Jean-Louis Peix

Quality monitoring in thyroid surgery using the Shewhart control chart

A control chart can help to interpret and reduce sources of variability in patient safety by continuously monitoring indicators. The aim of this study was to monitor the outcome of thyroid surgery using control charts.

Hospital volume influences the choice of operation for thyroid cancer

Many authors advocate total or near‐total thyroidectomy for thyroid carcinoma. This study examined the relationship between hospital volume of thyroidectomies and choice of bilateral thyroidectomy for thyroid carcinoma.

Résections pancréatiques par laparoscopie

The faisability of laparoscopic pancreatic resection has been demonstrated. However, the real clinical benefit for the patients remains questioned. The best indication for a laparoscopic approach appears to be the resection of benign or neuro-endocrine tumors without a need for pancreato-enteric reconstruction (i.e enucleation or distal pancreatectomy). The use of the laparoscopic approach for malignant tumors still remains controversial. The benefits of minimally invasive surgery are clearly correlated with the successful management of the pancreatic stump. Pancreatic related complication rate (fistula and collection) is 15% when using pancreatic transection with a laparoscopic endostappler

Can we consider immediate complications after thyroidectomy as a quality metric of operation

Background. Permanent recurrent laryngeal nerve palsy and hypoparathyroidism are 2 major complications after thyroid operation. Assuming that the rate of immediate complications can predict the permanent complication rate, some authors consider these complications as a valid metric for assessing the performance of individual surgeons. This study aimed to determine the correlation between rates of immediate and permanent complications after thyroidectomy at the surgeon level. Methods. We conducted a prospective, cross‐sectional study in 5 academic hospitals between April 2008 and December 2009. The correlation between the rates of immediate and permanent complications for each of the 22 participating surgeons was calculated using the Pearson correlation test (r). Results. The study period included 3,605 patients. There was a fairly good correlation between rates of immediate and permanent recurrent laryngeal nerve palsy (r = 0.70, P = .004), but no correlation was found for immediate and permanent hypoparathyroidism (r = 0.18, P = .427). Conclusion. The immediate hypoparathyroidism rate does not reflect the permanent hypoparathyroidism rate. Consequently, immediate hypoparathyroidism should not be used to assess the quality of thyroidectomy or to monitor the performance of surgeons.

Role of Preoperative Basal Calcitonin Levels in the Timing of Prophylactic Thyroidectomy in Patients With Germline RET Mutations

AbstractBackgroundThe American Thyroid Association (ATA) published recommendations for the timing of prophylactic surgery for medullary thyroid carcinoma based on the specific mutation, patient age, family history, and serum calcitonin levels. The aim of this study was to assess the role of preoperative basal calcitonin (prebCt) levels in predicting the presence of medullary carcinoma of the thyroid in patients with RET mutations.nMethodsWe conducted a retrospective study in two endocrine surgery departments. Between 1986 and 2012, a total of 32 patients with RET mutations underwent prophylactic thyroidectomy. The patients were stratified into four ATA risk levels: A, B, C, and D.ResultsAll of the patients were biologically cured. Microcarcinoma was observed in the final pathology report for four of the 20 patients with normal prebCt (25xa0%) and for nine of the 12 patients with elevated prebCt (75xa0%). In the level A group, four patients with normal prebCt and one patient with elevated prebCt presented with microcarcinoma. In the level C group, one patient with normal prebCt and six of the seven patients with elevated prebCt (86xa0%) presented with microcarcinoma.ConclusionsPrebCt can predict the presence of microcarcinoma according to surgical pathological analysis. Patients with microcarcinoma can be biochemically and clinically cured using prophylactic thyroidectomy.

Is it possible to limit the risks of thyroid surgery

OBJECTIVEnInferior laryngeal nerve (ILN) palsy and hypocalcemia remain the two most frequent major complications after thyroid surgery. Their occurrences may be explained by the influence of factors related to the patient, the surgical procedure, thyroid pathology, or the surgeons technique. This study aims To assess whether systematically following a rigorous surgical technique during thyroidectomy affects postoperative complications and long-term patient recovery.nnnMETHODSnWe conducted a multicenter, cross-sectional study of prospectively collected data in five high-volume referral centers enrolling all patients who underwent thyroid surgery between April 2008 and December 2009. Inferior laryngeal nerve (ILN) palsy and hypocalcemia were systematically assessed during hospitalization based on objective criteria. A six-month follow-up was conducted in cases of early complications. Multivariate regression models were computed to quantify their relationship with potential risk factors.nnnRESULTSnA total of 3574 thyroid procedures were completed. Non-visualization of the ILN during dissection and a large thyroid mass were major risk factors for permanent ILN palsy (OR, 4.17 and 2.61, p<0.01) and persistent complications after initial injury (OR, 4.17 and 2.42, p<0.05). The presence of thyroiditis on the surgical specimen was an independent risk factor for permanent hypoparathyroidism and poor recovery after initial dysfunction (OR, 1.76 and 1.88, p<0.05).nnnCONCLUSIONSnThorough meticulous technique in thyroid surgery is a determinant of ILN function but fails to prevent persistent hypoparathyroidism.

Tumeurs atypiques de la thyroïde et formes réfractaires

Les cancers issus des cellules folliculaires, papillaires et folliculaires, sont les plus frequents des cancers thyroidiens. Nous discuterons ici des formes atypiques ou variantes de ces cancers d’origine folliculaire ainsi que des formes generalement rares, qui ont pris naissance a partir d’autres types cellulaires presents dans la thyroide ou provenant de residus embryonnaires et de tissus ectopiques. La classification OMS des tumeurs thyroidiennes est indiquee dans le tableau I. Leur prise en charge therapeutique est globalement semblable a celles des cancers differencies de la thyroide (exception faite de l’administration d’iode 131) mais leur pronostic est generalement plus sombre quelle que soit la variante envisagee.

L’extension extrathyroïdienne et la réponse incomplète au traitement initial sont des facteurs de rechute pour les carcinomes thyroïdiens peu différenciés

Objectifs Le pronostic des carcinomes peu differencies de la thyroide (CPDT) est heterogene quoique generalement pejoratif. Pourtant leur prise en charge therapeutique est identique a celle des autres cancers de souche folliculaire. L’objectif de cette etude etait d’evaluer la valeur de la reponse au traitement initial sur la survie et d’identifier des facteurs de mauvais pronostic dans le but de modifier la prise en charge et le suivi de ces patients. Patients et methodes Au total, 104xa0patients operes d’un CPDT entre le 01/01/2000xa0et le 31/12/2010xa0ont ete inclus dans cette etude et analyses de facon retrospective. Une relecture anatomo-pathologique a ete faite pour tous les cas. Resultats Le traitement initial a consiste en une thyroidectomie totale chez 101xa0patients (97,1xa0%). Le stade TNM etait majoritairement pT3 (55,8xa0%) et M1xa0dans 40,4xa0%. Une extension extra-thyroidienne (EET) a ete observee chez 40xa0patients (40xa0%). La chirurgie a ete suivie chez 99xa0patients (95,2xa0%) par une totalisation isotopique (TI). Le taux de thyroglobuline (Tg) a la TI etaitxa0≥xa010xa0μg/l chez 47xa0patients (52,8xa0%) etxa0≥xa050xa0μg/l chez 40xa0patients (44,9xa0%). La remission clinique a l’issue de la TI et l’EET ont ete les seul facteurs pronostiques significatifs identifies en analyse multivariee pour la survie sans rechute. La survie globale n’etait influencee que par l’EET. Conclusion Les patients porteurs d’un CPDT, avec EET et/ou non en remission clinique apres la TI sont a risque important de rechute ou de poursuite evolutive et doivent beneficier d’un suivi rapproche.

Tumeurs des glandes parathyroïdes

Les cancers des glandes parathyroides sont rares et se developpent principalement dans un contexte d’hyperparathyroidie primaire (HPI). Toutefois il s’agit, meme dans ce contexte, d’un evenement exceptionnel qui n’entre pas en compte en pratique dans la prise en charge d’une hyperparathyroidie primaire. La difficulte d’affirmer la malignite sur des criteres histopathologiques explique les variations d’incidence dans la litterature. Le seul traitement curatif de ces cancers est l’exerese chirurgicale complete, les therapeutiques medicales n’ayant qu’un role de controle de l’hypercalcemie et de ses consequences cliniques.