Calcium management after thyroidectomy: a simple and cost-effective method.

OBJECTIVE: Hypocalcemia is one of the principal complications of total or completion thyroidectomy. A number of different protocols for managing this potential complication have been published. Our simple postoperative regimen is described and the safety and cost-effectiveness assessed. STUDY DESIGN: Case series with planned data collection. SETTING: Academic medical center. SUBJECTS AND METHODS: All patients undergoing total or completion thyroidectomy from January 2008 through June 2010 were evaluated. Data collected included age; gender; procedure performed; levels of ionized calcium, parathyroid hormone, and vitamin D; complications; and need for readmission. Standard descriptive statistics were used to summarize these data. RESULTS: In total, 526 patients had thyroid surgery during the 30-month study period. Of these, 307 underwent completion or total thyroidectomy and were prescribed a 3-week tapering course of calcium carbonate postoperatively. Twenty-three patients (7.5%) experienced symptoms of hypocalcemia that were managed on an outpatient basis with additional doses of oral calcium. Two patients (0.7%) required readmission. The cost of a 3-week regimen of calcium carbonate is approximately $15. This is considerably less expensive than either the cost of overnight admission or published laboratory protocols that are designed to predict the risk of hypocalcemia. CONCLUSIONS: Prophylactic calcium supplementation without routine laboratory assessment proved to be a safe and cost-effective method of preventing and managing postoperative hypocalcemia following total or completion thyroidectomy.

Robotic facelift thyroidectomy: patient selection and technical considerations.

OBJECTIVES: A series of remote access thyroidectomy techniques, some using a surgical robot, have been introduced in the last decade. Most of these approaches require awkward positioning, use unfamiliar dissection planes, and have been associated with a number of significant complications. As a result, acceptance has been limited. We describe technical details and patient selection criteria of a recently described robotic facelift thyroidectomy (RFT) approach that avoids these pitfalls. DESIGN: Analysis of preclinical and clinical studies. METHODS: Inanimate and cadaver dissection studies and clinical implementation were pursued. A 3-arm RFT technique with a 30-degree offset base location proved optimal. Supine positioning with arms tucked and the patient in slight Trendelenburg position facilitated the dissection of the optical pocket. Demographic and surgical data that have been obtained and considered include patient age, sex, body mass index, pathology, and complications. RESULTS: A series of consecutive RFT procedures has been accomplished in a limited population of patients. All cases were completed robotically with no conversions to open surgery necessary. All but the first case was accomplished on a drainless, outpatient basis. CONCLUSIONS: A RFT technique that is gasless and uses a single access port in the postauricular crease and occipital hairline location is feasible, technically less challenging than other remote access methods, and safe. Further study in an expanded patient population and in additional high-volume thyroid centers is warranted. See the videos, Supplemental Digital Content 1, http://links.lww.com/SLE/A36andSupplementalDigitalContent2, http://links.lww.com/SLE/A37.

Robotic facelift thyroidectomy: II. Clinical feasibility and safety.

OBJECTIVES: A number of remote access thyroidectomy techniques have been described in the last several years. These approaches are technically challenging, can be performed on only a limited patient population, and have been associated with significant complications. We describe a novel robotic facelift approach for thyroidectomy and report our initial clinical experience. DESIGN: Planned analysis of a prospectively maintained database with institutional review board approval. METHODS: Robotic facelift thyroidectomy (RFT) was performed on all patients. Demographic and surgical data were obtained and analyzed. Data collected included patient age, gender, body mass index (BMI), pathology, complications, and duration of surgery. RESULTS: A total of 18 RFT procedures were undertaken in 14 patients. There were 13 females and 1 male, with a mean age of 33.7 ± 18.1 years (range: 12-70). The mean BMI was 26.9 ± 4.5. The procedures included 13 lobectomies, one bilateral thyroidectomy, and 3 completion thyroidectomies. All but the first procedure was performed on an outpatient basis without use of a drain. There were no conversions to open surgery, no permanent nerve injuries, and no cases of hypoparathyroidism. Operative times ranged from 97 to 193 minutes. CONCLUSIONS: RFT is a feasible remote access thyroidectomy approach. It appears from our initial experience that it may be performed in a safe and reproducible manner without a drain and on an outpatient basis. Additional clinical experience is warranted to further validate this technique.

Restoring point-of-care testing during parathyroidectomy with a newer parathyroid hormone assay.

OBJECTIVE: Intraoperative parathyroid hormone (IOPTH) monitoring has emerged as a useful adjunct in parathyroidectomy. Originally performed within the operating room, removal of the Nichols assay from the market forced many surgeons to rely on testing done in central laboratories, reducing convenience and prolonging operative times. The authors hypothesized that PTH assessment with a newer point-of-care (POC) assay would reduce results reporting time compared with central-laboratory PTH assays. STUDY DESIGN: Cross-sectional study with planned data collection. SETTING: Academic medical center. SUBJECTS AND METHODS: Patients underwent parathyroidectomy for primary or recurrent hyperparathyroidism. Intraoperative monitoring of serum PTH levels was used to confirm biochemical cure following adenoma excision. Samples were run in duplicate using both a POC PTH assay (Future Diagnostics) located within the operating room and a laboratory-based assay (Turbo PTH). Samples were taken at incision and at 5-, 10-, and 15-minute intervals following removal of suspected parathyroid adenomas. Results reporting time was recorded and compared by nonparametric Wilcoxon rank sum test. RESULTS: Sixty-six serum samples were assayed. There was excellent correlation between POC and central-laboratory IOPTH results (r = 0.880, P < .001). The POC IOPTH results were available faster than corresponding central-laboratory results, with a mean of 14.4 minutes compared with 30.7 minutes, respectively (P < .001). All patients (100%) demonstrated a biochemical cure by the end of the procedure. CONCLUSION: Use of a rapid POC IOPTH assay results in a significant decrease in the amount of time for laboratory results to be communicated to the surgical team. This reduces operative times for parathyroidectomy and improves patient care.

Robotic facelift thyroidectomy: I. Preclinical simulation and morphometric assessment.

OBJECTIVES: Robotic thyroidectomy was introduced in the United States despite scant preclinical data. We pursued a systematic preclinical investigation of a new remote access, robotic thyroidectomy technique via a facelift incision, and sought to define differences in extent of dissection associated with this approach and a second, popular robotic thyroidectomy technique. DESIGN: Surgical simulation and morphometric analysis in fresh human cadavers. METHODS: Eleven specimens were obtained to complete four experiments designed to address two specific aims: to develop a reproducible surgical protocol for robotic removal of the thyroid through a facelift incision, and to quantify the extent of dissection required with two robotic thyroidectomy techniques. RESULTS: The feasibility of the facelift approach was determined using an endoscopic technique, and two lobectomies were accomplished. Inanimate study of the optimal robotic positioning to facilitate resection was then completed. Three additional cadavers were used to develop a reproducible surgical protocol and define a stepwise algorithm of dissection. Seven specimens were used to simulate 28 robotic thyroidectomy dissection pockets. The mean area of dissection required for robotic facelift thyroidectomy was 39.2 ± 6.6 cm(2) compared with 63.5 ± 9.6 cm(2) for robotic axillary thyroidectomy, representing a difference of 38.3% (P < .0001). CONCLUSIONS: We have described and refined a reproducible surgical protocol for accomplishing a new robotic facelift thyroidectomy, and then quantified the reduced dissection required when comparing it with a transaxillary technique. Cautious clinical implementation to explore safety and feasibility appears to be justified.

Minimally invasive thyroid surgery in children.

OBJECTIVES: As the prevalence of thyroid nodules and thyroid cancer increases, thyroid surgery is being performed in a growing number of pediatric patients. Minimally invasive thyroid surgery may be particularly beneficial in this patient population. Smaller incisions result in improved cosmesis in this young, predominantly female group, and minimal-access techniques better preserve tissue planes--an advantage, because of younger patients' higher lifetime likelihood of reoperation. METHODS: For this case series with planned data collection, Institutional Review Board approval was obtained to analyze a prospective database and assess outcome data. The outcome measures included pathologic classification, cosmetic results, rates of complications (especially hypocalcemia), true vocal fold paralysis, and the need for admission or readmission. RESULTS: We performed 495 thyroidectomy procedures during the study period (February 2003 to May 2008). Of these, 23 were in patients less than 21 years of age. The mean incision length was 3.3 +/- 1.0 cm (range, 1.5 to 5.0 cm), and 12 of the incisions (52.2%) were 3 cm or shorter. Nine patients (41%) had thyroid cancer, most commonly papillary carcinoma (compared with 21.9% of the adult population). There were no hematomas and no cases of permanent true vocal fold paralysis or permanent hypocalcemia. Two patients (8.7%) had temporary hypocalcemia, and both required readmission. CONCLUSIONS: Minimally invasive thyroid surgery has benefits over conventional thyroid surgery, particularly in a pediatric population. Among its many potential advantages, the social stigma of a large incision is reduced and preservation of tissue planes is improved.

Point-of-care rapid intraoperative parathyroid hormone assay of needle aspirates from parathyroid tissue: a substitute for frozen sections.

BACKGROUND: The intraoperative parathyroid hormone (IOPTH) assay is an important tool that facilitates targeted parathyroidectomy and may increase surgical cure rates. We sought to evaluate the utility of a point-of-care assay to distinguish parathyroid adenomas from nonparathyroid tissues, which can sometimes pose a challenge during parathyroidectomy and is commonly achieved with the use of frozen sections. We hypothesized that point-of-care rapid IOPTH assays of needle aspirates from suspected adenomas would be faster and equal in accuracy to frozen sections. METHODS: Parathyroid and nonparathyroid lesions were excised, and the tissues were needle aspirated, diluted in saline, and submitted to a rapid IOPTH assay located in the operating room. Frozen sections were simultaneously sent for analysis. The time intervals to result availability were tracked and compared using a paired t test. RESULTS: Point-of-care IOPTH assays of needle aspirates were available in a mean (±SD) of 11.6 ± 1.5 minutes compared to 18.7 ± 4.0 minutes for frozen sections (P = .005). The findings were concordant 100% of the time for both parathyroid (mean parathyroid hormone [PTH] > 3338.9 pg/mL) and parathyroid tissues (mean PTH = 8.7 pg/mL). CONCLUSION: Point-of-care IOPTH assay of needle aspirates is an accurate method of distinguishing parathyroid from nonparathyroid tissues. It is suggested that this would be particularly useful in instances where use of IOPTH is planned for assessment of a drop in serum PTH.

Modifications of Miccoli minimally invasive thyroidectomy for the low-volume surgeon.

OBJECTIVE: The objective of the study was to describe our experience with modifications of the Miccoli minimally invasive thyroidectomy. DESIGN: Planned analysis of a prospectively maintained database was undertaken after Institutional Review Board approval. METHODS: Demographic and surgical data were obtained and analyzed with attention to age, sex, pathology, incision lengths, and complications. RESULTS: From a single-surgeon series of 785 consecutive thyroidectomies, 178 patients were identified who underwent an endoscopic minimally invasive thyroidectomy. A series of modifications of the classic Miccoli technique evolved over a period of 4 years and include presurgical factors (patient marking in holding area, intubation with laryngeal EMG tube using videolaryngoscope, rotation of operating table away from anesthesia), intraoperative principles (use of operative loupes, slave monitor, laryngeal nerve monitoring, and novel instrumentation; identification of the medial cleft and ligation of superior pedicle bundle using ultrasonic technology; avoidance of clips), and postoperative techniques (deep extubation, laryngeal endoscopy, outpatient management, and oral calcium supplementation). CONCLUSIONS: A minimally invasive endoscopic thyroidectomy is possible even in a practice with moderate surgical volumes by using several techniques that facilitate the performance of this procedure. A high success rate and low complication rate can be achieved, resulting in improved patient satisfaction.

A new minimally invasive lingual thyroidectomy technique.

BACKGROUND: The lingual thyroid is uncommon, and the need for resection of this condition is even more rare. Techniques for removal have historically included wide access with associated disfiguring incisions. We sought to describe a minimally invasive and safe technique for the management of the obstructive lingual thyroid gland that achieves optimal hemostasis with the use of technology. METHODS: Institutional Review Board approval was obtained to evaluate the safety and efficacy of a minimally invasive technique to remove the obstructive lingual thyroid gland. The procedure is performed in ∼1 hour; requires no splitting of the lip, tongue, or mandible, is associated with negligible blood loss, and is accomplished on an outpatient basis. RESULTS: The procedure was undertaken in a 34-year-old woman with a longstanding lingual thyroid that began to cause dysphagia. She was found to be clinically and biochemically euthyroid, and was referred for surgical intervention. The procedural time was 90 minutes, and the estimated blood loss was 15 mL. She was discharged shortly after recovery, on an outpatient basis. CONCLUSIONS: A number of surgical approaches to the obstructive lingual thyroid have been described, including the use of a lip-split, tongue-split, mandibulotomy, and cervical pharyngotomy approach. We describe a minimally invasive transoral procedure that incorporates Harmonic technology and high-resolution endoscopy and is accomplished with no external incisions on an outpatient basis.

Minimally invasive thyroid and parathyroid surgery: where are we now and where are we going?

After nearly a century of performing thyroidectomy essentially the way it was described by Theodore Kocher in the nineteenth century, the technique has quickly evolved. Parathyroidectomy has advanced as biochemical assays and physiologic imaging have become available. Minimally invasive and endoscopic thyroidectomy and parathyroidectomy can now be performed in many patients who benefit from the reduced dissection and smaller incisions associated with these approaches. Although many of the cosmetic, quality of life, and functional improvements have been proved, a better understanding of the procedure and the appropriate indications for its application will continue to develop even as the technique itself evolves, and as new approaches emerge.

Outpatient thyroidectomy: experience in over 200 patients.

OBJECTIVES/HYPOTHESIS: Thyroidectomy has historically been performed on an inpatient basis out of fear of hemorrhage and transient but life-threatening hypocalcemia. An earlier favorable experience with outpatient surgery for a limited number of patients prompted our objective of an expanded evaluation of this practice. STUDY DESIGN: Retrospective analysis of a prospectively populated database. METHODS: A consecutive single-surgeon series of patients undergoing thyroidectomy in an academic otolaryngology department between February 2003 and November 2007, including 91 patients assessed in a previous report. Clinical variables including age, gender, type of surgery, indications, and complications were obtained and analyzed. Principal outcome measures were length of hospital stay, incidence of complications, and rate of readmission. RESULTS: Four hundred eighteen patients underwent thyroid surgery during the study period. Two hundred eight were accomplished on an outpatient basis, 128 patients were observed under a 23-hour status, and 82 were admitted for a mean of 2.9 days (the latter two cohorts were grouped together and designated as inpatients). There were four complications in the outpatient group (1.9%) and 28 (13.3%) in the inpatient group (P < .001). Four individuals in the outpatient group (1.9%) required readmission compared with 5.7% (12/210) of those in the inpatient group, most commonly for transient hypocalcemia. CONCLUSIONS: The initial favorable experience with outpatient thyroid surgery has been validated in this expanded patient population of more than 200 patients. In rare instances, readmission may be required secondary to transient hypocalcemia. Modern surgical techniques, avoidance of drains, and prophylactic calcium supplementation have combined to make outpatient thyroidectomy safe in carefully selected patients.

Reoperative thyroidectomy for benign thyroid disease.

BACKGROUND: Subtotal thyroidectomy for benign thyroid disease (BTD) may lead to delayed recurrence, thus necessitating reoperative surgery. We describe our experience with reoperative thyroidectomy for BTD and recommendations for definitive primary management. METHODS: Patients undergoing thyroid surgery between 2003 and 2007 by a single surgeon were prospectively assessed. Numerous clinical parameters were evaluated, including time interval between primary and reoperative surgery and complications. RESULTS: In all, 321 thyroidectomies were identified: 45 were reoperative and 22 were related to BTD after primary surgery done elsewhere. Median interval between the primary and reoperative procedure was 8.5 years. No recurrences followed total thyroidectomy or total thyroid lobectomy. There were no cases of permanent or transient recurrent laryngeal nerve (RLN) injury related to reoperative surgery. There was 1 case of transient hypocalcemia. CONCLUSIONS: Although reoperative thyroidectomy can be performed safely in the hands of experienced surgeons, a thorough initial surgical procedure should obviate the need for exposure to this additional risk.

Geriatric thyroidectomy: safety of thyroid surgery in an aging population.

OBJECTIVE: To ascertain whether there are incremental risks associated with thyroid surgery in the elderly population. DESIGN: Prospective analysis of a consecutive single-surgeon series of patients undergoing thyroid surgery at an academic health center. SETTING: Tertiary care health center. PATIENTS: The study included patients aged 21 to 35 years and patients 65 years and older who underwent thyroidectomy. MAIN OUTCOME MEASURES: Pathology reports, complications (including rates of temporary and permanent hypocalcemia and temporary and permanent true vocal fold [TVF] paralysis), and need for admission or readmission were included in the analysis. RESULTS: There were 86 youthful patients who underwent thyroidectomy between November 2003 and December of 2007; 44 elderly patients underwent surgery during that same time frame. There were no deaths in either cohort, no hematomas, and no cases of permanent TVF paralysis. The elderly patients had a similar rate of complications when compared with the youthful patients, including transient hypocalcemia (12.5% vs 11.1%, respectively) and temporary TVF paresis (2.9% vs 3.9%), but a higher rate of readmission (4.5% vs 1.2%, P = .26). CONCLUSIONS: Thyroid surgeons will be faced more often with the prospect of elective thyroid surgery in patients of advanced age as an increasingly aged population emerges and the prevalence of thyroid nodules and thyroid cancer increases. Thyroid surgery in elderly patients is safe and no more dangerous than surgery in youthful patients. There is a slightly higher rate of readmission.

Optimal use of intraoperative PTH levels in parathyroidectomy.

OBJECTIVES/HYPOTHESIS: Localization and the intraoperative parathyroid hormone assay (IOPTH) have facilitated minimally invasive parathyroidectomy. The precise algorithm governing use of IOPTH has been debated. Numerous authors advocate acquisition of a so-called pre-excision (P-E) baseline level (obtained after dissection of the adenoma, but prior to excision) in addition to a preincision baseline, to guard against spurious elevation in the baseline that might confuse interpretation of postexcision levels. We sought to clarify the optimal timing of PTH level determination. STUDY DESIGN: Consecutive single-surgeon case series with planned data collection from patients undergoing parathyroid surgery at a university hospital. METHODS: Demographic data and intraoperative laboratory and surgical findings from patients undergoing parathyroidectomy were prospectively gathered and analyzed. Attention was paid to the value of P-E and 5-minute postexcision levels and their impact on intraoperative decision-making. RESULTS: One hundred twelve patients underwent parathyroidectomy. Thirty were for secondary or tertiary hyperparathyroidism and were excluded. Seventy-nine (96.3%) of the 82 patients with primary hyperparathyroidism were rendered eucalcemic. In no case did the P-E value change what was otherwise destined to be a successful result. In 65.3% of cases, operative time was conserved as the procedure was correctly stopped after the 5-minute level, without the need to wait until the 10-minute postexcision level was reported. CONCLUSIONS: Pre-excision baseline IOPTH levels, although logical in their original proposal, appear to play little role in determining the completeness of an exploration. A 5-minute postexcision level adds value in nearly two thirds of cases by allowing earlier termination of the operation.

Normal values for pharyngeal pH monitoring.

OBJECTIVES: We performed a prospective study of asymptomatic adult volunteers to establish normative values of pharyngeal pH using a novel pH probe. METHODS: The Dx-pH probe is a novel pH device capable of measuring liquid and aerosolized acid levels. Twenty asymptomatic patients (Reflux Symptom Index less than 10 and Reflux Finding Score less than 6) underwent simultaneous investigation with this probe placed in the oropharynx and a dual antimony probe placed in the hypopharynx and esophagus. The reflux parameters measured from the oropharyngeal probe included the percentage of time and the number of events in which the pH was less than 5.5,5.0,4.5, and 4.0. RESULTS: The upper limits of normal (95th percentile) for the number of events below pH of 5.5, 5.0, 4.5, and 4.0 per 24-hour period were 16.6, 10.7, 7.4, and 0.2, respectively. The upper limits of normal (95th percentile) for an acid exposure time below pH of 5.5, 5.0, 4.5, and 4.0 per 24-hour period were 820 seconds, 385 seconds, 75 seconds, and 3 seconds, respectively. CONCLUSIONS: Normative pharyngeal pH values are presented. Further studies are required to determine clinical relevance.

Classification system for minimally invasive thyroid surgery.

BACKGROUND: Minimally invasive thyroid surgery has been increasingly embraced in the United States and elsewhere. The surgical standards have yet to emerge, resulting in a sometimes confusing assortment of designations for the techniques. DESIGN: Evidence-based analysis of prospectively collected data from a consecutive, single-surgeon experience with minimally invasive and conventional thyroid surgery. METHODS AND MATERIALS: Demographic parameters were obtained on patients undergoing thyroid surgery at the Medical College of Georgia from February 2003 to June 2007. Particular attention was paid to patient and tumor characteristics thought to have relevance to eligibility for minimally invasive thyroid surgery. Normally distributed variables were subjected to parametric tests, nonnormally distributed variables to nonparametric tests. RESULTS: A total of 359 patients underwent thyroidectomy during the study period; there were 57 males and 302 females, with a mean (+/- standard deviation) age of 45.9 +/- 15.1 years. Predictably, there was a strongly positive correlation between incision length and both the size of the nodule (p = 0.0001) and the patient body mass index (p = 0.0001). A classification system was designed which established distinct and discrete levels for minimally invasive thyroidectomy (MIT I, II and III). CONCLUSIONS: A patient- and disease-driven classification system for assigning eligibility for incremental levels of minimally invasive thyroid surgery is proposed. This system allows for both uniform reporting of outcome measures across patient populations and a logical basis for determining patient eligibility.

Findings from a public thyroid screening protocol: ultrasound and disease characteristics.

OBJECTIVES: A public thyroid screening protocol incorporating ultrasonography was developed and implemented as a feature of the National Thyroid Cancer Awareness month. Findings and lessons learned are described. METHODS: Prospective analysis of participants in a 1-day thyroid screening protocol and review of findings and referrals generated during the screening process. RESULTS: A total of 39 patients participated in the thyroid-screening protocol. Thirty-two (82%) patients were female and 7 (18%) were male, with an overall mean age of 52.9 +/- 14.1 years (range: 20-79). Seventeen (44%) patients indicated a known history of thyroid pathology, and 5 (13%) patients reported a family history of thyroid disease. The most common complaints offered on a patient intake survey were weight gain (38%) and dysphagia (36%). Thirty patients (77%) underwent thyroid ultrasound (US). The majority of patients (69%) had an abnormal US; the most common abnormality found was multinodular goiter (21%). Eighteen participants were referred to endocrinology for further evaluation, 13 have been evaluated and 3 patients have had fine-needle aspirations performed. Two patients have undergone thyroid surgery. The majority of patients (67%) believed that the thyroid-screening increased their awareness and knowledge of thyroid and head and neck cancer. CONCLUSIONS: A public thyroid screening activity proved to be a valuable mechanism for the dual purpose of identifying individuals with thyroid pathology needing further evaluation, and increased public awareness and knowledge of thyroid and head and neck cancer. Additional value related to the provision of a community service and opportunity to increase experience with ultrasonography.