Are there clinical variables determining antibiotic prophylaxis-susceptible versus resistant infection in open fractures?

Purpose

In Gustilo grade III open fractures, it remains unknown which demographic or clinical features may be associated with an infection resistant to the administered prophylactic agent, compared to one that is susceptible.

Methods

This was a retrospective case–control study on patients hospitalized from 2004 to 2009.

Results

We identified 310 patients with Gustilo-III open fractures, 36 (12 %) of which became infected after a median of ten days. In 26 (72 %) of the episodes the pathogen was susceptible to the prophylactic antibiotic agent prescribed upon admission, while in the other ten it was resistant. All antibiotic prophylaxis was intravenous; the median duration of treatment was three days and the median delay between trauma and surgery was one day. In multivariate analysis adjusting for case-mix, only Gustilo-grade-IIIc fractures (vascular lesions) showed tendency to be infected with resistant pathogens (odds ratio 10; 95 % confidence interval 1.0–10; p?=?0.058). There were no significant differences between cases caused by antibiotic resistant and susceptible pathogen cases in patient’s sex, presence of immune suppression, duration and choice of antibiotic prophylaxis, choice of surgical technique or materials, time delay until surgery, use of bone reaming, fracture localization, or presence of compartment syndrome.

Conclusion

We were unable to identify any specific clinical parameters associated with infection with antibiotic resistant pathogens in Gustilo-grade III open fractures, other than the severity of the fracture itself. More research is needed to identify patients who might benefit from a broader-spectrum antibiotic prophylaxis.     

Fine-Needle Aspiration of the Thyroid: Correlating Suspicious Cytology Results with Histological Outcomes

Purpose

Fine-needle aspiration cytology (FNAC) assists the diagnosis of thyroid malignancy. A ‘suspicious for malignancy’ on FNAC creates a management dilemma. The aims of this study were to investigate the malignancy rate for patients with suspicious cytology, and to describe a management approach for those with a suspicious result.

Methodology

A retrospective review of prospectively collected data in an endocrine surgery database was undertaken. Patients undergoing thyroidectomy with preoperative FNAC from 1992 to 2012 were analysed.

Results

Preoperative FNAC was undertaken in 2,692 patients, and the FNAC result was ‘suspicious for malignancy’ in 94 (3.5 %) patients. Of these, 53 (56.4 %) were malignant, with the majority 44 (83.0 %) being papillary thyroid cancer. 48 patients went straight to total thyroidectomy, 40 patients had an initial diagnostic hemithyroidectomy, and 1 patient had a diagnostic isthmusectomy. 5 patients required reoperative total thyroidectomy as an initial procedure. Of the 94 suspicious cases, 55 were reported by an unknown, presumably non-expert, thyroid cytopathologist. 38 of these cases were available for review and re-reporting by an experienced cytopathologist. On review, 28 (73.7 %) were reclassified as cytologically malignant, and all of these were confirmed as malignant on subsequent histopathology.

Conclusions

Suspicious cytology has a high risk of malignancy. Expert thyroid cytopathology can improve diagnostic accuracy and a preoperative malignant diagnosis should be pursued to enable one-stage surgery where possible.     

Use of antibiotic prophylaxis in elective inguinal hernia repair in adults in London and south-east England: a cross-sectional survey

Purpose

Evidence regarding whether or not antibiotic prophylaxis is beneficial in preventing post-operative surgical site infection in adult inguinal hernia repair is conflicting. A recent Cochrane review based on 17 randomised trials did not reach a conclusion on this subject. This study aimed to describe the current practice and determine whether clinical equipoise is prevalent.

Methods

Surgeons in training were recruited to administer the Survey of Hernia Antibiotic Prophylaxis usE survey to consultant-level general surgeons in London and the south-east of England on their practices and beliefs regarding antibiotic prophylaxis in adult elective inguinal hernia repair. Local prophylaxis guidelines for the participating hospital sites were also determined.

Results

The study was conducted at 34 different sites and received completed surveys from 229 out of a possible 245 surgeons, a 93 % response rate. Overall, a large majority of hospital guidelines (22/28) and surgeons’ personal beliefs (192/229, 84 %) supported the use of single-dose pre-operative intravenous antibiotic prophylaxis in inguinal hernia repair, although there was considerable variation in the regimens in use. The most widely used regimen was intravenous co-amoxiclav (1.2 g). Less than half of surgeons were adherent to their own hospital antibiotic guidelines for this procedure, although many incorrectly believed that they were following these.

Conclusion

In the south-east of England, there is a strong majority of surgical opinion in favour of the use of antibiotic prophylaxis in this procedure. It is therefore likely to be extremely difficult to conduct further randomised studies in the UK to support or refute the effectiveness of prophylaxis in this commonly performed procedure.     

Familial nonmedullary thyroid carcinoma—clinical relevance and prognosis. A European multicenter study

Purpose

Approximately 5% of differentiated thyroid carcinomas are of familial origin. These familial nonmedullary thyroid carcinomas (FNMTC) have an increased risk of multifocal disease and lymph node involvement. Consequently, higher recurrence rates and decreased disease-specific survival rates are described. The best surgical approach is discussed controversially.

Patients and methods

A survey among the international members of the German Society of Endocrine Surgeons revealed 20 families with two or more first-degree relatives with FNMTC. The mean age of the 41 patients (30 female, 11 male) with FNMTC was 40.6 years (18–73 years).

Results

Total thyroidectomy was performed in 31 of 41 patients (76%). Ninety-five percent of the tumors were papillary carcinomas. Two of 41 patients had follicular carcinomas. Ten patients (24%) with papillary carcinomas were diagnosed with Hashimoto's thyroiditis. The mean tumor size was 1.45 cm. FNMTC was multifocal in 12 patients (29%). A systematic lymph node dissection was performed in 21 of 41 patients (51%). Lymph nodes metastases were found in seven of these 21 patients. Twenty-eight of the patients (68%) underwent postoperative radioiodine ablation. After a mean follow-up of 7.2 years, 39 patients (95%) were disease free. One patient developed local recurrence and lung metastases, 10 and 25 years, respectively, after initial diagnosis. Another patient died 2 years postoperatively from advanced metastatic disease.

Conclusions

FNMTC is associated with an early onset of small, mostly papillary thyroid carcinomas and an increased risk of multifocality and lymph node involvement. Total thyroidectomy and systematic neck dissection are recommended together with radioiodine ablation. Screening for first-degree relatives should start at age 18 years.     

Papillary Thyroid Microcarcinoma: An Over-Treated Malignancy?

Background

The clinical importance of papillary thyroid microcarcinoma (PTMC) remains controversial, with current guidelines suggesting that thyroid lobectomy alone is sufficient. The purpose of this study was to identify population-level treatment patterns in the USA for PTMC.

Methods

Patients with PTMC in SEER (1998–2010) were included; demographic, clinical (extent of surgery, administration of post-operative radioactive iodine [RAI]), and pathologic characteristics were examined. Outcomes of interest were 5- and 10-year overall survival (OS) and disease-specific survival (DSS).

Results

The cohort consisted of 29,512 patients. Mean age at diagnosis was 48.5 years; mean tumor size was 0.53 cm. Overall, 73.4 % of patients underwent total thyroidectomy, and RAI was administered to 31.3 %. In multivariate analysis, total thyroidectomy was more frequently performed in patients with multifocal (odds ratio [OR] 2.55), ‘regional’, or ‘distant’ PTMC (OR 2.90 and 2.59). Non-operative management was associated with male patients (OR 4.24) and those aged ≥65 years (OR 6.31). Post-operative RAI was associated with multifocal PTMC (OR 2.57). Overall, 5- and 10-year DSS was 99.6 and 99.3 %, respectively, with no difference in DSS between patients who underwent partial versus total thyroidectomy. OS of patients with PTMC who underwent any thyroid operation was similar to that of the general population of the USA.

Conclusions

An increasing number of patients are undergoing total thyroidectomy and RAI for PTMC. While there may be a subset of patients for whom more aggressive therapy is indicated, many patients with PTMC may be over-treated, with no demonstrable benefit to survival.     

d-mannose powder for prophylaxis of recurrent urinary tract infections in women: a randomized clinical trial

Purpose

To test whether d-mannose powder is effective for recurrent urinary tract infection (UTI) prevention.

Materials and methods

After initial antibiotic treatment of acute cystitis, 308 women with history of recurrent UTI and no other significant comorbidities were randomly allocated to three groups. The first group (n = 103) received prophylaxis with 2 g of d-mannose powder in 200 ml of water daily for 6 months, the second (n = 103) received 50 mg Nitrofurantoin daily, and the third (n = 102) did not receive prophylaxis.

Results

Overall 98 patients (31.8 %) had recurrent UTI: 15 (14.6) in the d-mannose group, 21 (20.4) in Nitrofurantoin group, and 62 (60.8) in no prophylaxis group, with the rate significantly higher in no prophylaxis group compared to active groups (P < 0.001). Patients in d-mannose group and Nitrofurantoin group had a significantly lower risk of recurrent UTI episode during prophylactic therapy compared to patients in no prophylaxis group (RR 0.239 and 0.335, P < 0.0001). In active groups, 17.9 % of patients reported side effects but they were mild and did not require stopping the prophylaxis. Patients in d-mannose group had a significantly lower risk of side effects compared to patients in Nitrofurantoin group (RR 0.276, P < 0.0001), but the clinical importance of this finding is low because Nitrofurantoin was well tolerated.

Conclusions

In our study, d-mannose powder had significantly reduced the risk of recurrent UTI which was no different than in Nitrofurantoin group. More studies will be needed to validate the results of this study, but initial findings show that d-mannose may be useful for UTI prevention.     

Prognostic Significance of the Number of Metastatic Lymph Nodes to Stratify the Risk of Recurrence

Background

Prophylactic dissection facilitates identification of central lymph node (LN) metastasis in patients with papillary thyroid cancer (PTC). Because most staging systems do not stratify risks by the number of LN metastases, postoperative treatments vary among different institutions. Therefore we investigated the significance of number of LN metastases in risk stratification for recurrence in PTC.

Material and methods

A retrospective review was performed for 3,305 patients who had undergone thyroidectomy at Ajou University Hospital. A total of 2,462 patients (73.5 %) underwent total thyroidectomy, and another 3,152 (94.1 %) underwent central LN dissection. Lateral cervical LN dissection had been performed in 420 patients (12.5 %).

Results

There were 115 patients with recurrence (3.4 %). Recurrence-free rates were 94.6 % at 5 years and 89.4 % at 10 years. On univariate analysis, prognostic factors for recurrence were extent of thyroidectomy, tumor size, capsular invasion, T stage, N stage, number of LN metastasis, TNM stage, and radioactive iodine (RAI) therapy. On multivariate analysis, number of LN metastasis and N stage were significant prognostic factors for recurrence. Recurrence-free rate was significantly different between patients with 0–1 LN and those with 2 or more LN.

Conclusions

Number of metastatic LN was a significant prognostic factor, in addition to the N stage. Therefore, number of metastatic LN must be considered for postoperative staging system to tailor treatment and follow-up recommendations. In addition, patients with ≥2 metastatic LN may benefit from total thyroidectomy and RAI therapy with postoperative follow-up with serum thyroglobulin.     

Toxic Nodular Goiter and Cancer: A Compelling Case for Thyroidectomy

Background

Recent American Thyroid Association guidelines call for thyroidectomy or ¹³¹I (Recommendation 31) in managing hyperthyroidism due to toxic nodular goiter (TNG). Concern for concomitant malignancy favors surgery. A 3 % thyroid cancer incidence in TNG patients has been reported, yet recent studies suggest this rate is underestimated. This multi-institutional study examined cancer incidence in TNG patients referred to surgery.

Methods

Patients referred for thyroidectomy at three tertiary-care institutions were included (2002–2011). Patients with concurrent indeterminate or malignant diagnosis by fine-needle aspiration (FNA) were excluded. Cancer incidence in TNG patients was determined. Fisher’s exact and chi-square tests and nonparametric t tests were used.

Results

Among 2,551 surgically treated patients, 164 had TNG (6.4 %). Median age at presentation was 49.7 years, and 86 % were female. Overall cancer incidence was 18.3 % (30 of 164), and rates were not significantly different between institutions. A significantly greater cancer rate was noted in toxic multinodular goiter versus single toxic nodule patients (21 vs. 4.5 %, P < 0.05). Mean tumor size was 0.71 cm (range 0.1–1.5 cm; 23 % ≥1 cm). Most patients underwent total or near-total thyroidectomy. There were no significant differences in tumor sizes among institutions (P > 0.05). No significant cancer association was noted with age, preoperative dominant nodule size, lymphocytic thyroiditis or preoperative FNA (P > 0.05).

Conclusions

These data demonstrate a higher than expected incidental cancer rate in TNG patients compared to historical reports (18.3 vs. 3 %). This higher cancer incidence may alter the risk/benefit analysis regarding TNG treatment. This information should be provided to TNG patients before decision making regarding treatment.     

Risk Factors of Hypoparathyroidism Following Total Thyroidectomy for Thyroid Cancer

Background

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

Methods

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

Results

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

Conclusions

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

A Randomized, Double-blinded Placebo-controlled Clinical Trial of the Routine Use of Preoperative Antibiotic Prophylaxis in Modified Radical Mastectomy

Background

The effectiveness of antibiotic prophylaxis for prevention of surgical site infection (SSI) following specific types of breast cancer surgery remains uncertain. This study assessed the effectiveness of prophylaxis in modified radical mastectomy (MRM).

Methods

Women undergoing MRM for breast cancer were recruited. Women were excluded who had diabetes mellitus, severe malnutrition or known allergy to cephalosporins; were receiving corticosteroid therapy or were treated with antibiotics within one week prior to surgery; were scheduled for simultaneous breast reconstruction or bilateral oophorectomy; had existing local infection. Participants were randomized to receive either intravenous cefazolin 1 g or placebo within 30 min prior to skin incision. Standard skin preparation and operative technique for MRM were carried out. Wounds were assessed for SSI and other complications weekly for 30 days.

Results

A total of 254 women were recruited. Age, clinical stage, prior chemotherapy, and operative time were similar for antibiotic and placebo groups. The overall incidence of SSI was 14.2 %. There were no significant differences in the infection rate over the 30-day follow-up period between the placebo and antibiotic groups (15 % vs 13.4 %; p = 0.719) or at each week. The majority of SSI were either cellulitis or superficial infection for both groups. There were no significant differences between groups in treatments required for SSI, incidence of hematoma or seroma.

Conclusions

The findings of this study, alone and when meta-analyzed with data from studies in similar surgical populations, do not support the use of antibiotic prophylaxis in MRM.     

Efficacy of antibiotic prophylaxis in patients undergoing cystoscopy: a randomized clinical trial

Objective

To establish the efficacy of antibiotic prophylaxis prior to cystoscopy in outpatients in decreasing the incidence of post-procedure urinary tract infection.

Study design and setting

A randomized clinical trial in patients (men and women) older than 18 who underwent cystoscopy for any non-urgent indication. The intervention was Levofloxacin 500 mg single dose, and the control was placebo 500 mg single dose made with similar characteristics. The primary outcome was urinary tract infection (UTI) measured 3–10 days after the procedure. It was performed as per protocol analysis.

Results

Hundred and thirty-eight patients in each study arm completed the trial. The incidence of UTI in the intervention group was 0.7 % and in the placebo group was 3 % (p = 0.17), and no significant differences were found. The incidence of asymptomatic bacteriuria in the intervention group was 5.8 % and in the control group was 14.5 % (p = 0.01).

Conclusions

No significant differences were found in the use of prophylactic antibiotic compared to placebo to reduce the incidence of UTI in patients who undergo cystoscopy as an outpatient procedure with sterile urine demonstrated by urine culture.     

Short-term intravenous antimicrobial prophylaxis for elective rectal cancer surgery: results of a prospective randomized non-inferiority trial

Purpose

To investigate the non-inferiority of postoperative single-dose intravenous antimicrobial prophylaxis to multiple-dose intravenous antimicrobial prophylaxis in terms of the incidence of surgical site infections (SSIs) in patients undergoing elective rectal cancer surgery by a prospective randomized study.

Methods

Patients undergoing elective surgery for rectal cancer were randomized to receive a single intravenous injection of flomoxef (group 1) or five additional doses (group 2) of flomoxef after the surgery. All the patients had received preoperative oral antibiotic prophylaxis (kanamycin and erythromycin) after mechanical cleansing within 24 h prior to surgery, and had received intravenous flomoxef during surgery.

Results

A total of 279 patients (including 139 patients in group 1 and 140 in group 2) were enrolled in the study. The incidence of SSIs was 13.7 % in group 1 and 13.6 % in group 2 (difference [95 % confidence interval]: ?0.2 % [?0.9 to 0.7 %]).

Conclusion

The incidence of SSIs was not significantly different in patients undergoing elective rectal surgery who were treated using a single dose of postoperative antibiotics compared to those treated using multiple-dose antibiotics when preoperative mechanical and chemical bowel preparations were employed.     

Risk of lymph node metastases in multifocal papillary thyroid cancer associated with Hashimoto's thyroiditis

Aims

The aim of this study was to evaluate the risk factors of lymph nodes metastases (LNM) in patients with papillary thyroid cancer (PTC) and coexisting Hashimoto’s thyroiditis (HT).

Patients and methods

This was a retrospective cohort study of patients with PTC and HT who had undergone total thyroidectomy (TT) with central neck dissection (CND) over an 11-year period (between 2002 and 2012). Pathological reports of all eligible patients were reviewed. Multivariable analysis was performed to identify risk factors of LNM.

Results

During the study period, PTC was diagnosed in 130 patients with HT who had undergone TT with CND (F/M ratio?=?110:20; median age, 52.4?±?12.7 years). Multifocal lesions were observed in 28 (21.5 %) patients. LNM were identified in 25 of 28 (89.3 %) patients with multifocal PTC and HT versus 69 of 102 (67.5 %) patients with a solitary focus of PTC and HT (p?=?0.023). In multivariable analysis, multifocal disease was identified as an independent risk factor for LNM (odds ratio, 3.99; 95 % confidence interval, 1.12 to 14.15; p?=?0.033).

Conclusions

Multifocal PTC in patients with HT is associated with an increased risk of LNM. Nevertheless, the clinical importance of this finding needs to be validated in well-designed prospective studies.     

Lobectomy and Prophylactic Central Neck Dissection for Papillary Thyroid Microcarcinoma: Do Involved Lymph Nodes Mandate Completion Thyroidectomy?

Background

The present study was designed to investigate the necessity of completion thyroidectomy for patients who underwent thyroid lobectomy for low-risk papillary thyroid microcarcinoma (PTMC) that was later pathologically diagnosed as central lymph node (CLN) metastasis.

Methods

Between 1986 and 2001, we assessed 551 patients who underwent thyroidectomy with prophylactic ipsilateral central compartment neck dissection, and 409 patients were followed-up completely. Thyroid lobectomy were performed in 281 and 128 patients, respectively. The patients were divided into two groups according to CLN metastasis. Clinicopathological profiles and follow-up details were investigated by retrospective chart review.

Results

The CLN-positive and -negative groups were comprised of 43 (15.2 %) and 238 patients (84.8 %), respectively. The mean ages of the two groups were not significantly different (p > 0.05). The mean tumor size of the CLN-positive group (6.8 mm) was significantly larger than that of the CLN-negative group (5.6 mm; p < 0.05). Microscopic capsular invasion was significantly higher in the CLN-positive group (51.2 vs. 23.9 %; p < 0.05). Overall, 21 patients (7.4 %, 21/281) experienced recurrence. Among these, 2 (4.7 %, 2/43) and 19 (8.0 %, 19/238) were in the CLN-positive and -negative groups, respectively. There was no significant correlation between CLN metastasis and tumor recurrence.

Conclusions

Postoperative recurrence was lower in the CLN-positive group, and there was no significant correlation between CLN metastasis and tumor recurrence. Our results suggest that it is not necessary to perform completion thyroidectomy for PTMC patients who have undergone thyroid lobectomy and who have been pathologically diagnosed with CLN metastasis.     

How Many Contralateral Papillary Thyroid Carcinomas Can Be Missed?

Background

When surgeons decide to perform lobectomy as the treatment of papillary thyroid carcinomas (PTCs), they must consider the possibility of contralateral cancer. We wanted to determine the incidence of bilateral PTCs (bPTCs) and analyze their characteristics. We also wanted to determine how many patients with bPTC were missed preoperatively.

Methods

From January 2007 to May 2011, a total of 466 patients with PTC who were treated by total thyroidectomy at a single institution were enrolled. Patients were divided into two groups based on bilaterality. The patients with bPTCs were further investigated regarding the preoperative presence of the contralateral tumor.

Results

Bilaterality was seen in 29.8 % of PTC patients. In all, 36.8 % of PTCs ≥1 cm, and 25.7 % were papillary thyroid microcarcinomas (PTMCs). The presence of PTC in the contralateral lobe was missed in 15.8 % of bPTCs and in 21.3 % of bPTMCs. The rates of preoperatively nondetected contralateral cancer were 4.7 and 5.5 % for PTCs and PTMCs, respectively. Tumor size and multifocality were factors associated with bilaterality (p = 0.014 and p < 0.001, respectively).

Conclusions

Bilaterality is found more frequently when the tumor is large. Multifocality also can help predict the possibility of bilaterality. Therefore, total thyroidectomy may be necessary for patients with a multifocal or large tumor. It should be noted that the presence of a contralateral cancer is missed in 4.7 and 5.5 % of patients with preoperatively diagnosed unilateral PTC and PTMC, respectively.     

Analysis of Microscopic Tumor Spread Patterns According to Gross Morphologies and Suggestions for Optimal Resection Margins in Bile Duct Cancer

Background/purpose

Surgical resection is the only curative treatment for extrahepatic bile duct (EHBD) cancer, but guidelines for optimal resection margins have not yet been established. Therefore, the purpose of this study is to analyze the patterns of microscopic tumor spreads and their lengths according to gross morphology and to suggest optimal resection margins for EHBD cancer.

Methods

A total of 79 patients with EHBD cancers who underwent curative resection at Seoul National University Hospital between 2007 and 2010 were reviewed. Pathologic findings were reviewed by a single specialized pathologist.

Results

Mucosal and mural/perimural spreads were seen in 37.3 and 62.3 %, respectively. The mean length of tumor spreads in the papillary (n?=?13), nodular/nodular infiltrative (n?=?43), and sclerosing types (n?=?23) were 4.5?±?6.3, 1.8?±?6.4, and 6.4?±?6.7 mm, respectively. Spread patterns correlated with gross morphologies (P?<?0.001). The lengths of tumor spreads at the 90th percentile were 15.6, 10.0, and 15.6 mm, respectively.

Conclusions

The patterns of tumor spreads correlated with gross morphologies. Optimal resection margins in EHBD cancers should be 16 mm in the papillary and sclerosing types and 10 mm in the nodular/nodular infiltrative type.     

A Cost-Utility Analysis for Prophylactic Central Neck Dissection in Clinically Nodal-Negative Papillary Thyroid Carcinoma

Background

Although prophylactic central neck dissection (pCND) may reduce future locoregional recurrence after total thyroidectomy (TT) for low-risk papillary thyroid carcinoma (PTC), it is associated with a higher initial morbidity. We aimed to compare the long-term cost-effectiveness between TT with pCND (TT+pCND) and TT alone in the institution’s perspective.

Methods

Our case definition was a hypothetical cohort of 100,000 nonpregnant female patients aged 50 years with a 1.5-cm cN0 PTC within one lobe. A Markov decision tree model was constructed to compare the estimated cost-effectiveness between TT+pCND and TT alone after a 20-year period. Outcome probabilities, utilities, and costs were estimated from the literature. The threshold for cost-effectiveness was set at US$50,000 per quality-adjusted life year (QALY). Sensitivity and threshold analyses were used to examine model uncertainty.

Results

Each patient who underwent TT+pCND instead of TT alone cost an extra US$34.52 but gained an additional 0.323 QALY. In fact, in the sensitivity analysis, TT+pCND became cost-effective 9 years after the initial operation. In the threshold analysis, none of the scenarios that could change this conclusion appeared clinically possible or likely. However, TT+pCND became cost-saving (i.e., less costly and more cost-effective) at 20 years if associated permanent vocal cord palsy was kept ≤1.37 %, permanent hypoparathyroidism was ≤1.20 %, and/or postoperative radioiodine ablation use was ≤73.64 %.

Conclusions

In the institution’s perspective, routine pCND for low-risk PTC began to become cost-effective 9 years after initial surgery and became cost-saving at 20 years if postoperative radioiodine use and/or permanent surgical complications were kept to a minimum.     

Thyroidectomy as Primary Treatment Optimizes Body Mass Index in Patients with Hyperthyroidism

Objective

The purpose of this study was to determine how the timing of thyroidectomy influenced postoperative weight change.

Methods

We conducted a two-institution study, identifying patients treated with total thyroidectomy for hyperthyroidism. Patients were classified as ‘early’ if they were referred for surgery as the first treatment option, or ‘delayed’ if they were previously treated with radioactive iodine (RAI). Groups were compared with the Student’s t-test or χ ² test where appropriate.

Results

There were 204 patients undergoing thyroidectomy for hyperthyroidism. Of these, 171 patients were classified as early and 33 were classified as delayed. Overall, patients gained 6.0 % ±0.8 of their preoperative body weight at last follow-up. Preoperative body mass indexes (BMIs) were similar between groups (p = 0.98), and the median follow-up time was 388 days (range 15–1,584 days). Both groups gained weight until they achieved a normal thyroid-stimulating hormone (TSH) postoperatively. After achieving a normal TSH, the early group stabilized or lost weight (?0.2 lbs/day), while the delayed group continued to gain weight (0.02 lbs/day; p = 0.61). At last follow-up, there were significantly more patients in the delayed group who increased their BMI category compared with the early group (42.4 vs. 21.6 %; p = 0.01). Twice as many patients in the delayed group moved up or into an unhealthy BMI category (overweight or obese) compared with the early group (39.4 vs. 19.3 %; p = 0.01).

Conclusions

Compared with patients initially treated with RAI, patients with hyperthyroidism who underwent surgery as the first treatment were less likely to become overweight or obese postoperatively.     

Coexistence of papillary thyroid cancer with Hashimoto thyroiditis

Aims

Conflicting data have been reported with regard to Hashimoto thyroiditis (HT) and risk of malignancy. The aim of this study was to evaluate coexistence of papillary thyroid cancer (PTC) with HT.

Patients and methods

This is a retrospective cohort study in which HT was diagnosed in 452 (F/M ratio?=?405:47, median age 53.5?±?12.1 years) of 7,545 patients qualified for thyroidectomy throughout the years 2002 to 2010. Pathological reports were reviewed to identify prevalence of PTC in HT vs. non-HT patients.

Results

PTC was diagnosed in 106 of 452 (23.5 %) HT patients vs. 530 of 7,093 (7.5 %) non-HT patients (p?<?0.001). Metastases to level VI lymph nodes were observed in 81 of 106 (76.4 %) patients with PTC in HT vs. 121 of 530 (22.8 %) patients with PTC in non-HT disease (p?<?0.001).

Conclusions

HT was associated with a threefold increase of PTC prevalence as compared to other non-HT thyroid diseases, and the spread of PTC to level VI lymph nodes was four times more frequent in HT than in non-HT patients.     

Patient Attitudes toward Transaxillary Robot-assisted Thyroidectomy

Background

The transaxillary robot-assisted technique constitutes an acceptable treatment option for patients requiring thyroidectomy. However, patients’ attitudes toward this new technique have not yet been analyzed.

Methods

A sample of 596 randomly selected patients who underwent thyroidectomy between January 2000 and March 2010 was assessed. We evaluated patients’ attitudes toward transaxillary robot-assisted thyroidectomy, taking into account the validated Patient Scar Assessment Questionnaire, the SF-36 Health Survey Questionnaire, and 11 sociodemographic and surgical patient characteristics.

Results

Only 11.6 % of the patients would prefer to have been treated with the transaxillary method. Most patients had concerns that it would be a more painful procedure (39.2 %), and they expressed satisfaction with the existing esthetic outcome (29.1 %); other concerns were that the robotic approach would be of longer duration (25.4 %) and at higher cost (15.5 %). Nevertheless, the worse the appearance of the neck scar the more preferable is the new method (p = 0.025), a result that holds true irrespective of patients’ physical health, the invasive procedure attained (conventional or minimal), and the presence of postoperative complications, among other characteristics. Patients diagnosed with a benign or uncertain neoplasm (p = 0.022) and younger patients (p = 0.003) held a more positive view of the new method.

Conclusions

Patients who have undergone conventional thyroidectomy via the usual neck incision do not express a preference for the transaxillary method. The reasons given include various perceived disadvantages of the robotic procedure (increased pain, longer operative times, and higher cost). Younger patients, patients with poor appearance of their neck scar, and patients with benign thyroid pathology seem to hold a more positive attitude toward the robotic approach.