Temporary Recurrent Laryngeal Nerve Injury Research Articles

Recurrence and postoperative quality of life after surgical resection of unilateral cT1-T3N1bM0 papillary thyroid carcinoma.

Determining the optimal extent of surgery and improving postoperative quality of life for patients with papillary thyroid cancer has been an important challenge. Here, we evaluated postoperative quality of life after cT1-T3N1bM0 papillary thyroid carcinoma (PTC) to explore the optimal scope of surgical resection. In this study, we investigated surgical outcomes in patients diagnosed with unilateral cT1-T3N1bM0 PTC, who were treated at Harbin Medical University Cancer Hospital from January 2008 to December 2018. To achieve this, we divided the patients into two distinct groups based on the extent of surgery they received: the non-total thyroidectomy group (group A) and the total thyroidectomy group (group B). To comprehensively evaluate the patients' well-being, we assessed their psychological status, disease recurrence rate, postoperative complications, and quality of life. A total of 362 patients diagnosed with thyroid cancer were included in this study, with group A (n=88) and group B (n=274) classified based on the extent of surgery received. Significant differences were observed between the two groups in terms of clinical and pathological characteristics, including age (χ2=10.962, P=0.001), sex (χ2=5.906, P=0.02), multifocal (χ2=5.515, P=0.02), contralateral glandular nodule (χ2=34.616, P<0.001), clinical Tumor, Node, Metastasis (TNM) stage (χ2=11.340, P=0.001), and complication rate (χ2=4.265, P=0.04). Notably, group B exhibited higher rates of postoperative complications, including temporary recurrent laryngeal nerve injury (χ2=4.630, P=0.03), and temporary hypocalcemia (χ2=3.954, P=0.047) compared to group A. However, after adjustment for propensity score matching (PSM), the recurrence rate was independent of the surgical extent in both groups. In contrast, tumour size (>1 cm) (χ2=4.497, P=0.03), extrathyroidal invasion (χ2=5.133, P=0.02) and pathological T stage (χ2=7.663, P=0.02) increased the risk of recurrence. Moreover, there was no significant difference in the Hospital Anxiety and Depression Scale (HADS) scores between two groups (χ2=1.266, P=0.53). Nevertheless, the postoperative quality of life, as well as the incidence of hoarseness (t=11.77, P<0.001), symptoms of calcium deficiency (t=8.13, P<0.001), and willingness to reduce medication (t=3.60, P<0.001) were significantly lower in group A than in group B. In patients with PTC diagnosed as unilateral cT1-T3N1bM0 and a contralateral glandular nodule ≤2 cm, the preservation of the contralateral gland does not appear to have a significant impact on the rate of tumour recurrence in patients with tumour size (<1 cm), no extrathyroidal invasion, and pathological T stage (< T3). Instead, preserving gland potentially improves the prognosis, quality of life, and complication rates in these patients.

Systematic review with meta-analysis of intraoperative neuromonitoring during thyroid reoperation.

Recurrent laryngeal nerve (RLN) injury is a serious complication during thyroid reoperation. Intraoperative neuromonitoring (IONM) is one of the means to reduce RLN paralysis. However, the role of IONM during thyroidectomy is still controversial. The aim of this study was to assess whether the IONM could reduce the incidence of RLN injury during thyroid reoperation. We performed a systematic review to identify studies in English language which were published between January 1, 2004, and March 25, 2023 from PubMed, EMBASE, and Cochrane Library, comparing the use of IONM and Visualization Alone (VA) during thyroid reoperation. The RLN injury rate was calculated in relation to the number of nerves at risk. All data were analyzed using Review Manger (version 5.3) software. The Cochran Q test (I2 test) was used to test for heterogeneity. Odds ratios were estimated by fixed effects model or random effects model, according to the heterogeneity level. Eleven studies (3655 at-risk nerves) met criteria for inclusion. Data presented as odds ratio(OR) and their 95% confidence intervals(CI). Incidence of overall, temporary, and permanent RLN injury in IONM group were, respectively, 4.67%, 4.17%, and 2.39%, whereas for the VA group, they were 8.30%, 6.27%, and 2.88%. The summary OR of overall, temporary, and permanent RLN injury compared using IONM and VA were, respectively, 0.68 (95%CI 0.4-1.14, p=0.14), 0.82 (95%CI 0.39-1.72, p=0.60), and 0.62 (95%CI 0.4-0.96, p=0.03). The presented data showed benefits of reducing permanent RLN injury by using IONM, but without statistical significance for temporary RLN injury.

Intraoperative Neuromonitoring Does Not Reduce the Risk of Temporary and Definitive Recurrent Laryngeal Nerve Damage during Thyroid Surgery: A Systematic Review and Meta-Analysis of Endoscopic Findings from 73,325 Nerves at Risk.

While intraoperative neuromonitoring (IONM) helps the early identification of recurrent laryngeal nerve (RLN) damage, IONM's role in RLN damage prevention is not defined, given the lack of large studies on the subject. In a PRISMA-compliant framework, all original thyroid surgery prospective studies providing early postoperative endoscopic data for all patients were pooled in a random-effects meta-analysis. We compared the temporary (and definitive where available) RLN damage rates according to IONM use and IONM type (intermittent, I-IONM, or continuous, C-IONM). We identified 2358 temporary and 257 definitive RLN injuries in, respectively, 73,325 and 66,476 nerves at risk. The pooled temporary and definitive RLN injury rates were, respectively, 3.15% and 0.422% considering all procedures, 3.29% and 0.409% in cases using IONM, and 3.16% and 0.463 in cases not using IONM. I-IONM and C-IONM, respectively, showed a pooled temporary RLN injury rate of 2.48% and 2.913% and a pooled definitive injury rate of 0.395% and 0.4%. All pooled rates had largely overlapping 95% confidence intervals. Our data suggest that IONM does not affect the temporary or definitive RLN injury rate following thyroidectomy, though its use can be advised in selected cases and for bilateral palsy prevention.

Efficacy evaluation of transaxillary non-inflatable endoscopic surgery and open neck surgery in the treatment of PTC: a single center report of 342 cases

Objective:To compare the clinical effect of transaxillary non-inflatable endoscopic surgery and traditional open thyroid surgery in the treatment of PTC. Methods:A retrospective analysis was performed on 342 patients with PTC treated in the Otorhinolaryngology Department of Qilu Hospital of Shandong University from December 2020 to December 2022. There were 73 males and 269 females, aged 16-72 years, who underwent unilateral non-inflatable transaxillary endoscopic thyroid surgery（endoscopic group） and unilateral traditional open thyroid surgery（open group）. There were 108 patients in the endoscopic group and 234 in the open group. Results:The endoscopic group was lower in age（37.1±9.4 vs 43.5±11.2） years and BMI（23.4±3.4 vs 25.7±3.8 ）kg/m² than that in the open group, and the difference was statistically significant（t was 5.53, 5.67 respectively, P<0.01）. There was no significant difference in hospitalization days between the two groups（P>0.05）. The logarithmic curve of the operation time showed a smooth downward trend, and the overall operation time of the endoscopic group was relatively consistent. There was no significant difference in intraoperative blood loss between the endoscopic group（13.3±3.2） mL and the open group（14.7±6.3） mL（P>0.05）, but the operation time（130.1±37.9） min was longer than that in the open group（57.4±13.7） min, and the difference was statistically significant（t=19.40, P<0.01）. There was no significant difference in complications such as temporary recurrent laryngeal nerve injury within 3 days after operation between the two groups（P>0.05）. The aesthetic satisfaction score of the surgical incision and the incision concealment effect score in the endoscopic group were higher than those in the open group, and the difference was statistically significant（P<0.05）. Conclusion:Compared with traditional open thyroidectomy, transaxillary non-inflatable endoscopic thyroidectomy has more advantages in the concealment and aesthetics of postoperative incision. Although the former has longer operation time and more drainage, it is still a safe and feasible surgical method with good postoperative clinical effect.

Transoral endoscopic thyroidectomy vestibular approach as a novel technique for pediatric populations: Results from a single surgeon.

The transoral endoscopic thyroidectomy vestibular approach (TOETVA) is increasingly being adopted worldwide because of its many advantages. However, there are few reports on the effectiveness and safety of TOETVA in children. In this study, we report the results of the application of TOETVA on 27 pediatric patients in Vietnam. To the best of our knowledge, this is also the largest sample size of the TOETVA technique performed by a single surgeon on pediatric patients worldwide. Patients and methods: From June 2020 to February 2022, we performed TOETVA on 27 pediatric patients (≤ 18 years old). The outcomes of the procedure were retrospectively reviewed. Our study was conducted on 27 pediatric patients, of whom 24 were female (88.9%). The mean age was 16.3 ± 2 (range 10-18). Fifteen patients had benign thyroid nodules with a mean nodule size of 31.6 ± 7.1 (range 20-50mm), and 12 patients had papillary thyroid carcinoma with a mean nodule size of 10.2 ± 5.6 (range 4-19mm). All 27 patients underwent successful TOETVA without any conversion to open surgery. The 15 patients with benign thyroid nodules had lobectomies with a mean operative time of 83.3 ± 10.5 (range 60-105 minutes). Among the 12 patients diagnosed with thyroid cancer, ten had a lobectomy, isthmusectomy, and central neck dissection, with a mean operative time of 89.8 ± 5.7 (range 80-100 minutes). The other two underwent total thyroidectomy with central lymph node dissection with a mean operative time of 132.5 minutes. The mean hospital stay was 4.7 ± 0.9 (range 3-7 days). No patient had permanent complications, such as hypocalcemia, recurrent laryngeal nerve injury, or mental nerve injury. The rates of temporary recurrent laryngeal nerve injury and mental nerve injury were 3.7% and 11.1% respectively. TOETVA may be a feasible and safe surgical method for children with thyroid disease. However, we recommend that only high-volume thyroid surgeons with experience in TOETVA should perform TOETVA on the pediatric population.

An assessment of the role of surgical loupe technique in prevention of postthyroidectomy complications: a comparative prospective study.

Eighty patients with thyroid nodules who underwent thyroidectomy procedure were divided randomly into two comparable groups, group A subjected to thyroidectomy by using binocular magnification loupe, group B underwent conventional thyroidectomy without using magnification. Patients' demographics, operation time, and postoperative morbidities were recorded. All cases had preoperative and postoperative vocal cords assessment by video laryngoscopy. Pathology, laboratory, and radiology investigations were also conducted. Out of 80 patients, there were 58 females and 22 males. Benign thyroid pathology was found in 74 patients and malignant pathology in 6 patients. The mean operating time was 106min in group A compared to 138.5min in group B. The mean amount of intraoperative bleeding was 30ml in group A while 50ml in group B. There were no cases of the external branch of the superior laryngeal nerve in both groups; there was better identification in group A. There was only one patient who suffered from a temporary RLN injury in group A, while three cases of temporary and one case of permanent RLN injury were recorded in group B. Permanent hypoparathyroidism was diagnosed in only one patient in group B. The utilization of binocular surgical loupe magnification in thyroid surgery is considered a safe and effective maneuver that has the advantages of decreasing the overall operating time and significantly reducing postoperative complications.

Clinical application of endoscopic surgery using a gasless unilateral transaxillary approach in the treatment of primary hyperparathyroidism.

To investigate the safety and feasibility of gasless axillary parathyroid surgery in the treatment of primary hyperparathyroidism. A total of 12 patients who received gasless axillary parathyroidectomy (endoscope group) and 14 patients who received traditional open parathyroidectomy (open group) from January 2019 to April 2022 were screened and included. The differences in baseline characteristics, surgical efficiency, incidence rate of complications, changes in biochemical indicators, and incision satisfaction between the two groups were analyzed and compared. The proportion of young patients was higher in the endoscopic group than in the open group, and the difference was statistically significant [(41.33 ± 13.65) years vs. (58.00 ± 9.44) years, P < 0.01]. The differences in operation time, intra-operative blood loss, post-operative drainage volume, hospital stay, and surgical efficiency between the two groups yielded no statistical significance (P > 0.05). Patients in the open group had more significant neck pain 3 days after surgery (P = 0.046), but the degree of pain 3 months after surgery was the same in the 2 groups (P = 0.432). Evaluation of post-operative mature stage scar and incision satisfaction regarding aesthetics in the endoscope group were significantly superior to that in the open group [(1.92 ± 0.92) points vs. (0.92 ± 1.00) points, P = 0.017 and (1.57 ± 0.51) points vs. (1.00 ± 0.013) points, P = 0.013, respectively]. No statistical significance was found in terms of incidence rate of post-operative fever (P > 0.05). No temporary recurrent laryngeal nerve injury, post-operative bleeding, incision hematoma infection, or other complications were observed. Comparing the two groups, the extent of the level decrease of PTH was similar to that of serum calcium and phosphorus (P < 0.05), where most patients experienced transient hypocalcemia after operation yielding no significant difference in incidence (P = 0.225). During a follow-up period of 3 to 36 months, a total of 1 patient in the open group experienced recurrence at 10 months after surgery and was treated non-surgically. Gasless axillary approach to parathyroid surgery for primary hyperparathyroidism possesses good safety and patient satisfaction in terms of aesthetics.

Morbidity Associated With Surgical Removal of Substernal Thyroid Goiters.

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

The impact of intraoperative "Nerve Monitoring" in a tertiary referral center for thyroid and parathyroid surgery.

The most fearsome complication in thyroid surgery is the temporary or definitive recurrent laryngeal nerve (RLN) injury. The aim of our study was to evaluate the impact of intraoperative neuromonitoring (IONM) on postoperative outcomes after thyroid and parathyroid surgery. From October 2014 to February 2016, a total of 80 consecutive patients, with high risk of RLN injuries, underwent thyroid and parathyroid surgery. They were divided in two groups (IONM group and control group), depending on whether neuromonitoring was used or not. We used the Nerve Integrity Monitoring System (NIM)-Response 3.0® (Medtronic Xomed®). The operation time (p = 0.014). and the length of hospital stay (LOS) (p = 0.14) were shorter in the IONM group. Overall mean follow-up was 96.7 ± 14.3 months. The rate of transient RLN palsy was 2.6% in IONM group and 2.5% in the control group (p = not significant). Only one case of definitive RLN injury was reported in control group. No differences were reported between the two groups in terms of temporary or definitive RLN injury. Routine use of IOMN increases the surgery cost, but overall, it leads to long-term cost savings thanks to the reduction of both operating times (106.3 ± 38.7 vs 128.1 ± 39.3, p: 0.01) and LOS (3.2 ± 1.5 vs 3.7 ± 1.5 days, p = 0.14). Anatomical visualization of RLN remains the gold standard in thyroid and parathyroid surgery. Nevertheless, IONM is proved to be a valid help without the ambition to replace surgeon's experience.

Morbidity following thyroid and parathyroid surgery: Results from key performance indicator assessment at a high-volume centre in New Zealand.

Complications following thyroid/parathyroid surgery include recurrent laryngeal nerve (RLN) injury, hypocalcaemia and return to theatre for haematoma evacuation. Rates of these form the basis of key performance indicators (KPI). An endocrine database, containing results from 1997, was established at the North Shore Hospital in Auckland, New Zealand. We aimed to measure complication rates by procedure (thyroid and parathyroid), explore a temporal change in our unit and compare our results against international literature. A retrospective review of the database between July 1997 and February 2020 was performed. The results for each KPI were analysed in total and over consecutive time periods. A review of the literature was carried out to find international complication rates for comparison. A cumulative sum (CUSUM) analysis was performed to give visual feedback on performance. There were 1062 thyroidectomies and 336 parathyroidectomies from July 1997 to February 2020. Thyroid surgery results found rates of temporary/permanent RLN injury of 1.9%/0.3%, temporary/permanent hypocalcaemia of 22.3/2.5%, and return to theatre for haematoma evacuation of 1.1%. Parathyroid surgery results were, temporary RLN injury of 0.8% (no permanent injury), temporary/permanent hypocalcaemia of 1.7%/0.4%, and return to theatre for haematoma evacuation of 0.3%. CUSUM analysis found KPI results to be comparable with international literature. Our unit's KPI results are comparable to published results in the literature. The use of this clinical database will help in future monitoring of performance and help drive improvement in the service. Embedding prospective data collection as routine practice allows for continuous improvement for the unit.

Transoral Thyroidectomy: Safety and Outcomes of 200 Consecutive North American Cases.

North American adoption of the transoral endoscopic thyroidectomy vestibular approach (TOETVA) has been limited due to concerns regarding the generalizability of published outcomes, as data are predominantly from Asian cohorts with a different body habitus. We describe our experience with TOETVA in a North American population in the context of the conventional transcervical approach thyroidectomy (TCA). Cases of TOETVA and TCA were reviewed from August 2017 to March 2020 at a tertiary care center. Outcomes included operative time, major (permanent recurrent laryngeal nerve (RLN) injury, permanent hypoparathyroidism, hematoma, conversion to open surgery), and minor complications. The TOETVA cohort was stratified into body mass index (BMI) classes of underweight/normal < 25kg/m2, overweight 25-29.9kg/m2, and obese ≥ 30kg/m2 for comparative analysis. Multivariable logistic regression analyses were performed for odds of cumulative complication. Two hundred TOETVA and 333 TCA cases were included. There was no difference in incidence of major complications between the TOETVA and TCA cohorts (1.5% vs. 2.1%, p = 0.75). No difference was found in the rate of temporary RLN injury (4.5% vs. 2.1%, p = 0.124) or temporary hypoparathyroidism (18.2% vs. 12.5%, p = 0.163) for TOETVA and TCA, respectively. Surgical technique (TOETVA vs TCA) did not alter the odds of cumulative complication (OR 0.69 95% CI [0.26-1.85]) on logistic regression analysis. In the TOETVA cohort, higher BMI did not lead to a significantly greater odds of cumulative complication, 0.52 (95% CI [0.17-1.58]) and 1.69 (95% CI [0.74-3.88]) for the overweight and obese groups, respectively. TOETVA can be performed in a North American patient population without a difference in odds of complication compared to TCA. Higher BMI is not associated with greater likelihood of complication with TOETVA.

Clinical application of the gasless unilateral axillary approach in endoscopic thyroid surgery

Objective: To investigate the efficacy, safety and advantages of gasless unilateral axillary approach (GUAA) in endoscopic thyroid surgery. Methods: A total of 334 patients who underwent the GUAA endoscopic thyroid surgery (GUAA group) or conventional open thyroid surgery (OS group) in the Department of Head and Neck Surgery of Zhejiang Cancer Hospital from January 2017 to June 2018 were retrospectively analyzed. There were 45 males and 289 females, aged from 12 to 72 years old, of whom 139 patients were assigned to GUAA group and 195 patients to OS group. Pathological results included papillary thyroid carcinoma (282 cases), nodular goiter (41 cases) and thyroid adenoma (11 cases). Surgical exploration development curve of GUAA group was drawn and was divided into two parts: the technical exploration stage and the technical stable stage. Surgical efficiency, incidences of complications, and incision satisfaction were compared between GUAA group in technical stable stage and OS group. SPSS 25.0 software was adopted for statistical analysis. Results: The mean age in GUAA group was younger than that in OS group, with a significant difference [(35.3±9.5) years vs. (48.1±10.6) years, t=11.31, P<0.01]. The cases in the endoscope group were divided into technical exploration stage for 51 cases and technical stable stage for 88 cases according to the exploration and development curve. In unilateral radical thyroidectomy and unilateral thyroid lobectomy, the mean operation time [(90.6±18.6) min and (93.5±22.0) min] and postoperative drainage volumes [(121.5±87.6) ml and (155.5±69.1) ml] of GUAA group in the stable stage were more than those of OS group [(61.6±15.6) min and (46.5±8.4) min] and [(93.2±42.3) ml and (78.9±48.7) ml]. The difference was statistically significant (t=12.28, 7.23, 3.35 and 3.05 respectively, all P<0.05), but there were no significant differences in surgical bleeding volumes between two groups [(12.7±6.8) ml vs. (13.5±7.7) ml, t=0.74, P>0.05 and (16.3±14.1) ml vs. (11.9±5.1) ml, t=1.05, P>0.05]. Compared with OS group, GUAA group had the lower incidence of anterior cervical discomfort during swallowing (2.3% vs. 29.2%, P<0.01) and the higher incision satisfaction score (1.1±0.5 vs. 2.8±0.7, t=21.12, P<0.01), however, GUAA group had the higher incidence of supraclavicular (or infraclavicular) numbness after surgery (5.7% vs. 0, P<0.01). And there was no significant difference in the incidences of temporary recurrent laryngeal nerve injury, bleeding, hematoma, infection, lymphatic leakage or chylous leakage after surgery between two groups (P>0.05). Conclusion: GUAA endoscopic thyroid surgery is a safe method with high cosmetic satisfaction.

Advantages of intraoperative nerve monitoring in endoscopic thyroidectomy for papillary thyroid carcinoma.

This study aimed to evaluate the feasibility and effectiveness of intraoperative nerve monitoring (IONM) for reducing the recurrent laryngeal nerve (RLN) injury risk during central compartment lymph node dissection in endoscopic thyroidectomy of papillary thyroid carcinoma (PTC). The prospective cohort consisted of 69 patients diagnosed with PTC undergoing endoscopic thyroidectomy via the areola approach with (N.=42) or without IONM (N.=27). Multiple logistic regression models were used to assess the association between IONM and postoperative temporary vocal cord palsy or number of retrieved lymph nodes. IONM was a protective factor against temporary RLN injury. IONM use was positively correlated with number of retrieved lymph nodes (β=1.563, P=0.003). After adjustment for operation type, the result remained significant (β=1.581, P<0.001). IONM use reduced the risk of temporary vocal cord palsy and increased the number of retrieved lymph nodes in endoscopic thyroidectomy via the areola approach for patients with PTC.

Advantages of intraoperative nerve monitoring in endoscopic thyroidectomy for papillary thyroid carcinoma

Background This study aimed to evaluate the feasibility and effectiveness of intraoperative nerve monitoring (IONM) for reducing the recurrent laryngeal nerve (RLN) injury risk during central compartment lymph node dissection in endoscopic thyroidectomy of papillary thyroid carcinoma (PTC). Methods The prospective cohort consisted of 69 patients diagnosed with PTC undergoing endoscopic thyroidectomy via the areola approach with (n=42) or without IONM (n=27). Multiple logistic regression models were used to assess the association between IONM and postoperative temporary vocal cord palsy or number of retrieved lymph nodes. Results IONM was a protective factor against temporary RLN injury. IONM use was positively correlated with number of retrieved lymph nodes (β=1.563, P=0.003). After adjustment for operation type, the result remained significant (β=1.581, P Conclusions IONM use reduced the risk of temporary vocal cord palsy and increased the number of retrieved lymph nodes in endoscopic thyroidectomy via the areola approach for patients with PTC.

Increasing trend of bilateral neck exploration in primary hyperparathyroidism

BackgroundBilateral neck exploration was the standard operation for primary hyperparathyroidism. With improvements in preoperative localization and use of intraoperative PTH (ioPTH) monitoring, minimally invasive unilateral neck exploration has been widely adopted. This study evaluates the trend in parathyroidectomies for primary hyperparathyroidism. MethodsParathyroidectomy for sporadic primary hyperparathyroidism was analyzed from 2010 to 2017. Exclusion criteria included previous neck surgery and concomitant procedures. The operations were classified as unilateral exploration (UE), UE converted to bilateral exploration (BE), or BE. Variables included preoperative and intraoperative factors. Outcomes included persistence, recurrence, permanent hypocalcemia and recurrent laryngeal nerve (RLN) injury. ResultsFour hundred thirty-one patients were reviewed. Since 2010, the rate of BE has increased from 30% to 50%. Disease duration, presence of bone disease, negative localization, baseline ioPTH <100, and ≥2 abnormal glands have increased. Mean operative time has not changed over time. Two percent of patients had persistent disease, <1% had recurrent disease, and 2% have had reoperation. Nine percent had temporary hypoparathyroidism, and 15 patients had temporary RLN injury. ConclusionsThis study shows an increasing trend in BE for primary hyperparathyroidism. This increase was associated with lower baseline intraoperative parathyroid hormone (ioPTH) levels and smaller gland size. The operative approach for parathyroidectomy should be individualized and surgeons should not hesitate to perform BE when needed.

SENTINEL LYMPH NODE BIOPSY AS GUIDANCE FOR CENTRAL NECK DISSECTION IN PATIENTS WITH PAPILLARY THYROID CARCINOMA

Background: Occult lymph node metastasis of papillary thyroid carcinoma (PTC) can be detected by sentinel lymph node (SLN) biopsy. Aim of the work: Our objective in this study was to evaluate the accuracy of using sentinel lymph node biopsy as a marker to identify occult metastases early. Patients and methods: The present study was a prospectivestudy that was conducted in Ain Shams University Hospitals in Egypt, and included sixty (60) patients who had papillary thyroid carcinoma. The patients underwent sentinel lymph node biopsy with total thyroidectomy during the period between 1st of December 2016 and 1st of December 2018. Results: The study included 60 patients with papillary thyroidcarcinoma, 16 males and 44 females. Size of nodules ranged from 0.5- 4 cm and more nodules were confined to the left lobe (63.3%). SLNs were identified in 44 of 60 malignant cases (73.3%). 38 of identified SLN were positive for metastasis and 22 were negative while non SLN were positive in 31/60 and negative for 29/60. Thus, the sensitivity, specificity, negative predictive values, positive predictive values and accuracy of SLN biopsy were 86.7%, 100%, 72,7%, 100% and 73.3%, respectively. Post-operative complications included temporary symptomatic hypocalcaemia in 3 patients and temporary recurrent laryngeal nerve injury in 2 patients then recovered. Conclusion: SLN biopsy for patients with papillary thyroid carcinoma and negative LNs clinically and radiologically is an accurate and noninvasive means to identify subclinical lymph node metastasis.

Primary hyperparathyroidism and non-medullary thyroid cancer- A review

Background:&#x0D; The association of thyroid disease and primary hyperparathyroidism is well described, with thyroid carcinoma being reported in 2-15% of cases. The most commonly associated carcinoma is non-medullary thyroid cancer. While the association of PHPT and medullary thyroid cancer (MCT) is well known, that of NMTC, despite its increasing incidence, is still not established. Our study is a review of incidence and underlying mechanisms of non-medullary thyroid cancer associated with PHPT. Also, best imaging tools for concomitant diagnosis is reviewed to ensure an adequate plan of care.&#x0D; Methods &amp; findings:&#x0D; A search was done using two databases: Medline &amp; Embase. The search conducted from the period of 2008 until April 2018 yielded a total of 142 studies. After an adequate screening, 26 studies were reviewed. &#x0D; Incidence of DTC in association with PHPT in the literature ranged between 0.91% and 17.6%. The main histological thyroid malignancy found is micropapillary carcinoma. Despite its less aggressive presentation, these microcarcinomas may grow or develop nodal metastases on follow up. Although bilateral neck exploration with hemi/total thyroidectomy carries the risk of temporary recurrent laryngeal nerve injury or hypoparathyroidism, permanent complications are rare especially when compared to re-do neck surgery. Recently, parathyroid surgeries are going towards minimal invasive procedures, requiring an adequate imaging tool to ensure diagnosis of both diseases. Multiple risk factors for concomitant diseases were hypothesized, the more robust are the common embryologic origin and activation of angiogenic growth factors.&#x0D; Conclusion:&#x0D; NMTC is frequently associated with PHPT especially in endemic goiter areas. With the high prevalence of micropapillary carcinoma and its risks, a partial/total thyroidectomy in addition to parathyroidectomy may be warranted. With the recent need of adequate diagnostic tools, combining both Technetium Sestamibi scintigraphy and thyroid ultrasound improved sensitivities and accuracy of diagnosis, but dual-isotope scintigraphy (I-123 sodium iodide/ 99mTc-sestamibi) seems an attractive modality in hyperparathyroid patients with concomitant suspicious thyroid nodules. However, further studies for validation may be needed.

Application of da Vinci robot's bilateral axillo-breast approach in thyroid surgery of obese patients

Objective:To discuss the effect of obesity on the operation of thyroid gland surgery and surgical results.Method:The clinical data of 446 patients who underwent robot thyroid surgery through bilateral axillo-breast approach (BABA) from the General Hospital of Jinan Military region from February 2014 to November 2017 were analyzed retrospectively, and the patients were divided into BMI<25 kg/m²; group, BMI 25-30 kg/m²; group and BMI>30 kg/m²; group according to body mass index (BMI). The operative complications were compared between the three groups of benign and malignant patients, such as operation time, postoperative lead flow, postoperative hospitalization time, tumor size (malignant), lymph node metastasis (malignant), cosmetic satisfaction score, laryngeal nerve injury and parathyroid function decrease. Statistical methods using Variance analysis and χ² test to compare the differences between the two groups of indicators, difference is statistically significant (P<0.05).Result:The difference of operation time, postoperative average hospitalization time and postoperative drainage fluid volume in 3 groups was not statistically significant（P>0.05）. ①Intraoperative and postoperative pathological results were benign: BMI<25 kg/m²; group 69 cases, BMI 25-30 kg/m²; group 48 cases, BMI>30 kg/m²; group 8 cases, temporary recurrent laryngeal nerve injury were 1 case, 0 case and 0 case respectively, temporary parathyroid function decrease 3 cases, 2 cases and 1 case. ②Intraoperative and postoperative pathological results were malignant:BMI<25 kg/m²; group 180 cases, BMI 25-30 kg/m²; group 119 cases,BMI>30 kg/m²; group 22 cases, temporary recurrent laryngeal nerve injury were 2 cases,1 case and 0 case respectively, temporary parathyroid dysfunction in 64 cases,29 cases and 5 cases respectively.③1 patient in BMI<25 kg/m²; group had lymphatic leakage after operation, 1 patient in BMI 25-30 kg/m²; group had subcutaneous tunnel hemorrhage, and 1 patient had lymphatic leakage during operation.Conclusion:For overweight or obese patients, the da Vinci robot thyroid operation is reliable, does not increase the risk of surgical complications, but also has a good cosmetic effect.

A Systemic Review of Transoral Thyroidectomy.

Transoral thyroidectomy is a kind of "natural orifice transluminal endoscopic surgery (NOTES)" which is now being performed in increasing frequency. However, the safety and feasibility have not been concluded yet. A systemic literature search was performed in Pubmed, Cochrane, and Embase databases to identify all studies written in English and published up to April 2017. The keywords used were "transoral endoscopic," "transoral robotic," "oral vestibular endoscopic," and "oral vestibular robotic" combined with "thyroidectomy" or "thyroid surgery." Ten articles containing 211 cases matched the review criteria. The weighted average operative time was 119.9 minutes with an average intraoperative blood loss of 35.5 mL while the weighted average length of hospital stay was 4.0 days. The overall conversion rate to open surgery was 1.9%. An overall incidence rate of temporary hypoparathyroidism was 7.1%, temporary recurrent laryngeal nerve injury was 4.3%, whereas of mental nerve palsy was 4.3%. According to those reviewed literatures, we can conclude that transoral thyroidectomy is safe and feasible in well-selected patients and offers good perioperative and postoperative outcomes.

Comparison of functional outcomes after total thyroidectomy and completion thyroidectomy: Hypoparathyroidism and postoperative complications

ObjectiveThis study aimed to investigate differences in functional outcomes of postoperative complications and hypoparathyroidism between patients who underwent completion thyroidectomy (CT) after thyroid lobectomy or total thyroidectomy (TT) as an initial treatment. Materials and methodsWe retrospectively analyzed the differences of functional outcomes after completion thyroidectomy and total thyroidectomy without lymph node dissection. We reviewed the medical records of 396 patients who underwent CT or TT for thyroid disease at Korea University Guro Hospital from March 2002 to August 2016. ResultsOf the 396 patients, 32 underwent CT and 364 underwent TT. There were 72 male patients and 324 female patients. Transient hypoparathyroidism was observed in 4 (9.4%) of the CT patients and 97 (26.6%) of the TT patients, with a statistically significant difference (p=0.031). Permanent hypoparathyroidism was observed in 1 patient (3.1%) in the CT group and in 13 patients (3.6%) in the TT group, which was not significantly different. There were no significant differences in the postoperative complication of temporary recurrent laryngeal nerve injury, wound infection, and hematoma between two patients group. ConclusionThe incidence of transient hypoparathyroidism in CT patients was significantly lower than in TT patients. These safety and functional superiority of CT should be considered when determining the scope and extent of operation in patients requiring surgery for thyroid disease.