Complications after total thyroidectomy

Soft tissue injury events associated with neural integrity monitoring endotracheal tubes: A MAUDE database analysis

OBJECTIVE

Neural integrity monitoring (NIM) endotracheal tubes are widely used to provide intraoperative monitoring of the recurrent laryngeal nerve during certain neck surgeries, especially thyroidectomy, in order to reduce the risk of nerve injury and subsequent vocal fold paralysis. The unique design of NIM tubes and the increased technical skill required for correct placement compared to standard endotracheal tubes may increase the risk of upper aerodigestive tract soft tissue injury. This study aims to describe adverse events related to NIM endotracheal tubes.

STUDY DESIGN

Retrospective cross-sectional study.

SETTING

The US Food and Drug Administration's MAUDE database (2010-2022); (Manufacturer and User Facility Device Experience).

METHODS

The MAUDE database was queried for reports of adverse events that resulted in patient soft tissue injury involving the use of endotracheal tubes approved by the Food and Drug Administration.

RESULTS

There were 28 reported soft tissue injuries, with all events being related to the NIM EMG family of endotracheal tubes manufactured by Medtronic Xomed, Inc. Overall, 24 were categorized as device-related adverse events, and 4 were unspecified in the event description. The most common soft tissue injuries were edema (n = 7) and perforation (n = 7), each accounting for 25 % of adverse events. The second most common injury type was laceration (n = 4), representing 14 % of all adverse events. Overall, 9 patients (32 %) in our cohort required a surgical intervention to treat their injuries, which consisted of 6 tracheotomies and 3 instances of suture repair.

CONCLUSIONS

The most commonly reported types of soft tissue injury included edema and perforation, followed by laceration. Increased awareness of device-related patient injuries associated with NIM endotracheal tubes can be used to better inform surgeons and anesthesiologists during the process of intubation and surgical decision-making.

Application and advantages of a joystick-controlled robotic scope holder in transoral endoscopic thyroidectomy vestibular approach: a comparative study

Transoral endoscopic thyroidectomy has gained popularity due to its scarless nature, but the use of a handheld endoscope can lead to an unstable visual field. Soloassist II, a robotic scope holder, enables precise control using a joystick, ensuring stable vision. This study aims to evaluate the application and the advantages of Soloassist II in transoral thyroidectomy. Patients who underwent transoral thyroidectomy with Soloassist II or human assistance between June 2019 and May 2021 were reviewed. Patient demographics and surgical outcomes were compared. The ergonomic stress of the assistant in both groups was also measured. A total of 100 consecutive patients were included: 32 were assisted by Soloassist II and 68 by humans. The Soloassist II group demonstrated significantly shorter operation times (median [IQR]) (165 [149,179] vs. 181 [165,204] min, P = 0.004) in unilateral lobectomy and less blood loss (median [IQR]) (2 [2,2] vs. 2 [2,3] ml, P = 0.002) than the human-assisted group. Postoperative course and complication rates were similar. The musculoskeletal pain of the assistant was significantly higher and involved more areas in the human-assisted group. The utilization of Soloassist II in transoral endoscopic thyroidectomy is easy to set up and leads to shorter operation times, reduced blood loss, and decreased musculoskeletal pain compared to human handheld endoscope. These findings support the potential of Soloassist II in improving surgical outcomes and minimizing physical strain during transoral thyroidectomy.

Early hospital discharge through prediction of post-thyroidectomy hypoparathyroidism

INTRODUCTION

Hypoparathyroidism is the most common postsurgical complication of total thyroidectomy. Furthermore, it is the main cause of prolonged hospitalisation after this procedure.

OBJECTIVE

To predict the probability of post-thyroidectomy hypocalcaemia according to the levels of intact parathyroid hormone (iPTH), as well as to determine the needs for treatment with exogenous calcium according to the levels of serum calcium (Ca).

MATERIALS AND METHODS

Retrospective study was carried out on patients who underwent total thyroidectomy between January 2017 and January 2020 at Los Arcos del Mar Menor University Hospital (HULAMM). iPTH and Ca levels ​​were measured at 4, 24 and 48 h after the surgery. Follow-up was 6 months.

RESULTS

Ninety-four patients were operated on. Temporary and permanent postoperative hypoparathyroidism percentages were, respectively, 51.06% and 6.38%. iPTH level 24 h after the procedure was the most reliable predictor of post-thyroidectomy temporary hypoparathyroidism (Area Under the ROC Curve (AUC) = 0.933, p < .001). iPTH levels ​​≥29 pg/mL predicted normal parathyroid metabolism.

CONCLUSIONS

The combined values of iPTH and Ca levels 24 h after thyroidectomy seems to be a reliable, safe and efficient method to control the post-thyroidectomy hypoparathyroidism. Our protocol could reduce the hospital stay of patients at low risk of hypocalcaemia, allowing them to be discharged from the hospital on the first postoperative morning and identifying patients at high risk of hypocalcaemia early.

Thyroidectomy Outcomes in Obese Patients

INTRODUCTION

Obese patients often have higher complication rates after elective general surgeries; however, few studies have examined the outcomes after thyroidectomy. This study examines whether increased body mass index (BMI) is associated with poor postoperative outcomes after thyroid surgery.

METHODS

A retrospective review of patients who underwent thyroidectomy from 2015 to 2018 was performed. Demographics, comorbidities, pathology, and extent of resection (total versus hemithyroidectomy) were examined. Patients were classified into BMI groups according to the WHO definitions, and the incidence of surgical outcomes was determined in each group. Surgical outcomes of interest included readmission rates (RRs), length of stay, average operating room time, return to the operating room, hypocalcemia, postop infections, hematomas, and recurrent laryngeal nerve injury. Between-subjects statistics including independent samples t-test, ANOVA, and chi-square analyses were performed.

RESULTS

There were n = 465 patients included with a mean BMI 32.35 (standard deviation = 8.55) and median BMI 30.78 (Q1 = 26.26, Q3 = 36.73). There were no differences between BMI groups in age, gender, smoking, heart disease. There was a positive association between increased BMI and postoperative infection (P < 0.001), pneumonia (P = 0.018), and surgical site infection (P = 0.04), which were highest for BMI > 40. Increased BMI was associated with a higher 30-d RR (P = 0.008), particularly for BMI >40 versus BMI <40 (6.2% versus 1.05%; P = 0.003). There were no significant differences between surgical outcomes for patients with increased BMI who underwent total thyroidectomy or hemithyroidectomy.

CONCLUSIONS

Excellent postoperative outcomes were observed in all BMI categories. Higher postoperative infection and 30-d RRs were observed in the morbidly obese. Contrary to previous studies, operating room times were similar regardless of BMI.

Outcomes and predictors of complications of thyroidectomy in a scarce resource setting: Retrospective cross-sectional study

BACKGROUND

Outcomes and predictors of complications of thyroidectomy are diverse and have been extensively studied, but data from our country and other African countries with high disease burdens are limited.

OBJECTIVE

To evaluate the outcomes and predictors of complications of thyroidectomy among operated patients.

METHOD

Single institution retrospective cross-sectional study was conducted by reviewing charts from 365 patients who had undergone thyroidectomy on an elective basis between March 2018-February 2022. All patients who were admitted and underwent thyroidectomy were included in this study. Bivariate and multivariate logistic regressions were used to identify risk factors. P-value <0.05 was considered statistically significant.

RESULT

Overall, post-thyroidectomy complications occurred in 17 % of the cases. The two most common complications were hypocalcemia and voice change; the latter being due to injury of either external branch of superior laryngeal nerve or recurrent laryngeal nerve with an incidence of 4.9 % and 2.5 % respectively. Thyroidectomy performed by surgical residents and having total thyroidectomy were significantly associated with overall complications of thyroidectomy. Total thyroidectomy was found to be a risk factor for postoperative hypocalcemia (AOR = 12.24 (95%CI: 4.53, 19.65); P = 0.02). Younger age of the patient (AOR =0.3(95%CI, 0.12,0.51)) and prolonged duration of presentation (AOR = 2.53(95%CI, 1.17,7.76)) were detected predictors of voice change due to injury of either external branch of superior laryngeal nerve or recurrent laryngeal nerve.

CONCLUSION

The rate of thyroidectomy complications is relatively similar to other studies. In this study demographic and clinical factors associated with increased risk of complications after thyroid surgery were identified. This information will be useful for educating patients about the risks of thyroid surgery.

A unique complication of thyroidectomy for Hashimoto's thyroiditis: central retinal artery thrombosis

BACKGROUND

Central retinal artery occlusion (CRAO) is a rare ophthalmological emergency and also a unique complication after thyroid surgery.

METHODS

We present the first case of CRAO following thyroid surgery in a patient with Hashimoto's thyroiditis, along with a variety of interventions to overcome this complication.

RESULTS

A 42-year-old female patient suffering from sudden vision loss following total thyroidectomy was diagnosed with CRAO. Hyperbaric oxygen therapy was started within the postoperative first 6 hours.

CONCLUSION

Although it is extremely rare, it should be noted that patients may experience retinal artery occlusion following the thyroid surgery. Immediate evaluation of patients with visual impairment in the early postoperative period, and planning of emergent hyperbaric oxygen therapy for the management are critical.

The use of superior parathyroid gland as an anatomical landmark in identifying recurrent laryngeal nerve during total thyroidectomy: a prospective single-surgeon study

Purpose

This study was performed to determine the anatomical position of recurrent laryngeal nerve (RLN) relative to superior parathyroid gland (SPG) in a consecutive total thyroidectomy series.

Methods

A total of 421 patients (mean age, 45.6 years; female, 76.0%) who had total thyroidectomy accompanied with intraoperative exposure of RLN in relation to SPG were included in this prospective single-surgeon thyroidectomy series study. The relation of RLN to SPG was assessed based on the measurement of the natural distance between the RLN and SPG, which was categorized as 0-5 mm, 6-10 mm, and ≥11 mm.

Results

Most of the thyroidectomy indications (69.1%) were related to malignant disease including papillary carcinoma in 54.9% of cases. Overall, in 90.7% of patients RLN was identified within 5 mm of the SPG, and in 65.1% of cases, it was found within 1 mm of the SPG. The RLN was found between 6 and 10 mm from the SPG in 8.5% of cases, while it was at least 11 mm away from the SPG in 0.7% of cases.

Conclusion

In conclusion, this prospective single-surgeon thyroidectomy series study indicates the likelihood of localizing the RLN in close proximity to SPG during total thyroidectomy operations. Hence, the SPG can be used as a landmark to identify RLN, and as part of routine parathyroid-sparing thyroidectomy, it may represent a convenient complementary approach to minimize the risk of iatrogenic injury to RLN in patients with an intact SPG.

Results of thyroidectomies according to general surgeons and otolaryngologist and cervico faciale surgeons at the general Hospital of Reference of Niamey, what differences in the protocols of management?

OBJECTIVE

To evaluate the surgical management of thyroid pathologies at the Reference General Hospital.

METHODS

This was a retro-prospective study over 4 years 6 months carried out in the departments of General and Digestive Surgery (GDS) and Otorhinolaryngology and Cervico Facial Surgery (ORL/FCS). It involved 182 patients who underwent thyroid surgery.

RESULTS

A frequency of thyroidectomy of 9.46% was found. Females predominated with a sex ratio of 0.1. The average age of patients was 42.85 years, a standard deviation 12.80. 84.06% of patients had consulted for anterior cervical mass. EU-TIRADS score 3 represented 7,14% of cases. Heteromultinodular goiter was the main indication for thyroid surgery (59.34%). Total thyroidectomy was the most commonly performed gesture in general surgery in 88,23% (n = 105), in Otorhinolaryngology, it was in the same proportion as lobo-isthmectomy at 47.61% (n = 30). The first route was video-assisted thyroidectomy 2.2% (n = 4). The recurrent laryngeal nerve was dissected and seen in 159 cases (87.36%) and parathyroid glands were also seen and preserved in 58.24% of cases (n = 106). In immediate postoperative surgery, the main complications were unilateral recurrent paralysis with dysphonia in 3.3% (n = 6) and compressive hematoma in 2.2% (n = 4). No deaths had been recorded.

CONCLUSION

Total thyroidectomy was the most performed procedure in department of General and Digestive Surgery. Routine oral calcium and vitamin D supplementation in the general surgery ward, reduces the occurrence of hypocalcemia after total thyroidectomy and allows a safe and early exit. Standardizing protocols will further reduce complications.

Regional Collaboration and Trends in Clinical Management of Thyroid Cancer

OBJECTIVE

This study examines the trends in the management of thyroid cancer and clinical outcomes in the Southwestern region of The Netherlands from 2010 to 2021, where a regional collaborative network has been implemented in January 2016.

STUDY DESIGN

Retrospective cohort study.

SETTING

This study encompasses all patients diagnosed with thyroid cancer of any subtype between January 2010 and June 2021 in 10 collaborating hospitals in the Southwestern region of The Netherlands.

METHODS

The primary outcome of this study was the occurrence of postoperative complications. Secondary outcomes were trends in surgical management, centralization, and waiting times of patients with thyroid cancer.

RESULTS

This study included 1186 patients with thyroid cancer. Median follow-up was 58 [interquartile range: 24-95] months. Surgery was performed in 1027 (86.6%) patients. No differences in postoperative complications, such as long-term hypoparathyroidism, permanent recurrent nerve paresis, or reoperation due to bleeding were seen over time. The percentage of patients with low-risk papillary thyroid carcinoma referred to the academic hospital decreased from 85% (n = 120/142) in 2010 to 2013 to 70% (n = 120/171) in 2014 to 2017 and 62% (n = 100/162) in 2018 to 2021 (P < .01). The percentage of patients undergoing a hemithyroidectomy alone was 9% (n = 28/323) in 2010 to 2013 and increased to 20% (n = 63/317; P < .01) in 2018 to 2021.

CONCLUSION

The establishment of a regional oncological network coincided with a de-escalation of thyroid cancer treatment and centralization of complex patients and interventions. However, no differences in postoperative complications over time were observed. Determining the impact of regional oncological networks on quality of care is challenging in the absence of uniform quality indicators.

Role of Genetic Testing in the Management of Indeterminate Thyroid Nodules in the Indian Setting

The increased detection of thyroid nodules in the human population has led to an increase in the number of thyroid surgeries without an improvement in survival outcomes. Though the choice for surgery is straightforward in malignant thyroid nodules, the decision is far more complex in those nodules that get categorized into indeterminate thyroid nodules (ITN) by fine needle aspiration. Therefore, there is a pressing need to develop a tool that will aid in decision-making among the ITN. In this context, the development of various molecular testing (MT) panels has helped to confirm or rule out malignancy, reducing unnecessary surgeries and potentially guiding the extent of surgery as well. Currently, such tests are widely used among the Western population but these MT panels are not used by the South Asian population because of non-availability of validated panels and the high cost involved. There is a need to develop a suitable panel which is population-specific and validate the same. In this review, we would focus on current trends in the management of ITN among the South Asian population and how to develop a novel MT panel which is cost-effective, with high diagnostic accuracy obviating the need for expensive panels that already exist.

Factors Influencing a Favorable Outcome for RFA of Huge Benign Thyroid Nodules: Preliminary Results and Short-Term Evaluation

Objective

This study aimed to investigate potentially favorable factors influencing the therapeutic success of radiofrequency ablation (RFA) of huge benign thyroid nodules (BTNs) (volume >100 ml) and to evaluate the feasibility of RFA as an alternative treatment modality for patients unable or unwilling to undergo surgery.

Methods

This retrospective study evaluated a total of 868 patients, of which 22 patients had huge BTNs who underwent ultrasound-guided moving shot RFA treatment between May 2017 and January 2022. The huge BTNs were categorized into two groups according to a post-RFA treatment volume reduction ratio (VRR) of >80% and <80% at 6 months. Factors influencing these huge BTNs were reviewed, analyzed, and correlated with treatment effectiveness between the two groups.

Results

The factors influencing an effective VRR included huge BTNs located on the left side (OR 7.875, p = 0.03), predominant solid/spongiform nodules (OR 7.875, p = 0.03), and higher initial ablation rate (IAR) (p = 0.028). Multivariable logistic regression revealed predominant solid/spongiform nodule and the higher IAR were associated with the advanced VRR.

Conclusion

RFA was effective at decreasing the volume of huge BTNs with an acceptable complication rate. The BTN characteristics correlated with a better VRR at the 6-month short-term follow-up were predominant solid/spongiform BTNs and those with the first time ablation treatment initial ablation rate. Nevertheless, regarding the higher regrowth rate of these groups of patients who may need to be treated more times, RFA can only be a feasible alternative treatment modality for patients unable or unwilling to undergo operation.

Photothermal therapy of papillary thyroid cancer tumor xenografts with targeted thyroid stimulating hormone receptor antibody functionalized multiwalled carbon nanotubes

Multiwalled carbon nanotubes (MWCNTs) are being widely investigated in multiple biomedical applications including, and not limited to, drug delivery, gene therapy, imaging, biosensing, and tissue engineering. Their large surface area and aspect ratio in addition to their unique structural, optical properties, and thermal conductivity also make them potent candidates for novel hyperthermia therapy. Here we introduce thyroid hormone stimulating receptor (TSHR) antibody–conjugate–MWCNT formulation as an enhanced tumor targeting and light-absorbing device for the photoablation of xenografted BCPAP papillary thyroid cancer tumors. To ensure successful photothermal tumor ablation, we determined three key criteria that needed to be addressed: (1) predictive pre-operational modeling; (2) real-time monitoring of the tumor ablation process; and (3) post-operational follow-up to assess the efficacy and ensure complete response with minimal side effects. A COMSOL-based model of spatial temperature distributions of MWCNTs upon selected laser irradiation of the tumor was prepared to accurately predict the internal tumor temperature. This modeling ensured that 4.5W of total laser power delivered over 2 min, would cause an increase of tumor temperature above 45 ℃, and be needed to completely ablate the tumor while minimizing the damage to neighboring tissues. Experimentally, our temperature monitoring results were in line with our predictive modeling, with effective tumor photoablation leading to a significantly reduced post 5-week tumor recurrence using the TSHR-targeted MWCNTs. Ultimately, the results from this study support a utility for photosensitive biologically modified MWCNTs as a cancer therapeutic modality. Further studies will assist with the transition of photothermal therapy from preclinical studies to clinical evaluations.

Contralateral Low-to-Intermediate Suspicion Nodule Is Not a Contraindication for Lobectomy in Patients with Papillary Thyroid Carcinoma

Background: The optimal extent of surgery for unilateral papillary thyroid carcinoma (PTC) with contralateral nodules remains unclear. This study evaluated the long-term outcomes in a large cohort of patients with unilateral PTC and contralateral low-to-intermediate suspicious nodules who underwent lobectomy. Methods: This retrospective cohort study included patients with unilateral PTC who underwent lobectomy between January 2016 and December 2017 at Asan Medical Center in Korea. Patients were divided into two groups, those with and without contralateral nodules at the time of lobectomy: the Present group and the Absent group. All contralateral nodules observed at the time of surgery and during follow-up were evaluated. Results: The study cohort consisted of 1761 patients (1879 nodules), including 700 (39.8%) with and 1061 (60.2%) without contralateral nodules. The median size of the contralateral nodules was 0.5 cm. After a median follow-up of 59 months, the median growth of the contralateral nodules in the Present group was 0.1 cm (range, -3.4 to 4.7 cm). Of the contralateral nodules present at the time of lobectomy, 54.7% remained unchanged, decreased in size, or disappeared; whereas 14.8% increased ≥0.3 cm. Of the 700 patients with contralateral nodules, 20 (2.9%) were diagnosed with contralateral PTC. The 5-year contralateral PTC disease-free survival rates in patients with and without contralateral nodules were 98.2% and 99.3% (p = 0.003), respectively, whereas the 5-year recurrence-free survival rates did not differ significantly in these two groups. Of the 39 patients who underwent completion thyroidectomy, 2 (5.1%) experienced permanent hypocalcemia. Conclusions: Lobectomy may be a safe and feasible initial treatment option for patients with unilateral low-risk PTC and contralateral low-to-intermediate suspicious nodules.

The use of Zuckerkandl's tubercle as an anatomical landmark in identifying recurrent laryngeal nerve and superior parathyroid gland during total thyroidectomy: a prospective single-surgeon study

Objective

To determine the incidence and characteristics of Zuckerkandl's tubercle (ZT), and its relationship with recurrent laryngeal nerve (RLN) and the superior parathyroid gland (SPG) in the setting of total thyroidectomy.

Methods

A total of 421 patients (mean (min-max) age: 45.6 (18-78) years, 76.2% were females) who had total thyroidectomy were included in this prospective single-surgeon thyroidectomy series study. Patient demographics and thyroidectomy indications (benign and malignant) were recorded in each patient. The presence, grade and laterality of ZT, and its relationship with RLN and SPG were recorded during surgery.

Results

Most of the thyroidectomy indications (69.1%) were related to a malignant disease. The ZT was unrecognizable in 41(9.7%) of 421 patients. In 380 patients with identifiable ZT, the grade 2 (46.3%) ZT was the most common finding. Majority of ZTs (92.9%) were unilaterally located (right-sided: 64.9%; left-sided: 35.1%). In majority of the cases (83.2%), the RLN was found to lie medial to ZT. Overall, SPG was identified in close proximity to ZT in 66.6% of patients (Class 2 [0.5-1 cm from ZT] in 46.6% and Class 3 [<0.5 cm from ZT] in 20.0%). SPG was more likely to be identified in close proximity to ZT when the grade of ZT was higher, which was found to be located 0.5-1 cm from the ZT in 56.9% and 42.7% of grade 2 and grade 3 ZTs, respectively, and <0.5 cm from the ZT in 46.1% of grade 3 ZTs.

Conclusion

In conclusion, this prospective single-surgeon thyroidectomy series study indicates the likelihood of localizing the RLN medial to ZT, and the SPG in close proximity to ZT during total thyroidectomy operations. Hence, the ZT can be used as a reliable and constant landmark to localize both the RLN and the SPG during thyroid surgery, which enables minimizing the risk of iatrogenic injury to RLN, while ensuring a parathyroid-sparing thyroidectomy. The thyroid surgeon should have complete knowledge of thyroid gland anatomy and embryogenesis and should follow a careful and meticulous approach particularly for dissections around larger ZTs, given the increased likelihood of SPG and RLN to be in close proximity.

The Incidence Trend and Management of Thyroid Cancer-What Has Changed in the Past Years: Own Experience and Literature Review

Because of ambiguous and widely debated observations concerning the incidence, trend, and management of TC, we performed this analysis. We drew attention to some events, such as "cancer screening activity", introduction of noninvasive follicular neoplasm with papillary-like nuclear features (NIFTP) to TC types, possibility of papillary thyroid microcarcinoma (PTMC) active surveillance (AS), occurrence of personalized medicine in TC management, and, finally, COVID-19 pandemic time. Because of the opinion that all changes have been made mostly by PTC, we compared it to the remaining types of TC in terms of incidence, clinical and pathological characteristics, and treatment. We analyzed patients treated in a single surgical center in eastern Europe (Poland). The prevalence of TC significantly increased from 5.15% in 2008 to 13.84% in 2015, and then significantly decreased to 1.33% in 2022 when the COVID-19 pandemic lasted (p < 0.0001). A similar trend was observed for PTC, when the incidence significantly increased to 13.99% in 2015 and then decreased to 1.38% in 2022 (p < 0.0001). At that time, the NIFTP category was introduced, and observation of PTMC began. The prevalence of FTC and MTC also increased until 2015 and then decreased. Significant differences in age, types of surgery, necessity of reoperation, and pTNM between PTCs and other types of TCs were observed. The average age was significantly lower in PTC patients than in patients with the remaining types of TC (p < 0.0001). Four milestones, including NIFTP introduction, the possibility of PTMC AS, personalized cancer medicine, and the COVID-19 pandemic, may have influenced the general statistics of TC.

Robotic system for magnetic resonance imaging-guided focused ultrasound treatment of thyroid nodules

BACKGROUND

Herein, a robotic system offering Magnetic Resonance-guided Focused Ultrasound (MRgFUS) therapy of thyroid nodules was developed.

METHODS

The robotic system offers linear motion in 2 PC-controlled axes that navigate a 3 MHz single-element focused transducer. The system, through a C-arm structure attaches to the table of Magnetic Resonance Imaging (MRI) scanners and couples to the neck of patients lying in the supine position. The MRI compatibility of the developed system was assessed inside a 3 T scanner. Benchtop and MRI feasibility studies evaluating the heating performance of the system were executed on excised pork tissue and on homogeneous and thyroid model agar-based phantoms.

RESULTS

The MRI compatibility of the system was successfully established. Grid sonications executed using robotic motion inflicted discrete and overlapping lesions on the excised tissue, while magnetic resonance (MR) thermometry successfully monitored thermal heating in agar-based phantoms.

CONCLUSIONS

The developed system was found to be efficient with ex-vivo evaluation. The system can perform clinical MRgFUS therapy of thyroid nodules and other shallow targets after further in-vivo evaluation.

A Prospective Study of Electromyographic Amplitude Changes During Intraoperative Neural Monitoring for Open Thyroidectomy

BACKGROUND

Intraoperative nerve monitoring (IONM) of the vagus and recurrent laryngeal nerve (RLN) enables prediction of postoperative nerve function. The underlying mechanism for loss of signal (LOS) in a visually intact nerve is poorly understood. The correlation of intraoperative electromyographic amplitude changes (EMG) with surgical manoeuvres could help identify mechanisms of LOS during conventional thyroidectomy.

METHODS

A prospective study of consecutive patients undergoing thyroidectomy was performed with intermittent IONM using the NIM Vital nerve monitoring system. The ipsilateral vagus and RLN was stimulated, and vagus nerve signal amplitude recorded at five time points during thyroidectomy (baseline, after mobilisation of superior pole, medialisation of the thyroid lobe, before release at Ligament of Berry, end of case). RLN signal amplitude was recorded at two time points; after medialisation of the thyroid lobe (R1), and end of case (R2).

RESULTS

A total of 100 consecutive patients undergoing thyroidectomy were studied with 126 RLN at risk. The overall rate of LOS was 4.0%. Cases without LOS demonstrated a highly significant vagus nerve median percentage amplitude drop at medialisation of the thyroid lobe (- 17.9 ± 53.1%, P < 0.001), and end of case (- 16.0 ± 47.2%, P < 0.001) compared to baseline. RLN had no significant amplitude drop at R2 compared to R1 (P = 0.207).

CONCLUSIONS

A significant reduction in vagus nerve EMG amplitude at medialisation of the thyroid and the end of case compared to baseline indicates that stretch injury or traction forces during thyroid mobilisation are the most likely mechanism of RLN impairment during conventional thyroidectomy.

Thyroid ima artery embolization for the treatment of Graves' disease and thyroid storm

Graves' disease may be managed with thyroid embolization when other traditional strategies are less suitable. To date, no reports exist on the embolization of the thyroid ima artery for Graves' disease or the outcomes of this procedure. Here, we present a safe and successful report of thyroid ima artery embolization in a neutropenic patient with thyroid storm. A 30-year-old female with a history of Graves' disease presented to a community hospital with heat intolerance, anxiousness, tachycardia, and tachypnea. Further laboratory testing prompted the diagnosis of thyroid storm. Embolization of the thyroid was chosen for management because total thyroidectomy risked infection in the setting of methimazole-induced neutropenia. The patient's thyroid ima artery was significantly enlarged and had a large perfusion distribution across the thyroid. It was selected for embolization, along with the right superior thyroid artery, and successfully resulted in a 60% reduction of thyroid perfusion. No complications resulted from this procedure. Although the prevalence of patients with thyroid ima artery is low, this artery can be safely and effectively embolized for the management of Graves' disease and thyroid storm.

Parathyroid gland detection using an intraoperative autofluorescence handheld imager - early feasibility study

Introduction

Parathyroid glands may be compromised during thyroid surgery which can lead to hypoparathyroidism and hypocalcemia. Identifying the parathyroid glands relies on the surgeon's experience and the only way to confirm their presence was through tissue biopsy. Near infrared autofluorescence technology offers an opportunity for real-time, non-invasive identification of the parathyroid glands.

Methods

We used a new research prototype (hANDY-I) developed by Optosurgical, LLC. It offers coaxial excitation light and a dual-Red Green Blue/Near Infrared sensor that guides anatomical landmarks and can aid in identification of parathyroid glands by showing a combined autofluorescence and colored image simultaneously.

Results

We tested the imager during 23 thyroid surgery cases, where initial clinical feasibility data showed that out of 75 parathyroid glands inspected, 71 showed strong autofluorescence signal and were correctly identified (95% accuracy) by the imager.

Conclusions

The hANDY-I prototype demonstrated promising results in this feasibility study by aiding in real-time visualization of the parathyroid glands. However, further testing by conducting randomized clinical trials with a bigger sample size is required to study the effect on levels of hypoparathyroidism and hypocalcemia.

Patient's Scar Satisfaction after Conventional Thyroidectomy for Differentiated Thyroid Cancer

Differentiated thyroid carcinoma (DTC) is the most frequent endocrine neoplasm. Its treatment is based on surgery with consequent impact on patients' quality of life (QoL) and aesthetic implication. The aim of the present study is to assess scar satisfaction in patients affected by DTC who underwent total or partial thyroidectomy. A comparison was also made between scar satisfaction with different subcuticular suture. Validated questionnaires have been employed during a 3-month follow-up: Patient and Observer Scar Assessment Scale (POSAS) and the Patient Scar Assessment Questionnaire (PSAQ). Eventually, the impact of thyroid cancer on QoL of patients was performed in the studied population employing the Thyroid-related patient-reported outcome questionnaire (ThyPRO) and European Organisation for Research Additionally, Treatment of Cancer-Quality of Life questionnaire-C30 (EORTC QLQ-C30). It was conducted in a single center observational study considering 74 patients respecting inclusion criteria. Overall scar satisfaction was found to improve during follow-up, reaching the best scores at 3 months from surgery. Subcuticular suture does not seem to influence the scar satisfaction. In our study male patients seem to be more satisfied, on the other hand age does not seem to influence satisfaction. Overall, the ThyPRO questionnaire and EORTC QLQ-C30 scores did not statistically differ between preoperative and postoperative suggesting a small impact of DTC in QoL.

Modern Surgical Techniques of Thyroidectomy and Advances in the Prevention and Treatment of Perioperative Complications

Thyroid cancer is the most common cancer of the endocrine system, and, in recent years, there has been a phenomenon of overdiagnosis followed by subsequent overtreatment. This results in an increasing number of thyroidectomy complications being faced in clinical practice. In this paper, we present the current state of knowledge and the latest findings in the fields of modern surgical techniques, thermal ablation, the identification and assessment of parathyroid function, recurrent laryngeal nerve monitoring and treatment and perioperative bleeding. We reviewed 485 papers, from which we selected 125 papers that are the most relevant. The main merit of this article is its comprehensive view of the subject under discussion-both general, concerning the selection of the appropriate method of surgery, and particular, concerning the selection of the appropriate method of prevention or treatment of selected perioperative complications.

US Features of the Parathyroid Glands: An Intraoperative Surgical Specimen Study

Purpose

This study aimed to evaluate the US features of the parathyroid glands (PTGs) using surgical specimens of normal PTGs obtained during thyroid surgery.

Materials and Methods

This study included 34 normal PTGs from 17 consecutive patients who underwent thyroid surgery between December 2020 and March 2021. All normal PTGs were histologically confirmed by intraoperative frozen-section biopsy for autotransplantation. Surgically resected parathyroid specimens were scanned in sterile normal saline using high-resolution US prior to autotransplantation. The US features of echogenicity (hyperechogenicity or hypoechogenicity), echotexture (homogeneous or heterogeneous), size, and shape (ovoid or round) were retrospectively evaluated. The echogenicity of the three PTGs was compared with that of the thyroid parenchyma of the resected thyroid specimens in two patients.

Results

All PTGs showed hyperechogenicity similar to that of gauze soaked in normal saline. Homogeneous hyperechogenicity was observed in 32/34 (94.1%) patients, and the echogenicity of the three PTGs was hyperechoic compared with that of the thyroid parenchyma. The long diameter of the PTGs ranged from 5.1 mm to 9.8 mm (mean, 7.1 mm) and the shape of the PTGs was ovoid in 33/34 (97.1%) patients.

Conclusion

The echogenicity of normal PTG specimens was consistently hyperechoic, and the small ovoid homogeneously hyperechoic structure was a characteristic US feature of the PTGs.

Frequency and Risk Factors of Permanent Hypoparathyroidism After Total Thyroidectomy: An Experience at a Tertiary Care Hospital in Pakistan

OBJECTIVES

Thyroid surgeries are among the most common operations performed in the world. Hypocalcemia following total thyroidectomy (TT) is a common complication that is sometimes difficult to correct. This study aims to determine the frequency of hypocalcemia and permanent hypoparathyroidism (PtHPT) following TT.

METHODS

A total of 363 patient records were reviewed who underwent TT for any reason. Thirty-eight patients did not have a follow-up in the clinic in the postoperative period and were excluded from the final analysis with the final sample as 325. For patients who developed hypocalcemia during the postoperative hospital stay, their lowest calcium levels were recorded and medical records were reviewed for the period of one year for the requirement of oral calcium and active form of vitamin D (calcitriol or alpha calcidiol) in the outpatient setting. Patients who required calcium and vitamin D supplementation for up to 1 year were labeled as having PtHPT. Risk factors were analyzed among those who developed PtHPT.

RESULTS

From a total of 325 patients postoperative hypocalcemia developed in 163 (50.2%) patients, and 162 (49.8%) patients remained normocalcemic. Permanent hypoparathyroidism was found in 42(12.9%) patients and transient HPT in 121 (37.2%). Age, severe postoperative hypocalcemia (PoHC), and readmission for hypocalcemia were independent risk factors for PtHPT.

CONCLUSIONS

Transient hypoparathyroidism (THPT) is common in our setup. Patients who develop severe hypocalcemia postoperatively and need readmission should be closely followed for the development of PtHPT.

Effectiveness of Direct Transcricothyroid Electromyographic Monitoring in Thyroidectomy Surgery

Thyroid surgeries are associated with complications of vocal cord palsy and hypocalcemia which can be debilitating. The usage of intraoperative nerve monitoring is a useful adjunct to direct nerve visualization in thyroidectomies. We advocate the usage of direct transcricothyroid electromyographic monitoring in identifying recurrent laryngeal nerve. We retrospectively collected data of all patients who underwent thyroidectomies (total thyroidectomy, hemithyroidectomy, isthmusdectomy) using direct transcricothyroid electromyographic monitoring from April 2020 to August 2021. Data was analysed based on patient's demographics, comorbidities, complications post thyroidectomy such as vocal cord palsy, transient and permanent hypocalcemia. 50 thyroidectomies were performed, 10 developed unilateral vocal cord palsy. Out of 22 total thyroidectomies, 7 developed transient hypocalcemia and 4 permanently. 1 patient developed vocal cord hematoma secondary to direct insertion of intraoperative nerve monitor's electrode. Direct transcricothyroid electromyographic monitoring is a feasible and effective method in intraoperative monitoring of recurrent laryngeal nerve during thyroid surgeries.

The effect of different therapeutic treatments on the frequency of postoperative hypocalcemia in patients with thyroidectomy

Objectives

Thyroid gland surgery and its surgical complications are situations that a surgeon frequently encounters in his daily practice. In our study, it was aimed to examine the effect of different treatment methods given to patients who underwent thyroidectomy on hypocalcemia.

Material and Methods

Three hundred and seventy-one patients who underwent thyroidectomy at Ondokuz Mayıs University Medical Faculty General Surgery clinic between December 2016 and January 2021 were retrospectively included in the study. Parameters such as surgery indications, fine needle aspiration biopsy results, preoperative serum calcium values, type of surgery, serum calcium values at postoperative 1^st day and 1^st month, postoperative hospital stay, drugs prescribed at discharge, histopathological diagnosis of the patient, and whether there was incidental parathyroidectomy or not were included.

Results

Mean age of 371 patients who underwent thyroidectomy was 49 (19-82) years. Total thyroidectomy was the most common type of thyroidectomy with 61% (n= 225) of the patients. There was a significant decrease in pre-op and post-op calcium values in all three types of surgery performed on the patients, and there was no significant difference between the different types of surgery. Post-operative day one and month one serum calcium values were significantly increased in all groups (p= .000). The increase in post-op serum calcium level was most common in the group using calcium carbonate + cholecalciferol + calcitriol.

Conclusion

The use of post-op calcitriol in patients undergoing thyroidectomy seems to be quite effective in preventing the development of hypocalcemia.

Strategies for Treatment of Thyroid Cancer

More people are diagnosed with thyroid cancer than any other endocrine tumor. Differentiated thyroid cancer is often treated by removing the thyroid gland (thyroidectomy), iodizing radiation, or inhibiting thyroid stimulating hormone (TSH). Advanced thyroid carcinomas are notoriously resistant to chemotherapy, thus the pursuit of alternative treatments is vital. The best methods for treating individuals with advanced nonmedullary and medullary thyroid carcinomas are discussed in this post. Numerous tyrosine kinase inhibitors and antiangiogenic inhibitors, two types of novel target therapy, have shown promise in studies for individuals with thyroid cancer. Both the positive and unfavourable outcomes of clinical studies of these drugs were addressed. The findings presented here are encouraging, but more study is required to establish whether or not this method is effective in the treatment of thyroid cancer.

Upgraded hydrodissection and its safety enhancement in microwave ablation of papillary thyroid cancer: a comparative study

OBJECTIVES

To study the efficacy and safety of an improved hydrodissection protocol based on the perithyroidal fascial space during microwave ablation for papillary thyroid carcinoma (PTC).

METHODS

The data of 341 patients (94 men and 247 women, median age 41 years old, 25%-75% interquartile range 34-53 years old, nodule maximum diameter 0.2-1.9 cm) who underwent microwave ablation for PTC were retrospectively reviewed. Among them, 185 patients underwent traditional hydrodissection and served as a control group, and 156 patients underwent improved hydrodissection based on perithyroidal fascial spaces, constituting the improved group. Improvements in safety were analyzed by comparing complications between the two groups. The characteristics of hydrodissected spaces, complications, and follow-up results were recorded.

RESULTS

Hydrodissection was successfully performed in all enrolled patients according to the protocol. The incidence of hoarseness caused by recurrent laryngeal nerve injury, the most common complication in thermal ablation of thyroid nodules, was significantly lower in the improved group than in the control group (1.9% vs. 8.1%, p = 0.021). The median hoarseness recovery time in the improved group was shorter than that in the control group (2 months vs. 3 months, p = 0.032). During follow-up, no local recurrence was encountered in either group. The tumor disappearance rate was not significantly different between the two groups (69.9% vs. 75.7%, p = 0.228).

CONCLUSIONS

Improved hydrodissection based on perithyroidal fascial spaces had better protective effects than traditional hydrodissection.

Is routine drainage necessary after thyroid surgery? A randomized controlled trial study

Objective

To evaluate whether no drainage has an advantage over routine drainage in patients with thyroid carcinoma after unilateral thyroid lobectomy and central neck dissection.

Methods

A total of 104 patients with thyroid cancer who underwent unilateral thyroid lobectomy and central lymph node dissection were randomly assigned into no drainage tube (n=52) and routine drainage tube (n=52) placement groups. General information of each patient was recorded, including the postoperative drainage volume/residual cavity fluid volume, postoperative complications, incision area comfort, and other data, and the thyroid cancer-specific quality of life questionnaire (THYCA-QoL) and patient and observer scar assessment scale (POSAS) were evaluated after surgery. At the 3-6 month follow-up exam, the differences between the two groups were compared based on univariate analysis.

Results

Significant differences were not observed in the general and pathological information (including sex, age, body weight, body mass index (BMI), incision length, specimen volume, Hashimoto's thyroiditis, and number of lymph nodes dissected), operation time, and postoperative complications (postoperative bleeding, incision infection, lymphatic leakage, and temporary hypoparathyroidism) between the two groups. The patients in the non-drainage group had a shorter hospital stay (2.11 ± 0.33 d) than the patients in the drainage group (3.38 ± 0.90 d) (P<0.001). The amount of cervical effusion in patients in the non-drainage group (postoperative 24h: 2.20 ± 1.24 ml/48 h: 1.53 ± 1.07 ml) was significantly less than that in the drainage group (postoperative 24 hours: 22.58 ± 5.81 ml/48 h: 36.15 ± 7.61 ml) (all P<0.001). The proportion of incision exudation and incision numbness in the non-drainage group was lower than that in the drainage group (all P<0.05), and the pain score (VAS) and neck foreign body sensation score (FBST) decreased significantly (P<0.05). During the 3- and 6-month follow-up exams, significant differences were not observed between the THYCA-QoL and drainage groups and the non-drainage group, although the scarring and POSAS values were lower than those in the drainage group. In addition, the length of stay and cost of hospitalization in the non-drainage group were lower than those in the drainage group (P<0.05).

Conclusion

Routine drainage tube insertion is not needed in patients with unilateral thyroid lobectomy and central neck dissection.

Preoperative ultrasound identification and localization of the inferior parathyroid glands in thyroid surgery

INTRODUCTION

The parathyroid glands are important endocrine glands for maintaining calcium and phosphorus metabolism, and they are vulnerable to accidental injuries during thyroid cancer surgery. The aim of this retrospective study was to investigate the application of high-frequency ultrasound imaging for preoperative anatomical localization of the parathyroid glands in patients with thyroid cancer and to analyze the protective effect of this technique on the parathyroid glands and its effect on reducing postoperative complications.

MATERIALS AND METHODS

A total of 165 patients who were operated for thyroid cancer in our hospital were included. The patients were assigned into two groups according to the time period of surgery: Control group, May 2018 to February 2021 (before the application of ultrasound localization of parathyroid in our hospital); PUS group, March 2021 to May 2022. In PUS group, preoperative ultrasound was used to determine the size and location of bilateral inferior parathyroid glands to help surgeons identify and protect the parathyroid glands during operation. We compared the preoperative ultrasound results with the intraoperative observations. Preoperative and first day postoperative serum calcium and PTH were measured in both groups.

RESULTS

Our preoperative parathyroid ultrasound identification technique has more than 90% accuracy (true positive rate) to confirm the location of parathyroid gland compared to intraoperative observations. Postoperative biochemical results showed a better Ca²⁺ [2.12(0.17) vs. 2.05(0.31), P=0.03] and PTH [27.48(14.88) vs. 23.27(16.58), P=0.005] levels at first day post-operation in PUS group compared to control group. We also found a reduced risk of at least one type of hypoparathyroidism after surgery in control group:26 cases (31.0%) vs. 41 cases (50.6%), p=0.016.

CONCLUSION

Ultrasound localization of the parathyroid glands can help in the localization, identification and in situ preservation of the parathyroid glands during thyroidectomy. It can effectively reduce the risk of hypoparathyroidism after thyroid surgery.

The learning curve for single-port transaxillary robotic thyroidectomy (SP-TART): experience through initial 50 cases of lobectomy

The new da Vinci® single-port (SP) robotic system, which utilizes a smaller incision and work space compared to the previous versions, is suitable for thyroidectomy. This study aimed to evaluate the learning curve for SP transaxillary robotic thyroidectomy (SP-TART) in a single-center. Fifty consecutive patients who underwent SP-TART between October 2021 and April 2022 in Seoul St. Mary's Hospital in Seoul, Korea, were included in this retrospective analysis. We examined the clinicopathological characteristics and short-term surgical outcomes and assessed the learning curve for SP-TART using cumulative summation analysis. The mean operation time was 57.8 ± 14.1 min, and the mean tumor size was 1.0 ± 0.7 (range, 0.3-3.7) cm. The patients were discharged approximately 2 days after surgery, and only two (4%) patients developed postoperative complications, including drainage-site bleeding and surgical site infection. Risk factors for long operation time were thyroiditis, amount of blood loss, and lymph node metastasis. The learning curve for SP-TART was 20 cases for the experienced robotic surgeon. SP-TART is technically feasible and safe with a short incision length and short operation time. It is a valuable alternative operative option with good surgical outcomes and outstanding cosmetic results.

Loupe Assisted Thyroidectomy: A Tool for Reducing Complications

The objective of this study is to assess if the use of magnification can reduce the incidence of hypocalcemia and vocal cord palsy in thyroid surgery. Data of patients who underwent total thyroidectomy (N = 50) for thyroid malignancy were analyzed retrospectively for 1 year. The patients were divided into two groups based on surgery with and without loupes. Hypocalcemia and Vocal cord palsy was assessed pre as well as post-operatively and the observations were noted. Descriptive statistics were performed to assess the proportion of the respective groups. Inferential statistics to find out the difference between the groups was done using the chi-square test. Significance level was kept at 5%. The incidence of hypocalcemia was 36.9% in the group done without loupes compared to 7.6% with loupes. The event of vocal cord injury though transient was 33% when done without loupes (p < 0.05). Magnification is crucial for the visualization of the neurovascular anatomy which is depicted in our study. Although the study includes less number of cases, it is evident that the use of loupe magnification can reduce the morbidity associated with thyroid surgery to a great extent. We recommend the use of loupe magnification during surgery whenever possible.

Near-infrared fluorescent imaging techniques for the detection and preservation of parathyroid glands during endocrine surgery

Objectives

In over 30% of all thyroid surgeries, complications arise from transient and definitive hypoparathyroidism, underscoring the need for real-time identification and preservation of parathyroid glands (PGs). Here, we evaluate the promising intraoperative optical technologies available for the identification, preservation, and functional assessment of PGs to enhance endocrine surgery.

Methods

We performed a review of the literature to identify published studies on fluorescence imaging in thyroid and parathyroid surgery.

Results

Fluorescence imaging is a well-demonstrated approach for both in vivo and in vitro localization of specific cells or tissues, and is gaining popularity as a technique to detect PGs during endocrine surgery. Autofluorescence (AF) imaging and indocyanine green (ICG) angiography are two emerging optical techniques to improve outcomes in thyroid and parathyroid surgeries. Near-infrared-guided technology has significantly contributed to the localization of PGs, through the detection of glandular AF. Perfusion through the PGs can be visualized with ICG, which can also reveal the blood supply after dissection.

Conclusions

Near infrared AF and ICG angiography, providing a valuable spatial and anatomical information, can decrease the incidence of complications in thyroid surgery.

Intraoperative Assessment of High-Risk Thyroid Nodules Based on Electrical Impedance Measurements: A Feasibility Study

Precise diagnosis of thyroid nodules is challenging due to non-diagnostic/inconclusive results and uncertainties about the malignancy of follicular neoplasms (FNs), even in frozen-section pathology. Therefore, surgical management, especially in Bethesda III and IV categories, may be complicated, and sometimes a second surgery may be required. The Thyroid Nodule Impedance Measurement System (TN-IMS) consists of a metallic patch attached to submental skin and a G20 I.V. cannula inserted into the targeted nodules. Two impedance-based parameters named Z1kHz and impedance phase slope (IPS) in 100 kHz to 500 kHz of the thyroid nodules are recorded and compared with their histopathological results as the gold standard. TN-IMS was intra-surgically applied to 103 human thyroid nodules and normal thyroid tissues. A remarkable consistency between defined co-ranges of Z1kHz/IPS and the histopathological status of specimens was achieved (p < 0.001). Based on these measurements, it was concluded that intraoperative bioelectrical impedance scanning of thyroid nodules would be a helpful complementary approach to detecting high-risk excision-required thyroid nodules.

Propensity Score Matched Outcome Analysis of Lobar Ablation Versus Completion Thyroidectomy in Low-Risk Differentiated Thyroid Cancer Patients: Median Follow-Up of 11 Years

Background: Radioactive iodine lobar ablation (RAILA) of the contralateral thyroid lobe has been suggested as an alternative to completion thyroidectomy in patients of differentiated thyroid cancer (DTC) who underwent initial hemithyroidectomy. However, data on long-term outcomes are scarce. In this study, we intended to describe the long-term outcomes of RAILA versus completion thyroidectomy in a cohort of low-risk DTC patients. Methods: Data of patients with low-risk DTC who underwent initial hemithyroidectomy, and were subsequently treated with either completion thyroidectomy or RAILA between 1996 and 2015, were collected and analyzed. The treatment outcomes included ablation rate, recurrence rate, recurrence-free survival (RFS), and adverse events, and were validated by propensity score matching analysis. Results: Of the 1243 patients (median age: 34 years, range: 5-78) with low-risk DTC, 514 patients underwent upfront RAILA while 729 patients underwent completion thyroidectomy followed by remnant ablation. The ablation rate following the first radioactive iodine (¹³¹I) cycle was 75.3% [95% confidence interval (CI) 71.3-78.9] in the RAILA group versus 84.1% [CI 81.2-86.6] in the completion thyroidectomy group (p < 0.001). Over median follow-up of 11.4 years (interquartile range: 8.3-15.8), the recurrence rates between the two groups were not significantly different (1.6% [CI 0.7-3.2] vs. 1.0% [CI 0.4-2.1], respectively, p = 0.343). The product limit estimate of RFS at 10 years was 98.6% [CI 97.6-99.6%] in the RAILA group versus 99.1% [CI 98.3-99.9%] in the completion thyroidectomy group (p = 0.391). The outcomes in 497 matched pairs generated through propensity score analysis were similar. None of the patients in the RAILA group experienced permanent hypocalcemia or recurrent laryngeal nerve palsy, while the corresponding rates in the completion thyroidectomy group were 10/729 (1.4%) (p = 0.006) and 5/729 (0.7%) (p = 0.080), respectively. Radiation thyroiditis was seen in 25/514 (4.9%) patients in the RAILA group versus 3/729 (0.4%) in the completion thyroidectomy group (p < 0.001). Conclusions: Upfront RAILA is seen to be a noninvasive, safe, and effective alternative to surgical completion thyroidectomy in low-risk DTC patients in the absence of macroscopic malignancy in the remaining thyroid lobe.

An Audit of the Procedure of Open Thyroidectomy at A Tertiary Care Centre

We plan to evaluate the various variables associated with the complications of thyroidectomy performed at our department in the last 5 years. Medical records of the patients who underwent thyroidectomy during 2014-2018 were collected. Complications of hypocalcemia and recurrent laryngeal nerve palsy were analysed in terms of the demography, cytopathology and the extent of surgery. Student's t-test, Mann-Whitney U-test, Fisher exact test and chi square test were applied to look for any significant associations. P value < 0.05 was considered significant. 123 patients were analysed (87 females, 38 males). Mean age was 38.3 years (range 11-71 years). Most common cytopathology was papillary carcinoma thyroid (Bethesda VI) - 43/123 (35%). 107 of these 123 patients underwent primary surgery, 10 underwent revision surgery while 6 underwent completion thyroidectomy. Seven patients incurred RLN palsy out of which 3 were temporary. RLN palsy was seen in only malignant cases (p < 0.05). Incidence was higher in T4a stage (p < 0.05). However, it had no association with a simultaneous central or lateral neck dissection. Hypocalcemia was seen in 22 patients (17.8%), out of whom 9 patients developed permanent hypocalcemia. It was seen significantly higher in patients undergoing central neck dissection (p < 0.05) and in malignant thyroid lesions (p < 0.05). Gender, age and the cytopathology had no bearing on RLN palsy and hypoparathyroidism. Malignant thyroid lesions had a significantly higher incidence of RLN palsy and hypoparathyroidism. A thorough anatomical knowledge can reduce the incidence of these complications.

Update on the Diagnosis and Management of Medullary Thyroid Cancer: What Has Changed in Recent Years?

Medullary thyroid carcinoma (MTC) is a neoplasm originating from parafollicular C cells. MTC is a rare disease, but its prognosis is less favorable than that of well-differentiated thyroid cancers. To improve the prognosis of patients with MTC, early diagnosis and prompt therapeutic management are crucial. In the following paper, recent advances in laboratory and imaging diagnostics and also pharmacological and surgical therapies of MTC are discussed. Currently, a thriving direction of development for laboratory diagnostics is immunohistochemistry. The primary imaging modality in the diagnosis of MTC is the ultrasound, but opportunities for development are seen primarily in nuclear medicine techniques. Surgical management is the primary method of treating MTCs. There are numerous publications concerning the stratification of particular lymph node compartments for removal. With the introduction of more effective methods of intraoperative parathyroid identification, the complication rate of surgical treatment may be reduced. The currently used pharmacotherapy is characterized by high toxicity. Moreover, the main limitation of current pharmacotherapy is the development of drug resistance. Currently, there is ongoing research on the use of tyrosine kinase inhibitors (TKIs), highly specific RET inhibitors, radiotherapy and immunotherapy. These new therapies may improve the prognosis of patients with MTCs.

Re-do Operation Using a Robotic System due to Locoregional Recurrence after Initial Thyroidectomy for Thyroid Cancer

Locoregional recurrent thyroid cancer is commonly treated with re-do operation. This study aimed to investigate the feasibility of using robotic system for re-do operation in locoregional recurrent thyroid cancer. Sixty-five patients who underwent re-do robotic operation using trans-axillary approach for locoregional recurrent thyroid cancer from October 2007 to April 2021 at Yonsei University Hospital were analyzed. Completion total thyroidectomy (CTT) was performed in 26 cases, CTT and modified radical neck node dissection (mRND) in 16, and mRND in 23. Most of the re-do robotic operations were performed at site of previous incision. All patients were diagnosed with papillary thyroid carcinoma (PTC). CTT with central compartment neck dissection (CCND) took 117.6 ± 26.3 min, CTT with mRND 255.6 ± 38.6 min, and mRND, 211.7 ± 52.9 min. Transient hypocalcemia occurred in 17 (26.2%) patients and permanent hypocalcemia occurred in 3 (4.6%). There was one case of recurrent laryngeal nerve(RLN) injury. One patient was diagnosed with structural recurrence after re-do robotic operation. Median follow-up duration was 50.7 ± 37.1 months. Re-do robotic operation can be an alternative for patients who are diagnosed with locoregional recurrent thyroid cancer after thyroidectomy, with no increase in morbidity, similar oncologic outcomes, and superior cosmetic satisfaction.

Health-Related Quality of Life following Total Thyroidectomy and Lobectomy for Differentiated Thyroid Carcinoma: A Systematic Review

Health-related quality of life (HrQoL) is a major concern for patients with differentiated thyroid carcinoma (DTC). We aimed to systematically review the literature comparing HrQol following total thyroidectomy (TT) and hemithyroidectomy (HT) in DTC patients. A systematic review of publications indexed in Medline, Embase, and EBM reviews—Cochrane Central Register of Controlled Trials, which evaluated HrQoL following thyroid surgery for DTC, was conducted. Of 2507 identified records, 25 fulfilled the inclusion criteria. Our results suggest that patients undergoing TT may suffer more impairment in physical and social HrQoL than patients undergoing HT. Psychological-related HrQoL and long-term global HrQoL are, however, equivalent in both groups, which highlights the multidimensional nature of HrQoL and the importance of a multitude of factors aside from treatment modalities and related morbidities, such as the experience of receiving a cancer diagnosis, the fear of cancer recurrence, and other psychosocial factors. Addressing postoperative HrQoL when discussing therapeutic options with patients is an integral part of patient-centered care and informed shared decision-making, and should be approached in a holistic manner, accounting for its physical, psychological, and social aspects. This review supplies evidence regarding HrQoL following thyroid surgery, which can be employed in such decisions.

Transient Hypocalcemia After Total Thyroidectomy: The Obesity Paradox at Work?

INTRODUCTION

With increasing rates of obesity worldwide, a correlation between high body mass index (BMI) and postoperative morbidity after thyroid surgery remains unclear. Postoperative transient hypocalcemia is common after total thyroidectomy due to interruption of parathyroid function. This study examines the relationship between BMI and hypocalcemia after total thyroidectomy.

MATERIALS AND METHODS

A retrospective review of prospectively collected data for 1135 patients who underwent total thyroidectomy for cancer, multinodular goiter (MNG), or Graves' disease between June 2009 and November 2020 at a single institution was performed. BMI groups followed the World Health Organization classification. Hypocalcemia was defined as serum calcium ≤8 mg/dL. Calcium levels measured on postoperative day 0 and the following morning were compared between the BMI groups.

RESULTS

Of 1135 total thyroidectomy patients, 85% were women. The mean age and standard deviation of patients was 49 (± 13) y, with most of Hispanic origin (64%). Overall, 41.5% of patients had cancer, 45% nontoxic MNG, 5.8% toxic MNG, and 12% Graves' disease. Stratified by BMI, 27% of patients were normal, 34% overweight, and 39% obese. Overall, overweight and obese patients experienced less transient hypocalcemia at both time points compared to normal patients postoperatively (P = 0.01 and P = 0.009). Furthermore, overweight and obese patients with Graves' disease experienced less transient hypocalcemia at both time points (P = 0.04 and P = 0.05). There was no statistical difference in other groups.

CONCLUSIONS

A protective role of higher BMI or "obesity paradox" for postoperative hypocalcemia may exist in those obese patients after total thyroidectomy.

Efficacy of Radioiodine Therapy in Patients With Primary Hyperthyroidism: An Institutional Review From Pakistan

Background

Radioactive iodine (RAI) is the treatment of choice for most patients with primary hyperthyroidism. The most common etiologies of hyperthyroidism are Graves' disease (GD), toxic adenoma (TA), and toxic multinodular goiter (TMNG). A single dose of RAI is usually sufficient to cure hyperthyroidism. The aim of this study was to assess the effectiveness of RAI therapy for patients diagnosed with primary hyperthyroidism.

Methods and materials

Patients diagnosed with hyperthyroidism who received RAI therapy between 2008 and 2018 were included in the study. The data was acquired from the hospital's electronic medical record system. Following the RAI treatment, a cure was defined as the development of euthyroidism or hypothyroidism after a single fixed-dose without antithyroid medication within one year of RAI therapy. In addition, a simple logistics regression model was used to identify the prognostic factors that may lead to better outcomes.

Results

A total of 112 patients diagnosed with hyperthyroidism with a mean age of 47 ± 14 were included in this study. The majority of the patients were female, 79 (70.5%). Within one year of RAI therapy, 84 (75%) patients achieved a cure that is either hypothyroid or euthyroid status. RAI dose was higher in responsive patients (18.50 ± 4.10 millicurie [mCi] versus 16.50 ± 4.10 mCi) than in non-responsive patients. The mean RAI doses were 16.05 ± 2.99 mCi in GD, 19.81 ± 4.40 mCi in TMNG, and 20.50 ± 3.30 mCi in TA, with a statistically significant p-value of 0.001. In the univariable logistic regression model, RAI dose was a significant prognostic factor of the responsive group (OR: 1.15, CI [1.01-1.31], p-value 0.03).

Conclusion

Our data presented that RAI therapy is effective for primary hyperthyroidism. We achieved remission with a single fixed-dose in the majority of patients. Most of our patients were cured within three months of RAI therapy. In addition, the RAI dose was higher in the responsive group as compared to the non-responsive group.

A clinically relevant formulation for direct administration of nerve specific fluorophores to mitigate iatrogenic nerve injury

Iatrogenic nerve injury significantly affects surgical outcomes. Although intraoperative neuromonitoring is utilized, nerve identification remains challenging and the success of nerve sparing is strongly correlated with surgeon experience levels. Fluorescence guided surgery (FGS) offers a potential solution for improved nerve sparing by providing direct visualization of nerve tissue intraoperatively. However, novel probes for FGS face a long regulatory pathway to achieve clinical translation. Herein, we report on the development of a clinically-viable, gel-based formulation that enables direct administration of nerve-specific probes for nerve sparing FGS applications, facilitating clinical translation via the exploratory investigational new drug (eIND) guidance. The developed formulation possesses unique gelling characteristics, allowing it to be easily spread as a liquid followed by rapid gelling for subsequent tissue hold. Optimization of the direct administration protocol with our gel-based formulation enabled a total staining time of 1-2 min for compatibility with surgical procedures and successful clinical translation.

Seasonal variation in calcium treatment after thyroidectomy as surrogate for post-operative hypocalcemia: a retrospective register-based national cohort study

Background

Hypocalcemia is one of the most common complications of thyroidectomy, and vitamin D deficiency has been found to be an independent risk factor. Sweden is located north of the 55th latitude, resulting in a significant seasonal variation in sun exposure, thereby large variation in the naturally occurring levels of vitamin D. This study aimed to determine if there is a correlation between season of surgery and post-thyroidectomy hypocalcemia.

Methods

We conducted a retrospective register-based observation study on patients who had undergone total thyroidectomy during 2008–2015. In total, 7125 patients operated in Swedish facilities were identified via the Scandinavian Quality Register for Thyroid, Parathyroid, and Adrenal Surgery (SQRTPA). Patients operated during February–April were included in the dark group and patients operated during August–October were included in the bright group. Further stratification was made on the indication for surgery. The primary outcome was post-operative calcium treatment due to hypocalcemia, defined as having received calcium orally or intravenously before discharge.

Results

The risk of receiving post-operative calcium treatment was significantly lower in the bright group (29.7%) compared to the dark group (35.1%), with a relative risk of 0.846 (P < 0.001). This correlation held true if the indication for surgery was goiter or thyrotoxicosis. For malignancy, there was no significant difference between the groups.

Conclusion

In this cohort, total thyroidectomy performed during August–October was associated with a lower rate of calcium treatment given post-operatively when compared to total thyroidectomy performed during February–April. This would indicate a decreased risk of post-operative hypocalcemia if surgery was carried out after the brighter season.

Hipocalcemia posterior a tiroidectomía total: Análisis de dosis para suplemento rutinario profiláctico

Introducción. La hipocalcemia es la complicación más frecuente de la tiroidectomía. La profilaxis con calcio/ calcitriol es una alternativa costo-efectiva, sencilla y expedita para disminuir esta situación, sin alterar la función paratiroidea residual. Lo que no está claro es si hay superioridad de una dosis frente a otra, por lo que el objetivo de este estudio fue evaluar el comportamiento entre diferentes esquemas de profilaxis para hipocalcemia. Métodos. Estudio de cohorte retrospectivo de adultos operados en un hospital de cuarto nivel, entre febrero de 2017 y diciembre de 2020. Se calculó la tasa de síntomas, la hipocalcemia e hipercalcemia bioquímica en el control postquirúrgico durante las siguientes dos semanas. Se hizo análisis bivariado y multivariado entre dosis de calcio/ calcitriol, otros factores asociados y los desenlaces mencionados. Resultados. Se incluyeron 967 pacientes. El 10 % presentaron síntomas. No hubo diferencias significativas en el calcio sérico del control posquirúrgico entre los grupos con distintas dosis de calcio. La dosis de carbonato de calcio >3600 mg/día y el calcio en las primeras 24 horas de cirugía se asociaron a la presencia de síntomas. La dosis de calcitriol  <1 mcg/día y el bocio aumentaron el riesgo de hipocalcemia bioquímica, mientras que la dosis de 1,5 mcg/día lo disminuyó. Ninguna variable evaluada se asoció a hipercalcemia bioquímica. Conclusiones. Teniendo en cuenta los resultados observados con las dosis de calcio y calcitriol, sugerimos iniciar la profilaxis con un esquema de 3600 mg/día de carbonato de calcio y 1,5 mcg/día de calcitriol. Sin embargo, esta dosis debe modificarse en situaciones como bocio o calcio sérico temprano anormal, que fueron las variables asociadas a mayor riesgo en nuestro estudio.

Impact of thyroidectomy on quality of life in benign goitres: results from a prospective cohort study

PURPOSE

Benign thyroid diseases encompass a large spectrum of conditions that are chronic and subtle in nature. A majority of patients choose non-surgical management and continue living their daily lives with subconscious impairment of optimal functioning. We studied the effect of thyroidectomy on the quality of life (QoL) in patients with benign goitres.

METHODS

A prospective study was conducted on 50 patients between January 2017 and August 2018 using the ThyPRO 39 questionnaire. This is a disease-specific health-related questionnaire administered the day before surgery and 6 months following surgery. Data analysis was performed using EpiData Manager and EpiData Entry Client (v 3.1).

RESULTS

The mean age of the cohort was 43.30 years ± 11.61, with a female preponderance (34:16). The most common indications for surgery were suspicion of malignancy and compressive symptoms in 34% and 30%, respectively. The most common histopathology reported was nodular/adenomatous hyperplasia (56%). Prior to surgery, the most common domains affected were emotional susceptibility and tiredness. Following surgery, a significant improvement in all domains of the ThyPRO 39 questionnaire were seen except for psychological well-being (p=0.126). In addition, the composite scores significantly improved (p<0.001). Younger age, female gender, and longer duration of goitre were the factors that significantly affected the outcomes in various domains.

CONCLUSION

Patients with benign goitres have subtle impairment of QoL which showed significant improvement following thyroidectomy.

Repeat thyroid FNAC: Inter-observer agreement among high- and low-volume centers in Naples metropolitan area and correlation with the EU-TIRADS

Our institution (University Hospital "L. Vanvitelli" - Naples, Italy) is a high-volume (HV) center in Naples metropolitan area and many patients are referred there to repeat thyroid fine-needle aspiration cytology (FNAC) after initial FNAC performed in low-volume institutions (LV). The aims of the study were to 1) examine the inter-observer agreement between HV and LV institutions according to the Italian thyroid cytology system, and 2) explore how the discordant FNAC reports were distributed in the European Thyroid Imaging and Reporting Data System (EU-TIRADS) categories. All consecutive cases of repeat FNAC performed at University Hospital "L. Vanvitelli" from January 2016 to December 2021 were retrospectively reviewed. Fleiss' kappa (κ) was used to assess the inter-observer agreement, and categorical variables were compared by chi-square testing. P < 0.05 was considered statistically significant. A total of 124 nodules from 124 adults (mean age 49 years; mean maximum diameter 19 mm) were evaluated. Initial FNAC reports at LV were: 4 (3.2%) TIR1c, 64 (51.6%) TIR2, 48 (38.7%) TIR3A, 8 (6.5%) TIR3B, 0 TIR4, 0 TIR5. The overall FNAC reports were significantly different between the LV and HV institutions. At repeated FNAC, cytological diagnosis was unchanged in 64 (51.6%) cases including TIR2 and TIR3A results. A downgraded FNAC diagnosis (i.e., TIR2 vs TIR3A, TIR2 vs TIR3B) was observed in 36 (29%) nodules. An upgraded FNAC diagnosis (i.e., TIR3B vs TIR2, TIR3B vs TIR3A, TIR4 vs TIR3A, TIR5 vs TIR2, TIR5 vs TIR3B) was recorded in 24 (19.4%) nodules. The weighted inter-observer agreement between LV and HV institutions was poor (κ=0.133). Changed FNAC results were significantly (p=0.0023) more frequent in nodules at intermediate/high-risk (i.e., EU-TIRADS 4/5) than in those at no/low risk (EU-TIRADS 2/3) [i.e., 32/48 (66.7%) and 28/76 (36.8%), respectively]. Downgraded FNAC results were significantly more frequent in EU-TIRADS 2/3 (p=0.001) while upgraded FNAC were present only in EU-TIRADS 4/5 (24/24, 100.0%). The inter-observer agreement among LV and HV thyroid services was poor. The EU-TIRADS 4 and 5 categories included all the malignant nodules with FNAC results reclassified as higher risk (i.e., TIR3B-TIR4-TIR5) by the high-volume cytology service.

Combined Use of Autofluorescence and Indocyanine Green Fluorescence Imaging in the Identification and Evaluation of Parathyroid Glands During Total Thyroidectomy: A Randomized Controlled Trial

BACKGROUND AND OBJECTIVES

Accurate identification and evaluation of the parathyroid glands (PGs) intraoperatively is critical to reduce the incidence of postoperative hypoparathyroidism after total thyroidectomy. Near-infrared fluorescence imaging (NIFI), including the autofluorescence (AF) and indocyanine green fluorescence (ICGF) imaging, is a promising technique to protect PGs. This study aimed to assess whether the combined use of AF and ICGF could reduce the incidence of postoperative hypoparathyroidism and improve the identification and evaluation of PGs during total thyroidectomy.

METHODS

This randomized controlled trial enrolled 180 patients who were randomized into two groups and underwent total thyroidectomy with unilateral or bilateral central lymph node dissection. In the control group, the PGs were identified and evaluated by the naked eye. In the NIFI group, AF was used to identify the PGs and ICGF was applied to assess the blood perfusion of the PGs in situ. The primary outcome was the incidence of postoperative hypoparathyroidism. The secondary outcomes included the number of identified PGs, autotransplanted PGs, and known preserved PGs in situ.

RESULTS

The incidence of postoperative transient hypoparathyroidism was significantly lower in the NIFI group than in the control group (27.8% vs. 43.3%, P = 0.029). More PGs were identified in the NIFI group than in the control group (3.6 ± 0.5 vs. 3.2 ± 0.4, P < 0.001). No significant difference was observed in the number of autotransplanted PGs between the two groups (P = 0.134). Compared with the control group, a greater number of known PGs were preserved in situ in the NIFI group (1.3 ± 0.6 vs. 1.0 ± 0.5, P < 0.001). In the NIFI group, only 4.5% of the patients with at least one well-perfused PG (ICG score of 2) developed postoperative hypoparathyroidism, which was significantly lower than that of the control group (34.6%, P < 0.001).

CONCLUSION

Combined use of AF and ICGF during total thyroidectomy reduces the risk of transient postoperative hypoparathyroidism, enhances the ability to identify and preserve PGs, and improves the accuracy of evaluating the perfusion of PGs during surgery.

CLINICAL TRIAL REGISTRATION

Chinese Clinical Trial Register (www.chictr.org.cn), identifier ChiCTR2100045320. Registered on April 12, 2021.

The value of intraoperative nerve monitoring against recurrent laryngeal nerve injury in thyroid reoperations

Reoperative thyroidectomy is challenging for surgeons because of the higher incidence of recurrent laryngeal nerve (RLN) palsy. RLN identification is the gold standard during thyroidectomy; however, it is sometimes difficult to perform thyroid reoperations. In recent years, intraoperative nerve monitoring (IONM) has gained increased acceptance, and the use of IONM can be a valuable adjunct to visual identification. The aim of this study was to evaluate the value of IONM during thyroid reoperation.A total of 109 patients who met our criteria at the Affiliated Hospital of Hangzhou Normal University from January 2010 to June 2020 were retrospectively analyzed and divided into the IONM group and the visualization-alone group (VA group) according to whether neuromonitoring was used during the operation. The patients' characteristics, perioperative data, and intraoperative information including the RLN identification, time of RLNs confirmation, operative time, intraoperative blood loss, and the rate of RLN injury were collected.Sixty-five procedures (94 RLNs at risk) were performed in the IONM group, whereas 44 (65 RLNs at risk) were in the VA group. The rate of RLN identification was 96.8% in the IONM group and 75.4% in the VA group (P < .05). The incidence of RLN injury was 5.3% in the IONM group and 13.8% in the VA group (P > .05). The incidence of surgeon-related RLN injury rate was 0% in the IONM group compared to 7.7% in the VA group (P < .05), but the tumor-related or scar-related RLN injury rate between the 2 groups were not significantly different (4.3% vs 3.1%, 1.1% vs 3.1%, P > .05).IONM in thyroid reoperation was helpful in improving the RLN identification rate and reducing the surgeon-related RLN injury rate, but was ineffective in reducing the tumor-related and scar-related RLN injury rate. In the future, multicenter prospective studies with large sample sizes may be needed to further assess the role of IONM in thyroid reoperations.