Permanent Hypocalcemia Research Articles

The effect of body mass ındex on parathyroidectomy complications in primary hyperparathyroidism.

There are few studies evaluating the effect of high body mass index (BMI) on parathyroid surgery. The aim of this study was to examine the relationship between the BMI and post-operative outcome of the patients who were operated for primary hyperparathyroidism (PHP). Hospital files of patients who were operated for PHP between January 2013 and January 2020 were reviewed retrospectively. Patients operated by surgeons experienced in endocrine surgery (more than 25 cases/year) were included in the study. Patients were divided into two groups according to BMI (Group 1 < and Group 2 ≥ 25). Data were analyzed. Groups were similar in terms of age (p = 0.715) and sex (p = 0.253). There was no significant difference between groups regarding postoperative hospital stay (p = 0.561), rate of transient hypocalcemia (p = 0.748), or permanent hypocalcemia (p = 0.530). The mean operative time was shorter in Group 1 (84 min in Group 1 and 70 min in Group 2, p = 0.045). Parathyroid surgery can safely be performed in patients with high BMI by surgeons experienced in endocrine surgery.

Hypocalcemia after parathyroidectomy in patients with a history of bariatric surgery.

A growing body of literature has suggested that a history of bariatric surgery increases the risk of hypocalcemia after subsequent thyroidectomy, however little is known about the risk after parathyroidectomy. The purpose of this study was to determine the incidence of hypocalcemia after parathyroidectomy in patients with prior bariatric surgery. The TriNetX Research Network was queried using diagnosis and procedure codes to identify patients with a history of bariatric surgery who were subsequently diagnosed with primary hyperparathyroidism (PHP) and underwent parathyroidectomy between 2012 and 2022. The rate of hypocalcemia after parathyroidectomy was compared between those with a history of bariatric surgery and controls who underwent parathyroidectomy alone, matched for demographics, body mass index (BMI) ≥ 30 kg/m2, and history of calcium or vitamin D supplementation. There were 34,483 included patients diagnosed with PHP who underwent parathyroidectomy. Of this cohort, 1.4% (n = 472) had prior bariatric surgery. There were 90% females and 10% males in this subset of patients, and the average age was 58 years. Compared to matched controls who underwent parathyroidectomy alone, these patients had a significantly increased risk of hypocalcemia within 0-1 month (RR, 95% CI, P) (17.2% vs. 9.3%; 1.8, 1.3-2.6, P < 0.001), 1-6 months (8.5% vs. 2.5%; 3.3, 1.8-6.3, P < 0.001) and 6-12 months (6.8% vs. 2.3%; 2.9, 1.5-5.7, P < 0.001) following surgery. The current study is the first to indicate that patients with a history of bariatric surgery are at increased risk for short-term and permanent hypocalcemia after parathyroidectomy. Further research is required to determine optimal prevention and treatment strategies to decrease associated morbidity in this subset of patients.

Three-port transoral robotic thyroidectomy without axillary incision: A preliminary report of 20 cases in China.

Transoral scarless thyroid surgery has proven to be a popular alternative to traditional approaches. Transoral robotic thyroidectomy (TORT) has been reported using ports on the lower lip and axilla. Avoiding axillary incision can further reduce scars on the armpit. Here, we present our preliminary data from the initial 20 consecutive patients to explore the feasibility of three-port TORTwithout axillary incision. From September 2017 to June 2019, we performed TORT at Beijing United Family Hospital using three intraoral ports without axillary incision via the da Vinci Si system with three robotic arms. The outcomes of the procedure were retrospectively reviewed. Among 20 patients (mean age 30 ± 7 years; mean tumor size 1.64 ± 0.96 cm), 16 patients underwent unilateral thyroid lobectomy and four had total thyroidectomy with or without central neck dissection. Eighteen patients had papillary thyroid carcinomas (PTC), one had a follicular thyroid carcinoma, and one had a thyroid adenoma. The mean surgical time was 221 ± 68 min. The mean number of retrieved central lymph nodes in the PTC patients was 5.6 ± 5. There was no permanent vocal cord palsy or hypocalcemia postoperatively. One patient had transient vocal cord palsy, which resolved within 1 week. Paresthesia of the lower lip and the chin was observed in nine patients, and one patient had a first-degree burn of the skin flap due to the lens. Three-port TORT without axillary incision is feasible for selected patients and would be a potential alternative for remote-access thyroid surgery to avoid leaving scars on the neck or the armpit.

Surgical description and outcome of ultrasound-guided minimally invasive parathyroidectomy in 50 dogs with primary hyperparathyroidism.

To describe the surgical technique and clinical outcome of minimally invasive parathyroidectomy for primary hyperparathyroidism (PHPT) in the dog. Fifty client-owned dogs with PHPT that underwent minimally invasive parathyroidectomy. Retrospective cohort study. An ultrasound-guided mini lateral approach was made via a plane established between the sternocephalicus muscle and sternohyoideus muscles to expose the thyroid gland and enlarged parathyroid gland. Abnormal parathyroid glands were removed en bloc via partial thyroidectomy. The technique for bilateral disease was similar, the skin incision was made on midline and moved laterally to develop the above-mentioned plane of dissection. Age, sex, breed, bodyweight, ultrasound findings, histopathological diagnosis, surgical time, preoperative clinical signs, and clinical outcome were extracted from the records for descriptive statistics. A total of 62 glands were surgically removed, including 17 hyperplastic glands (17/62, 27.4%), 34 adenomas (34/62, 54.8%), and two carcinomas (2/62, 3.2%). Hypercalcemia resolved shortly after surgery in 44 dogs (44/45, 97.8%). One dog had recurrent hypercalcemia (1/45, 2.2%), one dog had persistent hypercalcemia (1/45, 2.2%), two dogs had permanent hypocalcemia requiring life-long calcitriol supplementation (2/45, 4.4%), and one dog died from clinical hypocalcemia (1/45, 2.2%). Minimally invasive parathyroidectomy was associated with a low morbidity and led to favorable outcomes in 44/45 dogs in this series. The results of this study supports the use of minimally invasive parathyroidectomy to treat PHPT in dogs.

Hypocalcemia After Thyroidectomy in Patients with Prior Bariatric Surgery: A Propensity Score Matched Analysis from a National Administrative Database.

Background: Studies have suggested that patients with prior gastric bypass may be at increased risk for hypocalcemia following thyroidectomy. Unfortunately, most of these studies are limited to case reports and small series. This study represents the largest sample size to date to assess the incidence of post-thyroidectomy hypocalcemia in patients with a history of bariatric surgery. Methods: The TriNetX Research Network was queried to retrospectively identify patients with prior bariatric surgery who underwent total thyroidectomy between 2011 and 2021. The incidence of hypocalcemia following surgery was compared with patients who underwent total thyroidectomy, and hemithyroidectomy with no history of bariatric surgery. Results: We identified 446 patients with a history of bariatric surgery and subsequent thyroidectomy, 29,346 patients with total thyroidectomy, and 19,603 patients with hemithyroidectomy alone. The one-month incidence of hypocalcemia was 54.7% in those with a history of bariatric surgery who underwent thyroidectomy, 43.9% in those with thyroidectomy alone (relative risk, RR = 1.2 [confidence interval, CI 1.1-1.4], p < 0.001), and 8.1% in those with hemithyroidectomy only (RR = 6.8 [CI 6.1-7.4], p < 0.001). Permanent hypocalcemia was documented in 11.4% of patients with prior bariatric surgery who underwent thyroidectomy, 7.7% of those with thyroidectomy only (RR = 1.5 [CI 1.1-1.9], p = 0.003), and 2.9% of patients with hemithyroidectomy alone (RR = 3.9 [CI 3.0-5.2], p < 0.001). Significant differences persisted after matching demographics, prior need for supplementation, and risk factors for hypocalcemia after thyroidectomy. When stratified by bariatric procedure, patients with a history of Roux-en-Y gastric bypass (RYGB) (n = 35) had a greater, although not statistically significant, risk of short-term hypocalcemia (51.4%; RR = 1.2 [CI 0.8-1.6], p = 0.37), and a significantly increased risk of permanent hypocalcemia (20.0%; RR = 2.6 [CI 1.3-5.1], p = 0.005) compared with thyroidectomy alone. Sleeve gastrectomy (SG) (n = 40) was not associated with an increased risk of short-term (40.0%; RR = 0.9 [CI 0.6-1.3], p = 0.62) or permanent (7.5%; RR = 1.0 [CI 0.3-2.9], p = 0.96) hypocalcemia. Conclusions: Prior RYGB, but not SG, may increase the risk of permanent hypocalcemia after thyroidectomy. Additional research is necessary to determine optimal prevention and treatment strategies to reduce morbidity in this population.

Propensity Score Matched Outcome Analysis of Lobar Ablation Versus Completion Thyroidectomy in Low-Risk Differentiated Thyroid Cancer Patients: Median Follow-Up of 11 Years.

Background: Radioactive iodine lobar ablation (RAILA) of the contralateral thyroid lobe has been suggested as an alternative to completion thyroidectomy in patients of differentiated thyroid cancer (DTC) who underwent initial hemithyroidectomy. However, data on long-term outcomes are scarce. In this study, we intended to describe the long-term outcomes of RAILA versus completion thyroidectomy in a cohort of low-risk DTC patients. Methods: Data of patients with low-risk DTC who underwent initial hemithyroidectomy, and were subsequently treated with either completion thyroidectomy or RAILA between 1996 and 2015, were collected and analyzed. The treatment outcomes included ablation rate, recurrence rate, recurrence-free survival (RFS), and adverse events, and were validated by propensity score matching analysis. Results: Of the 1243 patients (median age: 34 years, range: 5-78) with low-risk DTC, 514 patients underwent upfront RAILA while 729 patients underwent completion thyroidectomy followed by remnant ablation. The ablation rate following the first radioactive iodine (131I) cycle was 75.3% [95% confidence interval (CI) 71.3-78.9] in the RAILA group versus 84.1% [CI 81.2-86.6] in the completion thyroidectomy group (p < 0.001). Over median follow-up of 11.4 years (interquartile range: 8.3-15.8), the recurrence rates between the two groups were not significantly different (1.6% [CI 0.7-3.2] vs. 1.0% [CI 0.4-2.1], respectively, p = 0.343). The product limit estimate of RFS at 10 years was 98.6% [CI 97.6-99.6%] in the RAILA group versus 99.1% [CI 98.3-99.9%] in the completion thyroidectomy group (p = 0.391). The outcomes in 497 matched pairs generated through propensity score analysis were similar. None of the patients in the RAILA group experienced permanent hypocalcemia or recurrent laryngeal nerve palsy, while the corresponding rates in the completion thyroidectomy group were 10/729 (1.4%) (p = 0.006) and 5/729 (0.7%) (p = 0.080), respectively. Radiation thyroiditis was seen in 25/514 (4.9%) patients in the RAILA group versus 3/729 (0.4%) in the completion thyroidectomy group (p < 0.001). Conclusions: Upfront RAILA is seen to be a noninvasive, safe, and effective alternative to surgical completion thyroidectomy in low-risk DTC patients in the absence of macroscopic malignancy in the remaining thyroid lobe.

Morbidity Associated With Surgical Removal of Substernal Thyroid Goiters.

Surgical excision of substernal thyroid goiters (STG) can be challenging while minimizing postoperative morbidity. Postoperative complication rates associated with transcervical and transthoracic approaches (i.e., partial or total sternotomy) for STG compared to multinodular goiters (MNG) limited to the neck (i.e., non-substernal) remains unclear. This study examines postoperative morbidity related to surgical approaches in the removal of STG and MNG. A retrospective review of prospectively collected data of 988 patients with STG and non-substernal MNG from a single institution between 2010 and 2021 was performed. Patients were stratified by STG and conventional non-substernal MNG limited to the neck excised by transcervical and transthoracic approach. Postoperative complications including neck hematoma requiring return to the operating room, permanent recurrent laryngeal nerve injury and hypocalcemia, and transient or temporary recurrent laryngeal nerve injury and hypocalcemia were identified. Demographics including age, sex, and race, among others, were analyzed. Of the 988 cases, there were 887 (90%) MNG and 101 (10%) STG. Of the STG cohort, 11 (11%) required a partial sternotomy and 4 (4%) required a total sternotomy. Permanent complication rates for non-substernal MNG and STG patients were 1.5% and 0.9%, respectively. Only transient or temporary hypocalcemia rates were statistically different between the STG and MNG cohorts (9.9% versus 3.8%, P<0.001). Regardless of transcervical or transthoracic approach, postoperative complications associated with the surgical removal of STG are low in the hands of experienced, high-volume thyroid surgeons.

TH8.8 Retrospective study on the safety of thyroid surgery with confirmed benign histology in a UK district general hospital

Abstract Aim With increasingly aging population, more thyroidectomies are being performed in the elderly. These surgeries may be suspected to be unsafe as majority of the geriatric population suffer from comorbidities. Our local study explored the safety of thyroid surgery with confirmed benign histology in the elderly, with the post-operative complication rates being the primary outcome measures. Methods The study group included patients over 75 years who had thyroid surgeries with confirmed benign histology in a UK district general hospital from January 2010 to January 2022. We then analysed the rates of complications including temporary hypocalcemia, permanent hypocalcemia, vocal cord palsy and haematoma. Results 41 elderly patients underwent thyroid surgery with confirmed benign histology in our facility within the period. 78% of them had thyroid lobectomy and the commonest indication for surgery was benign multinodular goitre. There were no haematomas, no permanent vocal cord palsies and no cases of permanent hypocalcemia. Only 3(7.3%) patients had transient hypocalcemia, and 2(4.9%) had vocal cord palsy which all resolved before 6 months. Conclusions Our study has demonstrated that it is generally safe to perform thyroidectomy in the elderly population with low hypocalcemia and vocal cord palsy rates as compared to the British Association of Endocrine and Thyroid Surgeons’ report of 10.2% and 7.8% for hypocalcemia and early cord palsy rates respectively in all age-groups. Nevertheless, we would advocate appropriate patient selection in terms of ASA classification. For example, 50% of those who had post-operative vocal cord palsy in our study had an ASA of 3.

Usefulness of ICG Angiography-Guided Thyroidectomy for Preserving Parathyroid Function.

Hypoparathyroidism is the most frequent complication after total thyroidectomy and, when permanent, it becomes a severe chronic disease. We assessed the usefulness of indocyanine green (ICG) angiography-guided thyroidectomy to reduce the postoperative hypocalcemia. Prospective study with two consecutive cohorts of patients who underwent total thyroidectomy: historical control group (CG) and angiography-guided thyroidectomy group (AG). In all patients, ICG-angiography was performed at the end of the surgery to predict immediate parathyroid gland (PG) function. In the AG, ICG-angiography was also done after PG identification to show their vascular supply. We compared the rate of postoperative hypocalcemia (calcium supplementation needed due to hypocalcemia symptoms or calcium levels < 1.8mmol/L on the first postoperative day) and permanent hypocalcemia (need of calcium ± vitamin D supplementation 12months after thyroidectomy). We included 120 consecutive patients (84 CG; 36 AG). Thyroid cancer was the most common diagnostic (63.1% CG-69.4% AG; p = 0.646) and central neck dissection was also frequent (54.8% CG-64.3% AG; p = 0.468). The AG developed a lower rate of postoperative (26.2-5.6%; p = 0.011) and permanent hypocalcemia (11.9-0%; p = 0.032). The OR for permanent hypocalcemia was 0.673 (95% CI 0.591-0.766). A significant higher rate of well vascularized PG at the end of the surgery (score 2) in the AG (39.2-52.9%; p = 0.018) was also seen. ICG angiography-guided thyroidectomy is a useful tool to identify PG vascularization, allowing a better PG preservation and a significant decrease in hypocalcemia rates.

Parathyroidectomy for Normocalcemic Tertiary Hyperparathyroidism: A 19-Year Experience.

Parathyroidectomy is the standard management for patients with tertiary hyperparathyroidism (THPT) and hypercalcemia. However, a subset of patients with THPT have normal or mildly-elevated serum calcium levels in the setting of significantly elevated parathyroid hormone (PTH). The purpose of this study is to determine the effectiveness and safety of parathyroidectomy in normocalcemic THPT. Retrospective review of 212 consecutive patients with THPT who subsequently underwent parathyroidectomy between 2001 and 2020 was performed. Patients were categorized as normocalcemic, "mild" (Ca ≤ 10.4mg/dL) or hypercalcemic, "classic" THPT (Ca ≥ 10.5mg/dL) and clinical data are compared. 71 of 212 (34%) were normocalcemic with median pre-operative Ca and PTH levels of 9.7mg/dL and 225pg/mL, respectively and 141 of 212 (67%) were hypercalcemic with median preoperative Ca and PTH levels of 11mg/dL and 211pg/mL, respectively. The mean length of stay was shorter in normocalcemic patients (0.33 versus 0.50d; P=0.03). 10 of 71 (14%) normocalcemic patients underwent reoperative parathyroidectomy, more than double that of hypercalcemic patients (5.6%; P=0.06). Concomitant thymectomy was performed in 28.1% and 22.1% of normocalcemia and hypercalcemic patients, respectively (P=0.44). No patient in either group required intravenous calcium or had undetectable PTH levels, but permanent hypocalcemia was more frequent in normocalcemic compared to hypercalcemic patients (11.2% versus 1.4%; P=0.03). Parathyroidectomy for normocalcemic tertiary hyperthyroidism (HPT) can be performed safely. These data can help guide multidisciplinary discussions for earlier surgical referral and intervention. Future investigations are needed to evaluate the impact of parathyroidectomy on the renal allograft, bone health, and cardiovascular disease.

Early and Late Complications after Thyroid Surgery: A Retrospective Study in 163 Patients

Objective: The aim of this study was to evaluate the early and late (6 months after surgery) complications in patients undergoing thyroid surgery.&#x0D; Material &amp; methods: A retrospective study was done from January 2015 to December 2019 in the Department of ENT &amp; Head Neck Surgery, Enam Medical College &amp; Hospital. One hundred and sixty three patients with both benign &amp; malignant thyroid disease underwent surgical treatment was selected for this study. Patients were followed up for six months and peroperative &amp; postoperative complications were evaluated.&#x0D; Results: Out of 163 patients 132(80.9%) cases were benign and 31(19.1%) cases were malignant. Total thyroidectomy was done in 71(43.56%) patients and hemithyroidectomy was done in 82(50.3%) patients and 10(6.13%) patients had other thyroid surgery. 29(17.80%) patients develop complications after thyroid surgery. Most common post operative complication was hypoparathyroidism with a incidence of 17(10.43%). 15(9.20%) patients developed temporary hypocalcaemia and 2(1.23%) patients developed permanent hypocalcaemia. Others complications were recurrent laryngeal nerve (RLN) palsy 2(1.23%), superior laryngeal nerve (SLN) palsy 3(1.84%), wound infection 2(1.23%), haematoma 1(0.61%) and hypertrophied scar 4(2.45%).&#x0D; Conclusion: Hypocalcaemia was the most frequent post-thyroidectomy complication, while voice change, seroma, haematoma, wound infection and hypertrophied scar are additional complications. Surgeons have to pay attention to curtail the complications during thyroid surgery.&#x0D; Bangladesh J Otorhinolaryngol 2022; 28(1): 50-55

Re-do Operation Using a Robotic System due to Locoregional Recurrence after Initial Thyroidectomy for Thyroid Cancer

Locoregional recurrent thyroid cancer is commonly treated with re-do operation. This study aimed to investigate the feasibility of using robotic system for re-do operation in locoregional recurrent thyroid cancer. Sixty-five patients who underwent re-do robotic operation using trans-axillary approach for locoregional recurrent thyroid cancer from October 2007 to April 2021 at Yonsei University Hospital were analyzed. Completion total thyroidectomy (CTT) was performed in 26 cases, CTT and modified radical neck node dissection (mRND) in 16, and mRND in 23. Most of the re-do robotic operations were performed at site of previous incision. All patients were diagnosed with papillary thyroid carcinoma (PTC). CTT with central compartment neck dissection (CCND) took 117.6 ± 26.3 min, CTT with mRND 255.6 ± 38.6 min, and mRND, 211.7 ± 52.9 min. Transient hypocalcemia occurred in 17 (26.2%) patients and permanent hypocalcemia occurred in 3 (4.6%). There was one case of recurrent laryngeal nerve(RLN) injury. One patient was diagnosed with structural recurrence after re-do robotic operation. Median follow-up duration was 50.7 ± 37.1 months. Re-do robotic operation can be an alternative for patients who are diagnosed with locoregional recurrent thyroid cancer after thyroidectomy, with no increase in morbidity, similar oncologic outcomes, and superior cosmetic satisfaction.

The complex role of post-operative magnesium on the long term serum calcium and parathyroid hormone levels in patients undergoing total and near-total thyroidectomy.

To assess the role of hypomagnesaemia in the development of permanent hypocalcaemia following thyroidectomy. The prospective cohort study was conducted from April 3, 2017, to January 2, 2020, at Surgical Unit 1, Benazir Bhutto Hospital, Rawalpindi, Pakistan, and comprised of patients of both genders undergoing total and near total thyroidectomy. Post-operative calcium and magnesium levels were noted, and the patients were followed up after 6 months and fasting serum calcium, magnesium and parathyroid hormone levels were checked. Signs and symptoms of hypocalcaemia were noted. Data was analysed using SPSS 22. Out of the 62 patients followed up, 57 (91.9%) were females and 5 (8.1%) males. The overall mean age was 38.5 ± 12.1 years Post-operative hypomagnesaemia was seen in 6(9.8%) patients and none developed follow-up hypocalcaemia. Post-operative magnesium levels were significantly negatively correlated with follow-up parathyroid hormone level (p=0.006). Fall in magnesium post-operatively and follow-up magnesium were positively correlated with follow-up parathyroid hormone (p<0.05). Permanent hypocalcaemia was seen in 7(11.4%) patients and it was significantly associated with pre-operative and post-operative calcium levels, post-operative symptoms of hypocalcaemia and readmission for hypocalcaemia after discharge (p<0.05). Follow-up hypomagnesaemia was significantly associated with follow-up hypocalcaemia (p=0.024) and follow-up symptoms of hypocalcaemia (p=0.031). Acute development of mild hypomagnesaemia post-operatively may be beneficial in early positive feedback for parathyroid hormone secretion. Hypomagnesemia 6 months after surgery may be involved in PTH organ resistance. The complex role of hypomagnesemia on PTH levels must be further explored.

Preventing Inadvertent Parathyroidectomy during Thyroid Surgery - A Literature Narrative

Background: Accidental parathyroidectomy during thyroid surgery can lead to temporary or permanent hypocalcemia and serious morbidity. Proper identification of parathyroid glands during surgery can be an effective way to prevent this complication. Methods: The keywords “parathyroid gland,” “preserve,” “protect,” “inadvertent or accidental parathyroidectomy,” “surgery,” and “dissection” were used to search Medline and Embase databases. A total of 133 articles were selected after preliminary review, of which 80 indexed papers were reviewed for subject relevance. Results: Imaging techniques, such as the use of carbon nanoparticles or indocyanine green angiography, and operative techniques, such as meticulous capsular dissection of the thyroid gland, were associated with significantly improved rates of avoidance of inadvertent parathyroidectomy. Conclusion: During thyroid surgery, the use of imaging and careful operative techniques can prevent parathyroid injury. This, in turn, can prevent complications resulting from hypoparathyroidism such as tetany, ECG changes, and neurological sequelae.

Parathyroidectomy in the elderly is beneficial and safe with similar improvements in postoperative bone mineral density

BackgroundThis study evaluated bone health outcomes of parathyroidectomy in elderly primary hyperparathyroidism (pHPT) patients. MethodsA retrospective review was performed of parathyroidectomy patients with pHPT at a single institution from 2010 to 2019. Bone mineral density (BMD) improvements at postoperative dual-energy X-ray absorptiometry (DEXA) scans were analyzed between groups aged ≥75 and < 75 years using 1:1 matching on preoperative BMD. ResultsPatients ≥75 had BMD improvements through the second postoperative DEXA scans. While mean T-scores slightly improved in the ≥75 group during the study period, T-score improvement was more significant in the <75 group at first and third postoperative DEXA scans with +0.7 < 75 and +0.1 improvements ≥75 by the third DEXA (p = 0.026). Postoperative fragility fracture rates were similar in the ≥75 group, but significantly improved in patients <75 (10.4% preoperatively to 1.4% postoperatively, p = 0.020). Both cohorts had low complication rates with recurrent laryngeal nerve injury and permanent hypocalcemia of <1% (p = 0.316). ConclusionsPostoperative BMD improvement was similar between the two cohorts with no difference in complication rates suggesting parathyroidectomy is safe and effective in the elderly.

Carbon Nanoparticles for Thyroidectomy and Central Lymph Node Dissection for Thyroid Cancer.

To evaluate whether the application of carbon nanoparticles (CNs) in total or near-total thyroidectomy combined with central lymph node dissection (CLND) for thyroid cancer (TC) is beneficial to lymph node dissection, parathyroid, and recurrent laryngeal nerve (RLN) protection. Relevant literatures were systematically searched on PubMed, EMBASE, and Cochrane Library Databases until March 31, 2021. All analyses were performed using Revman Manager 5.3 software. The main results were the number of central lymph nodes, the number of central metastatic lymph nodes, accidental parathyroidectomy, postoperative hypoparathyroidism, postoperative hypocalcemia, and postoperative transient RLN paralysis. This meta-analysis identified 4 randomized controlled trials and 8 non-randomized controlled trials comprising 1870 patients. Compared with the control, the use of CNs was helpful to dissect more central lymph nodes (weighted mean difference [WMD]: 3.55, 95% confidence interval [CI]: 2.12-4.98, P < .00001) and central metastatic lymph nodes (WMD: 1.69, 95% CI:1.31-2.08, P < .00001), lower rate of accidental parathyroidectomy (odds ratio [OR]: .33, 95% CI: .23-.47, P < .00001), lower rate of both postoperative transient hypoparathyroidism (OR: .40, 95% CI: .31-.51, P < .00001), and transient hypocalcemia (OR: .37, 95% CI: .27-.51, P < .00001). However, there were no statistical difference between the groups for postoperative permanent hypoparathyroidism (OR: .29, 95% CI: .06-1.28, P = .10), postoperative permanent hypocalcemia (OR: .94, 95% CI: .10-9.16, P = .96), and postoperative transient RLN paralysis (OR: .66, 95% CI: .40-1.12, P = .12). The application of CNs in total or near-total thyroidectomy combined with CLND for TC can better dissect the central lymph nodes and protect parathyroid glands (PGs) and their function.

Modified thyroidectomy: 4 techniques to prevent recurrent laryngeal nerve injury and postoperative hypocalcaemia

Objective: To share 4 techniques that decrease the rate of postoperative hypocalcaemia and save recurrent laryngeal nerve with a good cosmetic outcome. Method: The research included all consecutive patients of thyroidectomy (hemi and total thyroidectomy) during 4-year practice. The techniques included (1) elevation of a circular flap after 4 cm collar incision. (2) Ligation of the pedicles (middle first-vein, inferior last-artery). (3) Sharp dissection of the parathyroid glands. (4) Sharp and blunt dissection and exposing the nerve in all of the patients. Result: The total numbers of patients were 2399. At least 1 symptom of hyperthyroidism was found in 1271 patients (53%). The main indication for operation was multinodular goiter and compression symptoms in 1331 (55.5%) patients, followed by thyrotoxicosis in 598 (25%) patients and malignancy in 402 (16.8%) patients. The most common operations were total thyroidectomy in 1880 (78.4%) patients, followed by thyroid lobectomy in 495 (20.6%) patients and completion thyroidectomy in 24 (1%) patients. Among all patients, 4 (0.16%) patients developed permanent voice change. Seven (0.3%) patients developed permanent hypocalcemia. Conclusion: This study offers a set of surgical techniques that reduced the risks of complications of thyroidectomy to a minimal range.

The Influence of Preoperative Thyroid Gland Volume On Intraoperative Time and Postoperative Complications for Total Thyroidectomy Patients

Objective: To determine the influence of preoperative thyroid gland volume on intraoperative time and postoperative complications for total thyroidectomy patients in a militaty tertiary hospital. Design: A cross-sectional analysis for data collected retrospectively from 106 consecutive patients who underwent thyroid surgery for various thyroid diseases at King Fahad Armed Forces Hospital in Saudi Arabia, between January 2015 and December 2019. Methods: A total of 106 patients (96 Female = 90.6% and 10 males = 9.4 %). Thyroid gland volumes were calculated preoperatively using ellipsoid model. FNA was done per American thyroid association guidelines. The patients underwent total thyroidectomy for benign and malignant thyroid conditions. The intraoperative time was measured starting from the skin incision till wound closure. Patients were followed for perioperative complications. The intraoperative time was correlated with preoperative ultrasonographic sizes of the thyroid glands. Independent sample t-Test done to compare mean US volumes in patients with complications and patients without complications. Results: The average thyroid gland volume was 43.48 ml the largest volume was 189.454 ml and the lowest volume was 1.46 ml. The average intraoperative time was 2 hours with longest time was 4 hours in a case with thyroid gland volume of 159.9 ml and the shortest intraoperative time was 1 hour and 1 minute in a case with thyroid gland volume of 58.44 ml. Total number of complications was 14 =13.2%. 1 case (0.9%) of expanding hematoma which required surgical drainage on a patient with thyroid gland volume of 34.59 ml, 7 cases (6.6%) of permanent hypocalcemia observed on patients with thyroid gland volumes of (9.16,14.21,19.81, 31.4, 37.57, 53.8, 159 ml). 4 cases (3.8%) of transient unilateral vocal fold immobility observed in patients with thyroid gland volumes of (11.55, 12.94, 26.98, 74.81ml) and 2 cases (1.9 %) of transient bilateral vocal folds immobility observed in patients with thyroid gland volumes of (60.53, 82.99 ml). Conclusion: The larger preoperative thyroid gland volume the longer operative time. Preoperative thyroid gland volume showed no significant influence on perioperative complications. Hence reviewing preoperative ultrasonographic thyroid gland volume may help the surgeon and operative staff preparations for larger cases.

Postsurgical complications after robot-assisted transaxillary thyroidectomy: critical analysis of a large cohort of European patients

In the last decade, robot-assisted trans-axillary thyroidectomy has spread rapidly and has been proven to be a safe and effective procedure. However, several case series have reported new complications that have led to criticism regarding this approach. This study analyzed the incidence of complications in a large cohort of European patients. We enrolled all patients who underwent robot-assisted trans-axillary thyroidectomy from 2012 to 2020 at the University Hospital of Pisa Department of Endocrine Surgery. We analyzed complications and divided them into 2 groups. Group A included conventional complications, such as transient or permanent recurrent laryngeal nerve palsy, transient or permanent hypocalcemia, hemorrhage, and tracheal injury. Group B included unconventional complications, such as brachial plexus palsy, track seeding, seroma, great vessels injury, and skin flap perforation. There were 31 postsurgical complications (5.7%). Group A included 25 complications (4.6%): transient and permanent recurrent laryngeal nerve palsy occurred in 7 patients (1.3%) and in 1 (0.2%), respectively; transient and permanent hypocalcemia occurred in 9 patients (1.7%) and in 1 (0.2%), respectively. Postoperative bleeding occurred in 6 patients (1.1%) and tracheal injury in 1 (0.2%). Group B included 6 complications (1.1%): 1 patient with brachial plexus injury (0.2%), 1 with track seeding (0.2%), and 4 with seroma (0.7%). Robotic trans-axillary thyroidectomy is a safe approach with a risk of postoperative complications comparable to the conventional technique. Almost all complications after a novel introduction are anecdotal. With an accurate patient selection, high-volume institutions with experienced surgeons can perform this technique safely.

Accumulation of Experience and Newly Developed Devices Can Improve the Safety and Voice Outcome of Total Thyroidectomy for Graves’ Disease

Total thyroidectomy (TT) in patients with Graves’ disease is challenging even for an experienced thyroid surgeon. This study aimed to investigate the accumulation of experience and applying newly developed devices on major complications and voice outcomes after surgery of a single surgeon over 30 years. This study retrospectively reviewed 90 patients with Graves’ disease who received TT. Forty-six patients received surgery during 1990–1999 (Group A), and 44 patients received surgery during 2010–2019 (Group B). Major complications rates were compared between Group A/B, and objective voice parameters were compared between the usage of energy-based devices (EBDs) within Group B. Compared to Group B, Group A patients had higher rates of recurrent laryngeal nerve palsy (13.0%/1.1%, p = 0.001), postoperative hypocalcemia (47.8%/18.2%, p = 0.002), and postoperative hematoma (10.9%/2.3%, p = 0.108). Additionally, Group A had one permanent vocal cord palsy, four permanent hypocalcemia, and one thyroid storm, whereas none of Group B had these complications. Group B patients with EBDs had a significantly better pitch range (p = 0.015) and jitter (p = 0.035) than those without EBDs. To reduce the major complications rate, inexperienced thyroid surgeons should remain vigilant when performing TT for Graves’ disease. Updates on surgical concepts and the effective use of operative adjuncts are necessary to improve patient safety and voice outcome.