Risk of injury to the external branch of the superior laryngeal nerve in thyroidectomy

OBJECTIVE: To establish in the Mexican population with thyroid disease the risk of injury to the external branch of the superior laryngeal nerve (EBSLN) based on its anatomical position. STUDY DESIGN: Non-randomized comparative clinical trial. METHODS: Seventy-three patients subjected to thyroidectomy because of thyroid nodule in which the EBSLN was identified and classified. The dependent variable was Cernea's classification of the EBSLN, and the independent variables were weight (in grams) of the nodule, side studied, gender, and age. For statistical analysis, chi2 test, Fisher's Exact test, and analysis of multiple variables (analysis of variance) were used. RESULTS: We studied 73 patients; 64 (87.62%) were women and 9 (12.38%) were men (average age, 39.3 years [age range, 17-73 y]; median age, 40 y; mode, 40 y; SD +/- 23.4 y). Regarding location of the EBSLN, for pathological lobes, 78.1% were located in a high-risk position and for nonpathological lobes, 72.7%. Comparative analysis between sides and relation between weight and classification revealed no statistical significance. CONCLUSION: The frequency of high-risk position for EBSLN lesion in our milieu was higher than that reported in series from other countries and races.     

Hyperparathyroidism associated with thyroid pathology

BACKGROUND: The pathological association between thyroid and parathyroid gland disease is here discussed. The multiphase analyzer has revealed a new type of subclinical primary hyperparathyroidism (HPP) and the role of surgery in these cases is not clear. METHODS: This is a prospective study of all cases of thyroid disease in association with parathyroid disease treated surgically in our Institute from July 1999 to June 2001. RESULTS: Of the 221 thyroidectomies carried out, 29 patients had an elevated preoperative serum level of parathyroid hormone (PTH). An ultrasonography examination was performed on all patients and a preoperative scanning with 99Tc-MIBI on 11 of 29 patients. We examined intraoperatively 19 cases of HPP (14 parathyroid adenoma, 5 hyperplasia). In 10 cases we observed a normal size of the parathyroid gland and we did not perform a parathyroidectomy. CONCLUSIONS: All patients with elevated serum parathyroid hormone and serum calcium levels before thyroidectomy should be considered candidates also for surgery to the parathyroid glands. The pathological association between thyroid and parathyroid gland diseases is not rare. We must conduct an accurate neck exploration in all these cases.     

Neuromonitoring Is Not a Standard Procedure in Thyroid Surgery

Summary BACKGROUND: The main concern with postoperative results is the integrity of the voice. As there is no causal therapy for recurrent nerve paralysis, close attention has to be paid to the preservation of the laryngeal motor nerve. Neuromonitoring (NM) is a new technique for identifying the nerve in its anatomical position, but it has failed to lower the postoperative complication rate. METHODS: The data from the literature were compared. Many studies showed a rapid decrease in palsy rates by general nerve preparation, but the outcome was still influenced by various factors such as underlying disease and surgical radicality. Only one study did not show any difference in outcome with or without nerve identification. RESULTS: Even though there is an unequal composition of data sources, it is highly suggestive that surgical development that has focussed attention on nerve preservation has led to an improvement in postoperative outcome. In general, palsy rates with nerve preparation are below 1%. The same improvement is reported with the use of neuromonitoring. It seems that these effects are similar to those obtained by nerve preparation alone. Moreover, intra- and postoperative nerve function does not always correlate. No clear-cut advantage in the results achieved with NM can be stated. CONCLUSIONS: Besides the fact that considerable basic research has been done using NM, the data concerning improvement of nerve palsy rates do not necessitate its general use in routine thyroid surgery. Subtle operative technique and visualization of the structure are still mandatory. NM might help shorten the learning curve in identification exercises.     

甲状腺手术的技术改进及并发症预防

目的:探讨甲状腺手术中技术要点及并发症预防方法.方法:总结55例甲状腺近全切除术及叶全切除术及其中多种手术入路结合、多角度腺体囊外游离、必要的喉返神经显露等方法改进经验;结果:颈部活动无牵拉感,无喉返神经和甲状旁腺损伤等并发症出现.结论:改进的技巧方法提高甲状腺叶全切除及近全切除手术的安全性及彻底性,降低手术操作难度.     

无注气内镜下甲状腺手术和传统手术的比较研究

目的通过前瞻临床对照研究，评价分析内镜下甲状腺手术组与传统手术组间手术时间、出血量、美容效果、并发症、费用等有无差异，评估技术是否有效、可行、安全。方法2001年7月至2005年10月中山大学附属第二医院耳鼻咽喉头颈外科对83例甲状腺肿瘤的患者施行无注气内镜下甲状腺手术（内镜组），同时对照分析80例在年龄、性别、术式、麻醉、病情轻重、手术医生水平相匹配的本科同期住院行传统手术病例（传统组）。结果内镜组无一例中转手术，美观效果好，颈部仅留小瘢痕或无瘢痕，但住院费用高于传统组，分别为（10844±2373）元和（7585±1081）元，两者比较差异有统计学意义（t=-7．230，P〈0．01）。手术失血量与常规手术相比要少，分别为（25±21）ml和（36±23）ml，两者比较差异有统计学意义（t=3．160，P〈0．01）；但手术时间要长，分别为（107±30）min和（79±19）min，两者比较差异有统计学意义（t=-7．225，P〈0．01）。当术者取得经验和应用先进的超声刀技术后，手术时间和失血量明显减少。结论无注气内镜下甲状腺手术是一个安全有效、可行的新手术，具有美容的优点，为手术治疗甲状腺肿物的患者多提供了一种选择。     

腔镜与开放手术治疗原发性甲状腺功能亢进症的临床对照分析

目的:对比分析腔镜与开放手术治疗原发性甲状腺功能亢进症的临床效果。方法:回顾分析17例腔镜和22例开放手术治疗甲状腺功能亢进的临床资料,对比两组术前与术后1、6、12、24个月的FT3、FT4、TSH、手术时间、出血量、住院时间、住院费用、美容效果、并发症、复发率等指标的差异。结果:两组手术前后血清FT3、FT4、TSH差异均有统计学意义(P0.05),腔镜组较开放组出血少、住院时间短、美容效果佳(P0.05),并发症、复发率两组差异无统计学意义(P0.05),但腔镜组手术时间较长,费用较高,两组差异有统计学意义(P0.05)。结论:腔镜手术治疗甲状腺功能亢进安全可行,且具有出血少、美容、康复快的效果。     

显露喉返神经在甲状腺手术中的意义探讨

目的探讨在甲状腺手术中显露喉返神经的意义。方法回顾性分析因甲状腺疾病行手术治疗的1082例患者的临床资料。结果所有患者均常规解剖并显露喉返神经。手术并发症有喉返神经损伤6例（0．5％），甲状旁腺功能减退3例（0．3％），喉上神经损伤2例（0．2％）。甲状腺手书并发症的发生率与水中是否显露喉返神经有密切关系。结论甲状腺手术中显露喉返神经是降低甲状旁腺、喉上神经和喉返神经损伤的重要措施。     

甲状腺微小癌的临床研究

目的 探讨甲状腺微小癌的临床特征及治疗原则.方法 回顾分析1997年1月至2006年12月收治的311例甲状腺微小癌的临床资料.结果 181例患者以结节性甲状腺肿、甲状腺瘤等良性病变为首发症状(偶发组),130例患者以甲状腺癌结节或体检B超怀疑恶性病变或以颈部淋巴结转移为首发症状(显性组).两组平均年龄分别为47岁及42岁(F=15.545,P=0.000).显性组恶性程度高于偶发组,其需行颈淋巴结清扫的比例分别为48.5%(63/130)及30.9%(56/181),颈部淋巴结转移率分别为27.7%(36/130)及10.5%(19/181),肿瘤两叶多发病灶分别为18.5%(24/130)及9.4%(17/181).结论 将甲状腺微小癌分为"偶发癌"和"显性癌"两个亚型对认识微小癌的发生、发展及指导临床治疗具有实际意义.对"显性癌"患者,患侧腺叶切除或甲状腺全切除应视为标准术式;而对"偶发癌"患者,在保证安全切缘的前提下,甲状腺次全或腺叶切除都可视为手术选择.同时应常规探查Ⅵ区淋巴结,肿大者应予以清扫,体检及B超提示颈淋巴结转移者需再加颈侧清扫.     

Hemiclamshell incision in the treatment of mediastinal goiter

Background  The thyroid disease can appear in 0.16–3.3% of cases as mediastinal goiter. The treatment is difficult and requires a mediastinal approach. Materials and methods  We have analyzed our experience from September 1995 to September 2007 among 2,439 thyroidectomies conducted for thyroid disease; 16 cases required a sternotomy, in seven patients conducted as hemiclamshell approach (median sternotomy associated to a fourth intercostals space incision). Preoperative evaluation included otorhinolaryngology evaluation and computed tomography. All the cases were followed up to 12 months. Results  For seven cases treated trough hemiclamshell, the mean age was 57.8 years; hospital stay is 5.2 days. All the patients were discharged after respiratory evaluation; two patients required a pneumological admittance to physio-kinesi-respiratory. There were no cases of hemorrhage, nerve injury, permanent hypocalcemia, and chylothorax. There was no mortality at 30 days. Conclusions  The hemiclamshell is a safe procedure to treat mediastinal goiter and permit a good exposure of subclavian vessels and mediastinal nodes.     

Does the risk of compressive hematoma after thyroidectomy authorize 1-day surgery?

BACKGROUND: Compressive hematoma after thyroidectomy is a rare complication (1%) but can potentially be severe. The aim of this study was to search for risk factors, in particular the use of anticoagulants or antiplatelet medication, and to see if the delay of hematoma formation would require 1-day surgery performed in a careful manner. MATERIALS AND METHODS: Retrospective review of 6,830 patients undergoing thyroidectomy in a single institution (1991 to 2006) identified 70 patients with hematomas requiring reoperation. Case controls (210 patients) were matched for age, gender, year of operation, type of thyroid disease, and type of operation. The notion of anticoagulant or antiplatelet medication was particularly studied. The delay of hematoma formation and the cause of bleeding were studied in univariate analysis by a chi-squared test and a Fischer's test. RESULTS: In univariate analysis, the formation of hematoma is not related to age, gender, type of thyroid disease, or type of bleeding. The pre or intraoperatory administration of anticoagulant or antiplatelet medication did not influence hematoma formation. Thirty-seven hematomas (53%) presented within 6 h postoperatively, 26 (37%) between 7 and 24 h and seven (10%) beyond 24 h. CONCLUSION: Patients undergoing anticoagulant or antiplatelet treatment are not a high-risk population for hematoma formation. Forty-seven percent of the patients presented postoperative hematomas beyond 6 h postoperatively, leading to the conclusion that 1-day surgery is not safe.