Outpatient thyroidectomy in the pediatric population

Preoperative optimization and patient education have allowed for the transition of thyroid surgery to the outpatient setting over the last few decades. Performing these operations in the outpatient setting has proven to be cost-effective and safe in the adult population. The purpose of this study is to evaluate the safety and efficacy of outpatient thyroid surgery in the pediatric population. A retrospective review from December 2015 to February 2019 of patients under the age of 18 years of age undergoing thyroidectomy performed by two endocrine surgeons at a large academic was performed. There were 55 consecutive operations performed in 51 patients for thyroid pathology, two were excluded as they were inpatient procedures. Cases were reviewed for complications, unplanned same-day admission, 30-day admission, unplanned reoperation, and death. Mean age was 15 ± 0.3 years (range 9–18 years), 79% of the patients were female. Operations were performed for Graves’ disease (n = 29), thyroid cancer (n = 9), thyroid nodule (n = 6), multinodular goiter (n = 4), Hashimoto’s disease (n = 3), and toxic adenoma (n = 2). Operations performed included: total thyroidectomy (n = 36), thyroid lobectomy (n = 13), total thyroidectomy with lymph node dissection (n = 2), and lateral neck dissection (n = 2). All patients were discharged home within 6 h after completion of the operation. Five (9.4%) patients had transient hypoparathyroidism, with parathyroid hormone levels <10 pg/mL immediately postoperatively. One patient (1.9%) developed a postoperative hematoma on postoperative day six and required reoperation and readmission. Two patients (3.8%) had permanent hypoparathyroidism and one had transient hoarseness (1.9%). There were otherwise no readmissions or ED visits. In conclusion, outpatient thyroid surgery is safe and effective for pediatric patients.     

腔镜与开放性甲状腺手术的对比研究

目的腔镜与开放性甲状腺手术临床效果的对比研究。方法回顾性分析2002年8月至2005年5月113例腔镜甲状腺切除术(腔镜组)和104例开放性甲状腺切除术(开放组)的临床资料。结果两组的手术时间、住院时间、术后住院时间差异无显著性意义。腔镜组失血量(42.5±62.8)mL明显少于开放组(118.2±120.8)mL,差异有显著性意义(P<0.05);而腔镜组引流量多于开放组(P<0.05);腔镜组术后恢复活动时间为(2.2±1.0)d,与开放组(2.5±1.1)d比较差异无显著性意义(P>0.05);腔镜组术后镇痛药需求比开放组明显减少,而住院费用高于开放组。术后并发症腔镜组以喉上和喉返神经损伤为主,且甲状腺功能亢进术后并发症发生率较高,而开放组主要是术后出血。结论选择合适的病例实施腔镜甲状腺手术是安全可行的,具有美容、疼痛轻、出血少的优点。     

Transoral robotic-assisted thyroidectomy with central neck dissection: preclinical cadaver feasibility study and proposed surgical technique

Recently, a transoral robotic-assisted technique to access the thyroid gland has been introduced. Despite the advantages this approach may have over other minimally invasive and robotic-assisted techniques, we found that the placement of the camera through the floor of mouth led to restricted freedom of movement. We describe our modification to this technique to overcome this problem. In a study using two fresh human cadavers, the camera port of the da Vinci robot was placed in the midline oral vestibule instead of the floor of the mouth. A transoral thyroidectomy and central neck dissection was successfully performed. Our modification led to an unfettered view of the central neck and allowed for a total thyroidectomy and central neck dissection. Our modification of transoral robotic-assisted thyroidectomy provides superior access to the central compartment of the neck over other robotic-assisted thyroidectomy techniques.     

胸乳入路腔镜手术与开放手术治疗甲状腺单侧叶结节的疗效分析

比较胸乳入路腔镜甲状腺手术与开放手术治疗甲状腺单侧叶结节的临床效果.回顾性分析2019年5～10月134例行甲状腺单侧叶切除术患者临床资料.根据患者意愿及腔镜甲状腺手术适应证,行开放手术患者90例(开放组),行胸乳入路腔镜甲状腺手术(腔镜甲状腺)患者44例(腔镜组).根据术中快速病理确定术式,甲状腺良性病变者行甲状腺单...     

Laparoscopic ureterocalicostomy: a feasibility study

PURPOSE: Ureterocalicostomy is occasionally indicated for reconstruction of recurrent, recalcitrant ureteropelvic junction obstruction associated with postoperative fibrosis and a relatively inaccessible renal pelvis. We investigated the feasibility of performing laparoscopic ureterocalicostomy in a survival porcine model. Anatomical, histological and chronic functional outcomes were evaluated. MATERIALS AND METHODS: Laparoscopic ureterocalicostomy was performed in 10 survival female swine. A ureteropelvic junction obstruction model was created by laparoscopic ligation of a 2 to 3 cm. segment of upper ureter. After an interval of complete ureteropelvic junction obstruction laparoscopic ureterocalicostomy was performed in a manner duplicating the steps of conventional open surgery. After transverse amputation of the lower renal pole end-to-end anastomosis of the proximal ureter to the inferior calix was formed by laparoscopic freehand suturing and knot-tying techniques. RESULTS: Mean ureter stricture length was 2.2 cm. (range 1.7 to 3.1). Mean duration of obstruction before laparoscopic ureterocalicostomy was 6.3 days (range 2 to 18). Mean operative time for laparoscopic ureterocalicostomy was 165.3 minutes (range 105 to 240). Mean estimated blood loss was 145 cc (range 25 to 400). Mean stent duration in 6 pigs was 8.7 days (range 7 to 11). Excretory urograms demonstrated immediate function with symmetrical and unobstructed drainage in all operated renal units. At 4 to 8 weeks of followup no urine leaks were noted and histological examination documented complete urothelial healing without fibrosis or scar formation. CONCLUSIONS: Laparoscopic ureterocalicostomy is technically feasible in the porcine model and it effectively duplicates the established principles of open surgery. Our technique further extends the application of laparoscopic surgery for difficult ureteropelvic junction obstruction.     

Comparison between minimally invasive video-assisted thyroidectomy and conventional thyroidectomy: a prospective randomized study.

BACKGROUND: Endoscopic procedures for thyroid surgery have been introduced since 1998, but their diffusion has remained limited because their advantages were never demonstrated. METHODS: Forty-nine patients undergoing surgery for either a thyroid nodule or a small papillary carcinoma were allotted to 1 of these procedures, minimally invasive video-assisted thyroidectomy (MIVAT) or conventional thyroidectomy (CT). Exclusion criteria were nodules greater than 35 mm, presence of thyroiditis, and thyroid volume greater than 20 mL. Preoperative diagnosis, operative time, postoperative pain, complications, and cosmetic result were evaluated. RESULTS: MIVAT group included 25 patients and the CT group 24 patients. Operative time was 66 +/- 24 minutes for MIVAT and 45 +/- 15 minutes for CT (P = .001). Postoperative course was significantly less painful in the patients who underwent MIVAT (P = .003). Cosmetic result evaluated by verbal response scale and numeric scale was in favor of MIVAT (P = .003 and P = .01, respectively). One recurrent nerve palsy and 1 transient hypoparathyroidism were present in CT patients; MIVAT patients experienced 2 transient palsies. CONCLUSIONS: Despite some MIVAT advantages in terms of postoperative pain and cosmesis, CT still offers an advantage in terms of operative time and its safety should not differ. Larger series of patients are needed before deciding whether endoscopic thyroidectomy can offer important advantages.     

Laparoscopic aortorenal bypass: a feasibility study

PURPOSE: To demonstrate the technical feasibility of laparoscopic aortorenal bypass in an acute porcine model. MATERIALS AND METHODS: An aorta-to-left renal artery bypass using an interposition Dacron graft was performed in five pigs. Intracorporeal laparoscopic free-hand suturing and knot-tying were employed exclusively. Renoprotective in-situ regional hypothermia was achieved intracorporeally by infusing ice-cold heparinized saline into the renal artery using a balloon catheter. RESULTS: The mean total surgical time was 325 minutes, and the mean renal ischemia time was 61 minutes. The end-to-side graft-to-aorta and end-to-end graft-to-renal artery anastomosis times were 34 minutes and 40 minutes, respectively. The mean estimated blood loss was 66 mL. On revascularization, prompt reperfusion of the kidney and Doppler-confirmed pulsation of the renal artery was noted. Graft patency was confirmed on autopsy. CONCLUSION: Laparoscopic aortorenal bypass is feasible. This study represents the initial report in the literature. A long-term animal survival study is planned.     

胸乳入路腔镜单侧甲状腺部分切除术与传统开放手术的比较

目的比较胸乳入路腔镜手术与传统开放手术在单侧甲状腺部分切除的临床效果。方法75例单侧甲状腺良性疾病,分别行胸乳入路腔镜手术(腔镜手术组24例)和开放手术(开放手术组51例),比较2种术式的临床治疗效果。结果腔镜手术组1例因瘤体大(直径6cm,曾行注射治疗导致舌骨下颈前肌群粘连)中转开放手术,其余23例均顺利完成手术。腔镜手术组手术时间(100.4±26.6)min显著长于开放手术组(73.5±14.5)min(t=5.627,P=0.000);腔镜手术组术后引流量(66.7±24.9)ml显著多于开放手术组(13.3±6.4)ml(t=14.403,P=0.000);腔镜手术组术后住院时间(4.3±1.1)d显著长于开放手术组(3.6±0.9)d(t=2.886,P=0.005);腔镜手术组住院费用(11572±1675.1)元显著高于开放手术组(5015.9±1211.0)元(t=19.058,P=0.000)。腔镜手术组对手术美容效果表示满意22例明显高于开放手术组34例(χ2=7.235,P=0.007);腔镜手术组术中出血量(22.5±15.3)ml与开放手术组(18.3±7.5)ml无显著差异(t=1.273,P=0.207);术后镇痛腔镜手术组9例,开放手术组21例,2组无显著差异(χ2=0.028,P=0.867)。2组均无术后大出血、喉返、喉上神经损伤、甲状旁腺损伤等严重并发症。75例术后随访6个月,无局部复发。结论胸乳入路腔镜单侧甲状腺部分切除术与传统开放手术均是安全、有效的手术方法,腔镜手术有更加令人满意的美容效果,但术后恢复较慢,费用较高。     

Modified subtotal thyroidectomy for Graves' disease: a two-institution study

In an effort to decrease the large number of patients who develop hypothyroidism after operations for Graves' disease, an identical modification of the conventional subtotal thyroidectomy (CST) was independently designed and tested in a prospective study at two institutions. The modified subtotal thyroidectomy (MST) essentially consists of leaving an accurately measured 5 gm thyroid remnant and an intact inferior thyroid artery on each side of the neck. By use of MST, euthyroidism, as demonstrated by serial clinical and thyroid function tests, has been achieved in 92% of a combined group of 107 patients followed longer than 2 years (average 62.1 months). Postoperative hypothyroidism developed in only two cases (2%), representing a marked improvement over the 40% to 75% rate of hypothyroidism resulting from CST. Recurrent hyperthyroidism occurred in only six cases, a rate of recurrence indistinguishable from that resulting from the more extensive resection required by CST. Enlargment of total remnant size to a total of 10 gm significantly improves long-term postoperative functional results without risking an increase in recurrence. The functional results obtained after MST are superior to those obtained after treatment with radioiodine and justify renewed interest in the surgical treatment of Graves' disease.     

Fractures following thyroidectomy in women: a population-based cohort study

Hip fracture risk has been associated with hyperthyroidism and thyroidectomy in men and with hyperthyroidism in women, but the influence of thyroidectomy on fracture risk in women has not been adequately addressed. The 630 Rochester, MN women who underwent thyroidectomy in 1950-1974 were followed subsequently for 12,804 person-years (retrospective cohort study) during which 601 fractures were observed. Relative to incidence rates in the community, there was no increase in overall fracture risk (standardized incidence ratio [SIR] 0.9; 95% confidence interval [CI] 0.8-1.00). No increase was seen in limb fractures generally or in distal forearm fractures specifically (SIR 1.1, 95% CI 0.8-1.4). There was a modest but statistically significant increase in the risk of hip fractures following thyroidectomy (SIR 1.3, 95% CI 1.01-1.8), but much greater increases were apparent in the risk of subsequent fractures of the ribs, spine, and pelvis. There was almost a threefold increase in vertebral fractures (SIR 2.8, 95% CI 2.3-3.3), but the excess was mostly observed long after the original operation and may be attributable to ascertainment bias. Fracture risk was associated with advancing age and with the presence of one or more of the diseases that have been associated with secondary osteoporosis but not with a history of hyperthyroidism, extent of thyroid surgery, or subsequent use of thyroid replacement therapy. Thus, with the exception of some fractures of the axial skeleton, which might have been more completely diagnosed among affected women, there was no increase in fracture risk among women following thyroidectomy performed mainly for adenoma or goiter.     

Outpatient versus inpatient renal biopsy: a retrospective study

OBJECTIVE AND METHODS: There is a growing interest in the safety and efficacy of percutaneous kidney biopsy for outpatients in Taiwan. We conducted a retrospective study for patients receiving the biopsy in 2002 and 2003. Complication and mortality associated with the biopsy were compared between 147 inpatients and 183 outpatients who had been judged to need no hospitalization. All biopsies were performed using the ultrasound guidance and an automated spring-loaded biopsy device. RESULTS: There were no death and no significant difference in complication rates between the two groups. No delayed gross hematuria, delayed pain, fever or biopsy site bleeding developed in outpatients, who were followed-up by telephone contacts for 1 - 5 days after they had been discharged. Both outpatients and inpatients with hematoma were younger than those without (p < 0.05). Template bleeding time was longer for inpatients with hematuria compared with inpatients without (12.0 vs. 5.8 minutes in average, p = 0.036), but not for outpatients (4.5 vs. 6.0 minutes in average, p = 0.282). There were moderate differences in platelet count between outpatients with hematuria and those without (p = 0.057), and in serum creatinine between inpatients with hematuria and those without (p = 0.069). CONCLUSION: The outpatient renal biopsy appears to be equally as safe and efficient as the inpatient biopsy. However, we suggest checking template bleeding time and platelet count before biopsy for patients with clinical bleeding tendency, such as patients with a serum creatinine level over 4 mg/dl (approaching CKD stages IV, V) due to a higher risk of prolonged bleeding time. Outpatient biopsy with a 6-hour inpatient observation can be considered as a medically adequate procedure.     

Telemicrosurgery: a feasibility study in a rat model

Telesurgery is frequently used in cardiac, urologic, gynaecologic or digestive surgery. Significant advances are due to this technology: reduction of the operative time, safety and precision of the surgical gesture, reduction of bleeding and more comfort for the surgeon. However, no telesurgical experiment has been reported yet in microsurgery with 10-0 nylon sutures. The aim of the present work was to assess the feasibility of vascular anastomosis by a telemicrosurgical technique. The material used for this experiment consisted of two Wistar rats, a standard set of surgical instruments and a Da Vinci S (Intuitive Surgical) telemanipulation system. Rats were prepared in compliance with the current regulation. The rat tail was approached by cutaneous incision. The following surgical steps were carried out by telemicrosurgery: dissection, fitting of a vascular clamp, section of the artery and suture by 10-0 nylon separate stitches. Following anastomoses, patency tests were carried out and showed the suture effectiveness. The procedure lasted one hour in both cases. Physiologic tremor was abolished by the telemicrosurgical interface. In this study, the operator's pronosupination amplitude was 360 degrees . Optical magnification was the same as with a conventional operative microscope. The adjunction of a third articulated arm improved the ergonomics of the working space. Preliminary results are in favour of the feasibility of telemicrosurgery. The learning curve was astonishingly short. It remains to be used in human clinical practice.     

Expandable intraluminal vascular graft: a feasibility study

An expandable intraluminal graft mounted coaxially over an angioplasty balloon catheter was used in dog arteries. The graft, a wire mesh tube that has the ability to retain its expanded shape, opposes elastic recoil of the arterial wall after maximum balloon inflation. Eighteen grafts were placed in the abdominal aorta and iliac femoral, renal, superior mesenteric, and carotid arteries of eight dogs through femoral or carotid arteriotomies. Two grafts were placed in areas of artificially induced stenosis, completely restoring the lumen. Overall patency rate at 35 weeks was 77%. Histopathologic examination of patent grafts showed complete endothelialization at 3 weeks. The smaller caliber grafts and those that had outflow obstruction showed significant degrees of intimal hyperplasia.