Endoscopic thyroidectomy via bilateral axillo-breast approach (BABA): review of 512 cases in a single institute

Background

Various techniques for endoscopic thyroidectomy have been introduced in the past decade, and the cosmetic superiority of these techniques has been universally acknowledged. We developed the endoscopic thyroidectomy via bilateral axillo-breast approach (BABA) and have performed more than 500 operations. The aims of this study are to analyze the surgical outcomes and to evaluate the effectiveness and safety of BABA endoscopic thyroidectomy.

Patients and methods

Between February 2004 and March 2008, 512 patients with thyroid diseases underwent BABA endoscopic thyroidectomy. The criteria analyzed were clinicopathologic characteristics, types of operation, operation time, tumor–node–metastasis (TNM) stage on the basis of the 7th edition of the American Joint Committee on Cancer (AJCC), results after radioactive ablation therapy, and recurrence of disease in these patients.

Results

Of 512 patients, 397 had a malignant tumor and 115 had benign thyroid disease. Eight patients were diagnosed with Graves’ disease, and nine patients underwent completion thyroidectomy. Three cases were subjected to open thyroidectomy due to uncontrolled bleeding. Mean operation time was 151.2?±?38.1?min for total and near-total thyroidectomy, and 141.7?±?50.1?min for subtotal thyroidectomy and lobectomy. Regarding postoperative complications, transient hypocalcemia occurred in 31.1% of patients and permanent hypoparathyroidism occurred in 4.2% of patients. Transient hoarseness occurred in 20.3% of patients, and permanent vocal cord palsy occurred in 1.7%. Mean hospital stay after operation was 3.34?±?0.8?days (range 3–7?days), and mean follow-up period was 57.1?±?17.6?months (range 38.5–71.7?months). There were eight cases of recurrent thyroid carcinoma, and no mortality has occurred up to the present time.

Conclusions

Endoscopic thyroidectomy via bilateral axillo-breast approach is a safe and effective method that gives good surgical completeness, a low rate of postoperative complications and recurrence, and an excellent cosmetic result. Therefore, this method is a good choice for patients with surgical thyroid diseases.     

Ten-Year Follow-Up of a Randomized Clinical Trial of Total Thyroidectomy Versus Dunhill Operation Versus Bilateral Subtotal Thyroidectomy for Multinodular Non-toxic Goiter

Background

The aim of this study was to validate in a 10-year follow-up the initial outcomes of various thyroid resection methods for multinodular non-toxic goiter (MNG) reported in World J Surg 2010;34:1203–13.

Materials and methods

Six hundred consenting patients with MNG were randomized to three groups of 200 patients each: total thyroidectomy (TT), Dunhill operation (DO), bilateral subtotal thyroidectomy (BST). Obligatory follow-up period of 60 months was extended up to 120 months for all the consenting patients. The primary outcome measure was the prevalence of recurrent goiter and need for revision thyroid surgery. The secondary outcome measure was the cumulative postoperative and post-revision morbidity rate.

Results

The primary outcomes were twice as inferior at 10 years when compared to 5-year results for DO and BST, but not for TT. Recurrent goiter was found at 10 years in 1 (0.6%) TT versus 15 (8.6%) DO versus 39 (22.4%) BST (p < 0.001), and revision thyroidectomy was necessary in 1 (0.6%) TT versus 5 (2.8%) DO versus 14 (8.0%) BST patients (p < 0.001). Any permanent morbidity at 10 years was present in 5 (2.8%) TT patients following initial surgery versus 7 (4.0%) DO and 10 (5.7%) BST patients following initial and revision thyroidectomy (nonsignificant differences). At 10 years, 23 (11.5%) TT versus 25 (12.5%) DO versus 26 (13.0%) BST patients were lost to follow-up.

Conclusions

Total thyroidectomy can be considered the preferred surgical approach for patients with MNG, as it abolishes the risk of goiter recurrence and need for future revision thyroidectomy when compared to more limited thyroid resections, whereas the prevalence of permanent morbidity is not increased at experienced hands.

Registration number:

NCT00946894 (http://www.clinicaltrials.gov).

     

What Is the Best Definitive Treatment for Graves’ Disease? A Systematic Review of the Existing Literature

Background

The management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists for Graves’ disease (GD) include any of the following modalities: ¹³¹I therapy, antithyroid medication, or thyroidectomy. No in-depth analysis has been performed comparing the treatment options, even though a single treatment option seems to be universally accepted.

Methods

A systematic review of the literature was performed to examine contemporary literature between 2001 and 2011 evaluating the management options of GD. We compiled retrospective and prospective studies analyzing surgery and radioactive iodine. Outcomes of interest included postoperative hypothyroidism, euthyroidism, and persistent or recurrent hyperthyroidism without supplementation. Success was defined as postoperative euthyroidism or hypothyroidism. Failure was defined as persistent or recurrent hyperthyroidism.

Results

Of the 14,245 patients, 4,546 underwent surgery [3,158 patients had subtotal thyroidectomy (STT) and 1,388 had total thyroidectomy (TT)] and 9,699 had radioactive iodine. The radioactive iodine group consisted of 2,383 patients receiving 1–10 mCi, 1,558 patients receiving 11–15 mCi, 516 patients receiving >15 mCi, and 5,242 patients receiving an unspecified amount. Surgery was found to be 3.44 times more likely to be successful than radioactive iodine (p < 0.001). STT and TT were found to be 2.33 and 94.45 times more likely to be successful than radioactive iodine (p < 0.001), respectively.

Conclusions

On the basis of the outcomes analyzed, surgery appears to be the most successful in the management of GD, with TT being the preferred surgical option.     

Total Thyroidectomy is Associated with Increased Risk of Complications for Low- and High-Volume Surgeons

Background

There has been an increased use of total thyroidectomy (TT), including in the management of benign thyroid diseases. We sought to compare the risk of complications between TT and unilateral thyroidectomy (UT) and to evaluate the effect of surgeon’s experience on outcomes.

Methods

Nationwide Inpatient Sample from 2003 to 2009 was used to perform cross-sectional analysis of all adult patients who underwent TT and UT for benign or malignant conditions. Logistic regression was used to evaluate outcomes and to provide correlation between outcome and surgeon volume. Surgeon volume was categorized as low or high (performing <10 or >99 thyroid operations/year, respectively).

Results

A total of 62,722 procedures were included. Most cases were TT (57.9 %) performed for benign disease. There was a significantly increased risk of complication after TT compared to UT (20.4 vs. 10.8 %: p < 0.0001). High-volume surgeons performed only 5.0 % of the procedures overall, with 62.6 % of the high-volume surgeon procedures being TTs. Low-volume surgeons were more likely to have postoperative complications after TT compared to high-volume surgeons (odds ratio 1.53, 95 % confidence interval 1.12, 2.11, p = 0.0083). Mean charges were significantly higher for TT compared to lobectomy ($19,365 vs. $15,602, p < 0.0001), and length of stay was longer for TT compared to lobectomy (1.63 vs. 1.29 days, p < 0.0001).

Conclusions

TT is associated with a significantly higher risk of complications compared to UT even among high-volume surgeons. Higher surgeon volume is associated with improved patient outcomes.     

Minimally Invasive Video-Assisted Thyroidectomy for Benign Thyroid Disease: An Evidence-Based Review

Background

A decade after nearly all surgical disciplines developed minimally invasive techniques, the first report of a single case of minimally invasive thyroidectomy was published. Minimally invasive video-assisted thyroidectomy (MIVAT) is now considered the most widely practiced and most easily reproducible minimally invasive procedure for thyroidectomy. The aim of this review was to analyze the treatment of benign thyroid diseases by MIVAT.

Methods

A systematic evidence-based literature review focusing on three questions was carried out. Additional data were obtained on the basis of our personal experience. (1) Are minimally invasive procedures indicated in the treatment of thyroid diseases? (2) Is MIVAT a safe technique and what are the demonstrated advantages? (3) Since different thyroid diseases may be treated by MIVAT, is it of any value in the treatment of benign thyroid diseases?

Results

MIVAT can be considered an appropriate treatment of some thyroid diseases; it represents a safe procedure with the same incidence of complications as traditional surgery, and also has advantages in terms of both cosmetic result and postoperative distress.

Conclusions

In spite of an increasing trend toward performing more extensive procedures other than thyroidectomy alone during videoscopic procedures, the current literature seems to reaffirm that the main and safest indication for MIVAT is benign disease.

     

Total Thyroidectomy Is Superior to Subtotal Thyroidectomy for Management of Graves’ Disease in the United States

Background  

In the United States, Graves’ disease is most commonly treated with radioiodine, yet thyroidectomy remains an important option for correcting hyperthyroidism. In many countries, limited access to thyroid hormone makes subtotal thyroidectomy the procedure of choice. In the United States, where levothyroxine is widely available, we hypothesized that total (TT) or near-total thyroidectomy (NT) is superior to subtotal thyroidectomy (ST) for long-term control of Graves’ disease.     

IONM-guided goiter surgery leading to two-stage thyroidectomy—indication and results

Purpose

Intraoperative neuromonitoring (IONM) in thyroid surgery allows for changing the operative strategy during bilateral procedures to avoid bilateral recurrent laryngeal nerve palsy (RLNP). While this strategy is comprehendible for the surgeon, the question remains, whether it is always necessary.

Methods

Two thousand five hundred forty-six patients underwent surgery with IONM between January 2008 and October 2010 (4,012 nerves at risk). We performed a retrospective review of all patients after thyroid surgery. In 98 cases, signal loss occurred on the primary side. Of these patients, 64 required bilateral surgery. We proceeded with the contralateral surgery in 24 cases. Forty operations were ended unilaterally. The second operation was performed on 18 patients in total, 16 after confirmation of primarily intact (n?=?8) or recovered vocal cord function (n?=?8) and twice under persisting dysfunction. Patient satisfaction was evaluated using a five-point scale.

Results

We have shown a significant difference (p?=?0.017) in the rate of bilateral RLNP when signal loss on the primary side resulted in termination of the procedure compared to continuation. Our evaluation of patient satisfaction did not show a significant difference when comparing the two-stage operation to other procedures.

Conclusions

We have shown a significant difference in the rate of bilateral RLNP when comparing termination and continuation of a bilateral procedure after primary IONM signal loss. We strongly recommend a two-stage thyroidectomy after signal loss on the primary side of resection in benign bilateral goiter surgery.     

Strumachirurgie in Deutschland

Background

The increase of certain operations in the wake of the introduction of the German Diagnosis-Related Groups (G-DRG) system rekindled debate on the risk–benefit profile of what is widely being perceived as a too high number of thyroidectomies for benign goiter in Germany.

Material and methods

The numbers of thyroidectomy for benign goiter from 2005–2011 were obtained from the Federal Bureau of Statistics (“Statistisches Bundesamt”). For the purpose of the study, the following operation and procedure key (OPS) codes were selected: hemithyroidectomy (OPS code 5-061); partial thyroid resection (OPS code 5-062); total thyroidectomy (OPS code 5-063); and thyroid surgeries via sternotomy (OPS code 5-064). The rates of permanent hypoparathyroidism and vocal cord palsy were calculated based on two prospective multicenter evaluation studies conducted in 1998–2001 (PETS 1) and 2010–2013 (PETS 2) in Germany.

Results

Between 2005 and 2011, the number of thyroidectomies for benign thyroid goiter decreased by 8?%, and the age-standardized surgery rate decreased by 6?% in men (2005: 599 per 1 million; 2011: 565 per 1 million) and 11?% in women (2005: 1641 per 1 million; 2011: 1463 per 1 million). At the same time, the rates of partial and subtotal thyroidectomy decreased by 59?% in men and 64?% in women, whereas the rates of hemithyroidectomy and total thyroidectomy increased by 65?% (113?%) in men and 42?% (97?%) in women. Despite a greater proportion of thyroidectomies over time, the approximated rates for postoperative hypoparathyroidism were reduced from 2.98 to 0.83?% and for postoperative vocal cord palsy from 1.06 to 0.86?%. Irrespective of that decline, either complication was more frequent after total than after subtotal thyroidectomy.

Conclusion

The total number of thyroid surgeries due to benign goiter has decreased substantially in Germany from 2005 through 2011. Despite changes in the resectional strategy with an increase in the total number thyroidectomies and a decrease of subtotal resections, the rates for postoperative hypoparathyroidism and vocal cord palsy have decreased. The complication rates for total thyroidectomy, however, are still higher compared to subtotal resection. An individualized risk-oriented surgical approach is warranted.     

The Learning Curve for Robotic Thyroidectomy: A Multicenter Study

Purpose

The learning curve for robotic thyroidectomy with central compartment node dissection (CCND) has not been established. We examined the effect of experience of robotic thyroidectomy on a range of perioperative parameters in order to determine the learning curve. The learner surgeon outcomes were compared with those of an experienced surgeon.

Methods

We conducted a prospective, controlled, multicenter study involving four endocrine surgeons at three academic centers. Patients underwent robotic total or subtotal thyroidectomy with CCND between September 2008 and October 2009. One surgeon was experienced in the technique (experienced surgeon, ES), while the other three surgeons had endoscopic thyroid surgery experience but no experience performing the robotic procedure (nonrobotic thyroid surgery experienced surgeon, NS). Outcome measures were demographic data, operative time, blood loss, hospital stay, pathologic results, and postoperative complications.

Results

A total of 644 total or subtotal robotic thyroidectomies with CCND were performed: 377 (58.7%) by NSs and 267 (41.5%) by the ES. Mean operative time was longer and the complication rate was higher for the NS patient group compared with the ES patient group (P < 0.001 for each). The operative times and complications rates for the NS group were similar to those of the ES group once the NSs had performed 50 cases for total thyroidectomies or 40 cases for subtotal thyroidectomies.

Conclusion

The learning curve duration for robotic thyroidectomy with CCND using gasless transaxillary approach for experienced endoscopic thyroidectomy surgeons was 50 cases for total thyroidectomy and 40 cases for subtotal thyroidectomy.     

Utilization of thyroidectomy for benign disease in the United States: a 15-year population-based study

Background

Recent recommendations suggest that total thyroidectomy (TT) is the preferred treatment for benign thyroid disease. This approach remains controversial because of the increased risk of morbidity compared with a partial thyroidectomy (PT). The aim of this study was to determine the use of thyroidectomy for benign disease over a 15-year period.

Methods

One hundred nineteen thousand eight hundred eighty-five patients from the Nationwide Inpatient Sample database (1993–2007) underwent surgery for benign thyroid disease. Logistic regression was used to assess the relation between extent of thyroidectomy and the year of admission, hospital volume, and surgical outcomes.

Results

The use of TT increased from 17.6% (1993–1997) to 39.6% (2003–2007) compared with 82.4% and 60.4% for PT over the same periods (P < .0001). A greater proportion of TTs was performed in high-volume centers in which the rates of postoperative complications were lower than low-volume centers.

Conclusions

The use of TT for benign thyroid disease has increased over the last 15 years in the United States. This pattern of practice is in keeping with the trends reported in recent literature.     

Surgical Management of Metastases to the Thyroid Gland

Background

Metastases to the thyroid gland are uncommon, with rates reported between 0.02% and 1.4% of surgically resected thyroid specimens. Our goal was to present our experience with surgical management of metastases to the thyroid gland.

Methods

Twenty-one patients with metastatic disease to the thyroid were identified from a database of 1,992 patients with thyroid cancer who had surgery during 1986–2005. Patient, tumor, treatment, and outcome details were recorded by analysis of charts. The median age at time of surgery was 68 (range, 39–83) years; 12 were men and 9 were women.

Results

All patients were managed by surgery, including lobectomy in ten patients, total thyroidectomy in six, completion thyroidectomy in two, and subtotal thyroidectomy in one. In two patients, the thyroid lesion was found to be unresectable at the time of surgery. Histopathology revealed renal cell carcinoma in ten, malignant melanoma in three, gastrointestinal adenocarcinoma in three, breast cancer in one, sarcoma in one, and adenocarcinoma from an unknown primary site in three patients. Seventeen patients have died. The cause of death in all 17 was widespread metastatic disease from their respective primary tumors. The median survival from surgery to death or last follow-up was 26.5 (range, 2–114) months.

Conclusions

In patients with metastases to the thyroid gland, local control of metastatic disease in the central compartment of the neck can be successfully achieved with minimal morbidity with surgical resection in selected patients.     

Minimally invasive video-assisted thyroidectomy: experience of 300 cases

Background

We report on patients selected for minimally invasive video-assisted thyroidectomy (MIVAT) over a 3-year period and evaluate the feasibility and effects of this procedure.

Methods

Between March 2005 and August 2008, 300 patients (36 male, 264 female; mean age = 54.6 years) underwent MIVAT using a single central incision with an average length of 2 cm (range = 1.5–3 cm), about 2 cm above the sternal notch. Small conventional retractors and dissectors, ultrasonic scalpel, 5-mm laparoscope, and a video screen were the instruments used.

Results

General anesthesia was used in 295 patients and regional block anesthesia in 5. MIVAT was performed successfully in 280 patients (93.3%). Conversion to open thyroidectomy with a 4-cm-long incision was required to achieve selective lymphadenectomy in 18 patients after frozen sections demonstrated differentiated thyroid carcinoma. Only two patients with benign thyroid nodules were converted because of large volume or massive hemorrhage from the upper pole vessels. Mean operative time was 35 min (range = 20–70 min) for unilateral lobectomy and 58 min (35–90 min) for bilateral thyroidectomy. No patients had wound infections, postoperative bleeding that required reoperation, permanent hypoparathyroidism, or bilateral recurrent laryngeal nerve palsy. However, permanent unilateral recurrent laryngeal nerve palsy appeared in five cases (1.7%), transient unilateral recurrent laryngeal nerve palsy in seven (2.3%), superior laryngeal nerve injury in five (1.7%), transient hypocalcemia in nine (3.0%), and mild skin burn from the ultrasonic scalpel in five (1.7%). Postoperative pain was minimal and better cosmetic results were obtained than conventional open thyroidectomy. Postoperative stay was shorter than with conventional open thyroidectomy.

Conclusions

MIVAT appears to be safe and feasible in patients with benign thyroid nodules, with minimal injury and excellent cosmetic results. Furthermore, after properly lengthening the skin incision, MIVAT can be used for patients with large benign thyroid nodules or even early–stage differentiated thyroid carcinoma.     

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.     

Multifocal papillary thyroid carcinoma—a consensus report of the European Society of Endocrine Surgeons (ESES)

Background

Multifocal papillary thyroid carcinoma (MPTC) has been reported in literature in 18–87 % of cases. This paper aims to review controversies in the molecular pathogenesis, prognosis, and management of MPTC.

Methods

A review of English-language literature focusing on MPTC was carried out, and analyzed in an evidence-based perspective. Results were discussed at the 2013 Workshop of the European Society of Endocrine Surgeons devoted to surgery of thyroid carcinoma.

Results

Literature reports no prospective randomized studies; thus, a relatively low level of evidence may be achieved.

Conclusions

MPTC could be the result of either true multicentricity or intrathyroidal metastasis from a single malignant focus. Radiation and familial nonmedullary thyroid carcinoma are conditions at risk of MPTC development. The prognostic importance of multifocal tumor growth in PTC remains controversial. Prognosis might be impaired in clinical MPTC but less or none in MPTC <1 cm. MPTC can be diagnosed preoperatively by FNAB and US, with low sensitivity for MPTC <1 cm. Total or near-total thyroidectomy is indicated to reduce the risk of local recurrence. Prophylactic central node dissection should be considered in patients with total tumor diameter >1 cm, or in cases with high number of cancer foci. Completion thyroidectomy might be necessary when MPTC is diagnosed after less than near-total thyroidectomy. Radioactive iodine ablation should be considered in selected patients with MPTC at increased risk of recurrence or metastatic spread.     

Bilateral Axillo-Breast Approach Robotic Thyroidectomy for Graves’ Disease: An Initial Experience in a Single Institute

Background

Bilateral axillo-breast approach (BABA) robotic thyroidectomy has shown excellent cosmetic and surgical outcomes. The aim of the present study was to evaluate the safety, feasibility, and initial outcome of this procedure in patients with Graves’ disease.

Methods

From June 2008 to July 2001, a total of 30 patients with Graves’ disease were reviewed retrospectively. Patient demographics, operative indications, and surgical variables, including operative time, blood loss, excised thyroid weight, and complications, were collected and investigated.

Results

The thyroidectomies were classified as total (n = 21), near-total (n = 6), or subtotal (n = 3). There were five indications for surgery: concomitant thyroid carcinoma or suspicious nodule (n = 22), recurrence after antithyroid medication (n = 2), local compressive symptoms (n = 1), patient’s preference (n = 4), and side effects of antithyroid medication (n = 1). The mean operative time, console time, blood loss, and excised thyroid weight were 190 min (range: 105–298 min), 113 min (range: 60–227 min), 229 mL (range: 50–550 mL), and 36.6 g (range: 7.8–123.0 g), respectively. There were no cases of postoperative bleeding or conversions to open surgery. Postoperative transient hypoparathyroidism and vocal cord palsy occurred in 13 (43.3 %) and 4 (13.3 %) cases. Permanent hypoparathyroidism occurred in 1 (3.3 %) case. All patients were satisfied with the cosmetic outcomes.

Conclusions

BABA robotic thyroidectomy is a feasible and safe treatment for Graves’ disease. It is recommended as an alternative for patients who are concerned by the cosmetic effects of traditional thyroidectomy.     

The Prevalence of Incidental Thyroid Carcinoma in Patients Who Underwent Thyroidectomy for Multinodular Goiter

The incidence of an incidental carcinoma following surgical treatment for MNG varies from 3 to 16%. The aims of this study are to determine the incidence of an incidental thyroid carcinoma (ITC) in patients with multinodular goiter (MNG) and to evaluate the primary surgical treatment modality for these patients. Between January 2010 and July 2015, a total of 3311 patients who underwent surgery for goiter were retrospectively evaluated. Demographic characteristics of the patients, previous medical history, thyroid hormone profiles, thyroid ultrasonography findings, fine-needle aspiration biopsy (FNAB) findings, thyroid scintigraphy findings, surgical techniques, early postoperative complications, and histopathological diagnoses were recorded. The patients were divided into two groups: those who were incidentially diagnosed with a thyroid carcinoma (ITC group; n = ?) and those with MNG (MNG group; n = ?). Of 3311 patients, FNAB was performed in 1524 (46%) patients. Of these, 1790 underwent total thyroidectomy (TT) or near total thyroidectomy (NTT), 1066 underwent bilateral subtotal thyroidectomy (BSTT), 354 underwent the Dunhill procedure, and 101 underwent unilateral lobectomy (ULL) due to the presence of unilateral MNG. Postoperative histopathological examinations revealed an incidental thyroid carcinoma (ITC) in 283 (8.54%) patients, papillary carcinoma in 201 patients (201/3311, 6%), follicular cancer in 68 patients (68/3311, 2%), medullary cancer in 13 patients (13/3311, 0.3%), follicular carcinoma in four patients (4/923, 0.4%), and anaplastic cancer in one patient (1/3311, 0.03%). Our study results suggest that TT should be the primary surgical treatment modality to avoid the complications of a complementary thyroidectomy.     

Total thyroidectomy en bloc or not? prospective,randomized clinical trial: Cerrahpasa experience

Aim-Background

While significant changes in the last century have enabled safe and effective total thyroidectomy, the utility and reliability of techniques for patients with benign diseases is debatable. The purpose of this study was to compare the complication rates of division of the isthmus vs. non-division in thyroid surgery performed for bilateral multinodular goiter by experienced endocrine surgeons. To the best of our knowledge, no such study has been published in the literature to date.

Methods

This prospective study includes 60 consecutive serial patients who underwent total thyroidectomy. Patients were randomly assigned to a thyroidectomy technique by the arbitrary draw from a bag of paper tags marked as ‘U’ (thyroidectomy without dividing the isthmus) classified as Group 1 or ‘D’ (thyroidectomy by dividing the isthmus) as Group 2. Patients in Group 1 (n=30) had a total thyroidectomy without dividing the isthmus (en bloc), patients in Group 2 (n=30) had total thyroidectomy by dividing the isthmus.

Results

Postoperative serum mean calcium and parathyroid hormone (PTH) levels, operation period, visual analogue pain score and recurrent laryngeal nerve paralysis did not differ between the groups. Permanent hypocalcaemia and permanent recurrent laryngeal nerve paralysis were not observed in either group, but total morbidity in Group 1 was higher (p=0.038). Postoperative PTH levels were significantly lower than preoperative PTH levels in both groups; (respectively, p=0.007, p=0.011). No surgical mortality was recorded.

Conclusion

Thyroidectomy without dividing the isthmus can be qualified as a safe and applicable surgical method.     

Risk Factors of Hypoparathyroidism Following Total Thyroidectomy for Thyroid Cancer

Background

The risk factors responsible for hypoparathyroidism after total thyroidectomy have not been completely defined. The present study evaluated one surgeon’s personal experience of postoperative hypoparathyroidism after total thyroidectomy for thyroid cancer and predisposing risk factors of postoperative hypoparathyroidism.

Methods

We performed a retrospective analysis of 531 consecutive total thyroidectomy cases for thyroid cancer operated by single surgeon at the Center for Thyroid Cancer, National Cancer Center, Korea, from March 2003 to August 2006.

Results

Postoperative hypoparathyroidism occurred in 135 patients (25.4 %), 19 of whom (3.6 % of total patients) experienced permanent hypoparathyroidism. Parathyroid autotransplantation, bilateral central lymph node dissection, gross extrathyroidal extension, and the presence of parathyroid gland in the pathologic specimen were associated with postoperative hypoparathyroidism in multivariate analysis (p < 0.05, respectively). The presence of parathyroid gland in the pathologic specimen and the early period of surgeon’s practice were statistically significant risk factors for permanent hypoparathyroidism in multivariate analysis (p < 0.05, respectively).

Conclusions

Careful surgical technique for in situ preservation of parathyroid gland and autotransplantation of inadvertently removed parathyroid gland are important, especially in case of gross extrathyroidal extension. Adequate surgical experience is also an important factor. And routine bilateral central lymph node dissection should be done thoughtfully for its effect on postoperative hypoparathyroidism.