Permanent Recurrent Nerve Palsy Research Articles

Subtotal Thyroidectomy Postoperative Complications with Unplanned Thyroid Surgery

Background: The surgical treatment for bilateral multinodular nontoxic goiter (BMNG) is still debatable. Avoiding RLN harm during thyroid surgery if the pathology is not identified. Reduce the incidence of hypoparathyroidism by reducing the rate of parathyroid gland damage during excision. Objective: To see the complications of subtotal thyroidectomy in random thyroid surgery. Materials and Methods: This was a prospective, observational study conducted in the Department of ENT & Head- Neck surgery, Rangamati Medical College, Rangamati for a period of 2 years from January 2019 and December 2020. Total 100 patients were operated for benign and malignant thyroid disorders. This study was done to assess complications after various types of thyroid surgeries indicated for benign as well as malignant thyroid lesions. Results: Ten (10.0%) patients had transient hypocalcemia followed by 4(4.0%) had transient recurrent nerve palsy, 1(1.0%) had permanent hypocalcemia, 1(1.0%) had permanent recurrent nerve palsy and 1(1.0%) had neck hematoma. Mean weight of the resected thyroid was found 62.4±14.1 gram in euthyroidism group and 74.2±26.4 gram in hypothyroidism group. Mean proportion of weight of the thyroid remnant in total weight of the thyroid was found 5.1±2.2 percent in euthyroidism group and 3.9±2.1 percent in hypothyroidism group. Conclusion: Transient hypocalcemia, transient recurrent nerve palsy, chronic hypocalcemia, permanent recurrent nerve palsy, and neck hematoma were the most frequent postoperative complications.

The relationship between thyroidectomy complications and body mass index.

Obesity is a growing public health problem associated with many comorbid diseases. The aim of this study was to evaluate the relationship between body mass index and complications of thyroidectomy. Patients who underwent total thyroidectomy between January 2015 and December 2018 were enrolled. Patients were divided into two groups, i.e., BMI <25 (group A) and BMI≥ 25 (group B). Demographics, operative time, and complications were retrospectively reviewed. The study included 145 patients (66 in Group A and 79 in Group B). There was no significant difference between the two groups in terms of age (p=0.330) and gender (p=0.055). No surgical site infection and bleeding complications were observed in any patients. The mean operative time was 148.4 minutes (90-235) in Group A and 153.4 minutes (85-285) in Group B (p=0.399). Transient hypocalcemia was observed in 25 (37.9%) patients in group A, and 23 (29.1%) patients in Group B (p = 0.291). Permanent hypocalcemia was not observed in any patient in group A, and in 2 patients in Group B (2.5%) (p = 0.501). Transient recurrent nerve palsy was observed in 1 (1.5%) patient in Group A and in 3 (3.8%) patients in Group B (p=0.626). None of the patients had permanent recurrent nerve palsy. Parathyroid autotransplantation was performed on 1 patient (1.5%) in group A and on 7 (8.9%) patients in Group B (p=0.055). We think there is no relationship between a high BMI and thyroidectomy complications, and surgery can also be performed safely in this patient group.

Prophylactic central node dissection in differentiated thyroid cancer: A prospective tertiary care center experience

BACKGROUNDWith increasing incidence of thyroid carcinoma, the optimal management of central lymph nodes remains an unanswered question although central neck nodes represent the most common site of recurrence. The aim of this study was to determine the morbidity of prophylactic central neck dissection in differentiated thyroid cancer and to evaluate histopathological correlation between nodal metastases and histological features. METHODThis was a prospective, observational study of 2 years duration (May 2017 to May 2019) involving 30 patients with proven differentiated thyroid cancers and clinicoradiologically negative lymph node with no history of neck surgeries. They all underwent total thyroidectomy with bilateral central neck dissection. Surgical outcomes in the form of transient or permanent hypoparathyroidism, transient and permanent recurrent nerve palsy were assessed along with histopathological correlation of primary tumor with central node positivity. DISCUSSIONClassical histology (p = 0.05), >4 cm tumor size (p = 0.04), lymphovascular invasion (p = 0.04) and multifocality (p = 0.04) were all significantly associated with increased risk of central lymph nodal metastasis. The incidence of transient and permanent hypoparathyroidism was 36.3% and 10% respectively. Metastatic lymph node ratio of >60% is significantly associated with increased preablative serum thyroglobulin levels. Around 35% of the pT1 or T2 lesions were upstaged for postoperative radioiodine ablation CONCLUSIONAn important role of prophylactic central neck dissection may lie in male patients, age > 45years, tumor size >4 cm, extrathyroidal extension, lymphovascular invasion and multifocality in accurate staging and can be performed with minimal morbidity at a high volume center.

Application of transoral endoscopic thyroidectomy for benign thyroid nodule

Objective:To evaluate the feasibility and application value of transoral endoscopic thyroidectomy for benign thyroid nodule.Method：Thirty-one patients with benign thyroid tumors underwent transoral endoscopic thyroidectomy via oral vestibular approach at our hospital between July 2016 and December 2017. Forty-five patients were enrolled as control group by conventional approach．Two groups were compared with regards to tumor size，types of operation, operation time， bleeding, volume of drainage, complication and postoperative hospital stay.Result:Pathology examinations proved benign in both groups.Two groups were matched by age, sex, tumor size and types of operation. No statistical significance was found in volume of drainage, postoperative hospital stay and complication. Endoscopic group：no permanent glottic paralysis；one patient had transient hoarseness and recovered after 3 months. In one case，subcutaneous seroma was noted.One patient suffered from cervical subcutaneous emphysema. One patient had a epidermal damage of the ala nasi on the side of the nasal intubation, and recovered after one week. no permanent glottic paralysis；One patient had transient hoarseness and recovered after 3 months. No local infection at the incision site or within the cervical spaces occurred. No mental nerve palsy was observed. Control group： one patients occurred transient hoarseness and recovered after 3 months. No permanent recurrent nerve paralysis occurred; one patient suffered from local infection; one patient had subcutaneous seroma; one cases of postoperative hematoma occurred after 8 hours later. The average blood loss of endoscopic surgery was (20±4) ml, and the mean of operation time was (107±11) min. The difference was statistically significant between the endoscopic surgery and the conventional surgery.Conclusion:The novel transoral endoscopic thyroidectomy is feasible and safe，and it may be a good choice for patients with beauty needs.

Hypoparathyroidism in Total Thyroidectomy due to Benign Thyroid Diseases

PurposeOur aim was to compare the effects of exposing the recurrent laryngeal nerve throughout its entire course with exposing the nerve only at its entry to the larynx in patients undergoing total thyroidectomy due to benign thyroid diseases, and to evaluate the effects of these methods on the risk for hypoparathyroidism. MethodsThe medical records of 437 patients who had undergone total thyroidectomy at the ear, nose, and throat clinic between 2001 and 2015 for benign thyroid diseases were evaluated retrospectively. Mean patient age was 46.7 years (range 18–79 years). Eighty-six patients were male and 351 were female. Patients were divided into 2 groups according to recurrent laryngeal nerve exposure during surgery. In the first group, the nerve was observed as it entered the larynx, and its course was not completely exposed. In the second group, the nerve was identified in the tracheoesophageal groove, and its course was fully exposed. Group 1 consisted of 256 patients (47 male and 209 female) and group 2 consisted of 181 patients (39 male and 142 female). There were no statistically significant differences between the groups in terms of age and gender, and the groups were homogeneously distributed. FindingsTransient hypoparathyroidism was observed in 15 (5.8%) patients and permanent hypoparathyroidism was observed in 3 (1.1%) patients in group 1, and transient hypoparathyroidism was observed in 23 (12.7%) patients and permanent hypoparathyroidism was observed in 7 (3.8%) patients in group 2. The rates of both transient and permanent hypoparathyroidism were higher in the patients in group 2, and the difference was statistically significant (P < 0.001). Transient recurrent nerve palsy was seen in 1 patient in each group. Permanent recurrent nerve palsy occurred in 1 patient in group 2, although the difference between groups was not statistically significant (P = 0.28). ImplicationsTransient and permanent hypoparathyroidism were less common in thyroidectomies that involved detection of the recurrent laryngeal nerve at the site of entry to the larynx and keeping its dissection minimal; this technique was also more reliable.

Clinical analysis of risk factors for central compartment lymph node metastasis in stage cNO papillary thyroid microcarcinoma and preventive dissection

Objective To discuss the clinical characteristics for central compartment lymph node metastasis in stage cNO papillary thyroid microcarcinoma and significance and feasibility of preventive dissection, aimed to provide reference for clinical treatment. Methods Reviewed the clinical data of 277 patients with stage cN0 papillary thyroid microcarcinoma from Jul. 2011 to Dec. 2015 underwent surgery in the Department of General Surgery of Lianyungang East Hospital. Evaluated the necessity of prophylactic central lymph node dissection. Adopted chi square test and Logistic regression to analyze its relationship with patients′ gender, age, tumor number, tumor size, enveloped infiltration, single and bilateral tumor. All 277 patients underwent primary radical resection with ipsilateral central lymph node dissection. The specimen of resection was analyzed by routine pathology. Results The positive rate of thyroid papillary microcarcinoma lymph node metastasis was 36.8% (102/277). The elements of male patients (P=0.023), age 0.5 cm (P=0.019) had high positive rate. The multivariable analysis showed that male patients (OR=2.63, P 0.5 cm (OR=2.13, P=0.009) were independent risk factors for CLN metastasis.Forty-three (15.5%) cases had transient parathyroid function. No Permanent recurrent nerve paralysis and hyperparathyroidism occurred in this group. Conclusions Prophylactic central lymph node dissection is helpful for accurate staging of tumor classification and risk assessment, has important significance, on the follow-up of patients after treatment of choice. For male patients, age 0.5 cm, enveloped infiltration, the central compartment lymph node dissection may be necessary. Key words: Papillary thyroid carcinoma; Prophylactic lymph node cleaning; Lymphatic metastasis; Chi-square distribution; Neck dissection

Complications of Bilateral Neck Dissection in Thyroid Cancer From a Single High-Volume Center

The morbidity of bilateral lateral neck dissection (BLND) for thyroid cancers has not been described in detail. This study delineates the specific complications arising from BLND for thyroid cancers at a single high-volume center. To determine the morbidity associated with BLNDs for differentiated thyroid cancers at our institution. This was a retrospective review of medical records performed to identify patients having undergone BLNDs for thyroid cancers by a single surgeon at an academic, tertiary medical center in Toronto, Ontario, Canada, from 1988 to 2015. Patients who underwent BLND for papillary, follicular, or medullary thyroid cancers were identified through operative procedure codes and review of operative and pathology reports. The indication for this procedure was suspicious bilateral lateral compartment on imaging and clinical examination. Sixty-two patients who underwent BLND for thyroid cancers, with or without total thyroidectomy and central compartment dissection, were identified. The main outcome measures for this study were unanticipated medical or surgical complications during the operation or in the postoperative period. Secondary measures were oncologic outcomes, including regional structural or biochemical recurrence. Of the 62 patients, 24 were male (39%), and 38 (61%) were female. Their mean age was 46 years (range, 17-80 years). The overall risk of permanent hypoparathyroidism was 37%. There was 1 case of unanticipated permanent recurrent nerve paralysis and 1 case of temporary nerve paresis. Postoperative chyle fistula occurred in 6 cases (10%). There were 3 readmissions within 30 days of surgery, 1 pulmonary embolism, and 1 perioperative mortality. Fifty percent of patients had pN0 contralateral necks despite preoperative clinical suspicion. Four patients were found to have anaplastic thyroid cancers intraoperatively. Five patients (8%) developed nodal recurrence in the neck. Four patients died of their disease within available follow-up (mean, 3.2 years). Bilateral lateral neck dissection for thyroid cancers confers a significant amount of morbidity, including a significant rate of hypoparathyroidism. Knowledge of the complications of this procedure, especially in the setting of questionable survival benefit, may assist in preoperative decision-making and patient counseling.

Indications and Morbidity of Reoperative Thyroid Surgeries in a Military Hospital of Senegal.

Objectives To describe reoperative thyroid surgeries in our department. Study Design Retrospective cross-sectional and descriptive study at the Ouakam Military Hospital in Dakar (Senegal), over a period of eight and a half years. Methods The study involved all records of patients who had a reoperative thyroidectomy regardless of the indication and time of the second surgery. Parameters evaluated for first and reoperative surgery were time interval between the two surgeries, operative indications, surgical procedures, intraoperative findings, pathological examination, and morbidity. Results 30 records of patients were selected out of a total of 698 thyroidectomies (4.3%). Thyroid cancers diagnosed on first surgical specimens were the first indications of reoperations (46.67%) followed by neck hematoma (20%). Completion thyroidectomy with a prophylactic central lymph nodes dissection was the most performed surgical procedure (43.33%) followed by haemostasis (20%). During reoperation, we found active bleeding (20%), textiloma (6.67%), and fourth branchial cleft fistula (3.33%). The morbidity accounted for 10%: lymphorrhea, permanent hypocalcemia, and permanent recurrent nerve palsy, in one case, respectively. There were no statistically significant differences between the morbidity in patients reoperated on and the one for patients operated on once. Conclusion We did not find an increased risk of postoperative morbidity after reintervention.

Efficiency of carbon nanoparticles in level VI lymphadenectomy for thyroid carcinoma and prevention of postoperative hypoparathyroidism

To assess the efficiency of carbon nanoparticle in guiding level VI lymphadenectomy and parathyroid preservation in thyroidectomy for carcinoma. One hundred and nine patients with well differentiated thyroid carcinoma, in whom thyroidectomy and bilateral lymphadenectomy for level VI were carried out at the same time, were prospectively studied. Fourty-five cases received carbon nanoparticle injecion in thyroid consistitued trial group, while sixty-four underwent conventional surgery as control group. The numbers of total dissected lymph nodes, metastasis lymph nodes, black-stained lymph nodes, detected parathyroids and mistakenly removed parathyroids were counted respectively. The PTH levels were measured at 1 d, 5 d and 30 d after surgery, respectively. Student's t test and Chi-square analysis were used for analyzing data. The number of lymph node found in the trial group in level VI was checked out as (9.7 ± 1.7) each side, whereas that of the control group was (6.7 ± 1.9) each side. The discrepancy of two groups was statistical meaningful (t = 23.14, P < 0.001). The discrepancy of the rate of lymph node black-stained 90.5% (738/815), incidence of metastasis of the black-stained lymph nodes 45.9% (339/738) and that without black-staining 13.0% (10/77), was statistical meaningful (χ(2) = 30.91, P < 0.001). On average, the trial group showed (1.8 ± 0.9) parathyroid each side, and had 5.9% (5/84) of mistakenly removed incidence , on contrary, the control group showed (1.8 ± 1.0) parathyroid each side, and had 8.2% (11/134) of mistakenly removed incidence averagely as well. The discrepancy of two groups was statistical meaningful. In the trial group, the amount of PTH 1 d, 5 d and 30 d postoperatively were 7.30, 11.19 and 30.50 ng/L respectively, while that of the control group were 7.51, 10.90 and 28.30 ng/L respectively. The amount discrepancy between the two groups was not differences. No permanent recurrent nerve paralysis was found in both groups. Carbon nanoparticle may improve the detected rate of metastasis lymph nodes, but may not be helpful to the prevention of postoperative hypoparathyrosim.

Video-Assisted Thyroidectomy for Selected Cases of Differentiated Thyroid Carcinoma. Initial Experience in Colombia

Background: Minimally invasive video-assisted thyroidectomy (MIVAT) has been proposed as an alternative procedure to get the same completeness as a conventional thyroidectomy in selected cases of differentiated thyroid cancer. It’s considered as safe as the conventional procedure. Objective: The purpose of the study was to do a retrospective evaluation in a series of patients who underwent MIVAT for thyroid nodule or thyroid cancer over a two and a half year period, in two academic centers in Colombia in terms of the completeness of the surgical resection, morbidity and short-term recurrence. Results: 45 patients underwent a MIVAT, and 20 had also a central neck dissection (CND); frozen section study was realized in 9 cases. The final pathology showed 27 patients with papillary carcinomas, and 1 patient with incidental medullary carcinoma. Post-operative complications included temporary recurrent nerve paralysis (1.1%), permanent recurrent nerve paralysis (1.1%), temporary hypocalcaemia (4.4%) and postoperative seroma (8.8%) No definitive hypoparathyroidism was found. The short term follow-up didn’t show recurrences. Conclusion: With this initial experience, we consider that this technique could be proposed as an alternative procedure to conventional surgery, including the resection of selected small thyroid carcinomas as other authors have proposed.

Influence of Prophylactic Neck Dissection on Rate of Retreatment for Papillary Thyroid Carcinoma

Prophylactic neck dissection (PND) for papillary thyroid cancer is controversial. The objective of this study was to analyze the influence of PND on the rate of retreatment. In this retrospective case-control study, papillary thyroid carcinomas >10 mm without ultrasonographic evidence of nodal disease (cN0) were treated with total thyroidectomy (TT) or TT with bilateral central compartment PND. All received postoperative radioactive iodine ((131)I) and were followed for at least 1 year. We compared the rate of retreatment (surgery or (131)I). Altogether, 246 patients (mean age 46 years, 78 % women) underwent TT (n = 91) or TT + PND (n = 155). The groups were similar in age, sex, tumor size, and follow-up (median 6.3 years) (p > 0.05). Overall, 11 (12 %) of the patients in the TT group underwent reoperation in the central compartment for recurrence versus 3 (2 %) in the TT + PND group (p < 0.001). There were 1.18 administrations of (131)I for the TT group versus 1.08 for the TT + PND group (p = 0.08). The average cumulative dose of (131)I was 3.9 ± 1.8 GBq for the TT group and 3.8 ± 1.3 GBq for the TT + PND group (p = 0.52). Actuarial (Kaplan-Meier) 5-year retreatment rates were 14.7 % in the TT group and 6.5 % in the TT + PND group (p = 0.01, log-rank). The rate of permanent recurrent nerve paralysis was 2 % for the TT group and 1 % for the TT + PND group (p = 0.98). The rates of permanent hypoparathyroidism were 7 versus 3 %, respectively (p = 0.12). Five-year retreatment rates were lower in patients treated with PND, with no added permanent morbidity.

Prophylactic neck dissection in papillary thyroid cancer: When is it necessary?

BACKGROUND The American Cancer Society estimates that there will be approximately 56,460 new diagnoses of thyroid cancer in the United States during 2012, and more than 90% will be papillary thyroid cancer (PTC). Despite the large, ever-increasing number of thyroid cancer cases, the ideal initial management of well-differentiated PTC remains controversial. The role of the prophylactic central neck dissection (pCND) has emerged as the most highly debated topic, with conflicting reports regarding indications, recurrence prevention, and reduction of cause-specific mortality. Currently, there is no argument that a formal, compartmental CND should be performed if preoperative or palpable nodal disease is encountered. However, the 2009 American Thyroid Association (ATA) guidelines state that, “Prophylactic central compartment neck dissection may be performed in patients with papillary thyroid carcinoma with clinically uninvolved central neck lymph nodes, especially for advanced primary tumors (T3 or T4; Grade C recommendation; expert opinion).” With the advent of personalized therapy based on molecular testing, the BRAF gene has shown the most promise in predicting lymph node metastases and may be used to direct clinicians on whether to perform a pCND. The focus of the review will seek to answer the question of best practice with regards to pCND in PTC. LITERATURE REVIEW Due to the excellent outcomes seen with PTC, the importance of lymph node metastases has been difficult to interpret. Recent, large, population-based studies have demonstrated a decrease in cause-specific survival in lymph-node positive PTC patients. Zaydfudim et al. used the Surveillance, Epidemiology, and End Results database to analyze outcomes of 30,054 patients with PTC. They concluded through multivariate analysis that metastatic LNs conveyed a 46% increased risk of death (HR, 1.46; P<.001) in patients 45 years, even with the majority of patients with excellent long-term survival. However, in patients< 45, lymph node status did not influence survival. While the presence of metastatic positive lymph nodes in PTC may dictate a decrease in cause-specific survival, does performing a prophylactic central neck dissection actually improve the patient’s outcome? A meta-analysis of five studies with a total of 1,264 patients demonstrated a decrease in lymph node recurrence (2% vs. 3.9%) in the thyroidectomy1pCND group, but this did not achieve statistical significance. The rate of transient recurrent laryngeal nerve paralysis (1.8%–5.4% thyroidectomy1pCND, 1%–1.3% thyroidectomy alone) and transient hypoparathyroidism (18%– 44% thyroidectomy1pCND, 8%–14% thyroidectomy alone (P< 0.02)) was higher in the group receiving pCND. Permanent recurrent nerve paralysis and hypocalcemia were not different between the two arms. The authors concluded that the balance between the risks and benefits favored thyroidectomy alone. However, they recognized several limitations to the study: inclusion of retrospective data, inconsistencies in the use of RAI and thyroid suppression postoperatively, limited data on timing of recurrence, and a lack of standardized reporting with regard to the extent of central neck dissection (ipsilateral vs. bilateral, etc.). The authors conclude with the call for a large, prospective trial to fully resolve the controversy. However, the feasibility of such a randomized trial was investigated by the ATA, which concluded that prohibitively large sample sizes (5,840 patients) and approximately $20 million would be required to demonstrate significant differences in outcomes. From the Louisiana State University Health Sciences Center– Shreveport, Department of Otolaryngology/Head and Neck Surgery, Shreveport, Louisiana, U.S.A.

Long-term results of surgery for papillary thyroid carcinoma with local recurrence

Surgical treatment of local recurrent papillary thyroid carcinoma is still controversial because of the increased morbidity in comparison to primary surgery, and the unclear efficacy. This study analyzed the efficacy and safety of surgery for recurrent disease. A retrospective cohort analysis of 86 patients who underwent surgery for local recurrent papillary thyroid carcinoma at a single institution during the period 1979-2009. The cause-specific survival rates of all patients at 5, 10, and 20 years were 86 % (95 % CI 77-95 %), 74 % (95 % CI 62-87 %), and 36 % (95 % CI 18-54 %), respectively. A univariate analysis found that gender, age >45 years at reoperation and macroscopic non-curative surgery for recurrence affected the cause-specific survival rates. The latter two features remained significant in a multivariate analysis. Permanent recurrent nerve paralysis and hypoparathyroidism developed in 4 (4.7 %) and 5 (5.8 %) patients, respectively. Surgery for local recurrent papillary thyroid carcinoma could be effective when macroscopic curative dissection was possible, and that the procedure was safe and was associated with minimal morbidity. Therefore, repeat surgery for local recurrent papillary thyroid carcinoma is worthwhile.

Risk groups in differentiated thyroid carcinomas

IntroductionWell-differentiated thyroid carcinoma represents 80% of all thyroid malignant tumours, with a survival rate of over 95% at 20 years in 80% of the cases. Although its incidence is increasing, survival remains unchanged. Prognostic factor evaluation allows identifying patients at high or low risk of recurrence, selecting those who will benefit from more aggressive therapy. MaterialWe have reviewed the incidence of malignant thyroid neoplasm, selecting them according to three different system definitions (TNM, GAMES, MACIS), as well as by post-surgical complication rate. ResultsMalignant neoplasm represents 28.8% of the thyroid-operated patients, 88% corresponding to well-differentiated carcinomas. 80% are in the low risk group, with similar numbers in all three staging system definitions. Multicentricity was found in 16%, with 50% of the lesions smaller than 2 cm. Permanent recurrent nerve palsy was 1.2% and 2.7% presented permanent postoperative hypocalcaemia. ConclusionsRisk group percentage is similar to that reported in the literature, with 80% having expected survival over 95% at 20 years. Risk factor evaluation should help to individualise treatment options, avoiding overtreatment and complications in patients that will not benefit from more aggressive therapy.

Grupos de riesgo en carcinomas diferenciados de tiroides

Introduction Well-differentiated thyroid carcinoma represents 80% of all thyroid malignant tumours, with a survival rate of over 95% at 20 years in 80% of the cases. Although its incidence is increasing, survival remains unchanged. Prognostic factor evaluation allows identifying patients at high or low risk of recurrence, selecting those who will benefit from more aggressive therapy. Material We have reviewed the incidence of malignant thyroid neoplasm, selecting them according to three different system definitions (TNM, GAMES, MACIS), as well as by post-surgical complication rate. Results Malignant neoplasm represents 28.8% of the thyroid-operated patients, 88% corresponding to well-differentiated carcinomas. 80% are in the low risk group, with similar numbers in all three staging system definitions. Multicentricity was found in 16%, with 50% of the lesions smaller than 2 cm. Permanent recurrent nerve palsy was 1.2% and 2.7% presented permanent postoperative hypocalcaemia. Conclusions Risk group percentage is similar to that reported in the literature, with 80% having expected survival over 95% at 20 years. Risk factor evaluation should help to individualise treatment options, avoiding overtreatment and complications in patients that will not benefit from more aggressive therapy.

Evolution de la chirurgie thyroïdienne vers la thyroïdectomie totale: A propos de 735 cas

To study the place of the total thyroïdectomy compared to the sub-total thyroidectomy and the lobectomy in benign nodular thyroid pathology, about complications and prevention of the recurrence.The evolution of the number and the type of thyroïdectomy among the total thyroidectomy, subtotal thyroidectomy and the lobectomy was analyzed in a retrospective study including 735 patients in the service of Head and Neck Surgery in the University Hospital in Amiens, France over a 12 years period, for a multinodular goiter, a toxic and a nontoxic solitary nodule. The post-operative transient and permanent recurrent nerve paralysis and hypocalcemia of the total thyroidectomies were studied and compared with the other surgical procedures of the study and in a review of the literature in order to study benefit and risks.Multinodular goiters were the most thyroid pathologies (80%). The total thyroidectomy became gradually the most frequent surgical procedure, from 17% to nearly 70% of the surgical procedures over 12 years, with depend on the currently abandoned subtotal thyroidectomy and the lobectomy. No significant difference appeared concerning the recurrent and parathyroid complications between the 3 procedures.The post-operative morbidity is not statistically different between the total thyroidectomy and the other procedures. The total thyroidectomy prevents moreover nodular recurrences whose surgical treatment is difficult without benefit of the L-thyroxine treatment prevention. It implies a substitute opotherapy that the other surgical techniques cannot nevertheless always avoid. Nowadays, the total thyroidectomy is the gold treatment for surgical treatment of multinodular benign goiters. Many factors must be considered concerning the solitary nodules: the size, the evolutivity, the fine needle aspiration the aspect of the contralateral lobe. In all the cases, the decision will have to be consensual between the patient, the endocrinologist and the surgeon.

A safe and reliable technique for visualization of the laryngeal recurrent nerves in the neck

Background The risk of an injury of the laryngeal recurrent nerve is an important issue during any surgical procedure in the lower neck. Methods Based on our experience with the transcervical-subxiphoid bilateral videothoracoscopic maximal thymectomies, we developed an original technique of visualization for both of these nerves. The key point of the presented technique is the dissection in the lower part of the neck, beneath the level of the thyroid gland. The central step is the division of the deep cervical fascial layers covering and obscuring the recurrent nerves. Preservation of the deepest layer protects the nerves from an injury. Results We used this technique in 100 consecutive transcervical-subxiphoid bilateral videothoracoscopic maximal thymectomies without any case of permanent recurrent nerve palsy. Conclusion The presented technique is safe, reliable, and relatively simple. It may be used during an extended thymectomy, as well as during a thyroid resection and other operations in the lower neck.

Frequent adverse events after treatment for childhood-onset differentiated thyroid carcinoma: a single institute experience

Since the mortality rate for childhood differentiated thyroid carcinoma is nearly zero, the focus must be to minimise morbidity following treatment. Our aim was to analyse early and late adverse events. Twenty-five of 26 children treated between 1962 and 2002 were evaluated. Median follow-up was 14.2 years (range 0.9–39.4 years). All underwent total thyroidectomy, 15 (60%) with lymph node dissection and 15 (60%) with adjuvant radio-iodide therapy. Mortality was zero. Seven developed recurrent disease, two developed a third recurrence. Twenty-one (84%) had ⩾1 adverse event. Eight had permanent hypoparathyroidism (PH), six permanent recurrent nerve paralysis (PRNP) and two Horner's syndrome. Risk factors for PH and PRNP were total thyroidectomy with lymph node dissection (RR: 6.45, P=0.015) and recurrent nerve tumour encasement (RR: 8.00, P=0.001), respectively. Other adverse events were fatigue ( n=5), scar problems ( n=4) and chronic myeloid leukaemia ( n=1). These results emphasise the need to improve treatment strategies.

Does intraoperative nerve monitoring reduce the rate of recurrent nerve palsies during thyroid surgery?

Two different aspects of the influence of neuromonitoring on the possible reduction of post-operative recurrent laryngeal nerve palsies require critical examination: the nerve identification and the monitoring of it's functions. Due to the additional information from the EMG signals, neuromonitoring is the best method for identifying the nerves as compared to visual identification alone. There are still no randomized studies available that compare the visual and electrophysiological recurrent laryngeal nerve detection in thyroid operations with respect to the postoperative nerve palsies. Nevertheless, comparisons with historical collectives show that a constant low nerve-palsy-rate was achieved with electrophysiological detection in comparison to visual detection. The rate of nerve identification is normally very high and amounts to 99 % in our own patients. The data obtained during the "Quality assurance of benign and malignant Goiter" study show that in hemithyreoidectomy and subtotal resection, lower nerve-palsy-rates are achieved with neuromonitoring as compared to solely visual detection. Following subtotal resection, this discrepancy becomes even statistically significant. While monitoring the nerve functions with the presently used neuromonitoring technique, it is possible to observe the EMG-signal remaining constant or decreasing in volume. Assuming that a constant neuromonitoring signal represents a normal vocal cord, our evaluation shows that there is a small percentage of false negative and positive results. Looking at the permanent recurrent nerve palsy rates, this method has a specificity of 98 %, a sensitivity of 100 %, a positive prognostic value of 10 %, and a negative prognostic value of 100 %. Although an altered neuromonitoring signal can be taken as a clear indication of eventual nerve damage, an absolutely reliable statement about the postoperative vocal cord function is presently not possible with intraoperative neuromonitoring.

Therapy of suspected intrathoracic parathyroid adenomas. Experiences using open transthoracic approach and video-assisted thoracoscopic surgery.

Ectopic mediastinal parathyroid adenoma as a cause of primary hyperparathyroidism (pHPT) can normally be resected from conventional collar incision. In rare cases with adenomas deeper in the chest, a transthoracic approach is necessary. We report our experience of 19 patients with suspected mediastinal parathyroid adenomas from a total of 1035 patients with pHPT who were operated on between 1986 and 2000 using an open approach (sternotomy or thoracotomy) or video-assisted mediastinal or thoracoscopic surgery (VAMS/VATS). Fourteen patients underwent an open approach with a success rate of 71% (10 of 14). Four patients remained hypercalcaemic. There were four complications in three patients: three permanent recurrent nerve palsies and one chylus fistula, requiring further surgery. VATS was successful in three of four patients with conversion to sternal splitting because of a false-negative frozen section in one patient. Another patient had parathyroid adenoma retrosternally which could not be resected by means of VAMS and had to be excised using a transsternal approach. There were no complications of minimal invasive procedures. All five patients were normocalcaemic after the operation. Ectopic parathyroid adenomas not resectable by means of a collar incision are rare causes of pHPT and comprise 1.25% of all patients with pHPT in our series. For these patients, VATS revealed an alternative to conventional open procedures. In questionable cases, however, the collar incision should precede the VATS procedure.