Total Thyroidectomy Is Superior to Subtotal Thyroidectomy for Management of Graves’ Disease in the United States

Background  

In the United States, Graves’ disease is most commonly treated with radioiodine, yet thyroidectomy remains an important option for correcting hyperthyroidism. In many countries, limited access to thyroid hormone makes subtotal thyroidectomy the procedure of choice. In the United States, where levothyroxine is widely available, we hypothesized that total (TT) or near-total thyroidectomy (NT) is superior to subtotal thyroidectomy (ST) for long-term control of Graves’ disease.     

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

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

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

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

Pharmacogenetics of Osteoporosis: What is the Evidence?

The early genetic prediction of personal drug therapy outcome, both in terms of identification of poor responders or nonresponders, as well as of subjects at risk of developing adverse reactions, and its translation into the clinical practice are the main challenges of personalized medicine. The application of pharmacogenetic predictive tests will be very useful mostly in cases of chronic disorders, as in metabolic bone diseases, that require long-term treatments and for whom exist effective differently acting drugs to be alternatively chosen. Pharmacogenetic tests, prior to drug administration, would hypothetically grant the optimization of drug therapy, based on patient's genotype, to ensure maximum efficacy with minimal adverse effects. This review aims to offer an overview on the principal findings in the field of pharmacogenetics of osteoporosis, and it will discuss future perspectives and possible clinical applications of pharmacogenetic tests for antiresorptive drugs.     

Endoscopic Thyroidectomy via Breast Approach for Patients with Graves’ Disease

Background  

Endoscopic thyroidectomy via breast approach provides excellent results from a cosmetic viewpoint. We applied this procedure to Graves’ disease and evaluated its feasibility and outcomes.     

Management of syndesmotic injuries:What is the evidence?

Ankle fractures are accompanied by a syndesmotic injury in about 10% of operatively treated ankle fractures. Usually, the total rupture of the syndesmotic ligaments with an external rotation force is associated with a Weber type B or C fracture or a Maisonneuve fracture. The clinical assessment should consist of a comprehensive history including mechanism of injury followed by a specific physical examination. Radiographs, and if in doubt magnetic resonance imaging, are needed to ascertain the syndesmotic injury. In the case of operative treatment the method of fixation, the height and number of screws and the need for hardware removal are still under discussion. Furthermore, intraoperative assessment of the accuracy of reduction of the fibula in the incisura using fluoroscopy is difficult. A possible solution might be the assessment with intraoperative three-dimensional imaging. The aim of this article is to provide a current concepts review of the clinical presentation, diagnosis and treatment of syndesmotic injuries.     

Partial Thyroidectomy for Papillary Thyroid Microcarcinoma: Is Completion Total Thyroidectomy Indicated?

Background

Total thyroidectomy is a well-established surgical approach for the management of papillary thyroid cancer (PTC). However, the best surgical approach for papillary microcarcinoma is nowadays still debated. Both total thyroidectomy and simple lobectomy are used. We report the experience of a single University center in the treatment of thyroid microcarcinoma.

Methods

A retrospective analysis on all patients who underwent thyroid surgery at our institution over a 24-year period (1991–2015) was performed. Patients were grouped according to whether they received total thyroidectomy (Group 1) or lobectomy (Group 2). Follow-up was made by routine clinical and ultrasound examination. Specific outcomes such as recurrence and need for reoperation as well as complications (transient vocal cord paralysis and hypocalcemia) were analyzed.

Results

During the study period 880 patients underwent surgery for PTC. Group 1 and 2 consisted, respectively, of 756 and 124 patients. A micro PTC (<10 mm) was present in 251 and 69 specimen of Group 1 and 2. No evidence of disease recurrence in the follow-up was reported in patients with microPTC in Group 1 and in 57 patients of Group 2. In the remaining 12 patients completion thyroidectomy was carried out due to ultrasound findings of contralateral nodules (10), lymphadenopathy (1), and capsular invasion (1). Five of these patients had a contralateral papillary carcinoma on final histopathologic examination. Thus recurrence rate for patients of Group 2 was 7.3 %. Morbidity rates were, respectively, for Group 1 and 2: transient nerve palsy 81 and 5 (11 vs. 7.3 %, p = ns), transient hypoparathyroidism (Calcium <2.00 mmol/L) 137 (18.6 %) and 0 (p < 0.0001). Three of the 12 patients of Group 2 undergoing further surgery had a transient hypoparathyroidism.

Conclusions

Thyroid lobectomy is an effective surgical strategy to manage papillary microcarcinomas with low complications. Routine completion thyroidectomy is not mandatory. Appropriate selection excluding high-risk patients is of paramount importance in order to achieve the best results.

     

Is Total Thyroidectomy the Surgical Procedure of Choice for Benign Multinodular Goiter? An Evidence-Based Review

BACKGROUND: Benign multinodular goiter is one of the most common endocrine surgical problems. The appropriate surgical procedure for its effective and safe management is a matter of debate. Though seen by some as an overly hazardous procedure because of the risk of recurrent laryngeal nerve injury and damage to parathyroid function, total thyroidectomy has replaced subtotal thyroidectomy as the procedure of choice, as the latter is associated with significant recurrences. METHODS: A systemic literature review was undertaken of all available medical literature to evaluate whether total thyroidectomy is the appropriate, safe and effective surgical procedure for benign multinodular goiter. RESULTS: There is consistent level II-IV evidence that subtotal thyroidectomy results in recurrence in up to 50% patients. Incidental thyroid cancers are detected in 3%-16.6% of apparently benign goiters in numerous studies, mostly providing level IV evidence, one third of which would need further surgical treatment after subtotal thyroidectomy. Studies comparing subtotal thyroidectomy and total thyroidectomy, including two each of prospective randomized and prospective nonrandomized ones, provide level II-IV evidence that permanent complication rates associated with subtotal thyroidectomy and total thyroidectomy are not different, although the rate of transient hypocalcemia is higher with total thyroidectomy. On basis of these findings, a grade B recommendation can be made that subtotal thyroidectomy is associated with significant recurrence of goiter, leaves a small number of incidentally detected thyroid cancers inadequately treated, and provides little significant safety advantage over total thyroidectomy. Grade C recommendations can also be made about total thyroidectomy being a safe and effective procedure for benign multinodular goiters in the hands of expert surgeons, based on the extensive level IV evidence, and limited level II and level III evidence, which show that the risk of permanent vocal cord palsy and hypoparathyroidism associated with total thyroidectomy is below the acceptable 2% rate, but not without exceptions. CONCLUSION: Total thyroidectomy is the procedure of choice for the surgical management of benign multinodular goiter.     

Should We Investigate Prostatic Inflammation for the Management of Benign Prostatic Hyperplasia?

ContextAlthough benign prostatic hyperplasia (BPH) is the most frequent disease in elderly men, only a few predictive factors have been identified. Recently, prostatic inflammation has emerged as one of them.ObjectiveThis review describes the relationship between inflammation and BPH prognosis that emerges from the literature.Evidence acquisitionPublications relating to the role of inflammation in BPH were identified by searching PubMed Medline database. Basic science and clinical studies were reviewed.Evidence synthesisAt 12-wk gestation, few inflammatory cells can be observed in the prostatic gland. This amount progressively increases and is more frequent in surgery-derived specimens than in young normal prostates. In fact, almost 80% of surgery-derived specimens show signs of inflammation. Microscopic and immunohistochemical analysis of the inflammatory infiltrate has shown a vast majority of antigen-presenting cells; these immune cells could ensure the sterility of the genitourinary tract. However, immune cells are also releasing numerous cytokines and growth factors that recruit other cells that promote the growth of epithelial and stromal prostatic cells. This process finally results in prostate enlargement. Because of the relationship between BPH and inflammation, anti-inflammatory treatments have been tested in BPH and have been shown to improve urinary symptoms. They could therefore be proposed to treat BPH patients with prostatic inflammation. Although inflammation can be diagnosed on prostate biopsy, noninvasive biomarkers that could be used to monitor BPH treatment are still needed.ConclusionsChronic prostatic inflammation is a risk factor for prostate enlargement, BPH symptoms, or acute urinary retention. For BPH patients with inflammation, close surveillance and therapies that exert anti-inflammatory effects could therefore be proposed. However, reliable biomarkers have not yet been validated to detect prostatic inflammation in routine clinical practice.     

What is the Evidence for Total Knee Arthroplasty in Young Patients?: A Systematic Review of the Literature

Background  

TKA is commonly performed to treat advanced inflammatory and degenerative knee arthritis. With increasing use in younger patients, it is important to define the best practices to enhance clinical performance and implant longevity.     

What is the evidence for the efficacy of cryoplasty?

Cryoplasty is a technique for treating vascular stenosis which combines balloon angioplasty with cold injury. The combination is proposed to reduce the incidence of restenosis by inhibition of neointimal hyperplasia. There have been several clinical studies which purport to show improved patency compared to conventional angioplasty. Unfortunately, these are not comparative or controlled studies and have not been performed, analyzed or reported in accordance with recognized reporting standards for peripheral vascular intervention. The studies on femoropopliteal disease have selected favourable patients. Of greatest concern is the use of surrogate endpoints in lieu of objective demonstration of vessel patency. Critical interpretation of the results fails to demonstrate any convincing superiority of cryoplasty compared to conventional balloon angioplasty. Where little difference in outcome exists between two techniques, a trial comparing them will require hundreds of patients to be sufficiently powered to demonstrate a benefit of one technique over the other. As cryoplasty is significantly more expensive than conventional angioplasty, the cost benefit ratio is unfavourable and such a trial is unlikely to occur.This article is a critical review of the technique of cryoplasty. The reader will be able to: describe expected outcomes from balloon angioplasty; describe the theoretical role for cold injury as a component of angioplasty; recognize the need to adhere to well defined standards when reporting the results of new techniques for treating vascular disease; critically review the results of cryoplasty; understand the limitations and relevance of the published clinical results of cryoplasty.     

Papillary Thyroid Carcinoma in Pregnancy: A Variant of the Disease?

Background

There are conflicting reports in the literature regarding the prognostic influence of pregnancy on patients with papillary thyroid carcinoma (PTC), and there is no literature on specific microRNA (miRNA) profiles of PTC in the context of pregnancy. We aim to examine clinically if pregnancy is an adverse factor in PTC, and if pregnancy-associated PTC are biologically different from those in nonpregnant women in terms of their miRNA profiles.

Methods

Women diagnosed with PTC during or soon after pregnancy were recruited into the pregnancy group. Age-matched nonpregnant females were recruited into the nonpregnancy group. MiRNA microarray was performed on PTC tissue of pregnant patients (10), nonpregnant patients (10), and normal thyroids (5). There were 6 differentially expressed miRNAs from the microarray comparisons validated with RT-PCR.

Results

There were 24 patients in the clinical pregnancy group and 30 in the nonpregnancy group. Tumors from the pregnancy group were significantly larger and showed more regional lymph node metastases. The microarray data showed a total of 27 miRNAs that were potential differentiators of PTC tissue samples from pregnant and nonpregnant patients. Of the 6 selected for validation, no significant difference in expression was found.

Conclusions

Our clinical data suggests that PTC during pregnancy may be more locoregionally aggressive. However, no difference in survival or recurrence is demonstrated. The miRNA profiles of the pregnancy-associated PTC have not been shown to be different to the nonpregnancy counterparts. This likely suggests that the differences seen clinically are related to patient factors rather than the disease itself.     

What is the outcome of treatment for osteolysis?

Periprosthetic osteolysis secondary to wear-induced particle generation is a common long-term complication of hip and knee replacement and frequently results in the need for revision surgery. Management of significant bone defects remains a surgical challenge. Surgical intervention must address the wear particle generator (usually, but not always, the bearing surface), the osteolytic defects, and implant-related issues, primarily fixation and alignment. Indications for surgical intervention in the absence of loosening and pain are not well established. In general, patient age and activity level, the location and size of the osteolytic defect, and the clinical record of the implant system will dictate treatment choices.     

Gastroparesis: What is the Current State-of-the-Art for Evaluation and Medical Management? What are the Results?

Gastroparesis is a chronic motility disorder that leads to delayed gastric emptying and negatively impacts morbidity, mortality, and quality of life. This paper provides an overview of the pathophysiology leading to symptoms in gastroparesis, discusses tests for diagnosis, and examines the evidence behind different treatment options for gastroparesis. Although delayed gastric emptying is the cardinal finding in gastroparesis, other physiologic abnormalities may contribute to the pathogenesis of symptoms. Gastric emptying scintigraphy is considered the gold standard for the diagnosis of gastroparesis but novel tests are currently available. Although metoclopramide is the only FDA approved medication to treat gastroparesis, alternative therapeutic options are available and should be tailored according to symptoms as well as physiologic abnormalities.     

What is the Future of Surgery in the UK?

Surgery is an invasive form of treatment and must be a ‘last resort’. Research into conditions that can be treated by surgery aims to make it extinct, by discovering the basis for various disease processes and treating them medically. A prime example of this is peptic ulceration, which was the ‘bread and butter’ of surgical training in the UK in the 1970s and 1980s, but is now a condition that has almost vanished from the surgical lexicon with the discovery of Helicobacter pylori and its treatment by triple therapy and proton pump inhibitors. In the ‘molecular age’, there is a strong possibility that other areas of surgery (which currently keep many surgeons occupied) will also diminish in volume and importance. Further, it would be worth looking briefly at a number of different specialties within surgery and speculating where changes may occur in the future, perhaps making operations less necessary. In those areas where molecular advances have not (or will not) eradicate open surgery, there will be a definite tendency towards minimally invasive procedures, even though the introduction of such procedures is seldom evidence based.