Video-assisted thyroidectomy: report of a 7-year experience in Rome

Background and aims We report on our series of patients selected for video-assisted thyroidectomy (VAT) over a 7-year period.Materials and methods VAT is a gasless procedure performed under endoscopic vision through a single 1×5×2.0-cm skin incision. The eligibility criteria are thyroid nodules ≤35 mm, thyroid volume <30 ml, and no previous conventional neck surgery. Small, low-risk papillary thyroid carcinomas (PTC) were considered eligible.Results There were 521 VATs attempted. Conversion was necessary six times (difficult dissection in one case, large nodule size in three, and gross lymph node metastases in two). Thyroid lobectomy was successfully accomplished in 113 cases, total thyroidectomy in 398, and completion thyroidectomy in 14. In 66 patients, the central neck nodes were removed through the same access. Pathology showed benign diseases in 313 cases, PTC in 187, and medullary microcarcinoma in 1. Postoperative complications included 9 transient recurrent nerve palsies, 73 transient hypocalcemias, 3 definitive hypoparathyroidisms, 1 postoperative haematoma, and 2 wound infections. The cosmetic result was excellent. In patients with PTC, no evidence of recurrent disease was shown.Conclusions The indications for VAT are still limited. Nonetheless, in selected patients, it seems a valid option for thyroidectomy and even preferable to conventional surgery because of its significant advantages, especially in terms of cosmetic result.Presented at the International Symposium “Modern Technologies in Thyroid Surgery”, 10–11 February 2006, Halle/Saale, Germany     

The relationships of surgeon volume and specialty with outcomes following pediatric thyroidectomy

BackgroundPrevious studies of pediatric thyroidectomies suggest a volume-outcome relationship, but none have focused exclusively on pediatric surgical specialists. Our objective was to examine the effects of pediatric surgeon volume and specialty on post-thyroidectomy outcomes.MethodsThe Pediatric Health Information System was queried for patients ≤ 21 years who underwent partial or total thyroidectomy between 2005 and 2016. Multivariable logistic regression with propensity score weighting was used to assess the relationships between surgeon volume or specialty and 90-day thyroidectomy-specific complications. High-volume surgeons/hospitals were defined as those in the top tertile of annual thyroidectomies.ResultsThe inclusion criteria were met by 3149 patients. Patients treated by higher-volume surgeons had significantly fewer complications than those treated by lower-volume surgeons (15.0% vs. 19.2%, p = 0.01). Patients with thyroid cancer also had less morbidity when treated by higher-volume surgeons compared to lower-volume surgeons (25.0% vs. 35.1%, p = 0.03), as did children with Graves' disease (19.8% vs. 29.3%, p = 0.007). Patients managed by pediatric surgeons had fewer complications than those managed by pediatric otolaryngologists across all patients (14.0% vs. 22.5%, p < 0.001) and among cancer (25.3% vs. 42.1%, p < 0.001) and Graves' patients (20.1% vs. 37.3%, p < 0.001) specifically.ConclusionsMorbidity following pediatric thyroidectomy is associated with surgeon volume.Type of StudyPrognostic Study.Level of EvidenceLevel II.     

“Minimally invasive video-assisted thyroidectomy. Initial experience in a general surgery department”

Background and aims  The aim of this study is to analyze our preliminary results from minimally invasive video-assisted thyroidectomy (MIVAT) and demonstrate the feasibility of MIVAT also in non-referral centers. Materials and methods  We report our initial experience based on a series of 47 patients selected for MIVAT at General Surgery Department of University of Trieste during a period from May 2005 to February 2007. The eligibility criteria were rigorously observed. Age, goiter volume, major diameter of the dominant nodule, operative times, pathologic findings, postoperative pain, length of hospital stay, cosmetic results, and complications were retrospectively analyzed. Results  Thyroid lobectomy was successfully accomplished in 33 cases, total thyroidectomy in 14. Conversion to standard cervicotomy was required in three patients (6%). Mean operative time of lobectomy was 82.6 min and 118.7 for total thyroidectomy. Postoperative complications included 11 (23.4%) transient hypocalcemias, 2 (4.2%) hematomas, and 2 (4.2%) temporary laryngeal nerve palsies. None-recurrent nerve palsies was observed. The cosmetic result was excellent in most cases. Conclusions  Our experience demonstrates that MIVAT, after adequate training, is feasible and safe, with results comparable to conventional thyroidectomy, also in a General Surgery Department, from a dedicated team, with a sufficient and specific activity volume. The present paper has been exposed to IV National Scientific Meeting of General Surgery residents to Giargini Naxos (Messina, Italy), 25–26 May 2007. (Italy).     

Thyroid surgery and obesity: Cohort study of surgical outcomes and local specific complications

Introduction

Obesity is associated with numerous complications after elective general surgeries. The aim is to compare surgical outcomes and local specific complications in obese and non-obese patients after thyroid surgery.

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目的 探讨甲状腺全切除术中技术要点及其术后并发症的防治方法。重点讨论甲状旁腺及喉返神经的保护。方法 对84例分化型甲门面腺癌病人进行甲状腺全切除术,对术后并发症进行观察。结果 暂时性甲状旁腺功能低下发生率为13.10%,暂时性单侧喉返神经损伤的发病率为10.98%。结论 甲状腺全切除术安全,可行,关键在于术中的操作。使术后并发症降至最低。     

Feasibility study of day case thyroidectomy

Introduction: The aim of this retrospective study was to assess the feasibility and outcome of day case thyroidectomy in an ambulatory surgery centre in Hong Kong. Methods: Patients with day case thyroidectomy carried out between July 2005 and December 2006 were retrospectively reviewed. Day surgery was offered to patients satisfying the selection criteria for day case and having from benign unilobular thyroid disease. Results: Fifty patients had hemithyroidectomy carried out during the study period. There were 6 men and 44 women and the mean (standard deviation SD) age was 45.6 years (7.4 years). All patients were American Society for Anesthesiologists grade I (76%) or II (34%). The mean (SD) operative time was 79.5 min (17 min). Twelve patients had episodes of postoperative nausea and vomiting. The mean (SD) analgesic requirement was 0.7 tablets (0.5 tablets) of combination acetaminophen and phenyltoloxamine citrate before discharge. The mean (SD) time to discharge was 7.5 h (0.7 h). The overall discharge rate was 98% and the complication rate was 8%. One patient was observed overnight because of postoperative haematoma. One patient had recurrent laryngeal nerve injury. There were no unplanned readmissions postoperatively. Three patients had unsuspected thyroid malignancy on histopathology. Conclusion: This study showed the feasibility and safety of day case thyroidectomy. The setting was not associated with any increase in morbidity or mortality and has the potential in reducing hospital costs.     

甲状腺癌次全或全切除术后甲状腺功能的变化

目的 观察甲状腺癌行甲状腺叶全切或次全切术后甲状腺功能的变化,为术后补充甲状腺素提供时间和量的依据.方法 对我院2009年1月至2011年4月间行甲状腺叶全切或次全切除的88例甲状腺癌患者术前(0 d)、术后第1天(1 d)、术后第3天(3 d)和术后第5天(5 d)的甲状腺功能[游离三碘甲腺原氨酸(FT3)、游离甲状腺素(FT4)、血清三碘甲腺原氨酸(T3)、四碘甲腺原氨酸(T4)、促甲状腺激素(TSH)]进行检测,对比手术前后变化规律.结果 88例行甲状腺叶全切或次全切除患者的FT3和T3在各时点均呈下降趋势,差异有统计学意义(FT3:F =47.752,P＜0.01;T3:F=15.317,P＜0.01),且术后3d起FT3和T3逐渐上升接近正常值下限;FT4和T4术后1d均上升,随后逐渐下降,FT4值在0d、术后1d及5d差异无统计学意义(P＞0.05),T4值在0d、术后1d差异无统计学意义(P＞0.05),其余各时间点间差异均有统计学意义(P＜0.05);TSH在术后1d下降,3d及5d逐渐上升,TSH值在0d、术后1d差异无统计学意义(P＞0.05),其余各时间点间差异均有统计学意义(P＜0.05),且TSH在术后3d接近正常值上限,于术后5d超过正常值上限.结论 甲状腺癌患者行甲状腺全切或次全切除术后1d甲状腺功能不降或下降不明显,可不检测甲状腺功能和补充甲状腺激素;术后3d起甲状腺功能明显下降,应及时监测,并根据甲状腺功能下降情况适当补充甲状腺激素.     

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。     

Safety of video-assisted thyroidectomy versus conventional surgery

BACKGROUND: Thyroid gland manipulation, surgical stress response, and postoperative outcome in cases of video-assisted thyroidectomy (VAT) and conventional thyroidectomy were compared to verify the safety of VAT. METHODS: Twenty consenting patients were randomly assigned to undergo VAT or conventional thyroidectomy. Serum thyroglobulin levels were monitored as indicators of thyroid manipulation, and C-reactive protein and white blood cell count were monitored to assess surgical stress response. Thyroid capsule integrity and the presence of spilled cells in the thyroid bed were verified. RESULTS: No significant differences were found in the indicators of thyroid gland manipulation and surgical stress response between groups. No thyroid capsules ruptured, and no spilled thyroid cells were found. Patients who had VAT experienced less pain, required fewer analgesics, and were more satisfied with the cosmetic result and the surgical outcome. CONCLUSIONS: VAT is as safe as conventional thyroidectomy and is characterized by a less painful postoperative course and by better cosmetic results and postoperative outcome.     

经口腔前庭入路腔镜与开放甲状腺切除术的临床研究

目的对比研究经口腔前庭入路腔镜甲状腺与开放甲状腺切除术的临床疗效。方法回顾性分析2016年3月至2017年6月在咸阳市第一人民医院就诊的68例甲状腺切除术临床资料。根据患者意愿,将患者分为经口腔前庭腔镜甲状腺组(观察组,32例)及开放甲状腺切除组(对照组,36例),对比分析两组手术时间、术中出血量、术后引流量、住院时间、甲状旁腺激素水平及美观满意度。结果两组术中出血量、住院时间、术后引流量、甲状旁腺激素水平无统计学差异,观察组的患者美观满意度明显高于对照组(P=0.035),但手术时间较对照组延长(P=0.015)。结论经口腔前庭入路腔镜甲状腺切除与开放甲状腺切除相比手术时间延长,但一样安全可靠,未增加手术风险,更符合年轻女性的美容要求,术后恢复快。     

Identifying predictors of a difficult thyroidectomy

Background

A Thyroidectomy Difficulty Scale (TDS) was previously developed that identified more difficult operations, which correlated with longer operative times and higher complication rates. The purpose of this study was to identify preoperative variables predictive of a more difficult thyroidectomy using the TDS.

Methods

A four item, 20-point TDS, was used to score the difficulty of thyroid operations. Patient and disease factors were recorded for each patient. Difficult thyroidectomy and non-difficult thyroidectomy (NDT) patients were compared. A final multivariate logistic regression model was constructed with significant (P < 0.05) variables from a univariate analysis.

Results

A total of 189 patients were scored using TDS. Of them, 69 (36.5%) suffered from hyperthyroidism, 42 (22.2%) from Hashimotos, 34 (18.0%) from thyroid cancer, and 36 (19.0%) from multinodular goiter. Among hyperthyroid patients, the DT group had a greater number preoperatively treated with Lugols potassium iodide (81.6% DT versus 58.1% NDT, P = 0.032), presence of ophthalmopathy (31.6% DT versus 9.7% NDT, P = 0.028), and presence of (>4 IU/mL) antithyroglobulin antibodies (34.2% DT versus 12.9% NDT, P = 0.05). Using multivariate analysis, hyperthyroidism (odds ratio [OR], 4.35, 95% confidence interval [CI], 1.23–15.36, P = 0.02), presence of antithyroglobulin antibody (OR, 3.51, 95% CI, 1.28–9.66, P = 0.015), and high (>150 ng/mL) thyroglobulin (OR, 2.61, 95% CI, 1.06–6.42, P = 0.037) were independently associated with DT.

Conclusions

Using TDS, we demonstrated that a diagnosis of hyperthyroidism, preoperative elevation of serum thyroglobulin, and antithyroglobulin antibodies are associated with DT. This tool can assist surgeons in counseling patients regarding personalized operative risk and improve OR scheduling.     

Pediatric thyroidectomy: Favorable outcomes can be achieved by a multidisciplinary team of pediatric providers

Aim of the study

Recent publications suggest pediatric surgeons may not be well suited to perform thyroid surgeries unless considered high volume. We sought to assess the outcome of thyroidectomies performed by pediatric surgeons in an academic setting.

Modified version of minimally invasive open thyroidectomy using an unilateral incision

Background/objectiveOpen thyroidectomy has been the standard approach for patients undergoing thyroidectomy. However, this approach leads to prominent scars, hypesthesia, paresthesia, and uncomfortable sensations. We aimed to describe our modified technique of minimally invasive open thyroidectomy (MIT) and to compare the results with those of conventional thyroidectomy.MethodsThis study included 880 patients who underwent surgery between January 2016 and December 2016. Modified MIT was performed in 249 patients (28.3%), and conventional thyroidectomy was performed in the remaining 631 patients.ResultsLobectomy was performed in the majority of cases (MIT 204 [81.9%] vs. conventional 429 [67.9%]). There were no significant differences in complications between the two approaches (6 [2.4%] vs. 8 [1.3%]). Patients who underwent surgery using the minimally invasive approach had a shorter operative time (77.99 ± 34.5 vs. 91.23 ± 36.58 min) and were discharged earlier (2.4 ± 0.8 vs. 3.2 ± 0.8) than those who underwent conventional thyroidectomy.ConclusionModified MIT is a safe alternative to standard open thyroidectomy and allows the performance of bilateral total thyroidectomy with proper central compartment neck dissection.Level of evidence2b.     

Outcomes for soft-tissue sarcoma in 8249 cases from a large state cancer registry

BACKGROUND AND OBJECTIVES: To date, outcome reports for soft-tissue sarcoma (STS) have largely been limited to single or paired institutional series. To more accurately elucidate population-based outcomes and prognostic factors associated with STS, a large cancer registry was examined. METHODS: STS arising in the Florida Cancer Data System were examined (1981-2004). RESULTS: A total of 8249 patients were identified, the calculated annual incidence of sarcoma being approximately 38 cases per million in 2003. The tumor histologies among these patients were leiomyosarcoma and gastrointestinal stromal tumor (LMS/GIST) (43.5%), malignant fibrous histiocytoma (MFH) (31.5%), liposarcoma (19.0%), and fibrosarcoma (6.0%). Tumors were situated in the extremities (30.7%), truncal or visceral locations (50.4%), retroperitoneum (11.7%), and head or neck (7.2%). Thirty-three percent of lesions were over 10 cm in greatest dimension, while 50.2% were classified as high grade. Median overall survival was 25 months. Superior survival was observed for liposarcomas and fibrosarcomas as compared to MFH and LMS/GIST (P < 0.001). Retroperitoneal and truncal sarcomas had a more ominous prognosis than did other sites (P < 0.001). Multivariate analysis of pretreatment variables demonstrated that increasing age, male gender, non-Caucasian race, advanced stage, and a truncal or retroperitoneal location were each independently associated with lower survival. Histological subtype was also an independent predictor of outcome. Surgical resection and radiation therapy were the only treatment variables shown to improve survival. CONCLUSIONS: Histological subtype, tumor site, and stage are independent prognostic factors in STS. Surgical resection and radiotherapy are unique among treatment modalities in association with a significant survival benefit.     

甲状腺全切除术治疗甲状腺癌的临床体会

目的探讨甲状腺全切除术在治疗甲状腺癌中的临床应用价值.方法我院1985～2000年经同一外科医生施行甲状腺全切除术治疗甲状腺癌87例,对其发生并发症及术后131I治疗进行回顾性分析.结果术后观察喉返神经损伤2例(2.3%),低钙血症1例(1.1%),无永久性喉返神经损伤或低钙血症,无死亡.84例患者术后获得随访,平均随访5年,无瘤生存82例(97.6%),其中选择性进行131I治疗58例,占70.7%(58/82).结论甲状腺全切除术是治疗甲状腺癌安全、有效的手术方式,能彻底切除腺体内恶性肿瘤的潜在转移性病变,为术后进行131I治疗创造有利条件.     

Complications to thyroid surgery: results as reported in a database from a multicenter audit comprising 3,660 patients

BACKGROUND AND AIM: During recent years, more radical surgery for thyroid disease, i.e., total instead of subtotal resection, has been evident. Results following this strategy on national levels are scarce. MATERIALS AND METHODS: From 2004 to 2006, 26 Scandinavian Departments registered 3,660 thyroid operations in a database. Risk factors for complications were analyzed with multiple logistic regression. RESULTS: After thyroidectomy, re-bleeding occurred in 2.1% and was associated with older age (OR 1.04; p < 0.0001) and male gender (OR 1.90; p = 0.014). Postoperative infection occurred in 1.6% and associated with lymph node operation (OR 8.18; p < 0.0001). Postoperative unilateral paresis of the recurrent laryngeal nerve was diagnosed 3.9% and bilateral paresis in 0.2%. Unilateral paresis was associated with older age, intrathoracic goiter, thyreotoxicosis, and if routine laryngoscopy was practiced (OR 1.92; p = 0.0002). After 6 months, the incidence of nerve paresis was 0.97%. After bilateral thyroid surgery (n = 1,648), hypocalcaemia treated with vitamin D analogue occurred in 9.9% of the patients at the first follow-up and in 4.4% after 6 months. CONCLUSION: Complications to thyroid surgery are not uncommon. The high frequency of hypocalcaemia treated with vitamin D after 6 months is a cause of concern.     

Outcomes research in pediatric surgery. Part 2: how to structure a research question

Innovative treatments and procedures are essential to the advancement of surgery. Outcomes research provides the mechanism to analyze these new treatments as they enter clinical practice and evaluate them against established therapies. Information gained through this methodology is essential because new techniques and innovations often gain rapid acceptance before clinical trials can be conducted to assess them. Increasing national emphasis is placed on comparative effectiveness as health care costs rise. Surgeons must take the lead in surgical outcomes and comparative effectiveness research, with the goal of identifying the most efficient and effective treatment for our patients. The authors show how to structure and design a research project involving pediatric surgical outcomes. The model consists of the following 3 phases: (1) study design, (2) data preparation, and (3) data analysis. The model we present provides the reader with a basic format and research structure to serve as a guide to performing high-quality surgical outcomes research.     

简化式甲状腺切除术4749例临床分析

目的:探讨规避甲状腺切除术后近期严重并发症的手术方法。方法:回顾性分析近30年来4749例简化式甲状腺切除术的临床资料,并将其分为1980年代(A组)、1990年代(B组)、2000年代(C组)三组进行对比研究。结果:全组术后并发症发生率为2.26%,病死率0.15%。A、B、C三组并发症发生率分别为4.48%、0.95%、和0.29%;病死率是0.31%、0.05%和0。结论:包括不横断颈前肌群、巾钳牵引处理甲状腺上下极、不常规暴露喉返神经、不结扎甲状腺下动脉主干、T管负压引流等在内的甲状腺切除术,是一种既安全又简化的甲状腺外科手术方法。     

Randomized study on oral administration of calcitriol to prevent symptomatic hypocalcemia after total thyroidectomy

BACKGROUND: Symptomatic hypocalcemia remains the main postoperative complication after total thyroidectomy. The aim of the present study was to evaluate the role of oral supplementation of calcitriol and calcium salts in preventing severe postoperative hypocalcemia after total thyroidectomy. METHODS: A consecutive series of patients undergoing total thyroidectomy followed by administration of 500 mg of calcium salts 3 times per day were randomized to 3 different postoperative medical treatments: in group A, .5 microg of calcitriol twice per day was administered to 104 patients; in group B, 1 mmicrog of calcitriol twice per day was administered to 111 patients; and in group C, 202 patients did not receive calcitriol. RESULTS: The rate of postoperative tetany in group A was 2.9%, in group B was 0%, and in group C was 7.4% (P=.03) and the rate of paresthesias was 28.8%, 17.1%, and 22.3%, respectively (P=.19). At discontinuation of calcitriol/calcium salts treatment, intact parathyroid hormone levels did not significantly differ from the preoperative levels. Receiver operating characteristic (ROC) curve analysis showed that the area under the curve for serum concentration of calcium in predicting postoperative tetany was .749, .858 and .862 on the first, second, and third postoperative day, respectively. The best cut-off value of calcemia for prediction tetany was 7.5 mg/dL, and the rate of severe hypocalcemia on the third postoperative day was 23.1% in group A, 9.9% in group B, and 27.2% in group C (P=.001). CONCLUSIONS: Oral administration of 1 microg of calcitriol twice per day and 500 mg of calcium salts 3 times per day after total thyroidectomy significantly decreases the risk of severe postoperative hypocalcemia.