Juan J. Sancho

Outcome of protracted hypoparathyroidism after total thyroidectomy.

Although the variables that influence the development of post‐thyroidectomy hypocalcaemia are now better understood, the risk factors and long‐term outcome of persistent hypoparathyroidism (HPP) are poorly defined. A retrospective review of a prospective protocol for the management of post‐thyroidectomy hypocalcaemia was performed.

Prospective study on loss of signal on the first side during neuromonitoring of the recurrent laryngeal nerve in total thyroidectomy

Staged thyroidectomy has been recommended when loss of the signal from intraoperative nerve monitoring is observed after first‐side dissection of the recurrent laryngeal nerve. There is no high‐quality evidence supporting this recommendation. In addition, it is not clear whether signal loss predicts postoperative vocal cord paralysis.

Importance of in situ preservation of parathyroid glands during total thyroidectomy

Parathyroid failure is the most common complication after total thyroidectomy but factors involved are not completely understood. Accidental parathyroidectomy and parathyroid autotransplantation resulting in fewer than four parathyroid glands remaining in situ, and intensity of medical treatment of postoperative hypocalcaemia may have relevant roles. The aim of this study was to determine the relationship between the number of parathyroid glands remaining in situ and parathyroid failure after total thyroidectomy.

Surgical management of adrenal metastases

PurposeThis paper aims to review controversies in the management of adrenal gland metastasis and to reach an evidence-based consensus.Materials and methodsA review of English-language studies addressing the management of adrenal metastasis, including indications for surgery, diagnostic imaging, fine-needle aspiration, surgical approach, and outcome was carried out. Results were discussed at the 2011 Workshop of the European Society of Endocrine Surgeons devoted to adrenal malignancies and a consensus statement agreed.ResultsPatients should be managed by a multidisciplinary team. Positron emission tomography coupled with computed tomography (PET/CT) scanning is the technique of choice for suspected adrenal metastasis. When PET/CT is not available or results are inconclusive, the CT scan or magnetic resonance imaging can be used. Patients should undergo complete hormonal evaluation. Adrenal biopsy should be reserved for cases in which the results of non-invasive techniques are equivocal. If malignancy has been reliably ruled out, patients with adrenal incidentalomas should be managed like noncancer patients.ConclusionsA patient with suspected adrenal metastasis should be considered a candidate for adrenalectomy when: (a) control of extra-adrenal disease can be accomplished, (b) metastasis is isolated to the adrenal gland(s), (c) adrenal imaging is highly suggestive of metastasis or the patient has a biopsy-proven adrenal malignancy, (d) metastasis is confined to the adrenal gland as assessed by a recent imaging study, and (e) the patient’s performance status warrants an aggressive approach. In properly selected patients, laparoscopic (or retroperitoneoscopic) adrenalectomy is a feasible and safe option.

Defining the syndromes of parathyroid failure after total thyroidectomy.

Acute and chronic parathyroid insufficiency syndromes are the most common complication after total thyroidectomy. Permanent hypoparathyroidism imposes an important medical burden on patient lifestyle due to the need for lifetime medication, regular visits and significant long-term costs. Its true prevalence has been underestimated due to lack of clear definitions, inadequate follow-up and conflicts of interest when reporting individual patient series. The aim of this review is to propose precise definitions for the different syndromes associated to parathyroid failure based on the follow-up and management of patients developing hypocalcemia (<8 mg/dL at 24 hours) after first-time total thyroidectomy for cancer or goiter at our unit. Short and long-term post-thyroidectomy parathyroid failure presents as three different metabolic syndromes: (I) postoperative hypocalcemia is defined as a s-Ca <8 mg/dL (<2 mmol/L) within 24 hours after surgery requiring calcium/vit D replacement therapy at the time of hospital discharge; (II) protracted hypoparathyroidism as a subnormal iPTH concentration (<13 pg/mL) and/or need for calcium/vit D replacement at 4-6 weeks; and (III) permanent hypoparathyroidism as a subnormal iPTH concentration (<13 pg/mL) and/or need for calcium/vit D replacement 1 year after total thyroidectomy. Each of these syndromes has its own pattern of recovery and should be approached with different therapeutic strategies.

Prophylactic synthetic mesh can be safely used to close emergency laparotomies, even in peritonitis

BACKGROUND This study was conducted to determine the efficacy and safety of the use of a partially absorbable large pore synthetic prophylactic mesh in emergent midline laparotomies for the prevention of evisceration and incisional hernia. METHODS Retrospective analysis of all patients who underwent an emergency midline laparotomy between January of 2009 and July of 2010 was performed. Patients with complicated ventral hernia repair, postoperative death, and lack of follow-up were excluded. RESULTS A total of 266 patients were included. Laparotomies were closed with a running suture of slow-reabsorbable material in 190 patients (Group S), and 50 patients within this group (26.3%) received additional retention sutures. In 76 patients (Group M), an additional partially absorbable lightweight mesh was placed in the Supra-aponeurotic space. Both groups presented similar complication rates (71.1% Group S vs 80.3% Group M, P = .97). There were no differences regarding surgical-site infection rates (17.9% Group S vs 26.3% Group M; P = .13) or postoperative mortality (13.7% Group S vs 18.3% Group M; P = .346). A total of 150 patients completed the follow-up (99 Group S; 51 Group M) at a mean time of 16.7 months. During follow-up, 36 cases of incisional hernia (24%) were diagnosed: 33 (33%) in Group S, whereas there were only three cases (5.9%) in Group M (P = .0001). Mesh removal for chronic infection was not required in any case. CONCLUSION The use of a partially absorbable, lightweight large pore prophylactic mesh in the closure of emergency midline laparotomies is feasible for the prevention of incisional hernia without adding a substantial rate of morbidity to the procedure, even if high contamination or infections are present.

Surgical management of secondary hyperparathyroidism in chronic kidney disease--a consensus report of the European Society of Endocrine Surgeons.

BackgroundDespite advances in the medical management of secondary hyperparathyroidism due to chronic renal failure and dialysis (renal hyperparathyroidism), parathyroid surgery remains an important treatment option in the spectrum of the disease. Patients with severe and complicated renal hyperparathyroidism (HPT), refractory or intolerant to medical therapy and patients with specific requirements in prospect of or excluded from renal transplantation may require parathyroidectomy for renal hyperparathyroidism.MethodsPresent standard and actual controversial issues regarding surgical treatment of patients with hyperparathyroidism due to chronic renal failure were identified, and pertinent literature was searched and reviewed. Whenever applicable, evaluation of the level of evidence concerning diagnosis and management of renal hyperparathyroidism according to standard criteria and recommendation grading were employed. Results were discussed at the 6th Workshop of the European Society of Endocrine Surgeons entitled Hyperparathyroidism due to multiple gland disease: An evidence-based perspective.ResultsPresently, literature reveals scant data, especially, no prospective randomized studies to provide sufficient levels of evidence to substantiate recommendations for surgery in renal hyperparathyroidism. Appropriate surgical management of renal hyperparathyroidism involves standard bilateral exploration with bilateral cervical thymectomy and a spectrum of four standardized types of parathyroid resection that reveal comparable outcome results with regard to levels of evidence and recommendation. Specific patient requirements may favour one over the other procedure according to individualized demands.ConclusionsSurgery for patients with renal hyperparathyroidism in the era of calcimimetics continues to play an important role in selected patients and achieves efficient control of hyperparathyroidism. The overall success rate and long-term control of renal hyperparathyroidism and optimal handling of postoperative metabolic effects also depend on the timely indication, individually suitable type of parathyroid resection and specialized endocrine surgery.

Preoperative risk factors for mortality after relaparotomy: analysis of 254 patients

IntroductionThe aim of this work was to analyze preoperative mortality risk factors after relaparotomy for abdominal surgery in a unit of General Surgery at a University Hospital.MethodsA total of 314 relaparotomies in 254 patients were performed between February 2004 and February 2008. We analyzed data about past medical history, first operation, as well as clinical and biochemical parameters previous to reoperation.ResultsIndications for relaparotomy were peritonitis, bleeding, abscess, exploratory laparotomy, and evisceration. Overall mortality was 22%. Mortality of the patients with a single relaparotomy was 20% vs. 44% if they were reoperated upon twice. Mortality was associated with age, past history of cardiovascular disease, active neoplasm, previous treatment with platelet anti-aggregant drugs, first surgery American Society of Anesthesia score, and the presence of an anastomosis. Preoperative data associated with mortality were the number of systemic inflammatory response syndrome criteria, suture dehiscense, ileus, positive blood cultures, mechanical ventilation, artificial nutrition, antibiotics or vasoactive drugs, tachycardia, and abnormal body temperature. High white blood cell count or bilirrubin levels and low albumin or prothrombin time were also associated with mortality. Multivariate logistic regression analysis isolated age (P = 0.02), abnormal body temperature (P = 0.02), and the need of mechanical ventilation (P = 0.004) as independent preoperative variables predictive for mortality after relaparotomy.ConclusionsAdvanced age, the presence of either fever or hypothermia, and the need of mechanical ventilation are preoperative risk factors associated with mortality after relaparotomy and should be considered when planning reintervention.

A randomized trial of hemithyroidectomy versus Dunhill for the surgical management of asymmetrical multinodular goiter.

Objective:To assess the immediate and long-term clinical results of 2 different surgical procedures for the treatment of asymmetrical multinodular goiter (AMG). Background:Half of the patients presenting with a single benign thyroid nodule have contralateral subclinical disease. There is a controversy whether these patients should be treated with hemithyroidectomy (HMT) or with a more extensive procedure. Methods:Adult patients with a benign unilateral dominant nodule and contralateral nodule(s) with a diameter of less than 10 mm detected on neck ultrasonography were randomized to HMT or Dunhill (DUN). Rates of complications, remnant growth, incidental carcinoma, and reoperation were assessed. Results:A total of 118 patients (F/M:110/8, mean age 43 years) were included and randomized: 65 to HMT and 53 to DUN. After randomization, 28 patients were excluded leaving 47 HMT and 43 DUN long-term (55 ± 35 months) evaluable patients. Mean nodule size was 38 and 6 mm for the dominant and contralateral nodules, respectively. No differences were found in operative time, accidental parathyroidectomy, parathyroid autotransplantation, or wound complications. Transient hypocalcemia was more common in DUN (30% vs 8%; P < 0.001). No permanent complications were observed. At the last follow-up visit, thyroid-stimulating hormone was similar in both groups. Remnant growth (20 vs 0%; P < 0.001), appearance of new nodules (55 vs 14%; P < 0.001), and overall reoperation rate (9.2 vs 1.8%, P = 0.2) were more common in HMT, mostly because of undiagnosed cancer requiring completion thyroidectomy. Thirty percent of HMTs developed hypothyroidism and required long-term T4 supplementation. Conclusions:DUN appears superior to HMT for the treatment of AMG in terms of early reoperation for missed carcinomas and disease progression. Both procedures have a similarly uneventful postoperative course.

Inadvertent parathyroidectomy during total thyroidectomy and central neck dissection for papillary thyroid carcinoma.

Background. The main drawback of central neck lymph node dissection is postoperative parathyroid failure. Little information is available concerning inadvertent resection of the parathyroid glands in this setting and its relationship to postoperative hypoparathyroidism. Our aim was to determine the prevalence of inadvertent parathyroidectomy during total thyroidectomy and central neck dissection for papillary thyroid cancer and its impact on short‐and long‐term parathyroid function. Methods. This was a prospective observational study of consecutive patients undergoing first‐time total thyroidectomy with a central neck dissection for papillary carcinoma >10 mm. Prevalence and risk factors for inadvertent parathyroidectomy were recorded. Serum calcium and intact parathyroid hormone concentrations were determined 24 hours after operation and then periodically in patients developing postoperative hypocalcemia. All patients were followed for a minimum of one year. Results. Whole gland (n = 33) or microscopic parathyroid fragments (n = 14) were identified in 47/170 (28%) operative specimens. The lower parathyroid glands were involved more often. Variables influencing inadvertent parathyroidectomy were extrathyroidal extension of the tumor and therapeutic lymphadenectomy. Neither lateral neck dissection nor the number of lymph nodes retrieved affected the rate of inadvertent parathyroid resection. Postoperative hypocalcemia and permanent hypoparathyroidism were more frequent after inadvertent parathyroidectomy (64% vs 46% and 15% vs 4%; P ≤ .03 each). Conclusion. Inadvertent parathyroidectomy during total thyroidectomy with central neck dissection for papillary thyroid carcinoma is common and involves the inferior glands more frequently in patients with extended resections and clinical N1a disease. Inadvertent resection of parathyroid glands is associated with greater rates of postoperative hypocalcemia and permanent hypoparathyroidism.