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PubMed2005

[Endoscope-assisted thyroidectomy by chest approach with good cosmetic results].

OBJECTIVE: To explore the feasibility, safety, and cosmetic efficacy of endoscope-assisted thyroidectomy (EAT) by chest approach. METHODS: Fifty-one patients with single benign thyroid nodule < or = 4.0 cm in diameter, and without history of neck surgery or irradiation, 8 males and 43 females, aged 33.9 (18-64), underwent endoscope-assisted thyroidectomy by chest approach: a skin incision with the length of 4 cm was made in the chest, an endoscope was inserted, and subtotal or total thyroidectomy with the technique similar to that in conventional surgery was performed with naked eyes. RESULTS: Subtotal thyroidectomy was performed in 49 patients, and total excision of unilateral thyroid lobe plus isthmus lobectomy and contralateral partial lobectomy was performed on the other 2 patients. No patient was transferred to traditional surgery. Only one case showed palsy of recurrent nerve. Most patients expressed with the cosmetic results. CONCLUSION: EAT is a feasible and safe procedure with rather good cosmetic

Adolescent↗
PubMedDate not supplied

Endoscopic transaxillary near total thyroidectomy.

BACKGROUND: Since first reported in 1996, endoscopic minimally invasive surgery of the cervical region has been shown to be safe and effective in the treatment of benign thyroid and parathyroid disease. The endoscopic transaxillary technique uses a remote lateral approach to the thyroid gland. Because of the perceived difficulty in accessing the contralateral anatomy of the thyroid gland, this technique has typically been reserved for patients with unilateral disease. OBJECTIVES: The present study examines the safety and feasibility of the transaxillary technique in dissecting and assessment of both thyroid lobes in performing near total thyroidectomy. METHODS: Prior to this study we successfully performed endoscopic transaxillary thyroid lobectomy in 32 patients between August 2003 and August 2005. Technical feasibility in performing total thyroidectomy using this approach was accomplished first utilizing a porcine model followed by three human cadaver models prior to proceeding to human surgery. After IRB approval three female patients with histories of enlarging multinodular goiter were selected to undergo endoscopic near total thyroidectomy. RESULTS: The average operative time for all models was 142 minutes (range 57-327 min). The three patients in this study had clinically enlarging multinodular goiters with an average size of 4 cm. The contralateral recurrent laryngeal nerve and parathyroid glands were identified in all cases. There was no post-operative bleeding, hoarseness or subcutaneous emphysema. CONCLUSION: Endoscopic transaxillary near total thyroidectomy is feasible and can be performed safely in human patients with bilateral thyroid disease.

Adolescent↗
PubMedDate not supplied

Does truncal ligation of the inferior thyroid arteries during bilateral subtotal thyroidectomy affect serum calcium levels? A prospective, randomized, controlled study.

This study was designed to investigate the effect of truncal ligation of the inferior thyroid arteries on post-thyroidectomy serum calcium levels. This prospective, randomized study was carried out in 98 patients. In group 1, bilateral inferior thyroid arteries were ligated truncally during bilateral subtotal thyroidectomy procedure, whereas in group 2, ligation was not performed. In all patients, serum ionized calcium levels were measured preoperatively and on postoperative days 1, 2, 3 and 30. There were no statistically significant differences in serum ionized calcium values between group 1 and 2 on postoperative days 1, 2, 3, and 30 (P > 0.05). Laboratory hypocalcemia was found on postoperative days 1, 2, and 3 in 9 (9.2%), 15 (15.3%), and 2 (2.0%) patients, respectively. In all patients, laboratory hypocalcemia improved until postoperative day 5. It was thought that truncal ligation of the inferior thyroid arteries during bilateral subtotal thyroidectomy had no effect on post-thyroidectomy serum calcium levels.

Adult↗
PubMedDate not supplied

[Video-assisted thyroidectomy with minimally invasive central cervicotomy: initial experience in an endocrine surgery division].

Minimally invasive video-assisted thyroidectomy, a recently developed technique, has been shown to be feasible and safe. Nevertheless, to obtain the best results, the surgeon should be well trained in endoscopic surgery. We attempted to answer the question whether an endocrine surgery division with no previous experience in endoscopic neck surgery could easily import the new technique. The inclusion criteria were nodules < or = 3.5 cm diameter or thyroid lobe volume less than 15 ml, and no thyroiditis or previous neck surgery. Suspect malignant nodules were excluded. The procedure was carried out through a 20 to 30 mm central neck incision, with external retraction and no neck insufflation. The vessels were ligated or closed by means of clips. From March 2004 to March 2005, 127 thyroidectomies were performed, of which 36 were thyroid lobectomies. Of these, 12 lobectomies by minimally invasive video-assisted thyroidectomy were performed for monolateral goiter (4 left, 8 right). There were no intraoperative complications. No recurrent laryngeal nerve palsy or permanent hypoparathyroidism occurred. The mean operative time was 74.4 min (median: 70; range: 45-115). The results, in terms of patient comfort, reduced postoperative pain and cosmetic quality were excellent. The technique allowed careful assessment of the inferior and superior laryngeal nerve. Thorough haemostasis was aided by the magnification of the image and optimal illumination. The learning curve appeared short, owing probably to previous experience in conventional endocrine surgery and the closer similarities of minimally invasive video-assisted thyroidectomy to enhanced-view conventional surgery than to laparoscopic surgery. In our experience the clinical impact was limited as a result of the small percentage of patients fulfilling the strict inclusion criteria.

Adenoma↗
PubMedDate not supplied

[Hypocalcemia after thyroidectomy: analysis on 804 treated patients].

BACKGROUND: Hypocalcemia is a possible sequela of thyroidectomy; the causes are not fully understood. METHODS: We analyzed 804 patients (594 total thyroidectomy, 209 emithyroidectomy) treated in our Institute from January 1995 to December 2000. Serum calcium, ionized calcium, parathyroid hormone (PTH), fosforemia were screened pre- and postoperatively. RESULTS: Hypocalcemia, defined by a serum calcium less than 7.5 mg/dL, occurred in 126 patients (21.2%). In 90.6% of these patients the serum calcium was normal at seven days after thyroidectomy. In two patients we have registered at 180 days after thyroidectomy a permanent hypoparathyroidism. CONCLUSIONS: Several factors are important in the incidence of postthyroidectomy hypocalcemia but the inadvertent excision of parathyroid gland, ischemia and injury are the major causes of lowering of serum calcium concentration.

Adult↗
PubMed1991

[Study of hormone replacement therapy following total thyroidectomy in thyroid cancer--with special reference to the analysis of thyroid hormone peripheral effects, using indirect calorimetry].

Peripheral effects of thyroid hormones were examined using an indirect calorimetry in 18 patients with thyroid cancer before and after total thyroidectomy. Peripheral effects of exogenous thyroid hormones in TSH-suppression therapy after thyroidectomy were also studied. The subjects were maintained without hormone replacement for 3 weeks after total thyroidectomy. The ratio of resting energy expenditure to basal energy expenditure (REE/BEE) was determined before operation, before hormone replacement, and 1 and 5 weeks after the beginning of replacement, and the values were compared with changes in the blood thyroid hormone levels. Positive correlations were observed between the changes in endogenous thyroid hormone levels before and after total thyroidectomy and those in REE/BEE (free T3 vs. REE/BEE; r = 0.756, p less than 0.01), suggesting that evaluation of REE/BEE is clinically useful as an index of peripheral effects of thyroid hormones. Five weeks after the beginning of hormone replacement, T4 and free T4 were slightly range, and no enhancement of energy metabolism was noted. From these findings, the post-operative TSH suppression therapy carried out at our department is considered to be justifiable also from the viewpoint of energy metabolism.

Adult↗
PubMed1990

Parathyroid autotransplantation in total thyroidectomy.

Although parathyroid autotransplantation during the course of thyroidectomy was first described by Halsted in 1907, it is only during the past 20 years that this simple and effective method of preserving parathyroid function is being used by an increasing number of surgeons. Our group has autotransplanted normal parathyroids since 1965, whenever these glands could not be preserved in situ with adequate blood supply. With increasing experience, we find it much simpler to autotransplant parathyroid glands attached to the thyroid, than to dissect their precarious blood supply, hoping they will survive postoperative edema and fibrosis. Furthermore, it is our impression that in operations for thyroid carcinoma, attempts to preserve the blood supply to the parathyroids may compromise the completeness of the thyroidectomy or of the dissection of cervical nodes in the tracheoesophageal groove. In a review of our experience during the past four years (January 1, 1984 to December 31, 1988), 87 patients underwent total thyroidectomy. Parathyroid glands that could not be saved in situ were biopsied to confirm their identity by frozen section and autotransplanted in the ipsilateral sternocleidomastoid muscle. Among the 87 patients undergoing total thyroidectomy, 34 required no autotransplantation, whereas 52 had one to three glands autotransplanted, and one had four glands autotransplanted. Postoperatively, 23 patients (26 percent) developed hypocalcemia, whereas 18 required CaCO3 and five required vitamin D in addition. All patients (98%) except two had normal parathyroid function at four-month follow-up and thereafter, as judged by serum calcium, phosphorus and parathormone, when indicated.

Adult↗
PubMed1989

The effect of thyroidectomy on bone mineral content in perimenopausal women.

To examine the effects of total thyroidectomy on skeletal mineral content we performed dual photon densitometry of the spine and hip in 18 patients with well differentiated thyroid cancer treated with total thyroidectomy and post-thyroidectomy 131-I thyroid remnant ablation. Study subjects were 18 Caucasian females, 45-55 years old, no more than 3 years post-menopausal, 4-20 years (mean 9.7) post-thyroidectomy and 131-I ablation. All subjects were free of disease by all criteria and receiving slightly supra-physiological doses of thyroxine. These subjects were compared with 16 carefully age and sex matched controls without thyroid disease. Patients and controls did not differ significantly in: age (mean-range) 50.2 (45-55) vs 48.7 (45-54) years, height 165.1 (152.4-177.8) vs 164.6 (157.5-172.7) cm, or weight 76.7 (49.1-122.7) vs 71.3 (54.5-104.5) kg. Neither did they differ in (mean +/- SEM): serum calcium 9.45 +/- 0.44 vs 9.49 +/- 0.36 mg/dl, serum inorganic phosphate 3.51 +/- 0.67 vs 3.60 +/- 0.43 mg/dl, serum creatinine 0.84 +/- 0.14 vs 0.91 +/- 0.11 mg/dl or PTH 151.7 +/- 71.0 vs 162.4 +/- 52.0 pg/ml. The T12 index was significantly greater in patients on exogenous thyroxine, 12.0 +/- 2.3 vs 8.7 +/- 1.3 (p less than 0.005) although TSH values performed with a standard sensitivity rather than a super sensitive TSH assay were not significantly different 1.8 +/- 0.9 vs 3.2 +/- 1.6 microU/ml. Lumbar vertebral (L2-4) mineral content was not different between patients and controls, 1.245 +/- 0.900 g/cm2 vs. 1.238 +/- 0.166 g/cm2.(ABSTRACT TRUNCATED AT 250 WORDS)

Bone Density↗
PubMed1989

Early total thyroidectomy in patients with multiple endocrine neoplasia IIb syndrome.

Medullary carcinoma of the thyroid gland (MCT) develops at an early age in children with multiple endocrine neoplasia (MEN) IIb syndrome. Prompt diagnosis of the syndrome and early total thyroidectomy offer the only chance for cure. Surgical guidelines for managing the pediatric patient with potential for MCT have included screening with provocative calcitonin tests beginning at one year of age and total thyroidectomy performed when either basal calcitonin or stimulated test levels become abnormal. The diagnosis of MEN IIb, however, can be made on the basis of pathognomic clinical features, including characteristic facies, marfanoid body habitus, submucosal ganglioneuromas and thickened corneal nerves. A family is described herein in which one member had the pathognomonic clinical findings of MEN IIb but did not have an elevated level of serum calcitonin in response to stimulation with pentagastrin and calcium. Nonetheless, a total thyroidectomy was performed and multiple microscopic foci of MCT were found on pathologic examination. This suggests that total thyroidectomy should be performed upon any patient with the characteristic phenotype of MEN IIb, regardless of the results of the stimulation test for calcitonin.

Adult↗
PubMed1989

Difficulties of parathyroidectomy after previous thyroidectomy.

Although the risks of reoperative thyroidectomy and parathyroidectomy have been well studied, the problems associated with parathyroidectomy after prior thyroidectomy have not been emphasized. Among a group of 282 patients who were treated for primary hyperparathyroidism in recent years at the University of Chicago Medical Center, 14 (4.8%) had undergone one or more previous thyroidectomies, and 6 others (2.1%) had undergone thyroid ablation with radioactive iodine as therapy for Graves' disease. Numerous difficulties were encountered during surgery in the postthyroidectomy group of patients as a result of scarring and fibrosis, prior recurrent laryngeal nerve injuries in 13%, the inability to known with certainty how many viable, normal parathyroid glands remained after previous operations, and the need for additional thyroid resection, mostly for associated malignant lesions. Preoperative vocal cord assessment, evaluation of prior operative and pathology reports, and localization studies with thallium-technetium scanning and ultrasonographic techniques were especially helpful. A "lateral approach" was used frequently during surgery. Each of these 14 patients was cured of the hyperparathyroidism. The postthyroid ablation group presented fewer intraoperative challenges, although in some patients the thyroid gland was virtually absent, which obscured the normal landmarks of the surgical field. Five of these six patients were cured of hyperparathyroidism. Parathyroidectomy after thyroidectomy presents many operative challenges to the surgeon and should be approached with the same care and concern that one reserves for a reoperative parathyroid operation.

Adult↗
PubMed1985

Total thyroidectomy: the treatment of choice in differentiated thyroid carcinoma?

A review of 46 patients with differentiated thyroid cancer, diagnosed and treated in the St. Radboud Hospital from 1977 till 1984, is presented. The age of the patients ranged from 16 to 80 years. There were 39 women and 7 men. Thirty of 31 patients with papillary carcinoma and 13 of 15 patients with follicular carcinoma underwent total thyroidectomy. If less than total thyroidectomy had been performed, 13 (43%) patients with papillary cancer and 2 (15%) with follicular cancer would have had cancer left in the residual lobe. The complication rate was acceptable, two cases of permanent hypoparathyroidism, one recurrent nerve palsy. During a short follow-up period of 7 years maximum already 6 patients older than 60 years with papillary carcinoma had died, 5 of widespread cancer (16.6%) and one of an unrelated disease. Three patients developed local recurrences, on in the trachea and 2 outside the thyroid bed. One patient with follicular carcinoma, who had undergone a lobectomy, developed recurrent disease. These figures plus the increased risk of complications in a second neck exploration suggest that total thyroidectomy is the treatment of choice for patients with differentiated thyroid cancer. Total thyroidectomy can be done without mortality and without significant morbidity.

Adenocarcinoma↗
PubMed1987

Total thyroidectomy in the treatment of thyroid disease.

In a review of thyroid surgery during the past 12 years, total thyroidectomy was performed in 20% of the cases. Forty percent were done for malignant disease and 60% for benign disease. Our indications for using this operation in benign thyroid disease include bilateral nodular goiter, Graves' disease, chronic thyroiditis, and cases in which the rapid frozen diagnosis is equivocal for carcinoma. We feel that the risks of reoperation for recurrent thyroid disease are greater than the risks of a total thyroidectomy as the initial surgical procedure. With the increased use of total thyroidectomy the incidence of permanent hypoparathyroidism can be decreased. We reviewed our preoperative work-up, indications for total thyroidectomy, surgical technique, diagnostic accuracy of needle biopsy, accuracy of rapid frozen section reports, and postoperative complications.

Goiter, Nodular↗
PubMed1984

Biologic considerations and operative strategy in papillary thyroid carcinoma: arguments against the routine performance of total thyroidectomy.

Reasons cited for the routine performance of total thyroidectomy in patients with papillary thyroid carcinoma include: fear of multicentric neoplastic foci causing local recurrence and death; risk of anaplastic transformation of unresected multifocal microscopic carcinoma; toxicity of high-dose radioactive iodine to ablate normal thyroid remnants; and lack of reliable criteria for grading malignancy and identifying patients at high risk. However, autopsy studies have detected microscopic foci of papillary thyroid cancer as incidental findings in up to 24% of patients dead of other diseases. The prevalence of anaplastic transformation of papillary thyroid carcinoma as determined from reports in the literature is less than 1%. A retrospective investigation of 90 patients with papillary thyroid carcinoma derived from the Swedish National Cancer Registry showed no complications from radioiodine ablation of postoperative thyroid remnants in 45 patients. Retrospective analysis of the DNA content of tumors at the time of the initial operation showed a significant difference between a group of 10 patients who died of recurrent and metastatic papillary thyroid carcinoma and a group of 16 patients alive at least 10 years after operation despite distant metastases or recurrent cancer in the thyroid bed and/or cervical lymph nodes. The risk of permanent hypoparathyroidism is higher in patients after total thyroidectomy without apparent improvement in survival rates when compared with less extensive resections. Therefore it is proposed that the criteria for total thyroidectomy in patients with papillary thyroid carcinoma be limited to: tumors that clinically involve both lobes of the thyroid gland, extracapsular spread of cancer requiring enbloc resection, and reoperations where scarring prevents accurate delineation of the extent of the tumor. By differentiating patients at high risk for death from papillary thyroid carcinoma from patients at low risk, the measurement of DNA content may decrease the need for routine total thyroidectomy.

Adolescent↗
PubMed1994

Total thyroidectomy in therapy-resistant Graves' disease.

BACKGROUND: Influences of total thyroidectomy have not been evaluated in patients with severe Graves' disease who might respond less satisfactorily to subtotal thyroid resection. METHODS: Thirty-three patients with Graves' disease underwent total thyroidectomy because of persistent endocrine ophthalmopathy (n = 28) or elevated thyrotrophin receptor antibody titers (n = 25) despite a mean of 2 years of thyrostatic therapy. Moreover, six and four patients had undergone radioiodine treatment and subtotal thyroid resection, respectively. Perioperative findings and complications have been investigated, as have influences on endocrine ophthalmopathy and thyrotrophin receptor antibody titers during a mean of 2.5 postoperative years. RESULTS: Total thyroidectomy substantiated mean thyroid weights of 17 gm, 2.3 hours of operating time, and total blood loss of 264 cc. Vocal cord paralysis and vitamin D-treated hypocalcemia occurred in two and three patients, respectively, and invariably persisted less than 6 months. Normalization of elevated thyrotrophin receptor antibody titers occurred in 86% of patients without radioiodine exposure, and stable or improved signs of endocrine ophthalmopathy were found in 96% of patients examined 6 or more months after the operation. CONCLUSIONS: Total thyroidectomy seems to be a surgically safe procedure in complicated Graves' disease and to provide normalization of therapy-resistant thyrotrophin receptor antibody titers. Because favorable influences might also encompass severe endocrine ophthalmopathy, prospective analysis on its efficiency is warranted.

Adult↗
PubMed1993

[Extension of thyroidectomy in the treatment of benign nodular thyroid diseases].

A series of 268 benign nodular goitres, operated on in a 10-year period, is presented. Subtotal thyroidectomy was the chosen operation; however, during the first period of our experience, when the goitre was obviously limited to one lobe we performed unilateral lobectomy in some cases. After surgery no patient received hormone therapy without previous evaluation of thyroid function. Thyroid function was evaluated after surgery and alterations were corrected. As recurrent goitre was a rare occurrence and complications of subtotal thyroidectomy are low, we do not support total thyroidectomy for nodular goitre. In order to avoid recurrences hemithyroidectomy no longer must be performed: the surgical treatment of nodular goitre is carried out by subtotal thyroidectomy, leaving little residual thyroid, to spare parathyroids and inferior laryngeal nerves, which is usually enough for adequate hormone production; in the case of TSH raising, thyroxine must be given.

Adolescent↗
PubMed1993

Amiodarone-induced thyrotoxicosis: clinical presentation and expanded indications for thyroidectomy.

BACKGROUND: Amiodarone-induced thyrotoxicosis (AIT) is a rare disorder that is frequently refractory to conventional pharmacologic therapy. METHODS: An analysis of seven patients who underwent thyroidectomy for control of AIT between 1987 and 1993 was completed to examine the clinical manifestations and the indications for surgical therapy. RESULTS: Five men and two women, 53 to 72 years of age, had AIT after 3 to 55 months of amiodarone treatment (mean, 21 months). The primary manifestations of AIT were ventricular tachycardia (five), exacerbation of chronic pulmonary disease (one), and occult hyperthyroidism (one). Medical therapy included propylthiouracil in doses up to 1200 mg/day in five patients, a beta-receptor antagonist in three, and withdrawal of amiodarone in five. Near-total or total thyroidectomy resulted in resolution of thyrotoxicosis in all patients. Morbidity included pneumonia (one) and cardiac dysrhythmias (two). One patient died of ventricular dysrhythmias 4 months after thyroidectomy. The mean thyroid weight was 50 gm (range, 17 to 216 gm). Microscopic examination showed destructive follicular lesions with fibrosis in all patients. Associated thyroid pathologic condition included multinodular goiter in four patients and a follicular adenoma in one. CONCLUSIONS: AIT may be clinically occult or manifested by unusual symptoms requiring a high index of suspicion for diagnosis. Near-total thyroidectomy is safe and effective in producing rapid resolution of AIT and is indicated for the initial treatment of patients who present with a resurgence of life-threatening cardiac arrhythmias and for all patients with AIT refractory to medical therapy.

Aged↗
PubMed1995

[Therapeutic implication of the decreased intrathyroidal iodine pool after partial thyroidectomy for simple goiter].

The residual intrathyroidal iodine pool has not been theoretically estimated in 65 subjects from Brussels submitted to partial thyroidectomy for simple goitre. The initial pool was found to be 6.28 mg +/- 3.15. The least invasive form of thyroidectomy (lobectomy) would have reduced this pool to approximately 4 mg and subtotal thyroidectomy to less than 0.5 mg. Various observations lead to the conclusion that the critical level of the thyroidal pool that would maintain euthyroidism lies near 2 to 3 mg. It is therefore concluded that a substitution therapy should be recommended after partial thyroidectomy for simple goitre in areas with relative alimentary iodine deficiency.

Goiter↗
PubMed1996

Completion thyroidectomy in 131 patients with differentiated thyroid carcinoma.

OBJECTIVE: To evaluate the prognostic factors that influence survival and recurrence after "completion" thyroidectomy (removal of the total thyroid remnant after diagnosis of carcinoma has been made in a specimen that was incompletely excised for a benign condition). DESIGN: Open study. SETTING: Teaching hospital, Germany. SUBJECTS: 131 Patients (65 with papillary and 66 with follicular thyroid cancer) who underwent completion thyroidectomy after primary subtotal resection. INTERVENTIONS: Indications for further operation were: tumour stage worse than pT1 ( n = 116), tumour stage pT1 and the suspicion of persistence of the tumour (n = 13), and incompletely resected tumour (n = 2). Multivariate analysis by Cox's proportional hazards model. MAIN OUTCOME MEASURES: Recurrence, development of metastases, and length of survival. RESULTS: Patients who underwent their completion thyroidectomies within six months of the primary operation had significantly fewer recurrences, fewer lymph node metastases, fewer haematogenous metastases and survived significantly longer than those in whom the second operation was delayed for longer than six months. The age at the time of diagnosis and the stage of the tumour influenced survival, whereas sex and type of tumour did not. CONCLUSION: Completion thyroidectomy as soon as possible after incomplete resection of the tumour may improve prognosis in differentiated thyroid cancers the stage of which is worse than pT1 or in patients whose recurrent tumour is diagnosed at follow-up.

Adenocarcinoma, Follicular↗