Temporary Hypocalcemia Research Articles

THE RELATION BETWEEN THE EXCISED THYROID GLAND WEIGHT AND POSTOPERATIVE COMPLICATIONS IN TOTAL THYROIDECTOMY PATIENTS

Aim: The purpose of this study was to determine the postoperative complications in total thyroidectomy patients based on the weight of the thyroid gland with retrospective screening.Material and Methods: A total of 263 adult patients, who underwent total thyroidectomy were included. The data automation system of the hospital and the files of the patients were examined retrospectively.Results: The total complication incidence was 24.3%, and these were determined as hypocalcemia, vocal cord paralyses (VCP), and hemorrhage and seroma at the surgery area. The rate of temporary hypocalcemia and permanent hypocalcemia rate was 20.1% and 1.5% respectively. The temporary VCP rate was 0.3% (n=1), and no permanent VCP was observed in the patients. The median thyroid weight was measured as 50 gr in patients without postoperative hypocalcemia, and as 40 g in the patients with hypocalcemia (p=0.283). There was no significant relation between the variability in the weight of the thyroid and postoperative hypocalcemia. However, the cervical lymph node dissection (LND) (p=0.006) and cervical dissection site (p=0.031) were significant in terms of postoperative complication development. In the multivariate analyses, it was found that female gender and LND were independent risk factors in the development of postoperative complications.Conclusion: It was determined that cervical LND and female gender were independent risk factors. Consistent with the literature findings, no significant results were found in the risk factors like heavy thyroid gland, presence of thyroid operation history, malignant thyroid pathology, retrosternal localization of the thyroid tissue, and hyperthyroidism.Keywords: Complications; hypocalcemia; thyroid weight; total thyroidectomy.

Focused Parathyroidectomy Under Local Anesthesia - A Feasibility Study.

Purpose:We conducted this study to evaluate the feasibility, patient satisfaction, and cost of performing focused parathyroidectomy under local anesthesia (LA) and mild sedation, administered and monitored by a surgeon.Materials and Methods:This was a prospective observational study of 30 patients with primary hyperparathyroidism (PHPT) undergoing a focused parathyroidectomy under LA and mild sedation at a single institution. The clinical features, gland weight, operating time, procedure time, postoperative pain scores, overall patient satisfaction, postoperative nausea and vomiting, analgesic requirements, complications, cost, and cure rates were documented. Data were analyzed using SPSS software version 17.0.Results:In two patients (6.7%), the procedure had to be completed under general anesthesia (GA). Postoperative temporary hypocalcemia was witnessed in 14 of 30 (46.7%), but only 1 required intravenous calcium infusion. About 21 of 30 (75%) were completely satisfied with LA, whereas 25 of 30 (89%) were completely satisfied with surgical procedure. Furthermore, all patients were keen to recommend this procedure under LA to their friends and family. Comparing the cost between performing the procedure under LA with that under GA, a significant difference was witnessed (P = 0.001). Among the 26 patients reviewed at 6 months, all had a normal serum calcium and parathyroid hormone levels indicating 100% cure rate.Conclusion:Performing focused parathyroidectomy under LA is feasible; additionally, this method can significantly reduce the cost of the procedure (P = 0.001).

Thyroidectomy Audit: Effects of Specialised, High Volume Work on Key Performance Indicators

We conducted this audit to assess and improve the quality of care for patients undergoing thyroid surgery at our institution. The audit process began in 2012. Key performance indicators assessed were rates of hypocalcemia (immediate postoperative, temporary and permanent), recurrent laryngeal nerve (RLN) injury, chyle leak rate, re-exploration for chyle leak and post-thyroidectomy haemorrhage. Data of patients undergoing thyroidectomy from 1st January to 31st December 2011 was retrospectively collected from the electronic database. Performance indicators were assessed and compared to international standards. Actions to correct the short falls were implemented and retrospective re-audits were performed on prospectively collected data in subsequent years until 2015. The data was analysed using STATA IC/13.1. There has been a steady increase in the number of thyroidectomies performed/year from 357 in 2011 to 577 in 2015. The most common procedure performed was total thyroidectomy (~70%) and histopathology revealed thyroid malignancy in the majority of patients. Over 5 years, a significant improvement in the rates of post-thyroidectomy immediate and temporary hypocalcemia was witnessed (p < 0.001) as well as a near significant fall in permanent hypocalcemia and RLN injury rate (p = 0.06). In 2014 and 2015, no patients were re-explored for a chyle leak. The rate of post-thyroidectomy haemorrhage (1.2–1.8%) has remained static over 5 years. This audit portrays specialisation in endocrine surgery and high volumes of patients treated have resulted in a significant improvement in outcomes for patients following thyroid surgery that meet international standards.

Changes in the hearing threshold using high frequency audiometry in medical personnel exposed to ionizing radiation

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Effect on sensorineural hearing loss by low dose ionizing radiation exposure in radiation workers has been rarely evaluated. A case control study was done among the radiation associated workers and normal subjects.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; The study was designed in low dose of radiation exposing healthy medical personnel. Age and sex matched healthy control group of subjects were selected. Groups were evaluated by normal otoscopic evaluation; normal tuning fork test and normal standard pure tone audiogram at frequencies from 250 to 8000 Hz. They underwent impedance audiometry, transient evoked otoacoustic emissions, and high frequency audiometry (from frequencies 10000 to 20000 Hz) was done. &lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; No statistically significant difference was found in the results of impedance audiometry, transient evoked otoacoustic emissions and standard pure tone audiogram from 250 to 8000 Hz between cases and controls. In the high frequency range, statistically significant difference was observed (p=0.0001). Mean thresholds were higher at all frequencies in cases compared to controls, except at 4000 Hz. A statistically significant correlation was found between duration of exposure and thresholds at 500 Hz (p=0.014) and 10000 Hz (p=0.048). Tinnitus, vertigo, ear block, hard of hearing and loss of appetite were seen more in cases, but was not significant.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Taking account of the very low incidence of nerve and parathyroid injury in this series, the authors suggest that meticulous capsular dissection is superior to dissection of the entire nerve in avoiding transcient nerve damage as well as temporary hypocalcemia. However it is stated that a deliberate search for the nerve is definitely indicated in cases where there is likely to be distorted anatomy, as in infiltrating malignancies and recurrent thyroidectomies.&lt;/p&gt;

Feasibility of Endoscopic Thyroidectomy via Axilla and Breast Approaches for Larger Goiters: Widening the Horizons.

Scarless (in the neck) endoscopic thyroidectomy (SET) has evolved into a cosmetically preferred alternative to conventional thyroidectomy (ConT). Recently many of our patients are demanding SET; however their goitres are larger than the recommended size of 4–6 cm. Our aim was to compare the outcomes of ET for small (<6 cm) vs large (≥6 cm) goitres and determine its feasibility in such cases. This is a retrospective analysis of prospectively maintained database of patients undergoing ET. Patients were divided into 2 groups: I, small (<6 cm) and II, large goitres (≥6 cm). Their demographic and clinicopathological profiles, operation time, conversion and complication rates, and hospital stay were compared. 99 patients (101 procedures) were included: group I, 60 patients (61 procedures), and group II, 39 patients (40 procedures). Mean tumor size (± SD) was 4.4 ± 0.9 cm and 6.7 ± 1.1 cm in groups I and II, respectively. The groups were comparable with respect to demographic and clinical profile except for mean duration of goiter [30.1 ± 32.6 months (group I) vs 60.5 ± 102.4 months (group I), p = 0.03] and gland weight [21.5 ± 15.3 grams (group I) vs 62.3 ± 51.3 grams (group II), p = 0.001]. Although there was no significant difference between mean operating times, long term perioperative outcomes, and conversion rates, temporary hypocalcaemia and length of stay were longer in group II. One patient had permanent vocal cord palsy (~1%, 1/101); none had permanent hypoparathyroidism. Our results indicate that ET can be offered to a subset of patients with larger goitres desirous of SET with no significant difference in mean operation time, conversions, and long term postoperative complications in experienced hands.

Robot-assisted transaxillary thyroidectomy: our early experience

Objective:To evaluate the feasibility, effectiveness and safety of robot-assisted transaxillary thyroidectomy (RATT).Method: The clinical data of 66 patients undergoing RATT from November 2016 to May 2018 were prospectively collected and analyzed. The average age was (38.61±11.72) years, 57 cases were female and 9 cases were male. Preoperative fine needle aspiration biopsy revealed papillary thyroid carcinoma in 58 cases and follicular thyroid tumor in 8 cases.Result:All the patients successfully completed RATT, and there was no open operation, in which 54 cases of ipsilateral lobetomy and isthmus resection and ipsilateral central lymph node dissection, 8 cases with ipsilateral lobectomy and contralateral near-total lobectomy, and total thyroidectomy with ipsilateral central lymph node dissection and selective neck dissection combined with retroauricular approach in 4 cases. The mean operative time was (124.30±23.41) min, and the average bleeding volume was (17.73±8.28) ml. The mean diameter of thyroid papillary carcinoma was (0.71±6.22) cm, and the postoperative drainage volume was (67.57±25.11) ml. The average postoperative hospitalization time was (3.24±0.81) days. 3 cases (4.5%) had temporary laryngeal nerve palsy after operation, and 1 case (1.5%) had temporary hypocalcemia after operation, all recovered after one month. No postoperative bleeding, subcutaneous emphysema, drinking water cough and permanent hypocalcemia were observed. The average numbers of lymph node dissection in PTC patients were (6.26±4.76), of which 21 cases (36.2%) had lymph node metastasis, postoperative stage T1 54 cases, T2 4 cases, N1a 17 cases, N1b 4 cases. The follow-up time were 1-18 months. The postoperative cosmetic VAS score in January was (9.66±0.54). Ultrasound showed no residual glands in the affected thyroid gland, and there was no recurrence in the local and regional regions.Conclusion:RATT is safe and feasible with good aesthetic effect and can be used as an option for the treatment of thyroid diseases..

Completion Thyroidectomy: Safer than Thought

Background: The aim of this study was to find out whether a substantial difference in terms of complication rates exists between primary and completion thyroidectomies following initial bilateral subtotal thyroidectomy in the light of current literature and our series. Patients and Methods: Total number of 696 patients who received completion thyroidectomy (Group 1, n = 289) and total thyroidectomy for differentiated thyroid cancer (Group 2, n = 407) and their data were reviewed and postoperative complications were compared between the groups and with the literature. Results: Transient and permanent hypocalcaemia rates were 20% and 5.8% in Group 1 and 10.5% and 5.1% for Group 2 respectively. Unilateral transient, bilateral transient and unilateral permanent recurrent laryngeal nerve palsy rates were 6.2%, 1.3% and 4.4% for patients in Group 1 whereas same complications were seen in 4.6%, 0.7% and 3.6% of patients in Group 2. When groups were compared for complications; temporary hypocalcaemia, unilateral temporary nerve palsy, and minor wound infection rates were statistically higher in Group 1, with no significant difference in permanent complications. Conclusion: When complication rates of re-operation after bilateral subtotal thyroidectomy and primary total thyroidectomy for differentiated thyroid cancer were compared in an unbiased fashion, completion thyroidectomy was shown to be as safe as a primary operation with regard to permanent complications.

Outcome of Thyroid Surgeries at Patan Hospital

Objective: To assess the outcome of thyroid surgeries at Patan HospitalMaterials and Methods: It is a retrospective study of in-patient records of patients undergoing thyroid surgeries for various indications from April 2013 to January 2015 at Patan Hospital, Lalitpur.Results: During the period of 21 months, 75 patients underwent thyroid surgeries. Majority of patients underwent hemithyroidectomy (35) followed by total thyroidectomy (28), subtotal thyroidectomy (7) and completion thyroidectomy (5). Out of 28 patients undergoing total thyroidectomy (TT), 11 underwent central compartment clearance (CCC), 5 underwent CCC and lateral neck dissection. Among 5 patients undergoing completion thyroidectomy, CCC was performed in all cases and in one patient lateral neck dissection was also performed. A total of 13 patients developed unilateral recurrent laryngeal nerve palsy (RLN), among them 5 had permanent palsy. Tracheostomy had to be done in immediate postoperative period for stridor following total thyroidectomy (TT) in one case. Temporary hypocalcaemia was observed in 10 (10/28) cases following TT, out of which 8 had undergone CCC. Permanent hypocalcaemia was observed in 7 (7/28) cases following TT out of which 3 had undergone CCC. Chylous leak occurred in one of the patient undergoing left level II-IV neck dissection which was managed conservatively. None of the patient had to be transfused postoperatively.Conclusion: Complications to thyroid surgery are not uncommon. Visualization of recurrent laryngeal nerve alone in our context is adequate in experienced hands. Identification of parathyroid during thyroidectomy is recommended to avoid hypocalcaemia. Meticulous dissection can reduce the complications.Nepalese Journal of ENT Head and Neck Surgery, Vol. 6, No. 1, 2015

Surgical outcomes of thyroid cancer patients in a tertiary cancer center in India.

Surgery is the mainstay in the management of thyroid cancer. Surgical outcomes need to be tempered against the excellent prognosis of the disease. This study aims to study the surgical outcomes including the 30-day morbidity and 5-year survival of thyroid cancer patients. Retrospective analysis of a prospectively maintained surgical database in a tertiary cancer center in India. We analyzed 221 surgically treated patients in the year 2012. Used IBM SPSS 24.0 (Armonk, NY) with p < 0.05. The median age was 40 years with predominantly papillary thyroid carcinoma (55%). Localized disease in 47% of cases, locoregional disease in 42.5% and distant metastasis in 10.2% of cases at presentation was noted. Treatment naïve patients were 71% and revision surgeries were done in 29% patients. Extended thyroidectomy constituted 11% of the surgeries. Temporary hypocalcemia was seen in 30.8% of patients, 5% requiring intravenous calcium supplementation. Vocal cord palsy as per nerve at risk and chyle leak were seen in 4.5% and 3.1%, respectively. Aggressive histology, extended thyroidectomy, and inadvertent parathyroidectomy were significant factors associated with complications. Five year estimated overall survival with median follow-up of 50 months was 98%, and event-free survival was 84.8%. Advanced age, distant metastasis at presentation and aggressive histology connoted poor outcomes. Thyroid cancer, irrespective of the extent of disease, has good prognosis. Aggressive histology, the extent of thyroid surgery, distant metastasis and age are important factors, which should be factored in the algorithm of thyroid cancer management.

A systematic approach to the recurrent laryngeal nerve dissection at the cricothyroid junction

BackgroundTo describe and evaluate a four step systematic approach to dissecting the recurrent laryngeal nerve (RLN) starting at the cricothyroid junction during thyroid surgery (subsequently referred to as the retrograde medial approach).MethodsAll thyroidectomies completed by the senior author between August 2014 and January 2016 were retrospectively reviewed. Patients were excluded if concurrent lateral or central neck dissection was performed. A follow up period of 1 year was included.ResultsSurgical photographs and illustrations demonstrate the four steps in the retrograde medial approach to dissection of the RLN in thyroid surgery.Three hundred forty-two consecutive thyroid surgeries were performed in 17 months, including 213 hemithyroidectomies, 91 total thyroidectomies, and 38 completion thyroidectomies. The rate of temporary and permanent hypocalcemia was 13% (95% confidence interval [CI]: 8–20%) and 3% (95% CI: 1–8%) respectively. The rate of temporary and permanent vocal cord palsy was 9% (95% CI: 6–12%) and 0.3% (95%CI: 0.01–2%) respectively. The median surgical times for hemithyroidectomy, total thyroidectomy, and completion thyroidectomy were 39 min (Interquartile range [IQR]: 33–47 min), 48 min (IQR: 40–60 min), and 40 min (IQR: 35–51 min) respectively. 1% of cases required conversion to an alternative surgical approach.ConclusionIn a tertiary endocrine head and neck practice, the routine use of the retrograde medial approach to RLN dissection is safe and results in a short operative time, and a low conversion rate to other RLN dissection approaches.

Calcium, vitamin D or recombinant parathyroid hormone for managing post-thyroidectomy hypoparathyroidism

Background Post-surgical hypoparathyroidism is a common complication after thyroid surgery. The incidence is likely to increase given the rising trend in the annual number of thyroid operations being performed. Measures to prevent post-thyroidectomy hypoparathyroidism including different surgical techniques and prophylactic calcium and vitamin D supplements have been extensively studied. The management of post-thyroidectomy hypoparathyroidism however has not been extensively evaluated. Routine use of calcium and vitamin D supplements in the postoperative period may reduce the risk of symptoms, temporary hypocalcaemia and hospital stay. However, this may lead to overtreatment and has no effect on long-term hypoparathyroidism. Current recommendations on the management of post-thyroidectomy hypoparathyroidism is based on low-quality evidence. Existing guidelines do not often distinguish between surgical and non-surgical hypoparathyroidism, and transient and long-term disease.The aim of this systematic review was to summarise evidence on the use of calcium, vitamin D and recombinant parathyroid hormone in the management of post-thyroidectomy hypoparathyroidism. In addition, we aimed to highlight deficiencies in the current literature and stimulate further work in this field. Objectives The objective of this systematic review was to assess the effects of calcium, vitamin D and recombinant parathyroid hormone in managing post-thyroidectomy hypoparathyroidism. Search methods We searched CENTRAL, MEDLINE, PubMed, Embase as well as ICTRP Search Portal and ClinicalTrials.gov. The date of the last search for all databases was 17 December 2018 (except Embase, which was last searched on 21 December 2017). No language restrictions were applied. Selection criteria We planned to include randomised control trials (RCTs) or controlled clinical trials (CCTs) examining the effects of calcium, vitamin D or recombinant parathyroid hormone in people with temporary and long-term post-thyroidectomy hypoparathyroidism. Data collection and analysis Two review authors independently screened titles, abstracts and full texts for relevance. Main results Database searches yielded a total of 1751 records. We retrieved potentially relevant full texts and excluded articles on the following basis: not a RCT or CCT; intervention, comparator or both did not match prespecified criteria; non-surgical causes of hypoparathyroidism, and studies on prevention. None of the articles was eligible for inclusion in the systematic review. Authors' conclusions This systematic review highlights a gap in the current literature and the lack of high-quality evidence in the management of post-thyroidectomy temporary and long-term hypoparathyroidism. Further research focusing on clinically relevant outcomes is needed to examine the effects of current treatments in the management of temporary and long-term post-thyroidectomy hypocalcaemia.

Cervical teratomas

Cervical teratomas

Parathyroid Adenoma - Surgical Challenge in a Crippling Condition

Background: Primary hyperparathyroidism (PHPT) is associated with either an adenoma or hyperplasia of chief cells of the parathyroid gland. It may occur sporadically, as a single autosomal dominant familial disorder, or as a part of the autosomal dominantly transmitted complex of multiple endocrine neoplasia (MEN). PHPT is relatively rare in children and adolescents. It is a condition characterized by an inappropriate excess of parathyroid hormone (PTH) secretion.Method: This study was carried out in the Department of Otolaryngology and Head-Neck Surgery, BIRDEM General Hospital, Dhaka, Bangladesh from July 2009 to June 2015. A total 35 patients of different age group of both sex were included in this study. Preoperative localization test, including sestamibi scan, ultrasound or both were done for all patients.Result: The total number of patients were 35 which included 19 males (54.29%) and 16 females (45.71%). The age of the patients varied from 18 to 65 years (average 40.90 years). All of these patients underwent operative removal of the adenoma. Serum PTH levels were above normal (&gt;53 pg/ml) in all patients and ranged from 65 to 700 pg/ml. Serum calcium levels were above normal (&gt;11 mg%) in most cases and ranged from 10.4 to 14.8 mg%. In our study, 25 patients (71.42%) had high calcium levels with the ten cases were at upper normal. Serum phosphate (PO4) levels were on an average 1.8 (lower normal). In view of the raised calcium levels, the PTH was estimated followed by either sonography or CT scan. Serum PTH levels (85-700 pg/ml) were very high in 18 cases, high in 11 cases (65-85 pg/ml) and upper normal in 6 cases (59-64). In our study after operation, 13 patients developed hypocalcaemic state and required intravenous calcium at operation day and first post operative day, and rest of the patient’s hypocalcaemic state corrected by oral calcium supplement. In our study temporary hypocalcaemia was very common and reported recurrent laryngeal nerve injury was less than one percent.Conclusion: In parathyroid adenoma bone resorption causes recurrent bone fractures leading to a crippling condition. Preoperative localization of parathyroid adenoma with the help of sestamibi scan, surgical expertise need to remove the tumor and post operative calcium level management with the help of endocrinology department are necessary for successful management of parathyroid adenoma.Birdem Med J 2017; 7(2): 138-142

Ambulatory thyroidectomy: an anesthesiologist's perspective.

Thyroidectomy has been performed on an inpatient basis because of concerns regarding postoperative complications. These include cervical hematoma, bilateral recurrent laryngeal nerve injury and symptomatic hypocalcemia. We have reviewed the current available evidence and aimed to collate published data to generate incidence of the important complications. We performed a literature search of Medline, EMBASE and the Cochrane database of randomized trials. One hundred sixty papers were included. Twenty-one papers fulfilled inclusion criteria. Thirty thousand four hundred fifty-three day-case thyroid procedures were included. Ten papers were prospective and 11 retrospective. The incidences of complications were permanent vocal cord paralysis 7/30259 (0.02%), temporary hypocalcemia 129/4444 (2.9%), permanent hypocalcemia 405/29203 (1.39%), cervical hematoma 145/30288 (0.48%) and readmission rate 105/29609 (0.35%). Analysis of cervical hematoma data demonstrated that in only 3/14 cases the hematoma presented as an inpatient, and in the remaining 11/14, it occurred late, with a range of 2–9 days. There is a paucity of data relating to anesthetic techniques associated with ambulatory thyroidectomy. Cost comparison between outpatient and inpatient thyroidectomy was reported in three papers. Cost difference ranged from $676 to $2474 with a mean saving of $1301 with ambulatory thyroidectomy. There is a body of evidence that suggests that ambulatory thyroidectomy in the hands of experienced operating teams within an appropriate setting can be performed with acceptable risk profile. In most circumstances, this will be limited to hemithyroidectomies to reduce or avoid the potential for additional morbidity. We have found little evidence to support the use of one anesthetic technique over another. The rates of hospital admission and readmission related to anesthetic factors appear to be low and predominantly related to pain and postoperative nausea and vomiting. A balanced anesthetic technique incorporating appropriate analgesic and antiemetic regimens is essential to avoid unnecessary hospital admission/readmission.

Six-Year Experience of Outpatient Total and Completion Thyroidectomy at a Single Academic Institution

Outpatient thyroidectomy has become slowly accepted with various published reports predominantly examining partial or subtotal thyroidectomy. Concerns regarding the safety of outpatient total and completion thyroidectomy remain, especially with regard to vocal fold paralysis, hypocalcemia, and catastrophic hematoma. We aimed to evaluate the safety of outpatient thyroid surgery in a large cohort by retrospectively comparing outcomes in those who underwent outpatient (n = 251) versus inpatient (n = 291) completion or total thyroidectomy between February 2009 and February 2015. Outpatient completion and total thyroidectomy had lower rates of temporary hypocalcemia (6% vs 24.4%; P < 0.001) and no significant difference in rates of return to emergency department (1.2% vs 1.4%), hematoma formation (0.8% vs 0.7%), temporary (2% vs 4.1%) or permanent (0.4% vs 0.7%) vocal fold paralysis, or permanent hypocalcemia (0.4% vs 0%) compared with the inpatient group. Outpatients requiring calcium replacement had shorter duration of postoperative calcium supplementation (44.4 ± 59.3 days vs 63.3 ± 94.4 days; P < 0.001). Our data demonstrate similar safety in outpatient and inpatient total and completion thyroidectomy.

Endoscopic Thyroidectomy: Experience of Breast and Axillary Approach

Background: The use of endoscopic thyroid surgical procedures leads to avoid the surgical scar in the neck. In this paper we evaluate the merits and limits of endoscopic thyroid surgery through breast and axillary approach. Methods: Between Aug 2013 and Nov. 2014, 437 thyroid surgeries were performed. 27 of them were operated endoscopically through axillary and breast approaches were reviewed prospectively. Three ports were used in this technique, two in axilla and one in ipsilateral areola. Carbon dioxide insufflation up to 6-8mm Hg was used. Results: Endoscopic procedures performed in 27 patients (22 hemi thyroidectomy and 3 total thyroidectomy and one completion thyroidectomy). The mean operating time for hemi thyroidectomy and total thyroidectomy was 148 and 270 minutes respectively. No evidence of recurrent laryngeal nerve injury was observed in any case however there was temporary hypocalcaemia in all four patients operated as total thyroidectomy. The postoperative cosmetic status of the patients was excellent. Conclusions: We believe that endoscopic thyroidectomy by axillary & breast approach will find a role in the treatment of nodular thyroid disease with excellent cosmetic outcome.

Total Thyroidectomy Without Prophylactic Central Cervical Lymph Node Dissection: Is It Oncologically Safe in Patients with Early-Stage Papillary Thyroid Carcinoma

Background: The necessity and the benefits of prophylactic central cervical lymph node dissection (PCLND) in clinically node negative patients with early-stage papillary thyroid carcinoma (PTC) remain controversial. Objective: to evaluate the safety of total thyroidectomy without PCLND in clinically node-negative early-stage PTC. Patients & Methods: 34 patients with T1 or T2 & N0 PTC were included in the study and submitted to total thyroidectomy without PCLND. Post-operatively, all patients received TSH suppression therapy & radio-active iodine (RAI) ablation. Any suspicious local neck recurrence during the follow up was confirmed cytologically and treated by RAI ablation. Results: The mean age was 42.1 years. 55.9% of patients were less than 45 years and 44.1% were 45 years old or more. Male to female ratio was 10:24. T1 was found in 14 cases & T2 in 20 cases. Total thyroidectomy was successfully done for all the cases. Central cervical lymph nodes sampling was done in 5 cases. Excised lymph nodes were found in 8 specimens; 5 cases with lymph node sampling (14.7%) and 3 cases (8.8%) with accidental lymph node excision during thyroidectomy. only 6 of these 8 patients (17.6%) showed positive metastasis (pN1). No recurrent laryngeal nerve injury was reported. In 12 patients (35.3%), temporary hypocalcemia was encountered. The mean follow up period was 34.6 months. There were 2 recurrences (5.9%); 1 in the central & 1 in the lateral neck compartment. All recurrences were treated by RAI ablation. No distant metastasis or mortality was reported. Conclusion: total thyroidectomy without PCLND in clinically node-negative early stage PTC is an excellent treatment option that gives adequate loco-regional control of the disease with low rate of surgical complications. Close follow up for longer periods is needed.

Sentinel Lymph Node Biopsy as a Guide for Central Neck Dissection in Patients with Suspicious Thyroid Nodule and Negative Cervical Lymphadenopathy

Background: Routine prophylactic central compartment neck dissection in patients with differentiated thyroid carcinoma is not always accepted as a standard management of occult metastasis due to the risk of hypocalcaemia and recurrent laryngeal nerve injury. Aim: To evaluate the accuracy of using sentinel lymph node biopsy as a guide in identifying occult cervical LN metastases early and thus to avoid the morbidity associated with routine unnecessary central lymph node dissection. Patients and methods: A prospective study was conducted in the period between April 2015 and January 2017 in Ain Shams University Hospitals, General Surgery Department, Endocrine Surgery Unit, Cairo, Egypt. The study included fifty two patients who had at least one suspicious thyroid nodule and not accompanied by clinical or radiological cervical LN. The patients underwent sentinel lymph node biopsy via intra-tumoral injection of methylene blue dye 1%, followed by tracking the lymphatics till the sentinel LN then total thyroidectomy and central LN dissection. Results: The study included 52 patients with suspicious thyroid nodule, 11 males and 41 females with mean age 41±6.7 (26-65). Co-morbid conditions included DM, HTN and ISHD. Size of nodules ranged from 0.8- 5.6 cm (1.9± 0.6) and most nodules were confined to one lobe (65.4%). After the final paraffin pathology 24 nodules were found to be benign and 28 proved malignant. SLNs were identified in 21 of 28 malignant cases (75%); number of sentinel LNs detected was 0-6 (2.8±1.9) and size ranged from 0.1- l.6 cm. 18 of identified SLN were positive for metastasis and 10 were negative while non SLN were positive in 15/28 and negative for 13/28. Thus, the sensitivity, specificity, negative predictive values, positive predictive values and accuracy of SLN biopsy were 85.7%, 100%, 70%, 100%, and 75%, respectively. Post-operative complications included temporary hypocalcaemia in 3 patients and extensive laryngeal edema in 1 patient needing prolonged intubation more than one day then recovered. Conclusion: SLN biopsy for patients with differentiated thyroid carcinoma and negative LNs clinically and radiologically is an accurate and noninvasive means to identify subclinical lymph node metastasis and so can be used as a guide to determine the need for zone 6 LN dissection.

The Effect of Prophylactic Central Neck Dissection on Locoregional Recurrence in Papillary Thyroid Cancer After Total Thyroidectomy: A Systematic Review and Meta-Analysis : pCND for the Locoregional Recurrence of Papillary Thyroid Cancer.

The use of prophylactic central neck dissection (pCND) for papillary thyroid cancer (PTC) without clinical evidence of nodal metastasis (cN0) remains controversial. This study was designed to examine whether pCND for PTC affected locoregional recurrence (LRR). A systematic review was performed to compare the LRR between patients with PTC who underwent total thyroidectomy (TT) and pCND and those who underwent TT alone. The primary outcome was LRR. Other outcomes, including postoperative radioiodine (RAI) ablation and surgically related complications, were evaluated. A meta-analysis was performed using the random-effects model. We included 17 studies, which comprised 4437 patients. Patients in the TT+pCND group had a significantly reduced risk of LRR (risk ratio [RR]=0.66; 95% confidence interval [CI]: 0.49-0.90; P=0.008). The LRR in the central neck compartment (RR=0.35; 95% CI 0.18-0.68; P=0.002) was significantly lower in the TT+pCND group, whereas the LRR in the lateral neck compartment was similar between the two groups. Compared with the TT alone group, patients in the TT+pCND group tended to receive higher RAI (74.6% vs. 59.9%) and experience temporary hypocalcemia (odds ratio [OR]=2.37; 95% CI 1.89-2.96; P<0.00001), permanent hypocalcemia (OR=1.93; 95% CI 1.05-3.57; P=0.03), and increased overall morbidity (OR=2.56; 95% CI 1.75-3.74; P<0.00001). This meta-analysis suggested that although pCND reduced the LRR in PTC-specifically in the central neck compartment-it was accompanied by an increased rate of postoperative hypocalcemia. However, the evidence is limited and randomized, controlled trials are needed to clarify this role further.

Revision neural monitored surgery for recurrent thyroid cancer: Safety and thyroglobulin response.

To evaluate the quantitative biochemical response, recurrence rate, and rate of surgical complications for thyroid cancer revision surgery. Retrospective review. This is a single institution analysis of a prospective database of 181 patients undergoing reoperation for local recurrent thyroid cancer by the same surgeon from 2004 to 2013 with intraoperative neural monitoring. Main outcome measures included pathologic findings, surgical complications, effect of reoperation on thyroglobulin (Tg) levels, and recurrence rate. We defined biochemical complete remission as postoperative stimulated Tg of 0.2 ng/mL or less. Fourteen percent of the patients presented with permanent vocal cord palsy (VCP), and 20% of the patients presented with hypocalcemia prior to surgery. Among them, 70% of the patients underwent first revision surgery; whereas in 30% the surgery represented second or higher revision surgery, with 8% being a third or higher revision. None developed temporary or permanent VCP. Temporary hypocalcemia occurred in 9% of the patients, and permanent hypocalcemia occurred in 4.2%. The rate of cervical node recurrence was 5% at a median follow-up of 3.4 years. There were no disease-specific deaths. Mean preoperative basal Tg was 22.3 ng/mL and mean postoperative Tg was 5.7 ng/mL, a decline of 74% (P = 0.023, paired t test). Biochemical complete remission was achieved in 58% of all revision cases. Reoperative neural monitored surgery for recurrent thyroid cancer is a safe and effective procedure with limited morbidity in experienced hands, even in the setting of multiple prior revision surgeries and existing comorbidities such as VCP and hypocalcemia. 4.