Analysis of the cause and management of persistent laboratory abnormalities occurring after the surgical treatment of primary hyperparathyroidism

Purpose@#The surgical success rate for primary hyperparathyroidism (PHPT) is currently 95%–98%. However, 3%–24% of patients show persistently elevated (Pe) parathyroid hormone (PTH) levels after parathyroidectomy (PTX). This singlecenter retrospective study aimed to compare the outcomes of patients with normal PTH and PePTH levels after successful PTX and to identify the factors associated with PePTH. @*Methods@#The normal group, defined as patients with normal serum calcium and PTH levels immediately after PTX, was compared with the PePTH group (patients with normal or low serum calcium and increased serum PTH levels up to 6 months postoperatively) to determine the causes of disease in the PePTH group. @*Results@#There were no significant differences in age, sex, or preoperative estimated glomerular filtration rate between the normal PTH group (333 of 364, 91.5%) and the PePTH group (31 of 364, 8.5%). However, there were significant differences in preoperative 25-hydroxyvitamin D (17.9 and 11.8 ng/mL, respectively; P = 0.003) and PTH levels (125.5 and 212.4 pg/mL, respectively; P < 0.001) between the 2 groups. Among the 31 cases of the PePTH group, 18 were attributed to vitamin D deficiency. @*Conclusion@#Preoperative vitamin D deficiency is a predictive factor for PePTH. Therefore, preoperative administration of vitamin D supplements may reduce the probability of postoperative disease persistence. Patients with temporary laboratory abnormalities within 6 months after successful PTX should be monitored, and appropriate vitamin D and calcium supplementation may reduce the effort and cost of various examinations or reoperations.

Comparisons Between Normocalcemic Primary Hyperparathyroidism and Typical Primary Hyperparathyroidism

Background@#Normocalcemic primary hyperparathyroidism (NPHPT) was first described in 2008. It is defined as consistently elevated serum parathyroid hormone (PTH) levels with normal serum calcium (sCa) concentration, after excluding secondary causes of PTH elevation. However, the exact definition and management strategy for NPHPT remain controversial. We retrospectively investigated the clinicopathological features and short-term outcomes of NPHPT patients. @*Methods@#A total of 280 patients who were surgically indicated for primary hyperparathyroidism (PHPT) at the Yonsei Severance Medical Center between 2015 and 2019 were included. Patients were classified according to preoperative PTH, corrected sCa, and ionized calcium (iCa) levels as follows: typical primary hyperparathyroidism (TPHPT, elevated PTH, sCa, and iCa, n = 158) and NPHPT (elevated PTH, normal sCa, n = 122). @*Results@#NPHPT was commonly seen in younger individuals (aged < 50 years, P = 0.025);nephrolithiasis and bone fractures were common. Preoperative PTH level was higher in the TPHPT group (P < 0.001). The NPHPT group had higher numbers of multiple parathyroid lesions (P = 0.004) that were smaller (P = 0.011). NPHPT patients were further divided into two subgroups according to iCa levels: the elevated (n = 95) and normal iCa (n = 27) groups. There was no significant difference between the two subgroups regarding symptoms and multiplicity of lesions. @*Conclusion@#We found that NPHPT may be a heterogeneous disease entity of PHPT with high rates of multi-gland disease, which appears to be biochemically milder but symptomatic.Intraoperative PTH monitoring might help increase the surgery success rate. Moreover, the short-term outcomes of NPHPT after surgery did not differ from that of TPHPT.

Lactate Dehydrogenase A as a Potential New Biomarker for Thyroid Cancer

Background@#Several cancers show increased levels of lactate dehydrogenase A (LDHA), which are associated with cancer progression. However, it remains unclear whether LDHA levels are associated with papillary thyroid cancer (PTC) aggressiveness or with the presence of the PTC prognostic marker, the BRAFV600E mutation. This study aimed to evaluate the potential of LDHA as a PTC prognostic marker. @*Methods@#LDHA expression was examined in 83 PTC tissue specimens by immunohistochemistry. Human thyroid cell lines were genetically manipulated to overexpress BRAFV600E or were treated with a BRAF-specific short hairpin RNA (shBRAF), whose effects on LDHA expression were evaluated by Western blotting. Data from 465 PTC patients were obtained from The Cancer Genome Atlas (TCGA) database and analyzed to validate the in vitro results. @*Results@#LDHA was aberrantly overexpressed in PTC. Intense immunostaining for LDHA was observed in PTC specimens carrying mutated BRAF, whereas the intensity was less in wild-type BRAF samples. Overexpression of BRAFV600E resulted in LDHA upregulation, whereas treatment with shBRAF downregulated LDHA in human thyroid cell lines. Furthermore, LDHA mRNA expression was significantly elevated and associated with BRAFV600E expression in thyroid cancer tissues from TCGA database. Additionally, LDHA overexpression was found to be correlated with aggressive clinical features of PTC, such as lymph node metastases and advanced tumor stages. @*Conclusion@#LDHA overexpression is associated with the BRAFV600E mutation and an aggressive PTC behavior. Therefore, LDHA may serve as a biomarker and therapeutic target in PTC.

Long-term outcomes of abdominal paraganglioma

Purpose@#Paragangliomas (PGL) are rare neuroendocrine tumors derived from chromaffin cells of the autonomic nervous system. We aim to describe our experience and the long-term outcome of abdominal PGL over the last decade. @*Methods@#A retrospective review of patients diagnosed with PGL in our hospital between November 2005 and June 2017 was conducted. All nonabdominal PGL were excluded and the clinicopathological features and long-term outcomes of the patients were analyzed. @*Results@#A total of 46 patients were diagnosed with abdominal PGL. The average age of diagnosis was 55.4 years and there was no sex predilection. The average tumor size was 5.85 cm and they were predominantly located in the infrarenal position (50%). The mean follow-up period was 42 months (range, 1.8–252 months). All patients with metastases had Pheochromocytoma of the Adrenal Gland Scaled Score (PASS) of ≥4. One patient presented with synchronous metastases while 2 developed local recurrence and distant metastases. One presented with only local recurrence. One patient died 5 years after diagnosis. @*Conclusion@#Abdominal PGL is a rare tumor with excellent long-term prognosis. Recurrence although uncommon, can occur decades after initial diagnosis. Long-term follow-up is therefore recommended for all patients with PGL, especially in patients with PASS of ≥4.

Surgical outcomes of laparoscopic adrenalectomy for primary hyperaldosteronism: 20 years of experience in a single institution

PURPOSE: Recently, posterior retroperitoneoscopic adrenalectomy (PRA) has been reported to have some advantages over laparoscopic transperitoneal adrenalectomy (LTA). The objectives of this study were to report our experience over 12 years with laparoscopic adrenalectomy for primary hyperaldosteronism (PHA) and to examine surgical outcomes of PRA compared with LTA in patients with PHA. METHODS: The medical records of 527 patients who underwent minimally invasive adrenalectomy, including LTA or PRA, from January 2006 until May 2017 were reviewed at Severance Hospital (Seoul, Korea). Clinicopathologic characteristics and surgical outcomes of 146 patients with PHA who underwent LTA (19 patients) or PRA (127 patients) were analyzed retrospectively by complete chart review. RESULTS: The overall rates of biochemical and clinical cure were 91.1% and 93.1%, respectively. The mean operation time of the PRA group was significantly shorter than that of the LTA group (72.3 ± 24.1 minutes vs. 115.7 ± 69.7 minutes, P = 0.015). The length of hospital stay in the PRA group was significantly shorter than in the LTA group (3.5 ± 1.3 days vs. 4.2 ± 1.6 days, P = 0.029), and the first meal after surgery came earlier in the PRA group (0.3 ± 0.5 days vs. 0.6 ± 0.5 days, P = 0.049). The number of pain-killers used was also significantly smaller in the PRA group (2.3 ± 2.1 vs. 4.3 ± 2.3, P < 0.001). CONCLUSION: PRA offers an alternative or likely superior method for treatment of small adrenal diseases such as PHA, with improved surgical outcomes.

Usefulness of dynamic risk stratification in pediatric patients with differentiated thyroid carcinoma

PURPOSE: Recently, the American Thyroid Association (ATA) dynamic risk stratification (DRS) has been verified to be more valuable than the static anatomical staging system for predicting prognosis in patients with differentiated thyroid carcinoma (DTC). The purpose of this retrospective study was to compare the clinical usefulness of DRS, which is based on the response to initial treatment, with that of ATA initial risk stratification in pediatric patients. METHODS: A total of 144 pediatric patients underwent thyroid operation from August 1982 to December 2013 at Yonsei University Hospital (Seoul, Korea). Among them, 128 patients with complete clinical data were enrolled in this study. Clinicopathologic features and surgical outcomes were retrospectively analyzed by medical chart review. The mean follow-up duration was 11.5 years. RESULTS: The mean tumor size was 2.1 cm; 80.4% of patients were diagnosed with conventional papillary thyroid carcinoma, and 7.0% of patients were diagnosed with follicular thyroid carcinoma. Low-risk patients had the highest probability of an excellent response to initial treatment (66.6%). High-risk patients had the highest probability of a structural incomplete response (100%) and the lowest probability of an excellent response (11.1%). The ATA risk stratification and the DRS system were independent risk factors for disease-free survival (DFS) (P = 0.041 and P < 0.001, respectively). CONCLUSION: The DRS system, which is based on the response to initial treatment, can offer more useful prognostic information compared with ATA risk stratification in pediatric patients with DTC.

Comparison of characteristics in patients with both thyroid and breast cancer: Based on order of incidence

PURPOSE: Clinicopathologic characteristics of patients with both thyroid and breast cancer during their lifetime were analyzed to investigate the association between the two malignancies according to the order of incidence.METHODS: A total of 405 patients who underwent surgery for breast and thyroid cancer at Severance Hospital between 1995 and 2014 were retrospectively selected and classified into 3 groups according to the order of incidence of the two cancers: simultaneous cancer (S), thyroid cancer followed by breast cancer (TB), and breast cancer followed by thyroid cancer (BT). Univariate analysis was conducted to compare parameters.RESULTS: S, TB, and BT groups were 166 (41.0%), 96 (23.7%), and 143 (35.3%) patients, respectively. In TB and BT groups, tumor size and surgical site for secondary cancer were smaller; therefore, adjuvant treatments were less frequently required for secondary cancer. ER positive rate was 77.1% in S, 75% in TB, and 63.7% in BT groups (P=0.027). The ratio of ER negative was higher in the group with BRAF mutation. Survival rate for index tumor was higher in order from TB, and BT, followed by S groups without statistical difference.CONCLUSION: It is difficult to find a significant difference according to the order of occurrence except by screening test, and more studies are needed in the future. Establishing an appropriate screening program is important in order to detect secondary breast or thyroid cancer after surgery for thyroid or breast cancer.

Is familial papillary thyroid microcarcinoma more aggressive than sporadic form?

PURPOSE: With the increasing incidence of papillary thyroid microcarcinoma (PTMC), familial papillary thyroid microcarcinoma (FPTMC) is now recognized more frequently. However, the biological behavior of FPTMC is poorly understood. The aim of this study was to investigate the prevalence of FPTMC and its biological aggressiveness. METHODS: Between March 2006 and July 2010, 2,414 patients underwent primary surgical therapy for PTMC and 149 (6.2%) were further classified as FPTMC. To determine the biological aggressiveness of FPTMC, we compared the clinicopathological features and prognosis between FPTMC and sporadic PTMC (SPTMC). RESULTS: The male-to-female ratio was higher in FPTMC than in sporadic papillary thyroid microcarcinoma (SPTMC: 1:4.5 vs. 1:7.2, P = 0.041). The central lymph node (LN) metastasis rate was significantly higher in FPTMC than in SPTMC (36.2% vs. 24.2%, P = 0.002). The local recurrence rate was also higher in FPTMC than in SPTMC (4.5% vs. 0.6%, P < 0.001). We identified familial occurrence in 6.2% of cases of PTMC. FPTMC is associated with a high rate of central LN metastasis and local recurrence. CONCLUSION: These findings suggest that close follow-up can be beneficial in FPTMC patients to detect local recurrence.

The Effects of Multi-Growth Factors-Containing Cream on Post-Thyroidectomy Scars: A Preliminary Study

BACKGROUND: Growth factors play important roles in wound healing. However, the evidence for the effects of growth factors on post-thyroidectomy scars is limited. OBJECTIVE: We performed a prospective study to assess the preventive and therapeutic effect of a multi-growth factor (MGF)-containing cream on post-thyroidectomy scars. METHODS: Twenty-one patients with thyroidectomy scars applied MGF cream twice a day. We assessed the changes in erythema, pigmentation, skin elasticity, and skin hydration status using the erythema index, melanin index, cutometer, and corneometer, respectively. In addition, Vancouver scar scale (VSS) and patient satisfaction were assessed at 10 days after surgery (baseline), 2 weeks, 6 weeks, and 12 weeks after baseline. RESULTS: The mean total VSS scores were significantly lower at 6 weeks (3.24±1.51 vs. 1.91±1.38) and 12 weeks (3.24±1.51 vs. 1.71±1.59) compared to the baseline. The degree of pigmentation was significantly lower at 12 weeks compared to the baseline, and the skin elasticity, and the skin hydration status were significantly higher at 12 weeks compared to the baseline. Over 85% of the patients were satisfied with the use of MGF cream without any adverse effect. CONCLUSION: MGF cream might have additive or supportive effect for scar formation after thyroidectomy.

Medullary thyroid carcinoma: a 30-year experience at one institution in Korea

PURPOSE: The objective of this study was to review the clinical outcome and prognosis of patients with sporadic and hereditary medullary thyroid cancer (MTC) who were treated at a single tertiary hospital in Korea. METHODS: We retrospectively reviewed the case files of 85 patients treated from August 1982 to February 2012. RESULTS: In all, 65 patients (76.5%) had sporadic MTC and 20 patients (23.5%) had hereditary MTC. Patients in the sporadic group were older than in the hereditary group (P < 0.001). However, the hereditary group had more tumor multiplicity (P < 0.001) and bilaterality (P < 0.001). Neither survival rate was significantly different between the sporadic and hereditary groups (P = 0.775 and P = 0.866). By multivariate analysis, distant metastasis was a significant prognostic factor for overall and progression-free survival. CONCLUSION: In general, patients with MTC have favorable outcomes. Distant metastasis appears to be the strongest predictor of overall and progression-free survival.

Risk Factors of Postoperative Hypocalcemia after Total Thyroidectomy of Papillary Thyroid Carcinoma Patients / 대한내분비외과학회지

PURPOSE: Postoperative hypocalcemia is a common complication of thyroidectomy. This study evaluated the incidence and predisposing risk factors for postoperative permanent hypocalcemia after total thyroidectomy. METHODS: There were 1,247 consecutive patients undergoing total thyroidectomy and complete treatment and observation for differentiated thyroid cancer between January 2012 to December 2012 who were enrolled in this study. Patients were divided into two groups, those remaining normalcalcemic (Group I-824 pts) and those who had hypocalcemia requiring treatment (Groups II-423 pts). Group II was subdivided into a transient hypocalcemic group (Group IIA-409 pts) and a permanent hypocalcemic group (Group IIB-14 pts). RESULTS: Female gender, thyroiditis, preserved parathyroid number, lateral lymph node metastasis, RAI treatment, preoperative parathyroid hormone and preoperative vitamin D were significantly associated with the development of postoperative hypocalcemia by multivariate analysis. Comparing patients with transient versus permanent hypocalcemia, tumor size and multiplicity were significantly related to the development of permanent hypocalcemia by multivariate analysis. RAI treatment and parathyroid hormone level on the postoperative third day were significantly related to recovery from transient hypocalcemia to normo-calcemia. CONCLUSION: Risk factors of postoperative hypocalcemia were associated with preoperative patient factors and advanced thyroid cancer. Advanced thyroid cancer was a risk factor for permanent hypocalcemia. To prevent postoperative hypocalcemia, we should focus on patient condition and need to preserve parathyroid gland more carefully in thyroid surgery.

Is focused parathyroidectomy appropriate for patients with primary hyperparathyroidism?

PURPOSE: The aim of this study was to determine whether focused or complete parathyroidectomy was more appropriate and to compare follow-up data in primary hyperparathyroidism (PHPT). METHODS: We retrospectively analyzed 225 operations for PHPT at Yonsei University Health System between 2000 and 2012. After excluding 93 patients, the remaining 132 were divided into 2 groups: those who underwent focused parathyroidectomy (FP) and those who underwent conventional parathyroidectomy (CP). We compared clinicopathological features; preoperative calcium, parathyroid hormone (PTH), phosphorus, vitamin D, 24-hour urine calcium, and alkaline phosphatase levels; postoperative calcium and PTH levels; pathologic diagnosis; multiplicity; and results of a localization study between the 2 groups. RESULTS: There was no significant difference in the rates of development of postoperative persistent hyperparathyroidism (1/122 FP patients and 1/10 CP patients) between the 2 groups due to a technical reason (FP 0.8% vs. CP 10.0%, P = 0.146). Multiglandular disease (MGD) was uncommon in all cases (6 of 132, 4.5%). All MGD cases were diagnosed using a preoperative localization study. Sestamibi scan and ultrasonography sensitivity were 94.2% and 90.2%, respectively. CONCLUSION: We suggest that FP is appropriate in PHPT, except in cases of MGD if detected before the operation using preoperative imaging. Knowledge of hereditary PHPT and improved preoperative localization studies, such as high-resolution ultrasonography, contributed to the decision to perform FP rather than CP in all cases of unilateral results of the localizing study.

Is focused parathyroidectomy appropriate for patients with primary hyperparathyroidism?

PURPOSE: The aim of this study was to determine whether focused or complete parathyroidectomy was more appropriate and to compare follow-up data in primary hyperparathyroidism (PHPT). METHODS: We retrospectively analyzed 225 operations for PHPT at Yonsei University Health System between 2000 and 2012. After excluding 93 patients, the remaining 132 were divided into 2 groups: those who underwent focused parathyroidectomy (FP) and those who underwent conventional parathyroidectomy (CP). We compared clinicopathological features; preoperative calcium, parathyroid hormone (PTH), phosphorus, vitamin D, 24-hour urine calcium, and alkaline phosphatase levels; postoperative calcium and PTH levels; pathologic diagnosis; multiplicity; and results of a localization study between the 2 groups. RESULTS: There was no significant difference in the rates of development of postoperative persistent hyperparathyroidism (1/122 FP patients and 1/10 CP patients) between the 2 groups due to a technical reason (FP 0.8% vs. CP 10.0%, P = 0.146). Multiglandular disease (MGD) was uncommon in all cases (6 of 132, 4.5%). All MGD cases were diagnosed using a preoperative localization study. Sestamibi scan and ultrasonography sensitivity were 94.2% and 90.2%, respectively. CONCLUSION: We suggest that FP is appropriate in PHPT, except in cases of MGD if detected before the operation using preoperative imaging. Knowledge of hereditary PHPT and improved preoperative localization studies, such as high-resolution ultrasonography, contributed to the decision to perform FP rather than CP in all cases of unilateral results of the localizing study.

Effect of a Low Iodine Diet vs. Restricted Iodine Diet on Postsurgical Preparation for Radioiodine Ablation Therapy in Thyroid Carcinoma Patients

PURPOSE: The radioiodine ablation therapy is required for patients who underwent a total thyroidectomy. Through a comparative review of a low iodine diet (LID) and a restricted iodine diet (RID), the study aims to suggest guidelines that are suitable for the conditions of Korea. MATERIALS AND METHODS: The study was conducted with 101 patients. With 24-hour urine samples from the patients after a 2-week restricted diet and after a 4-week restricted diet, the amount of iodine in the urine was estimated. The consumed radioiodine amounts for 2 hours and 24 hours were calculated. RESULTS: This study was conducted with 47 LID patients and 54 RID patients. The amounts of iodine in urine, the 2-week case and 4-week case for each group showed no significant differences. The amounts of iodine in urine between the two groups were both included in the range of the criteria for radioiodine ablation therapy. Also, 2 hours and 24 hours radioiodine consumption measured after 4-week restrictive diet did not show statistical differences between two groups. CONCLUSION: A 2-week RID can be considered as a type of radioiodine ablation therapy after patients undergo a total thyroidectomy.

Predictors of Thyroid Gland Involvement in Hypopharyngeal Squamous Cell Carcinoma

PURPOSE: Decision to perform concurrent ipsilateral thyroidectomy on patients with hypopharyngeal cancer is important, and unnecessary thyroidectomy should be avoided if oncologically feasible. We hypothesized that concurrent ipsilateral thyroidectomy is not routinely required to prevent occult metastasis. This study aimed to determine the prevalence of histological thyroid invasion in patients with hypopharyngeal cancer, and to refine the indications for prophylactic ipsilateral thyroidectomy in patients with hypopharyngeal cancer. MATERIALS AND METHODS: A retrospective review of the medical records from the Department of Otolaryngology at Yonsei University College of Medicine was conducted from January 1994 to December 2009. A total of 49 patients underwent laryngopharyngectomy with thyroidectomy as a primary treatment of hypopharyngeal cancer. RESULTS: The incidence of thyroid gland involvement was 10.2%. The most common route of invasion was direct extension through the thyroid cartilage. Thyroid cartilage invasion (p=0.034) was the most significant factor associated with thyroid invasion. Disease-specific survival at 5 years was lower in patients with than without thyroid gland invasion (26.7% vs. 55.2%, respectively; p=0.032). Disease-free survival at 5 years was also lower in patients with than without thyroid gland invasion (20.0% vs. 52.1%, respectively; p=0.024). CONCLUSION: Ipsilateral thyroidectomy in combination with total laryngopharyngectomy is indicated when invasion of the thyroid cartilage is suspected in patients with hypopharyngeal cancer.

Quality of Life Outcomes after Robotic Thyroid Surgery / 대한갑상선학회지

The robotic approach is the new frontier of thyroid cancer surgery, with several advantages over conventional open and endoscopic techniques. Recent assessments of quality of life (QoL) outcomes have found that patients undergoing robotic thyroid surgery using transaxillary approach experience lower levels of dissatisfaction and regret than patients undergoing conventional open thyroid surgery, largely due to differences in cosmetic outcomes. Prospective trials evaluating functional parameters, including pain, neck discomfort, and sensory changes in the neck, have favored robotic over conventional open thyroid surgery. Similarly, objective and subjective evaluations of voice and swallowing discomfort were improved in patients undergoing robotic thyroidectomy. Thus, use of a robot results in overall increases in cosmetic satisfaction and decreases in several measures of postoperative discomfort compared with the conventional open thyroid technique. However, a proper evaluation of QoL requires long-term assessments, and randomized controlled trials are necessary to definitively establish the real benefits of robotic surgery. This review provides merits and demerits of robotic thyroidectomy and radical neck dissection, based on published data, as well as comparing QoL outcomes after robotic and conventional open thyroidectomy.

Surgical Outcomes of Adrenocortical Carcinoma; 20 Years of Experience in a Single Institution / 대한내분비외과학회지

PURPOSE: Adrenocortical carcinoma (ACC) is a rare malignant tumor. Early detection is difficult and prognosis is poor. We report on 20 years of ACC surgical experience at our institution. METHODS: This study included 32 ACC patients who underwent surgical resection at the Department of Surgery of the Yonsei University Health System in South Korea between January 1990 and February 2012. We reviewed these 32 patients and retrospectively analyzed long-term clinical outcomes and prognosis after radical surgery for ACC. RESULTS: The median age of the 32 patients at diagnosis was 42.25 years (range 3~81 years). There were 16 (50%) female and 16 (50%) male patients. Mean tumor size was 12.36 cm (range 1.8~20 cm). Twenty-five patients (78.12%) had nonfunctioning tumors while the other seven patients (21.87%) had functioning tumors. Seventeen patients (53.12%) were classified as stage II, two (6.25%) as stage III, and 13 (40.62%) as stage IV. Fourteen patients underwent radical surgical resection, while 14 patients received adjuvant chemotherapy, two received adjuvant radiotherapy, and two received adjuvant chemoradiation. Four patients were lost to follow-up. Among the remaining 28 patients, 15 patients survived. The 5- and 10-year overall survival was 60.6% and 37.8%, respectively (median survival=85+/-24.3 months). Seventeen patients (53%) experienced disease recurrence. Five- and 10-year recurrence-free survival was 41.5% and 29.7%, respectively (median survival=18+/-5.5 months). CONCLUSION: Early stage at diagnosis and surgical resection were the most important prognostic factors associated with prolonged survival. The role of additional therapy remains controversial and new agents should continually be evaluated for efficacy.

Surgical Outcomes of Robotic MRND versus Conventional Open MRND for Papillary Thyroid Carcinoma with Lateral Neck Node Metastasis: Comparative Analysis using Propensity Score Matching / 대한내분비외과학회지

PURPOSE: During the past decade, various endoscopic thyroid surgeries have been conducted, each with its own benefits. The incorporation of robotic systems to endoscopic thyroid surgery has improved the visualization and precision of endoscopic techniques. We previously reported our initial experience with robotic modified radical neck dissection (MRND) of papillary thyroid carcinoma (PTC) with lateral neck node metastasis (LNM). The aim of this study was to compare surgical outcomes of robotic vs. conventional open MRND of PTC with LNM using propensity score matching. METHODS: From January 2008 to February 2011, 515 patients with PTC with LNM were enrolled. One hundred patients underwent robotic MRND, and 415 patients underwent conventional open MRND. These two groups were retrospectively compared with respect to their clinicopathological characteristics, surgical outcomes, and surgical completeness. Furthermore, to avoid selection bias, propensity score matching analysis was used to compare surgical outcomes of each group without any compounding factors. RESULTS: The operative time for the robotic MRND was longer than for the open MRND (297.9±60.2 min vs. 212.1±55.6 min, P=0.089). However, the mean numbers of retrieved lymph nodes and mean hospital stay after surgery were similar in the two groups (36.0±12.9 vs. 40.8±13.3, P=0.235), (6.1±1.6 days vs. 6.1±2.1 days, P=0.577). The complication rates were similar between the two groups, and there was no statistical difference in postoperative thyroglobulin levels between groups (0.51±0.83 ng/ml vs. 0.89±2.46 ng/ml, P=0.593). CONCLUSION: According to our study, robotic MRND shows similar surgical outcomes to conventional open MRND after case-matched analyses. We suggest that robotic MRND is an acceptable alternative as an operative method for PTC with LNM, resulting in excellent cosmesis and patient satisfaction.

Use of the On-Q system for pain management after robot - assisted endoscopic transaxillary thyroidectomy

BACKGROUND: The robot-assisted transaxillary approach to thyroid surgery is a novel method that has recently been used to improve patient safety and cosmetic outcomes. We evaluated post-operative pain, following robot-assisted endoscopic transaxillary thyroid surgery, and pain relief using a continuous wound perfusion system with local anesthetics. METHODS: In a control group of 25 female patients who underwent robot-assisted endoscopic transaxillary thyroidectomy, the post-operative pain scores and characteristics as well as analgesic use were monitored. Fifty female patients undergoing robot-assisted endoscopic transaxillary thyroidectomy were given the On-Q system. They were then randomly assigned to receive one of two different local anesthetic doses: Group I (0.25% Ropivacaine, n = 25); and Group II (0.375% Ropivacaine, n = 25). The pain score, pain site, analgesic requirements and side effects of each group were recorded during the 48 hour period post-surgery. RESULTS: Post-operative pain scores and analgesic demand were lower in the On-Q groups than in the control group. No difference was found between Group I and Group II. Until 6-12 hours after surgery, pain was mainly located in the axilla, while after 6-12 hours, the primary location of pain had a tendency to move to the neck. Pain scores gradually decreased in time for all patients. CONCLUSIONS: Patients who underwent robot-assisted endoscopic transaxillary thyroidectomy with an On-Q system injecting 0.25% ropivacaine had lower pain scores, showing the effectiveness of the system. As a potential pain blocker, continuous wound perfusion with the On-Q system attenuates side effects. This could lead to shortened hospital stays after robot-assisted endoscopic transaxillary thyroidectomy.

Use of the On-Q system for pain management after robot - assisted endoscopic transaxillary thyroidectomy

BACKGROUND: The robot-assisted transaxillary approach to thyroid surgery is a novel method that has recently been used to improve patient safety and cosmetic outcomes. We evaluated post-operative pain, following robot-assisted endoscopic transaxillary thyroid surgery, and pain relief using a continuous wound perfusion system with local anesthetics. METHODS: In a control group of 25 female patients who underwent robot-assisted endoscopic transaxillary thyroidectomy, the post-operative pain scores and characteristics as well as analgesic use were monitored. Fifty female patients undergoing robot-assisted endoscopic transaxillary thyroidectomy were given the On-Q system. They were then randomly assigned to receive one of two different local anesthetic doses: Group I (0.25% Ropivacaine, n = 25); and Group II (0.375% Ropivacaine, n = 25). The pain score, pain site, analgesic requirements and side effects of each group were recorded during the 48 hour period post-surgery. RESULTS: Post-operative pain scores and analgesic demand were lower in the On-Q groups than in the control group. No difference was found between Group I and Group II. Until 6-12 hours after surgery, pain was mainly located in the axilla, while after 6-12 hours, the primary location of pain had a tendency to move to the neck. Pain scores gradually decreased in time for all patients. CONCLUSIONS: Patients who underwent robot-assisted endoscopic transaxillary thyroidectomy with an On-Q system injecting 0.25% ropivacaine had lower pain scores, showing the effectiveness of the system. As a potential pain blocker, continuous wound perfusion with the On-Q system attenuates side effects. This could lead to shortened hospital stays after robot-assisted endoscopic transaxillary thyroidectomy.