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.     

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.     

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.     

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.     

The impact of age, vitamin D3 level, and incidental parathyroidectomy on postoperative hypocalcemia after total or near total thyroidectomy

Background

Hypocalcemia caused by transient or definitive hypoparathyroidism is the most frequent complication after thyroidectomy. We aimed to compare the impact of incidental parathyroidectomy and serum vitamin D₃ level on postoperative hypocalcemia after total thyroidectomy (TT) or near total thyroidectomy (NTT).

Patients

Two hundred consecutive patients with nontoxic multinodular goiter treated by TT and NTT were included prospectively in the present study. Group 1 (n = 49) consisted of patients with a postoperative serum calcium level ≤8 mg/dL, and group 2 (n = 151) had a postoperative serum calcium level greater than 8 mg/dL. Patients were evaluated according to age, preoperative serum 25-hydroxy vitamin D (25-OHD) levels, postoperative serum calcium levels, incidental parathyroidectomy, and the type of thyroidectomy.

Results

Patients in group 1 (n = 49) were hypocalcemic, whereas patients in group 2 (n = 151) were normocalcemic. Preoperative serum 25-OHD levels in group 1 were significantly lower than in group 2 (P < .001). The incidence of hypoparathyroidism was significantly higher following TT (13.5%) than following NTT (2.5%) (P < .05). The risk for postoperative hypocalcemia was increased 25-fold for patients older than 50 years, 28-fold for patients with a preoperative serum 25-OHD level less than 15 ng/mL, and 71-fold for patients who underwent TT. Incidental parathyroidectomy did not have an impact on postoperative hypocalcemia. The highest risk of postoperative hypocalcemia was found in the patients with all of the above variables.

Conclusions

Age, preoperative low serum 25-OHD, and TT are significantly associated with postoperative hypocalcemia. Patients with advanced age and low preoperative serum 25-OHD levels should be placed on calcium or vitamin D supplementation after TT to avoid postoperative hypocalcemia and decrease hospital stay.     

Risks and consequences of incidental parathyroidectomy during thyroid resection

BACKGROUND: Inadvertent removal of the parathyroid glands during elective thyroid surgery occurs more frequently in certain high-risk patients and can lead to symptomatic hypocalcaemia. METHODS: A case-control study was carried out at a tertiary referral, academic medical centre between May 1994 and August 2001. Five hundred and thirteen patients underwent thyroid resection. Pathology reports were reviewed to identify patients who had the inadvertent removal of a parathyroid gland during their thyroid surgery. Thirty-three (6.4%) patients had inadvertent resection of a parathyroid gland. The outcomes of these 33 patients (INCIDENTAL) were compared with the other 480 patients who did not have resection of parathyroid tissue (NO INCIDENTAL). RESULTS: Risk factors for inadvertent parathyroid resection included younger age (P = 0.003), bilateral thyroid resection (P = 0.001) and malignant pathology (P = 0.002). Factors that did not increase the risk of incidental parathyroidectomy included gland weight, sex, presence of a goitre, previous neck exploration and concurrent lymph node dissection. In the INCIDENTAL group 24% had a postoperative calcium levels less than 7.0 mg/dL (P = 0.001). Symptomatic hypocalcaemia developed in 12% of INCIDENTAL patients, compared to 4% in the NO INCIDENTAL group (P = 0.06). CONCLUSION: Incidental removal of parathyroid tissue occurred in 6.4% of thyroid resections. Younger patients undergoing a total or subtotal thyroidectomy for malignancy were at the highest risk. These patients had lower postoperative calcium levels, but the majority (88%) experienced no clinical consequences.     

The advantage of near-total thyroidectomy to avoid postoperative hypoparathyroidism in benign multinodular goiter

Background In recent years, total or near-total thyroidectomy has emerged as a surgical option to treat patients with multinodular goiter, especially in endemic iodine-deficient regions. The aim of this study was to compare the complication rates of total and near-total thyroidectomy in multinodular goiter and the incidence of thyroid cancer requiring radioactive iodine ablation and completion thyroidectomy between groups.Study design Patients with euthyroid multinodular goiter without any preoperative suspicion of malignancy, history of familial thyroid cancer, or previous exposure to radiation were randomized (according to a random table) to total thyroidectomy (group 1, n = 104) and near-total thyroidectomy leaving less than 2 g (group 2, n = 112).Results There were no persistent complications. The incidence of transient hypoparathyroidism in group 1 (26%) was significantly higher than in group 2 (9.8%) (p < 0.001). The rate of asymptomatic hypocalcemia in group 2 (7.4%) was lower than in group 1 (27%) (p < 0.001). The incidence of papillary cancer was 9.6% in group 1 and 12.5% in group 2 (p > 0.05). None of the patients underwent completion thyroidectomy before ablative therapy. Ten patients were found to have the histological criteria for radioactive iodine ablation. Of these 10 patients, four were in group 1 and six were in group 2 (p > 0.05).Conclusion In conclusion, we recommend near-total thyroidectomy in multinodular goiter instead of total or subtotal thyroidectomy. While near-total thyroidectomy and total thyroidectomy obviate the need for completion thyroidectomy in incidentally found thyroid cancer, and while there is no difference in the rate of recurrent laryngeal nerve palsy between the two methods, near-total thyroidectomy causes a significantly lower rate of hypoparathyroidism compared to total thyroidectomy.     

Incidental parathyroidectomy during total thyroidectomy

Aim — Background

Total thyroidectomy is the procedure of choice in many diseases of the thyroid gland. This study measures the frequency of incidental parathyroidectomy during thyroidectomy in our department and values the possible correlation between certain clinical parameters, such as inflammation and malignancy, and the frequency of incidental parathyroidectomy.

Patients — Methods

A retrospective study was conducted for the period July 2009–June 2012. The study included 63 patients (51 female, 12 male) with total thyroidectomy. We measured the number of parathyroid glands as recorded in the pathology reports and we compared this with the original disease of the thyroid gland.

Results

Parathyroid tissue was found in 12 cases (19%). One parathyroid gland was found in nine (14%) specimens (group A), and two parathyroid glands were found in three (5%) (group B). The cases in group A comprised: 5/21 (24%) goiter, 3/23 (13%) thyroid cancer, 1/19 (5%) thyroid nodule, and in group B: 1/21 (5%) goiter, 2/23 (9%) thyroid cancer. In 75% of all cases (both groups A & B), there was significant inflammation of the thyroid gland.

Conclusion

Incidental parathyroidectomy during thyroidectomy is usually found in cases of severe inflammation, goiter or thyroid cancer. It is essential that the surgeon recognizes and preserves the parathyroid glands during thyroidectomy.     

Rate of perioperative complications of thyroid surgery

Mortality and complication rate of thyroid surgery was evaluated between 1980 and 1987. Patients undergoing thyroidectomy during parathyroidectomy, tracheotomy or tumor operation in the anterior mediastinum were excluded. 548 thyroidectomies were performed in 536 patients. There were no mortalities. The incidence of local complications was 16% with paralysis of the recurrent nerve being the most frequent (6.2%). Other complications were hematoma or hemorrhage (4.9%), hypocalcemia (2.1%), allergic skin reaction (1.3%), or wound infection (0.7%). 2.2% of the patients needed reoperation because of false negative interpretation of a frozen section, or carcinoma in final histology. Systemic complications were found in 13 patients (2%), 6 of whom required intensive care treatment. Statistical analysis revealed that patients undergoing total thyroidectomy or re-thyroidectomy, and patients older than 50 years are at higher risk for local complications.     

Endoscopic Thyroidectomy Using a New Bilateral Axillo-Breast Approach

Introduction Endoscopic techniques have recently been applied in thyroid surgery using cervical, axillary, and breast approaches. We modified the axillo-bilateral breast approach (ABBA) and developed the bilateral axillo-breast approach (BABA) to obtain optimal visualization for total thyroidectomy. Methods We used two 12-mm ports through bilateral circumareolar incisions for flexible videoscopy and Harmonic scalpel and two 5-mm ports through both axillae for graspers and dissectors. Thyroidectomy was performed under full visualization of the superior and inferior thyroidal arteries, parathyroid glands, and recurrent laryngeal nerves. Results After performing 25 ABBA endoscopic thyroid surgeries, we developed BABA and performed 110 operations using this method. The BABA operations included 52 total thyroidectomies, 2 near-total thyroidectomies, 8 subtotal thyroidectomies, 43 lobectomies, and 3 subtotal lobectomies. Pathology revealed 41 benign lesions and 69 cancers. Mean operation time was 165.3 ± 43.5 minutes. There were 2 cases of conversion to open surgery, 1 due to cancer with capsular invasion and the other due to tracheal injury. Nine postoperative complications developed: transient unilateral vocal cord palsy in 4 cases, transient hypocalcemia in 4 cases, and postoperative infection in 1 case. The 2-month postoperative thyroglobulin level was less than 1 ng/ml in all examined cases of total thyroidectomy. Cosmetic results were excellent. Conclusions The BABA technique for endoscopic thyroid surgery is a feasible method of total thyroidectomy with a low rate of postoperative complications and, additionally, excellent cosmetic results. Therefore, in selected cases of thyroid cancer, the BABA endoscopic total thyroidectomy should be considered as a valid surgical option.     

Delayed Hypocalcemia After Thyroidectomy for Graves' Disease is Prevented by Parathyroid Autotransplantation

Late hypocalcemia appears associated with thyroidectomy for Graves' disease more frequently than with thyroidectomy for other conditions. Of 62 total thyroidectomies done by a single surgeon, 28 were done for carcinoma, 18 for benign disease (primarily nontoxic nodules with a history of radiation therapy to the head and neck (RT)) and 16 for Graves' disease. Mean calcium concentrations measured two months or more after surgery were 9.38 ± 0.07 (SEM)mg/% for patients with cancer, 8.79 ± 0.31 mg/dl for patients with Graves' disease and 9.38 ± 0.08 mg/dl for patients with other benign diseases. No patient without Graves' disease developed late hypocalcemia. In contrast, six of 16 patients with Graves' developed significant late hypocalcemia requiring calcium therapy. The incidence of hypocalcemia after total thyroidectomy for Graves' disease was significantly greater than that seen in other conditions (p < 0.01). Since no parathyroids were removed in the patients with Graves' disease, and since branches of the inferior thyroid artery were invariably ligated distal to the parathyroids, we hypothesized that the late hypocalcemia might be associated with a peculiarity in scar formation in the presence of this autoimmune disease. Accordingly, parathyroid autotransplantation was performed synchronously as a prophylactic measure in nine subsequent patients undergoing total thyroidectomy for Graves' disease; no instance of late hypocalcemia has occurred in this group. The decreased incidence of late hypocalcemia is highly significant (p < 0.01). Although the precise etiology of late hypocalcemia after thyroidectomy for Graves' disease remains undetermined, this experience indicates that synchronous parathyroid autotransplantation is beneficial in preventing this complication.     

Autotransplantation of at least one parathyroid gland during thyroidectomy in benign thyroid disease minimizes the risk of permanent hypoparathyroidism

OBJECTIVE:Permanent hypoparathyroidism is a distressing complication of thyroid surgery. The reported incidence varies between 0.4 and 13.8 % and is directly correlated to the extent of thyroidectomy. The aim of this retrospective study was to analyze whether simultaneous autotransplantation of at least one parathyroid gland during total thyroidectomy for benign thyroid disease could reduce the risk of permanent hypoparathyroidism. METHODS: Since 01/1999 all thyroid operations are prospectively recorded. Beside daily postoperative measurement of serum calcium level, iPTH is routinely determined on the third post op day. Patients with complications are followed closely. Postoperative hypoparathyroidism persisting for more than 6 months is defined permanent. RESULTS: Between 01/1999 and 02/2001 146 total thyroidectomies for benign thyroid disease have been performed (81 pat. with Graves disease, 62 with nodular goiter, 3 with thyroiditis de Quervain/Hashimoto). In 37 pat. (25 %) at least one parathyroid gland was simultaneously autotransplanted into the ipsilateral sternocleidomastoid muscle. Group I (no parathyroid autotransplantation, n = 109) and group II (parathyroid autotransplantation, n = 37) were comparable concerning patient age, thyroid disease and lowest post op calcium level (2.07 versus 2.05 mmol/l). The incidence of postoperative symptomatic hypocalcemia (14.7 % versus 21.6 %) and temporary hypoparathyroidism (15.6 % versus 18.9 %) was higher in group II patients (n. s.). Conversely, permanent hypoparathyroidism occurred exclusively in group I patients (2.75 %), patients with parathyroid autotransplantation (group II) did not develop this complication. CONCLUSIONS: Simultaneous autotransplantation of at least one parathyroid gland during total thyroidectomy for benign thyroid disease seems to minimize the risk of permanent hypoparathyroidism. The potential of routine autotransplantation in this setting has to be evaluated. The incidence of postoperative temporary hypocalcemia may be elevated with this policy.     

Complications of thyroid surgery

Background: The morbidity of thyroid surgery is low. Despite this, some authors advocate a subtotal thyroidectomy instead of a total thyroidectomy, to avoid the higher morbidity associated with a total thyroidectomy. Methods: We retrospectively evaluated the complications of thyroid surgery in Leiden between January 1, 1982 and October 1, 1990. Three hundred forty-one patients—261 women and 80 men—had 356 operations; 15 patients were operated on twice; there were 152 total hemithyroidectomies, 3 subtotal hemithyroidectomies, 33 total thyroidectomies, 122 bilateral subtotal hemithyroidectomies, 12 combinations of total and subtotal hemithyroidectomies, and 34 other operations. Results: Calculated for the nerves at risk (n=489), the percentage of permanent recurrent nerve lesions was 3.1 (in the 5 most recent years it was 1.2%). There was no significant difference between total or subtotal (hemi)thyroidectomies. Initial symptomatic hypocalcemia necessitating supplementation was encountered 42 times (12.5%). The occurrence of permanent symptomatic hypocalcemia (6%) was not significantly different between total and subtotal (hemi)thyroidectomies (p=0.06). The duration of surgery was 137.8 min for bilateral subtotal thyroidectomies and 182.9 min for bilateral total thyroidectomies (p<0.0001). There was no difference in blood loss between total and subtotal (hemi)thyroidectomies. Conclusions: Because total thyroidectomy carries a risk of complications similar to that for subtotal thyroidectomy, it is not logical to avoid total resections. If the number of total resections were increased, it is anticipated that fewer reoperations, which involve a relatively high morbidity rate, would have to be performed.Results of this work were presented at the 46th Annual Cancer Symposium of The Society of Surgical Oncology, Los Angeles, March 18–21, 1993.     

Incidental thyroid microcarcinoma in benign thyroid disease. Incidence in a total of 100 consecutive thyroidectomies

Over the past few years, incidental thyroid microcarcinoma has become a frequent disease and its incidence in some reports is considerable. Discovering new cases depends on the extended indications for total thyroidectomy for benign disease, on progress in the field of diagnostic instruments (ultrasound, scintigram, fine needle biopsy for cytology, CT scan, MRI), and on the pathology examination of very thin slices of specimens. In spite of the high incidence reported in some autopsy series, suggesting that this tumour may have a good prognosis, some Authors report an overall incidence of up to 11% of local recurrence, metastasis or mortality. For all these reasons the surgical treatment of incidental thyroid microcarcinoma is still controversial. The aim of this study was to estimate the incidence and examine the clinical-pathological findings of incidental thyroid microcarcinoma in a series of 100 consecutive thyroidectomies and to evaluate whether complete removal of the gland should be adopted in all cases. In the present series the incidence of incidental thyroid microcarcinoma was 21.6% (19/88). Total thyroidectomy was considered the treatment of choice for diffuse benign disease and appeared to be necessary for both the diagnosis and treatment of incidental thyroid microcarcinoma.     

Total Thyroidectomy for Benign Thyroid Disorders in an Endemic Region

Total thyroidectomy is increasingly being accepted as a treatment of choice for differentiated thyroid cancer. However, because of presumed increased morbidity associated with this procedure, it is still not considered a viable option for management of benign thyroid disorders. To assess the safety and efficacy of total thyroidectomy for management of benign thyroid disorders, we analyzed our data from 127 total thyroidectomies performed for benign thyroid disorders. Demographic details, biochemical findings, indications for operation, specimen weight, and complications were noted. Among these patients, 52 had a toxic goiter and 75 had a nontoxic goiter. The mean duration of the goiters being present was 6.08 ± 6.06 years (0.9–26.0 years), and the mean weight of the specimens was 136.88 ± 120.68 g. The incidence of occult malignancy was 6.3% (n= 8), and those of permanent hypothyroidism and permanent recurrent laryngeal nerve palsy were 1.6% and 0.8%, respectively. Total thyroidectomy should be considered a treatment of choice for multinodular goiter and Graves' disease in a setting of palpable nodule(s) or ophthalmopathy (or both). It is particularly relevant in endemic regions where patients present with a long-standing, large nodular goiter with virtually no normal thyroid tissue. Reoperation for recurrent goiter in such a setting would be fraught with distressing complications.     

Incidental carcinoma in multinodular goiter: risk factors

The aim of the study was to analyze the frequency of incidental thyroid carcinoma (unknown tumor smaller than or equal to 10 mm) in a consecutive series of 462 total thyroidectomies for multinodular goiter and to investigate the clinical risk factors for this type of malignancy. A retrospective, single-center study of outcome data collected from patients with preoperative diagnosis of multinodular goiter who underwent total thyroidectomy at the General Surgery Unit of Pavia (Italy) between January 2000 and December 2008 was performed. Possible risk factors for malignancy were: gender, age, time of evolution of goiter, presence of a dominant nodule in multinodular goiter, hyperthyroidism, history of radiation to the neck, residence in an area of endemic goiter, prior thyroid surgery, calcifications in the goiter detected by neck ultrasound or chest X-rays, and a family history of thyroid diseases. In a 9-year period, 462 patients underwent total thyroidectomy. We found 41 cases of incidental thyroid carcinoma; the most common histopathological type was papillary. The multivariable analysis demonstrated that the clinical variables associated with occult carcinoma were a personal history of radiation therapy to the neck, the presence of calcifications detected by ultrasound or neck X-rays, and a family history of thyroid diseases; residence in an area of endemic goiter was a protective factor. A personal history of radiation to the neck, detection of calcifications by ultrasound or by neck X-rays, and a family history of thyroid diseases should be considered clinical risk factors for malignancy in multinodular goiter.     

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.     

Changes in the choice of thyroidectomy for benign thyroid disease

Purposes

There is an increasing trend towards performing more radical resections instead of a subtotal resection for benign thyroid disease. The aim of this study was to examine the effect of this change in practice on the surgical treatment of bilateral thyroid diseases in this unit.

Methods

The data on 367 patients that underwent a bilateral thyroidectomy were categorized by dividing the operation types into 4 groups: (1) total thyroidectomy (TT), (2) near-total thyroidectomy, (3) Dunhill procedure, and (4) bilateral subtotal thyroidectomy.

Results

A statistically significant change in the choice of thyroidectomy occured during the study period (p < 0.001). TT has replaced subtotal thyroidectomy (STT; bilateral subtotal thyroidectomy and Dunhill procedure) as the preferred routine surgical procedure for bilateral benign thyroid diseases in this clinic. The permanent complication rates were similar for all surgical procedures. The rate of secondary thyroidectomy for both recurrence of multinodular goiter and incidental thyroid carcinoma were significantly higher in the STT groups, than the total in the TT and near-total thyroidectomy patients.

Conclusions

Total or near total thyroidectomy procedures are now being increasingly employed to treat bilateral benign thyroid disease, and are as safe as the sub-total thyroidectomy procedures, which are more conservative and associated with significantly higher recurrence rates.     

Importance of identifying the course of the recurrent laryngeal nerve in total and near-total thyroid lobectomies

In our clinic, near-total thyroidectomy is the principal surgical procedure performed for benign thyroid diseases. We conducted a single-institution study on 176 consecutive patients who underwent near-total thyroidectomy due to various thyroid diseases. We compared the incidence of recurrent laryngeal nerve injury between total and near-total thyroid lobectomy sides in each patient. Our hypothesis was that the incidence of recurrent laryngeal nerve injury after total thyroid lobectomy would be similar to that of near-total thyroid lobectomy when the course of the recurrent laryngeal nerve was identified during surgery. The temporary recurrent laryngeal nerve palsy rates on the total and near-total thyroid lobectomy sides were 3.9 per cent (7 of 176 nerves) and 2.2 per cent (4 of 176 nerves), respectively. The difference was not statistically significant. Permanent recurrent laryngeal nerve palsy did not occur in any of our patients. In conclusion, the incidence of recurrent laryngeal nerve injury in total versus near-total thyroid lobectomy is not different when the course of the recurrent laryngeal nerve is identified during surgery.     

Thyroid surgery at Children's Hospital Boston: a 35-year single-institution experience

Background/Purpose

Thyroidectomy is the primary therapy for thyroid cancer and an established treatment of hyperthyroidism. Because of the relative rarity of these conditions in childhood, few single-institution series exist in the pediatric literature. Here we analyze our institution's experience to assess patient demographics, operative risks, and the role of preoperative testing.

Methods

This is a retrospective chart review of 175 consecutive patients not older than 18 years who underwent thyroid surgery at Children's Hospital Boston from 1970 to 2004.

Results

The most common indication for thyroidectomy was thyroid nodules (83%), followed by hyperthyroidism (7%) and goiter (7%). For children referred for nodules, we observed a peak incidence in adolescence and a female to male ratio of 3.7:1. Cancer was found in 36%, with papillary thyroid cancer the most common subtype (85%). Operative complications were rare, with permanent hypocalcemia in 2 (4.7%) of 43 patients who underwent bilateral resection for thyroid nodules (no cases of permanent hypocalcemia in other procedures). Permanent unilateral vocal cord paralysis was documented in 2 children after the resection of malignant nodules.

Conclusions

Pediatric thyroidectomy can be performed with low operative risk. Because permanent hypocalcemia remains an obligate risk of bilateral thyroidectomy, we recommend the routine use of preoperative fine-needle aspiration to guide the extent of initial surgical resection, reserving near-total thyroidectomy for those cases where cytology is positive for malignancy.