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).

     

Subtotal and Near Total Versus Total Thyroidectomy for the Management of Multinodular Goiter

BACKGROUND: The purpose of the present work was to compare rates of postsurgical complications following thyroidectomy for multinodular goiter through a retrospective multicenter cohort study. METHODS: All cases of thyroidectomy (total-TT; near total-NT; and bilateral subtotal-ST) performed in two hospitals from 1990 to 2005 were studied to determine the incidence of complications after each procedure. Follow-up checked injury of laryngeal nerves, hypoparathyroidism, hypothyroidism, pathology recurrence, and appearance of neoplasm. RESULTS: There were 6,223 cases: TT, n = 3,834 (61.6%); ST, n = 2,238 (36%); and NT, n = 151 (2.4%) NT). Of this total, 2,758 (44.3%) patients were men and 3,465 (55.7%) were women with a mean age of 48.7. Postoperative mean follow-up was 7 years, 2 months. Permanent recurrent laryngeal nerve (RLN) injury was observed in 1.4% in the TT group, 1.2% in the ST group, and 1.1% in the NT group (p > 0.1). Permanent hypocalcemia was observed in 2% in TT group, 1.9% in the ST group, and 2% in the NT group (p > 0.1). Permanent hypothyroidism occurred in all patients in the TT and NT groups, compared to 91% of the patients in the ST group (p > 0.1). Recurrence of benign disease was noted in 491 patients (20.5% of ST and NT cases combined; p < 0.05), n = 482 (21.5%) after ST and n = 9 (5.9%) after NT. Of the patients with recurrence, 173 needed a completion thyroidectomy. Malignant transformation was observed in 28 cases. CONCLUSIONS: There is no statistically significant difference in complications among TT, NT, and ST groups. Partial thyroidectomies provide no decisive advantage over total thyroidectomies in terms of subsequent requirements of supplemental hormone therapy. The rate of reoperation in cases of recurrent pathology and incidental carcinoma was high.     

Recurrence after Total Thyroidectomy for Benign Multinodular Goiter

Background Total thyroidectomy is now the preferred option for the management of benign multinodular goiter (BMNG), and it ought not be associated with recurrent disease. The aim of the present study was to examine the efficacy of total thyroidectomy for BMNG and to review reasons for recurrence. Material and methods The study group comprised all patients from January 1980 to December 2005 who underwent a definitive procedure to remove all thyroid tissue for BMNG, and who were subsequently identified as having developed a recurrence. Included were patients who underwent primary total thyroidectomy at our unit, or a two or more stage procedure where a definitive secondary total thyroidectomy was performed at our unit. Results There were 3,044 total or secondary total thyroidectomies performed for BMNG during the study period. Ten patients were identified as having developed recurrent BMNG requiring reoperation despite previous complete “total” thyroidectomy. There were 11 sites of recurrence in 10 patients. Only one was a true local recurrence in the thyroid bed. Another 9 recurrences related to the embryology of the thyroid gland, 4 in the pyramidal tract and 5 in the thyrothymic tract. There was one recurrence at another site (submandibular) in a patient with presumed metastatic thyroid cancer despite benign histology. There were no complications in any of the 10 patients. Conclusions Total thyroidectomy for BMNG is not only a safe procedure but is efficacious in preventing recurrent disease. Failure to remove embryological remnants such as thyrothymic residue or pyramidal remnants during total thyroidectomy is the major cause of recurrence.     

Indications, Risks, and Acceptance of Total Thyroidectomy for Multinodular Benign Goiter

Selective morphology- and function-adapted resection is generally regarded as the surgical treatment of choice for benign goiter causing iodine deficiency. This procedure aims to reduce the need for patients to undergo reoperations for recurrence by completely removing all nodules. However, to achieve this sometimes requires a total thyroidectomy, the option of which is often rejected because of a presumed higher rate of complications. In this study, 324 patients who underwent total thyroidectomy were evaluated retrospectively. The patients were interviewed about their postoperative course and their acceptance of the procedure performed. The complications were compared with those associated with subtotal resection or hemithyroidectomies performed in our collective experience. The rate of complications associated with total thyroidectomy, namely, recurrent nerve palsy in 0.9%, hypocalcemia in 0.9%, wound infection in 0.9%, and secondary hemorrhage in 0.6%, did not differ significantly from that associated with subtotal resections/hemithyroidectomies. Moreover, 88.3% of the patients who underwent total thyroidectomy were satisfied with the results of surgery. These findings indicate that total thyroidectomy is an acceptable surgical alternative for benign multinodular goiters. Received: January 5, 2001 / Accepted: May 15, 2001     

The Change in Surgical Practice from Subtotal to Near-Total or Total Thyroidectomy in the Treatment of Patients with Benign Multinodular Goiter

Background  Although total thyroidectomy is the procedure of choice in patients with thyroid carcinoma, this surgical approach has emerged as a surgical option to treat patients with benign multinodular goiter (BMNG), especially in endemically iodine-deficient regions. The aim of this study was to review our experience with patients with BMNG in an endemically iodine-deficient region treated by either subtotal or total/near-total thyroidectomy, and to document whether total or near-total thyroidectomy decreased the rate of completion thyroidectomy for incidentally diagnosed thyroid carcinoma in comparison to the patients with BMNG treated initially by subtotal thyroidectomy. Methods  Two thousand five hundred ninety-two patients with BMNG were included. There were 1695 bilateral subtotal thyroidectomies (group 1) and 1211 total or near-total thyroidectomies (group 2) for BMNG during this period. All patients were euthyroid and had no history of hyperthyroidism, radiation exposure, or familial thyroid carcinoma. Any patient with preoperative or perioperative suspicion of malignancy or hyperthyroidism was excluded. Results  Bilateral subtotal thyroidectomy was performed in 1695 patients (58.3%) in group 1 and total or near-total thyroidectomy in 1211 patients (41.7%), in group 2, respectively. The incidence of incidental thyroid carcinoma was found to be 7.2% (n = 210/2906). Although the rate of permanent hypoparathyroidim and transient or permanent unilateral recurrent laryngeal nerve (RLN) palsy were not significantly different between the two groups, transient hypoparathyroidism was significantly higher in group 2 than in group 1 (8.4% vs. 1.42%; p < 0.001, odds ratio [OR] = 52.98). The incidence of thyroid carcinoma was significantly higher in group 2 (10.7%, n = 129/1211) than in group 1 (4.68%, n = 81/1695) (p < 0.001; OR = 39.1).Thirty-eight patients in group 1 (2.24%) underwent completion thyroidectomy, whereas completion thyroidectomy has been not indicated in group 2 (p = 0.007). Two of 38 patients (5.26%) had thyroid papillary microcarcinoma on their remnant thyroid tissue. The rate of recurrent goiter was 7.1% in group 1. The average time to recurrence in group 1 was 14.9 ± 8.7 years. Six of 121 patients with recurrent disease (4.95%) has been operated on. Conclusions  Subtotal thyroidectomy resulted in a significantly higher rate of completion thyroidectomy for incidentally diagnosed thyroid carcinoma compared with total or near-total thyroidectomy in patients with BMNG. The extent of surgical resection had no significant effect on the rate of permanent complications. We recommend total or near-total thyroidectomy in BMNG to prevent recurrence and to eliminate the necessity for early completion thyroidectomy in case of a final diagnosis of thyroid carcinoma.     

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.     

Five-year Mortality for Stable Angina in a Medical Practice Study and a Randomized Trial

Objective : Evolution of revascularization and medical therapy has increased the probability of improved survival in patients with stable angina. The present investigation tests the hypothesis that medical practice will generate lower mortality than randomly assigned bypass surgery in the European Coronary Surgery Study (ECSS) two decades earlier. Method : Using eligibility criteria of ECSS, a clinical decision strategy (CDS) cohort of 362 patients was selected from a nationwide study of medical practice in Sweden. Access to the individual data allowed common protocol design to compare 5-year mortality between CDS and surgical strategy of ECSS. Results and interpretation : CDS advised bypass surgery (BS) or percutaneous transluminal coronary angioplasty (PTCA) in 93% and medical treatment alone in 7%, while 94% of 394 patients randomized to surgery (Euro-S) in ECSS obtained BS. Operative mortality was 3.2% for Euro-S while no operative deaths occurred in CDS reflecting medical progress during two decades. However, the 5-year mortality for CDS decreased first when the risk ratio was adjusted for age, diabetes mellitus and hypertension (RR = 0.49 with 95% CI 0.26-0.93) p = 0.03 suggesting a need for improved comprehensive medical care.     

Clinical Efficacy of Intravenous Lidocaine for Thyroidectomy: A Prospective,Randomized, Double-Blind,Placebo-Controlled Trial

Background

Systemic lidocaine has analgesic and anti-inflammatory effects. The purpose of this prospective, randomized, double-blind study was to evaluate the effects of intravenous lidocaine on pain following thyroidectomy.

Methods

Fifty-eight adult patients scheduled for total thyroidectomy were randomly allocated to receive a 1.5 mg/kg lidocaine bolus followed by a 2 mg/kg/h infusion during surgery, or the same volume of normal saline (control). After thyroidectomy, we evaluated postoperative pain, nausea, fentanyl consumption, frequency of pushing the button (FPB) for patient-controlled analgesia (PCA), High-sensitivity C-reactive protein (hs-CRP) in serum, and patient satisfaction scores regarding the recovery process.

Results

Postoperative pain and nausea scores were significantly lower in the lidocaine group for the first 4 h following thyroidectomy, compared to the control group. Fentanyl consumption and FPB for the PCA were also significantly reduced in the lidocaine group for 4 h following thyroidectomy, and hs-CRP was significantly less in the lidocaine group at postoperative days 1 and 3. Furthermore, satisfaction scores were significantly higher in the lidocaine group compared to the control group.

Conclusions

Intravenous lidocaine effectively reduced postoperative pain and nausea following thyroidectomy as well as improved the quality of recovery. Trial registration number: Clinicaltrials.gov NCT01608360.

     

Randomized Controlled Trial of Visualization versus Neuromonitoring of the External Branch of the Superior Laryngeal Nerve during Thyroidectomy

Background  

Injury to the external branch of the superior laryngeal nerve (EBSLN) during thyroidectomy results in a lowered fundamental frequency of the voice and deteriorated voice performance in producing high-frequency sounds. It remains unclear if the use of intraoperative nerve monitoring (IONM) can improve the clinical outcome of thyroidectomy in terms of preserved individual voice performance. This study was designed to test that hypothesis.     

Five-Year Follow-up of a Randomized Clinical Trial of Unilateral Thyroid Lobectomy with or Without Postoperative Levothyroxine Treatment

Background  

The aim of this study was to compare the prevalence of recurrent nodular goiter in the contralateral thyroid lobe among patients after unilateral thyroid lobectomy for unilateral multinodular goiter (MNG) receiving versus not receiving postoperative prophylactic levothyroxine (LT4) treatment.     

Randomized Prospective Trial Comparing the Use of Intravenous versus Oral Acetaminophen in Total Joint Arthroplasty

Background

Multimodal pain management has had a significant effect on improving total joint arthroplasty recovery and patient satisfaction. There is literature supporting that intravenous (IV) acetaminophen reduces postoperative pain and narcotic use in the total joint population. However, there are no studies comparing the effectiveness of IV vs oral (PO) acetaminophen as part of a standard multimodal perioperative pain regimen.

Conventional Versus Computer-Assisted Technique for Total Knee Arthroplasty: A Minimum of 5-Year Follow-up of 200 Patients in a Prospective Randomized Comparative Trial

In the literature, studies of computer-assisted total knee arthroplasty (TKA) after mid-term period are not conclusive and long-term data are rare. In a prospective, randomized, comparative study 100 conventional TKAs (group REG) were compared with 100 computer-assisted TKAs (group NAV). Minimum follow-up was 5 years. No difference in implant failure was found with 1.1% in group NAV versus 4.6% in group REG (P = 0.368). Group NAV showed a significantly less mean deviation of mechanical limb axis (P = 0.015), more TKAs (90% versus 81% in group REG) were within 3° varus/valgus and a higher tibial slope and lateral distal femoral angle (LDFA) accuracy was found (P ≤ 0.034). Clinical investigational parameters showed no differences (P ≥ 0.058). Insall and HSS score total were also higher in group NAV (P ≤ 0.016).     

新型国产髋关节假体用于人工髋关节置换的随机对照研究

目的 通过随机对照临床试验,评价一种新型国产髋关节假体用于人工全髋关节置换术(total hip arthroplasty,THA)的临床疗效和安全性.方法 本研究采用多中心、随机、单盲、阳性平行对照设计,在全国5家医院共招募72例受试者,分别纳入试验组和对照组,各36例.试验组使用新型国产髋关节假体,对照组使用成熟的...     

Acne Lesion Extraction versus Oral Doxycycline for Moderate Acne Vulgaris: A Randomized Clinical Trial

Clinical trial ID{"type":"clinical-trial","attrs":{"text":"NCT04206631","term_id":"NCT04206631"}}NCT04206631BackgroundAcne vulgaris is a polymorphic skin condition comprising inflamed and noninflamed lesions. In addition to topical retinoids, systemic antibiotics play a role as a main therapy for acne with inflamed papules and cysts. However, due to the increasing tendency for bacterial resistance, alternatives to antibiotics are needed.ObjectiveThe aim of this study was to evaluate the effectiveness of acne lesion extraction compared to oral doxycycline for moderate acne vulgaris and to explore the impact of both treatments on Hypoxia-inducible factor (HIF)-1 alpha.MethodsThis randomized clinical trial was conducted in two teaching hospitals in 2016. Subjects with moderate acne vulgaris (N=140) were divided into two groups. Each subject in both groups received 0.05% tretinoin cream, applied to the entire face each night, and 2.5% benzoyl peroxide gel, applied to the acne lesions in the morning and afternoon. One group was also treated with oral doxycycline 100mg once daily and the other was treated with acne lesion extraction performed on all facial lesions every two weeks; the patients were evaluated via patient-reported self-assessment and lesion counts every two weeks for six weeks. HIF-1 alpha expression of the biopsied lessions was examined via immunohistochemistry.Results128 subjects completed the study. Among these 128 subjects there was a prominent decrease in inflamed lesions at Week 6 in the lesion extraction group compared to the oral doxycycline group (p<0.05). HIF-1 alpha expression of the biopsied lesions was found in 7 of 9 samples taken from the oral doxycycline group, while 3 of 4 samples in the lesion extraction group were found negative.ConclusionAccording to our results, acne lesion extraction appeared to be more effective than oral doxycycline in treating this sample of patients with moderate acne vulgaris. Additionally, HIF-1 alpha expression appeared to be decreased after acne lesion extraction.     

Computer-Assisted Kinematic and Mechanical Axis Total Knee Arthroplasty: A Prospective Randomized Controlled Trial of Bilateral Simultaneous Surgery

BackgroundRandomized controlled trials of kinematic alignment (KA) and mechanical alignment (MA) in primary total knee arthroplasty (TKA) have to date demonstrated at least equivalence of KA in terms of clinical outcomes. No trial of bilateral TKA has been conducted so patient preference for one technique over the other is unknown.MethodsForty-one participants underwent computer-assisted bilateral TKA. The outcome measures were as follows: (1) joint range of motion and functional scores including the KOOS, the KOOS JR, Oxford Knee Score, and the Forgotten Joint Score at a minimum of 2 years; (2) preference and perception of limb symmetry; (3) intraoperative alignment data; (4) release and gap balance data; and (5) postoperative radiographic joint angles.ResultsThere were no significant differences with respect to flexion range (P = .970) or functional scores (mean KOOS, P = .941; KOOS JR, P = .685; Oxford Knee Score, P = .578; FJS, P = .542). Significantly more participants who favored one knee preferred their KA TKA (P = .03); however, half of the patients had no preference and the overall numbers were small. Only 3 participants perceived any limb asymmetry (P < .001). More releases were required in the MA group (P = .018). Standing hip-knee-ankle angle means and frequency distributions were similar (P = .097 and P = .097, respectively).ConclusionClinical outcomes were equivalent at 2 years. Significantly more participants preferred their KA joint. Fewer releases were required using a KA technique. Participants were visually insensitive to modest hip-knee-ankle angle asymmetry.Level of EvidenceLevel 1.