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[Parathyroid risk in thyroid surgery. Reality and prevention. 502 bilateral thyroidectomies].

Prospective study of parathyroid risk in a bulk of 502 consecutive bilateral thyroidectomies. Early post-operative hypocalcemia has been documented in 8,8% of the patients, but persisted in only 1,6% one year later. Late parathyroid risk of total thyroidectomy is 3,3% but increases twofold if neck dissection is simultaneously performed. Methods of this study probably misdiagnose a number of mild hypoparathyroidism. Lack of early hyperphosphoremia seems to be an optimizing criteria for aftermath. In Grave's disease, early post-operative hypocalcemia is more common (6,9%) but often subsides (definitive risk: 0,4%). This acceptable morbidity is compared to the data of literature. To prevent post-operative hypoparathyroidism a painstaking dissection of parathyroid blood supply seems more promising and effective than routine autotransplantation of the glands.

Graves Disease↗

[Effect of thyroxine and thyroidectomy on the activity of adenylate deaminase in the tissues of guinea pigs].

The authors studied the influence of thyroxin and thyroidectomy on adenylate deaminase activity in the liver, the myocardium, the brain and the skeletal muscles of guinea pigs. Thyroxin used in normal animals (200 microgram/100 g of body weight for 7 days) failed to alter the enzymatic activity in the tissues under study, whereas in thyroidectomized guinea pigs (50 microgram/100 g of body weight at the same interval)--it enhanced this activity. Thyroidectomy diminished the adenylate deaminase activity in the skeletal muscles and considerably increased it in the myocardium and in the brain.

AMP Deaminase↗

Modified subtotal thyroidectomy in the management of Graves' disease.

A prospective study of a new surgical approach (modified subtotal thyroidectomy) in the management of Graves' disease was carried out in 55 patients. The patients were followed over an average of 4 years with a strict protocol involving serial clinical and chemical evaluations (T4, T3RIA, TSH) and yearly thyroid scans. Long-term euthyroidism was achieved in 94% of the patients. These results are markedly superior to the functional results occurring after the standard thyroidectomy in widespread current use. In particular, the development of postoperative hypothyroidism, which is usually manifest by the second year after operation, has not occurred in this series. Observations of TSH elevations in som euthyroid postoperative patients may have important implications regarding the mechanism by which appropriate surgical resection favorably affects the pathophysiology of Graves' disease.

Adolescent↗

[The parathyroid risk in thyroidectomy].

The authors report their experience of parathyroid risk in thyroid surgery on the basis of 1 188 thyroidectomies performed between 1973 and 1980. The benign thyroid pathology, the risk is negligeable, approximately 1%, though with the exception of operations for recurrence. In malignant tumour pathology, amongst 98 carcinomas treated by total thyroidectomy and mediastino-recurrent laryngeal lymph node dissection, the authors report an overall percentage of definitive major hypocalcaemia of 22.5%. Routine identification of the parathyroids at the start of the operation, at least on the healthy side, and care not to damage their vascular supply has made it possible to reduce the rate of hypoparathyroidism to 10% in the past two years. A study of anatomical dissection of 200 parathyroid glands with vascular injection is reported in the preamble. Finally, the authors analyse in the literature the results of parathyroid transplant and report their own experience.

Humans↗

Central nervous regulation of pituitary TSH response induced by thiouracil treatment or by thyroidectomy.

The serotoninergic neuron system of the midbrain and hypothalamus was previously shown to inhibit the basal secretion of the TRH-TSH-thyroid axis. The aim of the present study was to investigate the influence of the serotoninergic system on the TSH response of the adenohypophysis to specific loads. Serum TSH levels were determined 7 days after thyroidectomy or the beginning of thiouracil administration. Animals were simultaneously treated either by intrahypothalamic implantation of serotonin-containing needles or by intraventricular or daily subcutaneous injections of the same drug. The thiouracil-induced goitre formation and increase in serum TSH concentration were significantly diminished by serotonin treatment. Similarly, the thyroidectomy-induced rapid rise in TSH blood level was also remarkably inhibited in the serotonin-treated animals. Serotonin was proved to influence rather TRH-output than pituitary TSH secretion, since exogenous TRH, injected to serotonin-pretreated animals had the same TSH-mobilizing potency as found in the not premedicated group. It is concluded that besides the inhibition of the basal secretion of the TRH-TSH-thyroid axis by serotonin, there is an integrative role of the serotoninergic system in the mediation of the reactivity of this circuit in reply to specific influences loading pituitary-thyroid function.

Animals↗

[Early prediction of hypothyroidism after subtotal thyroidectomy (author's transl)].

30 patients were classified euthyroid (group A, n = 13) and hypothyroid (group B, n = 17) 4 years after subtotal thyroidectomy. A retrospective analysis of the hormonal status was then performed. In both groups (A and B) a significant decrease of serum T3 was found 3 days after surgery. 3 months later T3 levels had returned to normal. Serum T4 showed no significant change, neither at day 3 nor 3 months after the operation. Serum thyrotropin (TSH) also showed no significant change 3 days after surgery in both groups. However, 3 months later serum TSH levels were found to be significantly increased in group B (greater than 4.8 microU/ml, Mean = 13.0 +/- 6.7 microU/ml, p less than 0.001) while in group A TSH remained normal (normal range: 0--3.4 microU/ml). Assuming a serum TSH of 5.0 microU/ml as critical level at 3 months after subtotal thyroidectomy 25% of eventually hypothyroid patients will be missed and 1% will be classified hypothyroid. It is therefore suggested that all patients with serum TSH of more than 4.8 microU/ml 3 months after surgery should be considered chronically hypothyroid. The patients with a serum TSH between 3.4--4.8 microU/ml should be kept on prophylactic thyroid hormone therapy until further 3 months later the final diagnosis is established.

Humans↗

Thyroidectomy in patients with marked thyroid enlargement: airway management, morbidity, and outcome.

The medical records of 91 patients who underwent thyroidectomy from 1990 to 1993 were reviewed to evaluate airway management and operative morbidity in patients with marked thyroid enlargement. Twenty-nine patients with marked thyroid enlargement were identified: 13 unilateral, defined by a weight of > or = 40 g (mean 122 g, range 41-380 g), and 16 bilateral, defined by a weight of > or = 80 g (mean 160 g, range 82-404 g). Twenty-five patients had compressive symptomatology, 18 had tracheal narrowing and/or displacement, 19 had substernal extension, and one had superior vena cava syndrome. Unilateral vocal cord dysfunction was present in two of three patients with carcinoma and one of 26 patients with benign disease (P = 0.03). Pathology consisted of nodular goiter (11), adenoma (5), carcinoma (3), Grave's disease (5), and toxic multinodular goiter (5). All patients had an uncomplicated endotracheal intubation without the use of a fiberoptic bronchoscope as predicted on the basis of preoperative laryngoscopic findings. Ease of intubation was unrelated to the extent of abnormality seen on imaging studies of the neck. Thyroidectomy alone was effective in relieving compressive symptoms with no incidence of nerve injury, permanent hypoparathyroidism, or tracheomalacia. Six (21%) of 29 patients had temporary hypocalcemia compared to eight (13%) of 62 patients with lesser thyroid enlargement (P = 0.36). One patient with an unresectable follicular carcinoma died from aspiration pneumonia three weeks following tracheostomy placement. Marked thyroid enlargement and upper airway compression is predominantly caused by benign disease; however, when there is associated recurrent laryngeal nerve dysfunction, carcinoma is more common.(ABSTRACT TRUNCATED AT 250 WORDS)

Adenoma↗

Subtotal thyroidectomy, the preferred option for eu- and hyperthyroid goitre.

A series of 268 patients operated on for benign thyroid diseases is presented. Totally 168 subtotal thyroidectomies and 100 hemithyroidectomies have been performed, with no mortality and 0.74% morbidity. Postoperative thyroid function was assessed in 135 patients; this demonstrated that many patients do not need postoperative hormone supplementation and that subtotal thyroidectomy must be considered the intervention of choice, even in uninodular forms.

Adolescent↗

Hyperthyroidism with potent thyroid-stimulation-blocking antibodies and negative thyroid-stimulating antibodies after subtotal thyroidectomy for Graves' disease with follicular thyroid carcinoma.

A 39-year-old woman with Graves' disease associated with follicular thyroid carcinoma underwent subtotal thyroidectomy. TSH-binding inhibitor immunoglobulins (TBII) were positive, whereas thyroid-stimulating antibodies (TSAb) and thyroid-stimulation-blocking antibodies (TSBAb) were both negative before the operation. After the operation, TBII markedly increased above the pretreatment value. TSBAb became positive 3 months after the operation and then their activity increased, while TSAb remained negative after the operation. Subtotal thyroidectomy may have influenced the development of TSBAb in this patient. Irrespective of these findings, the patient became hyperthyroid again several months after the operation.

Adenocarcinoma↗

[The usefulness of thyroxine treatment after subtotal thyroidectomy for endemic goiter].

The aim of the present study was to assess the appropriateness and value of prophylactic thyroxine therapy in the treatment of postoperative complications (relapse, postoperative hypothyroidism) following subtotal thyroidectomy for endemic goiter. The study was carried out in a group of 139 patients undergoing subtotal thyroidectomy for endemic goiter between 1978 and 1987. Clinical follow-up included hematochemical and scintigraphic analyses. Patients were divided into two groups. The first group included 74 patients who received postoperative hormone replacement therapy. The second group of 65 patients did not receive any treatment. results show that hormone replacement therapy is unnecessary in most cases since the majority of patients require euthyroid values a few months after operation. Thyroxine therapy was indicated, however, in cases of clinically evident postoperative hypothyroidism which persisted during follow-up.

Adult↗

Short stay thyroidectomy in a tertiary care hospital.

BACKGROUND: Many procedures which earlier required a prolonged stay in hospital are now being performed on a short stay basis. METHODS: In 1989 we adopted a policy of 'short stay thyroidectomy' defined as a postoperative stay of less than 48 hours. Till 1992, 162 patients were included in this study. After early drain removal at 16-43 hours (median 38), these patients were discharged 18-45 hours (median 41) after surgery. We recorded the postoperative drainage of 155 of these patients. RESULTS: Out of 162 patients, 156 were discharged within 48 hours after surgery. No patient developed any complication which required re-admission and there was a fall in the amount of drainage within 12-18 hours. CONCLUSION: Short stay thyroidectomy is feasible in a developing country.

Adolescent↗

[Unfavorable characteristics in patients with early postoperative recurrence of Graves' disease after subtotal thyroidectomy].

Unfavorable characteristics of early postoperative recurrence of hyperthyroidism were studied in patients with Graves' disease after subtotal thyroidectomy. We examined 338 patients who underwent subtotal thyroidectomy during a 9-year period from 1981 to 1989. Thyroid functional status was determined biochemically and the following variables were collected and divided into two categories for each patient: sex, age at operation, indication for surgery, serum titer of antimicrosomal hemagglutination antibody, weight of resected thyroid tissue and size of remnant thyroid tissue relative to body surface area. Early postoperative recurrence was defined as relapse of the disease within one year after surgery, necessitating medication or radioiodine therapy. Logistic regression analysis disclosed that the most important characteristics were age < 20 yr, relatively large thyroid remnant and weight of resected thyroid tissue > or = 100g, the odds ratios for these variables being 20.6, 16.7 and 3.4, respectively (p < 0.05). Although candidates for surgical treatment of Graves' disease are likely to be younger and to have a large goiter, these characteristics are unfavorable, since they predict the early recurrence of hyperthyroidism. One alternative is to leave a smaller than usual thyroid remnant thyroid in these patients, even if the risk of postoperative hypothyroidism is high.

Adult↗

An unusual cause for respiratory difficulty after thyroidectomy.

Problems with breathing immediately after extubation following thyroidectomy are rare, but can usually be attributed to a surgical error such as damage to one or both recurrent laryngeal nerves. Tracheomalacia may also cause respiratory distress following extubation. We present an unusual cause of failure to resume spontaneous respiration after thyroidectomy.

Aged↗

High long term recurrence rate after subtotal thyroidectomy for nodular goitre.

OBJECTIVE: To establish the long term recurrence rate in patients operated on for nodular goitre and to find out if oral treatment with thyroxine reduces this risk. DESIGN: Retrospective study. SETTING: District hospital, Sweden. SUBJECTS: 43 patients who underwent subtotal thyroidectomy for nodular goitre (36 non-toxic, 7 toxic) from 1960-65, and who were re-examined in 1993; 11 patients were given oral thyroxine during the postoperative period and the remaining 32 had no medical treatment. MAIN OUTCOME MEASURES: Recurrence of goitre. RESULTS: 5/11 goitres recurred in the thyroxine group (45%) and 13/32 (41%) in the untreated group. CONCLUSION: The recurrence rate of nodular goitre is high 30 years after subtotal thyroidectomy. Long term oral thyroxine does not seem to change the picture.

Administration, Oral↗

[Total thyroidectomy with preservation of the parathyroid glands].

The operative treatment of thyroid pathology has to be distinguished for benign and malignant pathology. The major complications associated with thyroid surgery are injury to the recurrent laryngeal nerve and hypoparathyroidism. Postoperative hypoparathyroidism is rarely the result of inadvertent removal of all parathyroid glands but, non commonly, is due to disruption of their blood supply. Postoperative hypoparathyroidism results in patients with symptomatic hypocalcemia, transitory and permanent hypoparathyroidism. Subtotal thyroidectomy is used for the treatment of benign thyroid pathology while tumors are treated by total thyroidectomy with neck dissection.

Goiter, Nodular↗

T4 accumulation in lysosomes of rat thyroid remnants after subtotal thyroidectomy.

In chronically stimulated rat thyroids after subtotal thyroidectomy, lysosomes increased in number and volume. They contained iodocompounds and did not appear in iodine-deficient animals. In this study, we analyzed the subcellular localization and the nature of these intracellular iodocompounds. Classical subcellular fractions were isolated from homogenates of rat thyroids and remnants 14 weeks after sham-operation or subtotal thyroidectomy. Two lysosome subpopulations of increasing density, a light fraction, lysosomes 2 (L2, density 1.065-1.08 g/ml) and a dense fraction, lysosomes 1 (L1, density > 1.08 g/ml) were separated from crude lysosomal particulate fractions (ML) by centrifugation in Percoll gradients. Results obtained with thyroids of normal rats were used as controls. In TSH-stimulated thyroid remnants, total activities of three lysosomal enzymes and iodine concentration were increased by 1.6-fold compared with thyroids of sham-operated rats. Total iodoprotein-derived T3 and T4 concentrations, measured after pronase hydrolysis, were slightly decreased. Thyroglobulin (Tg) concentration in the supernatant was reduced by 50%. Iodine, T3 and T4 contents of Tg were not modified. After differential centrifugation, the iodine excess of remnants sedimented with subcellular particulate fractions. The concentration of iodine in dense lysosomes (L1) was 6 times that in sham L1. Intact Tg did not accumulate in L1. Two thirds of the iodine in L1 was soluble in methanol, double the normal proportion, with twice as much iodine included in hydrophobic peptides eluted after T4 by reverse-phase HPLC. Although iodoprotein-derived T4 and T3 concentrations were decreased in the remnant homogenate, they were increased in particles, particularly in L1 where they were increased by 8 and 4-fold, respectively. In contrast, specific activities of lysosomal enzymes in ML and L1 remained unchanged. It is concluded that the chronic TSH stimulation of thyroid remnants in subthyroidectomized rats receiving a normal iodine supply induces the endocytosis of a normal Tg with iodine kept in dense lysosomes. The expansion of the lysosomal compartment resulted from a limitation in iodopeptides degradation as though secondary lysosomes would be overloaded with Tg. The accumulation in L1 of hydrophobic iodopeptides and of more iodoprotein-derived T4 than T3 suggests that exopeptidases involved in the liberation of T4 become rate-limiting.

Animals↗

[Value of thyroidectomy in amiodarone-induced hyperthyroidism. Apropos of 3 cases].

Amiodarone-induced hyperthyroidism in a relatively rare complication of long-term treatment with this molecule. It usually carries a good prognosis with regression being the rule after withdrawal of the drug although lethal forms have been reported. Conventional medical therapy (synthetic antithyroid drugs, steroids, betablockers) used in severe forms, is not always effective. In addition, amiodarone may be essential for the treatment of life-threatening, poorly tolerated arrhythmias, refractory to other forms of treatment. The authors report the cases of three patients treated with amiodarone for malignant arrhythmias who developed severe hyperthyroidism resistant to medical therapy and who were treated by total thyroidectomy. Surgery was followed by rapid resolution of the thyrotoxicosis without significant complications and immediate represcription of amiodarone. Thyroidectomy therefore seems a simple solution for amiodarone-induced hyperthyroidism allowing very rapid resolution of the hyperthyroidism and the possibility of immediate represcription of amiodarone.

Adult↗