[Complications in thyroid surgery]. / Complicanze in chirurgia tiroidea.

Thyroidectomy is one of the most frequently performed surgical procedure worldwide, even if the risks of lethal postoperative complications prevented its evolution and diffusion until the beginning of the XX century. At that time, T. Kocher described his meticulous technique, reporting excellent results in terms of mortality and morbidity. At present, mortality for this procedure approaches 0% and overall complication rate is less than 3%. Nonetheless, major complications of thyroidectomy (i.e. compressive hematoma, recurrent laryngeal nerve palsy and hypoparathyroidism) are still fearful complications and account for a significant percentage of medico-legal claims. Patients volume and surgical skill play an important role in reducing the risk of complications. Accurate knowledge of anatomy and pathophysiology, complications incidence and pathogenesis and a careful surgical performance are essential. In this review, post-thyroidectomy complications basing on literature analysis and personal experience are described. The main anatomical, technical and pathophysiological factors that help preventing post-thyroidectomy complications are analyzed, taking into proper account new technologies and the minimally invasive surgical procedures that influenced thyroid surgery during the last decade.

Is there a role for video-assisted parathyroidectomy in regions with high prevalence of goitre?

Minimally-invasive procedures for parathyroidectomy have revolutionized the surgical treatment of primary hyperparathyroidism (pHPT). Coexistence of goitre is considered a major contraindication for these approaches, especially if unilateral. A specific advantage of video-assisted parathyroidectomy (VAP) compared to other endoscopic techniques is the possibility to combine it with thyroidectomy when necessary and when the selection criteria for video-assisted thyroidectomy (VAT) are met. We evaluated the role of VAP in a region with a high prevalence of goitre. The medical records of all patients who underwent parathyroidectomy and concomitant thyroid resection in our Division, between May 1998 and June 2012, were reviewed. Patients who underwent VAP and concomitant VAT were included in this study. Overall, in this period, 615 patients were treated in our Division for pHPT and 227 patients (36.9%) underwent concomitant thyroid resection. Among these, 384 patients were selected for VAP and 124 (32.3%) underwent concomitant VAT (lobectomy in 26 cases, total thyroidectomy in 98). No conversion to conventional surgery was registered. Mean operative time was 66.6 ± 43.6 min. Transient hypocalcaemia was observed in 42 cases. A transient recurrent nerve lesion was registered in one case. No other complications occurred. Final histology showed parathyroid adenoma in all but two cases of parathyroid carcinoma, benign goitre in 119 cases and papillary thyroid carcinoma in the remaining 5 patients. After a mean follow-up of 33.2 months, no persistent or recurrent disease was observed. In our experience, a video-assisted approach for the treatment of synchronous thyroid and parathyroid diseases is feasible, effective and safe at least considering short-term follow-up.

Are brown tumours a forgotten disease in developed countries?

Brown tumours (BT), an expression of osteitis fibrosa cystic due to primary hyperparathyroidism (pHPT), can occasionally be mistaken for malignancy. Among 615 patients who underwent parathyroidectomy for pHPT in our institution, the medical records of three patients affected by BT were reviewed. The first patient underwent surgical removal of the orbital mass for a suspected lachrymal gland neoplasm. The remaining two patients underwent, respectively, leg amputation and femur resection for a suspected bone malignancy. Final histology showed a BT in three cases. All three patients were admitted to our Division and underwent successful parathyroidectomy for parathyroid adenoma in two cases and for parathyroid carcinoma in the remaining case. When faced with an osteolithic bone lesion, complete evaluation of medical history, biochemical and radiographic findings can help to reach a correct diagnosis and avoid unnecessary bone resections.