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PubMed2003

Incision length for standard thyroidectomy and parathyroidectomy: when is it minimally invasive?

HYPOTHESIS: Current techniques for open conventional thyroidectomy or parathyroidectomy have evolved to enable a shorter incision (main proposition), and the length of the incision is influenced by objective factors. DESIGN: Case series. SETTING: University referral center. PATIENTS AND INTERVENTION: Retrospective study of the most recent 200 primary consecutive routine thyroid and parathyroid operations (excluding neck dissections). MAIN OUTCOME MEASURES: The length of incision was routinely measured with a ruler before the incision. Univariate and multivariate analysis was performed to distinguish variables affecting length of incision. RESULTS: Mean length of the incision was 5.5 cm for total thyroidectomy, 4.6 cm for lobectomy, and 3.5 cm for parathyroidectomy (P<.001). It was 4.1 cm for bilateral parathyroid exploration, but was reduced to 3.2 and 2.8 cm for unilateral (P<.001) and focal (P<.001) explorations, respectively. By multiple regression analysis, thyroid specimen volume and patient body mass index were independent predictors of incision length in thyroidectomy. Extent of exploration and resident training level were independent predictors of incision length in parathyroidectomy. CONCLUSIONS: Current techniques for open conventional thyroidectomy or parathyroidectomy have evolved to enable a shorter incision. Thyroid volume, patient body mass index, extent of the planned parathyroid exploration, and the resident clinical training stage are important variables for incision length in open operation and should be taken into account when minimally invasive thyroidectomy and parathyroidectomy are evaluated.

Female↗
PubMed1985

The advantages of subtotal thyroidectomy and suppression of TSH in the primary treatment of papillary carcinoma of the thyroid.

Patients between the ages of 6 and 45 years with distant metastases from papillary carcinoma of the thyroid can be treated as effectively by subtotal thyroidectomy and suppressive doses of thyroid hormone as by total thyroidectomy followed by treatment with iodine 131 (131I). Moreover, distant metastases can be treated by either 131I or suppression as effectively after they are apparent on x-ray as they can be when treated in a subclinical stage. Therefore, in patients younger than 45 years old it is rarely necessary to perform a total thyroidectomy or to do frequent postoperative scans. In patients older than 44 or younger than 7 who have distant metastases or extensive involvement of both lobes, total or almost total thyroidectomy is justified if it can be done with minimal morbidity. In patients of this age group whose tumors fail to respond to suppressive doses of thyroid, 131I should be used. In view of the importance of diagnostic related groups (DRG) to the economy of hospitals, we note that the cost of total thyroidectomy, ablation by 131I, and intermittent body scans is at least three times that of less radical procedures which, in conjunction with suppression by thyroid feeding, give the same survival with less morbidity.

Adolescent↗
PubMed2004

Total thyroidectomy for clinically benign disease of the thyroid gland.

BACKGROUND: The role of total thyroidectomy in the treatment of patients with benign thyroid disease remains controversial. However, this procedure may be appropriate when both thyroid lobes are involved and when the risk of recurrence is significant. This study is a review of a 15-year experience of total thyroidectomy for benign disease. METHODS: Between 1988 and 2002, 834 patients underwent total thyroidectomy for clinically benign disease at the Sydney Head and Neck Cancer Institute, Royal Prince Alfred Hospital. There were 128 men and 706 women with a mean age of 52 (range 16-91) years. Indications for surgery were euthyroid multinodular goitre (MNG), toxic MNG and Graves' disease in 730 (87.5 per cent), 57 (6.8 per cent) and 47 (5.6 per cent) respectively. A total of 74 patients had previously undergone partial thyroidectomy. RESULTS: The incidence of temporary recurrent laryngeal nerve palsy was 2.3 per cent and that of temporary hypoparathyroidism 14.4 per cent. Permanent recurrent laryngeal nerve palsy occurred in 1.1 per cent, and 2.4 per cent of patients had permanent hypoparathyroidism. Neither the initial clinical diagnosis nor a history of previous treatment significantly influenced the rate of complications. The incidence of malignancy, other than incidental microscopic papillary carcinoma, was 4.6 per cent. CONCLUSION: Total thyroidectomy has an important role in the management of patients with benign disease when both lobes of the thyroid gland are involved. This approach avoids disease recurrence and the increased risk of morbidity associated with secondary operation.

Adolescent↗
PubMed2003

Assessment of parathyroid autotransplantation for preservation of parathyroid function after total thyroidectomy.

BACKGROUND: Hypoparathyroidism with permanent hypocalcemia is a well-recognized complication after thyroid surgery. AIM: This study was conducted to assess the role of immediate parathyroid autotransplantation in the preservation of parathyroid function after total thyroidectomy. PATIENTS AND METHODS: Twenty-eight patients had autotransplantation of parathyroid glands resected or devascularized during total thyroidectomy. Data were collected prospectively regarding demographics, indication for surgery, operative procedure, pathologic diagnosis, number of glands transplanted, and subsequent course. Thyroid nodules were evaluated by ultrasonography, radionuclide scanning, and/or fine-needle aspiration cytology. All patients had serum ionized calcium, phosphorus, and intact parathyroid hormone (PTH) levels measured preoperatively and monitored regularly postoperatively for a period of 14 weeks and again at 6 months after operation. Patients were categorized into three groups according to the number of glands transplanted: one (group 1, n = 6), two (group 2, n = 14), or three glands (group 3, n = 8). In three other volunteers, one parathyroid gland was transplanted in the brachioradialis and subjected to electron microscopy 1, 2, and 4 weeks after transplantation. RESULTS: Total thyroidectomy was performed for malignant disease in 16 patients (57.1%) and for benign disease in 12 (42.9%) patients. All patients reverted to asymptomatic normocalcemia without the need for any medications within 4 to 14 weeks. Normal levels of serum markers were regained slower when one gland was transplanted compared with two or three glands (P <.01). Electron microscopic examination showed evidence of ischemic degeneration in the transplanted tissues 1 week postoperatively. Regeneration started by the second week and coincided with normalization of PTH levels. Optimum resting and nearly normal status of parathyroid tissue was achieved by the fourth week. CONCLUSIONS: This study showed that active PTH production coincides with regeneration of parathyroid cells and that autotransplantation of at least two resected or devascularized glands during total thyroidectomy nearly eliminates permanent postoperative hypoparathyroidism, thus improving the safety of total thyroidectomy performed for malignant or benign disease.

Adult↗
PubMed2004

LigaSure versus clamp-and-tie thyroidectomy for benign nodular disease.

BACKGROUND: LigaSure is an alternative bipolar diathermy system (BDS) combining vessel sealing with reduced thermal spread, which has been successfully used in many abdominal operations; however, there is a little experience in open thyroidectomy. This study compares the efficacy and the advantages of the LigaSure BDS when used for total thyroidectomy for benign thyroid disease with the conventional clamp-and-tie technique. METHODS: Between May 1998 and October 2002, 517 patients underwent total thyroidectomy for benign thyroid multinodular goiter. Among them, from May 1998 until May 2000, 247 patients (group I) were operated on with the conventional clamp-and-tie technique, whereas from May 2000 until October 2003, 270 patients (group II) underwent total thyroidectomy for benign multinodular goiter with LigaSure BDS through a 4-cm transverse suprasternal incision. Demographics, pathologic characteristics, gland mass, operative time, blood loss, and complications were assessed. RESULTS: There were no intraoperative complications. Thyroid mass was similar in both groups, but the operative time was shorter in group II than in group I (mean +/- standard deviation, 71 +/- 14 minutes vs 86 +/- 22 minutes; p < .01). Intraoperative total blood loss was similar between the two groups, but postoperative drain volume was less in group II than in group I (21 +/- 15 mL; p < .01). Major post-thyroidectomy complications (ie, laryngeal nerve palsy, hematoma, and hypocalcemia) occurred less frequently in the LigaSure group than in the clamp-and-tie group (0.7%, 0.4%, 1.1% vs 4%, 2%, 4.8%, respectively; p < .05). The mean +/- standard deviation postoperative hospital stay was significantly less for the patients in group II than for those in group I (2.3 +/- 1.7 days vs 2.8 +/- 1.3 days; p < .05). CONCLUSIONS: The use of the LigaSure vessel sealer for thyroid surgery is an effective and safe alternative that reduces the overall operative time and could be successfully applied through a narrow surgical incision.

Adult↗
PubMed2005

Electrothermal bipolar vessel sealing system is a safe and time-saving alternative to classic suture ligation in total thyroidectomy.

BACKGROUND: Total thyroidectomy is associated with minimal morbidity. The electrothermal bipolar vessel sealing system is an adjunct to the surgical technique, recently made available to thyroid surgery. METHODS: This is a prospective randomized trial of total thyroidectomies performed in single unit from July 2003 to May 2004. Patients were randomly assigned in two groups: group A (n = 90), total thyroidectomy with the classic suture ligation technique; and group B (n = 94), total thyroidectomy with the use of the electrothermal bipolar vessel sealing system. RESULTS: Operative time was significantly reduced in group B by 14 minutes (mean difference, 14.3 +/- 4.2 minutes, 95% CI, 5.88-22.6 minutes). No statistically significant differences were found in postoperative complications, postoperative serum calcium measurements, or hospital stay between the two groups. CONCLUSIONS: The electrothermal bipolar vessel sealing system is a safe and useful, time-saving adjunct for total thyroidectomy.

Electrocoagulation↗
PubMed2003

[Is primary total thyroidectomy justified in benign multinodular goiter? Results of a prospective quality assurance study of 45 hospitals offering different levels of care].

INTRODUCTION: After subtotal resection of multinodular goiter, rates of up to 40% are reported for recurrent goiter in the long-term follow-up. Because of the increased morbidity of surgery for recurrent goiter, this study evaluated the preconditions that would justify total thyroidectomy as part of the primary therapy concept for benign multinodular goiter. MATERIAL AND METHODS: The Quality Assurance Study of Benign and Malignant Goiter covering the period from 1 January to 31 December 1998 assessed 5195 patients treated for benign goiter by primary bilateral resection. With respect to the extent of resection three groups were analyzed: bilateral subtotal resection (ST+ST, n=4580), subtotal resection with contralateral lobectomy (ST+HT, n=527), and total thyroidectomy (TT, n=88). RESULTS: The age of the patients was significantly higher (60.3 years) in the TT group than in the ST+ST (52.5 years) and ST+HT (55.6 years) groups. ASA classification grades III and IV were significantly more frequent in the TT group. The postoperative morbidity increased with the extent of resection. The rate of permanent recurrent laryngeal nerve (RLN) palsy was 0.8% for ST+ST, 1.4% for ST+HT, and 2.3% for TT and of permanent hypoparathyroidism 1.5% for ST+ST, 2.8% for ST+HT, and 12.5% for TT. Multivariate analysis showed that the extent of resection significantly increased the risk of RLN palsy (transient RR 0.5, permanent RR 0.4) and hypoparathyroidism (transient RR 0.2,permanent RR 0.08). The surgeon's experience (RR 0.6) and identification of the RLN (RR 0.5) reduced the risk of permanent RLN palsy. Additionally, the development of permanent hypoparathyroidism was reduced if at least two parathyroid glands (RR 0.4) were identified. CONCLUSION: Total thyroidectomy is associated with an increased rate of RLN palsies and hypoparathyroidism in comparison to less extensive thyroid surgery. In the hands of well-trained surgeons using an appropriate intraoperative technique, primary thyroidectomy is justified if the patient has an increased risk of recurrent goiter. Due to the increased postoperative morbidity after total thyroidectomy, subtotal thyroid resection based on the morphologic changes in the thyroid gland is still recommended as the standard treatment regimen for multinodular goiter.

Female↗
PubMed2006

Thyroidectomy using monitored local or conventional general anesthesia: an analysis of outpatient surgery, outcome and cost in 1,194 consecutive cases.

BACKGROUND: Critical appraisal of safety, feasibility, and economic impact of thyroidectomy procedures using local (LA) or general anesthesia (GA) is performed. METHODS: Consecutive patients undergoing thyroidectomy procedures were selected from a prospective database from January 1996 to June 2003 of a single-surgeon practice at a tertiary center. Statistical analyses determined differences in patient characteristics, outcomes, operative data, and length of stay (LOS) between groups. A cohort of consecutive patients treated in 2002-2003 by all endocrine surgeons at the institution was selected for cost analysis. RESULTS: A total of 1,194 patients underwent thyroidectomy, the majority using LA (n = 939) and outpatient surgery (65%). Female gender (76%), body mass index > or = 30 kg/m2 (29%), median age (49 years), and cancer diagnosis (45%) were similar between groups. Extent of thyroidectomy (59% total) and concomitant parathyroidectomy (13%) were similarly performed. GA was more commonly utilized for patients with comorbidity [15% vs. 10%, Anesthesia Society of America (ASA) > or = 3; P < 0.001], symptomatic goiter (13% vs. 7%; P = 0.004), reoperative cases (10% vs. 6%; P = 0.01), and concomitant lymphadenectomy procedures (15% vs. 3%; P < 0.001). GA was associated with significant increase in LOS > or = 24 hours (17 % vs. 4%) or overnight observation (49 % vs. 14%), P < 0.001. Operative room utilization was significantly associated with type of anesthesia (180 min vs. 120 min, GA vs. LA, P < .001) and impacted to a lesser degree by surgeon operative time (89 minutes vs. 76 minutes, GA vs. LA; P = .089). Overall morbidity rates were similar between groups (GA 5.8 % vs. LA 3.2%). The actual total cost (ATC) per case for GA was 48% higher than for LA and 30% higher than the ATC for all procedures (P = 0.006), with the combined weighted average impacted by more LA cases (n = 217 vs. 85). CONCLUSION: These data from a large, unselected group of thyroidectomy patients suggest LA results in similar outcomes and morbidity rates to GA. It is likely that associated LA costs are lower.

Adolescent↗
PubMed2000

Surgery for Graves' disease: total versus subtotal thyroidectomy-results of a prospective randomized trial.

The effect of surgery on Graves' orbitopathy (GO) is still controversial. Retrospective analyses of many authors (including our own group) demonstrated GO improvement after subtotal thyroid resection in up to 70% of operated patients, so the question arose whether total thyroidectomy could add anything to this pronounced positive effect on GO. We therefore performed a prospective randomized trial on 150 patients with Graves' disease (125 women, 25 men; mean thyroid volume 80.5 ml) comparing three surgical procedures (bilateral subtotal thyroid resection-total remnant < 4 ml; unilateral hemithyroidectomy with contralateral subtotal thyroid resection-remnant < 4 ml; total thyroidectomy) and their effect on postoperative GO changes, postoperative thyroid-stimulating hormone receptor (TSH-R) antibody titers, and postoperative complication rates. After a period of at least 6 months (6-36 months) GO had improved in 71% to 74% of all patients regardless of whether total or subtotal thyroidectomy was performed. TSH-R antibody titers showed no differences for the three surgical groups. Postoperative recurrent hyperthyroidism occurred in two patients with subtotal resections, and early postoperative hypoparathyroidism was more frequently detected in patients with total thyroidectomy than in those with subtotal thyroid resection (28% vs. 12%; p < 0.002). In respect to possible postoperative hypoparathyroidism and a lack of difference in postoperative GO changes, we do not advocate total thyroidectomy for patients with Graves' disease and Graves' orbitopathy but prefer radical subtotal thyroid resection with a remnant of less than 4 ml.

Adolescent↗
PubMed2006

Video-assisted thyroidectomy: indications and results.

BACKGROUND AND AIMS: Minimally invasive video-assisted thyroidectomy (MIVAT) was set up and introduced in our department in 1998. Its results, after an acceptable relapse, can now be evaluated, also speculating on new possible indications. PATIENTS AND METHODS: The procedure is based on a unique incision in the central neck, 2 cm above the sternal notch, using small conventional retractors and needlescopic (2 mm) reusable instruments. Haemostasis is achieved by a harmonic scalpel. Patients, 833, underwent MIVAT since June 1998. There were 715 females and 118 males (ratio 4:1). Lobectomy was carried out in 323 (38.7%) patients, total thyroidectomy in 510 (61.2%) patients. RESULTS: Mean operative time of lobectomy was 36.2 min (range: 20-120); for total thyroidectomy, 46.1 min (30-130). Conversion to standard cervicotomy was required in 16 cases (1.9%); Operative complications were represented by transient monolateral recurrent nerve palsy in eight cases (0.9%), definitive monolateral recurrent nerve palsy in seven cases (0.8%). Twenty patients exhibited a hypoparathyroidism, which corresponds to 3.9% of total thyroidectomies performed, but only two showed permanent hypoparathyroidism (0.3%). CONCLUSION: MIVAT can be considered a safe operation offering significant cosmetic advantages with possible new promising indications such as prophylactic thyroidectomy in rearranged during transfection (RET) gene mutation carriers. It is still limited to a minority of patients, in particular, in endemic goitre countries.

Female↗
PubMed1998

Prophylactic thyroidectomy in MEN IIA: does the calcitonin level correlate with tumor spread?

BACKGROUND: The fate of patients with multiple endocrine neoplasia of type II A (MEN II A) is determined by medullary thyroid carcinoma, which occurs in all cases. This has led to the therapeutic concept of prophylactic thyroidectomy in affected family members with the goal of removing the thyroid before the manifestation of carcinoma. We investigated a prophylactically thyroidectomized MEN II A population to determine whether the highly specific and sensitive tumor marker calcitonin correlates with tumor spread. PATIENTS AND METHODS: Fifteen patients with MEN II A (aged 4-24 years) who had undergone prophylactic thyroidectomy since 1990 were included in the study. Baseline and pentagastrin-stimulated calcitonin levels were preoperatively determined in all cases. The indication for surgery was established on the basis of pathologic calcitonin levels in the first seven patients and on the basis of detected RET proto-oncogene mutation in the other eight patients. Bilateral central lymphadenectomy was performed in all patients in addition to thyroidectomy. RESULTS: Histology demonstrated C-cell hyperplasia in five patients (aged 4-13 years), unilateral medullary microcarcinoma in six (aged 9-17 years) and a bilateral medullary microcarcinoma in three cases (aged 17-24 years). One 9-year-old boy with bilateral microcarcinoma already had a lymph node metastasis. The mean baseline calcitonin level correlated with the histologic findings (r=0.71, P=0.003) but there was no correlation between pentagastrin-stimulated calcitonin levels and histology (r=0.21, P=0.47). CONCLUSION: In MEN II A patients undergoing prophylactic thyroidectomy, baseline but not stimulated calcitonin levels already correlate with the histologic tumor stage at the stage of clinically occult C-cell hyperplasia or medullary microcarcinoma. However, biochemical screening cannot reliably discriminate the transition from C-cell hyperplasia to invasive microcarcinoma. Individuals with MEN IIA should therefore undergo early prophylactic thyroidectomy once the diagnosis is confirmed by molecular genetic testing.

Adolescent↗
PubMed2003

Minimally invasive endoscopic thyroidectomy by a cervical approach.

BACKGROUND: The technique of thyroidectomy mandates adequate visualization of the operative field to identify pertinent anatomical structures. The purpose of this prospective review was to assess the feasibility and safety of endoscopic thyroidectomy by a cervical approach. METHODS: All patients who underwent endoscopic thyroidectomy were assessed by retrospective review of a prospective database. RESULTS: Thirty-eight patients underwent endoscopic thyroidectomy by a cervical approach. Thirty-five of 38 cases were successfully completed endoscopically with a mean OR time of 190 min. One patient experienced a permanent recurrent laryngeal palsy. CONCLUSION: Endoscopic thyroidectomy by a cervical approach is a feasible procedure. As in conventional thyroid surgery, great care should be exercised when dissecting the recurrent laryngeal nerve.

Endoscopy↗
PubMed2001

Indications, risks, and acceptance of total thyroidectomy for multinodular benign goiter.

Selective morphology- and function-adapted resection is generally regarded as the surgical treatment of choice for benign goiter causing iodine deficiency. This procedure aims to reduce the need for patients to undergo reoperations for recurrence by completely removing all nodules. However, to achieve this sometimes requires a total thyroidectomy, the option of which is often rejected because of a presumed higher rate of complications. In this study, 324 patients who underwent total thyroidectomy were evaluated retrospectively. The patients were interviewed about their postoperative course and their acceptance of the procedure performed. The complications were compared with those associated with subtotal resection or hemithyroidectomies performed in our collective experience. The rate of complications associated with total thyroidectomy, namely, recurrent nerve palsy in 0.9%, hypocalcemia in 0.9%, wound infection in 0.9%, and secondary hemorrhage in 0.6%, did not differ significantly from that associated with subtotal resections/ hemithyroidectomies. Moreover, 88.3% of the patients who underwent total thyroidectomy were satisfied with the results of surgery. These findings indicate that total thyroidectomy is an acceptable surgical alternative for benign multinodular goiters.

Adult↗
PubMedDate not supplied

Effect of thyroidectomy on oxidative phosphorylation mechanisms in rat liver mitochondria.

(1) In the presence of succinate, 2,4-dinitrophenol raised the oxygen consumption rate of state 3 liver mitochondria, whatever the thyroid state. The rise was clearly greater in thyroidectomized than in normal rats, but the uncoupled state 3 mitochondria of thyroidectomized rats nevertheless consumed oxygen more slowly than normal rat mitochondria. Thyroidectomy therefore weakened respiratory chain activity and phosphorylation reactions. (2) With beta-hydroxybutyrate as substrate, oxygen consumption V of state 3 mitochondria was greatly diminished in thyroidectomized rats, but the KM remained unchanged. In the presence of succinate, state 3 respiration was not affected by thyroidectomy when substrate concentrations were low, but diminished at concentrations above 3 mM. (3) Respiratory chain activity was estimated by determining the succinate cytochrome c reductase activity. After thyroidectomy, catalytic efficiency (V/KM) dropped by 60% in intact mitochondria at high concentrations of the substrate, but only by 30% when concentrations were low. In submitochondrial particles, thyroidectomy reduced V without changing KM. These results suggest that in thyroidectomized rats, succinate penetration is faster when substrate concentrations are low. (4) Mg2+ -stimulated ATPase activity dropped by 20% in thyroidectomized rats. In the presence of increasing concentrations of oligomycin, inhibition of ATPase activity was greater in normal than in thyroidectomized rat mitochondria. Thyroidectomy reduced by over 30% the ATPase activity actually involved in oxidative phosphorylation.

2,4-Dinitrophenol↗
PubMed2006

Thyroidectomy remains an effective treatment option for Graves' disease.

BACKGROUND: Recent experience with thyroidectomy for Graves' disease is limited. We report our current experience with thyroidectomy for Graves' disease at a tertiary hospital. METHODS: A prospective database showed 48 patients who underwent surgery for Graves' disease from April 1993 to June 2005. RESULTS: All patients had typical symptoms of Graves' disease. Twenty-three patients had ophthalmopathy. Indications for surgery were failed medical therapy (n = 24), presence of a dominant nodule (n = 12), or refusal of radioiodine (n = 12). Surgery included total thyroidectomy (n = 46) or subtotal thyroidectomy (n = 2). The incidence of cancer was 17%. Long-term follow-up data were available for 44 patients. No patients had recurrence of hyperthyroidism or cancer. Follow-up evaluation of 20 patients with ophthalmopathy showed the condition had either stabilized or resolved. CONCLUSIONS: Total thyroidectomy for Graves' disease offers rapid and durable control of hyperthyroidism, provides appropriate treatment for patients with coexisting cancer, and can stabilize or reverse ophthalmopathy.

Adolescent↗
PubMed2004

Minimally invasive video-assisted thyroidectomy: five years of experience.

BACKGROUND: In the last decade, development of videolaparoscopic surgery allowed several operations to be performed with minimally invasive techniques, making them less invasive and painful. Neck surgery was also involved in this effort, in spite of the skepticism shown by some authors. STUDY DESIGN: Minimally invasive video-assisted thyroidectomy was developed in 1998, and since then, about 600 operations have been performed. Access was the same as was previously described for parathyroidectomy; it was based on a small central incision (1.5 cm) and on external retraction without neck insufflation. RESULTS: From July 1998 to October 2003, 579 patients were selected from 5,450 for minimally invasive video-assisted thyroidectomy. The operation consisted of a total thyroidectomy in 312 patients and lobectomy in 267 patients. Mean operative time was 41 +/- 19.5 minutes (range 15 to 120 minutes) for lobectomy and 51.6 +/- 18.8 minutes (range 30 to 140 minutes) for total thyroidectomy. Postoperative hospital stay was 24 hours (overnight discharge) for all patients. Complications were postoperative bleeding (0.1%), recurrent nerve palsy (1.3%), and definitive hypoparathyroidism (0.2%). CONCLUSIONS: After 5 years of experience using this approach for various indications, we achieved a good esthetic result with an operative time comparable to that of conventional open surgery. Minimally invasive video-assisted thyroidectomy was found to be a safe operation, with advantages over traditional procedures represented by better cosmetic outcomes and postoperative course, as demonstrated by visual analogue scales and statistically analyzed numeric scales.

Adolescent↗
PubMed2005

Thyroidectomy using local anesthesia: a report of 1,025 cases over 16 years.

BACKGROUND: Thyroid surgery is performed using general anesthesia by the majority of surgeons in current practice. This study was conducted to analyze the utility and safety of local anesthesia for thyroid surgery. STUDY DESIGN: Prospective data were collected for 1,025 consecutive patients undergoing thyroidectomy using monitored local anesthesia during a 16-year period by a single surgeon at a tertiary referral center. Patient features, operative data, length of stay, and complications are reported with multivariate analysis for factors associated with outcomes. RESULTS: A total of 1,025 patients underwent local thyroidectomy procedures; 34 required conversion to general anesthesia (3.3%). Total thyroidectomy (n = 589), lobectomy (n = 391), or subtotal and partial resections (n = 45) were performed for benign (n = 402), suspicious (n = 154), or malignant (n = 463) conditions. Local anesthesia was successful for thyroidectomy with concomitant parathyroidectomy (n = 142) or lymphadenectomy (n = 27), extensive goiter (n = 102), and reoperative neck procedures (n = 59). The majority of patients (90%) were considered low to intermediate risk (American Society of Anesthesiologists score </= 2), but 10% were considered high-risk (American Society of Anesthesiologists score >/= 3). With accumulating experience, local anesthesia was applied more broadly to high-risk (p < 0.001), older (p = 0.04), or obese patients (p = 0.04), and likewise used in more extensive goiter resections (p = 0.05) and bilateral procedures (p < 0.001). Patients experienced temporary (n = 20) and permanent (n = 10) recurrent laryngeal nerve injuries, hematoma (n = 5), permanent hypocalcemia (n = 1), emergent tracheostomy (n = 1), wound infection (n = 1), and myocardial infarction (n = 1). Outpatient procedures (96%) substantially increased with maturation of the local anesthesia program (p < 0.001). Length of stay > 24 hours was associated with patient comorbidity (p < 0.001, relative risk 3.25). CONCLUSIONS: Thyroidectomy using local anesthesia appears safe and applicable to a wide range of patients, including those who pose a general anesthetic risk or require more complex procedures, when performed by an experienced surgeon.

Anesthesia, General↗
PubMed2005

Benefits resulting from 1- and 6-hour parathyroid hormone and calcium levels after thyroidectomy.

OBJECTIVE: Previous studies have established the efficacy of post-thyroidectomy hypocalcemia monitoring using parathyroid hormone (PTH) and corrected calcium levels at 1 and 6 hours. The goal of this study was to measure the impact of managing patients based on the above findings with respect to: duration of hospital stays, rates of transient hypocalcemia, number of blood tests, cost savings, and discharge from the hospital as early as 8 hours post-thyroidectomy without compromising safety. STUDY DESIGN AND SETTING: This is a prospective study involving 95 total thyroidectomy patients using historical data as controls. The previous protocol was modified in that all blood tests ceased for patients meeting the 6-hour critical level of PTH > or = 28 ng/L and simultaneous corrected calcium > or = 2.14 mmol/L (8.56 mg/dL). Furthermore, patients with 1-hour PTH levels < or = 8 ng/L were prophylactically treated with calcium and vitamin D supplementation. RESULTS: This study demonstrates lower rates of transient hypocalcemia from 28% to 9% (OR = 4.13, P = 0.016), a 10-hour reduction in mean hospital stay, and fewer blood tests (23 vs 15) for patients undergoing total thyroidectomy since the implementation of the new protocol. Furthermore, the experimental protocol resulted in an average cost savings of 766 Canadian dollars per patient. CONCLUSIONS: The new algorithm resulting from PTH and corrected calcium monitoring at 1 and 6 hours post-thyroidectomy has led to significant cost savings for our institution. It has also translated into greater patient satisfaction as a result of fewer blood tests, a lower incidence of transient hypocalcemia, and significantly shorter hospital stays.

Adult↗