Total Thyroidectomy For Benign Disease Research Articles

Long-term kidney outcomes in patients with permanent hypoparathyroidism after total thyroidectomy for benign disease: A population-based study

BackgroundPermanent hypoparathyroidism is a significant complication after total thyroidectomy. This study aimed to evaluate the long-term impact of postoperative permanent hypoparathyroidism on kidney outcomes. MethodsData of patients undergoing total thyroidectomy from 1999 to 2014 were retrieved. The estimated glomerular filtration rate was determined from serum creatinine results. Permanent hypoparathyroidism was defined as requiring oral calcium and vitamin D supplements postoperatively for at least 6 months. The primary outcome was a sustained decline in the estimated glomerular filtration rate from baseline by ≥50%. Secondary outcomes were end-stage kidney disease (a composite of sustained estimated glomerular filtration rate <15 mL/min/1.73 m2, need for dialysis, and kidney transplantation) and rate of estimated glomerular filtration rate decline. Patients with and without permanent hypoparathyroidism were compared. Multivariable Cox regression analysis was performed to identify independent risk factors for sustained estimated glomerular filtration rate decline by ≥50%. ResultsIn total, 3,245 patients were eligible for analysis; 418 patients (12.9%) had permanent hypoparathyroidism. Upon median follow-up of 11.6 years, more patients with permanent hypoparathyroidism had a sustained decline in estimated glomerular filtration rate from baseline by ≥50% compared to those without (15.6% vs 6.9%, P < .001). Similar findings were obtained on Kaplan–Meier analysis (P < .001). Permanent hypoparathyroidism was an independent risk factor for sustained estimated glomerular filtration rate decline by ≥50% (adjusted hazard ratio 2.77, P < .001). Other risk factors included age, preoperative estimated glomerular filtration rate <60 mL/min/1.73m2, and diabetes mellitus. Patients with permanent hypoparathyroidism had a more rapid estimated glomerular filtration rate decline (–1.60 vs –0.70 mL/min/1.73 m2/year, difference –0.91 mL/min/1.73m2/year, P < .001). ConclusionPatients with postsurgical permanent hypoparathyroidism were at greater risk of renal impairment. Further research is warranted to improve the identification and preservation of parathyroid glands during thyroidectomy to minimize patient morbidity.

Comparison of Dosing Schemes for Thyroid Hormone Replacement Therapy After Thyroidectomy

Current thyroid hormone replacement therapy (THRT) is built on weight-based standard calculation of dose. A novel Poisson regression model, which accounts for seven clinical variables, was recently proposed to improve accuracy of THRT. We aimed to compare the accuracy of estimated THRT dose to reach euthyroid and the difference in predicted dose between the Poisson (scheme A) and the weight-based standard (scheme B) in patients following total thyroidectomy for benign disease. We retrospectively reviewed medical record of patients who underwent total or completion thyroidectomy for benign disease at a single institution between 2011 and 2019. The THRT dose was calculated using both schemes. We compared the difference between calculated THRT and prediction rates for optimal THRT dosing needed to achieve a euthyroid state between dosing schemes. Patients were evaluated for achieving euthyroid state, defined as TSH 0.45-4.5 mIU/L. We also compared dosing error rates (> 25 mcg over- and underdosing) between schemes. Prediction rates were compared by BMI tertiles to account for the effect of BMI extremes in achieving euthyroid state. The difference in predicted dose between schemes was calculated in both the total sample size and patients that met euthyroid. A measure of agreement, Kappa, was used to estimate agreement between dosing schemes. A total of 406 patients underwent total thyroidectomy for benign disease, with 184 having sufficient follow up data confirming euthyroid state. Of the 184 patients, 85.9% (n=158) were women, 81% (n=149) were Hispanic, and 56.5% (n=104) were obese with a median BMI of 30.8 kg/m2. Scheme A resulted in a higher, but not statistically significant, accuracy rate (A: 60.3%, n=111 versus B: 53.8%, n=99; P=0.21). Overdosing errors were lower with Scheme A (A:17.9% versus B: 32.1%; P=0.0025) and less extreme > 25 µg (A: 17.9% versus B: 26.1%; P=0.08). A trend in improved accuracy in patients with a BMI > 35 kg/m2 was noted (A: 46.9% versus B: 34.4%; P=0.20). Scheme A also resulted in less overdosing errors in obese patients compared to Scheme B (A: 19.2% versus 45.2%; P=0.0006). The average difference in predicted dose between schemes was an entire dose difference, mean of 16.0 µg and 15.8 µg for the total and euthyroid samples respectively. Furthermore, for the majority of patients the predicted dose did not match between the two dosing schemes for total and euthyroid samples, 76% (n=311) and 76% (n=141) respectively. In patients that achieved euthyroid, agreement between dosing schemes was low to moderate (Kappa=0.360). Lower rates of overdosing were found for scheme A, particularly with obese patients. No statistically significant differences in predicted THRT dose was observed between schemes. The difference in predicted dose between schemes was on average 15 ug, correlating with an entire dose. The consideration of clinical variables other than weight (scheme A) when determining optimal THRT dosing may be of importance to prevent overdoses, with particular clinical relevance in patients with higher BMIs.

Risk of Permanent Hypoparathyroidism After Total Thyroidectomy for Benign Disease: A Nationwide Population-based Cohort Study From Sweden.

To investigate the prevalence and risk factors for permanent hypoparathyroidism after total thyroidectomy for benign disease in a population-based setting with data independent of input of complication data. The reported rate of permanent hypoparathyroidism is highly variable and mostly rely on reported complication data from national or institutional registries. All patients who underwent total thyroidectomy in Sweden from 2005 to 2015 were identified through Scandinavian Quality Register for Thyroid, Parathyroid and Adrenal Surgery and the Swedish National Patient Register. Patients were matched to outcome data from the Swedish Prescribed Drug Register. Permanent hypoparathyroidism was defined as treatment with calcium and/or active vitamin D more than 1 year after surgery. Seven thousand eight hundred fifty-two patients were included and 938 (12.5%) developed permanent hypoparathyroidism. The risk was lower in patients registered in the quality register (11.0% vs 16%, P < 0.001). In a multivariable analysis there was a higher risk of permanent hypoparathyroidism in patients with parathyroid autotransplantation [Odds ratio (OR) 1.72; 95% confidence interval 1.47-2.01], center-volume <100 thyroidectomies per year (OR 1.22; 1.03-1.44), age above 60 year (OR 1.64; 1.36-1.98) and female sex (OR 1.27; 1.05-1.54). Reported data from the quality register only identified 178 of all 938 patients with permanent hypoparathyroidism. The risk of permanent hypoparathyroidism after total thyroidectomy was high and associated with parathyroid autotransplantation, higher age, female sex and surgery at a low volume center. Reported follow-up data might underestimate the rate of permanent hypoparathyroidism.

NEAR TOTAL THYROIDECTOMY;

Objective: To evaluate the role of surgical drains in near total thyroidectomy.Study Design: It was a Randomized clinical trial conducted at department of surgery, DHQteaching Hospital, Dera Ghazi Khan from Jun 2012 to May 2013. Patients and Methods: Patientswere randomized into two groups by lottery method. Group A were those in which drains wereplaced and Group B patient were operated and no drains were placed. Inclusion criteria includedall patients presenting for near total thyroidectomy for benign diseases. Those with massivegoiters or nodules larger than 6 cm were excluded. 40patients were enrolled in the study.Complications, length of hospital stay, and overall cost were evaluated. Results: In the Group B(no drain group), there was 03 days mean hospital stay with no increase in postoperativecomplications like swelling. While Group A (drain group) mean hospital stay was 06 days.Conclusions: Thyroid surgery without the use of a drain decreases the length of hospital stay,with no increase in patient morbidity. The overall cost is significantly reduced.

Socioeconomic disparities in a population of patients undergoing total thyroidectomy for benign disease.

This study examines the effect of insurance status (as a measure of socioeconomic status) on patient with benign thyroid disease. A retrospective review was performed among 60 patients undergoing total thyroidectomy for benign thyroid disease. Univariate and multivariable analyses examined the relationship between insurance status and thyroid volume (sum of the left and right lobe volumes). Twenty-eight (47%) patients were considered of underinsured/uninsured status, and 32 (53%) patients were considered of private/government/military insurance status. Median pathologic whole thyroid volume was 66 mL (range, 2-855). After multivariable linear regression, underinsured/uninsured status was the only significant predictor of larger volume (correlation coefficient [r] = 118; 95% CI, 42 to 194; P = .003), after adjusting for age, sex, body mass index, and presence of concomitant thyroid disease and compressive symptoms. Patients of underinsured/uninsured status suffered more severe disease presentations at time of thyroidectomy, as measured by larger thyroid volumes.

Mortality in patients with permanent hypoparathyroidism after total thyroidectomy

Permanent hypoparathyroidism remains the most common adverse outcome after total thyroidectomy, but long-term effects of hypoparathyroidism are unknown. The aim was to investigate mortality in patients with permanent hypoparathyroidism after total thyroidectomy. Data from the Scandinavian Quality Register for Thyroid, Parathyroid and Adrenal Surgery were linked with the Swedish National Prescription Register for Pharmaceuticals and the Swedish National Inpatient Register. Patients who underwent total thyroidectomy between 1 July 2005 and 30 June 2014 for benign thyroid disease, and who used active vitamin D for at least 6 months after surgery, were classified as having permanent hypoparathyroidism and included in the study cohort. Risk of death was assessed using Cox regression analysis, adjusting for age, sex, thyrotoxicosis and co-morbidity. There were 4899 patients, with a mean(s.d.) age of 46·3(15·8) years; 83·1 per cent were women, and 2932 patients (59·8 per cent) had thyrotoxicosis. In all, 246 patients (5·2 per cent) were classified as having permanent hypoparathyroidism. Mean(s.d.) follow-up was 4·4(2·4) years, and 109 patients (2·2 per cent) died during follow-up. Compared with patients without permanent hypoparathyroidism, the risk of death was significantly higher among patients with permanent hypoparathyroidism after total thyroidectomy (adjusted hazard ratio 2·09, 95 per cent c.i. 1·04 to 4·20). Permanent hypoparathyroidism after total thyroidectomy for benign disease is common and associated with an increased risk of death.

Gauging The Extent Of Thyroidectomy For Indeterminate Thyroid Nodules: An Oncologic Perspective

Increasing emphasis is being placed on appropriateness of care and avoidance of over- and under-treatment. Indeterminate thyroid nodules (ITNs) present a particular risk for this problem because cancer found via diagnostic lobectomy (DL) often requires a completion thyroidectomy (CT). However, initial total thyroidectomy (TT) for benign ITN results in lifelong thyroid hormone replacement. We sought to measure the accuracy and factors associated with the extent of initial thyroidectomy for ITN. We queried a single institution thyroid surgery database for all adult patients undergoing an initial operation for ITN. Multivariate logistic regression identified factors associated with either oncologic under- or overtreatment at initial operation. There were 639 patients with ITN. The median age was 52 (range, 18 to 93) years, 78.4% were female, and final pathology revealed a cancer >1 cm in 24.7%. The most common cytology was follicular neoplasm (45.1%) followed by Hürthle cell neoplasm (20.2%). CT or initial oncologic undertreatment was required in 58 patients (9.3%). Excluding those with goiters, 19.0% were treated with TT for benign final pathology. Multivariate analysis failed to identify any factor that independently predicted the need for CT. Female gender was associated with TT in benign disease (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.0 to 4.5; P = .05). Age >45 years predicted correct initial use of DL (OR, 2.6; 95% CI, 1.2 to 5.7; P = .02). Suspicious for papillary thyroid carcinoma (OR, 5.7; 95% CI, 2.1 to 15.3; P<.01) and frozen section (OR, 9.7; 95% CI, 2.5 to 38.6; P<.01) were associated with oncologically appropriate initial TT. The highest frequency of CT occurred in patients with follicular lesion of undetermined significance (11.6%). TT for benign final pathology occurred most frequently in patients with a Hürthle cell neoplasm (24.8%). In patients with ITN, nearly 30% received an inappropriate extent of initial thyroidectomy from an oncologic standpoint. Tools to pre-operatively identify both benign and malignant disease can assist in the complex decision making to gauge the proper extent of initial surgery for ITN. ATA = American Thyroid Association AUS = atypia of undetermined significance CI = confidence interval CT = completion thyroidectomy FLUS = follicular lesion of undetermined significance ITN = indeterminate thyroid nodule OR = odds ratio PTC = papillary thyroid carcinoma TT = total thyroidectomy.

Expert consensus of general surgery residents’ proficiency with common endocrine operations

Proficiency with common endocrine operations is expected of graduating, general surgery residents. However, no expert consensus guidelines exist about these expectations. Members of the American Association of Endocrine Surgeons were surveyed about their opinions on resident proficiency with common endocrine operations. Overall response rate was 38%. A total of 92% of the respondents operate with residents. On average, they believed that the steps of a total thyroidectomy for benign disease and a well-localized parathyroidectomy could be performed by a postgraduate year 4 surgery resident. Specific steps that they thought might require more training included decisions to divide the strap muscles or leaving a drain. Approximately 66% of respondents thought that a postgraduate year 5 surgery resident could independently perform a total thyroidectomy for benign disease, but only 45% felt similarly for malignant thyroid disease; 79% thought that a postgraduate year 5 surgery resident could independently perform a parathyroidectomy. Respondents' years of experience correlated with their opinions about resident autonomy for total thyroidectomy (benign r=0.38, P<.001; malignant r=0.29, P=.001) but not parathyroidectomy. On multivariate analysis, sex and years of experience of the respondents were independently associated with opinions on autonomy but only for total thyroidectomy for benign disease (P=.001). Annual endocrine volume of the respondents did not correlate with beliefs in autonomy. There was general agreement among responding members of the AAES about resident proficiency and autonomy with common endocrine operations. As postgraduate year 5 residents may not be proficient in advanced endocrine operations, opportunities exist to improve training prior to the transition to independent practice for graduates that anticipate performing endocrine operations routinely.

In Brief

Proficiency with common endocrine operations is expected of graduating, general surgery residents. However, no expert consensus guidelines exist about these expectations.Members of the American Association of Endocrine Surgeons were surveyed about their opinions on resident proficiency with common endocrine operations.Overall response rate was 38%. A total of 92% of the respondents operate with residents. On average, they believed that the steps of a total thyroidectomy for benign disease and a well-localized parathyroidectomy could be performed by a postgraduate year 4 surgery resident. Specific steps that they thought might require more training included decisions to divide the strap muscles or leaving a drain. Approximately 66% of respondents thought that a postgraduate year 5 surgery resident could independently perform a total thyroidectomy for benign disease, but only 45% felt similarly for malignant thyroid disease; 79% thought that a postgraduate year 5 surgery resident could independently perform a parathyroidectomy. Respondents’ years of experience correlated with their opinions about resident autonomy for total thyroidectomy (benign r = 0.38, P < .001; malignant r = 0.29, P = .001) but not parathyroidectomy. On multivariate analysis, sex and years of experience of the respondents were independently associated with opinions on autonomy but only for total thyroidectomy for benign disease (P = .001). Annual endocrine volume of the respondents did not correlate with beliefs in autonomy.There was general agreement among responding members of the AAES about resident proficiency and autonomy with common endocrine operations. As postgraduate year 5 residents may not be proficient in advanced endocrine operations, opportunities exist to improve training prior to the transition to independent practice for graduates that anticipate performing endocrine operations routinely.

Visualizing fewer parathyroid glands may be associated with lower hypoparathyroidism following total thyroidectomy.

It remains uncertain whether the number of parathyroid glands (PGs) seen during extra-capsular dissection impacts short- and long-term hypoparathyroidism. Our study aimed to address this by analyzing patients who underwent total thyroidectomy for benign disease. Consecutive patients undergoing total thyroidectomy were analyzed. The extra-capsular dissection technique was performed throughout the study period. The number of PGs identified, auto-transplanted and found on excised specimen was recorded prospectively. The number of PGs in situ was equaled to four minus the number of PGs auto-transplanted and PGs found on specimen. Temporary hypoparathyroidism was defined as serum adjusted calcium <2.00 mol/L 24 h after surgery and/or need for oral supplements while protracted hypoparathyroidism meant subnormal PTH (<1.2 pmol/L) at 4-6 weeks and/or need for >6-week oral supplements. Permanent hypoparathyroidism was defined as need for oral supplements for ≥1 year. Five-hundred and sixty-nine patients were eligible for analysis. After adjusting for other significant parameters, greater number of PGs identified was an independent risk factor for temporary (p < 0.001) and protracted hypoparathyroidism (p = 0.007). Mean recovery time from protracted hypoparathyroidism for identifying ≤three PGs was significantly shorter than identifying all four PGs (2.8 vs. 7.8 months, p < 0.001). Chance of having all four PGs in situ decreased with greater number of PGs identified (p < 0.001). When the extra-capsular technique was adopted during total thyroidectomy, identifying fewer PGs in their orthotopic positions not only lowered risk of temporary and protracted hypoparathyroidism but also shortened recovery from protracted hypoparathyroidism.

Incidental thyroid cancer in patients undergoing total thyroidectomy for benign disease

Aim To determine the frequency of incidental thyroid carcinoma (ITC) in patients undergoing surgery for presumably benign thyroid diseases.

A new strategy to estimate levothyroxine requirement after total thyroidectomy for benign thyroid disease.

The current approach for calculating the starting dose of levothyroxine (LT4) after total thyroidectomy is based on the patient's body weight (BW). The aim of the study was to identify the major predictive factors of LT4 requirement and to elaborate a new method to improve the accuracy of the LT4 starting dose after total thyroidectomy. The study consists of two parts. The first part consisted of the retrospective identification of 92 adult patients (retrospective cohort) who had undergone a total thyroidectomy for benign disease and who had begun LT4 treatment at a dose of 1.6 μg/kg/day. Adjustments to optimize the LT4 dose were then performed at the post-surgery follow-up on the basis of serum thyrotropin (TSH) levels. The results of this retrospective analysis were used to formulate a nomogram for a proper calculation of the LT4 starting dose that was then used prospectively in the second part of the study on 31 consecutive patients (prospective cohort). At the first follow-up, 37 (40%) patients from the retrospective cohort were euthyroid. Univariate analysis indicated significant correlations between the optimal dose of LT4 and BW, body mass index (BMI), age, preoperative mean corpuscular volume, and free triiodothyronine (fT3). The optimal dose of LT4, analyzed for BMI and age, showed an inverse relationship with these two parameters, and ranged from 1.4 to 1.8 μg/kg/day. In the prospective cohort, the use of an age- and BMI-related nomogram improved the prediction of the optimal LT4 starting dose, with 68% of patients being euthyroid at the first follow-up compared to 41% of patients reported to have reached euthyroid state using the best strategy proposed in the literature. This study confirms that BW is not the only variable for predicting LT4 requirement, as it decreases with the increase in age and BMI, probably due to the relative decrease of lean body mass. A new correlation between optimal dose and presurgical levels of fT3 and mean corpuscular volume was observed. We propose an easy and more efficient method of calculating LT4 starting dose after total thyroidectomy for benign disease.

Assessing The Risk of False-Negative Fine-Needle Aspiration Cytology and of Incidental Cancer in Nodular Goiter

In cases of multinodular goiter with negative cytologic result, reasonable management options include surgical treatment, simple follow-up, or more recently introduced conservative therapies such as laser or radiofrequency ablation, and recombinant human thyroid-stimulating hormone-augmented radioiodine. For patients who are eligible for follow-up or nonsurgical treatments, the possibility that they may have an undiagnosed malignancy (false-negative [FN]-fine-needle aspiration cytology [FNAC] result or incidental thyroid cancer [ITC]) should be considered. The aim of our study was to assess the risk of malignancy in patients known to have presumably benign thyroid disease. Surgical series of patients who underwent total thyroidectomy for benign disease between 2000 and 2010 at two Italian centers were reviewed. Patients with any preoperative suspicion of malignancy were excluded. Histologic examination revealed that 84 of 970 (8.6%) thyroidectomized patients had malignancy (5% ITC and 3.6% FN-FNAC), with 89.8% of ITCs having a diameter <10 mm, and 65.7% of FN-FNAC cancers having a diameter >30 mm. Sixty-seven thyroid malignancy patients (79.8%) had stage I disease (American Joint Committee on Cancer criteria). The risk of FN-FNAC increases with increasing size of the nodule, while the risk of ITC increases as nodule size decreases. The risk of malignancy in presumably benign thyroid disease cannot be overlooked, but can be minimized through skillfully performed ultrasonography (US) examination and FNAC. Once a patient with multinodular goiter is referred for follow-up or nonsurgical therapy, careful US surveillance is mandatory.

Thyroid Frozen Section

A total of 704 cases of thyroid cancer were retrospectively reviewed (2005 to 2011) to assess the contribution of frozen section (FS) to preoperative fine-needle aspiration (FNA). There were 613 papillary carcinomas (87.1%), of which 237 were <1.0 cm. FNA was diagnostic or suspicious in 39.9% of micropapillary thyroid carcinomas and 75.8% of papillary carcinomas. FS was diagnostic in 52.3% and 76.6%, respectively. In no instance did the FS diagnosis change the procedure (total or near-total thyroidectomy). Neither FNA nor FS was diagnostically definitive in follicular neoplasms. A diagnosis of follicular carcinoma was made only after thorough histologic analysis. FS should have a less prominent role in the management of thyroid masses, especially in the context of total thyroidectomy for benign disease. FS may be more productively applied to the identification of metastatic lymph nodes or parathyroids in the surgical field.

Complications of Completion Versus Total Thyroidectomy

The objective of this study was to analyze the complication rates after completion thyroidectomy and compare them with primary total benign and malign thyroidectomy causes in total of 647 patients. Among 647 patients, there were 159 receiving completion thyroidectomy for differentiated thyroid cancer (DTC) (Group 1); 217 patients receiving total thyroidectomy for DTC (Group 2) and 271 given total thyroidectomy for benign diseases (Group 3). When groups were compared for complications, there were no significant difference except temporary hypocalcemia between completion thyroidectomy and total thyroidectomy for DTC. When the total thyroidectomies were compared (Group 2 and 3), there were no significant difference observed except unilateral temporary RLN palsy. With improvements in surgical technique and experience, complication rates of thyroidectomy performed for benign or malign diseases are reduced. In spite of the improvement in surgical experience, temporary RLN palsy and hypoparathyroidism are the main complications in completion thyroidectomies which need special attention. To evaluate the patients more carefully in preoperative period and performing adequate thyroidectomy appears more logical.

Hypocalcemia and Hoarseness Following Total Thyroidectomy for Benign Disease: Relationship of Incidence to the Size of the Gland

ABSTRACT Introduction Total thyroidectomy is considered as the standard surgical procedure for most malignancies and benign disease involving both lobes of the thyroid gland. Postoperative complications are likely to be commoner when the thyroid gland is large in size due to the alteration of structural anatomy. Methods Postoperative complications of 102 patients who underwent total thyroidectomy for benign disease, by the same surgeon, were analyzed. Patients were prospectively followed up and presence of hoarseness and hypocalcemia, both transient and temporary, were compared with the weight of the gland. Results Fourteen patients developed hypocalcemia of which 12 (11.7%) had transient and 2 (1.96%) had permanent deficiencies. Eight patients developed hoarseness following surgery of which seven (6.86%) had transient and only one (0.98%) had permanent hoarseness. A mean thyroid weight of 91.78 gm was observed in the uncomplicated group. Those who developed postoperative hypocalcemia and transient hoarseness had a mean thyroid weight over 100 gm. One patient, who had a thyroid weighing 195 gm developed permanent hoarseness due to RLN injury. Conclusion There is no statistically significant difference in the incidence of transient RLN and transient or permanent hypocalcemia. With increased size of the thyroid gland increased rate of complications was observed with a mean thyroid weight above 100 gm. There may be a significant risk of permanent RLN injury when the thyroid gland is enlarged over 10 times (closer to 200 gm) its normal size.

Total Thyroidectomy Performed With the Starion Vessel Sealing System Versus the Conventional Technique: A Prospective Randomized Trial

Meticulous dissection and accurate hemostasis are required in thyroid surgery. The authors recently performed a number of thyroidectomies using a new device that combines heat and pressure for sealing and cutting tissue. A prospective randomized trial was conducted on 98 patients subjected to total thyroidectomy for benign disease: 49 patients (group A) with the Starion tissue welding system and 49 (group B) with the clamp-and-tie technique. The 2 groups were comparable in mean age, gender, thyroidal volume (20-60 mL), incision length (<35 mm), and pathology. The authors evaluated operative time, postoperative serum calcemia, dosage and length of postoperative calcium and vitamin D treatment, drainage volume, hospital stay, and complications. Student's t test was used for quantitative variables; for categorical variables, the chi(2) test or Fisher's exact test, as appropriate, was used. The mean operative time was 53.8 +/- 6.1 minutes in group A and 63.2 +/- 8 minutes in group B (P < .0001). The difference in terms of postoperative calcemia was significant (group A: 8.35 +/- 0.39 mg/dL; group B: 8.08 +/- 0.39 mg/dL; P < .001). The duration of postoperative treatment with calcium and vitamin D was significantly different (group A: 4 days; group B: 5 days; P < .039). No significant difference in terms of postoperative complications was found. The new system reduced operative time and the duration of postoperative hypocalcemia, and there was minimal tissue necrosis and thermal spread. The reduction in duration of postoperative calcium and vitamin D treatment is also an indication of improvement in quality of the treatment.

Total thyroidectomy for benign disease in the pediatric patient—feasible and safe

Purpose Total thyroidectomy (TT) is a safe and efficacious treatment of malignant thyroid disease in children. The role of TT in benign thyroid disease is less well-defined. The goal of this study was to compare the safety of TT performed for benign and malignant disease. Methods The medical records of 31 patients undergoing TT from January 2000 to June 2007 at a single center were reviewed. The benign cohort totaled 15 patients consisting of 12 with Graves' disease, 2 with hyperthyroidism, and 1 with large and symptomatic multinodular goiter. The malignant cohort totaled 16 patients consisting of 9 with malignant disease, 4 with a nodule and history of cancer or radiation exposure, and 3 with RET proto-oncogene mutations. Results The most common complication was transient hypocalcemia observed in 7 (46%) of 15 patients with benign disease and 9 (56%) of 16 patients with malignancy ( P = .72). Permanent hypocalcemia, defined as need for calcium supplement 6 months postprocedure, was observed in 1 patient with benign disease (6.67%) and 1 patient with malignancy (6.25%; P = 1.0). A single parathyroid gland was reimplanted in 2 patients with malignancy and 2 patients with benign disease ( P = 1.0). One case of keloid scar was noted, and no cases of recurrent laryngeal nerve palsy, nerve paralysis, tracheal injury, tracheostomy, or wound infection were encountered in either cohort. There were no cases of relapse hyperthyroidism in the benign cohort. Conclusions Similar rates of postoperative complications can be expected with TT for benign thyroid disease as compared to TT for malignant disease. Total thyroidectomy is a safe treatment option for benign thyroid disease in children.

ES24P TOTAL THYROIDECTOMY AND POST OPERATIVE HYPOCALCAEMIA: A REVIEW OF OUR PRACTICE AT THE LAUNCESTON GENERAL HOSPITAL

Traditionally subtotal thyroidectomy has been the preferred operation for benign thyroid diseases such as Grave's disease and multinodular goitre. Towards the end of the 21st century total thyroidectomy has been the operation of choice. However there have been concerns that there is likely to be a larger percentage of patients to suffer from temporary and permanent hypocalcaemia. At the Launceston General Hospital total thyroidectomy has been preferred operation. There has not been an audit previously however anecdotally we do not perceive a high rate of complication. This study was a retrospective analysis of patient data from January 1996 to June 2008. The records for all patients that had undergone a total thyroidectomy for either malignant or benign disease at Launceston General Hospital was collected and reviewed. A total of 159 patients had undergone a total thyroidectomy from January 1996 to June 2008. The operations were performed by 12 different surgeons, however 4 surgeons performed the bulk of the operations (80%). The median age of patients was 54. 82% (130) of the study group were female. 89% (141) of the cases were performed for benign disease of the thyroid. 18% (29) patients had a post‐op calcium level less than 2.0. 7 (4.4%) of patients required long term supplements, however 4 out of the 7 had total thyroidectomies for malignant disease. Total thyroidectomy for benign disease of the thyroid is an operation associated with low mortality and morbidity. Hypocalcaemia is a problem that is encountered with this type of operation. Our results show that we have an acceptable rate of hypocalcaemia post total thyroidectomy, hence an appropriate operation for benign disease of the thyroid.

Incidental occult carcinomas in total thyroidectomy for benign diseases of the thyroid

Total thyroidectomy is increasingly recognised as the preferred surgical option for benign diseases of the thyroid. One factor contributing towards this change in policy is reports of incidental carcinomas in the resected specimens. This was a prospective study of patients, who underwent total thyroidectomy for benign diseases of the thyroid at the University Surgical Unit, Colombo North Teaching Hospital from January 2003 to December 2005. There were 68 patients (67 females) aged 28 to 67 years (mean 44.2 (SD=11.1). In 6 (8.8%) patients, histological examination of the post-operative specimen showed incidental carcinomas: 2 papillary, 2 medullary and 2 follicular carcinomas. There was no significant difference in age, clinical presentation and functional thyroid status of patients with incidental carcinomas and those with histologically confirmed benign diseases. Occurrence of incidental thyroid cancers was 8.8% in this series, and they were difficult to predict pre-operatively. The policy of performing total thyroidectomy for benign disease of the thyroid obviates the need for further surgery if an incidental carcinoma is found.