Total thyroidectomy for multinodular goiter. possibility of implementation in a district hospital.

UNLABELLED: Increasing number of surgical subspecialities causes general surgeons have little experience with more complex procedures as total thyroidectomy. The aim of the study was to present the outcome of total thyroidectomy following its implementation in a district hospital where such procedure has not been performed previously. MATERIAL AND METHODS: 293 patients were operated on for goiter between 01.10.2008 and 30.09.2011 in the District Hospital in Proszowice by one contracted endocrine surgeon. Hemithyroidectomy was performed in 75 (23.7%) patients and total thyroidectomy in 191 (76.3%) patients for multinodular goiter and only the latter group was subjected for further analysis. RESULTS: There were no bilateral recurrent laryngeal nerve palsy. A unilateral transient recurrent laryngeal nerve palsy occurred in 6 patients (3.1%; 1.5% per risk) and postoperative hypocalcemia in 29 (15.7%) patients. 2 (1%) patients required wound revision due to a postoperative bleeding. Postoperative pathology revealed in 12 (6.2%) patients differentiated thyroid cancer. CONCLUSIONS: 1. Total thyroidectomy in a district hospital is still a safe way to operate on thyroid for nonmalignant disorders with low number of complications. 2. Total thyroidectomy is a definite surgical treatment in patients diagnosed by postoperative pathology with differentiated thyroid cancer.

Total thyroidectomy for benign thyroid disease: is it really worthwhile?

OBJECTIVE: To compare the outcomes of bilateral subtotal (BST) versus total thyroidectomy (TT) for benign bilateral thyroid disease (BBTD). BACKGROUND: The extent of thyroid resection in benign goiter is controversial. Potential advantages of TT over BST may include: one-stage removal of incidental thyroid cancer, and a lower risk for goiter recurrence. However, these potential advantages should outweigh the risk of morbidity. METHODS: A retrospective cohort study was conducted of 8032 patients with BBTD operated in a single institution. Patients in Group A underwent BST (1999-2004, n = 5214; follow-up 72.3 ± 12.4 months), whereas patients in Group B underwent TT (2005-2009, n = 2918; follow-up 36.3 ± 10.6 months). Data were collected prospectively. The analysis included: prevalence of incidental thyroid cancer, recurrent goiter, need for completion thyroidectomy, and morbidity. RESULTS: Incidental thyroid cancer was found in 406 (5.00%) patients. One hundred twelve (2.15%) BST versus 3 (0.10%) TT patients required completion thyroidectomy (P < 0.001). Recurrent goiter was diagnosed in 364 (6.99%) BST patients and 165 (45.33%) required reoperation versus 0% after TT (P < 0.001). The prevalence of transient and permanent hypoparathyroidism was 2.70% and 0.15% versus 13.12% and 0.10% (BST vs. TT, P < 0.001 and P = 0.65, respectively). The prevalence of temporary and permanent RLN injury was 2.30% and 0.71% versus 2.60% versus 0.69% (BST vs. TT, respectively; nonsignificant). CONCLUSIONS: Compared to TT, BST resulted in a significantly higher rate of completion thyroidectomy for incidentally diagnosed thyroid cancer and need for redo surgery for recurrent goiter. The extent of surgical resection had no significant impact on the prevalence of permanent complications. REGISTRATION NUMBER: NCT01273714 (http://www.clinicaltrials.gov).

Five-year follow-up of a randomized clinical trial of unilateral thyroid lobectomy with or without postoperative levothyroxine treatment.

BACKGROUND: The aim of this study was to compare the prevalence of recurrent nodular goiter in the contralateral thyroid lobe among patients after unilateral thyroid lobectomy for unilateral multinodular goiter (MNG) receiving versus not receiving postoperative prophylactic levothyroxine (LT4) treatment. METHODS: From January 2000 through December 2003, 150 consenting patients underwent a unilateral thyroid lobectomy for unilateral MNG at our institution. They were randomized to two groups with 75 patients in each group. Patients in group A received prophylactic LT4 treatment postoperatively (dose range 75-125 microg/day to maintain thyroid-stimulating hormone values below 1.0 mU/L), whereas patients in group B received no postoperative LT4 treatment. All the patients underwent ultrasonographic, cytologic, and biochemical follow-up for at least 60 months postoperatively. The primary outcome was the prevalence of recurrent goiter in the contralateral thyroid lobe. The secondary outcome was the reoperation rate for recurrent goiter. The outcomes were stratified according to individual iodine metabolism status assessed by urinary iodine excretion. RESULTS: During the 5-year follow-up, among patients receiving vs. not receiving LT4, recurrent goiter within the contralateral thyroid lobe was found in 1.4% vs. 16.7% of patients, respectively (p = 0.001). Moreover, 1.4% vs. 8.3%, respectively, of patients receiving vs. not receiving LT4 required contralateral thyroid lobe surgery (p = 0.05). LT4 decreased the recurrence rate among iodine-deficient patients (3.4% vs. 36%, respectively; p = 0.002) but not among iodine-sufficient patients (0% vs. 6.4%, respectively; p = 0.09). CONCLUSIONS: Prophylactic LT4 treatment significantly decreased the recurrence rate of nodular goiter in the contralateral thyroid lobe and the need for completion thyroidectomy, mostly among patients with iodine deficiency.

Five-year follow-up of a randomized clinical trial of total thyroidectomy versus Dunhill operation versus bilateral subtotal thyroidectomy for multinodular nontoxic goiter.

BACKGROUND: The extent of thyroid resection in multinodular nontoxic goiter (MNG) is controversial. The aim of the present study was to evaluate results of various thyroid resection modes, with special emphasis put on the recurrence rate and morbidity rate, in a 5-year follow-up. MATERIALS AND METHODS: From 01/2000 through 12/2003, 600 consenting patients with MNG qualified for thyroidectomy at our institution were randomized to three groups equal in size, n = 200 in each. Patients in group A underwent total thyroidectomy (TT); patients in group B underwent Dunhill operation (DO), whereas patients in group C underwent bilateral subtotal thyroidectomy (BST). All patients were subjected to ultrasonographic, cytological, and biochemical follow-up at least for 60 months postoperatively. The primary outcome measure was prevalence of recurrent goiter and need for redo surgery. The secondary outcome measure was the postoperative morbidity rate (hypoparathyroidism and recurrent laryngeal nerve injury). RESULTS: Recurrent goiter was found in 0.52% TT versus 4.71% DO versus 11.58% BST (p = 0.01 for TT versus DO, p = 0.02 for DO versus BST, p < 0.001 for TT versus BST), and completion thyroidectomy was necessary in 0.52% TT versus 1.57% DO versus 3.68% BST (p = 0.03 for TT versus BST). Transient postoperative hypoparathyroidism was present in 10.99% versus 4.23% versus 2.1% (p = 0.007 for TT versus DO, p < 0.001 for TT versus BST), whereas the recurrent laryngeal nerve injury rate was 5.49% and 1.05% TT versus 4.23% and 0.79% DO versus 2.1% and 0.53% BST (transient and permanent, respectively; p = 0.007 for transient events TT versus BST). CONCLUSIONS: Total thyroidectomy can be regarded as the procedure of choice for patients with MNG. It is associated with a significantly lower incidence of goiter recurrence and less frequent need for completion thyroidectomy than other more limited thyroid resections. However, TT involves a significantly higher risk of postoperative transient but not permanent hypoparathyroidism and recurrent laryngeal nerve paresis.

Utility of intraoperative bilateral internal jugular venous sampling with rapid parathyroid hormone testing in guiding patients with a negative sestamibi scan for minimally invasive parathyroidectomy--a randomized controlled trial.

BACKGROUND AND AIMS: The purpose of this study was to determine the utility of bilateral internal jugular venous sampling with rapid parathyroid hormone assay (BIJV-IOPTH) in comparison to endocrine surgeon-performed ultrasonography of the neck as an alternative localizing modality in guiding patients with primary hyperparathyroidism (pHPT) and negative sestamibi scans for minimally invasive parathyroidectomy (MIP). PATIENTS AND METHODS: Seventy eight consenting patients with a negative subtraction sestamibi scan planned for parathyroidectomy underwent additional ultrasound parathyroid imaging and were randomized to undergo surgery without vs. with additional BIJV-IOPTH; n = 39 in each group. The patients with a positive alternative imaging test were qualified for video-assisted MIP, whereas the others underwent open neck explorations. The primary outcome measure was the number of patients with true-positive results of alternative imaging tests. RESULTS: Of the 78 patients, 50 (64%) had a single adenoma, eight (10.3%) had double adenomas, and 20 (25.7%) demonstrated four-gland hyperplasia. Ultrasonography alone vs. combined with BIJV-IOPTH was true positive in detecting a solitary parathyroid adenoma in 8/24 (33.3%) vs. 17/26 (65.4%) patients, respectively (p = 0.023). Curative video-assisted MIP was successfully performed in all the patients with true-positive results. The remaining individuals were cured by more extensive open neck explorations (unilateral-4/39 vs. 4/39, respectively; p = 1.0 or bilateral-27/39 vs. 18/39, respectively; p = 0.039). CONCLUSIONS: Most patients with pHPT and a negative subtraction sestamibi scan (64%) have a single adenoma. BIJV-IOPTH as an addition to a surgeon-performed ultrasound of the neck allows for more accurate guiding for MIP in patients with a solitary parathyroid adenoma and negative subtraction sestamibi scans.

Evaluation of Halle, Miami, Rome, and Vienna intraoperative iPTH assay criteria in guiding minimally invasive parathyroidectomy.

BACKGROUND AND AIMS: Intraoperative parathyroid hormone assay (IOPTH) has been used during minimally invasive parathyroidectomy (MIP) to predict operative success. However, the applied criteria are not equivalent in detection of multiglandular disease (MGD) and predicting cure. The purpose of this study was to evaluate the most commonly applied criteria of IOPTH in patients undergoing MIP in a tertiary referral center. MATERIALS AND METHODS: A retrospective review of 260 patients with sporadic primary hyperparathyroidism and concordant results of sestamibi scanning and ultrasound of the neck undergoing MIP (135 video-assisted and 125 open) between Dec 2002 and May 2008, with a 6-month postoperative follow-up of intact parathyroid hormone and serum calcium levels, was performed. The main outcome measures included evaluation of predictive values of Halle, Miami, Rome, and Vienna IOPTH interpretation criteria. RESULTS: The following overall accuracy, sensitivity, specificity, positive predictive value, and negative predictive values were found, respectively: 65%, 62.9%, 100%, 100%, and 14.2% for Halle criterion; 97.3%, 97.6%, 93.3%, 99.6%, and 70% for Miami criterion; 83.8%, 82,9%, 100%, 100%, and 26.3% for Rome criterion; and 92.3%, 92.2%, 93.3%, 99.6%, and 60.9% for Vienna criterion. CONCLUSIONS: Miami criterion followed by Vienna criterion was found to be the best balanced among other criteria, with the highest accuracy in intraoperative prediction of cure. However, Rome criterion followed by Halle criterion was found to be the most useful in intraoperative detection of MGD. Nevertheless, their application in patients qualified for MIP with concordant results of sestamibi scanning and ultrasound of the neck would result in a significantly higher number of negative conversions to bilateral neck explorations and only a marginal improvement in the success rate of primary operations.

Minimally invasive video-assisted thyreoidectomy (MIVAT) with and without use of harmonic scalpel--a randomized study.

BACKGROUND AND AIMS: Minimally invasive video-assisted thyroidectomy (MIVAT) has been used for the removal of small thyroid nodules to improve cosmetic results and diminish pain. The aim of this study was to compare the outcomes of the MIVAT operations with and without the use of an ultrasonic harmonic scalpel (HS). PATIENTS AND METHODS: Seventy-six patients with a solitary thyroid nodule below 30 mm in diameter were randomized to two groups of 38 patients each. Unilateral thyroid lobectomy was performed in each patient. In the clip-ligation group (CL-G), during MIVAT, the superior thyroid vessels were clipped and bipolar coagulation was used to secure smaller vessels, whereas in the harmonic scalpel group (HS-G), HS was used to dissect and divide all the thyroid vessels. The statistical analysis included the mean operative time, blood loss, postoperative morbidity, scar length, cosmetic satisfaction at 1 and 6 months following surgery, and cost-effectiveness. RESULTS: HS-G vs CL-G operations were shorter (31.4 +/- 7.7 vs 47.5 +/- 13.2 min; p < 0.001), the mean blood loss was smaller (12.9 +/- 5.7 vs 32.8 +/- 13.0 ml; p < 0.001), the mean scar length at 1 month following surgery was shorter (15.6 +/- 1.4 vs 21.5 +/- 1.9 mm; p < 0.001), and greater cosmetic satisfaction was achieved at 1 month after surgery (88.9 +/- 9.7 vs 81.9 +/- 5.4 pts; p < 0.001), but the difference became nonsignificant at 6 months postoperatively. MIVAT with HS was 20-30 euros more expensive. No major complications were observed in both groups. CONCLUSIONS: HS in the MIVAT operations is safe and facilitates dissection, allowing for a significant decrease in operative time. Other benefits, such as lower blood loss, a scar a few millimeters shorter, or a slightly better early cosmetic result, are offered at slightly increased costs.

Surgical management of mediastinal goiter: risk factors for sternotomy.

BACKGROUND AND AIMS: Mediastinal goiter constitutes an indication for surgical management. The procedure can most commonly be performed using the cervical access, but at times, a sternotomy or thoracotomy is necessary. The objective of the investigation was to analyze the prevalence and therapeutic results in patients with mediastinal goiter and to assess factors that affect the need of performing sternotomy in the course of mediastinal goiter surgery. MATERIAL AND METHODS: In the years 1984-2004, i.e., over 21 years, 11,849 patients with various types of goiter were operated on in the department. Mediastinal goiter was detected in 88 (0.76%) individuals. The analyzed material included 64 (72.7%) females and 24 (27.3%) males. The age of the patients ranged between 19 to 81 years, with the mean age of 61 +/- 13 years of life. The material was statistically analyzed. Risk factors for sternotomy were assessed using the multidimensional logistic regression method. RESULTS: The highest percentage of mediastinal goiter was noted in patients operated on due to recurrent goiter (3.86%). Goiter situated in the anterior mediastinum was noted in 61 (69.3%) individuals, while 27 (30.7%) patients demonstrated goiter located in the posterior mediastinum; of the latter, nine were previsceral and 18 retrovisceral. In the majority of cases, these were primarily cervical goiters, which descended from the neck to the mediastinum (53 patients). Aberrant adenomas were diagnosed in 32 (36.4%) individuals. Four patients presented with the superior cava vein syndrome. Primary goiters evaluated intraoperatively with blood supply originating from the mediastinal vessels were observed in 12 (13.6%) cases. In 27 (30.7%) patients, sternotomies were necessary. In the majority of cases, these were individuals with goiters showing additional blood supply originating from the mediastinal vessels, patients with aberrant adenomas in the mediastinum, especially in recurrent goiters, or else subjects with goiters situated in the posterior mediastinum as compared to anterior mediastinal goiters. No postoperative mortality during stay in a hospital was noted. CONCLUSIONS: Surgical management of patients with mediastinal goiter is the therapeutic modality that requires considerable experience of the surgical team, performed in specialized centers, and appropriate preoperative diagnostic management. Statistically significant risk factors for sternotomy are as follows: recurrent goiter, primary mediastinal goiter, posterior mediastinal location of goiter, and the presence of an aberrant adenoma situated in the mediastinum.

Applicability of intraoperative parathyroid hormone assay during total thyroidectomy as a guide for the surgeon to selective parathyroid tissue autotransplantation.

BACKGROUND: Intraoperative parathyroid hormone assay (IOPTH) has been suggested to have value in predicting the development of postoperative hypoparathyroidism after thyroid surgery. IOPTH has been validated in identification of patients at risk of postoperative hypocalcemia requiring early onset of calcium supplementation therapy and in improving selection of patients eligible for a safe early discharge. However, the value of IOPTH has not been assessed in a randomized study as a guide for the surgeon to parathyroid tissue autotransplantation (PA). The objective of this study was to evaluate the applicability of IOPTH in guiding the surgeon to selective parathyroid tissue autotransplantation during total thyroidectomy (TT). METHODS: Between January 2005 and December 2005, 340 patients qualified for total thyroidectomy (TT) who met the inclusion criteria were randomized to two equal-sized groups (n=170): group A, in which elective PA of at least one parathyroid gland was performed in all cases without IOPTH as a guide; and group B, in which selective IOPTH-guided PA was performed, if only the iPTH plasma level was <10 ng/L at 10-20 min after TT (before skin closure). The standard technique of PA consisting of implanting the parathyroid tissue into 10-20 sternocleidomastoid muscle pockets was used in both groups. IOPTH measurements were performed by the STAT-Intraoperative-iPTH-Assay. Serum calcium was routinely monitored at 4, 12, 24, 48, and 72 hr postoperatively. The incidence and severity of hypocalcemia and related symptoms were matched with the IOPTH results. On follow-up, serum calcium and plasma iPTH values were measured at 1, 3, and 6 months postoperatively. The primary end point was the success rate in preventing permanent postoperative hypoparathyroidism. The secondary end point was the use of postoperative medication for transient hypocalcemic symptoms. RESULTS: Twenty-one group B patients (12.3%) had plasma iPTH levels<10 ng/L at 10-20 min after TT (before skin closure) and they underwent selective IOPTH-guided PA. None of the patients from both groups experienced permanent postoperative hypoparathyroidism. Transient postoperative hypocalcemia occurred in 22.3% vs. 11.2% of patients (group A vs. B, respectively; p<0.05). The mean cumulated serum calcium values were significantly lower for group A vs. group B patients within the entire 3-month period after TT (2.12+/-0.09 mmol/L vs. 2.27+/-0.05 mmol/L, respectively; p<0.001). The mean oral calcium supplementation was significantly higher for group A vs. group B patients during the 3 months after TT (2.7+/-0.9 g/day vs. 0.9+/-0.4 g/day, respectively; p<0.001). CONCLUSIONS: IOPTH offers valuable information during TT, correctly identifying patients at risk of postoperative hypocalcemia. Selective IOPTH-guided PA in patients with plasma iPTH levels<10 ng/L at 10-20 min after TT reduces the risk of permanent postoperative hypoparathyroidism to zero, and this approach seems to be as effective as elective PA of at least one parathyroid gland without IOPTH guidance. Moreover, selective IOPTH-guided PA significantly decreases the incidence of transient postoperative hypoparathyroidism and the need for calcium supplementation therapy compared with elective PA without IOPTH.

Intraoperative parathyroid hormone assay improves outcomes of minimally invasive parathyroidectomy mainly in patients with a presumed solitary parathyroid adenoma and missing concordance of preoperative imaging.

OBJECTIVE: Intraoperative parathyroid hormone assay (IOPTH) is often used during minimally invasive parathyroidectomy (MIP) for primary hyperparathyroidism (pHPT). However, several investigators have reported conflicting outcomes, throwing doubt on the real influence of this adjunct on surgical decision-making. The aim of this study was to determine the impact of routine use of IOPTH on the success rate of MIP as the primary outcome, and whether it value-added to surgical decision-making during the operations at our institution. DESIGN: The results of MIP were determined on postoperative follow-up in 177 consecutive patients with pHPT and compared with the results of preoperative imaging, findings at surgery and the value-added accuracy of IOPTH in surgical decisions. PATIENTS: All 177 patients had biochemically documented pHPT and all were referred for first-time surgery. MEASUREMENTS: Group 1 patients (n = 62) underwent a unilateral neck exploration (UNE) without IOPTH, and group 2 patients (n = 115) underwent MIP (either video-assisted or open) with IOPTH. The primary outcome was the cure rate, whereas the secondary outcome was the value-adding of IOPTH to surgical decision-making during MIP. RESULTS: Of the group 1 vs. 2 patients, 57/62 (91.9%) vs. 114/115 (99.1%) were cured (P = 0.01). Five (8.1%) of the group 1 patients were hypercalcaemic postoperatively, owing to an additional, overlooked, hyperfunctioning parathyroid gland, whereas among the 115 group 2 patients, 104 (90.4%) underwent resection of a single parathyroid adenoma, met the Miami criterion, and were cured. The remaining 11 (9.6%) patients did not have an adequate reduction in parathyroid hormone levels and underwent further neck exploration, with resection of additional hyperfunctioning parathyroids in nine of them. One group 2 patient was not cured. However, a decrease of less than 50% of intraoperative parathyroid hormone (iPTH) assay correctly identified the risk of persistent disease in that patient. Another patient in group 2 had a false-negative IOPTH result. The value-added accuracy of IOPTH (correct assay-based surgeon's decision of further neck exploration) was demonstrated in 3 of 78 group 2 patients with concordant results of both imaging studies vs. 7 of 37 group 2 patients with only one positive imaging study, or 3.8 vs. 18.9% of patients (P = 0.007). CONCLUSIONS: Routine use of IOPTH significantly improves cure rates of MIP in comparison to open image-guided UNE without IOPTH. It is a valuable adjunct in surgical decision-making, allowing for intraoperative recognition and resection of additional hyperfunctioning parathyroid tissue missed by preoperative imaging studies. IOPTH offers substantial value-adding to surgical decision-making, particularly in patients with only one positive imaging study result, and significantly improves the success rate of MIP in these patients. However, in patients with concordant results of two imaging studies, the assay offers significantly lower value-adding to surgical decisions, as a vast majority of patients are cured after removal of a two-image-indexed parathyroid lesion. Despite this, we strongly advocate routine use of IOPTH in all patients undergoing MIP, as this adjunct offers maximum safety for the patient and confidence for the surgeon.

Which criterion of intraoperative iPTH assay is the most accurate in prediction of true serum calcium levels after thyroid surgery?

BACKGROUND AND AIMS: Intraoperative quick intact parathyroid hormone (iPTH) assay (IOPTH) has become a valuable adjunct in parathyroid surgery reliably predicting cure from hyperparathyroid state. Similarly to parathyroid surgery, the accuracy of the assay in predicting postoperative calcemia after thyroid surgery is related to blood sample timing and the criteria applied with no guidelines widely accepted, so far. This study compares different IOPTH criteria in predicting hypoparathyroidism-related hypocalcemia after thyroid surgery. MATERIALS AND METHODS: The study included 200 consecutive patients undergoing total thyroidectomy. Three blood samples for IOPTH were taken in each patient: preoperatively--baseline (BL), at the end of surgery--skin closure (SC), and at 4 h postoperatively (4H). Serum calcium was routinely monitored at 4, 12, 24, 48, and 72 h postoperatively. The incidence and severity of hypocalcemia and related symptoms were matched to IOPTH results. The following criteria were tested: A, greater than 50% drop from BL at SC; B, greater than 70% drop from BL at SC; C, greater than 50% drop from BL at 4H; D, greater than 70% drop from BL at 4H; E, serum iPTH less than 15 pg/ml at SC; F, serum iPTH less than 10 pg/ml at SC; G, serum iPTH less than 15 pg/ml at 4H; H, serum iPTH less than 10 pg/ml at 4H. The accuracy of the tested criteria was calculated in predicting serum calcium level less than 2.0 mmol/l at any point after thyroidectomy. RESULTS: Tested criteria had the following value in predicting serum calcium level less than 2.0 mmol/l after thyroidectomy (sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy, respectively): A (60, 89, 38, 95, and 86%), B (80, 93, 57, 98, and 92%), C (70, 90, 44, 96, and 88%), D (85, 95, 65, 98, and 94%), E (80, 91, 50, 98, and 90%), F (90, 95, 69, 99, and 95%), G (90, 95, 70, 99, and 95%), H (95, 99, 90, 99, and 98%). CONCLUSIONS: The criterion of iPTH serum level less than 10 pg/ml at 4 h postoperatively has the highest accuracy in predicting serum calcium level below 2.0 mmol/l after total thyroidectomy when compared with the other criteria.

Posterior retroperitoneoscopic adrenalectomy: a comparison between the initial experience in the invention phase and introductory phase of the new surgical technique.

BACKGROUND: Today, the posterior retroperitoneoscopic technique has become a standard procedure in adrenal surgery. The procedure allows direct access to the adrenal glands, but it seems to be difficult because of the uncommon anatomic view. This study compares the learning period of the new procedure of "posterior retroperitoneoscopic adrenalectomy" in the primary invention phase and the secondary introductory phase in a different hospital 10 years later. MATERIALS AND METHODS: The analysis included 100 posterior retroperitoneoscopic adrenalectomies (PRA) and involved 50 procedures in each center. Group A consisted of 44 patients (14 males, 30 females; age: 48.7 +/- 14.5 years) undergoing surgery between 07/1994 and 8/1996 (24 right, 26 left; 8 Cushing adenomas, 14 Conn adenomas, 11 pheochromocytomas, 7 nonfunctioning adrenocortical adenomas, 10 ACTH-dependent adrenal hyperplasias). Group B consisted of 50 patients (12 males, 38 females; mean age 59.3 +/- 10.7 years) operated between 01/2004 and 01/2006 (28 right, 22 left tumors; 5 Cushing adenomas, 12 Conn adenomas, 4 pheochromocytomas, 29 nonfunctioning adrenocortical adenomas). All PRAs were performed with the patient in the prone position with 3-4 trocars placed caudally in the region of the 11th and 12th ribs. In group A, the surgical team developed the technique of PRA themselves. Before their first PRA, the surgical team of group B was introduced to the technique by the group A surgeons and afterwards were supervised continuously. RESULTS: No serious intraoperative or postoperative complication occurred in either group. Group A experienced 7 conversions to open surgery, whereas group B had one conversion and one early reoperation due to bleeding (P = 0.03; chi(2)-test). The mean operative time was 117 +/- 41 minutes versus 83 +/- 35 minutes (group A and B respectively; P < 0.001; t-test). Estimated blood loss was similar in the two groups (47.2 +/- 46.2 ml versus 54 +/- 16.3 ml, group A versus B, respectively; P = 0.36; t-test). CONCLUSIONS: The study demonstrates the feasibility, safety, and reproducibility of the new surgical method of PRA both when it is employed in the early phase of invention, as well as when performed by surgeon-learners. After comprehensive training, the operative time and conversion rate are dramatically reduced, allowing for a short learning period.

[Value of the intraoperative neuromonitoring in surgery for thyroid cancer in identification and prognosis of function of the recurrent laryngeal nerves]. / Ocena wartosci sródoperacyjnego neuromonitoringu w operacjach raka tarczycy w identyfikacji i prognozowaniu czynnosci nerwów krtaniowych wstecznych.

INTRODUCTION: The aim of this study was both, to evaluate the usefulness of the method of neuromonitoring in intraoperative identification of the RLN and to estimate its value in the prognosis of postoperative RLN function in patients operated for TC. MATERIAL AND METHODS: Among 109 patients undergoing surgery for TC between 12/2004 and 12/2005 the neuromonitoring method was used in 69 (63.3%) individuals (including 5 operations of completion total thyroidectomy). A Neurosign 100 equipment with laryngeal electrodes was employed in identification and assessment of total number of 134 RLN. Intraoperative results were compared to the postoperative results of the ENT-specialist examination of vocal cords mobility in indirect laryngoscopy, in each patient. RESULTS: Transient vs. permanent, unilateral RLN palsy was noted in 3 vs. 2 patients (2.2% vs. 1.4% of nerves at risk). The method of neuromonitoring facilitated identification of 123 (91.8%) RLN being not helpful in 11 (8.2%) cases. However, neuromonitoring was helpful in identification of the RLN, the value of the method in prognosis of posteoperative function of the RLN was limited. Results of indirect neurostimulation were more accurate than direct neurostimulation and were more accurate in prognosis of late rather than early RLN function after surgery (sensitivity 98.3%; specificity 100%; positive predictive value 100%; negative predictive value 50%, accuracy 98.4%). CONCLUSIONS: Application of intraoperative neuromonitoring facilitates identification of the RLN during surgery for TC. However, the method is of limited value in prognosis of postoperative RLN dysfunction in cases of missing signal after nerve stimulation.

Metastases to the thyroid gland: seventeen cases operated on in a single clinical center.

BACKGROUND AND AIMS: In spite of its rich vasculature, the thyroid gland is rarely the site of metastatic disease. The incidence of such metastases differs depending on the type of the analyzed material. In clinical papers, the incidence is low and, according to various sources, amounts to 2-3% of all malignant tumors of the thyroid. Most commonly, the primary tumor is located in the breast, bronchi, gastrointestinal system, (the colon, esophagus, or stomach) and kidneys. Usually, metastatic thyroid disease is identified upon autopsy, and only sporadic cases are encountered in clinical material. The authors present their experience in treating metastatic disease involving the thyroid gland based on the analysis of their clinical material consisting of patients operated on in a single center. MATERIALS AND METHODS: Seventeen patients presented with metastatic tumors of the thyroid. The material was further analyzed retrospectively. The group included four men and 13 women, with the male to female ratio of 1:4.25. The age of the patients ranged from 46 to 76 years, with the mean age amounting to 62+/-9.78 years. Eleven patients were diagnosed based on fine needle aspiration biopsy (FNAB). RESULTS: In 13 patients, the primary lesion was a clear cell carcinoma of the kidney, in one breast cancer, in another one uterine carcinoma. In two patients, no primary focus location was established. All the patients were treated surgically. Twelve patients were consistently followed up after the surgery. Of this group, seven are still alive, including five individuals with metastases of renal carcinomas, but without recurrent disease. Five patients died due to disseminated neoplastic disease. No data are available on three patients. The mean follow-up time after thyroid surgery was 3.9 years. The longest followed-up survival time was 11 years. CONCLUSIONS: The most commonly clinically detected and treated surgically metastatic lesion of the thyroid gland is clear cell cancer of the kidney. In cases of renal cancer metastases to the thyroid gland, a total thyroidectomy seems to be warranted, although it does not affect the survival time.

[New horizons for increased sensitivity of radionuclide imaging in primary hyperparathyroidism]. / Nowe mozliwosci zwiekszenia czulosci diagnostyki izotopowej pierwotnej nadczynnosci przytarczyc.

The aim of the study was to evaluate the impact of therapy with biphosphonates in patients with primary hyperparathyroidism and negative result of parathyroid scintigraphic imaging on increase of diagnostic sensitivity in repeated scans. Three female patients with diagnosed primary hyperparathyroidism and negative parathyroid imaging with subtraction 99m-Tc-MIBI scintigraphy were included into this prospective study. Patients had been receiving 70 mg of sodium alendronate orally, once a week for 3 months. After this period they were reevaluated with parathyroid subtraction scintigraphy. In all three patients a solitary area of uptake was found in the repeated scans. Patients were qualified for minimally invasive video-assisted parathyroidectomy. In two of them the repeated scans after treatment with biphosphonates were found to be true positive and in those two patients a solitary parathyroid adenoma was removed with video-assisted technique. In one patient a multiglandular disease was revealed intraoperatively basing on intraoperative iPTH assay and in that patient a subtotal video-assisted parathyroidectomy has been successfully completed. All three patients have been eucalcemic within the 6-months follow-up with iPTH serum values within the reference range. In conclusion, treatment with oral biphosphonates in patients with primary hyperparathyroidism and negative result of radionuclide parathyroid imaging, results in increased diagnostic sensitivity of repeated scans. This allows for successful minimally invasive parathyroid surgery in this group of patients with a predominant solitary parathyroid adenoma.

Technetium-99m-sestamibi subtraction scintigraphy vs. ultrasonography combined with a rapid parathyroid hormone assay in parathyroid aspirates in preoperative localization of parathyroid adenomas and in directing surgical approach.

OBJECTIVE: To determine the sensitivity and positive predictive value (PPV) of subtraction scintigraphy (SS) vs. ultrasonography (US) of the neck combined with rapid intact parathyroid hormone (iPTH) assay in US-guided fine-needle parathyroid aspirates in preoperative localization of parathyroid adenomas and in directing surgical approach. DESIGN: The results of SS for localization of parathyroid adenoma were determined in 121 patients with primary hyperparathyroidism (pHPT) and compared with findings at surgery and with the results of US alone (in patients without nodular goitre) and US in combination with the iPTH assay in US-guided fine-needle aspirates (FNAs) of suspicious parathyroid lesions (in patients with concomitant nodular goitre). PATIENTS: All 121 patients had biochemically documented pHPT; all were referred for first-time surgery. MEASUREMENTS: SS was performed with 99mTc-sestamibi and 99mTc-pertechnetate. High-resolution US of the neck was performed by a single endocrine surgeon and combined with US-guided FNAs of suspicious parathyroid lesions in all patients with nodular goitre (n = 43). RESULTS: The sensitivity and PPV of SS were significantly higher in patients without vs. with goitre (89.3% and 95.7%vs. 74.3% and 76.5%, respectively; P < 0.001). The sensitivity and PPV of US were significantly higher in patients without vs. with goitre (96% and 97.3%vs. 67.7% and 71.9%, respectively; P < 0.001). The iPTH assay of US-guided FNAs of suspicious parathyroid lesions in patients with nodular goitre significantly improved both the sensitivity and PPV of US imaging (90.7% and 100%, respectively), allowing for an accurate choice of surgical approach in 118 (97.5%) of 121 patients. SS was more accurate than US alone in detection of ectopic parathyroid adenomas. However, US alone was characterized by a higher sensitivity in detection of small parathyroid adenomas (< 500 mg) at typical sites (P < 0.01). CONCLUSIONS: Both the sensitivity and PPV of SS and US alone are comparable, with significantly less accurate results obtained in patients with goitre. In cases of equivocal results of US and/or in patients with concomitant goitre, an iPTH assay in US-guided FNAs of suspicious parathyroid lesions may be used to establish the nature of the mass, distinguish between parathyroid and nonparathyroid tissue (goitre, lymph nodes) and improve the accuracy of US parathyroid imaging, allowing for successful directing of surgical approach in a majority of patients.

Minimally invasive video-assisted parathyroidectomy versus open minimally invasive parathyroidectomy for a solitary parathyroid adenoma: a prospective, randomized, blinded trial.

BACKGROUND: A variety of minimally invasive parathyroidectomy (MIP) techniques have been currently introduced to surgical management of primary hyperparathyroidism (pHPT) caused by a solitary parathyroid adenoma. This study aimed at comparing the video-assisted MIP (MIVAP) and open MIP (OMIP) in a prospective, randomized, blinded trial. MATERIALS AND METHODS: Among 84 consecutive pHPT patients referred for surgery, 60 individuals with concordant localization of parathyroid adenoma on ultrasound and subtraction Tc99m-MIBI scintigraphy were found eligible for MIP under general anesthesia and were randomized to two groups (n = 30 each): MIVAP and OMIP. An intraoperative intact parathyroid hormone (iPTH) assay was routinely used in both groups to determine the cure. Primary end-points were the success rate in achieving the cure from hyperparathyroid state and hypocalcemia rate. Secondary end-points were operating time, scar length, pain intensity assessed by the visual-analogue scale, analgesia request rate, analgesic consumption, quality of life within 7 postoperative days (SF-36), cosmetic satisfaction, duration of postoperative hospitalization, and cost-effectiveness analysis. RESULTS: All patients were cured. In 2 patients, an intraoperative iPTH assay revealed a need for further exploration: in one MIVAP patient, subtotal parathyroidectomy for parathyroid hyperplasia was performed with the video-assisted approach, and in an OMIP patient, the approach was converted to unilateral neck exploration with the final diagnosis of double adenoma. MIVAP versus OMIP patients were characterized by similar operative time (44.2 +/- 18.9 vs. 49.7 +/- 15.9 minutes; P = 0.22), transient hypocalcemia rate (3 vs. 3 individuals; P = 1.0), lower pain intensity at 4, 8, 12, and 24 hours after surgery (24.9 +/- 6.1 vs. 32.2 +/- 4.6; 26.4 +/- 4.5 vs. 32.0 +/- 4.0; 19.6 +/- 4.9 vs. 25.4 +/- 3.8; 15.5 +/- 5.5 vs. 20.4 +/- 4.7 points, respectively; P < 0.001), lower analgesia request rate (63.3% vs. 90%; P = 0.01), lower analgesic consumption (51.6 +/- 46.4 mg vs. 121.6 +/- 50.3 mg of ketoprofen; P < 0.001), better physical functioning aspect and bodily pain aspect of the quality of life on early recovery (88.4 +/- 6.9 vs. 84.6 +/- 4.7 and 90.3 +/- 4.7 vs. 87.5 +/- 5.8; P = 0.02 and P = 0.003, respectively), shorter scar length (17.2 +/- 2.2 mm vs. 30.8 +/- 4.0 mm; P < 0.001), and higher cosmetic satisfaction rate at 1 month after surgery (85.4 +/- 12.4% vs. 77.4 +/- 9.7%; P = 0.006). Cosmetic satisfaction was increasing with time, and there were no significant differences at 6 months postoperatively. MIVAP was more expensive (US$1,150 +/- 63.4 vs. 1,015 +/- 61.8; P < 0.001) while the mean hospital stay was similar (28 +/- 10.1 vs. 31.1 +/- 9.7 hours; P = 0.22). Differences in serum calcium values and iPTH during 6 months of follow-up were nonsignificant. Transient laryngeal nerve palsy appeared in one OMIP patient (P = 0.31). There was no other morbidity or mortality. CONCLUSIONS: Both MIVAP and OMIP offer a valuable approach for solitary parathyroid adenoma with a similar excellent success rate and a minimal morbidity rate. Routine use of the intraoperative iPTH assay is essential in both approaches to avoid surgical failures of overlooked multiglandular disease. The advantages of MIVAP include easier recognition of recurrent laryngeal nerve (RLN), lower pain intensity within 24 hours following surgery, lower analgesia request rate, lower analgesic consumption, shorter scar length, better physical functioning and bodily pain aspects of the quality of life on early recovery, and higher early cosmetic satisfaction rate. However, these advantages are achieved at higher costs because of endoscopic tool involvement.

[A case of primary malignant lymphoma of thyroid in young man]. / Przypadek pierwotnego chloniaka zlosliwego tarczycy u mlodego mezczyzny.

The aim of this study is to present a case of a 36-year old male with a rare thyroid malignancy--a primary thyroid lymphoma. The patient was admitted to the Department of Endocrinology due to a rapidly enlarging left-sided tumor of the neck and hoarseness lasting for 2 weeks. The only abnormality found on biochemical testing was a slightly elevated titre of anti-TPO antibodies. On X-ray examination, both a compression and deviation of the trachea was found. Ultrasound examination of the neck revealed a left-sided thyroid lesion and fine needle aspiration (FNA) was performed under ultrasound guidance. A monotonous population of mid-size lymphoid cells was found with negative immunocytochemistry for thyroglobuline and CD 68. After hematological and pathological evaluation the FNA report was considered as non-diagnostic. Taking into consideration the presence of rapidly occurring compressive symptoms caused by a tumor of unknown cytological origin, the patient was referred to urgent thyroid surgery. Pathological report of postoperative specimen allowed for the final diagnosis of a malignant lymphoma originating from non-Hodgkin B cells of the thyroid gland; diffuse large B-cell lymphoma (DLCL) according to WHO classification. L-thyroxin substitution therapy, chemo- and radiotherapy were used after the operation. The described case of a very rare type of primary thyroid malignancy illustrates difficulties which can be encountered in diagnostic approach and therapeutic decision making in patients with rapidly enlarging thyroid tumors.

A randomised study on a new cost-effective algorithm of quick intraoperative intact parathyroid hormone assay in secondary hyperparathyroidism.

BACKGROUND AND AIMS: The use of intraoperative intact parathyroid hormone (iPTH) assay in secondary renal hyperparathyroidism (SHP) has been limited by the relatively low cost effectiveness of the assay in improving the success rate for primary bilateral neck exploration. The study aimed at determining, in a prospective, randomised trial, the cost effectiveness and impact of the routine employment of a "six-sample" versus "two-sample" algorithm of the intraoperative iPTH assay during surgery for SHP on intraoperative decision making and surgical success rate. PATIENTS AND METHODS: One hundred and two consecutive patients with severe SHP and qualified for subtotal parathyroidectomy were randomly allocated to two equal-sized groups: group A, in which the intraoperative iPTH serum level was determined in six consecutive samples: preoperative, pre-excision, 5, 10, 20 and 60 min, and group B, in which the intraoperative iPTH serum level was determined twice only: preoperatively and 10 min. The STAT intraoperative intact-PTH immunoassay was employed. In group B, in patients with serum iPTH decrease lower than 60% of the baseline at 10 min, an additional measurement was performed at 20-min post-excision. If a decrease of 80% or more of the baseline was not obtained, the exploration was extended in search of remaining hyperfunctioning parathyroid tissue. RESULTS: The surgical success rate was 96.1% and 98.0% (in group A and B, respectively). The impact of the intraoperative iPTH assay on surgical decision making was demonstrated in 13.7% and 15.7% (in group A and B, respectively). The assay was helpful in identifying patients with supranumerary hyperfunctioning parathyroid tissue (5.9% vs 7.8% in group A and B, respectively), patients with fewer than four parathyroid glands (3.9% vs 5.9% in group A and B, respectively) and patients with remaining hyperfunctioning parathyroid tissue suspected to be located within the mediastinum in cases of negative bilateral neck exploration who benefit from transcervical thymectomy. The diagnostic accuracy of the intraoperative iPTH assay was 100% in both groups. The accuracy of two-sample algorithm increased from 96% to 100% if an additional serum iPTH determination was performed in borderline cases with an iPTH drop lower than 60% of the baseline at 10 min. The cost-effectiveness analysis showed significant savings in group B, equal to Euro 87.6 per patient, with the unchanged diagnostic accuracy of the two-sample algorithm. CONCLUSIONS: The intraoperative iPTH assay in patients operated on for secondary hyperparathyroidism offers support in surgical decision making in the majority of patients, allowing for correct identification of patients with supranumerary ectopic hyperfunctioning parathyroid glands, and in patients with fewer than four parathyroid glands. It also correctly identifies patients who do not benefit from blind thymectomy. The two-sample algorithm, extended to include three determinations in selected cases, has the same 100% diagnostic accuracy as the six-sample algorithm, the former being a much more cost-effective procedure.