Cases Of Permanent Hypoparathyroidism Research Articles

Surgical treatment of tertiary hyperparathyroidism: does one fit for all?

Tertiary hyperparathyroidism (3HPT) is defined as a condition of excessive autonomous excretion of intact parathyroid hormone (iPTH) with persistent hypercalcemia (>10.5 mg/dL) that lasts for more than 12 months after a successful kidney transplantation, in the context of a long course secondary hyperparathyroidism (2HPT). The chronic high levels of iPTH cause a worsening of graft function, accompanied by systemic symptoms of hypercalcemia. The only curative therapy is parathyroidectomy (PTX). It remains unclear whether total parathyroidectomy with autotransplantation (TPTX-AT) or subtotal parathyroidectomy (SPTX) lead to better outcomes. The aim of this retrospective, single-institution cohort study is to evaluate the rate of persistent or recurrent disease and postoperative calcium/iPTH disturbances in patients treated with TPTX-AT or SPTX for 3HPT. A single-center retrospective analysis of 3HPT patients submitted to TPTX-AT or SPTX between 2007-2020 with at least 24 months follow-up was conducted. The outcome parameters included persistence/recurrence of disease, incidence of transitory hypocalcemia, and temporary/permanent hypoparathyroidism. A cohort of 52 patients was analyzed and divided in two groups: 38 (73%) were submitted for TPTX-AT, and 14 patients (27%) were submitted for SPTX. The TPTX-AT population showed lower plasmatic calcium concentrations compared with the SPTX group during the entire follow-up period (p<0.001). There were eight cases (21%) of transitory hypocalcemia in the TPTX-AT group and none in the SPTX group, with p=0.065. Two cases (5%) of temporary hypoparathyroidism occurred in the TPTX-AT group and none in the SPTX group, with p= 0.530. There were no cases of permanent hypoparathyroidism and no cases of persistent disease. No statistical difference was assessed for the recurrence of 3HPT between the TPTX-AT group and the SPTX group (N=1, 3% vs N=1, 7%) (p=0.470). No significative difference was registered between the TPTX-AT and SPTX groups in terms of persistence/recurrence of disease, incidence of transitory hypocalcemia, and temporary/permanent hypoparathyroidism. Mean calcium levels iPTH values were statistically lower among the TPTX-AT group compared with the SPTX group while remaining always in the range of normality.

Transoral Thyroidectomy: Initial Results of the European TOETVA Study Group

BackgroundThe aim of this study was to evaluate a new surgical technique by the European Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) Study Group.MethodsThis study included 391 patients (47 [(12%]) male and 344 [(88%)] female) who had undergone endoscopic thyroid or parathyroid surgery via the vestibular approach between February 2016 and May 2022 at nine centers. The data were analyzed with regard to complications, surgery time and specimen retrieval.ResultsOverall, 376 (96.2%) TOETVA and 15 (3.8%) transoral endoscopic parathyroidectomy vestibular approach interventions were performed with an average surgery time of 145 (± 61.2) minutes and 509 nerves at risk. The specimens were retrieved via a transoral vestibular and retroauricular approach in 66 (16.9%) patients and via a transaxillary approach in 8 (2%). Benign histology including Grave’s disease was identified in 272 (69.6%) patients, 1 (0.3%) presented noninvasive follicular thyroid neoplasms with papillary-like nuclear features, and 103 (26.3%) showed differentiated thyroid carcinoma. Solitary parathyroid adenoma were removed in 15 (3.8%) patients. Conversion to open surgery was necessary in 13 (3.3%) and revision had to be performed in 2 (0.5%) patients. Transient recurrent laryngeal nerve palsy (RLNP) was present in 18 (4.6%) and permanent RLNP in 2 (0.5%) patients. Fifteen (3.8%) patients experienced transient hypoparathyroidism after thyroidectomy. No case of permanent hypoparathyroidism was observed. Postoperative surgical site infection occurred in 1 (0.3%) patient. Despite a higher rate of sensory and motor disorders and skin discoloration at discharge, permanent disorders were present in only 3 (0.8%) and 16 (4.1%) patients, respectively.ConclusionOur results show that transoral endoscopic surgery, performed by experienced endocrine surgeons, is a safe alternative to conventional thyroid surgery.

Quality of life and surgical outcome of ABBA versus EndoCATS endoscopic thyroid surgery: a single center experience

BackgroundThyroid surgery is often performed, especially in young female patients. As patient satisfaction become more and more important, different extra-cervical “remote” approaches have evolved to avoid visible scars in the neck for better cosmetic outcome. The most common remote approaches are the transaxillary and retroauricular. Aim of this work is to compare Endoscopic Cephalic Access Thyroid Surgery (EndoCATS) and axillo-bilateral-breast approach (ABBA) to standard open procedures regarding perioperative outcome and in addition to control cohorts regarding quality of life (QoL) and patient satisfaction.MethodsIn a single center, 59 EndoCATS und 52 ABBA procedures were included out of a 2 years period and compared to 225 open procedures using propensity-score matching. For the endoscopic procedures, cosmetic outcome, patient satisfaction and QoL (SF-12 questionnaire) were examined in prospective follow-up. For QoL a German standard cohort and non-surgically patients with thyroid disease were used as controls.ResultThe overall perioperative outcome was similar for all endoscopic compared to open thyroid surgeries. Surgical time was longer for endoscopic procedures. There were no cases of permanent hypoparathyroidism and no significant differences regarding temporary or permanent recurrent laryngeal nerve (RLN) palsies between open and ABBA or EndoCATS procedures (χ2; p = 0.893 and 0.840). For ABBA and EndoCATS, 89.6% and 94.2% of patients were satisfied with the surgical procedure. Regarding QoL, there was an overall significant difference in distribution for physical, but not for mental health between groups (p < 0.001 and 0.658). Both endoscopic groups performed slightly worse regarding physical health, but without significant difference between the individual groups in post hoc multiple comparison.ConclusionEndoscopic thyroid surgery is safe with comparable perioperative outcome in experienced high-volume centers. Patient satisfaction and cosmetic results are excellent; QoL is impaired in surgical patients, as they perform slightly worse compared to German standard cohort and non-surgical patients.

The significance of preoperative cervical thoracic enhancement CT and CTA in the selection of different tumor surgical methods at the base of the neck to minimize complications

Objective:To explore the significance of preoperative cervical thoracic enhancement CT and CTA in the selection of different tumor surgical methods at the base of the neck to minimize complications. Methods:Analysing the clinical data of 51 patients who had cervical root tumor surgery, including 24 benign lesions and 27 malignant tumors. Enhanced CT and/or CTA examinations were used before surgery to understand the relationship between tumors and/ or recurrent or metastatic lesions and the unnamed arteriovenous, internal jugular arteriovenous, clavicular arteriovenous, thyroid neck, and cone arteries of the cervical root. According to the preoperative enhanced CT and/or CTA, the tumor was removed by a simple neck incision approach or an endoscopic assisted neck incision approach or a combined neck and chest approach. Results:The patients were followed up for 6 months to 10 years. All 24 benign lesions were completely removed. Twenty-seven cases of malignant tumors were completely resected, 2 cases were palliative and cytoreductive, and no death occurred during the operation; There were 2 cases of hoarseness in 27 cases of malignant tumors in this group; 1 case of permanent hypoparathyroidism, died of complications 1 year after surgery; 1 case of subclavian artery injury and 1 case of subclavian vein rupture, repaired during operation; 2 cases of chylous leakage were cured after timely negative pressure suction and compression; 1 case of pleural trauma was repaired during the operation; 1 case of brachial plexus nerve and sacral nerve injury. One case had mediastinal infection after median dehiscence of the sternum was cured after 3 months of treatment. Conclusion:For different nature and different types of tumors at the neck-thoracic junction, appropriate surgical approaches should be selected according to preoperative enhanced CT and CTA to fully expose the tumors. While effectively protecting important neurovasculature, timely and effective treatment of intraoperative complications, so that it is feasible to safely remove part of the cervical root tumor.

Ultrasound-Guided Radiofrequency Ablation Versus Surgery for Low-Risk Papillary Thyroid Microcarcinoma: Results of Over 5 Years' Follow-Up.

Background: Papillary thyroid microcarcinoma (PTMC) typically carries an excellent prognosis regardless of the treatment option pursued. Radiofrequency ablation (RFA) for thyroid disease has been utilized for benign lesions and in patients who are poor surgical candidates for thyroid cancers with compression symptoms, but the efficacy and limitations of RFA as first-line therapy for PTMC has not been described in adequate detail. The purpose of our study was to investigate RFA versus thyroidectomy in terms of efficacy, oncologic outcomes, quality of life, complications, and costs over a 5-year period of follow-up. Methods: From January 2013 to November 2013, 174 consecutive patients with an isolated, solitary intrathyroidal PTMC were identified in a Chinese teaching hospital. Those with more aggressive or advanced PTMCs were not included. Ninety-four patients elected RFA and 80 patients elected surgery for treatment of these PTMC. Nodules were confirmed to be PTMC without an aggressive histological type by core needle biopsy in the RFA group and by final surgical pathology in the surgery group. The extent of surgery was decided based on patient preferences in consultation with the surgeons. Of all the patients, 58 (72.5%) underwent lobectomy, 22 (27.5%) underwent total thyroidectomy, and 53 (66.3%) underwent lymph node dissection. Pre- and post-treatment variables were compared between the two groups, including demographics, tumor characteristics, treatment, local tumor progression, lymph node metastasis, distant metastasis, local recurrence, complications, and quality-of-life findings. Results: Patient-specific variables were similar between groups, as were oncologic outcomes after 5 years of follow-up. When compared with RFA, surgery took longer, had a longer hospitalization time, and was costlier (all p < 0.001). The surgery group had three complications, with 2 (2.5%) permanent recurrent laryngeal nerve injuries and 1 (1.3%) case of permanent hypoparathyroidism, while none was reported in the RFA group (p = 0.095). The surgery group had a lower post-treatment thyroid-related quality of life. Conclusions: For carefully selected low-risk intrathyroidal PTMC, RFA was not oncologically inferior to open surgery, and it was associated with a higher quality of life and lower overall costs.

Near-infrared autofluorescence in thyroid and parathyroid surgery.

Contrast-free autofluorescence (AF) of the parathyroid glands (PTGs) and thyroid tissue occurs in the near-infrared (NIR) spectrum on excitation by light in the upper range of the visible spectrum or lower NIR spectrum. In vivo, PTGs autofluoresce more brightly than thyroid (by a factor of 2-20 times) and appear as a bright spot against surrounding thyroid, muscle or fat on a processed image which is generated in real-time. NIR-AF of PTGs was first described in 2009 although NIR-AF had previously been used in several other clinical applications. Since then there has been a great amount of interest in the use of NIR-AF in thyroid and parathyroid surgery with over 25 published reports of the utilisation of both self-built and proprietary NIR-AF devices in neck endocrine surgery. All of these reports have confirmed the feasibility of NIR-AF intraoperatively and its ability to detect PTGs, although the reported accuracy varies from 90-100%. Reports of the effect of NIR-AF on relevant clinical endpoints i.e., post-operative hypoparathyroidism in thyroidectomy and persistent disease in parathyroidectomy are however scant. There has been one multicentre clinical trial of NIR-AF in thyroidectomy but this did not report clinical outcomes and two single-centre, non-randomised studies which did report post-operative hypoparathyroidism but with differing results: one showing no benefit in 106 NIR-AF vs. 163 controls and one, a reduction of early hypocalcaemia from 20% to 5% in 93 NIR-AF patients vs. 420 controls. There were only 2 cases of permanent hypoparathyroidism across both studies and therefore no significant observable difference in this key outcome variable. In parathyroidectomy, possible variability of the AF signal due to composition of a PTG adenoma, secondary/tertiary disease and MEN1 as well as depth-penetration preventing detection of sub-surface PTGs would imply that NIR-AF in its current form is not well-placed to improve cure-rates in hyperparathyroidism, which may already be as high as 98%. Thus far, no study has addressed this. Despite the promising results of NIR-AF, the absence of data demonstrating an improvement in outcomes and the cost of its use currently limit its use in routine clinical practice, especially in a publicly funded healthcare system with budgetary constraints. However, it can be utilised in research settings and this should be undertaken within the context of well-designed and conducted randomised, multi-centre, appropriately powered studies, which will assist in establishing its role in neck endocrine surgery.

Hypoparathyroidism following thyroidectomy: Predictive factors

ObjectiveTo evaluate the incidence and predictive factors for transient and permanent hypocalcemia and hypoparathyroidism following thyroidectomy. MethodWe studied all the 162 patients that underwent thyroid surgery in the ENT department of the Centro Hospitalar Vila Nova Gaia/Espinho from January 2005 to December 2014. We reviewed pre-operative, 6h and 12h after surgery ionized calcium and PTH levels. All patients were reviewed and evaluated according to the following criteria: gender, age, thyroid function, histologic diagnosis of the specimen, surgery extension and presence or absence of hypoparathyroidism. ResultsThere were 31 (19.1%) cases of transient hypoparathyroidism and 8 (5%) of permanent hypoparathyroidism. No significant difference was found for transient hypoparathyroidism when patients were analyzed by gender. However, all cases of permanent hypoparathyroidism were observed in female individuals.Comparing hemithyroidectomy with all other surgical procedures, we found that extension of surgery was a great predictor of transient (p=0.0001) and permanent (p=0.001) hypoparathyroidism.Diagnosis of malignancy was a strong predictor of transient hypoparathyroidism (p=0.002). It was also associated with permanent hypoparathyroidism, although differences did not reach statistical significance (p=0.096). ConclusionExtension of surgery (total thyroidectomy) and diagnosis of malignancy are predictors of transient and permanent hypoparathyroidism.

Parathyroid reimplantation with PR-FaST technique in unselected patients during thyroidectomy. A case series with long term follow up confirming graft vitality and parathormone production

IntroductionParathyroid damage or unintentional excision still affect thyroid surgery and may cause permanent hypoparathyroidism. The only way to recover the excised or ischemic gland functionality is still reimplantation. Many sites of reimplantation have been described, each of one showing both advantages and drawbacks. The aim of this study is to verify results of a new procedure called PR-FaST: Parathyroid Reimplantation in Forearm Subcutaneous Tissue, in a series of unselected patients after long-term follow-up. Materials and methodsFrom January 2013 to October 2015, 296 consecutive total thyroidectomies have been performed) to treat both benign and malignant thyroid diseases. in 42 cases (14.1%), due to an insufficient blood supply or accidental removal, one parathyroid gland was reimplanted with the PR-FaST technique. Post-operative evaluation was carried out by: total serum calcium (Ca), magnesium (Mg) and phosphorus (P) analysis in the 1st and 2nd postoperative days; Ca, Mg, P and serum iPTH from both arms analysis one week after surgery; Ca and iPTH measurement from both arms 1 months, 3, 6 and 12 months after surgery. ResultsWe observed transient hypocalcemia requiring calcium replacement therapy in 5 on 42 (11.9%) patients submitted to PR-FaST. No case of permanent hypoparathyroidism was reported. At 1 week after surgery, only 20 patients (47.6%) showed graft vitality, while the number of patients showing graft vitality arised to 33 (79%) after 1 month and to 39 (92.8%) after three and six months. At 1 year 38 (90.5%) patients showed good graft functionality. Considering levels of serum iPTH from both arms, we observed that in case of graft functionality, samples from reimplanted arm revealed in almost all cases values at least 2–3 folds higher than in non reimplanted arm. ConclusionsResults from this prospective evaluation suggest that PR-FaST is a safe and effective procedure, with potential advantages when compared to other techniques of parathyroid reimplantation, that are mainly the possibility to evaluate graft functionality in the follow-up and the easy and well reproducible technique. Furthermore, it can be applied, when needed, to potentially all patients undergoing thyroidectomy.

Perioperative determinants of transient hypocalcemia after pediatric total thyroidectomy

PurposeWe seek to identify risk factors associated with hypocalcemia after pediatric total thyroidectomy. MethodsWe retrospectively reviewed patients younger than 21years undergoing total thyroidectomy between January 2002 and January 2016. We defined hypocalcemia as any serum calcium <8mg/dl or ionized calcium <1.0mmol/L. Perioperative risk factors were identified through multivariate logistic regression. ResultsNinety-one children underwent total thyroidectomy. The average age was 13.7±4.4years, and 77% were female. Transient hypocalcemia was diagnosed in 34% (n=31) of patients. There was one case of permanent hypoparathyroidism. Predictors of transient hypocalcemia included age (OR 0.87, 95% CI 0.8–0.97, p=0.01), lymphadenectomy (OR 6.6, 95% CI 1.7–31.6, p=0.01), and hyperthyroidism (OR 13.3, 95% CI 1.3–1849, p=0.03). Patients with malignancy undergoing central (OR 7.1, 95% CI 1.5–33.4, p=0.01) or central plus lateral lymphadenectomy (OR 6.33, 95% CI 1.0–40.1, p=0.05) had significantly increased risk for transient hypocalcemia. Malignancy, MEN2A/B, goiter, preoperative calcium supplementation, incidental parathyroid removal, and postoperative PTH <15pg/ml were not associated with transient hypocalcemia. ConclusionsYounger age, hyperthyroidism, and concomitant lymphadenectomy during total thyroidectomy increase risk of developing transient hypocalcemia. Malignant cases with central or central plus lateral lymphadenectomy are also at increased risk. Aggressive perioperative management of hypocalcemia should be initiated in patients with these risk factors.Level of evidence: 2b

Hypoparathyroidism following thyroidectomy: Predictive factors

ObjectiveTo evaluate the incidence and predictive factors for transient and permanent hypocalcemia and hypoparathyroidism following thyroidectomy. MethodWe studied all the 162 patients that underwent thyroid surgery in the ENT department of the Centro Hospitalar Vila Nova Gaia/Espinho from January 2005 to December 2014. We reviewed pre-operative, 6h and 12h after surgery ionized calcium and PTH levels. All patients were reviewed and evaluated according to the following criteria: gender, age, thyroid function, histologic diagnosis of the specimen, surgery extension and presence or absence of hypoparathyroidism. ResultsThere were 31 (19.1%) cases of transient hypoparathyroidism and 8 (5%) of permanent hypoparathyroidism. No significant difference was found for transient hypoparathyroidism when patients were analyzed by gender. However, all cases of permanent hypoparathyroidism were observed in female individuals.Comparing hemithyroidectomy with all other surgical procedures, we found that extension of surgery was a great predictor of transient (p=0.0001) and permanent (p=0.001) hypoparathyroidism.Diagnosis of malignancy was a strong predictor of transient hypoparathyroidism (p=0.002). It was also associated with permanent hypoparathyroidism, although differences did not reach statistical significance (p=0.096). ConclusionExtension of surgery (total thyroidectomy) and diagnosis of malignancy are predictors of transient and permanent hypoparathyroidism.

Six-Year Experience With Endoscopic Thyroidectomy: Outcomes and Safety Profile.

Though minimally invasive video-assisted thyroidectomy (MIVAT) offers many advantages over traditional thyroid surgery, its adoption in North America has been limited. This study analyzes the largest series of MIVAT in North America to explore its safety. A prospectively maintained database of all patients undergoing thyroid surgery by a single surgeon from 2003 to 2011 at an academic tertiary care medical center was evaluated. Demographic information, surgical and pathologic data, and postoperative outcomes were analyzed. Beginning in 2005, a total of 260 MIVATs were performed during the study period. Outpatient surgery was accomplished in 234 MIVATs (90%). MIVAT patients were predominantly young (46.8±14.8 years vs 52.4±14.6 years for conventional thyroidectomy) and female (88.5% vs 75.5% for conventional thyroidectomy). There were no cases of permanent hypoparathyroidism or permanent recurrent laryngeal nerve dysfunction. Observed complications included transient recurrent laryngeal nerve dysfunction (n=10; 3.8%), cellulitis (n=1; 0.4%), and temporary hypocalcemia (n=6; 2.3%). The overall complication rate for MIVAT (6.5%) was lower than the overall complication rate in conventional thyroidectomy (18.5%, P<.0001). MIVAT can be performed safely with a low complication profile in a high-volume practice. The safety of MIVAT represented by this experience supports broader adoption across surgical practices.

Validity of early parathyroid hormone assay as a diagnostic tool for sub-total thyroidectomy related hypocalcaemia.

To determine the validity of early (one hour postoperatively) parathyroid hormone (PTH) assay (² 10 pg/ml), keeping gold standard as the serum ionic calcium level, for predicting sub-total thyroidectomy-related hypocalcaemia and to calculate the sensitivity and specificity of latent signs of tetany. Cross-sectional validation study. Department of General Surgery, Pakistan Institute of Medical Sciences, Islamabad from August 2008 to August 2010. Patients undergoing sub-total thyroidectomy were included by convenience sampling. PTH assay was performed 1 hour post sub-total thyroidectomy. Serum calcium levels were performed at 24 and 48 hours, 5th day and 2 weeks after surgery. Cases that developed hypocalcaemia were followed-up for a period of 6 months with monthly calcium level estimation to identify cases of permanent hypocalcaemia. Symptoms and signs of hypocalcaemia manifesting in our patients were recorded. Data was analyzed through SPSS version 10. 2 x 2 tables were used to calculate sensitivity and specificity of PTH in detecting post-thyroidectomy hypocalcaemia. Out of a total of 110 patients included in the study, 16.36% (n=18) developed hypocalcaemia including 1.81% (n=2) cases of permanent hypoparathyroidism. The sensitivity of one hour postoperative PTH assay as a predictive tool for post-thyroidectomy related hypocalcaemia was 94.4% while its specificity was 83.6% with 53% positive predictive value and 98.7% negative predictive value. One hour post sub-total thyroidectomy PTH assay can be helpful in predicting post sub-total thyroidectomy hypocalcaemia. Moreover, it can be useful in safe discharge of day-care thyroidectomy patients.

Perioperative kinetics of parathyroid hormone in unilateral, primary thyroid surgery

Dysfunction of the parathyroid glands is an important cause of complications after thyroid surgery. Intraoperative monitoring of the function of the parathyroid glands can be performed using parathyroid hormone (PTH) kinetics. Unilateral thyroid surgery is associated with a decreased risk for postoperative hypocalcemia (POH) and permanent hypoparathyroidism (PEH). We focused on unilateral thyroid surgery by monitoring the functionality of the parathyroid glands and comparing the perioperative PTH kinetics of patients with and without POH. In a prospective study, 143 patients scheduled for unilateral thyroid surgery underwent monitoring of perioperative changes in serum PTH and serum calcium levels, and of clinical symptoms of hypocalcemia. The rates of POH and PEH were 18.2 and 0%, respectively. In patients without POH, PTH significantly increased from the time of skin incision to the end of the operation and after the operation (20.1 pg/ml, IQR 15.5-26.8 vs. 21.4 pg/ml, IQR 16.4-29.5; p=0.005), which was not the case in patients who developed POH. In a multivariate analysis of predictive factors for POH, two parameters became significant, namely female gender (odds ratio 6.87, 95% confidence interval 0.92-51.01) and lower initial serum calcium levels (odds ratio 3.54*e(-8), 95% confidence interval 3.63*e(-12); 0.00). The rate of POH was unexpectedly high. Rather than intraoperative PTH declines, an unstable balance of factors that influence calcium metabolism likely is the major contributor to POH after unilateral thyroid surgery. There was no case of PEH after unilateral, primary thyroid surgery, which underlines the need for an individualized approach to the extent of resection.

Pediatric Endocrine Surgery: A 20-Year Experience at the Mayo Clinic

Surgically managed endocrinopathies are rare in children. Most surgeons have limited experience in this field. Herein we report our operative experience with pediatric patients, performed over two decades by high-volume endocrine surgeons. The study was conducted at the Mayo Clinic (a tertiary referral center). Patients were <19 years old and underwent an endocrine operation (1993-2012). Demographics, surgical procedure, diagnoses, morbidity, and mortality were retrospectively reviewed. A total of 241 primary cases included 177 thyroid procedures, 13 neck dissections, 24 parathyroidectomies, 14 adrenalectomies, 7 paragangliomas, and 6 pancreatic procedures. Average age of patients was 14.2 years. There were 133 total thyroidectomies and 40 hemithyroidectomies. Fifty-three cases underwent a central or lateral neck dissection. Six-month follow-up was available for 98 total thyroidectomy patients. There were four cases of permanent hypoparathyroidism (4%) and no permanent recurrent laryngeal nerve (RLN) paralyses. Sequelae of neck dissections included temporary RLN neurapraxia and Horner's syndrome. Parathyroidectomy was performed on 24 patients: 20 with primary hyperparathyroidism (HPT), three with tertiary HPT, and one with familial hypocalciuric hypocalcemia. Three patients (16%) had recurrent HPT, all with multiglandular disease. One patient had temporary RLN neurapraxia. We performed seven bilateral and seven unilateral adrenalectomies; eight were laparoscopic. Indications included pheochromocytoma, Cushing's syndrome, adrenocortical carcinoma, congenital adrenal hyperplasia, and ganglioneuroma. One death was due to adrenocortical carcinoma. Five paraganglioma patients had succinate dehydrogenase subunit B mutations, and one recurred. Six patients with insulinoma underwent enucleation (n = 5) or distal pancreatectomy (n = 1). A single postoperative abscess was managed nonoperatively. Pediatric endocrine procedures are uncommon but can be safely performed with complication rates comparable to those of the adult population. It is imperative that these operations be performed by high-volume surgeons.

Ultrasound‐Guided Methylene Blue Dye Injection for Parathyroid Localization in the Reoperative Neck

The goal of this study was to review a single institution's experience using intraoperative ultrasound-guided (ioUSG) methylene blue dye injection for the localization and removal of enlarged parathyroid glands in patients with primary hyperparathyroidism and a history of previous neck surgery. We performed a retrospective review of nine consecutive patients who underwent reoperative parathyroidectomy using ioUSG methylene blue dye injection. All patients had successful resolution of their hyperparathyroidism, with at least a 50 % decrease in intraoperative parathyroid hormone level after resection. One patient had transient recurrent laryngeal nerve paresis. There were no permanent recurrent laryngeal nerve injuries or cases of permanent hypoparathyroidism. Blue dye injection is a safe and effective method of localizing diseased parathyroid glands in the reoperative neck.

Six‐Year Experience with Video‐Assisted Thyroidectomy: Outcomes and Safety Profile

Objectives: 1) Review complication profiles among various thyroidectomy techniques, including conventional, minimally invasive non-endoscopic, minimally invasive video-assisted (MIVAT), and robotic approaches. 2) Analyze factors contributing to the safety profile of MIVAT. 3) Describe potential steps to implement MIVAT in a surgical practice. Methods: The largest single series of MIVAT in North America was reviewed to explore its safety profile. An institutional review board (IRB)-approved prospectively maintained database was queried for all patients undergoing thyroid surgery by a single surgeon from 2003 to 2011. Demographic information, surgical and pathologic data, and post-operative outcomes were analyzed. Results: A total of 1,132 consecutive thyroidectomies were identified. MIVAT was incorporated beginning in 2005. There were 249 MIVATs (164 hemi, 85 total), 399 minimally invasive non-endoscopic thyroidectomies, 441 conventional thyroidectomies, and 43 robotic thyroidectomies. Two hundred twenty-eight MIVATs were accomplished on an outpatient basis. MIVAT patients were predominantly young (46.8 ± 14.8 years old) and female (89%). The mean incision length was 2.3 ± 0.4 cm. No cases of permanent hypoparathyroidism or permanent true vocal fold paralysis occurred. Observed complications included transient vocal fold dysfunction (n = 10; 4.0%), cellulitis (n = 1, 0.4%), and temporary hypocalcemia (n = 5; 2.0%). The overall complication rate for MIVAT was lower than the combined overall complication rate for minimally invasive non-endoscopic, conventional, and robotic thyroidectomy (6.8% vs. 14.8%; P = 0.001). Conclusions: MIVAT can be performed safely with a low complication profile in a high-volume practice. The safety of MIVAT represented by this experience may support expanded implementation.

Thyroid cancer in Graves’ disease: is surgery the best treatment for Graves’ disease?

Graves' disease is a common cause of thyrotoxicosis. Treatment options include anti-thyroid medications or definitive therapy: thyroidectomy or radioactive iodine (I(131) ). Traditionally, I(131) has been the preferred definitive treatment for Graves' disease in New Zealand. Reports of concomitant thyroid cancer occurring in up to 17% of Graves' patients suggest surgery, if performed with low morbidity, may be the preferred option. The aim of this study was to determine the rate of thyroid cancer and surgical outcomes in a New Zealand cohort of patients undergoing thyroidectomy for Graves' disease. This study is a retrospective review of Waikato region patients undergoing thyroid surgery for Graves' disease during the 10-year period prior to 1 December 2011. A total of 833 patients underwent thyroid surgery. Of these, 117 were for Graves' disease. Total thyroidectomy was performed in 82, near-total in 33 and subtotal in 2 patients. Recurrent thyrotoxicosis developed in one subtotal patient requiring I(131) therapy. There were two cases of permanent hypoparathyroidism and one of permanent recurrent laryngeal nerve palsy. Eight patients (6.8%) had thyroid cancer detected, none of whom had overt nodal disease. Five were papillary microcarcinomas (one of which was multifocal), two were papillary carcinomas (11 mm and 15 mm) and one was a minimally invasive follicular carcinoma. Thyroid cancer was identified in approximately 7% of patients undergoing surgery for Graves' disease. A low complication rate (<2%) of permanent hypoparathyroidism and nerve injury (<1%) supports surgery being a safe alternative to I(131) especially for patients with young children, ophthalmopathy or compressive symptoms.

Tireoidectomia total nas doenças benignas da tireóide

To review the indications for total thyroidectomy as the preferred option in certain benign diseases of the thyroid in order to prevent recurrence or future reoperations. A retrospective study of patients with benign thyroid diseases, carried out from January 1997 to December 2009, analyzing the data relating to age, surgical treatment and postoperative evolution. The mean age was 51.8 years (21/77), with the highest incidence in the fifth and sixth decades of life, with 34 (51.5%) patients. The most common preoperative diagnosis was nontoxic multinodular goiter, of which seven were also intrathoracic, followed by autoimmune thyroiditis; recurrent goiter occurred in 11 cases. Multinodular goiter was found in 37 (56.1%) patients, autoimmune thyroiditis in 22 (33.3%), follicular adenoma isolated in five (7.6%), Hurthle cell adenoma in two (3.0%). Sixteen patients (24.2%) had more than one histopathological diagnosis. Permanent injury of the recurrent nerve was observed in one patient (1.5%). There was no case of permanent hypoparathyroidism. There was no operative mortality. Total thyroidectomy is an operation that can be safely performed, with low incidence of permanent complications, which allows one to broaden its indications in various benign thyroid diseases, thus avoiding future recurrences and reoperations.

The role of fine‐needle aspiration cytology in the surgical management of thyroid cancer

Diagnosis of thyroid malignancy relies on clinical assessment, imaging and fine-needle aspiration cytology 'FNAC' of thyroid nodules. The purpose of this study was to evaluate how effective synoptically reported FNAC is in clinical practice in diagnosing thyroid cancer. We also examined the effectiveness of using preoperative FNAC results to plan the type of operation for treating thyroid cancer. A retrospective case series of all patients undergoing thyroid surgery from 1993 to 2008 was analysed. All data were collected prospectively and recorded in a dedicated endocrine surgery database. Data analysed included age, sex, preoperative FNAC result, type of surgery, final histology and complications. Cytology was reported based on a five-tiered classification system. There were 1373 patients in total and 125 patients with a final diagnosis of thyroid cancer. Female to male ratio was 3:1. Cytology reported as 'malignant' was confirmed as thyroid cancer in 100% of the cases. Of the patients, 47% with 'suspicious' cytology report and 14% with 'follicular/indeterminate' cytology report had a final diagnosis of cancer. Thyroid cancer subtypes were 90 patients with papillary thyroid cancer 'PTC', 24 with follicular 'FTC', eight with medullary 'MTC' and two with anaplastic cancer. Cytology was suggestive of cancer in 89% of the patients with PTC >10 mm, 75% with FTC and 88% with MTC. Transient hypocalcaemia was the commonest complication occurring in 7.2%. There were no cases of permanent hypoparathyroidism. Recurrent laryngeal nerve neuropraxia occurred in 2.4% with a permanent palsy occurring in 0.8%. There were three cancer-related deaths. Preoperative synoptically reported FNAC is effective when used in diagnosing and planning surgery for thyroid cancer.

Minimally Invasive Video-Assisted Thyroidectomy

To report the results of a multi-institutional experience with the minimally invasive video-assisted thyroidectomy, which was conceived in Europe and Asia and has only recently been embraced in the United States. Prospective, nonrandomized analysis. Four academic thyroid surgical practices. Consecutive series of 228 patients who required thyroid surgery and were deemed at surgeon discretion to be eligible for a minimal access surgery. Minimally invasive video-assisted thyroidectomy was performed in 216 patients. The data, which were recorded prospectively, included age, sex, indication for surgery, incision length, and complications of surgery. Because conversion to an open approach was required in 12 of the 228 patients, the study group comprised 216 patients (25 men and 191 women; mean [SD] age, 44.5 [14.1] years). There were no hematomas and no cases of permanent hypoparathyroidism or permanent vocal cord paralysis. Nine patients had a transient vocal cord paresis (3.2% of nerves at risk); 5 patients experienced temporary hypocalcemia (8.1% of total thyroidectomies); 1 patient reported a change in voice pitch; and 1 patient required a scar revision. Use of the minimally invasive video-assisted thyroidectomy technique has been adopted cautiously in the United States. The safety of the procedure represented by the data from this multi-institutional experience would support its expanded adoption by high-volume thyroid surgeons.