Carmela De Crea

Total thyroidectomy for management of benign thyroid disease: review of 526 cases

Total thyroidectomy is not frequently performed in cases of benign disease because of the associated risk of postoperative hypoparathyroidism and recurrent laryngeal nerve (RLN) damage. We chose a series of patients who had undergone total thyroidectomy (TT) for benign thyroid tumors to evaluate the safety of this approach and its role in the treatment of nonmalignant lesions of the thyroid. We considered only patients with a minimum follow-up of 24 months. Records of 526 patients who underwent TT were carefully reviewed, assessing for perioperative complications and late sequelae. The mean age was 44 ± 15.7 years; 109 patients (20.7%) were male and 417 (79.3%) were female. Altogether, 65 patients (12.3%) were operated on for toxic goiter, 429 (81.6%) for bilateral nodular goiter, and 32 (6.1%) for thyroiditis. Postoperative hemorrhage requiring reoperation occurred in 8 cases (1.5%). The incidences of permanent RLN palsy (considered as a percentage of the nerves at risk) and permanent hypocalcemia were 0.4% and 3.4%, respectively. A trend toward a decrease in the complication rate was observed during the last 5 years. There were no disease recurrences during a mean follow-up of 44 months. The results of our series show that TT can be performed safely in patients, with a low incidence of lifetime disabilities. TT has the advantage of reducing/avoiding the risk of disease recurrence and reoperation and should therefore be considered a valuable option for treating benign thyroid diseases.Résumé.La thyroïdectomie total mais n’est pas réalisée fréquemment en cas de maladie bénigne en raison du risque d’hypoparathyroïde postopératoire et de lésions du nerf récurrent. Nous avons sélectionné une série de thyroïdeectomies totales (TT) pour maladie bénigne afin d’évaluer la sécurité de cette approche et son rôle dans le traitement des lésions non malignes de la thyroïde. Nous avons pris en compte seulement les patients ayant un suivi minimum de 24 mois. Les dossiers de 526 patients ayant eu une TT ont été revus pour évaluers les complications péri-opératoires et les séquelles tardives. L’âge moyen était de 44 ± 15.7 ans. Cent neuf patients (20.7%) étaient des hommes et 417 (79.3%) des femmes. Soixante=cinq patients (12.3%) ont été opérés pour goitre toxique, 429 (81.6%) pour goitre nodulaire bilatéral et 32 (6.1%) pour thyroïdite. Une hémorragie postopératoire a nécessité une ré-intervention dans 8 cas (1.5%). L’incidence de paralysie permanente du nerf récurrent (pourcentage de nerfs récurrents à risque) et d’hypocalcémie permenente ont été, respectivement, de 0.4% et de 3.4%. On a observé une tendance vers une diminution du taux de complications pendant les cinq dernières années. Aucune récidive n’a été observée avec un suivi moyen de 44 mois. Les résultats de notre série indiquent que la TT peut être réalisée avec sécurité dans cette population avec une incidence d’incapacité permenent réduite. La TT a l’avantage de réduire/éviter le risque de récidive de la maladie et de réopération et devrait être une option valable pour le traitement de maladies bénignes de la thyroïde.ResumenLa tiroidectomia total no es un procedimiento de realización frecuente en la enfermedad benigna por razón del riesgo de hipoparatiroidismo postoperatorio y de lesión del nervio laríngeo recurrente. Tomamos una serie de tiroidectomías totales (TT) practicadas por tumores benignos con el objeto de evaluar la seguridad de esta conducta y su papel en el tratamiento de lea lesiones no malignas de la tiroides. En el presente estudio sólo fueron considerados pacientes con un seguimiento mínomo de 24 meses. Se revisaron las historias de 526 pacientes que habían sido sometidos a TT para determinar las complicaciones postoperatorias y las secuelas tardías. La edad promedio fue 44 ± 15.7 años; 109 (20.7%) eran hombres y 417 (79.3%) mujeres; 65 (12.3%) fueron operados por bocio tóxico, 429 (81.6%) por bocio nodular bilateral y 32 (6.1%) por tiroiditis. Se presentó hemorragia postoperatoria que requirió reoperación en 8 casis 91.5%). La incidencia de parálisis permamente del nervio laríngeo recurrente consierada como porcentaje de los nervios en riesgo y de hipocalcemia fue 0.4% y 3.4% respectivamente. Se observó tendencia hacia la disminución de las complicaciones en el curso de los últimos 5 años. No se registró recurrencia de la enfermedad en el seguimiento de 44 meses. Los resultados del análisis de nuestra serie indican que la TT puede ser practicada con seguridad en pacientes con enfermedad benigna de la tiroides, con una baja tasa de complicaciones permenentes. La TT tiene la ventaja de reducir o abolir tanto el riesgo de recurrencia de la enfermedad como el de una reoperación, y en consecuencia, debe ser considerada Bellantone et al.: Benign Thyroid Disease and Total Thyroidectomy como una opción valiosa en el tratamiento de la enfermedad tiroidea benigna.

Long-term outcome of functional post-thyroidectomy voice and swallowing symptoms.

BACKGROUND Voice and swallowing symptoms are frequently reported early after thyroidectomy even in the absence of laryngeal nerves injury. We evaluated the short-term and long-term outcomes of these functional alterations. METHODS Consenting patients undergoing total thyroidectomy (TT) were enrolled. Videolaryngostroboscopy (VSL), acoustic voice analysis (AVA), and maximum phonation time (MPT) were performed pre-operatively, 3 months postoperatively, and >1 year postoperatively. Subjective evaluation of voice (Voice Impairment Score=VIS) and swallowing (Swallowing Impairment Score=SIS) were obtained pre-operatively, as well as 1 week, 1 month, 3 months, and >1 year postoperatively. RESULTS The long-term evaluation was completed in 110 patients. The percentage of patients with symptoms 1 week after operation was significantly higher than preoperatively, whereas it was significantly lower at long-term evaluation. VIS was significantly worse than pre-operatively, 1 week, 1 month, and 3 months after surgery, but it was similar to pre-operative >1 year after TT. SIS was significantly worse 1 week after thyroidectomy but not 1 month and 3 months after thyroidectomy, and it was significantly lower than the pre-operative >1 year after TT. CONCLUSION Vocal and swallowing symptoms are frequent after TT. In the absence of laryngeal nerve injury, after an initial impairment, late after operation, patients experienced subjective amelioration of their voice and swallowing performances, which may be related to the resolution of compressive symptoms.

Management of Cystic or Predominantly Cystic Thyroid Nodules: The Role of Ultrasound-Guided Fine-Needle Aspiration Biopsy

OBJECTIVE Conventional fine-needle aspiration biopsy (FNAB) for cystic thyroid nodules (CTNs) has a high rate of nondiagnostic and false-negative results. Ultrasound-guided FNAB (UG-FNAB) permits direct sampling of the wall and/or the solid portion of CTNs, increasing the possibility of a representative sample. In this study we evaluated the role of UG-FNAB in CTNs management. METHODS Five-hundred-seventy-five UG-FNAB of CTNs were performed. Thyroidectomy was carried out in 119 of these cases. The medical records of these 119 patients were reviewed and form the basis of this report. RESULTS The nondiagnostic smear rate was 9.2%. Cytological diagnosis was benign nodule in 42 cases, predominantly follicular lesion in 50 cases, and suspicious or malignant lesion in 16 cases. The final pathology revealed a benign nodule in 98 cases (82.4%) and a carcinoma in 21 (17.6%). The overall accuracy of UG-FNAB was 88.0%. No significant differences were found in age, sex, lesion size, or echographic pattern (p = NS) comparing patients with benign CTNs to patients with malignant CTNs. CONCLUSION UG-FNAB has a low rate of nondiagnostic smears and a high overall accuracy in CTNs. All CTNs should undergo UG-FNAB to select patients for surgery, since the malignancy rate is not negligible and no clinical parameter can reliably predict it.

The use of “harmonic scalpel” versus “knot tying” for conventional “open” thyroidectomy: results of a prospective randomized study

PurposeWe evaluated the safety and cost-effectiveness of the harmonic scalpel (HS) during conventional “open” thyroidectomy (CT).Materials and methodsTwo hundred patients scheduled for conventional total thyroidectomy (TT) were included in the study and randomly assigned to TT with the use of HS (HS group) or with knot tying technique (KT group).ResultsMean operative time was significantly shorter in the HS group (P < 0.001), as well as the total operative room occupation time (P < 0.001). The cost of the disposable materials is significantly higher in the HS group (420.1 ± 23.2 vs 137.8 ± 25.3 euros; P < 0.001). Conversely, drugs, personnel and operative room charges were significantly higher in KT group patients (P < 0.001). Overall, no significant difference was found between the two groups concerning the charges of the hospitalisation (P = NS).ConclusionsHS is a safe alternative to KT, allowing for a significant reduction of operative time without increasing complications rate and overall costs and probably better utilization of health resources.

Video-assisted thyroidectomy

BACKGROUND In 1998, we developed a technique for video-assisted thyroidectomy (VAT). In this article we report on the entire series of patients who underwent VAT and discuss the results obtained. STUDY DESIGN Forty-seven patients were selected for VAT. Eligibility criteria were: thyroid nodules of 35 mm or less in maximum diameter; estimated thyroid volume within normal range or slightly enlarged; small, low-risk papillary carcinomas; neither previous neck surgery nor irradiation; and no thyroiditis. After a learning period, VAT was proposed also for completion thyroidectomy (of previous video-assisted lobectomy) and nodules with maximum diameter up to 45 mm. The procedure is performed by a totally gasless video-assisted technique through a single 1.5- to 2.0-cm skin incision. Dissection is performed under endoscopic vision using a technique very similar to conventional operation. RESULTS Fifty-three VATs were attempted on 47 patients. Thirty-three lobectomies, 10 total thyroidectomies, and 6 completion thyroidectomies were successfully performed. Six patients with papillary carcinoma underwent central neck lymph node removal by the same access. Mean operative time was 86.8 minutes for lobectomy, 116.0 minutes for total thyroidectomy, and 77.5 minutes for completion thyroidectomy. Conversion rate was 7.5%. Postoperative complications included one transient recurrent nerve palsy, three transient symptomatic postoperative hypocalcemias, and one wound infection. The cosmetic result was considered excellent by most of the patients who successfully underwent VAT. CONCLUSIONS VAT is feasible and safe and allows for an excellent cosmetic result. Not all patients are eligible for this procedure, but in selected cases it can be a valid option for the surgical treatment of thyroid diseases.

Open versus endoscopic adrenalectomy in the treatment of localized (stage I/II) adrenocortical carcinoma: results of a multiinstitutional Italian survey

BACKGROUND We compared the oncologic effectiveness of open adrenalectomy and endoscopic adrenalectomy in the treatment of patients with localized adrenocortical carcinoma. METHODS One hundred fifty-six patients with localized adrenocortical carcinoma (stage I/II) who underwent R0 resection were included in an Italian multiinstitutional surgical survey. They were divided into 2 groups based on the operative approach (either conventional or endoscopic). RESULTS One hundred twenty-six patients underwent open adrenalectomy and 30 patients underwent endoscopic adrenalectomy. The 2 groups were well matched for age, sex, lesion size, and stage (P = NS). The mean follow-up time was similar for the 2 groups (P = NS). The local recurrence rate was 19% for open adrenalectomy and 21% for endoscopic adrenalectomy, whereas distant metastases were recorded in 31% of patients in the conventional adrenalectomy group and 17% in the endoscopic adrenalectomy group (P = NS). The mean time to recurrence was 27 ± 27 months in the conventional open adrenalectomy group and 29 ± 33 months in the endoscopic adrenalectomy group (P = NS). No significant differences were found between the 2 groups in terms of 5-year disease-free survival (38.3% vs 58.2%) and 5-year overall survival rates (48% vs 67%; P = NS). CONCLUSION The operative approach does not affect the oncologic outcome of patients with localized adrenocortical carcinoma, if the principles of surgical oncology are respected.

Prospective evaluation of total thyroidectomy versus ipsilateral versus bilateral central neck dissection in patients with clinically node–negative papillary thyroid carcinoma

BACKGROUND Prophylactic central neck dissection (PCND) for papillary thyroid carcinoma (PTC) is controversial. We compared 3 different approaches to the management of central compartment nodes in patients with clinically unifocal and N0 PTC. METHODS A total of 186 patients were prospectively assigned to one of the following procedures: total thyroidectomy (TT), TT plus ipsilateral PCND (Ipsi-PCND), and TT plus bilateral PCND (Bil-PCND). RESULTS No difference was found concerning demographic, clinical or pathologic characteristics (P = NS). More patients in the Bil-PCND group had transient hypocalcemia (P < .001). One patient in the Bil-PCND group experienced permanent hypoparathyroidism (P = NS). One transient and one permanent unilateral laryngeal nerve palsy occurred in the Ipsi-PCND group (P = NS). Significantly more patients in the Bil-PCND and Ipsi-PCND groups had node metastases recognized (26 vs 18 vs 6; P < .001). Six of 26 pN1 patients (23%) in the Bil-PCND group had bilateral metastases. No difference was found concerning mean postoperative basal and stimulated thyroglobulin and mean postoperative radioiodine uptake. One patient in the Ipsi-PCND group experienced recurrent disease (P = NS). CONCLUSION TT seems adequate treatment for most patients with clinically N0 PTC. PCND could be considered for a more accurate staging. Ipsi-PCND could be a valid option, but it includes the risk of overlooking contralateral metastases.

Video-assisted Thyroidectomy: Report on the Experience of a Single Center in More than Four Hundred Cases

BackgroundWe report on our series of patients selected for video-assisted thyroidectomy (VAT) over a 7-year period and discuss the results obtained.MethodsVideo-assisted thyroidectomy is a gasless procedure performed under endoscopic vision through a single 1.5–2.0-cm skin incision, using a technique very similar to conventional surgery. Eligibility criteria were these: thyroid nodules <35 mm; thyroid volume <30 ml; no previous conventional neck surgery. Small, low-risk, papillary thyroid carcinomas (PTC) were considered eligible.ResultsA total of 473 VATs were attempted on 459 patients. Locoregional anesthesia was used in 15 patients. Conversion was necessary in 6 (difficult dissection in 1 case, large nodule size in 3, gross lymph node metastases in 2). Thyroid lobectomy was successfully performed in 110 cases, total thyroidectomy in 343, and completion thyroidectomy in 14. In 66 patients with carcinoma, central neck nodes were removed through the same access. Concomitant parathyroidectomy was performed in 14 patients. Pathology showed benign disease in 277 cases, PTC in 175, and medullary microcarcinoma in 1. Postoperative complications included 8 transient recurrent nerve palsies, 64 transient hypocalcemias, 3 definitive hypocalcemias, 1 postoperative hematoma, and 2 wound infections. Postoperative pain was minimal and the cosmetic result excellent. In patients with PTC no evidence of recurrent or residual disease was shown.ConclusionsIndications for VAT are still limited (20% of patients who require thyroidectomy). Nonetheless, in selected patients, it seems a valid option for thyroidectomy and it could be considered even preferable to conventional surgery because of its significant advantages, especially in terms of cosmetic result.

Endoscopic adrenalectomy: Is there an optimal operative approach? Results of a single-center case-control study

BACKGROUND The choice in between the laparoscopic lateral transabdominal (LTA) or the posterior retroperitoneoscopic (PRA) approach for adrenalectomy is usually based on surgeons preference, rather than on objective arguments. We compared the intraoperative and postoperative outcomes of LTA and PRA to determine whether there is a preferable approach. METHODS Thirty-eight consecutive patients successfully underwent PRA for benign adrenal tumors </=6 cm. A case-control study including 38 patients who successfully underwent LTA was performed. Operative time, intraoperative ventilatory parameters (CO(2) production [Vco(2)], whole body oxygen consumption, arterial partial pressure of carbon dioxide [Paco(2)], and arterial partial pressure of oxygen [Pao(2)]), final histology, complications, postoperative stay, analgesic requirement, time to regain normal bowel function, and time to return to work were recorded and compared between the 2 groups. RESULTS The 2 groups did not differ in terms of operative time, analgesic requirement, time to first flatus, complication rate, duration of postoperative stay, or final histology. Patients in the LTA group showed significantly lower Paco(2), Pao(2), and Vco(2) at the end of the operation. Patients in the PRA group experienced a significantly faster return to work. CONCLUSION No procedure can be considered preferable overall. In cases of bilateral adrenalectomy and previous abdominal surgery, PRA may offer some advantages. Surgeons preference and experience will continue to guide this choice.

Video-Assisted Thyroidectomy for Papillary Thyroid Carcinoma

Background. The results of video-assisted thyroidectomy (VAT) were evaluated in a large series of patients with papillary thyroid carcinoma (PTC), especially in terms of completeness of the surgical resection and short-to-medium term recurrence. Methods. The medical records of all patients who underwent video-assisted thyroidectomy for PTC between June 1998 and May 2009 were reviewed. Results. Three hundred fifty-nine patients were included. One hundred twenty-six patients underwent concomitant central neck node removal. Final histology showed 285 pT1, 26 pT2, and 48 pT3 PTC. Lymph node metastases were found in 27 cases. Follow-up was completed in 315 patients. Mean postoperative serum thyroglobulin level off levothyroxine was 5.4 ng/mL. Post operative ultrasonography showed no residual thyroid tissue in all the patients. Mean post-operative 131I uptake was 1.7%. One patient developed lateral neck recurrence. No other recurrence was observed.