter and Graves' disease in a setting of palpable nodule(s) or ophthalmopathy (or both). It is particularly relevant in endemic regions where patients present with a long-standing, large nodular goiter with virtually no normal thyroid tissue. Reoperation for recurrent goiter in such a setting would be fraught with distressing complications.     

Total thyroidectomy. The preferred option for multinodular goiter.

Total thyroidectomy is an operation that has generally been reserved for the management of differentiated thyroid carcinoma. Over the last decade total thyroidectomy has become used increasingly and is now the preferred option in the authors' unit for the management of multinodular goiter affecting the entire gland. Over the period from 1975 to 1985, 853 thyroidectomies have been performed for multinodular goiter; of these, 115 have been total thyroidectomies. During that time, the incidence of total thyroidectomy for multinodular goiter has increased in percentage terms from 9% in 1975 to 50% in 1985. There have been two cases of permanent hypoparathyroidism and one case of permanent recurrent laryngeal nerve injury, and these occurred in patients who had less than total thyroidectomy. Total thyroidectomy is an appropriate operation for the management of diffuse multinodular goiter where the entire gland is involved because it precludes patients from requiring further surgery for recurrent disease, with its high associated risks. It must be emphasized, however, that protection of the recurrent laryngeal nerve and parathyroid glands must still be paramount in dealing with benign thyroid disease.     

Totale Thyreoidektomie bei Knotenstruma

Multinodular goiter is a frequent disease which plays a central role in the daily routine of general and visceral surgeons. Analyses of the national DRG statistics reveal that total thyroidectomy is increasingly replacing partial thyroid resections. This paradigm shift is substantiated by the comprehension of multinodular goiter as a disease affecting the whole organ as well as the fact that total thyroidectomy avoids high risk secondary interventions for incidental thyroid carcinomas and recurrent disease while offering comparable operative risks. However, the available evidence on operative results originates predominantly from thyroid centers and clinical data regarding long-term effects of thyroid hormone substitution following total as well as sub-total thyroidectomy are lacking. Therefore, the preservation of functionally relevant normal thyroid tissue retains its relevancy as an alternative treatment. If a comparably low operative risk can be guaranteed and considering the patient’s compliance, life situation and wishes, total thyroidectomy represents the optimal therapy for bilateral multinodular goiter.     

Subtotal Thyroidectomy for Benign Multinodular Goiter: A 6-Month Postoperative Study of the Remnant’s Function and Sonographic Aspect

Background The purpose was to evaluate the thyroid function after subtotal thyroidectomy. Methods One hundred and nineteen patients operated on for multinodular benign goiter were included in this prospective study. Results of the surgical treatment were evaluated 6 months after operation by thyroid-stimulating hormone (TSH) assay and cervical echography. Results Thyroid-stimulating hormone levels correlated inversely (r = −0.78) with the thyroid remnant volumes. Forty-seven patients presented with a hypoechoic aspect of the remnant. Isoechoic and hypoechoic remnant volumes were similar; however, 46 of the 47 patients with a hypoechoic remnant (97.9%) had TSH levels higher than 5 mU/l vs. 39 of the 72 patients (54.2%) with an isoechoic aspect. No predictive factor for the occurrence of this hypoechoic feature was found. Conclusions After sub-total thyroidectomy for benign multinodular goiter, the volume of the remnant is not the only determinant of the occurrence of postoperative hypothyroidism. The appearance of a hypoechoic aspect of the remnant is also a strong predictive factor for such an outcome. In this case the occurrence of hypothyroidism is quite constant whatever the volume of the thyroid remnant. Since this evolution toward a hypoechoic aspect of the remnant is unpredictable, our results are an additional argument in favor of total thyroidectomy for benign multinodular goiter.     

Effect of thyroidectomy on circulating angiogenic cytokines in papillary thyroid carcinoma and benign goiter: Potential for new biomarkers?

BackgroundCirculating angiogenic factors have been associated with clinical outcomes of papillary thyroid carcinoma, although they may also be released in the context of benign multinodular goiter. We sought to investigate the effect of thyroidectomy on the activity and importance of multiple circulating angiogenic factors in papillary thyroid carcinoma and benign multinodular goiter.MethodsBetween May 2015 and December 2016, patients scheduled for total thyroidectomy for papillary thyroid carcinoma or benign multinodular goiter were offered to enroll in this study. Serum levels of angiopoietin-2, fibroblast growth factor-2, hepatocyte growth factor, platelet-derived growth factor-BB, placenta growth factor, heparin-binding epidermal growth factor, and vascular endothelial growth factor-A and -C were collected preoperatively and 2 weeks postsurgery. These levels were measured by enzyme-linked immunosorbent assay and compared with those of 35 healthy control subjects.ResultsSixty patients with a median age of 52 years, 37 of whom were females, were included: 36 had papillary thyroid carcinoma, and 24 had benign multinodular goiter. In both benign multinodular goiter and papillary thyroid carcinoma, preoperative, circulating angiogenic factors levels were increased with respect to controls (P < .0001), and a decrease after total thyroidectomy was observed in the levels of angiopoietin-2 (P < .0001), fibroblast growth factor-2 (P < .0001), hepatocyte growth factor (P < .001), and heparin-binding epidermal growth factor (P < .01 each). Only patients with papillary thyroid carcinomas, however, showed decrease in the postoperative levels of platelet-derived growth factor-BB and vascular endothelial growth factor-A (P = .001 each).ConclusionResults from this study raise the potential for vascular endothelial growth factor-A and platelet-derived growth factor-BB to be used as biomarkers of the effectiveness of treatment of papillary thyroid carcinoma. These results warrant further investigation and may have potential prognostic implications.     

Efficacy and cost-effectiveness of the UltraCision harmonic scalpel in thyroid surgery: an analysis of 200 cases in a randomized trial

BACKGROUND: Thyroid surgery technique has undergone very few changes in the last century. The UltraCision harmonic scalpel (UHS) (Smithfield, RI) has been widely used in laparoscopic surgery and is documented to be safe and fast for cutting and coagulating tissue. We studied whether the use of the UHS could have advantages in thyroid surgery in terms of operative time, length of hospitalization, morbidity, and general costs. METHOD: Our study was a prospective randomized trial of thyroidectomies and lobectomies performed for benign thyroid diseases in an endocrine surgery unit between February 2001 and July 2002. Patients were randomized in two groups: group A (n=100) underwent thyroidectomy using UHS and group B (n=100) with the conventional clamp-and-tie technique. Main outcome measures were demographics, operating time, length of hospitalization, intra- and postoperative complications, sequelae, and general costs. We used the unpaired 2-tailed Student's t test and the chi2 test to compare the series. RESULTS: The two groups were similar in age and sex. Mean +/- SD operative time was shorter in the UHS group compared with the conventional technique group for both lobectomy (61 +/- 06 vs. 78 +/- 10 minutes) and total thyroidectomy (86 +/- 20 vs. 101 +/- 16 minutes). Length of hospitalization was similar in both groups (1.07 vs. 1.15 days). We did not find statistical differences between the two techniques regarding transient postoperative complications. There were no deaths, no blood transfusions, no intraoperative complications, and no postoperative definitive sequelae. The global charges for every patient were significantly less in the UHS group (985.77 +/- 107.08 euro vs. 1148.40 +/- 153.25 euro). CONCLUSION: The use of ultrasonically activated shears resulted in a reduction of 15-20% in operative time and was cost-effective compared to the conventional technique group.     

Risk Factors for Recurrent Nodular Goiter after Thyroidectomy for Benign Disease: Case-control Study of 244 Patients

Surgery for recurrent nodular goiter is associated with a significant risk of parathyroid and recurrent laryngeal nerve (RLN) morbidity. Total thyroidectomy for benign disease is assessed. The aim of this study was to evaluate the risk factors for recurrence and the morbidity associated with reoperation. From 1969 to 1996 a total of 4334 thyroidectomies were performed, of which 122 were for recurrent nodular goiter (group I: 116 women, 6 men). A matched case-control study of 122 patients operated on for nonrecurrent multinodular goiter was performed (group II: 112 women, 10 men). Age, family history, initial surgery, pathology, and morbidity were compared in the two groups by ² test, Fishers exact test, and the Mantel-Haenszel test. The mean age was 39.88 years in group I and 47.89 years in group II. There was no statistical difference in relation to the extent of thyroidectomy or morbidity after initial surgery. Statistical differences were identified regarding age (p = 0.000002) and the multinodular nature of the initial goiter (p = 0.005). Bilaterality and family history were less significant (p = 0.09 and p = 0.08, respectively). Temporary RLN palsy and temporary hypoparathyroidism were higher in group I (12.3% vs. 5.7%, p = 0.0737; 10.6% vs. 1.7%, p = 0.00337). Permanent RLN palsy was found in 0.8% in group I and in none in group II (p = 0.5, NS). Young age and multiple nodules at initial surgery are risk factors for recurrence. A higher rate of temporary morbidity was demonstrated after surgery for recurrent goiter. Total thyroidectomy for multinodular goiter is advisable.This article was presented at the International Association of Endocrine Surgeons meeting, Uppsala, Sweden, June 14–17, 2004.