Total endoscopic thyroidectomy

We have developed endoscopic thyroidectomy procedures using anterior chest and axillary approaches. Both of our procedures differ significantly from the usual thyroidectomy, which involves lifting both the platysma and the sternohyoid muscle. Because only the platysma is lifted during our procedures, a CO(2) insufflation pressure of less than 4 mmHg is sufficient. While the sternohyoid muscle is transected to obtain greater exposure of the thyroid gland in minimally invasive procedures in the neck, we do not divide it so as to prevent adhesions to the platysma, unless the nodule is large. As we accumulated experience with these procedures in 58 patients, typical operation time decreased to less than 120 minutes for the anterior approach and to less than 150 minutes for the axillary approach. Large follicular tumours can be extracted using the axillary approach, with all of its cosmetic advantages, whereas the anterior chest approach is advocated for removal of bilateral multinodular goitres and parathyroid lesions. Both approaches result in minimal postoperative hypoaesthesia, paraesthesia, and discomfort during swallowing. We conclude that endoscopic neck surgery is the procedure of choice in carefully selected patients with thyroid disease.     

甲状腺全切术治疗甲状腺功能亢进症

目的探讨甲状腺全切除治疗甲状腺功能亢进症(甲亢)的可行性。方法回顾性分析9年余本院应用甲状腺全切除术治疗3 1例甲亢患者的临床资料,并与同期行传统甲状腺双侧叶次全切除的5 6例患者进行比较。结果甲状腺全切除手术组无术后出血病例,无甲亢复发病例,术后均合并甲减;而甲状腺双侧叶次全切除手术组术后出血率和甲亢复发率分别为3.6%和2 6.8%(两组比较,P值分别为P0.0 5,P0.0 1),术后出现甲减2 7(4 8.2%)例。两组术后均无永久性甲状旁腺功能低下并发症,喉返神经损伤发生率无明显差异(P0.0 5)。结论甲状腺全切除术治疗甲亢效果优于次全切除术,且其并发症总发生率和复发率低于后者。     

双侧结节性甲状腺肿手术方式的探讨

目的 探讨双侧甲状腺全切除/近全切除术治疗双侧结节性甲状腺肿是否安全可行.方法 2003年1月至2006年12月311例拟诊双侧结节性甲状腺肿者分为A、B两组;A组130例行双甲全/近全切术;B组181例行双甲次全切或/和大部切除术.结果 A、B两组各有6例和2例术中冰冻报告良性,但术后石蜡切片报告为乳头状癌.A组不需再手术,B组需再手术;两组术后各3例(2.42%,3/124 vs.1.68%,3/179)有暂时性声嘶,差异无统计学意义(P=0.48).术后2月A组2例有音调改变,无法发高音,喉镜示双侧声带活动好;B组1例有声嘶,喉镜示一侧声带活动减弱.两组术后各有11(8.87%,11/124)和9例(5.03%,9/179)术后48 h内有低钙血症,差异无统计学意义(P=0.16).两组无永久性甲状旁腺功能减退.B组术后2例(1.12%,2/179)因出血需再手术.A组术后无结节性甲状腺肿复发,B组12例复发(6.70%,12/179),差异有统计学意义(P=0.02).结论 双甲全/近全切除术可减少结节性甲状腺肿术后复发率和再手术率,且并发症并无增加,是安全可行的.     

Total thyroidectomy: Complications and technique

During the 27-year period from 1957 to 1984, four hundred thirty patients underwent total thyroidectomies for malignant or benign disease of the thyroid gland at our institutions. Thyroid cancer was found in 83.4% of cases, and 47.2% of these had concomitant lymph node dissections. Transient recurrent laryngeal nerve injury occurred in 6.2% of the entire series. Permanent unilateral vocal cord paralysis occurred in 2.5% of the patients operated on, although only 1 patient (0.45%) sustained this complication in the past 14 years. No patient had permanent bilateral vocal cord paralysis. Transient hypoparathyroidism was seen in 16.8% of patients with permanent hypoparathyroidism occurring in 4.0%. The incidence of permanent hypoparathyroidism fell to 2.7% during the past 14 years and was directly related to the extent of thyroid cancer found at operation. Postoperative complications decrease with the experience of the surgeon and increase with reoperations and extensive disease. Total thyroidectomy continues to be our treatment of choice for thyroid cancer.

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Resumen En el lapso de los 27 años entre 1957 y 1984, cuatro cientos treinta pacientes fueron sometidos a tiroidectomía total por enfermedad maligna o benigna de la glándula tiroides en nuestras instituciones. Cáncer tiroideo fue hallado en 83.4% de los casos, y 47.2% de éstos tuvieron disecciones ganglionares concomitantes. Lesión transitoria del nervio recurrente laríngeo ocurrió en el 6.2% de la serie total. Parálisis permanente unilateral de la cuerda vocal ocurrió en 2.5% de los pacientes operados, mientras sólo un paciente (0.45%) presentó esta complicación en los últimos 14 años. Ningún paciente presento parálisis bilateral permanente de las cuerdas vocales. Hipoparatiroidismo transitorio fue observado en 16.8% de los pacientes, y el hipoparatiroidismo permanente ocurrió en el 4.0%. La incidencia de hipoparatiroidismo permanente descendió a 2.7% en los ültimos 14 años y apareció directamente relacionado con la extensión del cancer tiroideo hallada en la operación. Las complicaciones postoperatorias disminuyen en relación a la experiencia del cirujano y se incrementan con las reoperaciones y con la enfermedad muy extensa. La tiroidectomía total continúa siendo nuestra forma preferida de tratamiento para cáncer tiroideo.

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Résumé Au cours d'une période de 27 ans de 1957 à 1984, quatre cent trente patients ont subi une thyroïdectomie totale dans notre établissement pour des lésions bénignes ou malignes du corps thyroïdien. Dans 83.4% des cas il s'agit d'un carcinome thyroïdien, nécessitant chez 47.2% d'entre eux un curage ganglionnaire associé. On observe une atteinte transitoire du nerf récurrent laryngé dans 6.2% des cas sur la totalité de la série. Une paralysie permanente unilatérale des cordes vocales survient chez 2.5% des patients opérés, alors que durant les 14 dernières années un seul patient présente cette complication. Aucun des cas de paralysie bilatérale permanente des cordes vocales n'est observé. Une hypoparathyroïdie transitoire est constatée chez 16.8% des patients avec hypoparathyroïdie définitive dans 4.0% des cas. L'incidence de l'hypoparathyroïdisme définitif tombe à 2.7% au cours des 14 dernières années et est directement liée à l'extension du cancer thyroïdien constaté lors de l'intervention. Les complications postopératoires diminuent avec l'expérience du chirurgien et augmentent lors des réinterventions et l'extension des lésions. La thyroïdectomie totale demeure pour les auteurs le traitement de choix du cancer thyroïdien.

     

全甲状腺切除术加中央区淋巴结清除术

近年来甲状腺癌的发病率逐年提高。甲状腺癌根治术是甲状腺分化型癌的标准治疗手段,是其序贯治疗过程中最为重要的一环。规范的甲状腺癌根治术包括至少一侧甲状腺叶的切除（原发灶切除）和中央区淋巴结清除（区域引流淋巴结清除）。甲状腺分化型癌大多预后良好,但甲状腺癌术后一旦复发,往往直接侵犯气管、食管、颈动脉等重要器官,再次手术时由于粘连紧密,解剖层次紊乱,病灶切除困难,喉返神经损伤及甲状旁腺功能低下的概率将明显增高,严重影响疗效。因此规范化的甲状腺癌根治术,对提高分化型甲状腺癌疗效有重要意义。     

Total thyroidectomy is improved by loupe magnification

With this study, we verified if a microsurgical approach with magnification could improve the outcome of total thyroidectomy. Ninety-seven patients were consecutively randomized into group A (surgery with x 2.5 magnification and microsurgical instruments, n = 47) or group B (surgery with no magnification, n = 50). The mean operative time was 125 +/- 4.0 min in group A, and 150 +/- 4.0 min in group B (P = 0.00012). The recurrent laryngeal nerve was identified in all patients of group A, and in 96.8% of group B. The overall morbidity rate was 4.0% in group A and 25.5% in group B (P = 0.0038). This study indicates that a microsurgical approach with magnification is feasible, reduces surgical time, and improves the outcome in total thyroidectomy.     

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目的 探讨甲状腺癌行甲状腺全切除术及术后甲状腺激素的应用。方法 自1994年10月至2000年10月对65例甲状腺癌病人行甲状腺全切除术,术后应用甲状腺激素治疗,并随访观察。结果 42例首次手术、18例第2次手术、5例第3次手术行甲状腺全切除术,31例同时行改良颈部淋巴结清扫术。65例术后均服用甲状腺激素。随访56例,2例术后死于转移癌。其余65例均存活,无癌复发。结论 以除未分化癌以外的甲状腺癌行甲状腺全切除术,术后常规予以甲状腺激素治疗,定期同位素复查,并辅以适当的放射性碘治疗,是有效的综合治疗方案。     

Total thyroidectomy for differentiated thyroid cancer: primary compared with completion thyroidectomy.

OBJECTIVE: To analyse morbidity after completion total thyroidectomy compared with primary total thyroidectomy in a specialist thyroid surgery centre. DESIGN: Retrospective study. SETTING: Tertiary referral hospital, India. PATIENTS: Medical records of 143 patients who had total thyroidectomy between January 1990 and December 1999. 95 had primary thyroidectomies and 48 were completion thyroidectomies. MAIN OUTCOME MEASURES: Complication rate in both groups. RESULTS: The groups were comparable in respect of clinicopathological variables. Residual tumour was found in 19/48 (40%). After completion thyroidectomy, transient hypoparathyroidism and transient recurrent laryngeal nerve palsy were recorded in 8/48 (17%) and 2/48 (4%), respectively. No permanent hypoparathyroidism or permanent recurrent laryngeal nerve palsy was recorded in the completion thyroidectomy group. CONCLUSIONS: Completion thyroidectomy can be done with acceptable morbidity in a specialist thyroid surgery centre. Fear of increased morbidity after the procedure should not deter surgeon from doing this operation or referring the patients to a specialist centre.     

Total thyroidectomy replaces subtotal thyroidectomy as the preferred surgical treatment for Graves' disease

BACKGROUND: Total thyroidectomy is increasingly being adopted for patients requiring surgical treatment for Graves' disease based on a comparable surgical risk and the lack of recurrence, as well as the questionable ability of subtotal thyroidectomy to maintain euthyroidism. The purpose of the present paper was to evaluate its safety and efficiency. METHODS: Total thyroidectomy was adopted as part of the routine surgical treatment for Graves' disease from 2000. Patients who underwent subtotal thyroidectomy (STT) from 1995 to 1999 (n = 119) were compared with those who underwent total thyroidectomy (TT) from 2000 to 2003 (n = 98) with respect to immediate postoperative morbidity and long-term outcome. RESULTS: Fourteen (11.8%) and 22 patients (22.4%) required calcium supplement on discharge in the STT and TT groups, respectively (P < 0.05). One (0.8%) and three patients (3.1%) developed permanent hypocalcaemia, respectively. Transient recurrent laryngeal nerve palsy occurred in 9.2% (n = 11) and 5.1% (n = 5) of patients or 5.0% and 2.6% of nerves at risk after STT and TT, respectively. None of the patients had permanent nerve palsy. The estimated blood loss was less and hospital stay shorter after TT. During a mean follow up of 64 months, 86 patients (72.3%) in the STT group required thyroxine replacement and seven patients (5.9%) developed relapse. CONCLUSION: Subtotal thyroidectomy was associated with relapse as well as hypothyroidism in a significant proportion of patients during long-term follow up. Total thyroidectomy can be performed as safely as STT and should be recommended as the procedure of choice for patients requiring surgical treatment for Graves' disease.     

Total video endoscopic thyroidectomy by an axillary approach

BACKGROUND: A permanent transverse surgical scar is an unavoidable problem after conventional thyroidectomy. Endoscopic thyroidectomy performed via an axillary approach leaves no scarring at the neck and anterior chest wall and so provides an excellent cosmetic result. The axillary scars are usually not seen when the arm is in a normal position. MATERIALS AND METHODS: From April 2001 to February 2003, we used a four-port technique to perform 45 lobectomy and isthmectomy procedures. One 12-mm port for the flexible laparoscope (EL2-TF410, Fuji Photo Optical, Tokyo, Japan) and three additional 5-mm ports for instruments and suction were inserted through the axilla on the side of the nodule. The CO(2 )insufflation pressure was set at 4 mm Hg, and in most cases, a 5-mm Johnson & Johnson Harmonic Scalpel (Ethicon Endo-Surgery, Cincinnati, Ohio, U.S.A.) was used for the dissection. RESULTS: Of 45 procedures, 44 were performed successfully. In one case, conversion to a conventional technique was required. The mean operating time was 131.2 minutes, and the mean blood loss was 51.6 mL. The recurrent laryngeal nerves were clearly identified in every case, and no case of permanent voice change occurred after surgery. In one patient, a 20-mL seroma developed on the 10th postoperative day, which was treated by simple aspiration. One patient experienced a transient voice change. The patients were discharged on average at 2.9 days after the operation. CONCLUSIONS: Endoscopic thyroidectomy by an axillary approach to manage benign thyroid disease is feasible and safe and provides promising cosmetic results. We think that this approach may play an important role in the near future.     

Total thyroidectomy in surgical treatment of euthyroid goiter

BACKGROUND AND AIMS: The aim of this study was to compare the experiences and results achieved by a single surgeon using total thyroidectomy and partial exeresis in the treatment of uni- and multinodular euthyroid goiter. METHODS: The results of two groups of operations performed at two different periods were analysed: a more recent group (1995-97) in which management tended to prefer total thyroidectomy, and a retrospective group (1984-1994) in which a more conservative attitude was adopted to benign thyroid pathology. RESULTS: An analysis of the results and complications in each group showed that there were no statistically significant differences between the percentage of recurrent and parathyroid lesions during total thyroidectomy and partial exeresis. In practice, the risk of these lesions is higher during redo surgery for cancer and/or recurrence. The recidivation of goitrogenic pathology is high, amounting to around 29% of total cases. The most significant findings, however, which further justifies the use of total thyroidectomy is the increasingly frequent observation of "occult carcinomas" within the benign pathology, registered in the retrospective group (13.27%) and in the more recent one (12.35%). CONCLUSIONS: On the basis of this analysis, the authors confirm their support for the use of total thyroidectomy on principle as the correct and rational treatment for euthyroid goiter, and reserve the use of conservative treatment for single nodular lesions where it is possible to perform a correct hemithyroidectomy and isthmectomy following the patient's informed choice.     

Total thyroidectomy for multinodular goiter in the elderly

BACKGROUND: Total thyroidectomy for multinodular goiter (MNG) is increasingly being performed for the elderly population and yet their perioperative and long-term outcomes remain unclear. METHODS: A total of 279 patients who underwent total thyroidectomy for MNG in a university-based hospital during a 9-year period were analyzed according to their age at the time of operation. RESULTS: The duration of operation (P=.023), intraoperative blood loss (P=.030), weight of resected thyroid glands (P<.001) and proportion of retrosternal goiter (P<.001) were significantly greater in the elderly group (>/=70 years) (n = 55), but the incidence of surgically related complications, including recurrent laryngeal nerve palsy and hypoparathyroidism, was similar. Postoperative pneumonia occurred more frequently in the elderly group (P=.034). The number of comorbidities tended to correlate with the length of hospital stay and long-term survival in elderly patients. CONCLUSIONS: Total thyroidectomy for MNG in elderly patients had a similar perioperative outcome as their younger counterparts, but their long-term outcome is likely to be influenced by the number of comorbidities.     

Total thyroidectomy: the evolution of surgical technique

The present paper outlines the development of thyroid surgery from early times to the twenty-first century. The significant changes that have occurred in the past few decades in relation to the evolution of techniques for safe and effective total thyroidectomy are then summarized. In the last 25 years total thyroidectomy has replaced bilateral subtotal thyroidectomy as the preferred option for the management of all patients with bilateral benign multinodular goitre, Graves' disease, and all but very low-risk thyroid cancer patients. The principal change in operative technique has been the move from 'lateral dissection' to 'capsular dissection'. Associated with that has been a focus on 'encountering' the recurrent laryngeal nerve (RLN), recognizing sympathetic-laryngeal nerve anastomoses, and routinely identifying the external branch of the superior laryngeal nerve (EBSLN). Completeness of resection has been assured by moving from an anatomically based approach to an embryologically based approach. This requires an awareness of the vagaries of thyroid development including attention to pyramidal remnants, to abnormalities associated with the tubercle of Zuckerkandl, and to thyrothymic thyroid rests. Preservation of parathyroid function has moved from the time-consuming technique of dissection of a vascularized pedicle in all cases, to initially selective, and then routine, parathyroid autotransplantation. These changes have ensured that total thyroidectomy can now be offered as a safe and efficacious procedure with a minimal complication rate.     

完全囊外甲状腺切除术的术式探讨

目的探讨完全囊外甲状腺切除的手术技巧。方法回顾性分析 10 4例完全囊外甲状腺切除术的结果。结果　从 1990年 5月至 2 0 0 0年 5月 10年间以完全囊外的入路行甲状腺次全或全切除 10 4例 ,患者无术后危象、术后出血致呼吸道梗阻、永久性甲状旁腺低功等严重并发症 ,仅1例出现暂时性喉返神经麻痹。结论完全囊外甲状腺切除术出血少 ,并发症少 ,安全 ,效果好 ,是理想的手术入路。     

Total thyroidectomy for the surgical treatment of multinodular goiter

Purpose  

The indications for surgical treatment of multinodular goiter (MNG) are pressure symptoms, suspicion of malignancy, and cosmetic concerns. We report our clinical experience of performing total thyroidectomy (TT) for MNG, focusing on outcome and complications, to evaluate its effectiveness.