Parathyroid Autotransplantation During Thyroid Surgery: A Novel Technique Using a Cell Culture Nutrient Solution

Introduction

Parathyroid autotransplantation is an easy procedure with a low complication rate. We adopted the transplantation into the sternocleidomastoid muscle, which allows an easier and time-saving surgical procedure using the same surgical incision.

Methods

In this study, we retrospectively reviewed the records of 396 consecutive patients, who underwent total thyroidectomy for benign thyroid disease. In all cases in which a parathyroid was damaged or inadvertently removed, the gland was transplanted; before the autotransplantation, the parathyroid tissue was put in a cell culture nutrient solution for 5 min, afterward fragmented, and then was transplanted in the sternocleidomastoid muscle. To demonstrate a beneficial effect of the cell nutrient solution step, we compared data of transplanted patients with a control group of cases (n = 190) undergoing a standard immediate autotransplantation.

Results

We divided patients in two main groups: group A (n = 160) including subjects that underwent one or more parathyroid gland autotransplantation using the cell nutrient solution, and group B (n = 236) concerning those who were not transplanted. Among patients, 62 hypocalcemias occurred, 40 in the group A and 22 in the group B (P < 0.001): 91.9 % were transient and 8.1 % (5 patients) definitive, all pertaining to the group B. Among controls (group C), 42 hypocalcemias occurred (P = 0.616 vs. group A and P = 0.002 vs. group B) and 3/42 became definitive (P = 0.096 vs. group A and P = 0.121 vs. group B). All differences concerning pre- and postoperative calcium values were statistically significant (P < 0.001).

Conclusions

We recommend the routine parathyroid autotransplantation, when a vascular damage is certain or suspected, in order to reduce the rate of permanent hypoparathyroidism, using a cell culture nutrient solution before gland transplantation.

     

Preserving Parathyroid Gland Vasculature to Reduce Post-thyroidectomy Hypocalcemia

Background

The failure to preserve parathyroid function in patients who have undergone total thyroidectomy is of major concern, because hypocalcemia is difficult to prevent and remains a common postoperative complication. Here, we describe procedures designed to preserve the vasculature supplying the parathyroid glands and examine both recent outcomes and retrospective reports of results obtained prior to the application of these preservation techniques.

Methods

Our technique for preserving parathyroid function during thyroidectomy was adopted in 2009 and involves separating a relatively long segment of a vessel distally from the thyroid gland. We reviewed the medical records of 1,411 patients who underwent total thyroidectomy, with or without lateral neck dissection, at the Samsung Medical Center from January 2006 through June 2014 to determine outcomes. Patients were divided into three groups according to the time period during which the surgery took place: Group A, 2006–2008 (before the vasculature-preserving technique was applied); Group B, 2009–2011 (the time when the technique was first adopted); and Group C, 2012–2014 (more recent results of the technique). We analyzed the incidence of hypoparathyroidism in the three groups, as well as risk factors that influenced its development.

Results

The rates of transient and permanent hypoparathyroidism in Group A were 25.4 and 4.3 %, respectively. However, the incidence of hypoparathyroidism decreased significantly over time after the vasculature-preserving procedure was adopted. Transient hypoparathyroidism developed in 4.8 % of Group C patients, and only four (0.7 %) of the 565 patients in this group required calcium supplementation, despite the fact that a greater number of patients were included who underwent total thyroidectomy combined with lateral neck dissection. Although female sex and lateral neck dissection tended to increase the rate of transient hypoparathyroidism, multivariate analysis showed that the vasculature-preserving procedure was the only significant risk factor related to postoperative hypoparathyroidism.

Conclusion

The blood flow of the final branch to the parathyroid gland is mostly in the lateral-to-medial direction; therefore, mobilization and preservation of the vessels lateral to the gland is essential to prevent devascularization of the parathyroid gland.

     

The Association of Discolored Parathyroid Glands and Hypoparathyroidism Following Total Thyroidectomy

Background

It remains uncertain whether a parathyroid gland (PG) that appears darkened or severely bruised but still has an attached vascular pedicle should be left in situ or taken out and auto-transplanted following total thyroidectomy. Our study aimed to examine the impact of discolored PGs (DPGs) on short- and long-term hypoparathyroidism.

Methods

One hundred and three patients who underwent total thyroidectomy with 4 clearly identified PGs were analyzed. Location (superior/inferior) and color of each PG were recorded. Patients without DPG were grouped into I while those with 1–2 DPGs and ≥3 DPGs were grouped into II and III, respectively. Transient hypoparathyroidism meant adjusted Ca <2.00 mol/L 24 h after surgery and/or need for supplements. Protracted hypoparathyroidism meant a subnormal PTH at 4–6 weeks and/or supplements >6 weeks. Permanent hypoparathyroidism meant supplements ≥1 year.

Results

Relative to I, group III had greater adjusted Ca drop at postoperative 1-h (p = 0.012), 24-h (p < 0.001) and lower day-1 PTH (p = 0.015). Having ≥3 DPGs (OR 14.00, 95 % CI 1.575–124.474, p = 0.018) was an independent factor of transient hypoparathyroidism. However, permanent hypoparathyroidism rate was higher than in group I than II (p = 0.019). Eight patients (25.8 %) in group I had undetectable day-1 PTH, while none in group III had undetectable day-1 PTH. Graves’ disease/toxic goiter (OR 15.166, 95 % CI 2.594–88.661, p = 0.003) and excised gland weight (OR 1.028, 95 % CI 1.010–1.046, p = 0.003) were independent factors of ≥3 DPGs.

Conclusions

PG discoloration is associated with transient hypoparathyroidism while normal colored PG with seemingly adequate blood supply does not always imply functionally normal gland. These findings highlights the need for a real-time intraoperative method to assess PG viability.

     

Do Low Preoperative Vitamin D Levels Reduce the Accuracy of Quick Parathyroid Hormone in Predicting Postthyroidectomy Hypocalcemia?

Background

Although some studies have suggested that low preoperative 25-hydroxyvitamin D (25-OHD) levels may increase the risk of hypocalcemia and decrease the accuracy of single quick parathyroid hormone in predicting hypocalcemia after total thyroidectomy, the literature remains scarce and inconsistent. Our study aimed to address these issues.

Methods

Of the 281 consecutive patients who underwent a total/completion total thyroidectomy, 244 (86.8 %) did not require any oral calcium and/or calcitriol supplements (group 1), while 37 (13.2 %) did (group 2) at hospital discharge. 25-OHD level was checked 1 day before surgery, and postoperative quick parathyroid hormone (PTH) was checked at skin closure (PTH-SC). Postoperative serum calcium was checked regularly. Hypocalcemia was defined by the presence of symptoms or adjusted calcium of <1.90 mmol/L. Significant factors for hypocalcemia were determined by univariate and multivariate analyses. The accuracy of PTH-SC in predicting hypocalcemia was measured by area under a receiver operating characteristic curve (AUC), and the AUC of PTH-SC was compared between patients with preoperative 25-OHD <15 and ≥15 ng/mL via bootstrapping.

Results

Preoperative 25-OHD level was not significantly different between groups 1 and 2 (13.1 vs. 12.5 ng/mL, p = 0.175). After adjusting for other significant factors, PTH-SC (odds ratio 2.49, 95 % confidence interval 1.52–4.07, p < 0.001) and parathyroid autotransplantation (odds ratio 3.23, 95 % confidence interval 1.22–8.60, p = 0.019) were the two independent factors for hypocalcemia. The AUC of PTH-SC was similar between those with 25-OHD <15 and ≥15 ng/mL (0.880 vs. 0.850, p = 0.61)

Conclusions

Low 25-OHD was not a significant factor for hypocalcemia and did not lower the accuracy of quick PTH in predicting postthyroidectomy hypocalcemia.     

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.     

Excessive Decrease in Serum Magnesium After Total Thyroidectomy for Graves’ Disease Is Related to Development of Permanent Hypocalcemia

Background

Transient postoperative hypocalcemia is one of the most common complications after thyroidectomy. Permanent hypocalcemia, however, is rare, but usually requires life-long treatment and follow-up. The risk of permanent hypocalcemia has been shown to be significantly higher in patients with Graves’ disease. In the present study we evaluated short-term and long-term changes in serum calcium, phosphate, magnesium, and parathyroid hormone (PTH) levels in order to characterize subjects at risk of postoperative hypoparathyroidism.

Methods

Forty patients who underwent total thyroidectomy for Graves’ disease were included in the study. Calcium, phosphate, magnesium, and PTH were measured before surgery and regularly during the year that followed.

Results

Postoperative hypocalcemia was seen in 21/40 (53 %) patients. Undetectable PTH (<0.6 pmol/L) was registered in 11/40 (27 %) patients. All patients with measurable PTH 6–48 h after operation regained normal calcium. Of those with undetectable PTH after 6–48 h, four developed permanent hypocalcemia. We found a significantly lower serum calcium level before operation in patients who developed permanent hypocalcemia compared to those who did not (p < 0.001). We also found a significant correlation between the decrease in serum magnesium from time 0 to 48 h after operation and permanent hypocalcemia (p = 0.015).

Conclusions

Serum calcium prior to operation, serum PTH, and degree of decrease in magnesium levels in serum 48 h after operation may predict development of permanent hypocalcemia. Magnesium plays an important role in calcium homeostasis via stimulation of PTH secretion and modulation of PTH receptor sensitivity. Both mechanisms may have played a role for the findings reported in this article.     

Attenuation of Postmenopausal Bone Loss in Patients with Transient Hypoparathyroidism After Total Thyroidectomy

Background

Increased bone mineral density (BMD) has been reported in patients with postsurgical permanent hypoparathyroidism. Hypoparathyroidism may attenuate the high-turnover bone loss in postmenopausal women. We reported previously that patients who had transient hypoparathyroidism postoperatively were at subclinical hypoparathyroid (hP) status even 5 years after surgery. We hypothesized that patients with transient hypoparathyroidism (ThP) may have altered BMD.

Methods

A total of 140 women who underwent total thyroidectomy had BMD measurements of the lumbar spine, femoral neck, and radius 3 years after surgery. At surgery, 99 patients were ≥50 years and 41 were <50 years. They were divided into three groups according to their postoperative parathyroid function: There were 80 patients in the no hP (NhP) group, 54 in the ThP group, and 6 in the permanent hP (PhP) group.

Results

Among the 99 patients aged ≥50 years, 36 ThP patients had median Z scores of the BMD in all three areas (lumbar spine, femoral neck, radius) that were significantly higher (by 1.083, 0.533, and 1.047, respectively) than those in the 60 NhP patients aged ≥50 years. The BMDs in the three PhP patients ≥50 years were higher than those in the NhP and ThP patients, but the difference did not reach significance except for in the femoral neck. Multivariate logistic regression analyses showed that Z scores > 0 were significantly associated only with the presence of ThP postoperatively. In the patients <50 years, the BMD values were not significantly different among the three groups except at the radius in PhP patients, which was significantly lower than those of the other patients.

Conclusions

We found that ThP was associated with increased BMD in postmenopausal women. This may be due to attenuation of the high-turnover bone loss in postmenopausal women.     

Cryopreservation of Parathyroid Tissue after Parathyroid Surgery for Renal Hyperparathyroidism: Does it Really Make Sense?

Background

Metachronous autotransplantation of cryopreserved parathyroid tissue is a technique for treating postoperative hypoparathyroidism after parathyroid surgery for renal hyperparathyroidism (rHPT). The aim of the present study was to evaluate our institution’s experience with metachronous autotransplantation to analyze the role of cryopreservation in the treatment of rHPT and to determine for whom and when cryopreservation of parathyroid tissue should be deemed necessary.

Methods

A prospective database of patients with rHPT who underwent surgery between 1976 and 2011 was screened for patients with hypoparathyroidism who received a metachronous autotransplantation. Data were analyzed regarding clinical data, histopathological findings of the cryopreserved parathyroid tissues, and patient outcome after metachronous replantation of parathyroid tissue.

Results

Fifteen of 883 patients with rHPT underwent a metachronous autotransplantation under local anesthesia at a mean time of 23?months following the last cervical surgery. Histopathology of the parathyroid tissue chosen for transplantation revealed a necrosis rate of 0?% in 14 and 70?% in one patient. Mean preoperative serum calcium and parathyroid hormone (PTH) levels were 2.0?mmol/l and 3.7?pg/ml, respectively. Autotransplantation raised mean serum calcium and PTH levels to 2.2?mmol/l and 97.5?pg/ml, respectively, after a mean follow-up of 78?months.

Conclusions

Metachronous autotransplantation following parathyroid surgery in patients with rHPT effectively normalizes PTH and calcium levels. The success rate is high if an adequate cryopreservation procedure is applied. However, it is rarely necessary, and therefore the cryopreservation of parathyroid tissue in all patients has to be questioned, at least from an economic point of view.     

Prospective Randomized Trial of Ligasure Versus Harmonic Hemostasis Technique in Thyroidectomy

Background

Two surgical devices have become popular in thyroid surgery: a bipolar energy sealing system (B) and ultrasonic coagulation (UC). Retrospective and prospective studies have demonstrated that the use of these surgical devices for thyroidectomy compared with conventional thyroidectomy (clamp-and-tie) techniques reduces operative time and cost. We conducted a prospective randomized clinical trial to determine if there is any difference in operative time and cost between B and UC.

Materials and Methods

A single-blinded prospective randomized controlled trial was conducted at a tertiary referral center. A total of 90 patients who required a thyroidectomy for thyroid cancer, thyroid nodules, or hyperthyroidism were randomized to either B or UC during thyroidectomy. The operative time and cost of thyroidectomy were compared between the two groups.

Results

There was no statistically significant difference in patient age, gender, body mass index, indication for thyroidectomy and thyroid gland weight between the two groups. There was no statistically significant difference in operating room cost or total cost for thyroidectomy between the B and UC groups. There was also no statistically significant difference in the operative time between the B and UC groups (187.6 vs. 184.2 min, P = 0.48) or in postoperative complication rates. The only statistically significant difference in total cost was between surgeons independent of the device used (P < 0.01).

Conclusions

In thyroid surgery, total cost and operative time were similar between the two surgical devices used.     

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.     

Parathyroid Cryopreservation after Parathyroidectomy: A Worthwhile Practice?

Background

Parathyroid cryopreservation is often utilized for patients having parathyroidectomy. This allows for future autotransplantation if a patient becomes permanently hypocalcemic after surgery. However, the practice of cryopreservation is costly and time-consuming, while the success rate of delayed autotransplantation is highly variable. We sought to determine the rate and outcomes of parathyroid cryopreservation and delayed autotransplantation at our institution to further evaluate its utility.

Methods

At our institution, 2,083 parathyroidectomies for hyperparathyroidism (HPT) were performed from 2001 to 2010. Of these, parathyroid cryopreservation was utilized in 442 patients (21 %). Patient demographics, preoperative diagnoses, and other characteristics were analyzed, as well as the rate and success of delayed autotransplantation.

Results

Of the 442 patients with cryopreservation, the mean age was 55 ± 1 years and 313 (70.8 %) were female. A total of 308 (70 %) had primary HPT, 46 (10 %) had secondary HPT, and 88 (20 %) had tertiary HPT. Delayed autotransplantation of cryopreserved parathyroid tissue was used in 4 (1 %) patients at an average time of 9 ± 4 months after initial surgery. Three of the 4 patients remained hypoparathyroid after this procedure. The single cured patient underwent the procedure only 4 days after the initial parathyroidectomy.

Conclusions

Although cryopreservation was used in over one-fifth of patients undergoing parathyroidectomy, the need for parathyroid reimplantation was very low (1 %). Furthermore, the success rate of parathyroid autotransplantation was poor in these patients. Therefore, the continued practice of parathyroid cryopreservation is questionable.     

Prediction of Permanent Hypoparathyroidism after Total Thyroidectomy

Background

Hypoparathyroidism is a common complication with thyroid surgery. The ability to predict a high risk of permanent hypoparathyroidism is important for individual prognosis and follow-up.

Methods

Permanent hypoparathyroidism, defined as continuing need for vitamin D medication at 1-year post-operatively, was investigated in patients after total thyroidectomy. Blood levels of calcium and parathyroid hormone (PTH) were measured intra-operatively, the day after surgery and at 1 month post-operatively. Logistic regression analysis was performed to investigate the risk of vitamin D treatment at last follow-up, calculated as odds ratios (ORs) with 95 % confidence intervals (CIs). Patients were followed until cessation of vitamin D and/or calcium medication, until death, loss to follow-up, or end of follow-up, whichever came first.

Results

A total of 519 patients were included. The median (range) follow-up in patients unable to cease vitamin D was 2.7 (1.2–10.3) years. The rate of permanent hypoparathyroidism was 10/519, 1.9 %. Parathyroid auto-transplantation was performed in 90/519 (17.3 %) patients. None of these developed permanent hypoparathyroidism, nor did any patient with normal PTH day 1 (>1.6 pmol/l or 15 pg/ml). The adjusted risk (OR, 95 % CI) for permanent hypoparathyroidism for log PTH on day 1 was 0.25 (0.13–0.50). In patients not auto-transplanted and with unmeasurable PTH day 1 (<0.7 pmol/l or 6.6 pg/ml), 8/42 (19.2 %) developed permanent hypoparathyroidism.

Conclusions

Auto-transplantation protects against permanent hypoparathyroidism, whereas low PTH day 1 is associated with high risk.     

Clinical Implication of Cancer Adhesion in Papillary Thyroid Carcinoma: Clinicopathologic Characteristics and Prognosis Analyzed with Degree of Extrathyroidal Extension

Background

Macroscopic extrathyroidal extension (ETE) is a poor prognostic factor in papillary thyroid carcinoma (PTC). However, intraoperative inspection for ETE is often inaccurate and could lead the surgeon to misconstrue simple adhesion as gross ETE. Such confusion could result in more aggressive treatment than necessary. In the present study we investigated the frequency and clinical implication of simple adhesions.

Methods

We identified 858 patients who underwent total thyroidectomy for papillary thyroid carcinoma (PTC). Clinicopathologic features, prognosis, and stimulated serum thyroglobulin (Tg) levels were compared between four groups divided according to degree of ETE: no ETE (n = 335), simple adhesion (n = 16), microscopic ETE (n = 378), and macroscopic ETE (n = 129).

Results

In the total of 145 cases, which were recognized as gross ETE under intraoperative inspection, 16 cases (11.0 %) were diagnosed as cancer confined to the thyroid without ETE by definite histology. The simple adhesion group showed no statistical differences in postoperative stimulated Tg levels from the no ETE and microscopic ETE groups (p > 0.05). In contrast, the distribution of postoperative Tg levels in the macroscopic ETE group was significantly higher than in the other groups (p < 0.001). During the 54-month median follow-up period, the macroscopic ETE and microscopic ETE groups showed poorer relapse-free survival than the no ETE and simple adhesion groups (p < 0.05).

Conclusions

The findings of the present study indicate that the discrepancy between intraoperative inspection and definite histology is not negligible when dense adhesions are present. When no tumor is found, the patient with inflammatory or fibrotic adhesions has a favorable prognosis.     

Utility of Intraoperative Parathyroid Hormone Monitoring in Patients with Multiple Endocrine Neoplasia Type 1-Associated Primary Hyperparathyroidism Undergoing Initial Parathyroidectomy

Background

Intraoperative parathyroid hormone monitoring (IOPTH) is a widely used adjunct for primary hyperparathyroidism (pHPT). However, the benefit of IOPTH in familial pHPT, such as in multiple endocrine neoplasia type I (MEN1), remains unclear.

Methods

We performed a retrospective analysis of 52 patients with MEN1-associated pHPT undergoing initial parathyroidectomy with IOPTH monitoring at our institution. Parathyroid hormone (PTH) levels were measured before skin incision and 10 min after resection of the last parathyroid gland. Variables analyzed included percent drop of PTH from baseline and the final PTH level compared to the normal reference range (RR).

Results

A total of 52 patients underwent initial subtotal parathyroidectomy with IOPTH. An IOPTH decrease cutoff of ≥75 % from baseline had the highest biochemical cure rate (87 %). In the remaining 13 % who met this cutoff, all had persistent pHPT, with ≥90 % drop of PTH from baseline. The remaining patients, who did not meet the ≥75 % cutoff, were cured. Follow-up was available for three of four patients with final IOPTH levels above the RR: one had persistent pHPT, two had hypoparathyroidism (50 %). When a postresection PTH level was within the RR, 88 % of patients were cured. While considered cured from pHPT, 7 % of patients in this group developed permanent hypoparathyroidism. When the final PTH level dropped below the RR, 28 % developed permanent hypoparathyroidism.

Conclusions

A cutoff in IOPTH decrease of ≥75 % from baseline has the highest biochemically cure rate in patients with pHPT associated with MEN1. However, a 75 % cutoff in IOPTH decrease does not exclude persistent pHPT. The absolute IOPTH value does not accurately predict postoperative hypoparathyroidism.     

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.     

Comparison of Endoscopic and Robotic Thyroidectomy

Background

Endoscopic thyroidectomy is a technically challenging procedure. Robot-assisted thyroidectomy has been recently introduced and offers improved visualization and dexterity. The present study compared conventional endoscopic and robotic thyroidectomy for thyroid cancer patients in terms of perioperative outcomes and learning curve. All operations were performed by the same surgeon.

Materials and Methods

Between April 2007 and March 2010, 96 patients underwent endoscopic thyroidectomy (endoscopy group) and 163 patients underwent robotic thyroidectomy (robot group). A gasless transaxillary approach was used in both groups. The 2 groups were compared in terms of patient characteristics, perioperative clinical results, complications, and pathologic details. Learning curves for the 2 procedures were compared based on the number of cases required to reach a consistent operation time.

Results

Patient characteristics were similar for both groups. The mean total operation time for thyroidectomy with central compartment neck dissection was 142.7 ± 52.1 min in the endoscopy group and 110.1 ± 50.7 min in the robot group (P = .041). Both patient groups were similar in terms of pathological features including TNM stage, intraoperative blood loss, length of hospital stay, and complication rate. However, the mean number of retrieved central lymph nodes was 2.4 ± 1.9 for the endoscopy group and 4.5 ± 1.5 for the robot group (P = .004). The learning curve was 55–60 cases for endoscopic thyroidectomy and 35–40 cases for robotic thyroidectomy.

Conclusion

Robotic thyroidectomy was found to be superior to endoscopic thyroidectomy in terms of operation time, lymph node retrieval, and learning curve. Complication rates and postoperative hospital stay were similar for the 2 procedures.     

Incidental parathyroidectomy during total thyroidectomy

Aim — Background

Total thyroidectomy is the procedure of choice in many diseases of the thyroid gland. This study measures the frequency of incidental parathyroidectomy during thyroidectomy in our department and values the possible correlation between certain clinical parameters, such as inflammation and malignancy, and the frequency of incidental parathyroidectomy.

Patients — Methods

A retrospective study was conducted for the period July 2009–June 2012. The study included 63 patients (51 female, 12 male) with total thyroidectomy. We measured the number of parathyroid glands as recorded in the pathology reports and we compared this with the original disease of the thyroid gland.

Results

Parathyroid tissue was found in 12 cases (19%). One parathyroid gland was found in nine (14%) specimens (group A), and two parathyroid glands were found in three (5%) (group B). The cases in group A comprised: 5/21 (24%) goiter, 3/23 (13%) thyroid cancer, 1/19 (5%) thyroid nodule, and in group B: 1/21 (5%) goiter, 2/23 (9%) thyroid cancer. In 75% of all cases (both groups A & B), there was significant inflammation of the thyroid gland.

Conclusion

Incidental parathyroidectomy during thyroidectomy is usually found in cases of severe inflammation, goiter or thyroid cancer. It is essential that the surgeon recognizes and preserves the parathyroid glands during thyroidectomy.     

Use of Spiral Computed Tomography Volumetry for Determining the Operative Approach in Patients with Graves’ Disease

Background

The purposes of the present study were to assess (1) the correlation between the weight of the postoperative thyroid specimen and the spiral computed tomography (CT) volumetry results of the thyroid gland in patients with Graves’ disease, and (2) the utility of CT volumetry for determining the operative approach.

Methods

From 2009 to 2010, a total of 56 patients with Graves’ disease underwent total or subtotal thyroidectomy. An enhanced spiral CT was taken in all patients prior to the operation. From 2.5 mm-thick slices of the thyroid gland, the surface area was calculated to measure the volume of the thyroid gland. The glandular volume was compared to the weight of the postoperative thyroid specimen.

Results

A total of 42 and 14 patients underwent total and subtotal thyroidectomy, respectively. The mean weight of the postoperative thyroid specimen was 43.9 ± 33.4 g, and the mean volume obtained by CT volumetry was 44.2 ± 32.8 mL. A good correlation was observed between the weight of the postoperative thyroid specimen and the volume calculated by CT (r = 0.98, p < 0.001). When 100 mL was set as the higher cut-off value of the thyroid volume for minimally invasive thyroid surgery, the estimated blood loss showed a significant difference between the >100 mL and the ≤100 mL groups (608.3 ± 540.8 vs. 119.7 ± 110.4 mL; p = 0.036).

Conclusions

: Spiral CT volumetry may be used to measure the thyroid volume reliably in patients with Graves’ disease. For cases in which surgery is indicated in patients with Graves’ disease, CT volumetry provides useful information from which to determine the operative approach. One hundred milliliter or less of thyroid volume in CT volumetry is recommended to perform minimally invasive thyroid surgery.     

Intraoperatives Parathormonmonitoring bei der Halsexploration wegen renalem Hyperparathyreoidismus?

Introduction. In operations for renal hyperparathyroidism the value of intraoperative parathormone monitoring was investigated. Patients and methods. Intraoperative intact parathyroid hormone levels were determined (PTH Quick assay) in 40 patients undergoing first cervical exploration and in two patients with graft-dependent recurrence of renal hyperparathyroidism. Results. In 33 patients, total parathyroidectomy with autotransplantation was carried out. The median parathormone levels decreased from 652 pg/ml to 120 pg/ml (19% of initial level) 5 min after total parathyroidectomy. In seven patients, fewer than 4 parathyroid glands each were identified during cervical exploration and “total parathyroidectomy (?)” without autotransplantation was performed. Intraoperatively median parathormone level decreased from 1193 pg/ml to 116 pg/ml (10% of initial level). In one of these seven patients, hyperparathyroidism persisted due to an ectopic fourth gland within the carotid sheath. In two of these patients, hypoparathyroidism occurred and a delayed autotransplantation of cryopreserved parathyroid tissue was carried out. On the first day after total parathyroidectomy with autotransplantation and “total parathyroidectomy (?)”, median levels of intact parathyroid hormone were 1.9 pg/ml and 82.5 pg/ml, respectively. Conclusion. Intraoperative monitoring is not useful in first cervical exploration for renal hyperparathyroidism because it cannot predict complete resection of parathyroid tissue. The parathormone level on the first postoperative day allows precise evaluation of the efficacy of the surgical procedure.     

The Impact of Surgical Volume on Racial Disparity in Thyroid and Parathyroid Surgery

Purpose

The aim of this study was to evaluate the association between surgeon volume and patient outcomes among different race ethnicities undergoing thyroid or parathyroid surgery.

Methods

The nationwide inpatient sample was used to identify all thyroidectomy and parathyroidectomy admissions from 2003 to 2009, using International Classification of Diseases, 9th Clinical Modification (ICD-9-CM) procedure codes. Race, demographic, and clinical characteristics of patients were collected, along with surgeon volume, to predict the length of stay (LOS), complication rates, mortality, and total charges by racial group, using univariate and multivariate analyses.

Results

A total of 106,314 thyroid and parathyroid surgeries were included in the current analysis. Of these patients, 54 % were Caucasian, 11 % African American, 7 % Hispanic, and 3 % Asian. Mean LOS was longer for African American patients (4 ± 8.7 days) than for Caucasians (2.3 ± 5.5 days) [p < 0.001]. African Americans had higher overall complications (16.8 %) compared with Caucasians (11 %), Hispanics (13.5 %), and Asians (12 %) [p < 0.001]. In-hospital mortality was higher for African Americans (0.8 %) compared with that from other race groups (0.3 %) [p < 0.001]. Mean total charges were significantly higher for African Americans ($33,292 ± $67,387) compared with those for Caucasians ($22,855 ± $40,167) (p < 0.001). African Americans had less access to intermediate- (10–99 cases) and high- (>100 cases) volume surgeons compared with Caucasians—45 versus 49 %, and 16 versus 19 %, respectively (p < 0.001). Higher surgeon volume was associated with improved outcomes (p < 0.001). Racial disparity in all investigated outcomes was still significantly evident even after stratification by surgeon volume.

Conclusion

Higher surgeon volume is associated with improved patient outcomes. However, our data suggests that the observed racial disparities in thyroid and parathyroid surgery go beyond access to quality healthcare providers.