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

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

全甲状腺切除术治疗甲状腺癌适应证选择及并发症防治

全甲状腺切除术治疗甲状腺癌今年报道较多,但其临床应用难度大,并发症多,素来存在争议。国外随着手术技术之进步,全甲状腺切除术应用适应证不断扩展,国内指南应根据地区实际情况、个体化原则,衡量外科手术风险性和彻底性进行选择。以减少甲状腺癌术后复发或转移为前提,同时预防全甲状腺切除术并发症发生,保证病人术后生活质量。     

Endoscopic transaxillary near total thyroidectomy.

BACKGROUND: Since first reported in 1996, endoscopic minimally invasive surgery of the cervical region has been shown to be safe and effective in the treatment of benign thyroid and parathyroid disease. The endoscopic transaxillary technique uses a remote lateral approach to the thyroid gland. Because of the perceived difficulty in accessing the contralateral anatomy of the thyroid gland, this technique has typically been reserved for patients with unilateral disease. OBJECTIVES: The present study examines the safety and feasibility of the transaxillary technique in dissecting and assessment of both thyroid lobes in performing near total thyroidectomy. METHODS: Prior to this study we successfully performed endoscopic transaxillary thyroid lobectomy in 32 patients between August 2003 and August 2005. Technical feasibility in performing total thyroidectomy using this approach was accomplished first utilizing a porcine model followed by three human cadaver models prior to proceeding to human surgery. After IRB approval three female patients with histories of enlarging multinodular goiter were selected to undergo endoscopic near total thyroidectomy. RESULTS: The average operative time for all models was 142 minutes (range 57-327 min). The three patients in this study had clinically enlarging multinodular goiters with an average size of 4 cm. The contralateral recurrent laryngeal nerve and parathyroid glands were identified in all cases. There was no post-operative bleeding, hoarseness or subcutaneous emphysema. CONCLUSION: Endoscopic transaxillary near total thyroidectomy is feasible and can be performed safely in human patients with bilateral thyroid disease.     

Video-assisted thyroidectomy for papillary thyroid carcinoma

Background: In patients with small papillary thyroid carcinomas (PTC), we evaluated the operative feasibility and safety of video-assisted thyroidectomy (VAT) and the completeness of the surgical resection. Methods: Video-assisted thyroidectomy was attempted in 24 patients with thyroid malignancy. Total thyroid resection for PTC was achieved completely by VAT in 20 of them, who were included in this study. Results: In this study, 12 total thyroidectomies and 8 lobectomies followed by completion thyroidectomies were performed. Eight patients also underwent central neck lymph node dissection. Mean postoperative serum thyroglobulin was 0.2 ng/ml for patients receiving LT4 suppressive treatment and 4.2 ng/ml for patients after LT4 withdrawal. Postoperative ultrasonography showed no residual thyroid tissue. The mean radioiodine uptake at postoperative scintiscan was 2.2%. Conclusions: In the case of PTC, VAT is feasible and safe. The completeness of the surgical resection seems comparable with that reported for conventional surgery. Nevertheless, larger series and longer follow-up evaluation are necessary for definitive conclusions to be drawn about its oncologic validity. This article is based on a communication at the 10th European Association for Endoscopic Surgery (E.A.E.S.) Annual Congress, Lisbon Portugal, 2–5 June 2002     

Minimally invasive thyroidectomy

Background: Conventional thyroidectomies by a direct approach through the neck require long incisions in the neck that can result in prominent scars, hypesthesia, and paresthesia. Minimally invasive procedures have recently been adopted for the surgical treatment of thyroid disease as a means of preventing such problems. Methods: In the present paper, the anterior chest approach and axillary approach to endoscopic thyroidectomy are described. Results: Twenty‐two patients were treated by the anterior chest approach to endoscopic thyroidectomy and 28 patients by the axillary approach. The only complication was one case of postoperative emphysema. The patients were satisfied with the cosmetic results of the procedures and with the minimal degree of postoperative hypesthesia, paresthesia and discomfort. Conclusion: Endoscopic thyroidectomy may become the procedure of choice for the surgical treatment of carefully selected patients with thyroid disease.     

Serum intact parathyroid hormone as a predictor of hypocalcaemia after total thyroidectomy

BACKGROUND: Hypocalcaemia from hypoparathyroidism is a complication of total thyroidectomy. The aim of the present study was to determine whether an early postoperative level of serum parathyroid hormone (PTH) after total thyroidectomy predicts the development of significant hypocalcaemia and the need for treatment. METHODS: Patients undergoing total thyroidectomy had their serum level of intact PTH checked 1 h after removal of the thyroid gland. Serum calcium level was checked on the following morning. Oral calcium and/or calcitriol was commenced if the patient developed hypocalcaemic symptoms, or if the corrected serum calcium level was <2.0 mmol/L. RESULTS: Seventy-nine patients were included in the present study. Thirteen patients had symptoms of hypocalcaemia on postoperative days 1 or 2 and 66 patients remained asymptomatic. The postoperative intact PTH, day 1 calcium and day 2 calcium was 0.32 +/- 0.60 pmol/L, 2.01 +/- 0.11 mmol/L, and 2.02 +/- 0.16 mmol/L, respectively, for the symptomatic group and 1.98 +/- 1.25, 2.21 +/- 0.13, and 2.19 +/- 0.14, respectively, for the asymptomatic group. Calcium support was given to 25 patients, of whom 14 also required calcitriol. CONCLUSION: Serum PTH 1-h after total thyroidectomy is a reliable predictor of hypocalcaemia and can allow safe early discharge of patients from hospital.     

经胸乳入路腔镜与开放手术治疗甲状腺良性肿瘤对比研究

目的 探讨经胸乳途径腔镜甲状腺手术治疗的安全性和可行性。方法 回顾性分析北京世纪坛医院2005年12月至2009年10月收治的275例甲状腺良性肿瘤的临床资料。结果 腔镜手术124例（腔镜组）,开放手术151例（开放组）,两组手术的切口引流量、术后对镇痛的需求、术后住院时间差异无统计学意义。腔镜组术中出血量［（24.52±9.87）mL］明显少于开放组［（39.67±25.88）mL］,差异有统计学意义（P<0.05）;但腔镜组手术时间［（127.66±34.83）min］长于开放组［（95.17±29.86） min］,P<0.05 ;腔镜组住院费用显著高于开放组。腔镜组对手术美容效果满意度评分（8.94±0.81）明显高于开放组（5.74±1.61）（P<0.05）。两组均无术后大出血及喉返喉上神经损伤和甲状旁腺损伤等严重并发症。结论 腔镜甲状腺手术具有切口小、出血少、美容满意度高等优点,是安全可行的手术方法。     

腔镜与开放性甲状腺手术的对比研究

目的腔镜与开放性甲状腺手术临床效果的对比研究。方法回顾性分析2002年8月至2005年5月113例腔镜甲状腺切除术(腔镜组)和104例开放性甲状腺切除术(开放组)的临床资料。结果两组的手术时间、住院时间、术后住院时间差异无显著性意义。腔镜组失血量(42.5±62.8)mL明显少于开放组(118.2±120.8)mL,差异有显著性意义(P<0.05);而腔镜组引流量多于开放组(P<0.05);腔镜组术后恢复活动时间为(2.2±1.0)d,与开放组(2.5±1.1)d比较差异无显著性意义(P>0.05);腔镜组术后镇痛药需求比开放组明显减少,而住院费用高于开放组。术后并发症腔镜组以喉上和喉返神经损伤为主,且甲状腺功能亢进术后并发症发生率较高,而开放组主要是术后出血。结论选择合适的病例实施腔镜甲状腺手术是安全可行的,具有美容、疼痛轻、出血少的优点。     

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。     

内镜治疗甲状腺功能亢进7例报告

目的总结内镜治疗甲状腺功能亢进（甲亢）的经验。方法7例原发性或继发性甲亢，内镜经胸人路行甲状腺全切或次全切除术。结果7例手术均成功，无中转开放手术。手术时间130～260min，平均168min；术中出血量10～200ml，平均70ml。无喉返、喉上神经损伤，无术后出血等并发症。术后恢复良好，近期随访美容效果满意。随访1～12个月，平均5．1月，无复发，2例出现甲状腺功能低下，1例在术后2个月时恢复。结论内镜治疗甲亢技术安全、可行。除常规手术前甲亢准备外，必须行CT检查确认腺体大小，确定残留腺体的大小和位置。     

Parathyroid hormone assay predicts hypocalcaemia after total thyroidectomy

BACKGROUND: Postoperative parathyroid gland function after total thyroidectomy (TT) has traditionally been monitored by the measurement of serum calcium concentrations. The purpose of this study is to determine whether measurement of parathyroid hormone (PTH) concentrations in the early postoperative period accurately predicts patients at risk of developing hypocalcaemia. METHODS: A prospective cohort study of patients undergoing TT was carried out. PTH concentrations were measured preoperatively and at 4 and 23 h postoperatively. Serum calcium concentration was measured preoperatively and twice daily for 48 h after surgery. RESULTS: One hundred patients undergoing TT were recruited into the study in the period June 2004 to July 2005. Benign multinodular goitre was the most common indication for surgery (77%). The incidence of temporary hypocalcaemia (Ca < 2.0 mmol/L) was 18%. The mean PTH concentration at 4 h after surgery was 22.3 ng/L and was not significantly different from the 23-h concentration of 23.2 ng/L (P = 0.18). A PTH concentration of < or = 3 ng/L measured at 4 h after surgery had a sensitivity, specificity and likelihood ratio of 0.71, 0.94 and 11.3, respectively, for predicting postoperative hypocalcaemia. The accuracy of a single PTH concentration at 4 h was good for predicting hypocalcaemia (area under receiver-operator characteristic curve 0.90; confidence interval 0.81-0.96). There was no significant difference in accuracy between the 4- and 24-h PTH concentrations (P = 0.14). CONCLUSIONS: A single measurement of PTH concentration in the early postoperative period after TT reliably predicts patients who are likely to develop hypocalcaemia. This approach facilitates early discharge and may decrease the need for multiple postoperative blood tests.     

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.     

Unintentional parathyroidectomy during total thyroidectomy

BACKGROUND: Unintentional parathyroidectomy during thyroidectomy has been evaluated in a few studies. Moreover, the impact of the surgeon's experience and operative technique has not been evaluated. Our aim was to identify the incidence of unintentional parathyroidectomy during total thyroidectomy, its clinical consequences, and factors affecting its occurrence. METHODS: We reviewed all total thyroidectomies during a 2-year period. Patients were categorized into 2 groups: those with unintentional parathyroidectomy (parathyroidectomy group) and those without unintentional parathyroidectomy (no-parathyroidectomy group). RESULTS: Incidental parathyroidectomy occurred in 100 (19.7%) of the 508 patients. The groups were comparable in age, thyroid weight and pathology, operative time, surgeon experience (high/low volume), operative technique (suture-ligation, LigaSure, or Ultracision), postoperative calcium, and transient hypocalcemia. No permanent hypocalcemia occurred. However, 11% of the parathyroidectomy group was men compared with 22% of the no-parathyroidectomy group (p =.002). CONCLUSIONS: Unintentional parathyroidectomy, although common, has no clinical consequences. Unlike surgeon's experience and operative technique, patient sex was the only factor affecting its occurrence.     

Intraoperative parathyroid hormone assay for management of patients undergoing total thyroidectomy

BACKGROUND: Rapid parathyroid hormone (PTH) assay has been applied to predict hypocalcemia after thyroidectomy compared with conventional close monitoring of serum calcium levels. We evaluated the reliability of intraoperative intact PTH (ioPTH) assay to predict hypocalcemia after total thyroidectomy and sought to develop an algorithm for the management of postthyroidectomy patients. METHODS: Rapid PTH assays were performed before and after thyroidectomy for 92 new patients receiving total thyroidectomy. Preoperative and postoperative serum calcium and standard PTH levels were serially obtained to 6 months after surgery RESULTS: Postoperative hypocalcemia developed in 34 of 92 patients (37%), who showed significantly lower ioPTH values compared with those of normocalcemic patients (mean 9.2 pg/mL vs 31.3 pg/mL). The ioPTH levels were significantly correlated with standard PTH levels (p < .001, r > 0.62), but not with early serum calcium levels within 8 hours after the operation. Sensitivity and specificity of ioPTH levels of <15.0 pg/mL for the prediction of postoperative hypocalcemia were 85% and 84%, respectively. A value of >15.0 pg/mL and <70% decline in ioPTH after thyroidectomy can reliably identify normocalcemic patients during thyroidectomy or patients requiring close monitoring and early calcium supplement CONCLUSIONS: Rapid ioPTH assay can reliably monitor parathyroid function after thyroidectomy and predict postoperative hypocalcemia. The proposed algorithm based on rapid PTH levels will lead to improved prediction of normocalcemic patients.