T. S. Reeve

Complications of Thyroid Surgery: How to Avoid Them, How to Manage Them, and Observations on Their Possible Effect on the Whole Patient

Surgery of the thyroid takes place in an area of complicated anatomy and in which a number of vital physiologic functions and special senses are controlled. Thyroidectomy rarely is associated with mortality; but unless the surgeon performing it is well trained in operative surgery and is knowledgeable of the gland and its function, pathology, and anatomy, excellent results cannot be achieved. Failure to observe cardinal surgical principles may result in legal difficulties, which can be avoided. It is well to observe the principles and avoid problems. We address this issue herein.

Increasing incidence of thyroid cancer is due to increased pathologic detection

BACKGROUND There has been a marked increase in the incidence of thyroid cancer worldwide over recent decades. Patients with retrosternal goiter (RSG) are not picked up generally by common surveillance techniques such as ultrasound. The aim of this project was to study the incidence of thyroid cancer in patients with RSG. METHODS This is a retrospective cohort study. Documented were patient demographics as well as the size, type, and numbers of thyroid cancers. The number of routine histologic blocks examined for multinodular goiter in the different time periods was also examined. RESULTS Within a cohort of 13,793 thyroidectomies performed over 40 years, there were 2,260 patients (14%) who underwent surgery for RSG. The percentage of patients with RSG containing thyroid cancer increased from 3.6 to 7.5% (P < .05); however, once papillary microcarcinomas (PMC) (</=10 mm) were excluded there was no increase in cancer incidence (3.4-3.5%, P = .9). The increase in the number of PMCs diagnosed is associated with the increase in the routine number of blocks sampled over the 40-year time period (P < .01). CONCLUSION This study has confirmed an increase in the incidence of thyroid cancer over 4 decades. However, that increase appears to be due to an increase in the diagnosis of PMC associated with increased sampling of resected specimens by pathologists, raising the possibility that the current epidemic of thyroid cancer may be largely manmade.

Catalysis of lipid peroxidation by glucose and glycosylated collagen

Peroxidation of membranes of linoleic/arachadonic acid vesicles at 40 degrees C was catalysed by glucose or glycosylated collagen. Kinetics of hydroperoxide production were similar in both cases. There was a kinetic lag, the duration of which was inversely proportional to the amount of glucose or glycosylated collagen used to initiate the peroxidation. This was followed by a rapid increase in the rate of oxidation. The final rate was independent of the amount of catalyst added. Vesicle lysis accompanied the increases in peroxidation. Addition of desferrioxamine, an iron chelator, only partially inhibited the oxidative process.

Endoscopically assisted, minimally invasive parathyroidectomy

BACKGROUND Despite the success of open parathyroid exploration, minimally invasive alternatives have been emerging. This study reports an experience with endoscopically assisted, minimally invasive parathyroidectomy and evaluates its current role in patients undergoing surgery for hyperparathyroidism. METHODS One hundred consecutive patients requiring surgery for hyperparathyroidism were evaluated. Endoscopic parathyroidectomy was offered based on the absence of coexisting nodular thyroid disease, previous neck surgery or irradiation, suspicion of parathyroid hyperplasia, or other anatomical or medical contraindications. Some 24 of 100 patients fulfilled the criteria and underwent endoscopic parathyroidectomy. Unequivocal localization to a single site by a technetium-99m-radiolabelled sestamibi scan allowed removal of the adenoma through a 25-mm suprasternal incision while being guided by a surgical telescope. RESULTS There were no statistically significant differences in operating time or the mean size of resected adenomas between patients undergoing endoscopic and open parathyroidectomy. Four patients required conversion to an open procedure. Two patients developed temporary recurrent laryngeal nerve paresis and one had persistent hyperparathyroidism. CONCLUSION Although endoscopic parathyroidectomy is technically feasible, its applicability is limited to a minority of patients undergoing operation for hyperparathyroidism. The potential for higher complication and failure rates makes optimism for the procedure appropriately guarded.

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.

Minimally invasive parathyroidectomy using the lateral focused mini-incision technique without intraoperative parathyroid hormone monitoring

Minimally invasive parathyroidectomy (MIP) involves scan‐directed removal of a single adenoma through a 2·0‐cm mini‐incision without intraoperative monitoring. The aim of this study was to analyse the outcomes of MIP using such a simplified technique.

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.

Increase in crosslinking of nonenzymatically glycosylated collagen induced by products of lipid peroxidation.

The increase in crosslinking in normal and nonenzymatically glycosylated rat tail tendon collagen after treatment with decomposing lipid hydroperoxides was assessed by measuring the breaking time of tendons immersed in 7 M urea under a 3 g weight at 40 degrees C (thermal rupture time). The incubation of tendons in 200 mM glucose for 43 h at 40 degrees C increased thermal rupture times from 5.15 to 26.38 min, (P less than 0.001) with no significant corresponding increase in tendons incubated in buffer alone. After incubation of the glycosylated tendons in the presence of peroxidized linoleic/arachidonic acid vesicles for about 20 h, their thermal rupture time increased to 3360 min (P less than 0.001). The rupture time for normal tendons after the same treatment was 206 min. These apparent crosslinking increases cannot be fully accounted for by reactions involving malondialdehyde, as incubation of both glycosylated and normal tendons in enzymatically produced malondialdehyde resulted in a modest two- to threefold increase in thermal rupture time.

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.