Retrosternal goiters: safety of surgical treatment.

Retrosternal goiters still pose a problem to expert endocrine surgeons. Whether surgery should be the treatment of choice or not remains controversial because of hypothetical increased morbidity rates associated with the surgical approach. Eighty-three patients were retrospectively reviewed for anesthetic risk, fibrobronchoscopic guidance for intubation, surgical technique, mortality and morbidity rates, and pathological findings. We found 6.09% of American Society of Anesthesiologists (ASA) I, 41.46% of ASA II, 40.24% of ASA III, and 12.19% of ASA IV risk. Twelve patients (14.45%) required fibrobronchoscopic guidance for intubation. Only one patient required a sternotomy. No mortality occurred. Seven patients (8.43%) had major complications, but there were no instances of permanent recurrent laryngeal palsy or hypocalcemia. Pathological examination revealed 9.63% incidence of malignancy. Surgery should be the treatment of choice for retrosternal goiters because there is a significant incidence of malignancy and an acceptable morbidity rate.

[Thyroidectomy in the ambulatory setting. A prospective study]. / Tiroidectomía en régimen de cirugía mayor ambulatoria. Estudio prospectivo.

INTRODUCTION: The recent reintroduction of local/regional anesthesia (LRA) for thyroidectomy has enabled this intervention to be performed in the outpatient setting. The aim of this study was to compare the results of thyroidectomy using two anesthesia methods. PATIENTS AND METHODS: One hundred twenty-five patients requiring thyroidectomy and who met the criteria for outpatient surgery were prospectively selected. The patients were offered LRA plus sedation; patients who did not accept this option were offered LRA combined with orotracheal intubation (CLRA). LRA was accepted by 58 patients and CLRA by 67. Age, sex, anesthesia risk, body mass index, and thyroid function were similar in both groups. Postoperative vomiting, pain at discharge, need for admission, postoperative morbidity, and complaints occurring at home were evaluated. RESULTS: Sixty-one bilateral and 64 unilateral thyroidectomies were performed, with no statistically significant difference between the two groups. There were no differences in surgical time, conversion to general anesthesia, intraoperative events, pathological diagnosis, or size and weight of the surgical specimen. The only difference between the two groups was the hour of discharge (LRA: 6.5 +/- 1.2 hours; CLRA: 7.76 +/- 2.07 hours; p = 0.0003). The admission rate was higher in the CLRA group (22.4%) than in the LRA group (8.62%); this difference was not statistically significant (p = 0.06) and the main cause was personal preference in patients in the CLRA group. Rates of postoperative morbidity, vomiting (7.2%) and nausea (6.4%), postoperative pain (2.47 +/- 1.85 on a visual analog scale), and analgesic requirements showed no differences between the two groups. One patient in the LRA group developed a noncompressive asymptomatic neck hematoma 36 hours after discharge. The patient was admitted for observation but did not require reoperation. Complaints occurring at home were minor. Satisfaction with the procedure was high or very high in 95% of the patients, with no differences between the two groups. CONCLUSIONS: In selected patients, outpatient thyroidectomy is safe and produces good patient satisfaction. Both anesthesia methods were valid, but postoperative recovery was faster with LRA than with CLRA.

[Hemithyroidectomy in a unilateral goiter: a valid therapeutic option. Review of the contralateral hemithyroid ten years after treatment]. / Hemitiroidectomía en el bocio unilateral: una opción terapéutica válida. Revisión del hemitiroides contralateral a los diez años del tratamiento.

INTRODUCTION: Nodular goiter (NG) is frequent among the general population and is considered a diffuse disease. Although NGs are rarely unilateral, they pose a dilemma in terms of the extent of the thyroidectomy. The aim of the present study was to evaluate the remaining thyroid in patients with NG compared with those with follicular adenoma who underwent hemithyroidectomy. PATIENTS AND METHODS: Patients who underwent surgery for unilateral NG with over 10 years of postoperative follow-up and normal findings on ultrasonography of the contralateral thyroid lobe were selected to form the study group (SG). Patients with follicular adenoma (with normal contralateral ultrasonography) who underwent hemithyroidectomy during the same period were selected to form the control group (CG). The selected patients underwent clinical, laboratory and ultrasound examinations. Both groups were compared statistically. No significant differences were found in age, gender, anesthetic risk, side, postoperative complications, length of hospital stay, or postoperative outcome. RESULTS: Less than 10% of the patients reported symptoms, and all symptoms were of little significance. Ultrasonographic nodules were found in the remaining thyroid lobe in 70% of patients in the SG and in 60% of those in the CG, with no statistically significant differences. The mean size of the largest nodule was 13.58 +/- 8.01 in the SG and 9.15 +/- 5.93 in the GC (p = 0.048). No differences were found in the anterior-posterior, transverse or longitudinal diameters of the remaining lobe. None of the patients underwent reintervention for nodular disease. CONCLUSIONS: After hemithyroidectomy, both groups of patients developed nodules in the remaining thyroid lobe, with no statistically significant differences. Hemithyroidectomy due to unilateral NG involves less risk to the patient and therefore we consider it to be a valid option. Long-term ultrasonographic follow-up seems advisable.

[Influence of superspecialization in endocrine surgery on outcomes of thyroidectomy in a general surgery department]. / Influencia de la superespecialización en cirugía endocrina en los resultados de la tiroidectomía en un servicio de cirugía general.

INTRODUCTION: The aim of this study was to analyze the influence of superspecialization in endocrine surgery on the standard of thyroidectomy, both before and after the creation of an endocrine surgery unit. PATIENTS AND METHODS: We performed a retrospective, comparative study of two 7-year periods. Three hundred forty thyroidectomies (G1) were performed before the instauration of the unit, and 583 were carried out afterwards (G2). The variables of age, gender, anesthesia risk, surgeon expertise (staff vs. resident), thyroid function, pathological features, intrathoracic growth, extent of the procedure (unilateral or bilateral), neck drainage, morbidity and mortality and length of hospital stay were compared. RESULTS: Age was older in G2 (G1: 44.7 +/- 15 years old, G2: 48.09 +/- 16.3 years old; p < 0.001). There were no differences (p NS) between the two groups in gender, anesthesia risk, thyroid function or rate of benign/malignant disease, but there was a greater frequency of nodular (p = 0.009) and intrathoracic goiters (p = 0.0004) in the second period. Residents operated on more patients in G2 (p < 0.001). Bilateral thyroidectomy was more frequent in G2 (G1: 155, G2: 315; p = 0.016) as was the rate of total thyroidectomy vs. subtotal or near total thyroidectomy (p < 0.001). Neck drainage also showed statistically significant differences (G1: 75.29%, G2: 12.18%; p < 0.001). No differences were found in overall postoperative complications. Although the procedures used were more aggressive in G2, similar rates of transient asymptomatic hypocalcemia (p NS) and transient symptomatic (p NS) and permanent hypocalcemia were found (G1: 1.17%, G2: 0.68%, p NS). The rate of transitory recurrent laryngeal nerve paralysis was similar with regard to patients (p NS) or nerves at risk (p NS). Permanent inferior laryngeal nerve paralysis was no different regarding patients (p = 0.083) but statistically significant differences were found with regard to nerves at risk (G1: 1.44%, G2: 0.33%; p = 0.04). One patient in G2 died (p NS). Length of hospital stay was shorter in G2 (p < 0.001) and more patients in this group stayed in hospital for only one day (p < 0.001) or were operated on in the outpatient setting (0 versus 71; p < 0.001). CONCLUSIONS: An endocrine surgical unit allows more efficient management of thyroidectomy. It increases the rate of total thyroidectomy, reduces definitive complications and improves training of resident surgeons. In addition, it reduces resource use and allows the development of programs of outpatient thyroid surgery.