Transient Recurrent Laryngeal Nerve Research Articles

Effect of intraoperative neuromonitoring on efficacy and safety using sugammadex in thyroid surgery: randomized clinical trial.

PurposeThe use of nondepolarizing neuromuscular blocking agents (NMBAs) may affect intraoperative neuromonitoring (IONM) during anesthesia used during thyroid and parathyroid surgery.MethodsThe use of sugammadex was evaluated in a prospective clinical study during thyroid surgery. Between July 2018 and January 2019, 129 patients were prospectively randomized to either the sugammadex group (group B) or the control group (group A). Group A patients underwent standardized IONM during thyroidectomy, while group B patients used an NMBA-reversal protocol comprised of rocuronium (0.6 mg/kg) in anesthesia induction and sugammadex (2 mg/kg) after first vagal stimulation (V0). A peripheral nerve stimulator was used to monitor the neuromuscular transmission.ResultsIn our clinical study, it took 26.07 ± 3.26 and 50.0 ± 8.46 minutes to reach 100% recovery of laryngeal electromyography at injection of the sugammadex group (2 mg/kg) and the control group, respectively (P < 0.001). The train-of-four ratio recovered from 0 to >0.9 within 4 minutes after administering 2 mg/kg of sugammadex at the beginning of resection. Surgery time was significantly shorter in group B than in group A (P < 0.001). Transient recurrent laryngeal nerve (RLN) paralysis was detected in 4 patients from group A and in 3 patients from group B (P = 0.681). There was no permanent RLN paralysis in the 2 groups.ConclusionOur clinical study showed that sugammadex effectively and rapidly improved the inhibition of neuromuscular function induced by rocuronium. The implementation of the nondepolarizing neuromuscular block recovery protocol may lead to tracheal intubation as well as favorable conditions for IONM in thyroid surgery.

Unilateral Axilla-Bilateral Areola Approach for Thyroidectomy by da Vinci Robot: 500 Cases Treated by the Same Surgeon.

Objective: To investigate the efficacy and safety of da Vinci robot-assisted thyroidectomy via an unilateral axilla-bilateral areola (UABA) approach.Methods: The clinical data of 500 patients undergoing robotic thyroidectomy via an UABA approach from July 2014 to April 2018 were retrospectively analyzed. All 500 patients were operated on by the same surgeon and divided into two groups by the time sequence. The efficacy and complications were compared between the two groups.Results: Robotic thyroidectomy via an UABA approach was performed successfully in 500 cases, including 196 cases of benign thyroid diseases with a lesion diameter of 3.1 ± 1.3 cm (0.4 - 8.2 cm) and 304 cases of thyroid cancer with a tumor diameter of 1.2 ± 0.7 cm (0.4 - 4.4 cm). Surgical procedures included unilateral lobectomy and total thyroidectomy with or without central lymph node dissection. Among the 500 patients, 9 (1.8%) had transient recurrent laryngeal nerve injury, 1 (0.2%) had permanent unilateral recurrent laryngeal nerve injury, 12 (2.4%) had subcutaneous hemorrhage of the trajectory area, and 6 (1.2%) had subcutaneous infection of the trajectory area after surgery. Among 239 thyroid cancer patients undergoing total thyroidectomy, 45 (18.8%) had transient hypoparathyroidism and 5 (2.1%) had permanent hypoparathyroidism. The incidence of permanent hypoparathyroidism was 1.9% (4/212) among the patients undergoing total thyroidectomy plus unilateral central lymph node dissection, and 3.7% (1/27) among the patients undergoing total thyroidectomy plus bilateral central lymph node dissection. During the follow-up of median 17 months, all patients were satisfied with postoperative appearance of the neck and no structural recurrence or metastases occurred. There was no significant difference in efficacy between the two groups (P > 0.05), while the complication rate in phase 2 was significantly lower than that in phase 1 (P < 0.05) as the surgeon became more proficient in the UABA approach.Conclusion: Robotic thyroidectomy via an UABA approach is simple, safe, and minimally invasive, suitable for radical resection of large benign tumors and early thyroid cancer and central lymph node dissection.

Safety and efficacy of thermal ablation (radiofrequency and laser): should we treat all types of thyroid nodules?

Background: Thermal ablation is a minimally invasive technique that is gradually acknowledged as an effective alternative to surgery to treat thyroid nodules. Two main techniques have been described: radiofrequency (RFA) and laser ablation.Objective: To evaluate the safety and efficacy of the two main techniques (RFA and laser ablation) for the treatment of benign thyroid nodules.Patients: This bicentric retrospective study included 166 consecutive patients, who received clinical, biological and ultrasound evaluations for thyroid nodules, from October 2013 to November 2017.Methods: One of the two techniques was proposed if a nodule was proven to be benign after fine needle aspiration cytology or micro-biopsy. Adverse events and outcomes (symptoms, nodule reduction) were assessed at 6 weeks and 6, 12, and 18 months after treatment.Results: One hundred and eighty-nine nodules (mean size 17.5 ± 16.9 mL, 86.1% palpable) were treated by RFA (n = 108 (57.1%)) or laser ablation (n = 81 (42.9%)) in 166 patients (80.1% women, mean age 51.7 years). Two cases of transient recurrent laryngeal nerve palsy, one hematoma, and two successfully drained abscesses (5/166 = 3%) were observed. Clinical symptoms improved significantly in the two groups (anterior cervical discomfort –83.6%, esthetic complaints –84.9% and dysphagia –86.4%). Nodule volume (mL) decreased significantly (baseline vs. 18 months) from 20.4 ± 18.6 to 5.8 ± 6.6 (−75%) in the RFA, and from 13.6 ± 13.3 to 3.4 ± 4.1 (−83.9%) in the laser ablation groups.Conclusions: Transient but potentially serious adverse events were reported in 3% of patients. A significant volumetric reduction was achieved with both techniques, regardless of nodule’s characteristics, at 18 months.

Transoral Robotic Thyroidectomy for Papillary Thyroid Carcinoma: Perioperative Outcomes of 100 Consecutive Patients.

Endoscopic transoral thyroidectomy is a recently introduced technique of remote access thyroidectomy. We previously reported the feasibility of the robotic approach (TORT). Nevertheless, experience to date is limited, with scant data on outcomes in patients with papillary thyroid carcinoma (PTC). This was a retrospective analysis of prospectively collected data. Patients with PTC, who underwent TORT at a single center between March 2016 and February 2017, were analyzed. There were a total of 100 patients (85 women, 15 men) with a mean age of 40.7 ± 9.8years, and a mean tumor size of 0.8 ± 0.5cm. Nine patients underwent a total thyroidectomy, and 91 underwent a lobectomy. The operative time for a total thyroidectomy and lobectomy was 270.0 ± 9.3 and 210.8 ± 32.9min, respectively. Ipsilateral prophylactic central neck compartment dissection was performed routinely with retrieval of 5.0 ± 3.6 lymph nodes. Perioperative morbidity was present in nine patients including transient recurrent laryngeal nerve palsy (n = 1), postoperative bleeding requiring surgical intervention (n = 1), zygomatic bruising (n = 2), chin flap perforation (n = 1), oral commissure tearing (n = 2), and chin dimpling (n = 2). There was no conversion to endoscopic or conventional open thyroid surgery. In this study, TORT could be safely performed in a large series of patients with PTC without serious complications. In selected patients, TORT by experienced surgeons could be considered an alternative approach for remote access thyroidectomy.

Increased risk of postoperative complications after total thyroidectomy with Graves' disease.

The effect of Graves' disease on the risk of postoperative complications in patients undergoing total thyroidectomy is unclear. The incidence of recurrent laryngeal nerve (RLN) injury and hypoparathyroidism were analyzed between 165 patients with Graves' disease (GD group) and 1:1 matched patients with euthyroid states (control group). The matched cohorts did not differ in age, sex, body mass index, pathologic diagnosis, and extent of operation. Excised thyroid weight was higher in the Graves' disease than in the control group (60.1 g vs 22.6 g; P < .001). Multivariate analysis showed that Graves' disease significantly increased risks of transient RLN injury (odds ratio [OR] = 4.7, 95% confidence interval [CI] = 1.5-15.5; P = .010) and transient hypoparathyroidism (OR = 2.8, 95% CI = 1.3-5.8; P = .007). Rates of permanent complications were comparable in the Graves' disease and control groups. Graves' disease can be a predictive factor for postoperative RLN injury and hypoparathyroidism after total thyroidectomy.

Total endoscopic thyroidectomy versus conventional open thyroidectomy in thyroid cancer: a systematic review and meta-analysis.

BackgroundDespite the considerable experience gained thus far using endoscopic technologies, the role of total endoscopic thyroidectomy (ET) for papillary thyroid cancer (PTC) remains controversial. We conducted a systematic review and meta-analysis to investigate the safety and effectiveness of total ET compared with conventional open thyroidectomy (OT) in PTC.MethodsA systematic search was conducted using the PubMed, Embase and Cochrane Library electronic databases up to March 2018. The quality of included studies was evaluated using the Newcastle–Ottawa Scale. Review Manager software version 5.3 was used for the meta-analysis.ResultsTwelve studies including 2,672 patients were ultimately included in the systematic review and meta-analysis. ET was associated with longer operative time (P<0.00001), drainage time (P<0.00001) and hospital stay (P=0.03), higher transient recurrent laryngeal nerve (RLN) palsy rate (P=0.004) and a greater amount of drainage fluid (P<0.0001) compared with OT. Furthermore, no significant differences were detected between ET and OT in terms of retrieved lymph nodes (P=0.17), blood loss (P=0.22), transient hypocalcemia (P=0.84), permanent hypocalcemia (P=0.58), permanent RLN palsy (P=0.14), hematoma or bleeding (P=0.15) and seroma (P=0.54). In addition, the rates of tumor recurrence were comparable (P=0.18), whereas the proportions of stimulated thyroglobulin levels <1 ng/mL measured after completion of thyroidectomy and radioactive iodine therapy were less (P=0.02) in the ET than in the OT group.ConclusionET is not superior to OT in terms of operation and drainage time, amount of drainage fluid, hospital stay or transient RLN palsy, but is comparable to OT in terms of retrieved lymph nodes and permanent complications. Despite the similar tumor recurrence rates between the two approaches, the level of surgical completeness in ET may not be as good as that for OT.

Transoral vestibule approach for thyroid disease: a systematic review.

Transoral endoscopic/robotic thyroidectomy vestibule approach (TOETVA/TORTVA) is a novel technology that has been proposed for the treatment of thyroid disease. Its adoption has increased because of its satisfying cosmetic effects. The primary aim of this systematic review was to assess the feasibility and safety of this approach, and the secondary aim was to discuss the indications for this technology. According to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines, we searched Pubmed, Embase and the Cochrane databases for published studies on the feasibility and safety of TOETVA or TORTVA. 11 articles containing 864 patients met the inclusion criteria after full-text screening, of which two were reports of randomized controlled trial (RCT), two were retrospective cohort studies and the remaining seven studies were case series. Only studies that evaluated the feasibility and safety of this approach were included. TOETVA/TORTVA was successfully performed in 857 out of the 864 cases (99.2%). The mean operative time ranged from 60.4 to 265.4min. In most articles, blood loss was less than 50mL and the mean hospital stay ranged from 1.1 to 8.2 days. The safety outcomes were presented in all articles. The total incidence of adverse events was 14.5%, of which the main complications were transient hypoparathyroidism (5.6%) and transient recurrent laryngeal nerve (RLN) injury (3.1%). This review preliminarily suggests that TOETVA or TORTVA could be an effective and safe treatment for thyroidectomy. Due to the small sample size and low level of evidence, further large-scale, well-designed RCTs are required to validate our findings.

Understanding Malignancies of the Thyroid Gland: Institutional Experience.

To study the epidemiological, pathological characters and determine survival in patients diagnosed of having thyroid gland malignancies. Retrospective chart review of patients having thyroid gland malignancies, which were managed by the two senior authors at our tertiary care institute from January 2000 to December 2006, were performed and evaluated in terms of various clinical, operative and histological parameters. Patients in which follow up of at least 10years are available were included in the study. Survival was enquired telephonically in those patients who got cured and did not consent to come for follow up. Slides were reviewed. Statistical analysis was done using SPSS statistical software. Kaplan-Meier method was used for calculating survival. A total of 182 patients were included in the study. Papillary carcinoma was the commonest malignant lesion with a frequency of 87.91% followed by follicular carcinoma (7.69%), medullary carcinoma (3.29%) and anaplastic carcinoma (1.09%). Female predominance was seen (F:M-5.06:1). The 5year and 10year survival rates were 89% and 73% respectively. The most common postoperative squeal was transient hypocalcaemia, seen in (27/182) 15% patients which was followed by permanent hypocalcaemia 16/182 (8.79%), transient recurrent laryngeal nerve paresis 12/182 (6.59%) and permanent recurrent laryngeal nerve palsy 8/182 (4.39%). Thyroid malignancies affect all age groups and have good long term prognosis. Management yields promising results and hence early and adequate treatment is emphasized.

Disease impacts more than age on operative morbidity in children with Graves’ disease after total thyroidectomy

In pediatric Graves' disease, operative morbidity after total thyroidectomy remains ill defined. The present study aimed to clarify whether total thyroidectomy entails greater operative morbidity in children with Graves' disease, in particular when they are very young, as compared with an age-matched reference group of children with hereditary C-cell disease who underwent total thyroidectomy at the same time. Operative morbidity after total thyroidectomy for Graves' disease was determined in relation to the child's age and in comparison with a reference group of age-matched children with hereditary C-cell disease. Included in the study were 58 children with Graves' disease (51 girls and 7 boys) and 108 children with hereditary C-cell disease (59 girls and 49 boys). When children with Graves' disease and children with hereditary C-cell disease were compared across and within the 4 age increments (≤ 3, 4-6, 7-12, and 13-18 years), operative mortality did not differ significantly among and within age increments. Children with Graves' disease had a 1.7-fold greater overall risk of transient hypoparathyroidism (29% versus 17%; P = .073) than children with hereditary C-cell disease. Permanent hypoparathyroidism was nil in either group. Transient recurrent laryngeal nerve palsy, wound hemorrhage, and wound infections were infrequent (≤ 3% each), resolving spontaneously and after reoperation, respectively. Disease impacts more than age on operative morbidity in children with Graves' disease after total thyroidectomy but is fairly low overall and rarely permanent in experienced hands.

Protective Effects of Intraoperative Nerve Monitoring (IONM) for Recurrent Laryngeal Nerve Injury in Thyroidectomy: Meta-analysis

Recurrent laryngeal nerve (RLN) injury is an intractable complication of thyroidectomy. Intraoperative nerve monitoring (IONM) was designed to prevent RLN injury. However, the results concerning the protective effect of IONM on RLN injury are still controversial. We searched all eligible databases from 1980 to 2017. Meta-analysis was performed to evaluate the effect of IONM on RLN injury. Sensitivity analysis was also conducted to check the stability of our results. There were 34 studies included in the analysis. Overall analysis found a significant decrease in total injury (RR = 0.68, 95%CI: 0.55 to 0.83), transient injury (RR = 0.71, 95%CI: 0.57 to 0.88), and permanent injury (RD = −0.0026, 95%CI: −0.0039 to −0.0012) with IONM. Subgroup analysis found IONM played a preventive role of total, transient and permanent injury in patients undergoing bilateral thyroidectomy. IONM also reduced the incidence of total and transient injury for malignancy cases. Operations with IONM were associated with fewer total and transient RLN injuries in operation volume < 300 NARs per year and fewer total and permanent RLN injuries in operation volume ≥ 300 NARs per year. The application of IONM could reduce the RLN injury of thyroidectomy. Particularly, we recommend routine IONM for use in bilateral operations and malignancy operations.

Endoscopic Thyroid Surgeries via Areola Approach: Experience and Outcomes of 500 Cases in a Single Institute

With the growing popularity of endoscopic thyroid surgery for treatment of thyroid diseases, this study aimed to summarize our experience of endoscopic thyroidectomy (ETE), and evaluate the feasibility and safety of ETE, in our institute. Five hundred patients underwent ETE via the areola approach. The learning curve, clinicopathologic characteristics, cosmetic satisfaction, complications, and so on were analyzed. Among the 500 cases, 497 were successfully managed with ETE, and 3 were converted to open procedure. The score of cosmetic satisfaction, average operation time, tumor diameter, mean total intra-operative blood loss, hospital stay, drainage time, and age were 9.4 ± 0.5, 142 ± 20 min, 2.6 ± 1.2 cm, 34 ± 12 ml, 11.4 ± 3.6 days, 3.3 ± 0.7 days, and 44.2 ± 11.9 years, respectively. Pathological types of the tumor included papillary thyroid carcinoma (PTC; n = 87), nodular goiters (n = 283), follicular adenoma (n = 84), and others (n = 46). The complications included transient recurrent laryngeal nerve (RLN) palsy (n = 15, 3.0%), transient superior laryngeal nerve (SLN) palsy (n = 3, 0.6%), transient hypoparathyroidism (n = 32, 6.4%), tracheal injury (n = 1, 0.2%), swallowing discomfort (n = 20, 4.0%), infection (n = 7, 1.4%), and others (n = 15, 3.0%). No patients experienced permanent RLN injury or SLN injury, asphyxia/dyspnea, esophagus injury, bleeding, chylous fistula, or death. Among the cases of PTC, 76 (87.4%) cases underwent the central lymph node dissection. The mean number of retrieved lymph nodes was 6.4 ± 2.1, while the mean number of metastatic central lymph nodes was 1.2 ± 2.3. The ratios of capsule invasion, central lymph node metastasis, and extrathyroidal extension were 10.3, 26.4, and 3.4%. ETE via areola approach is safe, feasible, and cosmetic, with good operative results and low complication rates. It provides an effective choice for treating patients.

Prophylactic Central Neck Dissection for Papillary Thyroid Carcinoma with Clinically Uninvolved Central Neck Lymph Nodes: A Systematic Review and Meta-analysis.

Central neck dissection and total thyroidectomy are standard treatments for patients with papillary thyroid carcinoma (PTC) with clinically involved central nodes. However, prophylactic central neck dissection (pCND) in patients with clinically uninvolved cN0 has been beneficial in some studies but ineffective in others. We conducted a meta-analysis to evaluate the efficacy and safety of pCND in patients with central neck lymph nodes cN0 PTC. The PubMed, EMBASE, Cochrane Library, and Scopus databases and the ClinicalTrials.gov registry were electronically searched for studies published until September 2017. The meta-analysis was conducted to calculate the pooled effect size by using random-effects model. Treatment efficacies were measured by determining locoregional recurrence (LRR). Secondary outcomes included transient recurrent laryngeal nerve (RLN) injury, permanent RLN injury, transient hypocalcemia, and permanent hypocalcemia. Twenty-three retrospective and prospective cohort studies involving 18,376 patients were reviewed. Patients who underwent pCND had significantly lower LRR (odds ratio [OR] 0.65; 95% confidence interval [CI] 0.48-0.88) but significantly higher incidence rates of transient RLN injury (OR 2.03; 95% CI 1.32-3.13), transient hypocalcemia (OR 2.23; 95% CI 1.84-2.70), and permanent hypocalcemia (OR 2.22; 95% CI 1.58-3.13) than that of no pCND group. Compared with no pCND, pCND significantly reduces LRR but is accompanied by numerous adverse effects. The clinical decision should be made after the shared decision-making process of clinicians and patients.

Comparative study between Focus harmonic scalpel and conventional hemostasis in open total thyroidectomy

Objective The aim was to compare between Focus harmonic scalpel and conventional hemostasis in open total thyroidectomy regarding operative time, postoperative complications (hypocalcemia and recurrent laryngeal nerve injury), postoperative blood drainage volume, postoperative pain, and hospital stays. Background Thyroidectomy is one of the most common operations, and many studies have been done to improve the technique of thyroidectomy. Therefore, the author conducted this study to determine if Focus harmonic scalpel is effective in thyroidectomy or not. Materials and methods This study is a prospective, comparative, randomized, and descriptive study of 40 patients having nontoxic multinodular goiter. The patients were divided into two groups: group A was subjected to open total thyroidectomy with Focus harmonic scalpel (20 patients), and group B was subjected to open total thyroidectomy with conventional hemostasis (20 patients). Both groups were compared for age, sex, operative time, postoperative complications (hypocalcemia and recurrent laryngeal nerve injury), postoperative blood drainage volume, postoperative pain, and hospital stays. Results Use of Focus harmonic scalpel in open total thyroidectomy leads to shorter operative time, asP value was highly significant; decrease of postoperative blood drainage volume, asP value was significant; decrease of postoperative pain, asP value was highly significant; and shorter postoperative hospital stays, asP value was significant; however, it does not decrease the rate of postoperative complications (hypocalcemia and the Recurrent laryngeal nerve (RLN) injury), asP value was nonsignificant. Conclusion In open total thyroidectomy, the Focus harmonic scalpel is a reliable and safe tool. Its use is more effective than conventional hemostasis. The surgical operative time and the hospital stay are shorter. The postoperative blood drainage volume is reduced; furthermore, the postoperative pain is less. However, the rates of transient hypocalcemia and recurrent laryngeal nerve injury are statistically nonsignificant.

The Impact of Thyroiditis on Morbidity and Safety in Patients Undergoing Total Thyroidectomy.

Background:The indications for surgery in thyroiditis vary from compressive symptoms to cosmesis. We analyzed the complications in patients who underwent total thyroidectomy (TT) in goiters associated with thyroiditis.Materials and Methods:This retrospective study was done in an endocrine surgical center over 4 years. A total of 724 patients, who underwent TT for benign thyroid disorders, were included in the study. Patients were divided into two groups based on histopathology into Group A (nonthyroiditis cases) and Group B (thyroiditis cases); Group B is subdivided into Group B1 (nodular goiter with associated thyroiditis) and Group B2 (Hashimoto's thyroiditis). The preoperative parameters analyzed were serum calcium, serum Vitamin D, serum parathyroid hormone (PTH), and vocal cord status. The intraoperative parameters observed were operating time, parathyroid preservation, and autotransplantation and course of recurrent laryngeal nerve (RLN). Postoperative parameters monitored were serum calcium, serum PTH, serum magnesium, signs and symptoms of hypocalcemia, and vocal cord status. Follow-up was done at 6 months with serum calcium, serum PTH, and video laryngoscopy.Results:Both groups were age and sex matched. All preoperative and intraoperative parameters were comparable among groups. Both transient complications (<6 months) were higher in Group B than A. Transient hypocalcemia was higher in Group B (39.70%) than Group A (24.77%) (P = 0.001). Transient hypocalcemia was higher in Group B1 (36.58%) than Group B2 (44.44%) (P = 0.014). Transient RLN palsy was higher in Group B (9.55%) than Group A (7.52%) (P = 0.040). Transient RLN palsy was higher in Group B1 (8.53%) than Group B2 (11.11%) (P = 0.039). Permanent hypoparathyroidism and permanent RLN palsy were comparable between the Groups A and B and between Groups B1 and B2.Conclusion:The incidences of transient complications are higher in patients with thyroiditis. Careful analysis of surgical indications will avoid unnecessary surgery in thyroiditis cases.

Are total thyroidectomy and loboisthmectomy effective and safe in benign thyroid diseases? An analysis of 420 patients

Objective. Ideal thyroid surgery is still a debated issue due to preoperative pathology and varying rates of postoperative incidental carcinoma and complications. In our clinic loboisthmectomy and bilateral total thyroidectomy are the treatment of choice in benign nodular thyroid diseases. The objective of this study was to analyse effectiveness and safety of bilateral total thyroidectomy and loboisthmectomy for treating benign thyroid diseases. Methods. Patient charts of the subjects that have undergone thyroid surgery due to benign thyroid diseases between 2009-2015 were evaluated retrospectively. We extracted data including number of patients, type of surgery, preoperative and postoperative pathologies and postoperative complications from departments medical records. Results. Four hundred and twenty patients including 98 (23.3%) male and 322 (76.7%) females aged between 14-80 years (mean; 47.3 ± 12.5) were included into the study. Bilateral total thyroidectomy was performed in 348 (82.9%) patients and loboisthmectomy was performed in 72 (17.1%). Mean duration of follow-up was 41 (range: 15-70) months. Incidental thyroid carcinoma rate was 24.5% (n = 103) in postoperative pathological examination. Temporary and permanent hypocalcemia was seen in 53 (15.2%) patients and 8 (2.3%), respectively. Permanent and transient recurrent laryngeal nerve palsy rate were 2.6% and 2.1%, respectively. Postoperative hematoma was observed in 7 (1.7%) patients. Conclusions. Incidental thyroid carcinoma is frequent in patients who had surgical operation for benign thyroid diseases. When revision surgeries and additional complications due to revision surgery in the remaining cases are kept in mind, bilateral total thyroidectomy or loboisthmectomy at the minimum can be considered as the ideal surgical approach for benign thyroid diseases.

A Meta-analysis of comparing effectiveness and safety between minimally invasive video-assisted thyroidectomy and conventional thyroidectomy in the treatment of papillary thyroid carcinoma without lymph node metastasis

Objective:To compare the effectiveness and safety between minimally invasive video-assisted thyroidectomy (MIVAT) and conventional thyroidectomy (CT) in the treatment of papillary thyroid carcinoma without lymph node metastasis, providing clinicians using video-assisted way to treat thyroid papillary carcinoma with a more reasonable basis.Method:According to the including and excluding criterion,we searched the published articles which compare the effectiveness of MIVAT and CT curing PTC in randomized controlled clinical trials. The searching time was from January 2011 to December 2016, and the data was analyzed by using revman 5.3 software.Result:Twelve articles involving 1 080 cases were included,and there were 514 cases in the MIVAT group and 566 cases in the CT group. The results of metaanalysis showed that: the operation time of MIVAT group is longer than that of CT group (MD=17.19, 95%CI12.43-21.96, P<0.05); however the VAS point of MIVAT group is less than that of CT group in twentyfour hours after surgery (MD-1.07, 95%CI-1.61--0.53, P<0.05). There is no significant difference in the incidences of transient recurrent laryngeal nerve injury(OR=2.21,95%CI0.9-5.07,P>0.05),transient hypoparathyroidism (OR=0.78, 95%CI0.48-1.28, P>0.05), serum thyroglobulin after five years followed up (MD-0.05, 95%CI -0.25-0.16, P>0.05), number of retrieved central lymph nodes (MD=-0.36, 95%CI -0.72-0.01, P>0.05) and number of retrieved central positive lymph nodes (MD=-0.15, 95%CI -0.45-0.16, P>0.05).Conclusion:Using MIVAT treating papillary thyroid carcinoma (without lymph node metastasis) is safe when its indications are strictly controlled.

Safety and Outcomes of the Transoral Endoscopic Thyroidectomy Vestibular Approach

Natural orifice transluminal endoscopic surgery thyroidectomy is a novel approach to avoid surgical scars. To compare the safety and outcomes of the transoral endoscopic thyroidectomy vestibular approach (TOETVA) with those of open thyroidectomy (OT). This study retrospectively reviewed all TOETVA and OT operations performed from April 1, 2014, through August 31, 2016, at Police General Hospital, Bangkok, Thailand. All patients who underwent TOETVA and patients who underwent OT were included. Exclusion criteria were (1) previous neck surgery, (2) substernal goiter, (3) lymph node or distance metastasis, and (4) suspicious invasion to the adjacent organs. Propensity score matching was conducted to reduce selective bias. Operative time, blood loss, and complications related to thyroid surgery. Of the 425 patients who underwent transoral endoscopic thyroidectomy (mean age, 35.3 [12.1] years; age range, 16-81 years; 389 [92.2%] female), 422 successfully were treated with the TOETVA; 3 patients were converted to a conventional operation because of bleeding. Twenty-five patients (5.9%) had transient recurrent laryngeal nerve palsy, and 46 (10.9%) had transient hypoparathyroidism. None had permanent recurrent laryngeal nerve palsy or permanent hypoparathyroidism. Three patients (0.7%) had transient mental nerve injury; all cases resolved by 4 months. One patient developed postoperative hematoma treated by OT. Twenty patients (4.7%) had seroma treated by simple aspiration. Operative time was longer for the TOETVA compared with the OT group (100.8 [39.7] vs 79.4 [32.1] minutes, P = 1.61 × 10-10). The mean (SD) visual analog scale score for pain was lower in the TOETVA group (1.1 [1.2] vs 2.8 [1.2], P = 2.52 × 10-38). Estimated mean (SD) blood loss (36.9 [32.4] vs 37.6 [23.1] mL, P = .43) and rate of complications (45 of 216 [20.8%] vs 38 of 216 [17.6%], P = .41) were not significantly different in the TOETVA vs OT group. The TOETVA was performed as safely as OT, requires only conventional laparoscopic instruments, and avoids incisional scars; thus, the approach may be an option for select patients.

Safety of same-day thyroidectomy: meta-analysis and systematic review.

Performance of thyroid surgery as a same day surgery procedure has been a controversial topic. This study aimed to compare the safety and efficacy of outpatient thyroid surgery with inpatient thyroid surgery by meta-analysis of current literature. Articles were identified from the following keyword searches: outpatient thyroidectomy/thyroid surgery, same day thyroidectomy/thyroid surgery. Outcomes included perioperative complications including recurrent laryngeal nerve (RLN) injury, hypocalcemia, and readmissions. Data were extracted following review of appropriate studies by authors and random effects models were used. 34 potentially relevant publications were identified and 14 studies fulfilled the predetermined inclusion criteria, totaling 10,478 patients, 4,565 of whom were discharged the same day following thyroid surgery. There was no difference in malignancy rate between the two groups (95% CI, 0.84-2.31; P=0.196). Inpatient group were 2.23 times (95% CI, 1.36-3.36; P=0.001) more likely to develop transient RLN injury and 2.32 times (95% CI, 1.06-5.06; P=0.034) more likely to have documented transient hypocalcemia compared to outpatients. Inpatient groups were 2.10 times (95% CI, 1.33-3.33; P=0.002) more likely to have documented other complications. The two groups also had similar readmission rates (95% CI, 0.71-1.41; P=1.000). Our meta-analysis suggests that discharging selective patients the same day after a thyroid surgery is as safe, feasible, and efficacious as admitting them for observation. Admitting patients after thyroid surgery is associated with higher reported risk of complications.

Intraoperative nerve monitoring reduces recurrent laryngeal nerve injury in geriatric patients undergoing thyroid surgery

Objective: This research was aimed to investigate whether the intraoperative nerve monitoring (IONM) can reduce the incidence of recurrent laryngeal nerve (RLN) injury in geriatric patients undergoing thyroid surgery.Methods: This retrospective cohort study included 522 geriatric patients undergoing thyroid surgery between January 2013 and June 2016 in the Sun Yat-sen Memorial Hospital. Patients with IONM during the surgery (n = 340) were compared with patients without IONM (n = 212). RLN injury was verified by direct or indirect laryngoscope and relative factors for injury would be retrospectively analyzed.Results: The use of IONM group showed significant reduction in both total and transient RLN injury incidence, when compared with that in control group (1.76 versus 4.72%, p = .01 and 1.32 versus 3.67%, p = .03, respectively). However, the permanent RLN injury incidence did not show difference between the two groups (p = .3).Conclusions: Our finding showed the use of IONM resulted in significantly reduction in RLN injury incidence. The technology of IONM is safe and convenient to detect, track and monitor the complete function of RLN and to provide the guidance for the surgeons during the thyroid surgery in geriatric patients, who are at high risk of RLN injury.

Intra-capsular total thyroid enucleation versus total thyroidectomy in treatment of benign multinodular goiter. A prospective randomized controlled clinical trial

BackgroundDue to high recurrence rate after subtotal thyroidectomy, most of centers have shifted to total thyroidectomy as a surgical treatment for benign multinodular goiter (BMNG), but serious complications, as laryngeal nerve affection & hypocalcaemia, are still present. This study aimed to evaluate treatment of BMNG using intra-capsular total thyroid enucleation in comparison to standard total thyroidectomy. Patients &methodsThis is a prospective randomized controlled clinical trial conducted in a hospital in the period from December 2009 to December 2015. Of total 224 patients with clinically BMNG. 112 patients operated by intracapsular total thyroid enucleation (ITTE group) and the other 112 patients operated by standard total thyroidectomy (STT group). The minimal follow up period was 36 months. ResultsThe mean operative time in ITTE group was (93.7 ± 9.6 min) compared to (86.9 ± 8.3 min) in STT group. Transient recurrent laryngeal nerve (RLN) palsy was 0% in ITTE group VS 7.1% in STT group. No cases (0%) developed permanent RLN palsy in ITTE group VS 0.9% in STT group. Symptomatic transient hypocalcaemia occurred in 1.8% in ITTE group VS 11.6% in STT group. No cases (0%) developed permanent hypocalcaemia in ITTE group VS 0.9% in STT group. No recurrence (0%) in both groups after minimal 3 years of follow up. ConclusionIntracapsular Total thyroid enucleation technique is safe with the least serious complications, especially RLN injury and hypoparathyroidism, with no recurrence, but this technique still not radical so couldn't be used in suspicious cases for malignancy.