Surgery in the setting of Hashimoto's thyroiditis.

BACKGROUND: Hashimoto's thyroiditis (HT) is a chronic autoimmune thyroiditis typically resulting in hypothyroidism. In itself, HT is not an indication for surgery but the co-existence of thyroid nodular disease creates diagnostic and management difficulties. Indications for thyroidectomy include risk of malignancy and pressure symptoms. While fine needle aspirate cytology is effective in the diagnosis of thyroid lesions, in HT there is increased diagnostic uncertainty. This study aimed to document the results of cytology and the rate of malignancy in HT. METHODS: Data were analysed for the period 1996­2009. All patients who underwent thyroidectomy and had a formal histological diagnosis of HT were included and compared with a control population who underwent thyroidectomy but did not have HT. In both groups, patient demographics, clinical parameters, cytology findings, operative procedure and final histology were reviewed. RESULTS: One hundred and twelve patients had histologically proven HT, with a significant female preponderance compared with controls (P = 0.002). There were no significant differences between cases and controls for type of procedure or preoperative examination findings. Incidence of hypothyroidism was increased: 17 patients (15.2% versus 1.6%; P < 0.0001), whereas thyrotoxicosis was decreased: four patients (3.6% versus 14.4%; P = 0.002). There was an increased incidence of follicular/indeterminate cytology (35.7% versus 22.1%; P = 0.001). While there was an increased false negative rate in HT, this failed to achieve statistical significance (8.8% versus 2.5%; P = 0.09). Malignancy rates were more prevalent in the setting of HT (23.2% versus 11.4%; P < 0.001). CONCLUSIONS: Given the increased rate of associated malignancy and increased diagnostic uncertainty in patients with HT, we recommend routine preoperative thyroid antibody measurement.

Local recurrence following surgical treatment for carcinoma of the lower rectum.

BACKGROUND: The present paper examines the local recurrence rate following surgical treatment for carcinoma of the lower rectum with principally blunt dissection directed at tumour-specific mesorectal excision (including total mesorectal excision when appropriate). METHODS: During the period April 1987-December 1999, 123 consecutive resections for carcinoma of the middle and distal thirds of the rectum were performed. The patients had low anterior resection, ultra low anterior resection or abdomino-perineal resection. Ninety-six eligible patients underwent curative resection. The mean follow-up period was 66.8 months +/-44.3 (range 3-176 months). Data were available on all patients having been prospectively registered and retrospectively collated and computer coded. RESULTS: The overall rate of local recurrence was 5.2% (four recurrences following ultra low anterior resection and one following abdomino-perineal resection. No local recurrence occurred after low anterior resections.). Local recurrences occurred between 16 and 52 months from the time of resection, and the cumulative risk of developing local recurrence at 5 years for all patients was 7.6%. The overall 5-year cancer specific survival of the 96 patients was 80.8%, and the overall probability of being disease free at 5 years, including both local and distal recurrence, was 71.8%. CONCLUSION: The results of the present series confirm the safety of careful blunt techniques combined with sharp dissection for rectal mobilization along fascial planes resulting in extraction of an oncologic package with tumour-specific mesorectal excision (or total mesorectal excision when appropriate).

Does neck extension elevate the thyroid gland cephalad to potentially improve access during thyroidectomy?

BACKGROUND: Patients undergoing thyroidectomy are positioned with the neck extended to facilitate exposure of the neck. Computed tomography (CT) scanning of the thyroid, without i.v. contrast, is often used preoperatively to investigate the extent of large goitres. Currently, patients are scanned in the neutral position rather than the surgical position of neck extension. The aim of the present study was to determine the degree, if any, of movement of the thyroid, as measured by CT, achieved by neck extension. METHODS: A trial was designed using CT scanning of the neck. Fourteen patients were studied. Patients attended for the usual CT thyroid. In addition, they were then rescanned with their neck extended. The position of the inferior aspect of the gland in relation to the sternal notch was measured in both positions. The degree of neck extension was measured and correlated with the extent of thyroid gland movement. The data were analysed with the Wilcoxon signed rank test and Spearman correlation coefficients. RESULTS: Results showed a median difference between the two positions of 5 mm (P = 0.0002). CONCLUSION: The minimal cephalad movement of the thyroid achieved by neck extension, although statistically significant, is of doubtful clinical use, and overextension of the neck should be avoided because of its associated risks of pain, vomiting and spinal damage.