Transient Recurrent Laryngeal Nerve Palsy Research Articles

New Technique Using the Snake Retractor for Complete Lymph Node Dissection in Robotic Thyroid Surgery

We introduce a new technique using a snake retractor to allow for a complete central lymph node dissection (CND) under a more optimal view for robotic thyroid surgery using bilateral axillo-breast approaches. Fifty-eight patients diagnosed with papillary thyroid cancer who underwent robotic thyroidectomy from April to December 2010 were analyzed. A total of 20 patients underwent a robotic surgery without use of snake retractor initially, and 38 patients underwent surgery using snake retractor. Ipsilateral CNDs were performed in all cases. The number of harvested lymph nodes was 5.3 without use of the snake retractor and 7.9 with use (P = 0.04). Serum thyroglobulins off thyroid hormone in total cases were 0.6 and 0.2, respectively (P = 0.42). The rate of postoperative complications including transient hypocalcemia (n = 8) and transient recurrent laryngeal nerve palsy (n = 2) were low between the 2 groups without a significance. Utilization of the snake retractor facilitated safely effective CND with using of 2 arms simultaneously, while providing a superior view to that obtained with robotic thyroid surgery using bilateral axillo-breast approach.

Continuous intraoperative vagus nerve stimulation for identification of imminent recurrent laryngeal nerve injury

Conventional intraoperative nerve monitoring, predicated on intermittent stimulation, can predict recurrent laryngeal nerve (RLN) palsy only after the damage has been done. Fifty-two patients (52 nerves at risk) who underwent continuous intraoperative nerve monitoring (CIONM) for thyroid surgery via vagus nerve stimulation had their electromyographic (EMG) tracings recorded and correlated with surgical maneuvers and postoperative RLN function. There was 1 imminent loss of signal (LOS) with intraoperative signal recovery and there were 4 losses of signal with corresponding unilateral transient RLN palsy. When EMG amplitude decreased >50% and EMG latency increased >10%, LOS and postoperative RLN palsy were noted in 4 of 8 patients (50%) who had multiple combined events. In 9 of 13 patients (70%) who developed adverse EMG changes, modification of the causative surgical maneuver resulted in recovery of those EMG changes and aversion of impending RLN palsy. CIONM reliably signaled impending nerve injury, enabling immediate corrective action.

Sentinel lymph node biopsy:Is it a reliable indicator of lateral nodal involvement in papillary thyroid carcinoma?

Aim: Is to evaluate the role of sentinel lymph node biopsy (SLNB) in diagnosis of lateral nodal involvement in NO papillary thyroid cancer patients. Methods: 20 patients were included in this study; total thyroidectomy with dissection of the central neck compartment was done in all patients. 0.5 ml of 2% methylene blue dye was injected into the primary tumour; blue stained SLN in lateral neck was identified and examined by frozen section. If any of the SLNs were positive on the frozen section, selective neck dissection (levels II-IV) was performed during same operation. In false-negative cases of SLNs reoperation was carried out after 1 week. Results: There were 6.7%false-negative rate; 100% specificity; 80% sensitivity, 93% negative predictive value; 100% positive predictive value, with 94.7% overall accuracy. Postoperative transient recurrent laryngeal nerve palsy occurred in 2 patients; but none of the patients had permanent nerve palsy. One patient required calcium supplement on discharge; however, no patient developed permanent hypocalcaemia. Conclusion: SLNB is an easy and accurate method for assisting the diagnosis of metastasis in the lateral neck compartment, and it could reduce the risk of complications of thyroid surgery. We recommend this technique to support the decision to perform selective neck dissection in NO papillary thyroid cancer patients.

Effect of intraoperative neuromonitoring on recurrent laryngeal nerve palsy rates after thyroid surgery—A meta-analysis

Though intraoperative nerve monitoring (IONM) during thyroid surgery has gained universal acceptance for localizing and identifying the recurrent laryngeal nerve (RLN), its role in reducing the rate of RLN injury remains controversial. In order to assess the effect of IONM during thyroid surgery, its value in reducing the incidence of RLN palsy was systematically evaluated. Studies were evaluated for inclusion in this analysis by researching PubMed, Embase, the Cochrane Central Register of Controlled Trials, and the references of included studies. The initial screening of article titles and abstracts was independently performed by five reviewers based on the research protocol criteria. Each article was then read in detail and discussed before inclusion in the meta-analysis. Data were independently extracted, including the level of evidence, number of at-risk nerves, allocation method, baseline equivalence between groups, definitions of transient and permanent vocal fold palsy, systematic application of electrodes, etc. The meta-analysis was then performed. Odds ratios were pooled using a random effects model. Five randomized clinical trials and 12 comparative trials evaluating 36,487 at-risk nerves were included. Statistically significant differences in terms of total recurrent laryngeal nerve palsy (3.37% with intraoperative nerve monitoring [IONM] vs. 3.76% without IONM [OR: 0.74; 95% confidence interval [CI]: 0.59-0.92]) and transient recurrent laryngeal nerve palsy (2.56% with IONM vs. 2.71% without IONM [OR: 0.80; 95% CI: 0.65-0.99]) were identified. The persistent incidence of recurrent laryngeal nerve palsy was 0.78% for IONM versus 0.96% for nerve identification alone (OR: 0.80; 95% CI: 0.62-1.03). Based on this meta-analysis, statistically significant differences were determined in terms of the incidences of total and transient recurrent laryngeal nerve palsy after using IONM versus recurrent laryngeal nerve identification alone during thyroidectomy. However, no statistically significant differences were identified regarding the incidence of persistent recurrent laryngeal nerve palsy between groups.

“Mystic” transient recurrent nerve palsy after thyroid surgery

The mechanism of transient recurrent laryngeal nerve (RLN) palsy remains unclear. Samples were harvested from the RLN adjacent thyroid capsule and perineural fascia during 223 lobectomies and 89 RLNs from cadavers were used for histologic and immunohistologic evaluation. Intraoperative chromoendoscopic features of the RLN were compared with postoperative ear, nose, and throat examinations. Those nerves that macroscopically seem to be single-branched (35 of 89 = 39.3%), microscopically consist of multiple fascicles in most of the cases (23 of 35 = 65.7%), resembling a plexus more than a single cord. Chronic lymphocytic infiltration of the thyroid capsule adjacent to the RLN was present in 29% (65 of 223) of the cases. The perineural fascia showed lymphocytic (18 of 223 = 8.1%) or granulocytic (7 of 223 = 3.1%) infiltration. The origin of transient RLN palsy is multifactorial: plexus shaped microscopic nerve structure with or without branches, frame-like adventitial tissue, variable epineurium, inflammatory changes that involve not only the thyroid capsule but the perineural fascia, resultant nerve edema, and diffuse microhemorrhages by injury of fragile capillaries.

Harmonic scalpel compared to conventional hemostasis in thyroid surgery.

The aim of this study was to determine whether conventional hemostasis (CH) or the harmonic scalpel (HS) results in shorter operative times for thyroidectomy and to evaluate the incidence of postoperative complications with each approach. In this study, 85 consecutive patients undergone open thyroidectomy were randomized into two groups: group CH (conventional hemostasis with classic technique of tying and knots, resorbable ligature, bipolar diathermy) and group HS (harmonic scalpel). Demographics, pathological characteristics, thyroid size, operative time, blood loss, and complications using the Student's t-test and χ (2)-test. The two groups were similar regarding age and sex. There were no intraoperative complications. There was no difference between the two techniques regarding the amount of blood loss for different procedures. No significant differences were found between the two groups concerning mean thyroid weight and mean hospital stay (2.2days in HS vs. 3.7 in CH; P > 0.05). The mean operative time was significantly shorter in the HS group (47.2min vs. 79.2min; P < 0.001). Two (4.7%) transient recurrent laryngeal nerve palsies were observed in the CH group and no one (0%) in the HS group. No patient developed permanent palsy. Postoperative transient hypocalcemia occurred more frequently in the CH group (21/43, 48% vs. 7/42, 16%). In patients undergoing thyroidectomy, HS is a reliable and safe tool. Comparing with CH techniques, its use reduces operative times, postoperative pain, drainage volume, and transient hypocalcemia.

A Standard Approach to Expose the Recurrent Laryngeal Nerve During Endoscopic Thyroidectomy

Exposing the recurrent laryngeal nerve (RLN) during all types of thyroid surgery is essential to protect this nerve. Endoscopic thyroidectomy (ET) has gained acceptance from both patients and physicians, in part due to the cosmetic benefits. Therefore, the avoidance of intraoperative RLN impairment during ET is of critical significance. We have developed a standard approach to expose the RLN during ET that prevents RNL impairment. ET was performed in 120 consecutive patients with thyroid disease. In order to develop a standard procedure that protects the RLN, several steps that differed from the traditional open procedure were introduced. First, the thyroid gland was freed from the isthmus instead of the superior pole. Then, the inferior pole of the thyroid gland was meticulously freed, and the lateral side of the thyroid gland was freed followed by the superior pole. At this point, the RLN was easily visualized in the tracheoesophageal groove. The thyroidectomy was then performed simultaneously with exposure of the RLN from the inferior to superior aspects. All RLNs were exposed when hemithyroidectomies, subtotal thyroidectomies, or total thyroidectomies were performed. The operative time and parathyroid hormone (PTH) and calcium levels were recorded prospectively and analyzed. Using this method, all RLNs were easily exposed within 15 minutes. Only one case of transient RLN palsy occurred due to accidental contact of the harmonic scalpel to the nerve. Postoperative hypocalcemia occurred in 23 cases (19.2%), and the PTH level decreased significantly in 33 cases (27.5%). The PTH levels returned to normal within 3 months. Use of the described approach to expose and protect the RLN when performing ET is safe and feasible.

Trans-areola single-site endoscopic thyroidectomy: pilot study of 35 cases

Endoscopic thyroidectomy via thoracic/breast approach is an acceptable and successful technique in Asia. This technique has the advantage of better cosmesis compared with open or even video-assisted thyroidectomy. Unfortunately, because of the need for three separate ports, conventional endoscopic thyroidectomy usually involves significantly more tissue dissection, and thus more injury to patients, limiting the popularity of this technique. We herein present 35 cases of trans-areola single-site endoscopic thyroidectomy (TASSET), which was first performed in 2009. Thirty-five patients who underwent TASSET for thyroid nodules from September 2009 to March 2011 were evaluated. The surgical outcomes of the surgery were retrospectively analyzed, including conversion, operative time, estimated blood loss, complications, length of stay, and patient satisfaction. Thirty-one of the 35 patients (88.5%) underwent successful TASSET, with subtotal lobectomy being the most common procedure. Median operative time for the surgery was 153.65 min (range 100-190 min). Estimated blood loss ranged from 20 to 40 mL. Length of postoperative stay ranged from 2 to 4 days (average 2.5 days). Visual analog scale scores were 0 to 4 without administration of analgesics. The complication rate was low (8.6%) and included one case of transient recurrent laryngeal nerve (RLN) palsy, one case of subcutaneous seroma, and one case of tracheal injury. All patients were satisfied with the cosmetic outcome after mean follow-up of 8 months. TASSET is feasible and safe, with great cosmetic benefits and less injury than other procedures. It may become an alternative procedure for treatment of patients with benign thyroid tumors, especially those with strong desire for cervical cosmesis.

Does Mediastinal Extension of the Goiter Increase Morbidity of Total Thyroidectomy? A Multicenter Study of 19,662 Patients

To compare the outcome in patients with cervical goiters and cervicomediastinal goiters (CMGs) undergoing total thyroidectomy using the cervical or extracervical approach. This was a retrospective study conducted at six academic departments of general surgery and one endocrine-surgical unit in Italy. The study population consisted of 19,662 patients undergoing total thyroidectomy between 1999 and 2008, of whom 18,607 had cervical goiter (group A) and 1055 had CMG treated using a cervical approach (group B, n = 986) or manubriotomy (group C, n = 69). The main parameters of interest were symptoms, gender, age, operative time, duration of drain, length of hospital stay, malignancy and outcome. A split-sternal approach was required in 6.5% of cases of CMG. Malignancy was significantly more frequent in group B (22.4%) and group C (36.2%) versus group A (10.4%; both P < .001), and in group C versus group B (P = .009). Overall morbidity was significantly higher in groups B + C (35%), B (34.4%) and C (53.5%) versus group A (23.7%; P < .001). Statistically significant increases for group B + C versus group A were observed for transient hypocalcemia, permanent hypocalcemia, transient recurrent laryngeal nerve (RLN) palsies, permanent RLN palsies, phrenic nerve palsy, seroma/hematoma, and complications classified as other. With the exception of transient bilateral RLN palsy, all of these significant differences between group B + C versus group A were also observed for group B versus group A. Symptoms, malignancy, overall morbidity, hypoparathyroidism, RLN palsy and hematoma are increased in cases of substernal goiter.

Is minimally invasive, video-assisted thyroidectomy feasible in Graves’ disease?

Although the safety and advantages of minimally invasive, video-assisted thyroidectomy (MIVAT) are well documented in nodular thyroid disease, its role in Graves' disease is controversial. We compared the outcomes of patients undergoing MIVAT with those undergoing conventional thyroidectomy for Graves' disease. Of the 497 patients with Graves' disease referred for surgery (1999-2009), 157 (31.6%) patients underwent the MIVAT procedure (video-assisted group). As a control group, 340 patients undergoing conventional thyroidectomy (conventional thyroidectomy group) were included in the current analysis. MIVAT was proposed if the thyroid volume was ≤ 30 mL. The data were obtained through a prospectively maintained surgical database. Most patients in both groups underwent total thyroidectomy (98% in the MIVAT group and 96.5% in the conventional group). Three (1.9%) conversions to open surgery occurred in the video-assisted group. Hospital stay was significantly shorter (P = .008) in the video-assisted group (2.1 ± 0.4 days) compared with the conventional thyroidectomy group (2.4 ± 1.4 days). The mean operative time was shorter (84 ± 29 min; range, 15-240) for the video-assisted group compared with the conventional thyroidectomy group (94 ± 43 min; range, 20-360), although this difference was not statistically significant (P = .05). Postoperative transient hypocalcemia occurred in 14 (8.9%), transient recurrent laryngeal nerve palsy occurred in 2 (1.3%), and postoperative hematoma occurred in 5 (3.2%) patients in the video-assisted group compared with 23 (6.8%), 11 (3.2%), and 8 (2.3%) patients in the conventional thyroidectomy group, respectively (P = ns). In selected patients with Graves' disease, MIVAT is feasible and can be performed safely with results comparable with open surgery.

Focus Harmonic Scalpel Compared to Conventional Haemostasis in Open Total Thyroidectomy: A Prospective Randomized Trial

The aim of this prospective randomized trial was to compare operative factors, postoperative outcomes and surgical complications of open total thyroidectomy when using the Harmonic Scalpel (HS) versus Conventional Haemostasis (CH). Methods. 100 consecutive patients underwent open total thyroidectomy were randomized into two groups: group CH (Conventional Haemostasis) and group HS (Harmonic Scalpel). We recorded the following: age, sex, pathology, thyroid volume, haemostatic technique, operative time, drainage volume, thyroid weight, postoperative pain, postoperative complications, and hospital stay. The results were analyzed using the Student's t test and χ 2 test. Results. No significant difference was found between the two groups concerning mean thyroid weight and mean hospital stay. The mean operative time was significantly shorter in the HS group. The total drainage fluid volume was lower in HS group. Two (4%) transient recurrent laryngeal nerve palsies were observed in CH group and no one (0%) in the HS group. Postoperative transient hypocalcemia occurred more frequently in the CH group. HS group experienced significantly less postoperative pain at 24 and 48 hours. Conclusions. In patients undergoing thyroidectomy, HS is a reliable and safe tool. Comparing with CH techniques, its use reduces operative times, postoperative pain, drainage volume and transient hypocalcemia.

Outcomes of 109 patients with papillary thyroid carcinoma who underwent robotic total thyroidectomy with central node dissection via the bilateral axillo-breast approach

We developed the bilateral, axillo-breast approach (BABA) to endoscopic thyroidectomy and applied it to the da Vinci robotic surgical system in 2008. Herein, we have analyzed the immediate postoperative outcomes and 1-year follow-up results of robotic BABA total thyroidectomy with central node dissection (CND). In 2008 and 2009, 109 patients with PTC underwent robotic BABA total thyroidectomy with CND. Clinicopathologic characteristics, short- and long-term complications, and postoperative thyroglobulin (Tg) level were obtained prospectively and analyzed. The mean age was 39 ± 10 years and the male to female ratio was 1:5.8. The mean operation time was 206 ± 36 minutes. Transient recurrent laryngeal nerve (RLN) palsy occurred in 17 cases (16%) and transient hypocalcemia in 21 cases (19%). The median follow-up was 12 months. There were 1 and 2 cases of permanent RLN palsy and permanent hypoparathyroidism, respectively. Postoperative radioactive iodine ablation was performed on 54 patients (50%). Their mean stimulated Tg level was 1.84 ± 6.35 ng/mL and 76% had stimulated Tg levels <1.0 ng/mL. Robotic BABA total thyroidectomy with CND yields good postoperative outcomes. Given the excellent cosmetic outcomes, this technique may be a suitable operative alternative for low-risk patients with PTC.

Complications and risk factors related to the extent of surgery in thyroidectomy. Results from 2,043 procedures

To evaluate the rate of complications and the risk factors in relation to the extent of surgery in patients undergoing thyroidectomy in a tertiary university center. Data were collected retrospectively from 2,043 consecutive patients who underwent thyroid surgery for various thyroid diseases at the University Hospital of Patras, Greece, between January 1996 and December 2007. Recurrent laryngeal nerve palsy (RLNP) and hypoparathyroidism were set as the primary end points, while hematoma and wound infection were set as the secondary endpoints. Total, near-total and subtotal thyroidectomy was performed in 1,149,777 and 117 patients, respectively. Transient RLNP occurred in 34 (1.6%) and permanent in 19 (0.9%) patients. Multivariate logistic regression analysis showed that extended resection (OR-odds ratio-1.6), Graves' disease (OR 2.7), thyroiditis (OR 2.1), recurrent goiter (OR 2.3) and thyroid malignancy (OR 1.7) were all independent risk factors for transient RLNP, whereas Graves' disease (OR 2.2) and recurrent goiter (OR 1.7) emerged as independent risk factors for permanent RLNP. The rates of transient and permanent hypoparathyroidism were 27.8% and 4.8%, respectively. Multivariate analysis for transient hypoparathyroidism revealed that the extent of surgical resection (OR 2.2), Graves' disease (OR 2.1), recurrent goiter (OR 1.7), female gender (OR 1.5) and specimen weight (OR 1.6) were independent predictors. However, the extent of surgical resection (OR 2.7), Graves' disease (OR 1.8), recurrent goiter (OR 1.5) and malignant disease (OR 1.5) were independent risk factors for permanent hypoparathyroidism. Postoperative wound infection and hematoma occurred in 6 (0.3%) and 27 (1.3%) patients, respectively. No correlation was observed between wound infection or postoperative hemorrhage and the extent of surgery. Despite the higher morbidity, total thyroidectomy is emerging as an attractive surgical option even for benign thyroid disease due to the risk of subclinical (occult) malignancy, the possibility of goiter relapse as well as of the increased risk of complications following reoperation.

Management of unilateral cervical radiculopathy in the military: the cost effectiveness of posterior cervical foraminotomy compared with anterior cervical discectomy and fusion

To review the cost effectiveness for the management of a unilateral cervical radiculopathy with either posterior cervical foraminotomy (PCF) or anterior cervical discectomy and fusion (ACDF) in military personnel, with a particular focus on time required to return to active-duty service. Following internal review board approval, the authors conducted a retrospective review of 38 cases in which patients underwent surgical management of unilateral cervical radiculopathy. Nineteen patients who underwent PCF were matched for age, treatment level, and surgeon to 19 patients who had undergone ACDF. Successful outcome was determined by return to full, unrestricted active-duty military service. The difference in time of return to active duty was compared between the groups. In addition, a cost analysis consisting of direct and indirect costs was used to compare the PCF group to the ACDF group. A total of 21 levels were operated on in each group. There were 17 men and 2 women in the PCF group, whereas all 19 patients in the ACDF group were men. The average age at the time of surgery was 41.5 years (range 27-56 years) and 39.3 years (range 24-52 years) for the PCF and ACDF groups, respectively. There was no statistically significant difference in operating room time, estimated blood loss, or postoperative narcotic refills. Complications included 2 cases of transient recurrent laryngeal nerve palsy in the ACDF group. The average time to return to unrestricted full duty was 4.8 weeks (range 1-8 weeks) in the PCF group and 19.6 weeks (range 12-32 weeks) in the ACDF group, a difference of 14.8 weeks (p < 0.001). The direct costs of each surgery were $3570 for the PCF and $10,078 for the ACDF, a difference of $6508. Based on the 14.8-week difference in time to return to active duty, the indirect cost was calculated to range from $13,586 to $24,045 greater in the ACDF group. Total cost (indirect plus direct) ranged from $20,094 to $30,553 greater in the ACDF group. In the management of unilateral posterior cervical radiculopathy for military active-duty personnel, PCF offers a benefit relative to ACDF in immediate short-term direct and long-term indirect costs. The indirect cost of a service member away from full, unrestricted active duty 14.8 weeks longer in the ACDF group was the main contributor to this difference.

Comparison of minimally invasive video-assisted thyroidectomy and conventional thyroidectomy: a single-blinded, randomized controlled clinical trial

Comparison of minimally invasive video-assisted thyroidectomy and conventional thyroidectomy: a single-blinded, randomized controlled clinical trial Gouda Mohamed El-labbanDepartment of General Surgery, Faculty of Medicine, Suez Canal University, Ismailia, EgyptAim: We aimed to test the hypothesis that minimally invasive video-assisted thyroidectomy (MIVAT) affords comparable safety and efficacy as open conventional surgery in patients with unilateral thyroid nodules or follicular lesions in terms of cosmetic results, intraoperative and postoperative complications, postoperative pain, and hospital stay.Methods: A single-blinded randomized controlled trial compared MIVAT with conventional thyroidectomy. The primary endpoints of the study were measurement of postoperative pain after 24 and 48 hours and cosmetic outcome 3 months postoperatively. The secondary outcome measures were operative time, incidence of recurrent laryngeal nerve injury, length of incision, and hospital stay.Results: Operative time was less with open thyroidectomy than with MIVAT, while MIVAT was associated with less pain 24 hours postoperatively. Pain score showed statistically significant differences in favor of MIVAT after 24 hours. MIVAT was associated with less scarring and more satisfaction with cosmetic results. There was no difference between both procedures for presence of transient recurrent laryngeal nerve palsy and hypoparathyroidism.Conclusion: MIVAT is a safe procedure that produces outcomes similar to those of open thyroidectomy, and is superior in terms of immediate postoperative pain and cosmetic resultsKeywords: endoscopic neck surgery, mini-incision

Minimally Invasive Video-Assisted Thyroidectomy Versus Conventional Thyroidectomy: A Single-Blinded, Randomized Controlled Clinical Trial

We aimed to test the hypothesis that Minimally Invasive Video-assisted Thyroidectomy (MIVAT) affords comparable safety and efficacy as to the open conventional surgery, when dealing with patients with unilateral thyroid nodules or follicular lesions, in terms of cosmetic results, intraoperative and postoperative complications, postoperative pain and hospital stay. Materials And Methods: This was a single-blinded randomised controlled trial comparing the MIVAT with conventional thyroidectomy. The primary endpoints of the study were measurement of postoperative pain after 24 and 48 hours from operation and self-rated patient satisfaction with cosmetic outcome three months postoperatively. The secondary outcome measures were operative time, incidence of temporary and permanent recurrent laryngeal nerve injury, postoperative haematoma formation, length of incision, and duration of hospital stay. Results: Operative time was significantly less with open thyroidectomy than with MIVAT, while MIVAT was associated with less pain 24 hours postoperatively. Blood loss did not reach significance between procedures. Comparisons between the two procedures with regard to pain scores after 24 and 48 hours, respectively, depicted statistically significant differences in favour of the MIVAT after 24 hours. MIVAT was associated with less scarring and more satisfactory cosmetic results. There were statistically no significant differences between both procedures for the presence of transient recurrent laryngeal nerve palsy and hypoparathyroidism. Conclusions: MIVAT is a safe procedure that produces outcomes, in view of short-term adverse events, similar to those of open thyroidectomy, and is superior in terms of immediate postoperative pain and cosmetic results.

Could total thyroidectomy become the standard treatment for Graves’ disease?

Graves' disease is the most frequent cause of hyperthyroidism. Although treatment with antithyroid drugs or radioactive iodine is effective, surgery remains the preferred treatment for many patients. We analyzed the results of 55 prospectively followed patients who underwent total thyroidectomy for Graves' disease. Total thyroidectomy was performed by experienced endocrine surgeons in all 55 patients. We monitored the patients postoperatively for early and late complications. There were 19 men, with a mean age of 42 years (range, 34-68 years) and 36 women, with a mean age of 38 years (range, 19-78 years). One patient suffered postoperative hemorrhage and subsequent wound infection, two patients had transient recurrent laryngeal nerve palsy, and 24 patients had transient hypocalcemia. The mean follow-up time was 4 years (range, 10 months to 6 years). Recurrence of hyperthyroidism was not reported in this period. Removal of all thyroid tissue offers the best chance of preventing recurrent hyperthyroidism. Total thyroidectomy is the most effective surgery for achieving the goal of treatment of Graves' disease to ensure that hyperthyroidism will not recur.

Total Thyroidectomy Is Superior to Subtotal Thyroidectomy for Management of Graves’ Disease in the United States

In the United States, Graves' disease is most commonly treated with radioiodine, yet thyroidectomy remains an important option for correcting hyperthyroidism. In many countries, limited access to thyroid hormone makes subtotal thyroidectomy the procedure of choice. In the United States, where levothyroxine is widely available, we hypothesized that total (TT) or near-total thyroidectomy (NT) is superior to subtotal thyroidectomy (ST) for long-term control of Graves' disease. A retrospective review of patients who underwent ST, NT, or TT for Graves' disease between 1990 and 2008 was conducted. Differences in rates of disease recurrence were assessed by analysis of variance (ANOVA). Rates of parathyroid autotransplantation, complications, gland weight, and final pathology were determined. A total of 136 patients with Graves' disease were treated with thyroidectomy. Average age was 36.4 +/- 11.3 years (range: 16-81 years) and 88% were female. From 1990 to 1994, 10 patients underwent ST and 6 had NT. Since then, all patients have undergone TT (n = 120). There was a significantly higher rate of recurrence for ST (30%) compared to NT (0%; P = 0.15) and TT (0%; P < 0.0001). Parathyroid autotransplantation was performed in 36 (26.5%) patients, only 2 of whom underwent ST or NT. Transient postoperative hypocalcemia was more common after TT (P = 0.04). No patient in any group had permanent hypoparathyroidism. Two TT pts had transient recurrent laryngeal nerve palsy. Subtotal thyroidectomy resulted in 30% long-term failure to correct Graves' hyperthyroidism. We saw no recurrences and no increase in postoperative complications in the TT group. We feel that TT is safe and superior to ST for management of Graves' disease in the United States.

Evaluation of video-assisted thoracoscopic surgery lobectomy requiring emergency conversion to thoracotomy

Video-assisted thoracoscopic surgery (VATS) lobectomy has been employed for the treatment of lung cancer. Many investigators have reported that the outcomes of VATS lobectomy for lung cancer are comparable to those of thoracotomy; however, several controversial issues remain. One of the critical concerns is the safety. VATS lobectomy often requires an emergency conversion to thoracotomy, for example, in the event of massive bleeding. In this study, cases in which VATS lobectomy for lung cancer was converted to thoracotomy intra-operatively (converted VATS lobectomy) were identified. The safety of the converted VATS lobectomy was evaluated. Between 2003 and 2007, VATS lobectomy was converted to thoracotomy in 24 out of 492 cases. Information regarding the patients' characteristics, reasons for the conversion and perioperative complications as well as the recurrence and survival data were carefully reviewed. The reasons for the conversion were classified into two groups: (1) problems related to the VATS procedure (VATS-related problems) and (2) problems not related to the VATS procedure (non-VATS-related problems). Of the 24 converted cases, 19 (79%) had a history of smoking. Nine patients (38%) had a history of lung disease. Left upper lobectomy was the most frequently associated with conversion (11/24, 46%), followed by right lower lobectomy and right upper lobectomy. The most frequent reasons for the conversion were hilar lymphadenopathy and bleeding (seven patients each), followed by fused fissure. Eight of the conversions were considered to be attributable to VATS-related problems. Perioperative complications were observed in four patients, consisting of prolonged air leak in three patients and transient recurrent laryngeal nerve palsy in one patient. However, there were no life-threatening complications. The median follow-up period was 26 months. Recurrence occurred in two patients: pleural dissemination in one and bone metastasis in the other. Two deaths were observed during the follow-up period: one related to lung cancer and another related to other type of cancer. The safety of the conversion was acceptable. Our findings suggest that VATS lobectomy for lung cancer is feasible from the viewpoint of safety, even after taking into account the potential need for conversion to thoracotomy in some patients.

The learning curve for endoscopic thyroidectomy: a single surgeon’s experience

Endoscopic thyroidectomy has been known to surgeons for only 20 years. Related studies still are needed to make up for the deficiency of clinical experience. Research on the learning curve for the endoscopic thyroidectomy could be the method for investigating the operation experience. This retrospective study investigated 300 consecutive patients who underwent endoscopic thyroidectomy by a single endoscopist during the past 7 years. The study population was equally divided into 10 groups chronologically. Pearson's chi-square test and one-way analysis of variance were used to compare differences in the demographic data, operative time, operation score system, and follow-up data. The mean operative time was 98.07 min. The mean operation score was 6.00, and the rate of conversion to open surgery was 3.7%. There were no differences in demographic data or complications among the 10 groups. Subcutaneous edema occurred in five cases and transient recurrent laryngeal nerve palsy in five cases. There were significant differences in the mean operative time (p < 0.01) and the mean operation score (p < 0.01) among the 10 groups. Comparison of two neighboring groups showed differences in both operative time (p < 0.05) and operation score (p < 0.01) between groups 2 and 3 and in operation score between groups 5 and 6 (p < 0.05). The first 60 cases constitute the early stage of the learning curve for endoscopic thyroidectomy. The proficiency and stability of the operation reach the advanced level after 150 cases.