РЕТРОСПЕКТИВНЫЙ АНАЛИЗ ЧАСТОТЫ И ТИПОВ ОСЛОЖНЕНИЙ ПОСЛЕ ОПЕРАЦИЙ НА ЩИТОВИДНОЙ ЖЕЛЕЗЕ: КЛИНИЧЕСКИЙ АСПЕКТ

Avaliação da cirurgia da tiroide num serviço hospitalar: resultados a 10 anos

Thyroid surgery in children is arare operation. The aim of our paper is to point out the specifics of thyroid surgery in children. Retrospective analysis of patients hospitalized at the Department of Paediatric Surgery, Faculty of Medicine, Comenius University and National Institute of ChildrensDiseases in Bratislava during a10-year period (20072016) who underwent thyroid surgeries. The retrospective analysis included 81 patients: 66 (81%) girls and 15 (19%) boys. The mean age of the patients was 14 years ±8 months (range 418 years). The most common indications for thyroid surgery were: anodule in 36 (44.4%) patients, Graves Basedow thyrotoxicosis in 19 (23.5%) patients, and suspected thyroid carcinoma in 11 (13.6%) patients. Cervical lymph node metastases (mts) were diagnosed in 9 (11.1%) patients, and distant pulmonary metastases in 5 (6.17%) patients. Total thyroidectomy (TTE) was performed in 43 (53%) patients, total lobectomy (TL) in 20 (24.7%) patients. Extended surgery on regional lymph nodes was performed in 9 (11.1%) patients. Eight (9.9%) patients underwent reoperation. Atotal of 12 (14.8%) patients experienced postoperative complications. Unilateral transient recurrent laryngeal nerve (RLN) paralysis occurred in 2 patients, and permanent in one patient. Transient postoperative hypoparathyroidism with hypocalcaemia was reported in 8 (9.9%) patients; no permanent condition of this type was observed. Multidisciplinary collaboration ensures that optimal surgical results are achieved in the patients. Experience of the surgeon performing thyroid surgery in children remains crucial.

Recent trends in thyroid surgery in Wales

Pediatric thyroidectomy in a high volume thyroid surgery center: Risk factors for postoperative hypocalcemia

To identify any risk factors for incidental parathyroidectomy and to define its association with symptomatic postoperative hypocalcemia. Retrospective study. Tertiary referral cancer center. Consecutive patients who underwent thyroid surgery between 1991 and 1999. Patients who underwent procedures for locally advanced thyroid cancer requiring laryngectomy, tracheal resection, or esophagectomy were excluded. All pathology reports were reviewed for the presence of any parathyroid tissue in the resected specimen. Slides were reviewed, and information regarding patient demographics, diagnosis, operative details, and postoperative complications was collected. Identification of parathyroid tissue in resected specimens and postoperative symptomatic hypocalcemia. A total of 141 thyroid procedures were performed: 69 total thyroidectomies (49%) and 72 total thyroid lobectomies (51%). The findings were benign in 68 cases (48%) and malignant in 73 cases (52%). In the entire series, incidental parathyroidectomy was found in 21 cases (15%). Parathyroid tissue was found in intrathyroidal (50%), extracapsular (31%), and central node compartment (19%) sites. The performance of a concomitant modified radical neck dissection was associated with an increased risk of unplanned parathyroidectomy (P =.05). There was no association of incidental parathyroidectomy with postoperative hypocalcemia (P =.99). Multivariate analysis identified total thyroidectomy as a risk factor for postoperative hypocalcemia (P =.008). In the entire study group, transient symptomatic hypocalcemia occurred in 9 patients (6%), and permanent hypocalcemia occurred in 1 patient who underwent a total thyroidectomy and concomitant neck dissection. Unintended parathyroidectomy, although not uncommon, is not associated with symptomatic postoperative hypocalcemia. Modified radical neck dissection may increase the risk of incidental parathyroidectomy. Most of the glands removed were intrathyroidal, so changes in surgical technique are unlikely to markedly reduce this risk.

PurposeIntraoperative neuromonitoring (IONM) can serve as a tool to increase skills in recurrent laryngeal nerve (RLN) identification and complete removal of thyroid tissue. The aim of this study was to validate this hypothesis.MethodsThis prospective study involved 632 patients (1161 RLNs at risk) who underwent thyroid surgery in 2011–2014. Although IONM was not used until 2012, this prospective study started on 1 January 2011. The three participating surgeons knew about the study before that date and that the rate of RLN identification would be carefully measured in total and near-total surgery. Solely, visual identification of the RLN was used throughout 2011. IONM was introduced as a training tool in 2012–2014 for the first 3 months of each year. In the remaining months, thyroid operations were performed without IONM. Outcomes of non-monitored thyroid operations were compared before (01-12/2011) vs. after (04-12/2012–2014) 3 months of exposure to IONM yearly (01-03/2012–2014). The rate of RLN identification was assessed in total and near-total thyroidectomies and in totally resected lobes in Dunhill’s operation. The prevalence of RLN injury and the utilization of total thyroidectomy were evaluated.ResultsIn 2011, the rate of successful RLN visual identification in total and near-total thyroidectomies and in totally resected lobes in Dunhill’s operation was 45.71 %. After the introduction of IONM in 2012–2014, in the procedures performed without IONM, the rate was 86.66, 90.81, and 91.3 %. The prevalence of RLN injury in 2011 was 6.8 %, while in the years following the introduction of IONM, it was 3.61, 2.65, and 1.45 %. Utilization of total thyroidectomy increased from 47.9 % in 2011 to 100 % in 2014.ConclusionsExperience with IONM led to an increase in RLN identification (p < 0.0001), a decrease of RLN injury (p < 0.05), and an increase in the safe utilization of total thyroidectomy (p < 0.0001) in non-monitored thyroid operations. IONM is a valuable tool for surgical training.

The aim of this study was to investigate the incidence, risk factors, and clinical relevance of incidental parathyroidectomy during thyroid surgery. Prospective analysis of data in patients following thyroidectomy, specifically regarding the presence of parathyroid parenchyma in the thyroidectomy specimens, the underlying thyroid pathology, and the presence of postoperative hypocalcemia (biochemical/clinical). The clinical records of 158 patients who underwent thyroid surgery during a 2-year period were reviewed. Pathology reports were carefully reviewed for the nature of the underlying thyroid disease, the presence, number, and size of incidentally resected parathyroid gland(s), their location, and possible parathyroid pathology. Serum calcium levels were measured preoperatively, on the day of surgery, and on postoperative days 1, 2, and 7 or even later as needed. Two groups of patients were studied: a group with incidental parathyroidectomy following thyroidectomy (group A) and a group without incidental parathyroidectomy after thyroidectomy (group B). Total/near-total thyroidectomy was the procedure of choice and was performed in 154 patients; total lobectomy and contralateral subtotal lobectomy was performed in the other 4 patients. Elective central neck lymph node dissection was performed in four patients with neck lymphadenopathy. Inadvertently removed parathyroid tissue was found in 28 cases (17.7 %); in 6 of these patients (21%) the parathyroid tissue was intrathyroidal. The percentage of women in group A was significantly higher than in group B (93% vs. 58.5%, P = 0.0002). There was no statistically significant difference between the two groups (A and B) regarding the preoperative (presumed) diagnosis, the histologic diagnosis of thyroid disease (benign versus malignant), the type/extent of surgery, or the presence of thyroiditis. Biochemical and clinical hypocalcemia was observed in 6 (21%) and 2 (7%) patients in group A, respectively, and in 30 (23%) and 8 (6%) patients of group B, respectively. There was no statistically significant difference regarding the occurrence of postoperative hypocalcemia (clinical/biochemical) between the two groups (P = 0.33). Incidental parathyroidectomy is not uncommon following thyroidectomy and in a significant percentage of cases it may be due to the intrathyroidal location of the parathyroid glands. Incidental parathyroidectomy was not found to be associated with postoperative hypocalcemia (biochemical/clinical). Incidental parathyroidectomy may be considered as a potentially preventable but clinically minor complication of thyroid surgery.

Background: Thyroid surgery is the mainstay of the treatment of surgical goiters. Treatment modalities for the surgical management of goiter include lobectomy, sub-total thyroidectomy, near-total thyroidectomy and total thyroidec-tomy.Aim of Study: To compare current surgical management of thyroid diseases in Assuit University Hospital with man-agement guidelines, planning for improving our management of thyroid diseases and correct obstacles to achieve reduction in the morbidity and mortality result from thyroid diseases.Patients and Methods: Our study included 60 patients who were admitted to General Surgery Department with any thyroid disease during a period of six months and managed surgically. All patients had neck ultrasound and FNAC was done for suspicious cases for malignancy. Benign solitary nodular goiter was managed by unilateral lobectomy and isthmusectomy. MNG was managed by total and sub-total throidectomy. Malignant goiter was managed according to cytology with total thyroidectomy being done for most cases. Controlled toxic goiter was managed by total or sub-total thyroidectomy. All cases were subjected to pre-and post-operative layrngoscopic examination for assessement of vocal cord mobility. Post-operative histopathology is amust in all cases.Results: Mean age of the studied patients was 39.18±11.75 years with range between 15 and 63 years. Out of 60 patients, 49 (81.7%) patients were females and 11 (18.3%) patients were males. 17 (28.3%) of the studied had toxic manifestations and 15 (25%) patients were on anti-thyroid medications. Iodine deficiency was noticed in 9 (15%) patients while 7 (11.7%) patients had endemic goiter. Out of the studied patients, 5 (8.3%) patients had family history of thyroid disease.Unilobar enlargement presented in 12 (20%) patients while 48 (80%) patients had Bilobar thyroid enlargement. Diffuse goiter presented in 4 (6.7%) patients and nodular goiter in 56 (93.3%) patients, 13 (21.7%) solit all patients were subjected to thyroid function tests (TSH, free T3 and T4) before and after thyroidectomy. It was noticed that there were significant improvement in level of TSH, free T3 and free T4 after thyroidectomy (p<0.05).FNAC was done in 41 (68.3%) patients. Total thyroidec-tomy was performed in 43 (71.7%) patients while 10 (16.7%) and 7 (11.7%) patients had subtotal thyroidectomy and uni-lateral lobectomy with isthmusectomy respectively. The most frequent complications post-operatively were hoarseness of the voice and choking occurred in 18 (30%) and 16 (26.7%) patients respectively. Injury of RLN occurred in 5 (8.3%) patients.All of those patients received replacement therapy and none of them received chemotherapy or iodine therapy.Post-operative complications were frequent in those patients had total thyroidectomy where hoarseness of the voice, chocking and injury of recurrent laryngeal nerve oc-curred in 13 (30.2%), 12 (27.9%) and 5 (11.6%) patients respectively.In case of subtotal thyroidectomy 4 (40%) patients had choking and 4 (40%) patients had hoarseness of the voice. Only one patient from those had unilateral thyroidectomy had post-operative complication in form of hoarseness of the voice.Duration of surgeon experience was less than 5 years in majority of cases (56.7%) while in 16 (26.7%) and 10 (16.7%) patients duration of surgeon experience was 5-10 and more than 10 years respectively. With experience less than 5 years, post-operative complications were; 3 patients had R.L.N. injury, 12 patients had hoarseness of voice, and 10 patients had chocking. With surgical experience between 5 to 10 years, complications were; 2 patients had R.L.N. injury, 4 patients had hoarseness of voice, and 5 patients had chocking. While with experience more than 10 years, the complications were so minimal with only 2 patients had transient hoarseness of voice and chocking.In case of controlled toxic goiter; 15 (75%), 3 (15%) and 2 (10%) patients had total, subtotal and unilateral thyroidec-tomy respectively. In case of simple goiter; 7 (58.3%) patients had total thyroidectomy, 4 (8.3%) patients had unilateral thyroidectomy and 1 (8.3%) patient had subtotal thyroidectomy.21 (75%) patients from those with multinodular goiter had total thyroidectomy, 6 (21.4%) had subtotal thyroidectomy and 1 (3.6%) patient had unilateral thyroidectomy.Conclusion: In our study, no major difference was noticed between our surigal management strategy of thyroid diseases and international guidelines. Pre-operative assessement was focused with neck U/S and FNAC being the most important investigations. Choice of the type of operation was based on the type of thyroid disease and the risk of post-operative complications was considered.post-operative complications in the form of RLN injury, hypothyroidism and hypo-parathyroidism were markedly decreased.

Effect of intravenous versus intratracheal lidocaine on airway and hemodynamic responses during extubation after thyroid surgery. A prospective cohort study

Fine-needle aspiration biopsy is the most accurate diagnostic test for thyroid nodules, its only limitation being the diagnosis of follicular neoplasm that does not distinguish between benign and malignant follicular lesions. To determine the utility of intraoperative frozen-section analysis in cases of a cytological diagnosis of follicular neoplasm, a retrospective review of 66 patients with a solitary thyroid nodule and follicular neoplasm who underwent thyroid surgery was carried out. Fine-needle aspiration was classified following the Papanicolaou Society of Cytopathology Classification, and frozen section was defined as malignant or "deferred." If a malignant diagnosis was made by frozen-section analysis, a total thyroidectomy was carried out. The extension of thyroid surgery in the deferred cases was based on the definitive histological diagnosis. Sixty-four cases were classified as deferred, and two as suspect for malignancy. Among the 64 deferred cases, 15 were malignant in the final pathological findings, and 49 were benign. The two suspect cases were papillary carcinoma. Frozen-section analysis classified 2 of 17 (11.7%) cases as follicular variant of papillary carcinoma that could not be diagnosed by cytological study. However, these two cases had a strong clinical evidence of malignancy. The routine use of frozen-section analysis is useless in cases of cytological diagnosis of follicular neoplasm on fine-needle aspiration biopsy, because of the low probability of achieving the diagnosis of follicular carcinoma and the inability to provide additional information apart from the clinical and the cytological data.

To evaluate the incidence and predictive risk factors of complications in patients who underwent thyroid surgery at our hospital with a residency training program. This retrospective cohort study analyzed the complications in all patients who underwent thyroid surgery between January 2008 and December 2017. Demographic data, preoperative diagnosis based on fine needle aspiration cytology, surgical approach, permanent pathology, postoperative complications, and factors associated with complications were recorded. At our hospital, 456 patients underwent thyroidectomy. The most common surgical complications were asymptomatic biochemical hypocalcemia and symptomatic hypocalcemia in 109 (23.9%) and 50 (11%) patients, respectively. Other surgical complications included permanent hypocalcemia, transient vocal cord palsy, permanent vocal cord palsy, hematoma, seroma, chyle fistula, and Horner's syndrome. Mean age > 45years and more extensive surgery were significantly associated with overall complications (P = 0.003; < 0.001). Mean age > 50years and vitamin D level < 25nmol/L (< 10ng/mL) were significantly associated with hypocalcemia (P = 0.008; < 0.001). Moreover, the extent of surgery and advanced thyroid carcinoma were significantly associated with vocal cord palsy (P < 0.001; 0.05). Hypocalcemia and vocal cord palsy are the most significant complications. Thyroid surgery can be performed safely by senior residents in the residency training program under the direct supervision of an experienced surgeon.

The technique of thyroidectomy has undergone little change in several decades. The harmonic scalpel, using ultrasonic frictional heating to ligate vessels, is widely used in laparoscopic surgery, but there is little experience in open thyroidectomy. We hypothesized that the use of the harmonic scalpel could lead to a significant reduction in operative time as compared with knot tying in thyroid surgery. Retrospective case-controlled study. Teaching institution. One hundred seventy-one consecutive patients undergoing lobectomy or total thyroidectomy by one surgeon (A.E.S.). Eighty-six patients underwent thyroid surgery with the conventional clamp-and-tie technique (lobectomy, n = 49; total thyroidectomy, n = 36) and 85 with the harmonic scalpel (lobectomy, n = 38; total thyroidectomy, n = 47). Demographics, pathological characteristics, thyroid size, operative time, blood loss, and complications using a 2-tailed t test, chi(2)test, and Wilcoxon rank sum test. The 2 groups were similar regarding age and sex. There were no intraoperative complications. Mean +/- SD thyroid size tended to be larger in the harmonic scalpel group for both lobectomy (5.1 +/- 2.6 cm vs 4.2 +/- 2.2 cm; P =.06) and total thyroidectomy specimens (6.3 +/- 3.8 cm vs 4.8 +/- 2.9 cm; P =.08) compared with the conventional technique. Mean +/- SD operative time was shorter in the harmonic scalpel group compared with the conventional technique group for both lobectomy (89 +/- 20 minutes vs 115 +/- 25 minutes; P<.01) and total thyroidectomy (132 +/- 39 minutes vs 161 +/- 42 minutes; P<.01) procedures. There was no difference between the 2 techniques regarding the amount of blood loss for different procedures. There was no effect of tumor size on operative time (Pearson correlation factors: 0.14 for total, 0.21 for unilateral thyroidectomy). The use of the harmonic scalpel for the control of thyroid vessels during thyroid surgery is safe, and it shortens the operative time by almost 30 minutes compared with the conventional technique for both unilateral lobectomy or total thyroidectomy procedures.

Determination of risk factors causing hypocalcaemia after thyroid surgery

Thyroidectomy Complications in Patients with Diabetes Mellitus.

Background: Thyroidectomy is one of the most common operations performed worldwide by various surgeons whether general or endocrine surgeons. The rate of complications following thyroidectomy has been progressively decreasing yet it still carries significant morbidity if preoperative preparation and patient as well as procedure selection were not optimized. Objective: This study was designed to evaluate the problem of hypoparathyroidism following thyroid surgery and to assess the use of parathyroid hormone (PTH) level to predict patients with risk of postoperative hypocalcemia. Through this study, it was sought that we could reach a recommendation to rely on the routine technique of total thyroidectomy and utilization of PTH assay to allow for a safe and timely discharge of patients with normocalcemia and for the early identification of patients requiring treatment of post thyroidectomy hypocalcemia. Patients and Methods: This prospective study included 50 patients from two different hospitals undergoing total thyroidectomy to evaluate the efficacy of postoperative serum PTH and calcium (Ca) levels as an early and accurate predictor of post-thyroidectomy hypocalcemia. Ionized serum calcium as well as PTH were measured for each patient preoperatively, intraoperatively (just after skin closure), at every day postoperative when patient admitted and after one month in patients with hypocalcemia. Results: Our results showed an overall incidence of 18% of hypocalcemia after total thyroidectomy. Of them, only 6% developed symptomatic hypocalcemia. Transient hypocalcemia occurred in 4% of patients while permanent hypocalcemia affected 2%. Conclusion: Serum calcium concentrations have been the basis of identification of post-operative hypocalcemia, however this has been replaced by PTH levels being more sensitive and specific to the early prediction of transient as well as permanent hypocalcemia. Postoperative PTH; also known as quick PTH assay, level of < 12 pg/ml was found to have an overall accuracy of 98% in early prediction of permanent hypocalcemia in our study.