Carbon nanoparticles beneficial for prophylactic central compartment lymph node dissection in cN0 papillary thyroid carcinoma

Objective

This study explored prophylactic central compartment lymph node dissection (pCCLND) for patients with cN0 papillary thyroid carcinoma (PTC) and the effect of carbon nanoparticles (CNP) on surgical outcomes.

Methods

This retrospective study reviewed PTC cases treated at our tertiary medical institution between January 2019 and December 2022. Only patients with indications for total thyroidectomy and cN0 disease were included. CNP has been associated with a higher number of harvested lymph nodes and a lower rate of accidental parathyroid gland (PTG) removal. Patients who used CNP in this study were classified as group 1, while those who denied its use were classified as group 2.

Results

In total, 116 cases were included, with 80 patients in group 1 and 36 in group 2. Most patients were in stage T1, with 68 (85.0 %) patients in group 1 and 31 (86.1 %) in group 2. Postoperative hoarseness occurred in 3 (3.8 %) patients in group 1 and 1 (2.8 %) in group 2, which recovered within two months. In group 2, 250 nodes were harvested, 72 (28.8 %) of which were metastatic; in group 1, 889 nodes were harvested, 316 (35.5 %) of which were metastatic; the difference regarding the rates of metastatic lymph nodes between the 2 groups was statistically significant (P = 0.047). Differences in postoperative blood calcium and parathyroid hormone levels between the two groups were statistically significant (P = 0.035 and P = 0.034, respectively). There were symptoms of hypocalcemia in 6 (16.7 %) patients in group 2 but in only 2 (2.5 %) in group 1, all of which recovered within three months; the difference was statistically significant (p = 0.017).

Conclusion

pCCLND is worth undertaking for cN0 PTC. CNP is beneficial for achieving more thorough dissection and reducing temporary hypoparathyroidism.

Distribution of inadvertently excised parathyroid glands during thyroid surgery and the link with post-surgical hypoparathyroidism

OBJECTIVES

To evaluate the incidence of inadvertent parathyroidectomy, identify risk factors, determine the location of inadvertently excised glands, review pathology reporting in inadvertent parathyroidectomy, and explore relationships between inadvertent parathyroidectomy and post-surgical hypoparathyroidism or hypocalcaemia.

METHODS

A retrospective cohort study of 899 thyroidectomies between 2015 and 2020 was performed. Histopathology slides of patients who had an inadvertent parathyroidectomy and a random sample of patients without a reported inadvertent parathyroidectomy were reviewed.

RESULTS

Inadvertent parathyroidectomy occurred in 18.5 per cent of thyroidectomy patients. Central neck dissection was an independent risk factor (inadvertent parathyroidectomy = 49.4 per cent with central neck dissection, 12.0 per cent without central neck dissection, p < 0.001). Most excised parathyroid glands were extracapsular (53.3 per cent), followed by subcapsular (29.1 per cent) and intrathyroidal (10.9 per cent). Parathyroid tissue was found in 10.2 per cent of specimens where no inadvertent parathyroidectomy was reported. Inadvertent parathyroidectomy was associated with a higher incidence of six-month post-surgical hypoparathyroidism or hypocalcaemia (19.8 per cent who had an inadvertent parathyroidectomy, 7.7 per cent without inadvertent parathyroidectomy).

CONCLUSION

Inadvertent parathyroidectomy increases the risk of post-surgical hypoparathyroidism or hypocalcaemia. The proportion of extracapsular glands contributing to inadvertent parathyroidectomy highlights the need for preventative measures.

Postoperative hypoparathyroidism after thyroid operation and exploration of permanent hypoparathyroidism evaluation

Background

To investigate the risk factors for hypoparathyroidism, discuss the prevention of postoperative hypoparathyroidism, and explore permanent postoperative hypoparathyroidism evaluation (PPHE).

Methods

A total of 2,903 patients with thyroid nodules were treated between October 2012 and August 2015. Serum calcium and intact parathyroid hormone (iPTH) levels were measured at 1 day, 1 month, and 6 months postoperatively. The incidence and management of hypoparathyroidism were analyzed. The PPHE was established based on the risk factors and clinical practice.

Results

A total of 637 (21.94%) patients developed hypoparathyroidism, and 92.15% of them had malignant nodules. The incidence rates of transient and permanent hypoparathyroidism were 11.47% and 10.47%, respectively. The iPTH level was lower in patients with malignant nodules who underwent total thyroidectomy (TT) and central-compartment neck dissection (CND). These factors were independently associated with the recovery rate of parathyroid function. The formula for PPHE is as follows: {iPTH} + {sCa} + {surgical procedure} + {reoperation} + {pathologic type}. A scoring system was developed, and we scored low, middle, and high risk of permanent postoperative hypoparathyroidism as 4-6, 7-9, and 10-13, respectively. The differences in the recovery rates of parathyroid function in several risk groups were statistically significant (p < 0.001).

Conclusion

Simultaneous TT and CND is a risk factor for hypoparathyroidism. The reoperation is not associated with hypoparathyroidism. Identification of parathyroid glands in situ and preservation of their vascular pedicles are key factors in managing hypoparathyroidism. PPHE can forecast the risk of permanent postoperative hypoparathyroidism well.

Impact of Lymph Node Dissection on Postoperative Complications of Total Thyroidectomy in Patients with Thyroid Carcinoma

Background: Lymph node dissection (LND) in primary treatment of differentiated thyroid carcinoma is controversial. The aim of our retrospective study was to analyse the risk factors of post-thyroidectomy complications and to assess the morbidity of lymph node dissection, especially in the central neck compartment, since prophylactic central lymph node dissection has not been proven to bring an overall survival benefit. Methods: We performed a retrospective analysis of postoperative complications from 1547 consecutive patients with differentiated thyroid carcinoma in an academic department of endocrine surgery over a period of 10 years. Results: A total of 535 patients underwent lymph node dissection, whereas the other 1012 did not. The rate of postoperative hypoparathyroidism was higher in patients with LND (17.6% vs. 11.4%, p = 0.001). No significant difference in the rate of permanent hypoparathyroidism (2.4% vs. 1.3%, p = 0.096) was observed between these two groups. A multivariate analysis was performed. Female gender, ipsilateral and bilateral central LND (CLND), parathyroid autotransplantation, and the presence of the parathyroid gland on the resected thyroid were associated with transient hypoparathyroidism. Bilateral CLND and the presence of the parathyroid gland on specimen were associated with permanent hypoparathyroidism. The rate of transient recurrent laryngeal nerve (RLN) injury (15.3% vs. 5.4%, p < 0.001) and permanent RLN injury (6.5% vs. 0.9%, p < 0.001) were higher in the LND group. In multivariate analysis, ipsilateral and bilateral lateral LND (LLND) were the main predictive factors of transient and permanent RLN injury. Bilateral RLN injury (2.6% vs. 0.4%, p < 0.001), chyle leakage (2.4% vs. 0%, p < 0.001), other nerve injuries (2.2% vs. 0%, p < 0.001), and abscess (2.4% vs. 0.5%, p = 0.001) were higher in the patients with LND. Conclusions: The surgical technique and the extent of lymph node dissection during surgery for thyroid carcinoma increase postoperative morbidity. A wider knowledge of lymph-node-dissection-related complications associated with thyroid surgery could help surgeons to carefully evaluate the surgical and medical therapeutic options.

The utility of indocyanine green (ICG) for the identification and assessment of viability of the parathyroid glands during thyroidectomy

We conducted this study to evaluate the ability of indocyanine green (ICG) and near infra-red fluorescence (NIRF) camera to aid in the identification and assessment of viability of parathyroid glands during thyroid surgery. A prospective observational study was conducted between May and October 2020 among 50 consecutive patients who underwent total thyroidectomy at a single institution. Parathyroid glands were identified under white light during thyroidectomy following which reconstituted ICG was injected through a peripheral vein and the location of parathyroid glands was confirmed. The perfusion to the parathyroid gland was assessed by documenting the fluorescence intensity score (FIS) and the parathyroid angiogram score (PAS). There was no difference in the number of parathyroid glands seen on visual inspection 147 (73.5%) when compared to under NIRF camera, 146 (73%). Though the rate of postoperative hypoparathyroidism was lower in the cohort with FIS 3 (14.2%) compared to score 2 and 1 (28.5% and 100%, respectively), this was not significant (p = 0.35). A significant correlation was noted between a delayed flow on PAS and the development of post-thyroidectomy hypoparathyroidism (p = 0.01). PAS had a sensitivity of 100%, specificity of 88.6%, NPV of 100% and PPV of 55.6% to predict the development of post-thyroidectomy hypoparathyroidism. In this study, there was no additional benefit of ICG and NIRF camera in the identification of parathyroid glands. However, ICG angiogram seems to be a good adjunct for the intraoperative assessment of the viability of the parathyroid glands and accurately predicts the development of postoperative hypoparathyroidism.

Relationship between the extent of central node dissection and parathyroid function preservation in thyroid cancer surgery

Background

The risk and effect of hypocalcemia following surgery of different magnitudes remains unclear. Thus, we assessed whether different extents of central lymph node dissection (CLND) and status of preserved parathyroid glands can influence parathyroid function in differentiated thyroid carcinoma (DTC) patients with initial surgical resection.

Methods

Participants were categorized into 6 groups based on the extent of the surgical procedures, number of parathyroid glands preserved in situ, and parathyroid autotransplantation. The frequencies of hypocalcemia, serum calcium (Ca) levels, and parathyroid hormone (PTH) levels among the different groups were analyzed.

Results

The prevalence of hypocalcemia, number and status of parathyroid glands preserved in situ, and parathyroid autotransplantation were inversely related to extensive CLND (r=-0.18; P<0.05). The decrease of serum Ca and PTH was most severe on postoperative days (POD) 1-7. The incidence of hypocalcemia was higher in Group C than in Group B and A (P<0.05). The average postoperative serum Ca and PTH levels in Group C were significantly lower than group A on POD 1-7 (P<0.05). The incidence of hypocalcemia was obviously increased in Group D compared to Groups E and F (P<0.05). The mean serum Ca and PTH levels in Group D were significantly lower than in Group F (P<0.05), and the same results could be observed between Groups D and E (P<0.05). However, through parathyroid autotransplantation, there was no significant difference that could be found between Groups E and F on POD 1-7 (P>0.05).

Conclusions

With the expansion of CLND scope, postoperative parathyroid function will be affected, increasing the risk of postoperative hypocalcemia. When at least 1-2 parathyroid glands were reserved in situ plus at least 1 parathyroid gland autotransplantation, there was little effect on postoperative parathyroid function.

The impact of near infrared fluorescence imaging on parathyroid function after total thyroidectomy

BACKGROUND

Compared with conventional thyroidectomy, hypocalcemia rate was reported to be lower after total thyroidectomy (TT) utilizing near infrared fluorescence imaging (NIFI). The aim of this study is to evaluate the impact of NIFI on postoperative parathyroid function after TT.

METHODS

This was a retrospective institutional review board-approved study comparing 100 patients who underwent TT with NIFI guidance and 200 patients without, by the same surgeon. Clinical parameters were compared using χ² and t test.

RESULTS

Average number of parathyroid glands identified intraoperatively was similar between two groups. However, rate of incidental parathyroidectomy was higher in conventional (14%) versus NIFI group (6%) (P = .039), despite similar (4% vs 6%, respectively) autotransplantation rates (P = .562). Incidences of transient (6.5% vs 5.0%) and permanent (0.5% vs 0%) hypocalcemia were not statistically different between conventional and NIFI groups (P = NS).

CONCLUSION

The use of NIFI during thyroidectomy may decrease the rate of incidental parathyroidectomy by increasing the ability of the surgeon to recognize parathyroid glands with fluorescent contrast distinction. Nevertheless, in contrary to recent reports in literature, postoperative hypocalcemia rate was not altered compared with conventional technique, suggesting that preservation of parathyroid vasculature, rather than an augmented ability to detect the glands, may dominantly affect postoperative function.

Vitamin D Status as a Predictor of Postoperative Hypocalcemia after Thyroidectomy

OBJECTIVE

To determine whether perioperative vitamin D levels are predictive of postoperative hypocalcemia in patients receiving thyroidectomy.

STUDY DESIGN

Single center retrospective study.

SUBJECTS AND METHODS

This study included all patients receiving total or completion thyroidectomy between January 2007 and March 2017 at a single tertiary care hospital. 25-Hydroxyvitamin D (25[OH]D) levels were measured within 42 days prior to surgery or 1 day postoperatively. Hypocalcemia was defined as an adjusted serum calcium <8.0 mg/dL (based on albumin levels) or symptomatic hypocalcemia. Univariate analysis was performed with a 2-sample t test and chi-square test, while multivariate analysis was performed with logistic regression analysis to determine whether perioperative 25(OH)D level is a predictor of postoperative hypocalcemia.

RESULTS

A total of 517 subjects were included in the study, 15.7% (n = 81) of whom experienced postoperative hypocalcemia with a mean ± SD serum calcium level of 7.6 ± 0.5 mg/dL as compared with 8.9 ± 0.5 mg/dL in the normocalcemic population (P < .01). The mean 25(OH)D level for patients with hypocalcemia was 24.4 ± 12.0 ng/mL as compared with 27.5 ± 12.2 ng/mL in patients with normocalcemia (P = .038). Subjects who were hypocalcemic experienced a significantly longer hospital stay (2.9 ± 2.5 vs 1.4 ± 1.1 days, P < .01). After adjusting for preoperative calcium, age, and performance of a neck dissection, subjects with a 25(OH)D level <30 ng/mL were significantly associated with postoperative hypocalcemia (odds ratio, 1.9; P = .041; 95% CI, 1.0-3.3).

CONCLUSION

Using a single-center retrospective study design, we demonstrated that 25(OH)D level is a significant predictor of postoperative hypocalcemia after thyroidectomy.

Clinical Applied Anatomy in Trans-Areolar Endoscopic Thyroidectomy: Crucial Anatomical Landmarks

Introduction: Endoscopic thyroidectomy (ET) has been successfully established as an excellent surgical approach. This study summarizes and describes the crucial anatomical landmarks for clinical applied anatomy in trans-areolar ET, which may help further improve the quality and safety of trans-areolar ET. Materials and Methods: Five hundred forty patients who underwent trans-areolar ET from January 2015 to June 2018 at our institution were evaluated. Several crucial anatomical landmarks were described during the surgical procedures. The surgical outcomes, including the operative time, conversion, intraoperative blood loss, postoperative complications, and postoperative stay, were collected. Results: All patients successfully underwent trans-areolar ET without conversion. The mean operative time was 142.18 ± 49.91 minutes (150.84 ± 50.32 minutes for total thyroidectomy and 110.20 ± 32.4 for lobectomy with isthmusectomy). The mean intraoperative blood loss was 20.45 ± 10.89 mL. The postoperative stay was 5.42 ± 1.49 days. The postoperative complication rate was 7.78%, including transient hypocalcemia in 30 patients, transient recurrent laryngeal nerve palsy in 3 patients, and skin ecchymosis in 9 patients. Conclusions: An understanding of crucial anatomical landmarks for clinical applied anatomy may improve the quality and safety of trans-areolar ET and subsequently help promote the development of ET.

Fine-needle aspiration with rapid parathyroid hormone assay to identify parathyroid gland in thyroidectomy

To determine the levels of parathyroid hormone (PTH) in the fluids of various tissues for identification of parathyroid glands during thyroidectomy.Our study comprised 31 patients with thyroid cancer who underwent lobectomy with central compartment dissection at our hospital from October 2014 to February 2015. A total of 186 tissue samples, including 28 from parathyroid glands and 158 from non-parathyroid tissues, were obtained during the operations. Tissue fluids were collected via fine-needle aspiration to measure PTH levels; the tissue was punctured 3 times with a 26-gauge syringe needle and washed with 0.5 mL normal saline. Tissues were also prepared for pathological examination.PTH concentrations were significantly higher in parathyroid tissues than non-parathyroid tissues. None of the patients had irremediable parathyroid dysfunction after surgical resection.Use of fine-needle aspiration for quantification of PTH levels in tissue fluids rapidly, safely, and effectively identifies the parathyroid glands during thyroidectomy.

Factors contributing to unintentional parathyroidectomy during thyroid surgery

Unintentional parathyroidectomy during thyroid surgery has an incidence ranging between 1% and 31% across institutions. Many studies have identified malignancy and central neck dissection as risk factors for losing parathyroid glands, but few studies have evaluated the impact of other factors such as lymphocytic thyroiditis, hyperthyroidism, or concomitant primary hyperparathyroidism. The purpose of this study was to investigate which factors contribute to parathyroid loss during thyroid surgery. Charts of 269 patients undergoing thyroid surgery at a tertiary care medical center from 2010 to 2013 were retrospectively reviewed. Sixty-six patients (24.5%) experienced unintentional parathyroidectomy. Bivariate analysis showed no significant differences in patient characteristics. Patients with unintentional parathyroid removal had a significantly smaller largest thyroid nodule size (P = 0.002), higher rate of central neck dissection (30.3% vs 7.9%, P < 0.0001), and higher rate of malignancy (50% vs 36.0%, P = 0.04). Multivariable analysis showed that the strongest risk factor for unintentional parathyroidectomy was central neck dissection (P = 0.0008; odds ratio 4.72, confidence interval 1.91-11.71). In conclusion, central neck dissection for thyroid malignancy is the strongest risk factor for unintentional thyroidectomy. The presence of concomitant primary hyperparathyroidism, lymphocytic thyroiditis, or hyperthyroidism did not appear to increase the risk of unintentional parathyroidectomy.

Risk factors and outcomes of incidental parathyroidectomy in thyroidectomy: A systematic review and meta-analysis

Introduction

Postoperative hypocalcemia is the most common complication of thyroidectomy. Incidental parathyroidectomy (IP) was thought to be associated with postoperative hypocalcemia. However, according to previous studies, the risk factors and clinical outcomes of IP remain controversial.

Methods

Eligible studies were searched in databases including PubMed, Web of Science, and EMBASE from January 1990 to September 2017. Articles focusing on the relationship between IP and postoperative hypocalcemia were included. The risk of publication bias was assessed using Begg’s test and Egger’s regression asymmetry test. Pooled analysis was performed to evaluate the effect of IP on postoperative hypocalcemia and related risk factors. Sensitivity analysis was also conducted to test the stability of our results. The effects of hypocalcemia type, permanent definition, IP incidence, total thyroidectomy, and malignancy operation were also examined using a further subgroup analysis.

Results

Thirty-five studies were finally included in the analysis after an exhaustive literature review. Pathology data demonstrate that incidental parathyroidectomy occurred in various locations: intrathyroidal (2.2–50.0%), intracapsular (16.7–40.0%) and extracapsular (15.7–81.1%) regions. Overall, the analysis found that malignancy (RR = 1.60, 95% CI: 1.27 to 2.02; p< 0.0001), central neck dissection (RR = 2.35, 95% CI: 1.47 to 3.75; p = 0.0004), total thyroidectomy (RR = 1.42, 95% CI: 1.20 to 1.67; p< 0.0001) and reoperation (RR = 1.81, 95% CI: 1.20 to 2.75; p = 0.005) were significant risk factors of IP in thyroid surgery. There was an obvious effect of IP on temporary/permanent (RR = 1.59, 95% CI: 1.37 to 1.84; p< 0.0001) and permanent (RD = 0.0220, 95% CI: 0.0069 to 0.0370; p = 0.0042) postoperative hypocalcemia. Sensitivity analysis showed that these results were robust. The subgroup analysis found that IP played a significant role in both biochemical and clinical hypocalcemia in thyroidectomy (p < 0.0001 and p = 0.0003, separately). The association of IP and permanent hypocalcemia using different definitions (6 months or more than 12 months) was also confirmed by the analysis. IP increased the incidence of temporary/permanent and permanent hypocalcemia for cases undergoing total thyroidectomy (40.4% vs 24.8% and 5.8% vs 1.4%, respectively). Thyroidectomy with IP was associated with more permanent hypocalcemia (RR = 3.10, 95% CI: 2.01 to 4.78; p< 0.0001) in malignant cases but was not associated with temporary/permanent hypocalcemia.

Conclusions

Malignancy, central neck dissection, total thyroidectomy and reoperation were found to be significant risk factors of IP. IP increases the risk of postoperative hypocalcemia after thyroidectomy. We recommend a more meticulous intraoperative identification of parathyroid gland in thyroidectomy to reduce IP, particularly for total thyroidectomy and malignancy cases.

A new classification of parathyroid glands to evaluate in situ preservation or autotransplantation during thyroid surgery

The indication for autotransplantation of parathyroid glands is still controversial. A new classification of parathyroid glands based on the positional relationship among parathyroid glands, thyroid gland and thymus was created to decide in situ preservation or autotransplantation during thyroid surgery.A retrospective study included patients with papillary thyroid cancer who underwent total thyroidectomy with bilateral central lymph node dissection between November 2014 and November 2016. According to the application of the new classification (December 2015-November 2016) or traditional method (preservation of all functional parathyroid glands in situ, November 2014-November 2015), the patients were divided into new classification and traditional groups.The traditional method was utilized in 288 patients who underwent surgery during the first half of the study, while the new classification was applied to 249 patients during the latter half of the study. The incidence of transient hypoparathyroidism was 43.0% (107/249) in new classification group and 35.8% (103/288) in the traditional group, respectively (P = .093). The corresponding incidence of permanent hypoparathyroidism was 0.4% (1/249) and 4.5% (13/288) (P = .002).The new classification of parathyroid glands potentially reflects the difficulty of preservation and helps to make a reasonable decision on preservation or autotransplantation of a parathyroid gland, which may minimize the incidence of permanent hypoparathyroidism.

Decision making for the central compartment in differentiated thyroid cancer

The central compartment is a common site for nodal spread from differentiated thyroid carcinoma, often occurring in patients without clinical or ultrasonographic (US) evidence of neck lymph node metastasis (cN0). However, the role of elective central compartment neck dissection (CND) among patients with DTC remains controversial. We performed a systematic literature review, also including review of international guidelines, with discussion of anatomic and technical aspects, as well as risks and benefits of performing elective CND. The recent literature does not uniformly support or refute elective CND in patients with DTC, and therefore an individualized approach is warranted which considers individual surgeon experience, including individual recurrence and complication rates. Patients (especially older males) with large tumors (>4 cm) and extrathyroidal extension are more likely to benefit from elective CND, but elective CND also increases risk for hypoparathyroidism and recurrent nerve injury, especially when operated by low-volume surgeons. Individual surgeons who perform elective CND must ensure the number of central compartment dissections needed to prevent one recurrence (number needed to treat) is not disproportionate to their individual number of central compartment dissections per related complication (number needed to harm).

Clinicopathological characteristics of incidental parathyroidectomy after total thyroidectomy: The effect on hypocalcemia. A retrospective cohort study

BACKGROUND

The reported rate of incidental parathyroidectomy (IP) during total thyroidectomy varies between 6.4 and 31.1%. The aim of this study was to investigate the clinicopathological characteristics associated with IP.

MATERIALS AND METHODS

This is a retrospective cohort study which included 2556 patients who underwent total thyroidectomy between 2002 and 2012 at a single tertiary institution. Demographics, clinicopathological risk factors, and postoperative calcium levels were compared between IP and control group.

RESULTS

Incidental parathyroidectomy occurred in 18.3% of patients. IP patients had higher risk of postoperative biochemical (40.3% vs 17.3%, p < 0.001) and symptomatic hypocalcemia (14.3% vs 7.3%, p < 0.001) than no-IP group. Multivariate analysis showed malignancy, tumor size >10 mm, thyroid capsule invasion, extrathyroidal extension, lymph node metastases and central neck dissection, operation time, RLN injury, thyroid gland dimensions were independent risk factors for IP.

CONCLUSIONS

Our results indicate that patients with certain preoperative findings such as larger thyroid dimensions, diagnosis of malignancy and especially tumor >10 mm, extrathyroidal extension, and lymph node metastasis are at higher risk of IP and postoperative symptomatic hypocalcemia and these patients should be adequately informed and treated. Α meticulous intraoperative identification and the preservation of all parathyroid glands results in lower incidence of IP and postoperative hypocalcemia.

Inadvertent parathyroidectomy risk factors in 1,373 thyroidectomies-male gender and presence of lymphadenopathy, but not size of gland, independently increase the risk

Background

Inadvertent parathyroidectomy (IP) during thyroid operations is a recognised phenomenon. We evaluated the incidence of IP during thyroid operations in a large case-series and identified the risk factors involved.

Methods

Retrospective review of all thyroidectomy operations [total thyroidectomies (TT) and near-total thyroidectomies (NTT)] performed in a single institution from January 2004 to January 2009. We excluded re-operative cases, combined thyroid and parathyroid pathology, hemithyroidectomies and neck lymph nodes (LN) dissections. Pathology reports were correlated with operative records to identify the details of the IP glands. Relevant data (patient demographic data, preoperative diagnosis and operative details) were collected and a logistic regression was performed.

Results

One thousand three hundred and seventy-three patients were included in our study, 1,149 of them females (84%). IP rate was 11.3%. Univariate analysis showed that gender, thyroid gland weight, thyroid activity pre-operatively and type of operation are associated with IP. Logistic regression analysis has shown that female gender and the absence of LN in pathology were associated with less likelihood in developing IP than males and patients with presence of LN (P=0.051 and 0.014 respectively). IP occurs 2.14 and 2.28 times more often in TT and NTT when compared to the combination of TT and NTT (P=0.047 and 0.048 respectively).

Conclusions

We present the largest single-centre case series on this topic, to our knowledge. The presence of LN, female gender and the type of operation are positively correlated to the IP rate. These factors could alert the surgeon to consider early calcium supplementation if the parathyroid glands (PG) have not been identified intraoperatively.

Hypomagnesemia predicts postoperative biochemical hypocalcemia after thyroidectomy

Background

To investigate the role of magnesium in biochemical and symptomatic hypocalcemia, a retrospective study was conducted.

Methods

Less-than-total thyroidectomy patients were excluded from the final analysis. Identified the risk factors of biochemical and symptomatic hypocalcemia, and investigated the correlation by logistic regression and correlation test respectively.

Results

A total of 304 patients were included in the final analysis. General incidence of hypomagnesemia was 23.36%. Logistic regression showed that gender (female) (OR = 2.238, p = 0.015) and postoperative hypomagnesemia (OR = 2.010, p = 0.017) were independent risk factors for biochemical hypocalcemia. Both Pearson and partial correlation tests indicated there was indeed significant relation between calcium and magnesium. However, relative decreasing of iPTH (>70%) (6.691, p < 0.001) and hypocalcemia (2.222, p = 0.046) were identified as risk factors of symptomatic hypocalcemia. The difference remained significant even in normoparathyroidism patients.

Conclusions

Postoperative hypomagnesemia was independent risk factor of biochemical hypocalcemia. Relative decline of iPTH was predominating in predicting symptomatic hypocalcemia.

Preoperative vitamin D level as predictor of post-thyroidectomy hypocalcemia in patients sustaining transient parathyroid injury

BACKGROUND

Several studies have sought to identify predictors of postoperative hypocalcemia after total thyroidectomy; however, there have been conflicting results regarding the impact of preoperative vitamin D deficiency.

METHODS

The medical records of patients undergoing total thyroidectomy were retrospectively reviewed. The number of parathyroid glands identified or reimplanted at the time of surgery was used as a marker of transient parathyroid gland damage.

RESULTS

Sixty-seven patients were included in the study. Vitamin D deficiency was a significant predictor of hypocalcemia in patients in whom ≥3 parathyroid glands were identified, but not in patients in whom 0-2 parathyroid glands were identified intraoperatively (odds ratio [OR] 5.8; P = .036).

CONCLUSION

Vitamin D deficiency is a significant predictor of postoperative hypocalcemia in patients in whom ≥3 parathyroid glands are identified intraoperatively, but not in patients who sustain minimal transient damage to the parathyroid glands.

Inadvertent parathyroidectomy during thyroid surgery

INTRODUCTION

Inadvertent parathyroidectomy is a recognised complication of thyroid surgery. We aimed to investigate the incidence of and risk factors for inadvertent parathyroidectomy during thyroid surgery, in our patient cohort.

METHODS

A retrospective review of the records of all patients undergoing thyroid surgery in our institution between January 2012 and December 2014 was performed. Medical records, laboratory investigations and histopathology reports were evaluated. Patient demographics, indication for surgery, surgery performed, final pathology, incidental parathyroidectomy and post-operative hypocalcaemia were recorded. Univariate analysis using the Fisher's exact test was performed.

RESULTS

Two hundred and thirty procedures were included: 147 hemi-thyroidectomies and 83 total thyroidectomies. Central neck dissection was also performed in 13 cases. The most common indication for surgery was indeterminate cytology (81 cases). Post-operatively, malignant disease was reported in 52 cases (22.6%). Inadvertent parathyroidectomy occurred in 40 cases (17.3%). There was a statistically significant increased risk of inadvertent parathyroidectomy with malignant disease (p = 0.001) and after central neck dissection (p = 0.013) but no difference was seen between hemi- and total thyroidectomies (p = 0.47), gender (p = 1.00) or with increasing age (p = 1.00). Hypocalcaemia occurred in four cases and was transient in three.

CONCLUSION

Inadvertent parathyroidectomy is a potential risk during thyroid surgery but post-operative hypocalcaemia as a result is rare. Malignancy and more extensive surgery appear to carry an increased risk for this complication.

INCIDENTAL PARATHYROIDECTOMY DURING THYROID SURGERY - RISK, PREVENTION AND CONTROVERSIES; AN EVIDENCE-BASED REVIEW

Background

Postoperative hypocalcemia after thyroid surgery has a high prevalence ( 16-55% in different series). Incidental parathyroidectomy (IP) is a less discussed complication of thyroidectomy with consequences not properly defined. The aim of our study was to find incidence, risk factors and how to prevent IP.

Methods

Extensive search of English literature publications via PubMed was performed and 73 papers from 1980 to 2017 were analysed using the GRADE system/classification, quality of evidence was classified as "strong" when the result is highly unlikely to change existing recommendation and "weak" when opposite.

Results

Incidence of IP is 3.7-24.9%, while prevalence of permanent hypoparathyroidism is less frequent 6-12%. Direct relation between IP and hypoparathyroidism/hypocalcemia remains controversial. Female patients, ectopic parathyroids, small thyroids, Graves', malignancy, redo surgeries and total thyroidectomy favour IP. Routine visualization of parathyroids, new hemostatic devices, magnifying instruments and fluorescence can prevent incidental removal of parathyroids. Incidence of IP during videoassisted or robotic thyroidectomies was similar to open procedures. High volume, experienced and younger surgeons have lower complication rates (including hypoparathyroidism).

Conclusions

Incidental parathyroidectomy is more frequent than we might have expected. It should be avoided and parathyroid glands should be kept in situ. Majority of studies are retrospective (low degree of evidence according to previous mentioned GRADE classification) and further meta-analysis or randomized control studies are welcome in order to define the impact of incidental removal of parathyroids on postoperative outcome.

Parathyroid Autotransplantation During Thyroid Surgery: A Novel Technique Using a Cell Culture Nutrient Solution

INTRODUCTION

Parathyroid autotransplantation is an easy procedure with a low complication rate. We adopted the transplantation into the sternocleidomastoid muscle, which allows an easier and time-saving surgical procedure using the same surgical incision.

METHODS

In this study, we retrospectively reviewed the records of 396 consecutive patients, who underwent total thyroidectomy for benign thyroid disease. In all cases in which a parathyroid was damaged or inadvertently removed, the gland was transplanted; before the autotransplantation, the parathyroid tissue was put in a cell culture nutrient solution for 5 min, afterward fragmented, and then was transplanted in the sternocleidomastoid muscle. To demonstrate a beneficial effect of the cell nutrient solution step, we compared data of transplanted patients with a control group of cases (n = 190) undergoing a standard immediate autotransplantation.

RESULTS

We divided patients in two main groups: group A (n = 160) including subjects that underwent one or more parathyroid gland autotransplantation using the cell nutrient solution, and group B (n = 236) concerning those who were not transplanted. Among patients, 62 hypocalcemias occurred, 40 in the group A and 22 in the group B (P < 0.001): 91.9 % were transient and 8.1 % (5 patients) definitive, all pertaining to the group B. Among controls (group C), 42 hypocalcemias occurred (P = 0.616 vs. group A and P = 0.002 vs. group B) and 3/42 became definitive (P = 0.096 vs. group A and P = 0.121 vs. group B). All differences concerning pre- and postoperative calcium values were statistically significant (P < 0.001).

CONCLUSIONS

We recommend the routine parathyroid autotransplantation, when a vascular damage is certain or suspected, in order to reduce the rate of permanent hypoparathyroidism, using a cell culture nutrient solution before gland transplantation.

Postoperative Hypoparathyroidism and the Viability of the Parathyroid Glands During Thyroidectomy

OBJECTIVES

To prevent hypoparathyroidism after thyroidectomy, preservation of the parathyroid glands and their vascularity are essential. The aim of this study was to determine the association between postoperative parathyroid function and the viability of the parathyroid glands during thyroidectomy.

METHODS

We prospectively analyzed 111 patients who underwent total thyroidectomy and in whom all 4 parathyroid glands were preserved in situ during the operation. The surgeons scored the viability of each parathyroid gland from 0 (normal) to 3 (severely compromised viability) based on its gross appearance and vascularity intraoperatively. The index of parathyroid viability score (IPVS) was defined as the sum of the viability scores of the 4 parathyroid glands. We evaluated the relationship between postoperative parathyroid function and IPVS.

RESULTS

Transient hypoparathyroidism occurred in 25 patients (22.5%), and permanent hypoparathyroidism in 4 patients (3.6%). The IPVS were significantly different in the three groups: 2.87±1.46 in the normal group, 3.68±1.41 in the transient hypoparathyroidism group and 7.50±1.00 in the permanent hypoparathyroidism group. The rates of transient hypoparathyroidism were 13.6% in patients with IPVS 0-2, 23.8% in patients with IPVS 3-4, and 42.9% in patients with IPVS 5-6. All the patients with IPVS of 7 or more had permanent hypoparathyroidism.

CONCLUSION

IPVS is correlated with the incidence of hypoparathyroidism. It could be a good quantitative indicator of the probability of hypoparathyroidism after thyroidectomy.

Analysis of the incidence and factors predictive of inadvertent parathyroidectomy during thyroid surgery

BACKGROUND

Inadvertent (or incidental) parathyroidectomy can occur during thyroidectomy. However, the factors associated with inadvertent parathyroidectomy remain unclear. This study aimed to report the rate of inadvertent parathyroidectomy during thyroidectomy and associated risk factors.

METHODS

Variables including fine needle aspiration cytology findings, age, sex, thyroid weight, concurrent neck dissection, extent of thyroidectomy, and the presence of cancer and parathyroid tissue within the specimen were recorded for 266 patients. The incidence of post-operative hypocalcaemia was also recorded. Univariate and multivariate analysis were performed to identify factors associated with inadvertent parathyroidectomy.

RESULTS

The inadvertent parathyroidectomy rate was 16 per cent. Univariate analysis revealed that cancer and concurrent neck dissection predicted inadvertent parathyroidectomy. On multivariate analysis, only concurrent neck dissection remained an independent predictor of inadvertent parathyroidectomy: it was associated with a fourfold increase in inadvertent parathyroidectomy.

CONCLUSION

The inadvertent parathyroidectomy rate was 16 per cent and concurrent neck dissection was identified as an independent predictor of inadvertent parathyroidectomy.

Incidental Parathyroidectomy during Total Thyroidectomy: Risk Factors and Consequences

Objective. To evaluate the incidence of accidental parathyroidectomy in our series of total thyroidectomies, to investigate its clinical and biochemical consequences, and to identify potential risk factors. Methods. Patients who underwent total thyroidectomy between January 2006 and December 2015 were retrospectively analyzed. Pathology reports were reviewed to identify those cases who had an incidental parathyroidectomy and these were compared to patients with no parathyroidectomy, in terms of clinical (age, sex, and symptoms of hypocalcemia), pathological (thyroid specimen weight, Hashimoto thyroiditis, and malignancy), and biochemical (serum calcium and phosphate levels) factors. Results. 281 patients underwent total thyroidectomy during the study period. Incidental parathyroidectomy was noticed in 24.9% of cases, with 44.3% of parathyroid glands found in an intrathyroidal location. Evidence of postoperative biochemical hypocalcemia was noticed in 28.6% of patients with parathyroidectomy, compared with 13.3% in the no-parathyroidectomy group (p = 0.003). Symptomatic hypocalcemia was observed in 5.7% and 3.8%, respectively (p = 0.49). Age, sex, thyroid specimen weight, Hashimoto thyroiditis, and malignancy did not differ significantly between the two groups. Conclusions. Our study found an association of incidental parathyroidectomy with transient postoperative biochemical hypocalcemia, but not with clinically symptomatic disease. Age, sex, thyroid gland weight, Hashimoto thyroiditis, and malignancy were not identified as risk factors.

Association between decreased serum parathyroid hormone after total thyroidectomy and persistent hypoparathyroidism

Background

Postoperative hypocalcemia caused by hypoparathyroidism is one of the most common morbidities of total thyroidectomy. The aim of this study was to analyze the kinetics and factors affecting PTH levels after total thyroidectomy and central neck dissection (CND).

Material/Methods

We performed a retrospective study in 438 consecutive patients who underwent total thyroidectomy between January 2007 and December 2010. No patient had a history of thyroid or neck surgery. PTH and calcium levels were recorded 1 day before the operation, during the first 5 days, and during follow-up (2 weeks and 2, 6, and 12 months).

Results

PTH levels declined to 41.90% of its initial value on the first day after the operation. After surgery, PTH was correlated positively with calcium and inversely with phosphate levels from postoperative day 1 to 14. Based on clinical observation, using a PTH threshold of <7 ng/L on postoperative day 1 was predictive of persistent hypoparathyroidism, with sensitivity and negative predictive value 100%, but poor specificity (70.19%). CND increased the risk of transient hypoparathyroidism compared with total thyroidectomy alone. Patients with thyroiditis had an increased risk of permanent hypoparathyroidism compared with those without thyroiditis. Iatrogenic removal of the parathyroid glands increased the risk of permanent hypoparathyroidism compared with those without iatrogenic parathyroidectomy.

Conclusions

PTH declined on the first day after thyroidectomy. PTH levels <7 ng/L on the first day after surgery might be associated with persistent hypoparathyroidism. CND, thyroiditis, and iatrogenic parathyroidectomy increased the risk of hypoparathyroidism.

The Cost of Prolonged Hospitalization due to Postthyroidectomy Hypocalcemia: A Case-Control Study

The aim of this study is to evaluate the additional costs associated with calcium monitoring and treatment as well as evaluate the incidence and predictors of postthyroidectomy hypocalcemia. Methods. This case-control study involved thyroidectomy and completion thyroidectomy patients operated on between January 2012 and August 2013. Cases were defined as requiring calcitriol supplementation, and controls did not require supplementation. Patient (age, sex), nodule (cytology, pathology), surgical data (neck dissection, parathyroid identification, and reimplantation), and hospital stay (days hospitalized in total and after drain removal) were compared. Comparisons were made using t-tests and chi-square tests with an alpha of 0.05. The estimated cost associated with the extended stay was then compared with the cost of supplementation. Results. A total of 191 patients were evaluated (61 cases and 130 controls). Predictors of hypocalcemia include female age, neck dissection, and parathyroid reimplantation. Hypocalcemic patients were hospitalized for a longer period of time after drain removal (2.5 versus 0.8 days, P<0.001), and hospitalization costs after neck drain removal were higher in this group as well (8,367.32$ versus 2,534.32$, P<0.001). Conclusion. Postoperative hypocalcemia incurs significant additional health care costs at both the local and health care system levels.

The oral microbiome and oral cancer

The role that bacteria play in the etiology and predisposition to cancer is of increasing interest, particularly since the development of high-throughput genetic-based assays. With this technology, it has become possible to comprehensively examine entire microbiomes as a functional entity. This article focuses on the understanding of bacteria and its association with oral squamous cell carcinoma.

Dissection and identification of parathyroid glands during thyroidectomy: association with hypocalcemia

BACKGROUND

The purpose of this study was to evaluate preoperative features, surgical details, and postoperative findings related to the identification of parathyroid glands and to establish the relationship between identification of parathyroid glands and postoperative hypocalcemia.

METHODS

Seven hundred eighty-eight total thyroidectomies performed between January 2002 and April 2012 by a single surgeon were studied. To evaluate the impact of parathyroid glands identification on study variables, patients were stratified into 2 study groups: group 1 with 0 to 2 parathyroid glands identified and group 2 with 3 to 4 parathyroid glands identified.

RESULTS

Multivariate analysis identified younger age (p = .007), female sex (p = .001), and no usage of the Biclamp hemostatic technique (p < .001) related to the higher number of parathyroid glands identified. Univariate analysis revealed a higher incidence of temporary hypocalcemia (p = .015) and permanent hypoparathyroidism (p = .040) in group 2 than in group 1.

CONCLUSION

Identification of a higher number of parathyroid glands is associated with a higher incidence of postoperative temporary hypocalcemia and permanent hypoparathyroidism.

Incidental parathyroidectomy during thyroid surgery using capsular dissection technique

OBJECTIVE

To identify incidence, preoperative features, surgical factors, and postoperative events of incidental parathyroidectomy (IP) during thyroidectomy.

STUDY DESIGN

A total of 1068 consecutive patients who underwent thyroidectomy performed by a single surgeon between January 2003 and April 2012 were enrolled in retrospective study with prospectively collected data.

SETTING

University hospital.

SUBJECTS AND METHODS

To assess the impact of IP on study variables, patients were stratified into 2 study groups: IP group and non-IP group. Univariate and multivariate analyses identified significant correlates of IP.

RESULTS

In all, 5.4% patients experienced IP. Significant difference (P < .001) was in incidence of temporary hypocalcemia between IP group (36.2%) and non-IP group (16.8%). Multivariable logistic regression model identified total thyroidectomy (odds ratio 3.937, 95% confidence interval [CI] 1.462-10.601, P = .007) and Graves' disease (odds ratio 2.192, 95% CI 1.157-4.158, P = .016) as risk-adjusted factors associated with IP. Multivariate analysis of repeated measures identified statistically significant difference of repeated total calcium level (P < .001) and ionized calcium level (P = .020) between study groups.

CONCLUSION

IP during thyroidectomy might be potential complication. Total thyroidectomy, Graves' disease, longer operation time, and identification 3 and more parathyroid glands seemed to be predictive factors for IP. IP is significantly associated with temporary hypocalcemia, but not with permanent hypoparathyroidism.

Hypocalcemia after total laryngectomy: incidence and risk factors

OBJECTIVES/HYPOTHESIS

Hypocalcemia is common in the initial period after total laryngectomy. The purpose of the present study was to study the incidence of and risk factors for postlaryngectomy hypocalcemia at our institution.

STUDY DESIGN

Retrospective review of 65 consecutive total laryngectomies.

METHODS

Clinical data and calcium levels for the first postoperative week were collected. Biochemical hypocalcemia was defined as any corrected calcium level of < 2.0 mmol/l in the first postoperative week. Severe hypocalcemia was defined as a calcium of < 1.8 mmol/l, or symptoms of hypocalcemia. Risk factors for hypocalcemia were studied.

RESULTS

Five cases were excluded due to concomitant abdominal surgery (3), preoperative hypocalcemia (1), and no postoperative calcium levels (1). A total of 43% of patients had postoperative biochemical hypocalcemia. On univariate analysis, bilateral neck dissection was significant for hypocalcemia (P = 0.02), with pT4 classification having borderline significance (P = 0.07). On multivariate analysis, bilateral neck dissection (P = 0.02) and salvage surgery were significant (P = 0.03), with pT4 stage again having borderline significance (P = 0.05). Extent of thyroidectomy, extent of pharyngectomy, and preoperative tracheostomy were not significant. Fifteen patients (25%) had severe hypocalcemia. There were no significant risk factors for severe hypocalcemia identified.

CONCLUSIONS

Hypocalcemia is common after total laryngectomy, particularly in the postradiotherapy setting and in patients undergoing bilateral neck dissection. Preservation of one thyroid lobe does not appear to significantly reduce the risk.

The false thyroid capsule: new findings

PURPOSE

The false thyroid capsule is an important anatomical structure involved in thyroidectomy, yet it is rarely studied. This study aimed to define the anatomy of the false thyroid capsule, and its clinical significance.

METHODS

A prospective study was performed involving 151 patients with goitre who underwent thyroid lobectomy. The anatomy of the false thyroid capsule was carefully documented intra-operatively.

RESULTS

The false thyroid capsule enclosed the inferior and middle thyroid veins and the superior thyroid vessels, forming a mesentery-like structure by attaching to the gland. Once the unilateral lobe had been removed, the thyroid mesentery could be seen to have a C-shaped edge. The recurrent laryngeal nerve, inferior thyroid artery and parathyroid glands were located beneath the C-shaped edge of the thyroid mesentery.

CONCLUSION

The thyroid mesentery is a distinctive structure that can be used as a guide for surgical dissection.

Is systematic identification of all four parathyroid glands necessary during total thyroidectomy?: a prospective study

OBJECTIVES/HYPOTHESIS

Routine identification of all four parathyroid glands has been advocated as a means of reducing rates of postoperative hypocalcemia and inadvertent parathyroidectomy. The object of the present study was to investigate whether identification of more parathyroid glands during thyroidectomy performed by capsular dissection technique had any impact on incidence of postoperative hypocalcemia and unintentional parathyroid resection.

STUDY DESIGN

Prospective cohort study of consecutive patients undergoing total thyroidectomy by capsular dissection technique over a 3-year period. Exclusion criteria included performance of concomitant central neck dissection, hyperparathyroidism, revision surgery, and invasive cancer.

METHODS

The number of parathyroid glands identified intraoperatively was recorded. No effort was made to find glands that were not obviously apparent during the course of dissection. Patients were not placed on routine calcium supplementation.

RESULTS

The final study population consisted of 126 patients. The mean number of parathyroid glands identified was 2.3. The incidence of biochemical (any postoperative calcium <2 mmol/L) and clinical hypocalcemia was 22.2% and 10.3%, respectively. Patients in group A (0-2 parathyroids identified) had a significantly lower incidence of clinical hypocalcemia than patients in group B (3-4 parathyroids identified) (3.2% vs. 17.1%, P = .02). The differences in biochemical hypocalcemia were not significant (16.1% vs. 28.1%, P = .13). The incidence of inadvertent parathyroidectomy was 9.5%. There was no difference between the groups in incidence of inadvertent parathyroidectomy (9.7% vs. 9.4%, P = 1.0).

CONCLUSIONS

Routine identification of all four parathyroid glands is not necessary in thyroidectomy performed using capsular dissection technique.

Incidental parathyroidectomy during thyroid resection: incidence, risk factors, and outcome

BACKGROUND AND OBJECTIVES

Thyroidectomy is a commonly performed procedure for thyroid problems. Inadvertent removal of the parathyroid glands is one of its recognized complications, which occurs more frequently in certain high-risk patients. The aim of this study was to identify the incidence, risk factors, and clinical relevance of incidental parathyroidectomy during thyroid surgery.

DESIGN AND SETTING

A retrospective review of thyroid operations performed at a tertiary referral hospital between January 2004 and December 2008.

METHODS

Pathology reports were reviewed to identify the specimens that included parathyroid tissue and underlying thyroid pathology. Postoperative calcium levels were reviewed in these patients.

RESULTS

During the study period, 287 thyroidectomies were performed and 47 (16.4%) patients had incidentally removed parathyroid glands. Risk factors for inadvertent parathyroid resection included total thyroidectomy (P=.0001), Hashimoto thyroiditis (P=.004), and extrathyroidal spread (P=.0003). Postoperative hypocalcemia occurred in 18 (38.3%) of the patients in whom the parathyroid gland was removed inadvertently and in 48 (20%) of the rest of the patients (P=.0123).

CONCLUSION

The incidence of incidental removal of parathyroid tissue during thyroidectomy is 16.4%. Total thyroidectomy, extrathyroidal extension of the tumor, and thyroiditis were found to be the risk factors. Hypocalcemia was significantly higher among patients who had inadvertent parathyroidectomy.

Transtemporal management of temporal bone encephaloceles and CSF leaks: review of 56 consecutive patients

CONCLUSIONS

This report details our experience in the management of 56 consecutive patients with mastoid encephaloceles and cerebrospinal fluid (CSF) leaks. The majority were managed through the transmastoid route with temporalis fascia and calvarial bone graft. Among the patients operated on at least 18 months before analysis, there was a median follow-up of 54 months with no intracranial complications. The average body mass index (BMI) of patients with spontaneous CSF leaks was found to be statistically significantly greater than that of patients with CSF leaks with traumatic, infectious or iatrogenic etiologies.

OBJECTIVES

To investigate the long-term follow-up of patients with spontaneous, iatrogenic, and traumatic temporal bone encephaloceles and CSF leaks to determine the effectiveness of the repair, late intracranial complications, and recurrent lesions.

METHODS

This is a retrospective review from a tertiary care center of 56 consecutive patients managed with CSF otorrhea, encephaloceles, and spontaneous pneumocephalus. All patients were repaired through transtemporal, middle cranial fossa or combined approaches for extradural repair and bone grafting.

RESULTS

Of the 56 consecutive cases, 12 had CSF otorrhea alone, 19 had encephaloceles, and 23 had both. Two patients presented with spontaneous pneumocephalus without CSF leak. Thirty-three patients had spontaneous onset of their lesion without any history of temporal bone surgery or trauma. The average BMI of patients with spontaneous CSF leaks was found to be greater than the average BMI of patients with CSF leaks due to traumatic, infectious or iatrogenic causes. This difference was found to be statistically significant. Six of these had either preceding or subsequent contralateral mastoid or anterior fossa (sphenoid, ethmoid) CSF leak. Intracranial pressure was evaluated in these cases and most underwent VP shunting to reduce their intracranial pressure. Sixteen cases followed previous mastoid surgery or chronic ear disease and seven were attributed to previous temporal bone trauma. Lesions were repaired with the transtemporal approach (42), middle fossa (4), and combined (5) approaches. Five cases required petrosectomy and fat obliteration. There was one recurrent CSF leak 4 years after initial repair; the leak was anterior to the previously placed bone graft.

Loupe Magnification Reduces Postoperative Hypocalcemia after Total Thyroidectomy

We aimed to evaluate the impact of loupe magnification (LM) on incidental parathyroid gland removal (from pathology reports), hypocalcemia, and recurrent laryngeal nerve (RLN) injury after total thyroidectomy and answer the question of whether this tool should be always recommended for patient's safety. Between January 2005 and December 2008, 126 patients underwent total thyroidectomy with routine use of 2.5 X galilean loupes; their charts were compared with data on 118 patients operated on between January 1997 and December 2000 without LM (two different equally skilled surgical teams operating in the two periods). LM decreased the rate of inadvertent parathyroid glands removal (3.8 vs 7.8% of total parathyroid glands; P = 0.01), as well as of biochemical (20.6 vs 33.9%; P = 0.028) and clinical (12.7 vs 33%; P = 0.0003) hypocalcemia after thyroidectomy. All cases (16 of 16) of symptomatic hypocalcaemia in the LM group proved to be associated with parathyroidectomy vs 76.9 per cent (30 of 39) without LM ( P = 0.046). A trend toward decreased RLN injury rate, although statistically insignificant, was reported, being unilateral transient, unilateral permanent, and bilateral transient palsy rates 6.8, 2.5, and 1.7 per cent, respectively, without LM vs 4.8, 2.4, and 0.8 per cent, respectively, with LM ( P = 0.69; P = 1, and P = 0.61, respectively). Our results do support the routine use of LM during total thyroidectomy.

Postoperative hypocalcemia--the difference a definition makes

BACKGROUND

Review of the literature reveals considerable variability in the definitions and criteria used for reporting postoperative hypocalcemia. The lack of standardization prevents a meaningful comparison of results and performance locally with the national standard. It also prevents the pooling of data when performing meta-analysis, and may affect the comparison of research results.

METHODS

A literature review was performed to identify the different definitions used to define hypocalcemia in post-thyroidectomy patients. We analyzed the incidence of hypocalcemia in the same cohort of 202 post thyroidectomy patients using these definitions.

RESULTS

The reported hypocalcemia rates varied from 0% to 46% for the same cohort depending on the definition of hypocalcemia used. Only one-third of biochemically hypocalcemic patients requested calcium supplementation.

CONCLUSION

This study demonstrates the need for more uniformity and standardization in the definitions used for reporting hypocalcemia rates.