Clinical aspects of endocrinology

Providing anaesthesia for surgery of the endocrine system requires an understanding of the physiology, pathology, anatomy and pharmacology of the endocrine organs. The physiology and pharmacology determine how the patient’s condition may be controlled preoperatively and what disturbances may happen intraoperatively and postoperatively. The anatomy and surgical pathology determine the nature and extent of the procedure and (in the case of the thyroid gland) any likely impact on airway control. This article discusses anaesthetic management for surgery of the thyroid and parathyroid glands and for surgery related to conditions of the adrenal cortex. In the case of thyroid surgery, the importance of tracheal distortion, control of thyrotoxicosis and occurrence of postoperative airway problems are emphasized. For parathyroid surgery, the consequences of hypercalcaemia and of a sudden reduction in parathyroid hormone concentrations are discussed. Conditions of the adrenal cortex vary in severity and often require judgement as to preoperative optimization, the use of invasive monitoring and the appropriateness of postoperative critical care. These issues are discussed. Postoperative pain is rarely a problem (particularly with the increased use of laparoscopic surgery) and postoperative stay is short. Some procedures are now being performed as day cases with careful postoperative protocols. The input of a motivated endocrinologist is essential both for preoperative management of these sometimes complex cases and for postoperative management of hormone replacement. Close collaboration among surgeon, anaesthetist and endocrinologist is essential.     

从传统到腹腔镜：开展甲状腺微创腔镜手术初期感悟

目的 探讨甲状腺微创腔镜手术的安全性、可行性及其优势.方法 回顾性分析福建医科大学附属协和医院甲状腺外科笔者所在治疗组自 2011 年 11 月至 2013 年 8月完成甲状腺手术 1048 例患者的临床资料,其中开放手术（ open thyroidectomy,OT ）组 721 例,腔镜辅助（ video-assisted thyroidectomy,VAT ）组 252 例,胸乳入路全腔镜甲状腺手术（ total endoscopic thyroidectomy,TET ）组 75 例.对比分析三种术式在喉返神经麻痹、甲状旁腺机能减退、乳糜漏、术后出血、Horner 综合症、手术时间、甲状旁腺辨识个数、喉上神经外支辨识率、第一天引流量、引流天数、引流总量、淋巴结个数、术后住院天数及病理甲状旁腺检出率等方面的差异.结果 所有手术均顺利完成,未出现术中大出血和术式转换.喉返神经麻痹、永久性甲状旁腺机能减退、乳糜漏、术后出血等并发症三组之间的差异无统计学意义（ P ＞ 0.05 ）;一过性甲状旁腺机能减退及 Horner 综合征等并发症三组之间差异有统计学意义（ P ＜ 0.05 ）.VAT、TET 及 OT 组在手术时间、第一天引流量、引流天数、引流总量、喉上神经外支辨识率等方面差异有统计学意义（ P ＜ 0.05 ）,甲状旁腺辨识个数、淋巴结个数、术后住院天数及病理甲状旁腺检出率等方面差异无统计学意义（ P ＞ 0.05 ）.VAT 组与 OT 组比较,手术时间、第一天引流量、引流时间、术后引流总量,喉上神经外支辨识率等方面差异有统计学意义（ P ＜ 0.05 ）;甲状旁腺辨识个数、淋巴结个数、术后住院天数及病理甲状旁腺检出率等方面差异无统计学意义（ P ＞ 0.05 ）.TET 组与 OT 组比较,手术时间、第一天引流量、引流总量、引流时间、喉上神经外支辨识率等方面差异有统计学意义（ P ＜ 0.05 ）,甲状旁腺辨识个数、淋巴结个数、术后住院天数及病理甲状旁腺检出率差异无统计学意义（ P ＞ 0.05 ）.结论 甲状腺微创腔镜手术具有等同于 OT 手术的治疗效果及安全性;VAT 手术具有明显的微创优势;TET手术具有明显的美容优势.     

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.     

Changes of the speaking and singing voice after thyroid or parathyroid surgery

BACKGROUND: While permanent dysphonia is a rare complication of thyroid or parathyroid surgery, postoperative changes of the speaking and/or singing voice often remain unrecognized. METHODS: In a prospective 4-arm study, vocal fold videolaryngostroboscopy and functional assessment of pre- and postoperative vocal performance was used to evaluate voice disturbances in 120 patients undergoing extended cervical surgery and in 19 patients with limited interventions for thyroid and/or parathyroid pathology. RESULTS: Impairments, especially of the singing voice, were predominantly observed after extended endocrine neck surgery. In women, the highest pitch of the singing voice (HPS) dropped from 651 Hz to 563 Hz (E5 to Csharp5, P < .001). In men, the HPS decreased to a lesser extent (423 Hz to 374 Hz, (Gsharp4 to Fsharp4, P = .009). Covariant analysis of influencing factors revealed the preoperative maximum frequency range and the HPS as predictors of the postoperative voice outcome. CONCLUSIONS: While alterations of the speaking voice after thyroid and parathyroid surgery usually remain subclinical, transient changes of the singing voice will matter to voice professionals.     

A case complicated with Horner's syndrome after off-pump coronary artery bypass.

In the present report, a case complicated with Horner's syndrome after off-pump coronary artery bypass (OPCAB) was presented. This case showed ptosis and miosis in the left eye promptly after OPCAB. No abnormal neurological findings other than Horner's syndrome were observed in postoperative examinations including head magnetic resonance imaging (MRI), and this case was thought to have Horner's syndrome as a complication after cardiac surgery through median sternotomy.     

Horner's syndrome after carotid endarterectomy--a case report

Horner's syndrome is described in a patient with anisocoria and unilateral lid ptosis 48 hours after an ipsilateral carotid endarterectomy. This case illustrates a rare iatrogenic complication of sympathetic nerve dysfunction following elective surgery.     

Dysfunction of calcium metabolism following resection of the thyroid gland. An analysis of important risk factors

PURPOSE: Dysfunction of the parathyroid glands is a typical complication following thyroid surgery. Risk factors for the development of postoperative symptomatic hypocalcemia were retrospectively analyzed. METHODS: 308 consecutive thyroid resections (women n = 236, men n = 72, mean age 53 years) performed in 1996 and 1997 were evaluated. Main diagnosis was non-toxic nodular goiter (n = 234, 76 %), 28 patients (9 %) had thyroid carcinoma. The most common operation performed was bilateral functional thyroid resection (n = 116, 38 %), the proportion of thyroidectomies was 14 % (n = 44). The patients with postoperative symptomatic hypocalcemia were followed for a median of 32 months. RESULTS: Clinical symptoms of hypocalcemia were observed in 18 patients (6 %) postoperatively. Three patients developed transient (n = 1) or permanent hypothyroidism (n = 2). In univariate analysis, the underlying thyroid disease, the method of operative therapy, removal, identification and autotransplantation of parathyroid glands, in multivariate analysis, thyroidectomy (relative risk 6.9) and removal of parathyroid glands (relative risk 23.9) were proved to be significant risk factors for the development of postoperative symptomatic hypocalcemia (p < 0.05). CONCLUSIONS: Patients with thyroidectomy, operation for thyroid carcinoma and intraoperative removal of parathyroid glands should be closely followed for postoperative hypocalcemia. Exact surgical technique provided, permanent hypoparathyroidism is rare, particularly if several parathyroid glands were identified intraoperatively and autotransplanted, if necessary.     

甲状腺微小癌临床诊治：附28例报告

目的:探讨当前甲状腺微小癌(TMC)的诊断及治疗现状,并为进一步规范外科术式的选择提供临床依据。方法:回顾2013年2月—2015年2月间28例手术和病理均证实为TMC患者的临床资料,对其诊断、手术方式及预后等进行分析。结果:28例TMC患者术前彩超检查均发现病灶,15例彩超下细针穿刺确诊者4例(26.7%),术中冷冻切片确诊者27例(96.4%),术后病理确诊者1例(3.6%)。所有患者行手术治疗,包括甲状腺全切除术8例(28.6%)、甲状腺次全切除术7例(25.0%)、甲状腺患侧腺叶+峡部切除术10例(35.7%)、患侧腺叶切除术3例(10.7%)。术后均获随访,无复发、转移或死亡者。结论:TMC的检出率有增高趋势,目前的术前明确诊断仍较为困难,外科手术是主要治疗手段;如何提高术前诊断率与规范化手术治疗已成为当务之急。     

Horner's syndrome as a complication of acute otitis media

A seventeen-year-old girl presented with acute otitis media, unilateral miosis and ptosis (partial Horner's syndrome) and tenderness of the ipsilateral jugular vein. A culture of the otorrhoea showed Staphylococcus aureus and Streptococcus pyogenes. A CT scan revealed an infiltrate near the ipsilateral carotid artery and jugular vein. The patient was hospitalised and treated with antibiotics. Clinical signs disappeared within 6 days. This report discusses the first case with a partial Horner's syndrome as an unusual complication of acute otitis media (AOM). Imaging studies suggest extracranial lymphatic spread of the infection along the adjacent jugular vein causing pressure on the postsynaptic sympathetic fibres. Recognition of the Horner's syndrome is of importance because it may be an early sign of an extracranial complication of AOM.     

The results of thoracoscopic sympathetic trunk transection for palmar hyperhidrosis and sympathetic ganglionectomy for axillary hyperhidrosis.

OBJECTIVES: To review our total experience of thoracoscopic sympathetic trunk transection for the treatment of palmar hyperhidrosis and second and third thoracic sympathetic ganglionectomy for axillary hyperhidrosis. DESIGN: Longitudinal cohort study following up consecutive patients for 0.3 to 5.5 years. SUBJECTS: Fifty-four consecutive patients undergoing thoracoscopic sympathectomy for hyperhidrosis. METHODS: Prospective evaluation of immediate technical success, complications, late recurrence of hyperhidrosis and patient acceptability. RESULTS: 100% initial cure for palmar hyperhidrosis, 91% of sympathetic ganglionectomies for axillary hyperhidrosis were technically successful and initially curative. Compensatory sweating 44% patients, most severe after bilateral sympathetic ganglionectomy. Complications occurred in 14% patients, all resolving without further intervention. There were no cases of Horner's syndrome. 13% patients reported a return of some palmar sweating. 5.4% patients developed recurrent palmar hyperhidrosis at 6, 15 and 21 months postoperatively. CONCLUSION: Transection of the sympathetic trunk between the first and second thoracic sympathetic ganglia initially cures 100% of patients treated primarily for palmar hyperhidrosis. Technically successful 2nd and 3rd thoracic sympathetic ganglionectomy initially cures 100% of patients with axillary hyperhidrosis. Compensatory sweating is common after bilateral sympathectomy. Recurrent palmar hyperhidrosis occurs in 5.4% of cases, but can be cured by a second thoracoscopic sympathectomy. Horner's syndrome is an avoidable complication of thoracoscopic sympathectomy.     

Parathyroid autotransplantation during thyroidectomy. Results of long-term follow-up.

SUMMARY BACKGROUND DATA: Permanent hypoparathyroidism is a recognized complication of thyroidectomy. Operative strategies to prevent this complication include preservation of parathyroid glands in situ and autotransplantation of parathyroid glands resected or devascularized during thyroidectomy. METHODS: An analysis of 194 patients having thyroidectomy and simultaneous parathyroid autotransplantation at Barnes Hospital from 1990 to 1994 was performed. Data were collected regarding patient demographics, indication for thyroidectomy, operative procedure, pathologic diagnoses, and postoperative course, including biochemical assessment of parathyroid autograft function. RESULTS: Of 194 patients having either total, subtotal, or completion thyroidectomy, 104 (54%) experienced a [Ca(+2)]nadir less than or equal to 8.0 mg/dL and had symptoms and signs of hypocalcemia. Parathyroid autotransplantation was successful in 103 (99%) of these 104 cases and resulted in a 1.0% incidence of hypoparathyroidism in this series. CONCLUSIONS: Although preservation of parathyroid glands in situ is desirable, routine parathyroid autotransplantation during thyroidectomy virtually eliminates postoperative hypoparathyroidism. Normal parathyroid glands resected or devascularized during thyroidectomy for well-differentiated thyroid carcinoma or benign disease should be transplanted in the sternocleidomastoid muscle. Patients with Multiple Endocrine Neoplasia type 2A should have parathyroid glands resected at the time of thyroidectomy for medullary thyroid carcinoma and transplanted in the nondominant forearm. Postoperative management in most patients after thyroidectomy and parathyroid autotransplantation involves temporary calcium and vitamin D replacement and close biochemical evaluation. This precautionary measure of parathyroid autotransplantation markedly reduces the incidence of permanent postoperative hypoparathyroidism.     

Minimally invasive approach of the cervical endocrine glands

Improved preoperative functional and topographic diagnostic techniques and availability of intra-operative hormone monitoring, stimulated the introduction of video-assisted minimally invasive operations in parathyroid and thyroid surgical pathology. The first cases of such pathology operated on in our clinic are presented. The first one is a 62 year old man with renal hyperparathyroidism consecutive to a chronic renal insufficiency and hemodialysis from five and three years respectively. The technique of a minimally invasive gapless resection of all four "adenomised" parathyroid glands using laparoscopic and classic instruments is described. Fragments of one gland are implanted in the left forearm musculature. The second case was a 48 year old woman with a three cm diameter right toxic adenoma. With a lateral 15 mm incision, dissociation of the musculature and adequate moving of the retractors the excision of the thyroid nodule was done in 25'. The video-assisted minimally invasive approach allows magnification and adequate identification and removal of endocrine secreting tissues in thyroid and parathyroid pathology. The authors believe that these techniques represent a feasible and attractive alternative to conventional surgery.     

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.     

First bite syndrome: a complication of surgery involving the parapharyngeal space

INTRODUCTION: First bite syndrome (FBS) is the development of pain in the parotid region after the first bite of each meal and can be seen after surgery of the parapharyngeal space. The cause is not clear but has been proposed to involve a loss of sympathetic nerve function to the parotid, causing a denervation supersensitivity of salivary gland myoepithelial cells. The purpose of this study was to review the records of 12 patients with FBS to determine any common features of the operations performed that would support this theory of parotid "sympathectomy" as an etiologic factor of FBS. METHODS: Retrospective review of 12 patients with FBS managed at two tertiary care centers. RESULTS: Twelve patients were diagnosed with FBS after surgery involving the parapharyngeal space. All patients had most of their parotid gland preserved. Six patients exhibited a postoperative Horner's syndrome, suggesting sympathetic chain interruption. The six patients without Horner's syndrome were found to have undergone external carotid artery ligation inferior to the parotid gland, suggesting an interruption of sympathetic innervation to the parotid gland itself. CONCLUSIONS: Preservation of parotid gland tissue and a loss of its sympathetic nerve supply, whether by disruption of the cervical sympathetic chain as evidenced by a Horner's syndrome or more selective denervation by ligation of the external carotid artery with its accompanying sympathetic nerve plexus, were common features of all patients. This series supports the concept of parotid "sympathectomy" as an etiologic factor in FBS.     

双极电凝镊联合超声刀经颈部入路切除胸骨后甲状腺肿34例临床分析

目的探讨双极电凝镊联合超声刀经颈部入路切除胸骨后甲状腺肿治疗经验。 方法回顾性分析2013年7月至2020年12月收治的34例胸骨后甲状腺肿患者的病例资料。 结果根据术前分型，其中Ⅰ型9例，Ⅱ型17例，Ⅲ型8例。34例患者中，无明显临床症状者23例，表现为怕热多汗者1例，表现为吞咽困难、呼吸困难、声音嘶哑等压迫症状者10例。术后病理显示：良性31例，甲状腺乳头状癌1例，甲状腺滤泡性癌1例，甲状腺神经鞘瘤1例。患者均首选经颈部入路手术，其中有4例联合了胸骨劈开术。术后并发症发生率8.8%（3/34），均为术后暂时性四肢麻木，补钙治疗后症状消失，均顺利出院。 结论经过充分的术前评估和准备，双极电凝镊联合超声刀经颈部入路切除胸骨后甲状腺肿是安全有效的，能在手术过程中实施“精细化解剖”，最大限度地保护甲状旁腺、喉返神经等甲状腺周围组织器官。     

Improvement of vocal cord paresis after thyroidectomy

Iatrogenic vocal cord paralysis is a well-publicized complication of thyroid and parathyroid operations. Less appreciated is the improvement of vocal cord function after resection of a thyroid or parathyroid tumor. Over the last 22 years, 14 patients presented with vocal cord paresis in the presence of thyroid or parathyroid tumors. Of these 14 patients, nine had complete resolution of paresis following resection of the thyroid or parathyroid tumors: three had a thyroid carcinoma impinging upon the nerve, three had large colloid goiters, two had a follicular adenoma and one had a parathyroid adenoma displacing the nerve. In five of the 14 patients the vocal cord paralysis persisted after operation. In three, the pathology accounted for the vocal cord paralysis and was not amenable to operative improvement: one patient had an unresectable anaplastic thyroid carcinoma, one patient had long-standing idiopathic unilateral vocal cord paralysis, and one patient had laryngeal adenoid cystic carcinoma with thyroid invasion. The fourth patient had an extensive thyroid hemangioma. The paralysis persisted after resection. The fifth patient had long-standing idiopathic vocal cord palsy. A preoperative vocal cord paresis in a patient with thyroid or parathyroid disease does not indicate permanent loss of recurrent nerve function, even in the presence of carcinoma. In this series, vocal cord function was restored in 9 of 10 patients with resectable thyroid or parathyroid tumors.     

Horner's syndrome after posterior spinal fusion in a child: a case report

STUDY DESIGN: A case report of a complication after posterior spinal fusion. OBJECTIVES: To present the clinical findings of a Horner's syndrome after posterior spinal fusion. SUMMARY OF BACKGROUND DATA: A 14-year-old girl underwent posterior spinal fusion for idiopathic scoliosis. METHODS: Clinical examination and pharmacologic pupillary testing were used to diagnose Horner's syndrome. RESULTS: After surgery, the patient developed a left-sided Horner's syndrome. The Horner's syndrome had resolved 6 months after surgery except for slight ptosis. CONCLUSIONS: This is the first reported case of Horner's syndrome occurring after posterior spinal fusion without the use of epidural analgesia.     

原发性甲状腺功能亢进症合并甲状腺癌的诊断与治疗：附31例报告

目的：探讨甲状腺功能亢进症（甲亢）合并甲状腺癌（甲癌）的临床病理特点。 方法：回顾性分析吉林大学第一医院甲状腺外科2010年1月—2013年8月收治的甲亢合并甲癌患者临床资料,并结合文献比较。 结果：手术治疗甲亢患者85例,其中31例（36.5%）合并甲癌。术前结合临床表现和颈部超声结果甲亢合并甲癌确诊率80.6%（25/31）。31例患者待甲亢症状得到控制、甲状腺功能经检查恢复正常后行手术治疗,并根据具体情况选择术式,术后均顺利出院,未发生永久性医源性喉返神经损伤及甲状旁腺功能减退。经术后病理证实,1例为髓样癌,30例为甲状腺乳头状癌;17例（54.8%）侵及被膜者,9例（29.1%）中央区淋巴结转移,各项病理特点与文献报道的单纯甲癌比较,差异均无统计学意义（均P>0.05）。 结论：甲亢伴甲癌发病率有增高趋势,应强调颈部超声在该病早期诊断中的重要性,确诊后尽早行手术治疗并合理选择手术方式,预后较好。

     

Perforated appendicitis: current experience in a Childrens Hospital.

A review of 89 consecutive cases of perforated appendicitis recently treated surgically at Childrens Hospital of Los Angeles revealed no mortality and a complication rate of 17%. Significant factors in this low morbidity are: adequate preoperative resuscitation, routine administration of broad spectrum antibiotics pre and postoperatively, and attention to surgical detail. Anaerobic organisms were invariably present in cultures of the peritoneal fluid taken at operation. Anaerobes were also present in the blood in all 5 patients having positive blood cultures and were frequently pathogens whenever postoperative infectious complications occurred. The use of antibiotics effective against anaerobic organisms was common in this series and produced no morbidity.