Yusuf Bukey

Impact of initial surgical treatment on survival of patients with differentiated thyroid cancer : Experience of an endocrine surgery center in an iodine-deficient region

This retrospective clinical study was designed to analyze the impact of the initial surgical procedure on the survival of 1000 patients with differentiated thyroid cancer of follicular cell origin who had a thyroid operation and were followed for the 30 years between 1968 and 1998 (median 14 years) in an iodine-deficient region where goiter is endemic. There were 753 women and 247 men with a mean age of 42.8 ± 6.7 years (range 17–86 years). Patients were divided into three groups. All patients had undergone thyroxine treatment and thyroid-stimulating hormone (TSH) suppression, and most had had iodine-131 treatment postoperatively. Group A consisted of 336 patients with differentiated thyroid cancer (DTC) who were treated with bilateral subtotal thyroidectomy in our institution or elsewhere. Group B consisted of 158 patients with DTC who were treated initially with unilateral total lobectomy and contralateral subtotal lobectomy in our institution or elsewhere and underwent reoperation in our department. Group C consisted of 506 patients with DTC who were treated initially with total or near-total thyroidectomy in our department. Kaplan-Meyer survival analysis was used. Recurrence was seen in 23% and death in 8% of the patients. The 20-year survival rates were 76%, 85%, and 92% for groups A, B, and C, respectively. The survival difference among the patients of group A and groups B and C was found to be statistically different (p < 0.001). Long-term survival of patients with differentiated thyroid cancer living in endemic areas for goiter can be influenced by the initial surgical treatment. Patients treated initially with total or near-total thyroidectomy appear to have a better prognosis.

Bupivacaine application reduces post thyroidectomy pain: Cerrahpasa experience

BACKGROUND We aimed to evaluate the impact of bupivacaine administration into the surgical field after total thyroidectomy on post-operative pain and analgesic requirement with a double-blind, prospective, clinical and randomized study. METHODS The study was performed between 2010 and 2011. Pain assessment was performed with the visual analog score (VAS). Patients were pre-operatively, randomly divided into two groups to receive either bupivacaine or saline. One group received a 10-mL of bupivacaine solution while the other group was treated with the same volume of 0.9% NaCl through the drain after completion of total thyroidectomy procedure. All patients were anesthetized and operated with the same anesthesia and surgical team. RESULTS Ninety-one patients (20 males) were included in the study. No patient dropped out of the study during the procedures. No mortality was seen. The VAS scores were significantly lower in the bupivacaine administered group at post-operative minute 30 (3.7±3.2 vs. 5±2.9; P=0.03), hour one (3.04±2.4 vs. 4.2±2.8; P=0.04), and hour eight (1.8±2.04 vs. 3.2±2.1; P=0.005). Thirteen patients required analgesia during their hospital stay in the bupivacaine group while this number was twenty-two in the saline group (P=0.005). CONCLUSIONS Local bupivacaine administration into the surgical field after total thyroidectomy reduces pain and analgesic requirement during the hospital stay.

Missed thyroid gland after total thyroidectomy

Missed gland is an extremely rare condition. It is a mediastinal thyroid mass found after total thyroidectomy. We report a case of missed gland. The patient underwent total thyroidectomy due to multinodular goiter and thyroid stimulating hormone levels did not increase after surgery. Pathological tests revealed a micropapillary carcinoma. Thyroid ultrasonography and scintigraphy scan revealed mediastinal thyroid mass. The patient underwent redo surgery without sternotomy and there was no morbidity after the second surgical procedure. Most missed thyroid gland cases are due to incomplete removal of plunging thyroid goiter during total thyroidectomy. They also can be attributed to a concomitant, unrecognized mediastinal goiter, which is not connected to the thyroid gland with vessels or a thin fibrous band. It should be noted that absence of signs like mediastinal mass or tracheal deviation in preoperative chest X-ray does not exclude substernal goiter. The presence of a missed thyroid gland should be kept in mind when postoperative thyroid stimulating hormone levels remain unchanged.

The effect of thyroid gland weight on early complications in total thyroidectomy: Cerrahpasa experience

In this study we aimed to show whether thyroid gland weight has an effect on early and late complications in thyroidectomy done in an experienced center. 721 patients in Istanbul University Cerrahpaşa Medical Faculty General Surgery Department, in whom sutureless total thyroidectomy with vessel sealing devices were done, were retrospectively evaluated from January 2012 to December 2015. Reoperations, plonjan goiter, patients with capsule invasion and lymph node metastases who were operated due to thyroid cancer were excluded in the study. Demographic data, operation indications, operation duration, incision length, postoperative complications of the patients were recorded. The complications were recurrent nerve paralysis, hypocalcemia, hematoma and wound infection. These complications were compared according to the thyroid gland weight separately. Also, each complication group was divided into four groups, according to thyroid gland weight, as below 30 grams, 30-60 grams, 60-90 grams and heavier than 90 grams. The effect of thyroid gland weight on postoperative complications was evaluated. 22.2 % of the patients (n=160) were males and 77.8 % (n=561) were females. Mean age of the patients was 48,58±SD (18-85) years. Recurrent laryngeal nerve paralysis was seen in 5.68% (n=82) of the 721 patients, to whom vocal cord examination was done. Hypocalcemia symptoms in 5.54% of the patients (n=40), wound infections in 0.97% (n=7) of the patients and hemorrhage in 0.69% (n=5) of the patients were seen. Mean thyroid gland weight in patients with thyroid surgery complication was 56.1±SD (15-315) grams, while it was 56,94±SD (20-795) grams for noncomplicated thyroid surgery. The complications were divided into four groups. When these groups were compared according to thyroid gland weight separately, it was seen that thyroid gland weight does not affect early complications (p >0,5). Total thyroidectomy, when done in an experienced center, is the suggested surgery, which has 1% complication rate and the least recurrence rate. In our study, there was no statistically significant difference. This may be due to lighter thyroid gland weights in our study.

Skin metastasis on the neck: an unusual presentation of recurrence of papillary thyroid carcinoma

Skin metastasis of papillary thyroid carcinoma (PTC) is rare. Here, two cases of skin metastases of PTC are presented. Both of the patients were females, one is 83 and the other is 65 years old. The patients were admitted to the hospital with a movable skin lesion on anterior neck region. Free T3 and T4 levels were in normal levels and TSH levels were low in both patients. The 83-year-old patient underwent total thyroidectomy due to papillary thyroid cancer and received 131I ablation therapy and then thyroid suppression therapy. After the surgery, the patient lived without evidence of disease for 3 years and then skin metastasis occurred. The 65-year-old patient had a total thyroidectomy 5 years ago due to PTC then neck dissection due to metastasis 3 years later and then received 131I ablation therapy. Thyroid ultrasonography of both patients showed hypoechoic nodules with central vascularization. In the histological examination of both patients, cystic lesions filled with papillary structures were seen. Fine needle aspiration biopsy (FNAB) taken from both patients were papillary carcinoma with solid trabecular pattern. PTC tends to metastasize to regional lymph nodes but distant metastasis is rare. When distant metastasis develops, prognosis of the disease is poor. Therefore, skin metastasis of papillary thyroid cancer is a poor prognostic factor. If the patient does not have a thyroid malignancy history, diagnosis of PTC metastatic to the skin may be difficult since primary skin tumors such as apocrine tumors have similar histopathological features. However, in the presented cases since there was a PTC history, the diagnosis was easier with the help of histopathological examination. Skin metastasis of PTC should be kept in mind when differential diagnosis of atypical skin lesions are made especially in the patients with thyroid malignancy history.

Silk suture reaction in thyroid surgery

Silk suture reaction (i.e., a benign granulomatous inflammatory foreign body reaction) is a rare complication of thyroid surgery. Here, two cases of post-thyroidectomy suture reaction are presented. Both of the patients were female, one is 48 and the other is 34 years old. The patients were presented with neck swelling and leakage of serous fluid from the Kochers incision. Both patients had normal free T4, free T3, and TSH values. The 48-year-old female patient had a right subtotal and left near-total thyroidectomy 6 years ago and the other had bilateral total thyroidectomy 6 years ago. In the physical examination a mobile, painless, red, swelling was palpated in front of neck. In the ultrasound of both patients, a heterogeneous nodule with hypoechoic rim was seen, however, in scintigraphy no radiopharmaceutical involvement was observed in thyroid region. Due to suspicion of thyroid malignancy, a fine needle aspiration biopsy was performed and foreign body reaction was revealed cytologically. A suture reaction can vary from an erythematous swelling to chronic granulomatous reaction. The time interval between the operation and formation of suture reaction was 6 years in both of the cases thus these patients were considered as chronic patients. Foreign body reaction diagnosis was confirmed with fine needle aspiration biopsy. It is important to diagnose these chronic inflammation cases since these cases can mimic recurrence in thyroid malignancies. A post-thyroidectomy suture reaction is diagnosed cytologically with fine needle aspiration biopsy and by surgical removal of suture, this chronic inflammatory reaction can be cured.

Single port thoracoscopic treatment of thoracic duct injury after thyroidectomy with neck dissection

Chylous leakage is a complication of thyroidectomy accompanied by bilateral neck dissection with incidence of 0.5-6.2%. A 51-year-old female patient underwent total thyroidectomy, bilateral and central neck dissection for papillary thyroid carcinoma. In post-operative 4th day, left sided chylous leakage was observed as 1,500 cc/day through neck drain. Leakage did not cease after 1-month conservative treatment so single port thoracoscopic intervention was performed. Under general anesthesia, patient was placed in left lateral decubitus position. An Alexis® retractor was placed through sixth intercostal space. Thoracic cavity was visualized with 30º scope. Posteroinferior edge of lower lobe was retracted superior posteriorly with a Foerster clamp to display inferior pulmonary ligament, which was then divided with electrocautery. Posterior mediastinal pleura between azygous vein and chest wall was incised to mobilize the vein. After that, mediastinal pleura between azygous vein and esophagus was cut longitudinally and esophagus was retracted anteriorly to dissect towards aorta. By dissection, thoracic duct was revealed as a thin tubular structure with occasional peristalsis. After isolation of the duct, it was clipped using Hem-o-lok®. Finally, fibrin sealant was applied to decrease risk of recurrence. One chest tube was placed to ensure adequate drainage of thoracic cavity and complete re-expansion of lung. Neck drain and chest tube was extracted in postoperative second and fourth day respectively and patient was discharged at 8th day. Single port thoracoscopy is a safe choice for treatment of chylous leakages due to cervical ductus thoracicus injury with faster recovery.

Effect of obesity on total thyroidectomy: Cerrahpasa experience

Aim-BackgroundObesity prevalence has increased all over the world and has become an epidemic disease. Studies in the literature show that obese patients who have undergone various surgical operations have an increased risk of morbidity and mortality. There are several studies on morbidity and mortality in parathyroid surgery. However, there is insufficient information concerning the thyroidectomy outcomes of obese patients. The aim of this study is to evaluate the effect of obesity in the postoperative stage and minimize the disadvantages that can be seen in obese patients undergoing total thyroidectomy.Materials and MethodsNinety-nine patients who underwent total thyroidectomy between April and September 2012 were included in this study. Patients who were under/normal weight were grouped as Group 1, overweight as Group 2, obese as Group 3. The analyzed parameters include incision length, operation duration, specimen weight, postoperative pain, postoperative early complications, amount of postoperative drainage, and duration of postoperative hospital stay.ResultsThe average age of the patients was 50.4 years. Seventy-one patients were women and 28 were men. No differences were noticed among the groups in terms of age, gender, sternomental length, operation duration, pain score, amount of postoperative drainage, postoperative hospital stay, vocal cord paralysis, hypocalcaemia, bleeding that required re-operation, specimen weight, and incision length. No relation between operation duration and specimen weight was observed. The relation between specimen weight and incision length was evaluated and a meaningful but weak correlation was observed. No wound infection was seen.ConclusionTotal thyroidectomy can be performed safely even in obese patients.

Total thyroidectomy en bloc or not? prospective, randomized clinical trial: Cerrahpasa experience

Aim-BackgroundWhile significant changes in the last century have enabled safe and effective total thyroidectomy, the utility and reliability of techniques for patients with benign diseases is debatable. The purpose of this study was to compare the complication rates of division of the isthmus vs. non-division in thyroid surgery performed for bilateral multinodular goiter by experienced endocrine surgeons. To the best of our knowledge, no such study has been published in the literature to date.MethodsThis prospective study includes 60 consecutive serial patients who underwent total thyroidectomy. Patients were randomly assigned to a thyroidectomy technique by the arbitrary draw from a bag of paper tags marked as ‘U’ (thyroidectomy without dividing the isthmus) classified as Group 1 or ‘D’ (thyroidectomy by dividing the isthmus) as Group 2. Patients in Group 1 (n=30) had a total thyroidectomy without dividing the isthmus (en bloc), patients in Group 2 (n=30) had total thyroidectomy by dividing the isthmus.ResultsPostoperative serum mean calcium and parathyroid hormone (PTH) levels, operation period, visual analogue pain score and recurrent laryngeal nerve paralysis did not differ between the groups. Permanent hypocalcaemia and permanent recurrent laryngeal nerve paralysis were not observed in either group, but total morbidity in Group 1 was higher (p=0.038). Postoperative PTH levels were significantly lower than preoperative PTH levels in both groups; (respectively, p=0.007, p=0.011). No surgical mortality was recorded.ConclusionThyroidectomy without dividing the isthmus can be qualified as a safe and applicable surgical method.