Bruce Barraclough

Total thyroidectomy is now the preferred option for the surgical management of Graves’ disease

Purpose:  Subtotal thyroidectomy has been advocated as the standard treatment for Graves’ disease because of the possibility of avoiding thyroxine therapy as well as the assumed lower risk of complications compared to total thyroidectomy. However, the long‐term results of subtotal thyroidectomy are not as good as they were previously believed to be, as evidenced by the increasing incidence of hypothyroidism. If the risk of complications from total thyroidectomy is no higher, then that procedure offers significant advantages in the surgical management of Graves’ disease. The aim of this study therefore was to compare the complication rate of the two procedures in patients with Graves’ disease.

Parathyroid Autotransplantation during Total Thyroidectomy—Does the Number of Glands Transplanted Affect Outcome?

Parathyroid autotransplantation is a technique for ensuring the continued function of parathyroid tissue at the time of total thyroidectomy (TT). The aim of this study was to ascertain whether the number of parathyroids transplanted affects the incidence of temporary and permanent hypoparathyroidism. A retrospective cohort study included all patients undergoing a TT in a single unit between July 1998 and June 2003. The number of parathyroids transplanted, the final pathology, and the incidence of temporary and permanent hypoparathyroidism were documented. Fisher’s exact test was used for statistical analysis. A total of 1196 patients underwent a TT during the 5 years studied. Of these, 306 (25.6%) had no parathyroids transplanted, 650 (54.3%), 206 (17.2%), 34 (2.8%) had 1,2, or 3 glands autotransplanted, respectively. The incidence of temporary hypoparathyroidism was 9.8% for no gland transplants, 11.9%, 15.1%, and 31.4% for 1,2,and 3 gland transplants, respectively (p < 0.05). The incidence of permanent hypoparathyroidism was 0.98%, 0.77%, 0.97%, and 0%, respectively (p = NS). The incidence of temporary hypoparathyroidism was higher when surgery was performed for Graves’ disease. Temporary hypocalcemia is closely related to the number of autotransplanted parathyroids during TT. The long-term outcome is not affected by the number of parathyroids autotransplanted. A “ready selective” approach to parathyroid autotransplantation is an effective strategy for minimizing the rate of permanent hypoparathyroidism.

Minimally invasive parathyroidectomy using the 'focused' lateral approach. II. Surgical technique.

Background: This paper describes the technique of minimally invasive parathyroidectomy. The technique is based on a thorough understanding of the anatomy of the fascial planes in neck, the surgical pathology and embryology of parathyroid glands and precise anatomical interpretation of preoperative localization studies.

Minimally invasive parathyroidectomy using the ‘focused’ lateral approach. I. Results of the first 100 consecutive cases

Background: A feasibility study of ‘focused’ minimally invasive parathyroidectomy (MIP) using a lateral approach was commenced in 1999. The aim of the present paper was to evaluate the effectiveness and safety of this procedure in the first 100 consecutive patients.

Minimal access thyroid surgery: Is it feasible, is it appropriate?

Background:  Reports of minimal access thyroid surgery (MATS) using various techniques have recently appeared. This study examined the feasibility of MATS using either a lateral ‘focused’ or endoscopically assisted approach.

Systematic review of the impact of volume of oesophagectomy on patient outcome

Purpose:  This systematic review aims to assess whether overall survival, mortality, morbidity, length of stay and cost of performing oesophagectomy are related to surgical volume.

Combined chemotherapy and radiotherapy for patients with breast cancer and extensive nodal involvement.

PURPOSE This retrospective review examines local control, freedom from distant failure, and survival for patients with nonmetastatic breast cancer with extensive nodal disease (> 10 nodes, 45 patients; or > or = 70% involved nodes, if < 10 nodes found, 19 patients). All patients received chemotherapy and radiotherapy following mastectomy. PATIENTS AND METHODS Sixty-four patients were treated between January 1980 and December 1988 at Westmead Hospital, Westmead, NSW Australia. The median follow-up duration for surviving patients was 91.5 months (range, 56 to 121). The median age was 51 years, and the median number of positive nodes was 11. Four successive protocols evolved, each with three phases, as follows: induction chemotherapy (doxorubicin or mitoxantrone, plus cyclophosphamide; three cycles), radiotherapy (50 Gy in 25 fractions to chest wall and regional nodes), then chemotherapy (cyclophosphamide, methotrexate, and fluorouracil [CMF]) of progressively shorter duration. Radiotherapy and chemotherapy were concurrent in the fourth regimen. RESULTS One patient (1.5%) developed local recurrence before distant relapse, and seven patients (11%) developed local and/or regional recurrence simultaneously or after distant relapse. The 5-year actuarial freedom from distant relapse and overall survival rates were 45% and 65%, respectively. Overall survival did not vary significantly by menopausal status, nodal subgroup, or dose-intensity. There were no treatment-related deaths. CONCLUSION Combined chemotherapy and radiotherapy in standard dosage is an acceptable approach following mastectomy for patients with extensive nodal involvement at high risk for local recurrence and distant relapse. This approach should be considered standard best therapy for any randomized trials that examine high-dose chemotherapy or bone marrow transplantation for this subgroup of patients.

Effect of hospital and surgeon volume on patient outcomes following treatment of abdominal aortic aneurysms: a systematic review.

OBJECTIVES This systematic review assessed the efficacy of centralisation for the treatment of unruptured and ruptured abdominal aortic aneurysms. Patient outcomes achieved by low and high volume hospitals/surgeons, including morbidity, mortality and length of hospital stay, were used as proxy measures of efficacy. DESIGN Systematic review was designed to identify, assess and report on peer-reviewed articles reporting outcomes from unruptured and ruptured abdominal aortic aneurysms. No language restriction was placed on the databases searched. MATERIALS Only peer-reviewed journals articles were included. METHODS To ensure the contemporary nature of this review, only studies published between January 1997 and June 2007 were sought. Studies were included if they reported on at least one volume type and patient outcome. RESULTS Twenty two studies were included in this review. In the majority of group assessments, the number of studies reporting statistical significance was similar to the number of studies reporting no statistical significance. CONCLUSION The paucity of studies reporting statistically significant results demonstrates that although this evidence exists, its potential to be overstated must also be taken into account when drawing conclusions as to its efficacy for twenty first century healthcare systems.

TWO HUNDRED CONSECUTIVE PARATHYROID ULTRASOUND STUDIES BY A SINGLE CLINICIAN: THE IMPACT OF EXPERIENCE

OBJECTIVE To assess the ability of ultrasound studies, performed by an experienced clinician, to predict surgical findings and provide precise anatomic localization of abnormal parathyroid glands. METHODS We retrospectively examined 200 consecutive parathyroid ultrasound studies performed by a single experienced clinician in our unit. All patients subsequently underwent parathyroidectomy, with histopathologic confirmation of abnormal parathyroid tissue. The correlation between the ultrasound and surgical findings was assessed. RESULTS Of the 200 study patients, 197 (98.5%) were cured of their disease at the initial operation. Ultrasound studies correctly predicted the surgical findings in 88% of patients, including 168 of 180 (93%) with single gland disease and 7 of 20 (35%) with multiple gland disease (MGD). In all cases in which a single adenoma was identified, precise information regarding its location relative to adjacent anatomic structures was provided. In 92% of these cases, anatomic details correlated closely with surgical findings. Ectopic and descended superior adenomas were most frequently missed. Patients with two nonlocalizing studies (scintigraphy and ultrasonography) had a >50% likelihood of having MGD. CONCLUSION In experienced hands, parathyroid ultrasonography is a highly sensitive technique that provides both localization of enlarged parathyroid glands and precise anatomic detail. Thus, in this study, focused parathyroidectomy was possible in 76.5% of patients. MGD remains difficult to diagnose preoperatively. Nonlocalizing studies should alert the surgeon to a high probability of MGD and prompt the performance of 4-gland exploration.

Centralization and the relationship between volume and outcome in knee arthroplasty procedures

Background:  Centralization aims to reduce adverse patient outcomes by concentrating complex surgical procedures in specified hospitals.