Permanent Vocal Cord Paralysis Research Articles

Gasless Endoscopic Thyroidectomy Using Trans-axillary Approach; Surgical Outcome of 581 Patients

During the past decade, various techniques of endoscopic thyroid surgery have been introduced. We have developed a novel method of gasless endoscopic thyroidectomy via an axillary approach. The present report describes the technique of this method, and analyzes its surgical outcome. Between Nov. 2001 and Dec. 2007 (actual operation period was 50 months), 581 patients with thyroid tumors underwent gasless endoscopic thyroidectomy via an axillary approach. The clinical and pathologic characteristics of patients, operation type, operation time, post operative hospital stay and post operative complications were analyzed retrospectively. Among the 581 patients, 171 patients had benign tumor and 410 patients had malignant tumor. There was no conversion to open surgery. The operating time and the length of post-operative hospital stay were 129.4+/-51.3 minutes, 3.3+/-1.7 days in benign tumor, and 135.5+/-47 minutes, 3.4+/-0.9 days in malignant tumors, respectively. The tumor size was 2.7+/-1.2 cm in benign tumor and 0.78+/-0.5 cm in malignancy. Central compartment lymph node metastasis was found in 112 (27.3%) patients and lateral neck lymph node metastasis in 13 (3.1%) patients. As post-operative complications, transient hypocalcemia occurred in 19 patients and transient hoarseness was in 13 patients and permanent vocal cord palsy occurred in 2 patients. In the TNM stage, 366 (89.2%) patients were stage I, 43 (10.5%) patients were stage III and 1 (0.2%) patient was stage IVA. According to our experience, gasless endoscopic thyroidectomy using a trans-axillary approach is a feasible and safe method. Endoscopic thyroid surgery has become a new treatment modality for the patients with benign tumors and can be an effective alternative treatment for the selected patients with thyroid cancer.

Recurrent Papillary Thyroid Cancers: An Evolving Paradigm

Objective Improved diagnostic techniques are changing the paradigm of recurrent thyroid cancer detection. High resolution ultrasound techniques, recombinant thyroglobulin assays and fused PET/CT imaging are detecting small recurrent thyroid cancers and prompting earlier surgical intervention. Our study seeks to identify the surgical outcomes in one of the largest series of recurrent papillary thyroid cancers. Methods A retrospective chart review identified 48 patients who underwent central and/or lateral neck dissections for recurrent papillary thyroid disease at our institution between 1999 and 2007. All of the patients had previously undergone primary thyroid surgery. Results There were 36 females, 12 males and the mean age of first recurrence was 49.8 years. 11 recurrences were identified by screening thyroglobulin, 10 had positive ultrasound findings, and 11 presented with a cervical mass. 14 patients underwent PET/CT scans and 28 had fine needle aspirations as part of their workup. No patients (0%) acquired permanent vocal cord paralysis and two (4.2%) developed hypoparathyroidism as a result of their initial reoperation for recurrent disease. 10 patients had a second recurrence. Conclusions Recurrent papillary thyroid cancer is a challenging dilemma for the thyroid surgeon. Improved surveillance techniques are allowing the earlier diagnosis of recurrence. While reoperative thyroid surgery carries many risks, our series demonstrates that it can be done with minimal complications. The long-term implications of early intervention in this setting are still largely unknown and will warrant future research.

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

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

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.

Endoscopic Thyroidectomy for Thyroid Malignancies: Comparison with Conventional Open Thyroidectomy

Endoscopic techniques have recently been applied to thyroid surgery. We developed the bilateral axillo-breast (BAB) approach for total thyroidectomy. The aims of this study were to evaluate the completeness of this approach for total thyroidectomy and to compare complications between endoscopic thyroidectomy and conventional open thyroidectomy. We analyzed 198 patients who underwent open thyroidectomy and 103 patients who underwent endoscopic thyroidectomy for papillary thyroid microcarcinoma between January 2003 and June 2006 at Seoul National University Hospital. The postoperative thyroglobulin (TG) level was used to assess the completeness of the two methods. Complications such as hypocalcemia or vocal cord palsy were also evaluated. The mean hospitalization period was 3.18 days following open thyroidectomy and 3.04 days after endoscopic thyroidectomy. The 3-month postoperative TG levels were <1.0 ng/ml in 90.4% of patients after open total thyroidectomy and in 88.9% following endoscopic total thyroidectomy. Transient hypocalcemia occurred in 17.7% and 25.2% of patients, respectively. Permanent hypocalcemia occurred in 4.5% and 1.0% of patients, respectively. Permanent vocal cord palsy frequencies were 0.5% and 0%, respectively. There were no significant differences in postoperative TG levels, hypocalcemia, or permanent vocal cord palsy. Transient vocal cord palsy occurred in 2.5% of patients after open thyroidectomy and in 25.2% after endoscopic thyroidectomy (p < 0.0001), but it disappeared within 3 months. Cosmetic results were excellent after endoscopic thyroidectomy. The bilateral axillo-breast (BAB) approach for endoscopic thyroidectomy shows insignificant postoperative complications, except transient vocal cord palsy, as well as good cosmetic results. It is also a feasible method for total thyroidectomy. Therefore, the BAB approach for endoscopic total thyroidectomy can be the surgical treatment of choice for selected cases of thyroid cancer.

Nonrecurrent inferior laryngeal nerve in patients with esophageal cancer: report of two cases

The preservation of the recurrent laryngeal nerve is a fundamental skill in cervical procedure such as thyroid, parathyroid or esophagus surgery. Any damage to this nerve could lead to permanent ipsilateral vocal cord paralysis. Therefore this iatrogenic complication must be absolutely avoided by surgeons. However, surgeons rarely encounter the nonrecurrent inferior laryngeal nerve. The aim of this report is to describe this nerve anomaly and its causes based on our recent experience obtained during two esophageal operations.

Safety and Efficacy of Surgical Management of Hyperthyroidism: 15‐year Experience from a Tertiary Care Center in a Developing Country

Ideal management of toxic goiter still remains elusive. Though surgical management of toxic multinodular goiter (MNG) is well accepted, surgical treatment of Graves' disease (GD) is still controversial in view of the presumed increased incidence of complications. In this paper, we discuss the experience of the surgical management of hyperthyroidism at a specialized tertiary care endocrine center in a developing country, highlighting the minimal morbidity and satisfactory outcome in experienced hands. We retrospectively reviewed 325 consecutive patients with hyperthyroidism managed surgically from 1990 to 2005. The etiologic diagnoses were Graves' disease (185), toxic MNG (105), and autonomously functioning thyroid nodules (AFTN) (n = 35). The indications for surgery in Graves' patients were large goiter, relapse after antithyroid drug therapy (ATD), Graves' ophthalmopathy, and presence of nodule. The indications for surgery in toxic MNG were retrosternal extension (n = 15), compressive symptoms (n = 20), and large size (grade II). Among the AFTN nodule size, those greater than 4 cm (85%) formed the major indication for surgery. Subjects with GD and toxic MNG were subjected to subtotal thyroidectomy (n = 93 prior to 1995) or total thyroidectomy (n = 205 post-1995). Hemithyroidectomy was the procedure of choice in patients with AFTN. Patients with Graves' disease were younger in age, with shorter mean duration of goiter when compared with the other 2 groups. Eight percent of patients with Graves' disease without a clinically palpable nodule and 25% of those with nodules had associated differentiated carcinoma, including papillary, follicular, and medullary thyroid cancer. Four percent of patients with toxic MNG had malignancy. Complications included temporary hypocalcemia (24%), permanent hypocalcemia (3%), and permanent vocal-cord palsy (1%). Surgery for hyperthyroidism has negligible mortality and acceptable morbidity in experienced hands. It is a definite option in selected cases. Immediate and permanent cure of hyperthyroidism is achieved, with no recurrences, after total thyroidectomy. The cosmetic outcome is good, with excellent patient satisfaction and acceptance.

Radiofrequency ablation and percutaneous ethanol injection treatment for recurrent local and distant well-differentiated thyroid carcinoma.

To assess the long-term efficacy of radiofrequency ablation (RFA) and percutaneous ethanol (EtOH) injection treatment of local recurrence or focal distant metastases of well-differentiated thyroid cancer (WTC). RFA and EtOH injection techniques are new minimally invasive surgical alternatives for treatment of recurrent WTC. We report our experience and long-term follow-up results using RFA or EtOH ablation in treating local recurrence and distant focal metastases from WTC. Twenty patients underwent treatment of biopsy-proven recurrent WTC in the neck. Sixteen of these patients had lesions treated by ultrasound-guided RFA (mean size, 17.0 mm; range, 8-40 mm), while 6 had ultrasound-guided EtOH injection treatment (mean size, 11.4 mm; range, 6-15 mm). Four patients underwent RFA treatment of focal distant metastases from WTC. Three of these patients had CT-guided RFA of bone metastases (mean size, 40.0 mm; range, 30-60 mm), and 1 patient underwent RFA for a solitary lung metastasis (size, 27 mm). Patients were then followed with routine ultrasound, I whole body scan, and/or serum thyroglobulin levels for recurrence at the treatment site. No recurrent disease was detected at the treatment site in 14 of the 16 patients treated with RFA and in all 6 patients treated with EtOH injection at a mean follow-up of 40.7 and 18.7 months, respectively. Two of the 3 patients treated for bone metastases are free of disease at the treatment site at 44 and 53 months of follow-up, respectively. The patient who underwent RFA for a solitary lung metastasis is free of disease at the treatment site at 10 months of follow-up. No complications were experienced in the group treated by EtOH injection, while 1 minor skin burn and 1 permanent vocal cord paralysis occurred in the RFA treatment group. RFA and EtOH ablation show promise as alternatives to surgical treatment of recurrent WTC in patients with difficult reoperations. Further long-term follow-up studies are necessary to determine the precise role these therapies should play in the treatment of recurrent WTC.

Sensitivity and Specificity of Intraoperative Recurrent Laryngeal Nerve Stimulation Test for Predicting Vocal Cord Palsy after Thyroid Surgery

Recurrent laryngeal nerve (RLN) palsy after thyroidectomy, although infrequently encountered, can decrease quality of life. In addition to the hoarseness that occurs with unilateral RLN palsy, bilateral RLN palsy leads to dyspnea and often to life-threatening glottal obstruction. Therefore, intraoperative awareness of the nerve's status is of great importance. This study examined the sensitivity and specificity of a palpation technique to detect contraction of the posterior cricoarytenoid muscle (PCA) through the posterior hypopharyngeal wall while the RLN was being stimulated with a disposable nerve stimulator during thyroid surgery (the laryngeal palpation test) to predict postoperative RLN deficits. A total of 2197 RLNs in 1376 patients were identified to be at risk of injury during thyroidectomy performed between July 2003 and August 2004. Postoperative RLN integrity was assessed using direct laryngoscopy or laryngofiberoscopy to visualize vocal fold mobility. Altogether, 76 RLNs failed to elicit a PCA contraction in response to nerve stimulation, and 80 cases of temporary vocal cord palsy and 21 cases of permanent vocal cord palsy were recognized on postoperative evaluation. For postoperative vocal cord palsy, the sensitivity and specificity of the laryngeal palpation test were 69.3% and 99.7%, respectively, with a positive predictive value of 92.1% and negative predictive value of 98.5%. For permanent vocal cord palsy, the sensitivity and specificity were 85.7% and 97.3%, respectively, with a positive predictive value of 23.7% and negative predictive value of 99.8%. The laryngeal palpation test is not a particularly useful method for predicting the level of RLN function after thyroidectomy. All patients must be examined postoperatively by direct laryngoscopy or laryngofiberoscopy to check vocal cord mobility. Even if there is no contraction of the PCA and we detect vocal cord palsy immediately after surgery, vocal cord palsy often recovers within 1 year when visual preservation of RLN is successful.

Increased Mortality and Morbidity Associated With Thyroidectomy for Intrathoracic Goiters Reaching the Carina Tracheae

Complications associated with thyroidectomy for intrathoracic goiters have been underestimated because of the lack of a precise definition of high-risk patients. Retrospective multicenter multinational review of medical records and radiographic images of patients who underwent thyroidectomy for intrathoracic goiters reaching the carina tracheae. Demographic, clinical, operative, anatomical, and pathological data were recorded. There were 35 patients (mean +/- SE age, 63 +/- 11 years) included in the study. In 4 patients, the goiter was asymptomatic; 10 patients had dysphagia, 24 patients had dyspnea, and 3 patients had superior vena cava syndrome. A median sternotomy was required in 12 patients and a right-sided thoracotomy in 1 patient. The mean +/- SE operative time was 145 +/- 72 minutes (range, 50-360 minutes). Transient hypoparathyroidism developed in 13 patients. Four patients experienced transient hoarseness, and 1 patient had permanent vocal cord paralysis. There were no significant differences between the proportion of patients who underwent or did not undergo sternotomy or thoracotomy regarding vocal cord dysfunction (2 [15%] of 13 patients vs 3 [13%] of 22 patients) or hypoparathyroidism (5 [38%] of 13 vs 6 [28%] of 22 patients). The mean postoperative hospital stay was 10 days (range, 2-84 days). Four patients required reoperation. Two patients died. Nine of 14 patients with thyroid glands weighing at least 260 g required sternotomy vs 3 of 14 patients with thyroid glands weighing less than 260 g (P = .02). Overall, 18 [52%] of 35 patients were discharged without any complication. Intrathoracic goiters reaching the carina tracheae carry a high unreported risk of sternotomy, postoperative complications, reoperation, and death.

Long term follow-up of hyperthyroid patients treated by subtotal thyroidectomy.

The early and long term complications of subtotal thyroidectomy in 306 hyperthyroid patients (multinodular goitre and diffuse hyperplasia) followed for up to 30 yr are reviewed. There were no perioperative deaths. Sixteen patients (5.2 per cent) had transient symptomatic hypocalcaemia, while 9 (2.9 per cent) had permanent hypocalcaemia. Permanent unilateral vocal cord paralysis occurred in 11 (3.6 per cent) patients (1.8 per cent of nerves at risk). Cumulative per cent (+/- s.e.m.) relapse and hypothyroid rates at 30 yr (life-table analysis) were 15.6 +/- 2.4 per cent and 20.5 +/- 2.1 per cent, respectively. Lifelong follow-up of post-thyroidectomy patients is mandatory because of the risk of relapse of hypothyroidism.

Prävention der Rekurrensparese durch routinemäßige Nervendarstellung bei Schilddrüsenoperationen

Recurrent laryngeal nerve paralysis is one of the major complications of thyroid surgery. The importance of dissection and exploration of the recurrent laryngeal nerve during thyroid surgery remains controversial. 74 thyroid gland operations with obligatory dissection and exploration of the recurrent laryngeal nerve were analysed. 118 recurrent laryngeal nerves were explorated in these operations. Transitory postoperative vocal cord paralysis was observed in 4 patients. In one patient vocal cord paralysis was permanent. This results in a transitory vocal cord paralysis rate of 3.4 % and a permanent vocal cord paralysis rate of 0.85 %. Our results and the literature review indicate that dissection and visualization of the recurrent laryngeal nerve can reduce the risk of permanent paralysis to a minimum. Obviously mechanical trauma like compression and crushing due to dissection do not increase incidence of permanent nerval disorders. Certain dissection and identification of the recurrent laryngeal nerve during thyroid surgery is recommended in principle.

Surgical complications after thyroid surgery performed in a cancer hospital

This study evaluates the incidence and risk factors of complications in patients submitted to thyroidectomy in a cancer hospital with residency training. A retrospective chart and complications review of 1020 patients (1990-2000) underwent to thyroidectomy. At our cancer hospital, 1020 patients underwent thyroidectomy. The main postoperative complications consisted of transient hypocalcemia in 134 (13.1%) patients, permanent hypocalcemia in 26 (2.5%) patients, transient vocal cord palsy in 14 (1.4%) patients, and permanent vocal cord palsy in 4 (0.4%) patients. The type of thyroidectomy, neck dissection, and paratracheal lymph node dissection were significantly associated with transitory and permanent hypocalcemia. Thyroid surgery can be performed safely in a surgical residency training program under direct supervision of an experienced surgeon with little morbidity to the patients. Hypocalcemia is the most significant complication. Neck and paratracheal lymph node dissections were the most significant predictors of hypocalcemia in patients who underwent total thyroidectomy.

Unilateral hypoglossal nerve injury following the use of a ProSeal™ laryngeal mask

We would like to report a complication following the use of a ProSeal™ laryngeal mask airway (PLMA) (Intavent Orthofix Ltd, Maidenhead, UK). A 28-year-old male required open reduction and internal fixation of a comminuted tibial plateau fracture. General anaesthesia was induced with infusions of propofol and remifentanil and his airway secured with a size 5 PLMA. The laryngeal mask was inflated with 40 ml of air. Anaesthesia was maintained with propofol, remifentanil, and nitrous oxide 70% in oxygen. Anaesthesia and surgery (which lasted 3.5 h) were uneventful. The PLMA was removed as the patient woke and was noted to be apparently overinflated. There were no immediate postoperative complications. The following day the patient complained of difficulty in swallowing and numbness on the left side of his tongue, present since shortly after waking up. Examination confirmed unilateral hypoglossal nerve injury. Throughout the rest of his time in hospital eating remained difficult. Full recovery of his hypoglossal nerve function was slow but complete at 4 months. Hypoglossal nerve, lingual nerve and recurrent laryngeal nerve injury have previously been reported during use of the classic laryngeal mask [1–4]. In most cases a full recovery was made. In one case hypoglossal nerve injury was accompanied by severe weight loss [1] and in another unilateral recurrent laryngeal nerve injury lead to permanent vocal cord paralysis [4]. The mechanism of injury is neuropraxia, due to pressure on the pharynx from the airway. In the case of the hypoglossal nerve this occurs at the medial side of the hyoid bone as the nerve crosses the greater cornu [5]. This is the first report of nerve injury associated with the PLMA. The PLMA has a larger cuff than the classic laryngeal mask airway and has a posterior extension. As a result the mask makes a larger area of contact with the pharynx and exerts lower pharyngeal pressures for the same intracuff volume [6]. The PLMA allows a better airway seal than the classic laryngeal mask airway for any given intracuff volume [6]. The rise in PLMA-airway seal is greatest for the first 10 ml of inflation, across the size range [6]. This, and other data suggest, that the PLMA is the least likely of the laryngeal masks to cause complications associated with increased pressure on pharyngeal mucosa, with the classic also better than the intubating laryngeal mask [7]. The 40 ml of air inserted into this PLMA represents the maximum volume that should be inserted into a size 5 PLMA. It is likely that the use of nitrous oxide and the long duration of surgery [8] both contributed to increased intracuff pressure, increased pharyngeal mucosal pressure and therefore neuropraxia. Audit elsewhere has shown that use of the maximum recommended volumes of air in all laryngeal masks routinely leads to intracuff pressures in excess of 120 cmH2O [9] and our own local audit has confirmed this. The practice of reducing the volume of air in the cuffs of laryngeal mask airways to half the recommended maximum has been shown not to interfere with mask function [10]. Brain has recommended both for the classic laryngeal mask airway and the PLMA that the maximum intracuff pressure should not exceed 60 cmH2O [11,12] and this information is contained in the instruction manuals of both devices [13,14]. At an intracuff pressure of 60 cmH2O, the pressure exerted on all areas of the mucosa by the PLMA is below that considered critical for mucosal perfusion [6]. Following this case, we have altered the practice in our hospital in order to try to prevent recurrence of this and similar complications. We have introduced cuff inflator/pressure gauges (VBM Mediztechnic, Sulz, Germany) to all areas where laryngeal mask airways are used allowing inflation to pressure of 60 cmH2O, and to enable monitoring of that pressure throughout anaesthesia. It appears that without use of such monitoring it is not possible to use the devices as recommended by the manufacturers. Dr Cook has received an honorarium from Intavent Orthofix Ltd, manufacturers of the laryngeal masks and has advised a number of airway companies.

A Randomized Prospective Study of Complications Between General Surgery Residents and Attending Surgeons in Near-Total Thyroidectomies

Recurrent laryngeal nerve palsy and hypoparathyroidism are the most common and serious complications after thyroid operations. Surgeon experience has been defined as a significant factor in the number of complications occurring in thyroid surgery. There has so far been no prospective randomized study that compares the complication rates between residents and the attending surgeon in statistically similar patient groups in which all of the patients undergo the same type of thyroid surgery by the same surgical team. In this prospective study the performances of residents and attending surgeons were evaluated and compared according to the complication rates in near-total thyroidectomies. One hundred and fifty-two patients underwent near-total thyroidectomies between April 2001 and May 2003. The number of randomly selected patients operated on by residents at the level of postgraduate year two, under the direct supervision of an attending surgeon, and the number of patients operated on by attending surgeons were 78 and 74, respectively. All patients had preoperative and postoperative videolaryngostroboscopic examinations of the vocal cords and serum calcium level evaluation. The rates of temporary vocal cord paralysis with respect to the nerves at risk for residents and attending surgeons were 3.7% and 2.7%, respectively. The temporary hypoparathyroidism rate was 8.1% for attending surgeons, whereas it was found to be 6.4% for residents. Neither any cases of permanent vocal cord paralysis nor permanent hypoparathyroidism were detected. Our results indicate that the complication rates in near-total thyroidectomies performed by residents and attending surgeons are similar. Thyroid surgery can therefore be safely and effectively performed by residents under close supervision.

Focused Cervical Exploration for Primary Hyperparathyroidism without Intraoperative Parathyroid Hormone Monitoring or Use of the Gamma Probe

Selected patients with primary hyperparathyroidism (pHPT) who have a positive preoperative sestamibi scan can be managed safely and successfully with a focused cervical exploration without either adjuvant intraoperative parathyroid hormone (PTH) monitoring or use of a gamma probe. This article reports a retrospective analysis of a consecutive series of patients surgically treated at a tertiary referral center. From August 1998 to August 2002, 100 patients (68 women, 32 men; mean age 63 years [range: 29-89 years]) underwent a focused cervical approach without intraoperative PTH monitoring or use of the gamma probe after perioperative sestamibi injection. The study group comprised 9% of all patients (n = 1063) undergoing cervical exploration for pHPT during the study period. Ninety patients underwent an initial exploration, and 10 others underwent repeat cervical exploration following prior parathyroid (n = 7) or thyroid (n = 3) operation. Sestamibi scanning correlated with one enlarged parathyroid gland in all patients. Other enlarged glands were, however, not demonstrated in three patients (true positive = 97%; false negative = 3%). The single enlarged glands excised in all patients had a mean weight of 795 mg (range: 90-3640) and were histologically compatible with an adenoma. Postoperatively, 97% of patients were eucalcemic. Three patients remained hypercalcemic (3%). Of the three patients with persistent hypercalcemia, one underwent successful re-exploration with excision of a 500 mg second adenoma, whereas the other two patients (with confirmed familial HPT) remained hypercalcemic. Mean hospitalization was 0.5 days (range: 0-3 days). There was no operative mortality. No patients had permanent hypocalcemia. Postoperative morbidity occurred in three patients: two self-limiting cervical hematomas and one permanent vocal cord paralysis. Selected patients with pHPT due to single-gland disease and an unequivocally positive preoperative sestamibi scan can safely and successfully be managed with a focused unilateral cervical exploration without either intraoperative PTH monitoring or use of the gamma probe. Further experience with this surgical approach seems warranted to determine the overall cure rate, operative morbidity, and the sensitivity and specificity of preoperative localization studies.

Postoperative complications of thyroidectomy for differentiated thyroid carcinoma

Objective This study evaluates the incidence and risk factors of complications in patients submitted to thyroidectomy for differentiated thyroid carcinoma in a cancer hospital with residency training. Study design A retrospective chart and complications review of 316 consecutive patients who underwent thyroidectomy for differentiated thyroid carcinoma. Results Of the 316 patients, the main postoperative complications were transient hypocalcemia in 87 (27.5%), permanent hypocalcemia in 16 (5.1%), transient vocal cord palsy in 4 (1.2%), and permanent vocal cord palsy in 2 (0.6%). Neck dissection and paratracheal lymph node dissection when associated with total thyroidectomy were significantly related to transitory and permanent hypocalcemia. Conclusion Thyroid surgery can be performed safely in a hospital with medical residency training program under direct supervision of an experienced surgeon with acceptable morbidity. Hypocalcemia is the most significant complication. Neck and paratracheal lymph node dissections were the most significant predictors of hypocalcemia in patients submitted to total thyroidectomy.

Intraoperative parathyroid hormone assay and parathyroid reoperations

Background The purpose of this study was to determine whether intraoperative parathyroid hormone (IOPTH) assay improved results of reoperations. Methods One hundred two patients with persistent/recurrent sporadic primary hyperparathyroidism underwent 108 reoperations (1996-2002). IOPTH was not used (n = 58) from 1996-1998 (group 1). IOPTH was used (n = 50) from 1999-2002 (group 2). Sensitivity and positive predictive value of IOPTH and its influence on surgical strategy were analyzed. A 50% decrease occurring 10 minutes after removal of parathyroid tumor was used to determine if all abnormal tissue had been removed. Results Groups 1 (58 patients) and 2 (50 patients) were comparable except for duration of follow-up. The cure rate was 84% (group 1, 87%; group 2, 82%, P = 0.7). Hypocalcemia developed in 20 patients (permanent in 2 patients). There was 1 permanent vocal cord paralysis and 1 patient died of toxic shock syndrome. IOPTH successfully predicted cure in 44 of 49 patients (sensitivity, 90%); the positive predictive value was 90%. Values for parathyroid hormone level and the ratio parathyroid hormone/calcium at day 1 were at least as accurate as IOPTH in predicting cure. IOPTH was helpful in 1 patient but misleading in 4 patients. It failed to modify intraoperative strategy in most other patients. Conclusions IOPTH testing was relatively reliable in patients with persistent or recurrent sporadic primary hyperparathyroidism, but the test unfortunately failed to improve the overall success rate at reoperation.

Surgical treatment of thyrotoxicosis: a local institution's perspective

Objective: The most optimal form of thyroidectomy for thyrotoxicosis is controversial. Geographical factor, possibly due to the difference in iodine intake, can profoundly influence the therapy outcomes. The results of different forms of thyroidectomy in a local hospital for thyrotoxicosis is presented. Their pros and cons were evaluated.Methods: From January 1995 to December 2001, 69 patients with toxic goitres treated surgically were retrospectively studied. The factors potentially affecting the postoperative thyroid function were also analysed.Results: The mean follow‐up duration was 22.6 ± 17.2 months. The incidence of permanent vocal cord palsy and hypoparathyroidism were 0 and 2.9%, respectively. Remission, hypothyroidism, and recurrent hyperthyroidism occurred in 39, 52.5 and 8.5% respectively, of patients who have undergone either subtotal thyrodiectomy or Dunhill procedure (hemithyroidectomy plus contralateral subtotal lobectomy). Only the size of the remnant was found to be a significant factor of postoperative hypothyroidism (P = 0.048).Conclusion: Subtotal thyroidectomy or Dunhill procedure are efficacious in treating thyrotoxicosis with acceptable incidence of operative complications and recurrent hyperthyroidism. A significant portion of patients were rendered euthyroid without the need of thyroxine replacement.

Arteria lusoria identified on preoperative CT and nonrecurrent inferior laryngeal nerve during thyroidectomy: a retrospective study.

To evaluate surgical identification of nonrecurrence of the inferior laryngeal nerve (NRILN) during thyroidectomy in patients with an aberrant subclavian artery (a. lusoria) as seen on CT. The medical files of patients treated by thyroidectomy between January 1998-December 2000 (n = 583) were retrospectively reviewed for preoperative and postoperative mobility of the vocal cords and perioperative identification of NRILN. The available preoperative CT studies (n = 163) were reviewed for presence of a. lusoria. In five patients, the CT study revealed an a. lusoria (3.16%). In one of five of these patients, an NRILN was surgically detected; the overall detection rate of NRILN was 0.21%. In one of four patients with nonidentification of this nerve during surgery, immediate unilateral and permanent vocal cord paralysis were present after surgery. No permanent vocal cord paralysis occurred in any of the other patients. The identification of a. lusoria should alert the radiologist and surgeon that a NRILN is present, allowing an anticipating surgical technique, reducing the risk of neural injury.