Minimal access thyroid surgery: Is it feasible,is it appropriate?

Background: Reports of minimal access thyroid surgery (MATS) using various techniques have recently appeared. This study examined the feasibility of MATS using either a lateral ‘focused’ or endoscopically assisted approach. Methods: The study group comprised all patients undergoing minimally invasive parathyroidectomy (MIP) during the period May 1998 to April 2002 in whom a concomitant thyroid procedure was undertaken. All procedures were performed either through a 2‐cm lateral cervical incision (n = 19) or endoscopically (n = 7). Results: Twenty‐six patients underwent thyroid surgery, consisting of either local excision of a thyroid nodule (n = 25) or hemi­thyroidectomy (n = 1). In 13 patients the nodule was incidentally discovered, in four patients removal of the parathyroid necessitated partial thyroidectomy, and in nine patients the lesion identified by preoperative parathyroid localization proved to be a thyroid nodule. There were no permanent complications in the study group. Two patients required drainage of a haematoma. The final pathology of all 26 cases revealed benign nodular thyroid disease. Conclusion: Thyroid surgery can safely be performed as a minimally invasive procedure. Minimal access thyroid surgery is therefore a feasible option for selected patients. The question remains to be answered as to whether this surgical approach is appropriate treatment for nodular thyroid disease.     

Completion thyroidectomy for malignancy after initial minimal access thyroid surgery

BACKGROUND: Minimal access thyroid surgery (MATS), carried out through a lateral 2.5-cm incision, provides excellent clinical and cosmetic outcomes when carried out for small (<3 cm), single nodules. However, if the final pathology shows thyroid malignancy and a completion thyroidectomy is required, the small lateral incision requires conversion to a standard collar incision and the second operation must be carried out in the presence of previous lateral dissection. The aim of this study is to determine if there is any demonstrable disadvantage to completion thyroidectomy for malignancy after MATS when compared with the same procedure after conventional hemithyroidectomy. METHODS: This retrospective cohort study examined all patients undergoing completion thyroidectomy for malignancy in the University of Sydney Endocrine Surgical Unit from January 2002 to January 2005. Outcome measures were complication rates, final scar length and patient's self-assessment of scar appearance. RESULTS: A total of 106 patients underwent MATS during the study period, 11 of whom required completion thyroidectomy for malignancy. During the same period, 42 patients required completion thyroidectomy for malignancy after previous conventional hemithyroidectomy. There was no difference in complication rates between the two groups. The two complications in the study consisted of one case of flap oedema (control) and one case of keloid scar (MATS). Mean final incision length, scar appearance and patient's satisfaction with scar did not differ between the two groups. CONCLUSION: There is no demonstrable disadvantage when completion thyroidectomy for malignancy is required after MATS.     

Safety and feasibility of thyroid lobectomy via a lateral 2.5-cm incision with a cohort comparison of the first 50 cases: evolution of a surgical approach

Background and aims Over 500 minimal-access parathyroidectomies (MIPs) have been performed in our unit, and, from these, a technique for thyroid resection has evolved. We present a report on the evolution of minimal-access thyroid surgery (MATS) and compare the results with those from a cohort of patients operated on prior to the use of MATS.Methods We reviewed the evolution towards the MATS technique. The results of the MATS procedures were compared with those from an equal number of consecutive patients undergoing conventional lobectomy prior to the use of MATS.Results Fifty patients (mean age 45.6 years) underwent MATS between March 2002 and May 2004. The mean nodule diameter was 18.5 mm. In the MATS group there was one recurrent laryngeal nerve (RLN) injury, two temporary RLN neuropraxias, which recovered, and one haematoma. The control group (mean age 47.9 years) had a mean nodule size of 22 mm. In the controls there was one temporary RLN neuropraxia, which recovered, and two haematomas—P>0.05 (Fishers exact test) for all the complications.Conclusions MATS has evolved from an experimental approach into a safe and feasible surgical procedure based on the same operative approach as used for MIP. It provides an alternative to open thyroid surgery in appropriately selected cases.Presented at the European Society of Endocrine Surgery (ESES), Pisa, Italy, May 2004     

Minimally invasive thyroid surgery for diagnostic excision of solitary thyroid nodules

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

Video-assisted thyroid lobectomy through a small wound in the submandibular area

BACKGROUND: Endoscopic thyroidectomy has not gained wide acceptance because of the expertise required, the long operation time, the wide dissection, and the extra cost of specialized instruments. We developed a video-assisted hemithyroidectomy procedure that requires only one small incision at the upper neck. METHODS: Hemithyroidectomy was performed through a 25 to 30 mm transverse incision made in the upper lateral neck for the treatment of benign thyroid nodule. No gas or external lift dissection was needed. RESULTS: The mean age of 39 patients was 33.8 years. The tumor size ranged from 1.9 to 5.5 cm (mean 3.1 cm). All patients underwent total lobectomy without conversion to traditional cervicotomy. The mean operation time was 56 minutes (range 36 to 90). Follicular adenoma was the final pathologic diagnosis in 25 patients and adenomatous goiter in 14. Transient recurrent laryngeal nerve palsy was seen in 1 patient. CONCLUSIONS: Our technique is safe, minimally invasive, less time consuming, and cosmetically excellent.     

Incidental thyroid carcinoma in a large series of consecutive patients operated on for benign thyroid disease

BACKGROUND: The diagnosis of incidental thyroid carcinoma (ITC) in patients operated on for a benign disease is frequent. This study aims to determine both its clinical effect and the possibility of identifying this class of patients preoperatively. METHODS: A total of 998 consecutive patients (697 women and 301 men; mean age, 49.5 years) undergoing surgery for benign thyroid pathology in a single institution were studied. The mean time between first diagnosis of thyroid disease and operation was 9.0 years (range, 0-50 years). All patients underwent at least one ultrasonography before surgery, and 678 patients underwent fine-needle aspiration cytology. Patients with undetermined cytology or follicular nodules were excluded from the study. RESULTS: Histology revealed an ITC in 104 patients (10.4%): 99 had a papillary carcinoma. Mean and median diameters of ITC were 1.4 and 0.7 cm, respectively (range, 0.1-7.5 cm). In 43 patients, the tumour size was greater than 1 cm, whereas it exceeded 2 cm in 25 patients. Tumours were multicentric in 19.8% of the patients and occurred in 8.2% of patients with nodular toxic goiter, 8.7% of patients with toxic diffuse goiter and 13.8% of patients with multinodular goiter. DISCUSSION: The results confirm the high frequency of ITC. ITC was more frequent in euthyroid patients than in thyrotoxic patients (P < 0.03). Sex, age, thyroid volume and interval between diagnosis and surgery did not significantly influence its incidence. The majority of ITC was represented by microcarcinomas, but in approximately 25% of patients, the tumour size was greater than 2 cm. The role played by FNAC in excluding malignancies proved to be fairly inconclusive.     

Evaluation and management of incidental thyroid nodules in patients with another primary malignancy

BACKGROUND: Studies indicate that incidentally discovered thyroid nodules >or=1 cm in size may have a higher rate of malignancy (7% to 29%) than traditionally discovered nodules (5%). We sought to determine the rate of malignancy in incidental thyroid nodules in patients with other malignancies, and examine the accuracy of ultrasound (US) versus computed tomography (CT) in determining nodule size. METHODS: We evaluated 41 patients with history of another known malignancy (gastrointestinal, 23; breast, 11; other, 7) referred with an incidental thyroid nodule. Patients underwent office-based US and biopsy of nodules >or=1 cm. Surgical intervention was based on biopsy results. We compared nodule size at pathology with size seen on CT or US. RESULTS: Thirty-five patients met criteria for biopsy. Of the 35, 20 (57%) had atypical biopsy results warranting resection. Sixteen of those 20 underwent surgery. Pathology yielded 4 papillary thyroid cancers (PTC), 4 microPTC, 2 metastatic cancers, and 7 benign lesions. Ultrasound measurement of nodules compared to size measured at pathology had an r2 correlation value of 0.90 with P value <.0001. CT scan had an r2 value of 0.83 and P value of .005. CONCLUSIONS: Incidental thyroid nodules in patients with another primary malignancy warranted resection in 57%. The rate of malignancy in incidental thyroid nodules was 24%, which is above the expected rate of 5% seen in traditionally discovered nodules. US correlation with nodule size at pathology was excellent and superior to CT scan. Incidentally discovered thyroid nodules >or=1 cm, seen in patients with another malignancy, warrant further evaluation.     

甲状腺结节的规范诊治

目的 探讨甲状腺结节的规范诊治,避免过度诊治问题.方法 回顾大连医科大学附属第二医院2005年1月至2009年12月间住院的2 581例甲状腺结节诊治的临床资料,分析各主要诊治方法在临床中的应用情况,总结目前甲状腺结节较为规范的诊治方法和可以避免的过度诊治情况.结果本组2 581例患者术前检查以超声最为常见,约占90%,且含有2个或2个以上超声检查危险特征者对恶性结节敏感性92.9%,特异性44.3%,所有患者根据实际病情行不同手术治疗,其中单发低危微小癌患者行单侧腺叶加或不加峡部切除术后2.5年复发率4%.结论 甲状腺结节的诊治方法多种多样,超声作为初检在术前诊断上特异性、敏感性较高,且较为经济,治疗仍以手术治疗为最主,合理选择诊治方法是避免甲状腺结节过度诊治的关键.     

Endoscopic Lateral Approach Thyroid Lobectomy: Safe Evolution from Endoscopic Parathyroidectomy

Introduction Endoscopic thyroid surgery has been shown to be feasible. Most minimal access procedures have been performed via a midline approach. Based on our experience of more than 500 endoscopic parathyroidectomies via a lateral approach we have used the same method for thyroid lobectomy. Methods We present our experience of endoscopic thyroid lobectomy via a lateral approach (ETLA) and review of the results over a 1-year period (2004). Inclusion criteria for ETLA were (1) solitary nodule with atypical/suspicious fine–needle biopsy (FNB) or solitary toxic nodule; (2) lesions with a diameter of <3 cm. Patients with a history of previous neck surgery or radiation exposure were excluded. All patients underwent postoperative vocal cord checks and plasma calcium evaluation. Results A total of 742 thyroid procedures were performed during 2004. Among them, 38 patients (5.1%) underwent ETLA. Indications for surgery were suspicious FNB results (36 patients) and a toxic nodule (2 patients). Mean nodule size was 19.2 mm. Mean ± SD operating time was 102 ± 27 minutes. All recurrent laryngeal nerves were identified (including one that was nonrecurrent). Of the 38 patients, the superior parathyroid gland was identified in 36 and the inferior parathyroid gland in 33. There were two conversions due to difficulty with the dissection. Two operations were converted because malignancy was diagnosed on frozen section examination. Two patients underwent a delayed completion thyroidectomy when definitive histology necessitated it. There were no permanent operative complications, and all patients were discharged on the first postoperative day. Conclusions ETLA offers excellent intraoperative visualization of the vital structures and is a safe alternative to conventional thyroid lobectomy in selected cases.     

Isthmectomy: A Conservative Operation for Solitary Nodule of the Thyroid Isthmus

Purpose : To assess the results obtained in patients with nontoxic uninodular goiter confined to the isthmus undergoing isthmectomy.

Methods : Between April 1994 and June 2006, 330 consecutive patients with nontoxic uninodular goiter underwent thyroidectomy at our institution. In 31 patients, lesions were limited to the thyroid isthmus with evidence of benign or undetermined pathology on ultrasound-guided fine-needle aspiration biopsy. Total isthmectomy was performed. Results : Preoperatively, thyroid nodules on ultrasonography were solid in 26 patients and mixed with cystic and solid components in 2. The mean size of nodules was 2.43 (± 0.88) cm. No intraoperative or postoperative complications occurred. Histological examination showed nodular hyperplasia in 29 cases, follicular adenoma in 1 and papillary thyroid carcinoma in 1. The patient with papillary carcinoma underwent bilateral lobectomy 7 days later. A total of 24 patients (77.4%) attended clinical visits at follow-up (mean 70, 57 months). Ultrasonographic scanning revealed thyroid nodules in 17 patients, in 16 of which nodules range from one to five (0.5 to 2 cm in size) and further surgery was not indicated. One patient with a 4-cm nodule and tracheal displacement found at ultrasonography 2 years after isthmectomy had inconclusive results of FNAB. This patient was re-operated for completion thyroidectomy, which was successfully performed without technical difficulties. The detection of recurrent nodules was independent of the time elapsed since thyroid isthmectomy.

Conclusions : These findings document the feasibility and efficacy of isthmectomy in solitary thyroid nodules confined to the isthmus.     

Recommendations for the management of cystic thyroid nodules

BACKGROUND: The management of cystic thyroid nodules has not been standardized with respect to an initial fine-needle aspiration cytology (FNAC) cystic change result, which is defined as fluid aspiration and a smear with numerous macrophages but scant or no follicular cells. In the present study the physical characteristics of cystic thyroid nodules predictive of the pathology were investigated, and recommendations made on their management. METHODS: The aspiration results of 1436 thyroid nodules managed between 1998 and 2000 were investigated. A total of 157 patients who had a subsequent operation or follow-up data with reaspiration were the subjects of the present study. Age, sex, nodule characteristics and others were examined as possible predictors of cancer risk. RESULTS: The malignancy rate was 8.9%. Ten cases (71%) of malignancy were not cytologically diagnosed. Male sex and a nodule size of > or = 4 cm were found to be statistically significant predictors of malignancy. The malignancy rate was highest (100%) when a cystic lesion had malignant cytology on reaspiration and local invasion on radiology. CONCLUSIONS: When a cystic change is observed by initial FNAC of thyroid nodules, nodules of > or = 4 cm must be reaspirated and a firm cytologic diagnosis made to rule out malignancy. Nodules should be considered for surgery having taken into account other characteristics, in particular male sex and radiologic findings of local invasion.     

超声引导下粗针穿刺活检在甲状腺疾病诊断中的应用

[摘要] 目的 探讨超声引导下粗针穿刺活检(ultrasound-guided Core-needle biopsy ,US-CNB) 在甲状腺疾病诊断中的应用。方法 对2004年5月～2013年3月在我院手术的146例甲状腺疾病患者共计152个甲状腺结节术前进行超声引导下粗针穿刺活检,将穿刺病理与手术病理结果进行对照,并分析其超声图像特点。结果 152个粗针穿刺病理报告中,恶性92个,术后病检证实其中90例确诊为甲状腺癌,2例为良性病变;甲状腺良性病变56个 ,术后病检其中2例为甲状腺癌;未明确诊断者4个,术后病检3例为良性,1例为甲状腺癌,USCNB对直径>0.7cm的结节穿刺确诊率较高,甲状腺粗针穿刺活检的敏感度、特异度、准确率分别为：96.7%、91.5%、94.7%。结论 USCNB对甲状腺疾病确诊率因结节直径大小不同而有差异,超声引导下甲状腺粗针穿刺活检操作简单,定位准确,创伤小,并发症少,准确性高,是非手术条件下取得病检的首选方法。     

Thyroid calcification and its association with thyroid carcinoma

AIM: Calcification within the thyroid gland may occur in both benign and malignant thyroid disease, and its detection on ultrasonography is frequently dismissed by many clinicians as an incidental finding of little significance. As a tertiary referral center, most of our thyroid patients will have had thyroid ultrasonography before being referred to us, and in our experience, the incidence of malignancy in a thyroid nodule containing calcification seems to be higher than that in the average thyroid nodule. To assess this risk, we conducted this retrospective review. MATERIALS AND METHODS: Our analysis included 462 consecutive patients who underwent thyroid surgery at our institution between 1995 and 1999. We reviewed all the patients' charts for data regarding clinical findings, preoperative diagnostic investigations, and histopathologic diagnosis. Of the 462 patients, 361 (78.1%) had thyroid ultrasonography before surgery, and 49 (13.6%) of these ultrasounds showed intrathyroidal calcification. RESULTS: Of the 49 patients whose ultrasounds showed intrathyroidal calcification, 29 (59.2%) were found on histopathologic examination to have thyroid carcinoma. Twelve of the remaining 20 patients had multinodular goiters. Of the 29 patients with malignancy, seven (24.1%) had preoperative fine-needle aspirates that were reported as benign. After excluding patients who were initially seen with multinodular disease, in the subset of 37 patients who presented with a solitary thyroid lesion with calcification, 28 (75.7%) were found to have carcinoma. CONCLUSIONS: When calcification is noted within a solitary thyroid nodule, the risk of malignancy is very high. Surgery should be recommended regardless of the result of fine-needle aspiration cytologic findings.     

血清促甲状腺激素水平与分化型甲状腺癌致病风险关系研究

目的 探讨甲状腺结节患者术前血清促甲状腺激素（TSH）水平与分化型甲状腺癌（DTC）的关系.方法 回顾性分析2004 年1 月至2010 年12 月我科收治的6170 例符合条件的各类甲状腺手术治疗患者临床资料,检测患者术前血清TSH 水平并与术后病理组织结果 进行对照分析.结果 6170 例手术患者中389 例术后病理证实为DTC（6.3%）.5781 例良性组甲状腺结节患者血清TSH 浓度为（1.1 ± 0.5）mU/L,389 例恶性组患者为（2.8 ± 0.3）mU/L,两组间比较差异有统计学意义（P 〈 0.01）.高于TSH 参考值范围与低于此范围的患者中患DTC 的比例分别为9.1%、4.9%,二者差异有统计学意义（P 〈 0.001）.并随血清中TSH 水平的增高,患甲状腺癌的机会增加.DTC 患者中颈淋巴结转移组患者平均TSH 水平高于无转移组（P 〈 0.05）.结论 随着血清中TSH 水平的增高,甲状腺结节患者患DTC 的概率增加,血清TSH 水平与DTC 颈淋巴结转移相关.     

甲状腺良性疾病手术中使用超声刀和电刀的对比研究

【摘要】 目的〓分析超声刀与电刀在开放甲状腺良性疾病手术中的临床效果。方法〓选取2010年1月至2014年1月于本院进行甲状腺良性疾病手术的220例患者,其中150例采用超声刀进行甲状腺手术,70例采用传统的电刀进行甲状腺手术,对两组患者的切口长度、手术时间、术中出血量、住院天数、手术费用、术后引流管拔除时间、术后第1、2天引流管引流量及并发症,进行分析比较。结果〓两组患者无死亡病例,无神经损伤病例,电刀组有1例术后出血,予以再次手术止血后好转。超声刀及电刀组在手术费用、病人性别、并发症、年龄无差异。超声刀组在切口长度、手术时间、术中出血量、术后住院天数、术后引流管拔除时间及术后第1、2天引流管引流量明显低于电刀组,有统计学意义。结论〓在甲状腺良性疾病手术中,超声刀明显优于电刀,手术中可优先使用超声刀。     

改良低位小切口甲状腺切除术的临床应用

目的探讨改良小切口甲状腺切除术在甲状腺手术中的临床应用价值。方法回顾性分析我科2006年10月至2010年4月应用改良小切口行甲状腺手术治疗的78例甲状腺结节的临床资料,手术要点包括．切口选择在胸骨上窝处,切口小以及应用超声刀。结果本组78例疗效满意,切口长度3．0～3．5cm,手术时间30～95min,术中出血量少,术后无声音嘶哑,无继发性出血或血肿等并发症。切口一期愈合,于术后第2～4d出院,住院时间4～5d。随访5～24个月,手术切口瘢痕细小、美观。结论改良小切口甲状腺切除术是一种安全、有效的治疗方法,且创伤小、并发症少、恢复快、美容效果好,患者满意度高,值得临床推广应用。     

颈前小切口鼻内镜辅助下甲状腺良性肿瘤切除术的临床体会

【摘要】 目的 采用内镜辅助下颈前小切口甲状腺良性肿瘤切除的手术经验并与传统手术比较处理经验。 方法〓回顾性分析62例肿瘤最大直径<4.0 cm的甲状腺良性肿瘤切除术,按手术方式分为内镜组(鼻内镜辅助下甲状腺切除术,n=33)和传统组(传统开放甲状腺切除术,n=29)比较两组的临床治疗效果。 结果〓2组62例患者的肿块均完整切除,切口均I期愈合。术后均无声音嘶哑、呛咳、继发血肿等并发症,无手术死亡病例。鼻内镜辅助下颈前小切口组的手术时间较传统组长,术中出血量较传统组少,且患者术后疼痛程度也较低。 结论〓与传统开放手术相比,鼻内镜辅助下颈前小切口甲状腺手术具有美容、出血少、术后疼痛小等优点,是治疗甲状腺良性肿瘤一种很好的手术选择。     

Minimally invasive approach of the cervical endocrine glands

Improved preoperative functional and topographic diagnostic techniques and availability of intra-operative hormone monitoring, stimulated the introduction of video-assisted minimally invasive operations in parathyroid and thyroid surgical pathology. The first cases of such pathology operated on in our clinic are presented. The first one is a 62 year old man with renal hyperparathyroidism consecutive to a chronic renal insufficiency and hemodialysis from five and three years respectively. The technique of a minimally invasive gapless resection of all four "adenomised" parathyroid glands using laparoscopic and classic instruments is described. Fragments of one gland are implanted in the left forearm musculature. The second case was a 48 year old woman with a three cm diameter right toxic adenoma. With a lateral 15 mm incision, dissociation of the musculature and adequate moving of the retractors the excision of the thyroid nodule was done in 25'. The video-assisted minimally invasive approach allows magnification and adequate identification and removal of endocrine secreting tissues in thyroid and parathyroid pathology. The authors believe that these techniques represent a feasible and attractive alternative to conventional surgery.