Inadvertent parathyroidectomy during thyroid surgery: the incidence of a complication of thyroidectomy

Background and aims Incidental parathyroidectomy is a complication of thyroid surgery. The aim of this report is to explore the incidence, risk factors, and clinical relevance of inadvertent parathyroidectomy during thyroidectomy.Materials and methods Patients who underwent thyroidectomy between January 1998 and June 2005 were evaluated. Pathology reports were reviewed for the presence of parathyroid tissue in the thyroidectomy specimens. Information regarding diagnosis, operative details, and postoperative hypocalcemia were collected.Results Three hundred and fifteen thyroid procedures were performed: 163 total thyroidectomies, 124 near-total thyroidectomies, and 28 lobectomies. The findings were benign in 240 and malignant in 75 cases. Incidental parathyroidectomy was found in 68 (21.6%) cases: 58 were benign and 10 were malignant. One and two parathyroids were accidentally removed in 46 and 22 patients, respectively. Parathyroid tissue was found in intrathyroidal (33%) and extracapsular (27%) sites. Total/near-total thyroidectomy was not associated with increased risk of incidental parathyroidectomy (P=0.646), and there was no association of inadvertent parathyroidectomy with postoperative hypocalcemia (P=0.859). Thyroid malignancy was associated with decreased incidence of incidental parathyroidectomy (P=0.047).Conclusion Inadvertent parathyroidectomy, although not uncommon, is not associated with postoperative hypocalcemia. The type of surgical procedure does not increase the risk of incidental parathyroidectomy, while thyroid malignancy may reduce the incidence of inadvertent parathyroidectomy.     

Incidental Parathyroidectomy during Thyroid Surgery: An Underappreciated Complication of Thyroidectomy

The aim of this study was to investigate the incidence, risk factors, and clinical relevance of incidental parathyroidectomy during thyroid surgery. Prospective analysis of data in patients following thyroidectomy, specifically regarding the presence of parathyroid parenchyma in the thyroidectomy specimens, the underlying thyroid pathology, and the presence of postoperative hypocalcemia (biochemical/clinical). The clinical records of 158 patients who underwent thyroid surgery during a 2-year period were reviewed. Pathology reports were carefully reviewed for the nature of the underlying thyroid disease, the presence, number, and size of incidentally resected parathyroid gland(s), their location, and possible parathyroid pathology. Serum calcium levels were measured preoperatively, on the day of surgery, and on postoperative days 1, 2, and 7 or even later as needed. Two groups of patients were studied: a group with incidental parathyroidectomy following thyroidectomy (group A) and a group without incidental parathyroidectomy after thyroidectomy (group B). Total/near-total thyroidectomy was the procedure of choice and was performed in 154 patients; total lobectomy and contralateral subtotal lobectomy was performed in the other 4 patients. Elective central neck lymph node dissection was performed in four patients with neck lymphadenopathy. Inadvertently removed parathyroid tissue was found in 28 cases (17.7 %); in 6 of these patients (21%) the parathyroid tissue was intrathyroidal. The percentage of women in group A was significantly higher than in group B (93% vs. 58.5%, P = 0.0002). There was no statistically significant difference between the two groups (A and B) regarding the preoperative (presumed) diagnosis, the histologic diagnosis of thyroid disease (benign versus malignant), the type/extent of surgery, or the presence of thyroiditis. Biochemical and clinical hypocalcemia was observed in 6 (21%) and 2 (7%) patients in group A, respectively, and in 30 (23%) and 8 (6%) patients of group B, respectively. There was no statistically significant difference regarding the occurrence of postoperative hypocalcemia (clinical/biochemical) between the two groups (P = 0.33). Incidental parathyroidectomy is not uncommon following thyroidectomy and in a significant percentage of cases it may be due to the intrathyroidal location of the parathyroid glands. Incidental parathyroidectomy was not found to be associated with postoperative hypocalcemia (biochemical/clinical). Incidental parathyroidectomy may be considered as a potentially preventable but clinically minor complication of thyroid surgery.     

Primary hyperparathyroidism: its clinical pattern and results of surgical treatment in Hong Kong Chinese

Primary hyperparathyroidism has been increasingly diagnosed among whites since the advent of the biochemical autoanalyzer. However, the condition remains uncommon among Orientals. Our experience with 31 patients at the Queen Mary Hospital, University of Hong Kong, in the periods before and after we began to use the biochemical autoanalyzer was reviewed. The prevalence of primary hyperparathyroidism rose slightly from 3.1 to 3.7 per 100,000 hospital population. In both periods skeletal manifestation was the major clinical presentation, followed by hypercalcemic symptoms and urologic disease. Asymptomatic hypercalcemia occurred in three of 31 patients despite the use of the biochemical autoanalyzer. Preoperative localization was carried out in 27 patients and was helpful in nine (33.3%) of them. The surgeon explored all four parathyroids, removed the diseased gland(s), and examined a biopsy specimen of one normal-appearing gland. There were 27 adenomas, two carcinomas, one four-gland hyperplasia, and one sarcoidosis. Twenty-eight patients had transient hypocalcemia after parathyroidectomy and required calcium supplements for variable periods. Before and after we began to use the biochemical autoanalyzer, there was minimal change in the prevalence and clinical pattern of primary hyperparathyroidism seen in our hospital. In our experience, successful parathyroidectomy depends more on the surgeon's operative technique than on preoperative localization.     

Routine parathyroid autotransplantation during thyroidectomy

BACKGROUND: Parathyroid autotransplantation (PTHAT) during thyroidectomy has been shown to reduce the incidence of permanent hypoparathyroidism. Although selective PTHAT is most commonly adopted, the value of routine PTHAT has not been well documented. METHODS: From January, 1998 to March, 1999, an operative strategy incorporating routine autotransplantation of at least 1 parathyroid gland was used during thyroidectomy. The postoperative outcome of patients (n = 118) was evaluated and compared with patients (n = 271) operated during a policy of selective PTHAT (January, 1995 to October, 1997). RESULTS: Two or more parathyroid glands were autotransplanted in 26 patients (22%) while 92 patients (78%) received autotransplantation of 1 parathyroid gland. Postoperative hypocalcemia occurred in 29 patients (25%) and 2 patients (1.7%) had permanent hypocalcemia develop. When a policy of selective PTHAT was adopted, 98 patients (36%) underwent PTHAT, and 5 patients developed permanent hypocalcemia (1.8%). The incidence of postoperative hypocalcemia was higher in patients who underwent routine PTHAT (25%) compared with that in patients who underwent selective PTHAT (15%) (P =.014). In addition, the operating time was significantly longer when routine PTHAT was adopted (153 minutes vs 130 minutes; P <.001). CONCLUSIONS: A low incidence of permanent hypoparathyroidism can be achieved by either routine or selective PTHAT during thyroidectomy but routine PTHAT is associated with a high incidence of postoperative hypocalcemia.     

甲状腺手术中甲状旁腺误切和术后低钙血症

目的分析常见甲状腺手术时甲状旁腺误切和术后患者发现低钙血症之间的关系。方法回顾性分析126例甲状腺手术患者的临床资料,其中双侧腺叶大部切除术18例,一侧或双侧腺叶全切术74例和六区清扫术34例。结果 126例患者中,共有25例（19.8%）病理证实存在旁腺误切,有30例（23.8%）术后出现低钙血症,25例（19.8%）出现低钙临床表现,经治疗后症状在2 d内消失。低钙血症的发生（23.8%）和旁腺误切（19.8%）之间是相关的（r=0.87,P=0.0333）。随访6个月,低钙血症消失时间平均为4.25（1-12）周,没有患者出现永久性低钙血症。六区清扫术的总体旁腺误切率为41.2%（14/34）,高于大部切除术的5.6%（1/18）（P〈0.01）,亦高于腺叶全切除术的13.5%（10/74）（P=0.0013）。结论甲状腺腺叶切除及六区清扫术后短暂的低钙血症是比较常见的并发症;旁腺误切可以导致术后低钙血症的发生;六区清扫术有很高的旁腺误切风险。     

Outcomes of Parathyroid Autotransplantation During Total Thyroidectomy: A Comparison with Age- and Sex-Matched Controls

Purpose: To determine the effect of parathyroid autotransplantation (PA) on postoperative hypocalcemia in cases of total thyroidectomy. Materials and Methods: Cases undergoing total thyroidectomy and PA were compared with age and sex-matched controls who had not undergone PA. The postoperative percentage changes (PC) of parathyroid hormone (PTH) and calcium (Ca+2) in the first 12–24 hours (12–24hr→preop), between the 1st-3rd weeks (1-3wk→preop) and at the 6th month (6mo→preop), the rates of hypocalcemia (Ca+2< 8mg/dL) and low PTH level (PTH< 15 pg/mL), permanent hypocalcemia, inadvertent parathyroidectomy in both groups were compared. Results: The number of patients with PTH12-24hr<15 pg/mL was significantly higher (n:34,(55.7%)) than the number of patients in the control group (n:16(26.2%)), (p=0.001). The rate of decrease in the blood Ca+2 median PC (6mo→preop) was significantly higher in the PA group (4.2%) than the control group (1.1%), (p=0.008). There was no significant difference between the 2 groups in terms of the postoperative frequency of hypocalcemia (p>0.05). In the PA&age≤50 group, the rate of inadvertent parathyroidectomy was higher than that of cases over age 50 (p=0.029). Conclusion: In spite of the presence of an increased postoperative hypocalcemia trend in cases requiring PA during total thyroidectomy, the rates of transient and permanent hypocalcemia were not different to the control cases. But the frequency of cases with low PTH level in cases undergoing PA was higher than that of the control cases. In cases of 50 years of age and under, who had undergone PA, the possibility of inadvertent parathyroidectomy increased.     

Influence of the Refinement of Surgical Technique and Surgeon’s Experience on the Rate of Complications after Total Thyroidectomy for Benign Thyroid Disease

Background: In recent years, many surgeons dealing with endocrine surgery have increasingly performed total thyroidectomy for benign thyroid disease. However, total excision of the thyroid in the treatment of benign lesions has been surrounded by even more controversy than its role in cancer treatment. The complication rate appears to be higher when the operation is done by inexperienced surgeons who have no special skills in endocrine surgery using proper techniques. The aim of this study is to determine whether surgeons experience and the refinement of surgical techniques are associated with postoperative recurrent laryngeal nerve (RLN) palsy or hypocalcemia after total thyroidectomy for benign thyroid disease.

Methods: A total of 68 consecutive patients who underwent total thyroidectomy for benign thyroid disease were reviewed. Twenty-six of these were from between January 1998 and June 1999 (first period) and 42 from between June 1999 and September 2000 (second period). Patients were divided into two subgroups according to different periods and different surgical techniques to identify the RLNs and the parathyroid glands. RLNs function was evaluated pre-and post-operatively by an otolaryngologist, and serum calcium levels were measured at the postoperative follow-up. Results: During the first period of the study, transient hypocalcaemia was determined in 8 (31%) patients. Hypocalcaemia was clinically symptomatic in 5 (19%) patients. Transient RLN palsy developed in 4 (15%) patients. Unilateral permanent RLN palsy due to operative injury was observed in 1 (4%) patient. During the second period, we noted transient hypocalcemia in 11 (26%) patients and symptomatic hypocalcemia in 6 (4%) patients. Serum calcium levels returned to normal within 4 weeks after operation in all patients. Neither transient nor permanent RLN palsy was observed during this period.

Conclusions: Complications of total thyroidectomy can be minimized with increasing experience and the refinement of surgical technique.     

LigaSure versus clamp-and-tie thyroidectomy for benign nodular disease

BACKGROUND: LigaSure is an alternative bipolar diathermy system (BDS) combining vessel sealing with reduced thermal spread, which has been successfully used in many abdominal operations; however, there is a little experience in open thyroidectomy. This study compares the efficacy and the advantages of the LigaSure BDS when used for total thyroidectomy for benign thyroid disease with the conventional clamp-and-tie technique. METHODS: Between May 1998 and October 2002, 517 patients underwent total thyroidectomy for benign thyroid multinodular goiter. Among them, from May 1998 until May 2000, 247 patients (group I) were operated on with the conventional clamp-and-tie technique, whereas from May 2000 until October 2003, 270 patients (group II) underwent total thyroidectomy for benign multinodular goiter with LigaSure BDS through a 4-cm transverse suprasternal incision. Demographics, pathologic characteristics, gland mass, operative time, blood loss, and complications were assessed. RESULTS: There were no intraoperative complications. Thyroid mass was similar in both groups, but the operative time was shorter in group II than in group I (mean +/- standard deviation, 71 +/- 14 minutes vs 86 +/- 22 minutes; p < .01). Intraoperative total blood loss was similar between the two groups, but postoperative drain volume was less in group II than in group I (21 +/- 15 mL; p < .01). Major post-thyroidectomy complications (ie, laryngeal nerve palsy, hematoma, and hypocalcemia) occurred less frequently in the LigaSure group than in the clamp-and-tie group (0.7%, 0.4%, 1.1% vs 4%, 2%, 4.8%, respectively; p < .05). The mean +/- standard deviation postoperative hospital stay was significantly less for the patients in group II than for those in group I (2.3 +/- 1.7 days vs 2.8 +/- 1.3 days; p < .05). CONCLUSIONS: The use of the LigaSure vessel sealer for thyroid surgery is an effective and safe alternative that reduces the overall operative time and could be successfully applied through a narrow surgical incision.     

Hypomagnesemia and Hypocalcemia after Thyroidectomy: Prospective Study

Hypomagnesemia after total thyroidectomy has not been studied extensively. Our anecdotal experience suggests that it may be important in some patients after thyroid excision. The hypomagnesemic hypocalcemic syndrome has been described in other disease states in which a state of functional hypoparathyroidism exists. This study was designed to determine the incidence of hypomagnesemia after total thyroidectomy and relate it to hypocalcemia and symptoms during the postoperative period. A prospective study of all patients undergoing total thyroidectomy between September 1994 and July 1996 was performed. Patient data, thyroid function, retrosternal extension, initial versus reoperative surgery, operative details, parathyroid resection, and pathology were recorded. Calcium, magnesium, electrolytes, blood count, liver function tests, and albumin were measured prior to surgery and twice daily during the postoperative period. Fifty patients underwent total thyroidectomy: 68% were hypocalcemic, 72% were hypomagnesemic, and 36% were symptomatic during the postoperative period. Hypomagnesemia and gender were associated with hypocalcemia. Volume of fluid and neck dissection were associated with low magnesium levels. Hypomagnesemia and parathyroid resection were risk factors for symptoms after thyroidectomy. No patients developed permanent hypoparathyroidism. Transient hypocalcemia and hypomagnesemia occur frequently after total thyroidectomy. The etiology of this phenomenon is probably multifactorial. Patients are more likely to be symptomatic when both cations are low, and attempting to correct only hypocalcemia may prolong symptoms. It is important to monitor both calcium and magnesium levels after total thyroidectomy and to correct deficiencies to facilitate prompt resolution of symptoms.     

Life-threatening neck hematoma complicating thyroid and parathyroid surgery

BACKGROUND: Observation following thyroidectomy and parathyroidectomy has been progressively shortened. The challenge has been to reduce the duration of postoperative observation without jeopardizing patient safety. METHODS: A retrospective review of patients who underwent thyroidectomy and/or parathyroidectomy between July 1990 and March 2007 was completed to determine the frequency of life-threatening hematoma and hospital readmission and their impact on postoperative observation. RESULTS: Of 1,050 patients, life-threatening hematoma developed in 6 (.6%) patients, 5 following bilateral and 1 following unilateral thyroidectomy. Hematoma developed 10 minutes to 7 days postoperatively, four within 4 hours, one at 21 hours, and one at 7 days. Twelve patients were readmitted an average of 5 days postoperatively for hypocalcemia, hematoma, infection, or respiratory distress. CONCLUSION: Without factors contributing to bleeding, unilateral thyroidectomy and parathyroidectomy can be performed as an ambulatory procedure. To maximize safety, we recommend 4-hour and 23-hour observation following unilateral and bilateral thyroidectomy, respectively.     

Incidental parathyroidectomy in thyroidectomy and central neck dissection

BackgroundAlthough higher thyroidectomy volume has been linked with lower complication rates, its association with incidental parathyroidectomy remains less studied. The volume relationship is even less clear for central neck dissection, where individual parathyroid glands are at greater risk.MethodsPatients undergoing thyroidectomy with or without central neck dissection were evaluated for incidental parathyroidectomy, hypoparathyroidism, and hypocalcemia. Univariate and multivariable analyses were performed using binary logistic regression.ResultsOverall, 1,114 thyroidectomies and 396 concurrent central neck dissections were performed across 7 surgeons. Incidental parathyroidectomy occurred in 22.4% of surgeries (range, 16.9%–43.6%), affecting 7.1% of parathyroids at risk (range, 5.8%–14.5%). When stratified by surgeon, lower incidental parathyroidectomy rates were associated with higher thyroidectomy volumes (R² = 0.77, P = .008) and higher central neck dissection volumes (R² = 0.93, P < .001). On multivariable analysis, low-volume surgeon (odds ratio 2.94, 95% confidence interval 2.06–4.19, P < .001), extrathyroidal extension (odds ratio 3.13, 95% confidence interval 1.24–7.87, P = .016), prophylactic central neck dissection (odds ratio 2.68, 95% confidence interval 1.65–4.35, P <.001), and therapeutic central neck dissection (odds ratio 4.44, 95% confidence interval 1.98–9.96, P < .001) were the most significant factors associated with incidental parathyroidectomy. In addition, incidental parathyroidectomy was associated with a higher likelihood of temporary hypoparathyroidism (odds ratio 2.79, 95% confidence interval 1.45–5.38, P = .002) and permanent hypoparathyroidism (odds ratio 4.62, 95% confidence interval 1.41–5.96, P = .025), but not permanent hypocalcemia (odds ratio 1.27, 95% confidence interval 0.48–3.35, P = .63). Higher lymph node yield in central neck dissection was not associated with higher incidental parathyroidectomy rates (odds ratio 1.13, 95% confidence interval 0.85–8.81, P = .82).ConclusionHigher surgical volume conferred a lower rate of incidental parathyroidectomy. Nonetheless, greater lymph node yield in central neck dissections did not result in greater parathyroid-related morbidity. Such findings support the value of leveraging surgical volume to both optimize oncologic resection and minimize complication rates.     

Pancreatitis following parathyroid surgery.

While pancreatitis may provide the clue to the diagnosis of hyperparathyroidism preoperatively, the occurrence of pancreatitis following parathyroidectomy is not generally recognized. In this study preoperative and postoperative serum amylase estimations, together with a clinical assessment, were performed on 86 patients undergoing neck exploration for hyperparathyroidism. It was found that postoperative hyperamylasaemia occurred in 35% of the total group, while clinically significant pancreatitis was found in 9% of cases. Pancreatitis was significantly more common when thyroidectomy was performed at the time of parathyroidectomy, occurring in 23% of this group of patients, and may be due to the blunted C-cell response of calcitonin secretion to the induced hypercalcaemia associated with operative manipulation. Careful attention should be paid to postoperative abdominal symptoms, for they may indicate pancreatitis.     

Use of BiClamp Decreased the Severity of Hypocalcemia after Total Thyroidectomy Compared with LigaSure: A Prospective Study

BACKGROUND: Postoperative hypocalcemia is the most common complication after thyroidectomy. New surgical devices have been propose to achieve vessel sealing and hemostasis. However, the risk of parathyroid glands damage has not been fully elucidated. This prospective study was designed to evaluate the severity of hypocalcemia after total thyroidectomy by using two different sealing devices. METHODS: Between January 2005 and December 2006, 86 patients underwent total thyroidectomy by using BiClamp((R)) (n = 46) or LigaSure((R)) (n = 40) devices in our institution. The severity of postoperative hypocalcemia was analyzed. RESULTS: No mortality or recurrent laryngeal nerve palsy was observed. Patients characteristics were similar in both groups. The mean operation time was significantly shorter in the BiClamp group (142 +/- 35 minutes versus 170 +/- 57 minutes, P = 0.023). Eleven patients had symptomatic hypocalcemia. Hypocalcemia (< 2 mmol/l) at postoperative day 1 was more frequent in the LigaSure group than in the BiClamp group (P = 0.034). Significantly more patients in the LigaSure group required oral calcium supplementation than in the BiClamp group (67.5% versus 34.7% respectively; P = 0.002). CONCLUSION: The present prospective study suggests that total thyroidectomy can be performed safely with both surgical devices. However, BiClamp reduced the operative time and the severity of postoperative hypocalcemia.     

Subtotal parathyroidectomy as an adequate treatment for primary hyperparathyroidism in multiple endocrine neoplasia type 1

HYPOTHESIS: The most appropriate surgical approach for hyperparathyroidism (HPT) in multiple endocrine neoplasia type 1 remains controversial. It has been advocated that reoperations for recurrent disease are easier to perform after total parathyroidectomy (TP) with autotransplantation than after subtotal parathyroidectomy (SP). In view of our large experience in patients with secondary HPT for whom TP with autotransplantation did not simplify reoperations, SP remains our preferred treatment for patients with HPT and multiple endocrine neoplasia type 1. DESIGN: Retrospective cohort study. SETTING: Tertiary referral medical center. PATIENTS: A total of 29 consecutive patients (22 women, 7 men; mean age, 42.2 years) with multiple endocrine neoplasia type 1 who underwent definitive cervical exploration for HPT. MAIN OUTCOME MEASURES: Temporary and permanent hypocalcemia, pattern of parathyroid disease, and sites and timing of recurrent HPT. Definitive primary surgery included SP in 21 patients, TP with autotransplantation in 4 patients, and less-than-subtotal parathyroidectomy in 4 selected patients. RESULTS: The mean follow-up was 88.5 months (range, 8-285 months). Four patients died during follow-up; 2 of these deaths were related to multiple endocrine neoplasia. No patients had persistent HPT. Temporary hypocalcemia occurred in 12 SP cases (57%), 4 TP with autotransplantation cases (100%), and 0 less-than-subtotal parathyroidectomy cases. Permanent hypocalcemia requiring long-term treatment occurred in 2 SP cases (10%), 1 TP with autotransplantation case (25%), and 0 less-than-subtotal parathyroidectomy cases. Four patients developed recurrent disease, including 1 with SP, 2 with TP with autotransplantation, and 1 with less-than-subtotal parathyroidectomy at 57 months, 197 and 180 months, and 164 months, respectively, representing 14% of all of the patients and 43% of patients with more than 10 years of follow-up. CONCLUSIONS: Recurrent HPT occurs many years after definitive primary surgery (median, 14.3 years). Surgical treatment should therefore aim to minimize the risk of permanent hypocalcemia and facilitate future surgery. When correctly performed, SP fulfills these objectives.     

ES17PIPTH FACILITATES DAY 1 DISCHARGE AFTER TOTAL THYROIDECTOMY: THE FIRST 50 CASES

In recent years there has been much published about the use of iPTH to predict hypocalcemia with a view to achieving earlier safe discharge after total thyroidectomy. After recent publication of Australian data on this practice we developed a new protocol for post‐operative calcium management with the aim of achieving a greater number of patients being safely discharged on the first post‐operative day. We present our experience with the first 50 patients being treated under the new protocol. The first 50 patients admitted for total or completion thyroidectomy since May 2006 were studied and compared to 50 consecutive patients from 2002–2003, before the iPTH assay was used for thyroid surgery. iPTH was measured at 4‐hours post‐operatively and patients with iPTH in the normal range were discharged on the first post‐operative day. Statistical analysis was performed using the Mann‐Whitney U test. Fifty patients in each group were analyzed. Mean age in the study group was 56 years (51 years in the control group) and sex distribution were similar in both groups (M : F, 1 : 3). Mean lowest post‐operative corrected calcium levels in the study group were 2.19 mmol/L (2.15 mmol/L in the control group). Length of stay was significantly shorter in the study group, mean 1.71 days vs. 2.20 days (P < 0.05). The use of iPTH accurately predicts hypocalcemia after total thyroidectomy and can be used to facilitate safe early discharge for patients. This study demonstrates a significant reduction in the length of stay for patients undergoing total thyroidectomy when managed with a protocol based on a 4‐hour iPTH level.     

Thyroid surgery: comparison between the electrothermal bipolar vessel sealing system, harmonic scalpel, and classic suture ligation

BACKGROUND: This study was conducted to compare the outcome of total thyroidectomy using the electrothermal bipolar vessel sealing system, the harmonic scalpel, and the classic suture ligation technique. METHODS: This was a retrospective study of prospectively collected data from 382 consecutive total thyroidectomies from September 2004 to August 2006. Patients were divided into 3 groups: group SL patients (n = 90) underwent total thyroidectomy with the classic suture ligation technique, group L (n = 148) with the electrothermal bipolar vessel sealer, and group U (n = 144) with the harmonic scalpel. The main outcomes measured were surgical and hospitalization time, intraoperative and postoperative bleeding, postoperative hypocalcemia, and superior and inferior laryngeal nerves injuries. RESULTS: The 3 groups were similar in terms of demographics, thyroid gland weight and pathology, perioperative complications, and hospital stay. Compared with the classic technique, surgical time was reduced significantly by about 20% when the bipolar vessel sealer or harmonic scalpel was used (93.3 +/- 12.5 vs 74.3 +/- 14.2 and 73.8 +/- 13.8 min, P = .001, and P = .001, respectively). CONCLUSIONS: Both the bipolar vessel sealer and harmonic scalpel are safe, useful, and time-saving alternatives to the traditional suture ligation technique for thyroid surgery. Because no differences were observed regarding these 2 devices, the choice should be made based on the surgeon's preferences and experience.     

Harmonic Scalpel Compared to Conventional Hemostasis in Thyroid Surgery

The aim of this study was to determine whether conventional hemostasis (CH) or the harmonic scalpel (HS) results in shorter operative times for thyroidectomy and to evaluate the incidence of postoperative complications with each approach. In this study, 85 consecutive patients undergone open thyroidectomy were randomized into two groups: group CH (conventional hemostasis with classic technique of tying and knots, resorbable ligature, bipolar diathermy) and group HS (harmonic scalpel). Demographics, pathological characteristics, thyroid size, operative time, blood loss, and complications using the Student’s t-test and χ²-test. The two groups were similar regarding age and sex. There were no intraoperative complications. There was no difference between the two techniques regarding the amount of blood loss for different procedures. No significant differences were found between the two groups concerning mean thyroid weight and mean hospital stay (2.2 days in HS vs. 3.7 in CH; P > 0.05). The mean operative time was significantly shorter in the HS group (47.2 min vs. 79.2 min; P < 0.001). Two (4.7 %) transient recurrent laryngeal nerve palsies were observed in the CH group and no one (0 %) in the HS group. No patient developed permanent palsy. Postoperative transient hypocalcemia occurred more frequently in the CH group (21/43, 48 % vs. 7/42, 16 %). In patients undergoing thyroidectomy, HS is a reliable and safe tool. Comparing with CH techniques, its use reduces operative times, postoperative pain, drainage volume, and transient hypocalcemia.     

Drains for thyroidectomy/parathyroidectomy: fact or fiction?

BACKGROUND: Many authorities advocate draining the neck routinely after thyroid and parathyroid surgery with no scientific evidence to support this practice. We aimed to establish if the routine use of drains following thyroid/parathyroid surgery is of any value. METHOD: Medical records of patients who underwent thyroidectomy or parathyroidectomy under the care of a single endocrine surgeon (GP) over a 14-year period were reviewed. For the first 6 years, the neck was routinely drained (drain group) and for the subsequent 8 years the neck was only drained if the surgeon felt it necessary according to the operative situation (selective group). RESULTS: A total of 606 procedures (425 thyroidectomy and 181 parathyroidectomy) were performed on 582 patients. Drains were routinely used in 134 (22%) procedures (drain group) and were selectively used in 472 (78%) (selective group) of which 191 (40%) were drained. In all patients, there was a significant increase in the rate of postoperative bleeding/haematoma in patients with a drain (8/314 versus 1/282, Fisher's exact, P < 0.05). Wound infection occurred only in the patients with a drain. There was no difference in the incidence of postoperative bleeding and airways obstruction between the drain and selective groups. CONCLUSION: We conclude that the routine use of neck drains is unnecessary and may indeed be harmful, drain insertion being associated with an increased incidence of wound infection. Drains should, therefore, be used selectively after thyroidectomy and parathyroidectomy.     

The impact of single parathyroid gland autotransplantation during thyroid surgery on postoperative hypoparathyroidism: a multicenter study

BACKGROUND: We compared the surgical outcomes in patients undergoing bilateral thyroid surgery with or without parathyroid gland autotransplantation (PTAT). METHODS: One thousand three hundred nine patients underwent surgery for treatment of various thyroid diseases at three Academic Departments of General Surgery and one Endocrine-Surgical Unit throughout Italy. A nonviable gland or difficulties in dissection of the parathyroid glands were encountered in 160 (13.7%) patients. The subjects were divided into two groups: (1) patients undergoing PTAT during thyroidectomy (n = 79) versus (2) control group (n = 81), patients not undergoing PTAT. RESULTS: Clinical manifestations occurred in 5.0% of PTAT patients and in 13.6% of control patients (P = NS). Total postoperative hypocalcemia was less among PTAT than control patients (17.7% and 48.1%, respectively; P = .0001). There was no significant difference between the two groups in terms of definitive hypocalcemia (0% vs 2.5% in PTAT and control, respectively). Transient postoperative hypocalcemia was less among PTAT than controls (17.7% vs 45.7%; P = .0002). PTAT was associated with decreased occurrence of hypocalcemia in the two subgroups of patients operated for benign euthyroid disease (P < .0001), as compared with the control group. CONCLUSIONS: PTAT is an effective procedure to reduce the incidence of permanent hypoparathyroidism. Transient hypoparathyroidism appears to not be influenced by PTAT. Moreover, we observed that damage to one parathyroid gland has more side effects (ie, transient hypocalcemia) among patients who were preoperatively at low rather than at high risk of postoperative hypocalcemia.     

Use of a diathermy system in thyroid surgery

HYPOTHESIS: New hemostatic methods have been widely used in open and laparoscopic surgery. The LigaSure Precise diathermy system (Valleylab, Boulder, Colo) has been recently used in thyroid surgery. We hypothesized that its use could lead to reduced operative time and fewer complications compared with conventional knot tying in total or near-total thyroidectomy. DESIGN: Prospective case-controlled study. SETTING: Tertiary care private hospital. PATIENTS: Eighty patients underwent total or near-total thyroidectomy by 1 surgeon. INTERVENTIONS: Forty patients underwent thyroidectomy with the conventional knot tying technique and 40 patients with the LigaSure diathermy system. MAIN OUTCOME MEASURES: Demographics, histopathological diagnosis, operative time, intraoperative blood loss, complications, and cost, using chi2 test and Wilcoxon rank sum test. RESULTS: The study groups had similar demographic and histopathological characteristics. The mean +/- SD operative time was nonsignificantly reduced in the LigaSure group compared with the conventional knot tying group (84 +/- 6 vs 89 +/- 7 minutes, P = .60). The mean +/- SD intraoperative blood loss was less for the LigaSure group (30 +/- 5 vs 35 +/- 8 mL, P = .36). There was 1 case of transient recurrent laryngeal nerve palsy in the LigaSure group. One patient from this group and 2 patients from the other group exhibited transient hypocalcemia; permanent postoperative hypocalcemia was not encountered in either group. The cost of the LigaSure diathermy system was significantly greater than that of conventional knot tying. CONCLUSION: Use of the LigaSure in thyroid surgery did not significantly reduce operative time, blood loss, or complication rates compared with conventional knot tying, but it increased operative cost.