Extensive thyroidectomy in Graves' disease

BACKGROUND: The best surgical treatment for hyperthyroidism caused by Graves' disease remains a controversial subject. METHODS: Seven hundred fourteen consecutive patients underwent total or near-total thyroidectomy for Graves' disease in a 13-year period. In a first analysis, postoperative rates of suffocating hematoma, wound infection, recurrent laryngeal nerve (RLN) palsy, hypoparathyroidism, and persistence or recurrence of hyperthyroidism, were studied and compared with the same parameters in 4,426 patients who underwent bilateral thyroid gland resection for other conditions. A second analysis identified factors associated with postoperative complications among Graves' disease patients. RESULTS: Comparing Graves' disease patients with patients who had bilateral thyroid resection for other conditions, the transient morbidity rate was 13.3% versus 8.2% (p < 0.0001), with 10.2% versus 5.0% (p < 0.0001) hypoparathyroidism, 2.2% versus 1.7% (p = 0.35) RLN palsy, 1.7% versus 0.9% (p < 0.05) suffocating hematoma, and 0.3% versus 0.4% (p = 0.67) wound infection, respectively. Permanent morbidity rate was 2% versus 2.2% (p = 0.72), including 0.4% versus 0.6% RLN palsy and 1.5% versus 1.7% hypoparathyroidism. Among the Graves' disease patients, univariate analysis revealed that those who experienced postoperative complications had a higher weight resected thyroid gland (odds ratio = 1.5; 95% CI, 1.0-2.3) and a higher rate of total thyroidectomy (24.4% versus 19.5%, odds ratio = 2.2; 95% CI, 1.4-3.4) than patients without complications. In the multivariable model, these two factors remained independent. There was no recurrence of hyperthyroidism with a median followup of 6.7 years (interquartile range 4.1 to 10.1 years). Persistent hyperthyroidism developed in three patients. CONCLUSIONS: Total or near-total thyroidectomy is an effective and safe treatment for Graves' disease when performed by an experienced surgeon.     

Reoperative Thyroid Surgery

Reoperative thyroid surgery is an uncommon operation associated with a high complication rate. We retrospectively reviewed the data of 115 patients to study the incidence of complications after reoperative thyroid surgery. There were 107 women and 8 men (13.4:1.0) with an average age of 42.8 years (range 18–80 years). The most frequent indication for reoperation was completion thyroidectomy for a carcinoma identified by permanent sections (50 patients, 43.5%). Reoperative surgery was performed on 13 (11.3%) patients with recurrent thyroid cancer. The remaining 52 patients underwent reoperation for recurrent thyrotoxicosis (12 patients, 10.4%), recurrent nodular goiter (28 patients, 24.3%) or recurrent multinodular goiter (12 patients, 10.4%). Seven patients with recurrent nodular goiter and one patient with recurrent thyrotoxicosis underwent total thyroidectomy for the presence of malignancies that were identified by frozen sections. Overall, the interval between the initial and reoperative procedures ranged from 1 day to 33 years (2335 ± 272 days). The length of hospital stay was 5.8 ± 0.5 days. The length of time needed for reoperative thyroid surgery was 122.0 ± 6.2 minutes. There was no 30-day perioperative mortality. The postoperative complications consisted of transient hypoparathyroidism in six patients (5.2%), permanent hypoparathyroidism in two patients (1.7%), transient RLN palsy in 3 patients (2.6%), and permanent recurrent laryngeal nerve palsy in two patients (1.7%). Reoperative thyroid surgery can be performed safely with little morbidity to the patient.     

Rolle der totalen Thyreoidektomie im primären Therapiekonzept der benignen Knotenstruma

INTRODUCTION: After subtotal resection of multinodular goiter, rates of up to 40% are reported for recurrent goiter in the long-term follow-up. Because of the increased morbidity of surgery for recurrent goiter, this study evaluated the preconditions that would justify total thyroidectomy as part of the primary therapy concept for benign multinodular goiter. MATERIAL AND METHODS: The Quality Assurance Study of Benign and Malignant Goiter covering the period from 1 January to 31 December 1998 assessed 5195 patients treated for benign goiter by primary bilateral resection. With respect to the extent of resection three groups were analyzed: bilateral subtotal resection (ST+ST, n=4580), subtotal resection with contralateral lobectomy (ST+HT, n=527), and total thyroidectomy (TT, n=88). RESULTS: The age of the patients was significantly higher (60.3 years) in the TT group than in the ST+ST (52.5 years) and ST+HT (55.6 years) groups. ASA classification grades III and IV were significantly more frequent in the TT group. The postoperative morbidity increased with the extent of resection. The rate of permanent recurrent laryngeal nerve (RLN) palsy was 0.8% for ST+ST, 1.4% for ST+HT, and 2.3% for TT and of permanent hypoparathyroidism 1.5% for ST+ST, 2.8% for ST+HT, and 12.5% for TT. Multivariate analysis showed that the extent of resection significantly increased the risk of RLN palsy (transient RR 0.5, permanent RR 0.4) and hypoparathyroidism (transient RR 0.2,permanent RR 0.08). The surgeon's experience (RR 0.6) and identification of the RLN (RR 0.5) reduced the risk of permanent RLN palsy. Additionally, the development of permanent hypoparathyroidism was reduced if at least two parathyroid glands (RR 0.4) were identified. CONCLUSION: Total thyroidectomy is associated with an increased rate of RLN palsies and hypoparathyroidism in comparison to less extensive thyroid surgery. In the hands of well-trained surgeons using an appropriate intraoperative technique, primary thyroidectomy is justified if the patient has an increased risk of recurrent goiter. Due to the increased postoperative morbidity after total thyroidectomy, subtotal thyroid resection based on the morphologic changes in the thyroid gland is still recommended as the standard treatment regimen for multinodular goiter.     

Morbidity of Redo Surgery for Thyroid Disease

Objective: Redo thyroid surgery is generally associated with more complications than firsthand surgery. The actual study reports a single center experience of redo thyroid surgery compared to primary bilateral thyroidectomy. Study Design: Mono institutional retrospective study.

Materials and Methods: Institutional review of redo thyroid surgery patients (Group 2: completion thyroidectomy and Group 3: thyroidectomy for recurrent thyroid diseases) compared to Group 1: primary bilateral thyroidectomy operated on during the same time interval.

Results: Demographic characteristics were not different between groups. Substernal extension and hyperthyroidism were more frequent in group 1. Weight of the resected thyroid gland was lower in groups 2 and 3. Incidence of transient hypocalcemia, permanent hypoparathyroidism, transient and permanent recurrent laryngeal palsy was not different between the groups. Hematoma occurred in 5% of cases in the 3 groups and postoperative length of stay was 1 day in 92% of cases of the 3 groups.

Conclusions : Redo thyroid surgery can be performed with no excess morbidity provided strict selection criteria, having reoperation in mind while performing firsthand intervention.     

Total thyroidectomy for differentiated thyroid cancer: primary compared with completion thyroidectomy.

OBJECTIVE: To analyse morbidity after completion total thyroidectomy compared with primary total thyroidectomy in a specialist thyroid surgery centre. DESIGN: Retrospective study. SETTING: Tertiary referral hospital, India. PATIENTS: Medical records of 143 patients who had total thyroidectomy between January 1990 and December 1999. 95 had primary thyroidectomies and 48 were completion thyroidectomies. MAIN OUTCOME MEASURES: Complication rate in both groups. RESULTS: The groups were comparable in respect of clinicopathological variables. Residual tumour was found in 19/48 (40%). After completion thyroidectomy, transient hypoparathyroidism and transient recurrent laryngeal nerve palsy were recorded in 8/48 (17%) and 2/48 (4%), respectively. No permanent hypoparathyroidism or permanent recurrent laryngeal nerve palsy was recorded in the completion thyroidectomy group. CONCLUSIONS: Completion thyroidectomy can be done with acceptable morbidity in a specialist thyroid surgery centre. Fear of increased morbidity after the procedure should not deter surgeon from doing this operation or referring the patients to a specialist centre.     

Multivariate Analysis of Risk Factors for Postoperative Complications in Benign Goiter Surgery: Prospective Multicenter Study in Germany

Risk factors for postoperative complications of benign goiter surgery have not been investigated systematically. To this end, a prospective multicenter study (January 1 through December 31, 1998) was conducted involving 7266 patients with surgery for benign goiter from 45 East German hospitals. High-volume providers (>150 operations per year) performed 69% (5042/7266), intermediate-volume providers 27% (50–150), and low-volume providers 4% (258/7266) of operations. Among the hospital groups, the pattern of thyroid disease did not vary significantly, but there was a trend that small-volume providers tended to perform more operations for uninodular goiter and high-volume providers treated more patients with Graves' disease and recurrent goiter. Extent of resection (p < 0.0001) and remnant size (multinodular goiter and recurrent goiter, p < 0.001), differed significantly, with total thyroidectomy being performed more often in hospitals with more than 150 operations compared to hospitals with an operative volume of less than 150 procedures per year. Despite the larger extent of resection and smaller remnant size, rates of recurrent laryngeal nerve (RLN) palsy or hypoparathyroidism were not increased. When the logistic regression analyses were fitted to evaluate the impact of risk factors on transient and permanent RLN palsy and hypoparathyroidism, larger extent of resection [relative risk (RR) 1.5–2.1] and recurrent goiter (RR 1.8–3.4) consistently evolved as independent risk factors. With hypoparathyroidism, additional significant factors included patient gender (RR 2.1–2.4), hospital operative volume (RR 0.8–1.5), and Graves' disease (RR 2.8). Unlike parathyroid gland identification during hypoparathyroidism, RLN identification (RR 1.6) significantly (p= 0.01) reduced permanent RLN palsy rates. The multivariate analyses clearly confirmed the pivotal role of routine RLN identification, independent of the extent of the thyroid resection. These findings might help hospitals with lower operative volumes to identify patients at increased risk whom they might consider for specialist care.     

How to prevent recurrent nerve palsy during thyroid surgery?

Recurrent laryngeal nerve (RLN) injury and hypoparathyroidism can occur after thyroid surgery. The rate of RLN injury, mostly transient, ranges from 0.5% to 5% of patients. The risk is more important in patients who undergo reoperative thyroid surgery and in patients with thyroid cancer or hyperthyroidism. Rationales for technique of thyroidectomy are discussed. Meticulous and reproductive surgical technique can lower the postoperative morbidity. However, the potential for RLN injury still exists and must be explained to the patients who are candidate for thyroid surgery. The fact that this information has been delivered during the preoperative visit must be written by the surgeon in the patient's chart.     

Completion thyroidectomy for differentiated thyroid carcinoma

Completion thyroidectomy is performed because of a deferred diagnosis of differentiated carcinoma of the thyroid or a significant thyroid remnant after initial operation. During a period of 6 years, data from 40 patients with differentiated thyroid carcinoma undergoing completion thyroidectomy were retrospectively reviewed. There were 4 men and 36 women (1:9), and the average age was 39.6 ± 1.9 years (range, 20 to 62 years). The indications for the initial surgery were a solitary thyroid nodule in 36 (90%) patients, multinodular goiter in 3 (7.5%) patients, and Graves’ disease in 1 (2.5%) patient. Three patients underwent completion thyroidectomy during the same hospital stay. In the remaining 37 patients, completion thyroidectomy was performed 4 to 252 days (44.1 ± 7.8 days) after the initial operation. The length of hospital stay for the initial operation was not different from that for completion thyroidectomy (5.1 ± 0.3 days vs. 5.2 ± 0.3 days). The length of time needed to accomplish the initial operation was not different from that required for the completion thyroidectomy (122 ± 7.5 minutes vs. 110.8 ± 5.9 minutes). There was no 30-day perioperative mortality. The postoperative morbidity in completion thyroidectomy consisted of transient hypoparathyroidism in 3 (7.5%) patients, permanent hypoparathyroidism in 1 (2.5%) patient, transient recurrent laryngeal nerve palsy in 1 (2.5%) patient, and permanent recurrent laryngeal nerve palsy in 1 (2.5%) patient. On the other hand, one transient recurrent laryngeal nerve palsy and one transient hypoparathyroidism occurred at the initial operation. Completion thyroidectomy is a safe procedure to remove the thyroid remnant. (Otolaryngol Head Neck Surg 1998;118:896-9.)     

Analysis of surgery-related complications in thyroid carcinoma — A German prospective multicentre study with 275 patients

Summary   Background: The rate of postoperative complications following surgery for thyroid carcinoma is increased compared to that following benign goitre surgery; however, risk factors have not been investigated systematically. Methods: A prospective multicentre study was conducted from 1 January to 31 December 1998. During that period 275 patients were treated for thyroid carcinoma in 45 hospitals including 5 university hospitals. Results: By univariate analysis no difference in complication rates could be shown for primary surgery versus redo surgery (completion surgery or surgery for recurrent carcinoma). Additionally, tumour size (pT4) was a significant risk factor for prolonged postoperative ventilation, general complications and permanent hypoparathyroidism. Lymphadenectomy evolved as a major risk factor for permanent hypoparathyroidism. By multivariate analysis independent risk factors were evaluated for 1) tracheotomy: tumour size (pT4 versus pT1–3), relative risk (RR) 2.1; 2) permanent recurrent laryngeal nerve (RLN) palsy: lymphadenectomy in the left cervicolateral compartment (C3), RR 5.4, and resection of soft tissue (muscle), RR 4.4; 3) transient hypocalcaemia: tumour size (pT4 versus pT1–3), RR 1.25, and extent of resection (subtotal resection versus total thyroidectomy), RR 3.02; 4) permanent hypoparathyroidism: lymphadenectomy, RR 8.01, and resection of soft tissue (vessels), RR 5.70. Conclusions: The results of the risk analysis might help to identify patients at increased risk for postoperative complications who should receive treatment in specialised hospitals.      

Incidence and risk factors for injuries to the recurrent laryngeal nerve during neck surgery in the moderate-volume setting

Purpose

Total lobectomy is currently recommended also in benign thyroid disease in order to reduce the risk of goitre recurrence, an approach claimed not to increase post-operative morbidity. The aim of the study was to analyse risk factors for recurrent laryngeal nerve (RLN) palsy during neck surgery, with particular interest in complications after total lobectomy and subtotal resection, respectively.

Methods

All consecutive patients operated for thyroid and parathyroid diseases at one institution between 1984 and 2011 were prospectively recorded, and 1,322 patients were included. Patients with permanent post-operative RLN palsy were re-examined in 2011.

Results

The risk of permanent RLN palsy after parathyroid surgery was 0.3 %. Patients operated for thyroid cancer had a 5.9 % risk of permanent nerve injury, higher than that of patients with benign thyroid disease (1.4 %; P?=?0.029). Independent risk factors for RLN paralysis after benign thyroid surgery were intrathoracic goitre (odds ratio (OR), 3.57; 95 % confidence interval, 1.70–7.48), ipsilateral redo-surgery (OR, 3.64; 1.00–13.28) and total lobectomy (OR, 2.41; 1.05–5.55). At long-time follow-up (median, 10 years), 7 of 12 patients with permanent RLN palsy still suffered moderate or severe symptoms.

Conclusions

RLN paralysis is an infrequent complication after neck surgery, but with major negative impact on patients’ well-being when permanent. Hemithyroidectomy/total thyroidectomy is increasingly preferred over subtotal resection in multinodular goitre. This is supported by an increased risk of RLN injury during redo-surgery for recurrency but should be carefully weighed against individual risk factors for nerve palsy, including surgical experience and volume.     

甲状腺全切除术治疗良性甲状腺疾病128例临床疗效

目的：探讨甲状腺全切除术治疗甲状腺良性疾病的疗效及术后并发症的预防。方法：回顾性分析128例行甲状腺全切除术的甲状腺良性疾病病人的临床资料,其中首次手术者98例,再次手术者30例。分析总结该128例病人的术后并发症。结果：128例病人术后均未发生永久性甲状旁腺功能低下和永久性喉返神经损伤。首次甲状腺全切除组术后暂时性喉返神经损伤和暂时性甲状旁腺功能低下的发生率均为1．02％,再次手术组的发生率明显增高,分别为10．00％和13．33％,两组比较,Fisher精确概率P分别为0．040、0．011。两组暂时性喉上神经损伤发生率均很低,无明显差别。结论：对符合指征的良性甲状腺疾病,甲状腺全切除术是一合适的治疗选择。熟悉甲状腺解剖和精细手术操作,可有效预防并发症发生。     

COMPLETION TOTAL THYROIDECTOMY IN THE MANAGEMENT OF DIFFERENTIATED THYROID CARCINOMA

Background: Completion thyroidectomy is the removal of any thyroid tissue that remains after a less than total thyroidectomy. This procedure has been commonly performed when the final histopathology of the excised ipsilateral thyroid lobe reveals papillary or follicular carcinoma of the thyroid. Complete thyroidectomy carries little morbidity if performed by experienced surgeons using a lateral approach. The purpose of this study is to reinforce the usefulness of a lateral approach. Methods: A retrospective analysis over a 5 year period at the Department of Endocrine Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS) yielded 19 patients who underwent completion thyroidectomy. This group represents 23% of 82 patients who underwent total thyroidectomy for differentiated thyroid cancer (DTC) during that period. The residual thyroid tissue was excised through a lateral approach and could be resected safely, preserving the recurrent laryngeal nerve (RLN) and the parathyroid glands. Results: A lateral approach dissection could be performed with ease in a virgin area. Excision of residual thyroid tissue could be performed safely even in cases with prior partial lobectomy or bilateral subtotal resection. Tumour was found in 52% of the re-operative specimens: in three out of four of those after a previous partial lobectomy, in six out of 12 of those after a total lobectomy, and in one out of three of those after a prior bilateral (although incomplete) thyroid resection. Postoperative complications included transient RLN palsy (n = 2) and transient hypoparathyroidism (n = 4). Conclusions: Completion thyroidectomy using a lateral approach is safe in re-operative thyroid surgery.     

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

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

喉返神经隧道解剖法结合神经监测在腔镜甲状腺手术中的应用

目的:探讨喉返神经隧道解剖法结合神经监测在腔镜甲状腺手术中的应用价值。方法:回顾分析2014年11月至2018年12月施行的141例腔镜甲状腺手术,术中均采用喉返神经隧道解剖法结合神经监测技术。其中甲状腺良性结节93例,甲状腺恶性肿瘤48例;行单侧腺叶切除术52例,单侧甲状腺癌根治术44例,双侧甲状腺癌根治术4例,41例部分切除术。结果:140例手术顺利完成,1例因喉返神经横断伤转开放手术行神经对端吻合;术后9例(9/141,6.38%)暂时性神经麻痹,无永久性声音嘶哑患者。结论:腔镜甲状腺手术中采用喉返神经隧道解剖法结合神经监测技术可快速定位喉返神经,降低手术难度,提高手术安全性,利于腔镜甲状腺手术更好地在基层医院推广普及。     

Emergencies in thyroid surgery. Our experience

The rate of complications after thyroid surgery is about 5% and among these real emergencies account for less than 1%, consisting in intraoperative and postoperative bleeding, bilateral recurrent palsy, severe hypoparathyroidism and, rarely, laryngeal oedema and tracheomalacia. Between 2000 and 2004 849 patients were submitted to total thyroidectomy for various thyroid pathologies in our institution. Complications observed were postoperative bleeding in 13 patients (1.5%), laryngeal recurrent nerve palsy in 18 (monolateral in 14 - 8 transient and 6 permanent - and bilateral in 4, 3 of which transient), transient hypoparathyroidism in 390 (45.9%), permanent hypoparathyroidism in 10 (out of 400 patients followed up for more than one year = 2.5%). Tetanic crises were observed in 33 patients (3.9%). One patient, on treatment with heparin, showed a glottic haemorrhagic oedema (probably caused by trauma after endotracheal intubation) treated by an emergency tracheotomy on postoperative day two. Thyroid surgery is today very safe and morbidity is rare. Anatomical knowledge and accuracy of surgical indications are the main factors capable of reducing the number of complications. Experience in performing thyroid surgery is essential for the best outcome with the fewest complications. Complications of total thyroidectomy can be minimised with increasing experience and refinement of surgical technique.     

The role of intraoperative neuromonitoring of recurrent laryngeal nerve during thyroidectomy: a comparative study on 1000 nerves at risk

BACKGROUND: The role of intraoperative neuromonitoring of recurrent laryngeal nerve (RLN) during thyroidectomy has not been well established. The present study evaluates whether RLN injury can be reduced by the application of this technique during thyroidectomy in a single center. METHODS: Of 1000 RLNs that were at risk of injury in 639 consecutive patients who underwent thyroidectomy, the outcome of 501 RLNs with the use of neuromonitoring was compared with that of 499 nerves that were operated by routine identification only. The incidences of RLN paralysis were compared between the 2 groups and the assigned risk subgroups. RESULTS: Postoperative palsy was identified in 47 RLNs (4.7%), with complete recovery in 37 of 44 RLNs (84%) without documented injury. The overall incidence of postoperative RLN paralysis was significantly higher during thyroidectomy for malignancy (P = .025) and secondary thyroidectomy (P = .017). There was no significant difference in postoperative, transient, and permanent paralysis rates between the neuromonitoring and control groups. In subgroup analysis, the postoperative RLN palsy rate was higher during reoperative thyroidectomy (19% vs 4.6%; P = .019) in the control group but not in the neuromonitoring group (7.8% vs 3.8%; P > .05). CONCLUSION: Neuromonitoring of the RLN during thyroid surgery could not be demonstrated to reduce RLN injury significantly, compared with the adoption of routine RLN identification. However, its application can be considered for selected high-risk thyroidectomies.     

Validity of intra-operative neuromonitoring signals in thyroid surgery

Background Although intra-operative neuromonitoring (IONM) is widely used in thyroid surgery, the validity of the received IONM signals are still unknown.Method Prospective collection of data forms in 29 hospitals from 8,534 patients with 15,403 nerves at risk, who underwent surgery for benign and malignant goitre disorders between August 1999 and January 2001. IONM was performed by indirect stimulation via the vagal nerve and by direct recurrent laryngeal nerve (RLN) stimulation in 12,486 cases. IONM signals were compared with early (<14 days) and late (6 months) postoperative vocal cord function findings.Results The transient and permanent RLN palsy rate was 2.8% and 0.7%, respectively. Monitoring of the RLN function was significantly more reliable via the indirect IONM stimulation route than via the direct IONM stimulation route (specificity P<0.05). IONM by indirect stimulation via the vagal nerve reliably excluded postoperative, permanent, vocal cord palsy (specificity 97.6%, negative predictive value 99.6%). However, a changed IONM was insufficient to predict permanent RLN palsy (sensitivity 45.9%, positive predictive value 11.6%). IONM was not associated with increased general morbidity.Conclusions For intra-operative neuromonitoring, indirect stimulation of the RLN is superior to direct stimulation. An intact acoustic IONM signal is highly predictive of intact postoperative RLN function. When the IONM signal is abnormal or absent, a one-stage extensive thyroid resection should be performed only if the surgeon is absolutely convinced that the first RLN is not harmed or a total thyroidectomy is mandatory.     

Second operations for "completion" of thyroidectomy in treatment of differentiated thyroid cancer.

The role of elective completion thyroidectomy after lobectomy for differentiated thyroid cancers remains controversial. The potential benefit of tumor removal by the second procedure is considered by some to be overbalanced by a prohibitive operative morbidity rate. During a 20-year period at the University of Chicago Medical Center, 26 patients underwent completion thyroidectomy within a 6-month period of the original thyroid operation. This group represents 8% of the 326 patients who underwent surgery during that time for differentiated thyroid cancer (269 papillary and 57 follicular). Of the 26 patients, 18 had papillary and eight had follicular cancers. The average size was 2.5 cm, with 24 of 26 being greater than 1 cm in diameter. At the first operation, 81% of tumors were intrathyroidal. Eight percent had lymph node metastases and 12% manifested local invasion. Tumor was found in eight (31%) of 26 of the reoperative specimens. The incidence of tumor did not vary by histologic type but did differ according to the extent of the original operation. Cancer was found in 50% (three of six) of those who had undergone previous partial lobectomy, in 33% (five of 15) of those after a total lobectomy, and in none of five who had undergone a prior bilateral (although incomplete) thyroid resection. One permanent recurrent nerve injury occurred at the first operation. No additional recurrent nerve injuries or hypoparathyroidism occurred as a result of the second operation. Finally, no disease characteristic of the initial tumor (e.g., size, clinical class, tumor capsular invasion, multifocality, thyroiditis, or extrathyroidal tumor invasiveness) predicted the presence or absence of tumor on the second side. We conclude that completion thyroidectomy is appropriate for patients with lesions 1 cm or greater who have undergone lobectomy or less at the original operation, because 40% of such patients would be expected to have residual cancer. With care, this operation can be performed with minimal morbidity.     

The impact of surgical technique on postoperative hypoparathyroidism in bilateral thyroid surgery: a multivariate analysis of 5846 consecutive patients

BACKGROUND: Limited information exists about risk factors for postoperative hypoparathyroidism after bilateral thyroid surgery. METHODS: Between January 1 and December 31, 1998, bilateral thyroid surgery was performed on 5846 patients for benign and malignant thyroid disease. Data were prospectively collected by questionnaires from 45 hospitals. A logistic regression model was used to determine independent risk factors. RESULTS: The overall incidence of transient and permanent hypoparathyroidism was 7.3% and 1.5%, respectively. On logistic regression analysis, total thyroidectomy (odds ratio [OR], 4.7), female gender (OR, 1.9), Graves' disease (OR, 1.9), recurrent goiter (OR, 1.7), and bilateral central ligation of the inferior thyroid artery (OR, 1.7) constituted independent risk factors for transient hypoparathyroidism. When the multivariate analysis was confined to permanent hypoparathyroidism, total thyroidectomy (OR, 11.4), bilateral central (OR, 5.0) and peripheral (OR, 2.0) ligation of the inferior thyroid artery, identification and preservation of no or only a single parathyroid gland (OR, 4.1), and Graves' disease (OR, 2.4) emerged as independent risk factors. CONCLUSIONS: Extent of resection and surgical technique had a greater impact on the rates of permanent postoperative hypoparathyroidism than thyroid pathologic condition. In bilateral thyroid surgery, peripheral ligation of the inferior thyroid artery at the thyroid capsule should be favored over central ligation, and at least 2 parathyroid glands should be identified and preserved. High-risk procedures, such as total thyroidectomy and Graves' disease, require special surgical training and expertise.     

Selective parathyroid auto‐transplantation during thyroidectomy

Aim: Permanent hypoparathyroidism is a debilitating morbidity following thyroidectomy and parathyroid auto‐transplantation has been shown to be effective in preventing permanent hypoparathyroidism. Controversy exists regarding the benefit of routine versus selective auto‐transplantation. We evaluate the outcome of selective parathyroid auto‐transplantation in our hospital. Methods: A retrospective study was conducted to assess the incidence of postoperative hypocalcaemia. Indication for parathyroid auto‐transplant was doubtful viability of parathyroid gland during thyroidectomy. From 1 July 2000 to 30 June 2005, all patients who underwent total, subtotal and completion thyroidectomy were included. Other outcome measures including recurrent laryngeal nerve injury and operative time were also analyzed. Results: A total of 170 bilateral or completion thyroidectomies were performed within this period. Total, subtotal, and completion total thyroidectomies were performed in 103 (60.6%), 62 (36.5%), and five (2.9%) patients, respectively. Median age was 45 years (range 19–82). One hundred and twenty‐four patients (73%) had benign thyroid disease, and 46 patients (27%) had thyroid carcinoma. Parathyroid auto‐transplant was performed in 35 patients (20.6%). Mean operation time was 204 min (range 95–510 min). There was no difference in the operation time between the patients with parathyroid auto‐transplant and those without auto‐transplant (217 vs 200 min, P = 0.229). Transient hypocalcaemia occurred in 31 patients (18.2%) whereas two patients had permanent hypocalcaemia (1.2%). Permanent recurrent laryngeal nerve injury occurred in one patient (0.6%). Conclusions: The adoption of selective parathyroid auto‐transplant during thyroidectomy achieves an extremely low incidence of permanent hypoparathyroidism without excessive transient hypoparathyroidism.