Health-Related Quality of Life and Cosmesis After Thyroidectomy: Long-Term Outcomes.

BACKGROUND: Health-related quality of life (HRQoL) after thyroidectomy has been recently reported with conflicting conclusions. In this study, we assess HRQoL and neck scar cosmesis of thyroid patients several years after thyroidectomy for benign and malignant pathology. METHODS: Three hundred and thirty patients who underwent thyroidectomy between 2000 and 2010 answered the SF-36 Health Survey and Patient Scar Assessment Questionnaire (PSAQ) in 2010 and at the end of 2018. Changes in the SF-36 and PSAQ scores were analyzed taking into account various demographic, surgical and medical characteristics of the patients. RESULTS: Patients reported worse SF-36 scores after 8.5 years, in scales of physical functioning (p < 0.001), social role functioning (p = 0.002), bodily pain (p = 0.001) and general health perceptions (p < 0.001). Interestingly enough, there were no significant changes in scales of physical role functioning (p = 0.304), mental health (p = 0.681), emotional role functioning (p = 0.903) and vitality (p = 0.121). Multivariate analysis showed that several chronic diseases were related to worse HRQoL scores. On the other hand, PSAQ appearance, symptoms and consciousness scores improved during this period (p < 0.001). CONCLUSIONS: In the long term, patients undergoing thyroidectomy do not show worse HRQoL outcomes in terms of mental health, emotional functioning and vitality, whereas scar cosmesis perception is improved. They show deteriorated outcomes in terms of physical, social functioning and bodily pain, which is mainly related to specific chronic diseases that are common to the aging person.

Classic Primary Hyperparathyroidism Versus Normocalcemic and Normohormonal Variants: Do They Really Differ?

BACKGROUND: Normocalcemic (NCpHPT) and normohormonal (NHpHPT) variants have been recognized primary hyperparathyroidism entities that pose serious challenges. We sought to define the differences among them in a series of surgically treated patients. PATIENTS AND METHODS: Between 2011 and 2015, 149 patients were enrolled into three groups: CpHPT (Ca > 10.2 mg/dL, PTH > 65 pg/mL), NCpHPT (normal Ca, PTH > 65 pg/mL) and NHpHPT (Ca > 10.2 mg/dL, normal PTH). Descriptive statistics and inter-group differences were computed, whereas multiple logistic/linear regression tests were used for further analysis. RESULTS: Of these patients 125 were female and 24 male, mean age 56.3 years (range 8-83). A total of 115 (77.2%) patients presented with CpHPT, 23 (15.4%) with NCpHPT and 11 (7.4%) with NHpHPT. MGD was found in 25 (16.8%) patients and SGD in 124 (83.2%); multivariate analysis failed to reveal statistically significant association of MGD with any pHPT variant (CpHPT 16.5% vs NCpHPT 21.7% vs NHpHPT 9.1%, p = 0.726). Conversely, NCpHPT patients exhibited statistically significant smaller adenoma weight (p = 0.023). Moreover, U/S in these patients had smaller positive predictive value (p = 0.278), whereas concordance between U/S and MIBI was also lower (p = 0.669). The utility of MIBI and U/S differed significantly (p < 0.001); more frequent use of U/S was observed for all groups. However, their predictive values did not differ significantly (p = 0.832). CONCLUSIONS: NCpHPT is more similar than different to CpHPT. NCpHPT constitutes the most challenging entity: it is associated with smaller adenoma weight, whereas U/S exhibited lower positive predictive value and lower concordance rate with MIBI. A trend for higher MGD presence in this group of patients was observed, though without statistical significance.

Intraoperative Neuromonitoring in Thyroid Surgery: A Systematic Review.

This study aimed to assess the efficacy of intraoperative neurophysiologic monitoring (IONM) in preventing recurrent laryngeal nerve palsy (RLNP) during thyroid surgery. When IONM results in false positives, it seeks to evaluate contributing factors. A systematic review was conducted gauging the predictive power of neuromonitoring in determining RLN function intraoperatively, its reductions of temporary and permanent RLNP rates, and surgeons' response to the technology. MEDLINE, EMBASE, and PubMed were searched for RLN monitoring in thyroid surgery following a set of inclusion/exclusion criteria. Seventeen studies comparing thyroid surgery with and without IONM were reviewed, including 30,926 patients. Selected studies were pooled to gage the predictive power. Mean specificity of IONM in identifying functional nerves was 90.24 % among 7366 nerves at risk (NAR). However, mean positive predictive power (PPP) was low, and both specificity and PPP varied substantially when stratified by risk levels. Among the pooled studies focusing on IONM efficacy-there were 44,575 NAR, of which (57.98 %) were operated on with IONM and 18,732 (42.02 %) without (control). The rates of overall RLNP per NAR were 3.18 and 3.83 % for the IONM group and control, respectively. There is no statistically significant difference between IONM and control, a conclusion supported by qualitative analysis from many individual studies. IONM is not recommended as the standard of care for thyroidectomies. Low PPP of IONM and complications associated with IONM-assisted thyroidectomies may be attributed to either the absence of a standardized negative-signal cutoff value or injury from intubation.

Multifocal Versus Solitary Papillary Thyroid Carcinoma.

BACKGROUND: Papillary Thyroid Carcinoma (PTC) which accounts for >85 % of all thyroid cancers in iodine-rich areas, appears either as a single tumor or as two or more, neoplastic foci within the thyroid gland (Multifocal PTC). We present the comparative results between solitary and MFC PTC. MATERIALS AND METHODS: Demographics, tumor characteristics (size, laterality, foci number, histologic subtype) and TNM staging were compared between solitary and MFPTC patients. The presence of lymphocytic or Hashimoto's thyroditis was also recorded. RESULTS: From January 2008 to December 2012, among 647 PTC patients, 241(37.2 %) had MFPTC 177 females (73.4 %) and 64 males (26.6 %), mean age 48.5 years (range 12-87). Mean number of tumor foci was 3.3 (range 2-26). MFPTC patients presented with more advanced T stage (28.2 vs. 18.7 %, p = 0.01) and more LN metastases (28.6 vs. 15.5 %, p < 0.001). Foci number correlates with male gender and LN metastases (p = 0.014 and p = 0.019, respectively). Central (N1a) or lateral (N1b) LN involvement correlates strongly with male gender (p  = 0.024) and younger age (p < 0.001). The follicular variant was the next most frequent histologic subtype associated with extremely rare LN metastases. CONCLUSION: MFPTC comprises a more aggressive form of papillary thyroid cancer since it is associated with more frequent N1a/ N1b disease and occurs more frequently in T3/T4 patients. MFPTC foci number correlates with male gender and LN metastases.

Posterior retroperitoneoscopic versus laparoscopic adrenalectomy in sporadic and MENIIA pheochromocytomas.

INTRODUCTION: Retroperitoneal adrenalectomy (PRA) comprises an alternative approach in the management of adrenal tumors that has been set as the treatment of choice in our Institution. We assess the impact of PRA the management of hereditary and sporadic pheochromocytomas comparing its outcomes to the laparoscopic technique, in a case-controlled setting. PATIENTS AND METHODS: From May 2008 to January 2013, 17 patients [5 males and 12 females, mean age: 51 yrs (range 26-73)] with pheochromocytomas underwent PRA. Demographics, tumor characteristics, operative time, complications, hospital stay, and postoperative pain (based on VAS score at days 1 and 3) were compared to 17 selected laparoscopic patient controls [7 males and 10 females, mean age 49 yrs (range 25-64)]. RESULTS: 17 patients, 11 with the sporadic form and 6 with MENIIA associated pheochromocytomas, comprised the retroperitoneoscopic group. 19 pheochromocytomas with a mean size 3.7 cm (range 1.7-7.0) at a mean operative time: 105.6 min (range 60-180) were accordingly excised. In the laparoscopic group, 13 patients had sporadic pheochromocytomas, whereas 4 patients had MENIIA syndrome. Mean tumor size of the laparoscopic series was 5.1 cm (range 1.7-8.5) at a mean operative time of 137 min (range 75-195). No mortality or conversions were encountered in both groups. No blood transfusions were needed. Mean visual analog scale pain scores were significantly lower for the retroperitoneoscopic group both on days 1 and 3 [0.94 (0-3) vs 4.15 (3-6), p < 0.001 and 0.06 (0-1) vs 3.5 (2-6) p < 0.001] respectively. Mean hospital stay for the patients of the retroperitoneoscopic group was significantly better than the laparoscopic group [(2.1 ± 0.24 days vs 40 ± 0.70 days) p < 0.001]. CONCLUSIONS: Retroperitoneoscopic adrenalectomy is associated with excellent clinical results in the management of sporadic and hereditary pheochromocytomas. Moreover, it appears to be superior to the laparoscopic approach, because it is faster and affords the patient with less pain and shorter hospital stay.

The effect of Greek herbal tea consumption on thyroid cancer: a case-control study.

BACKGROUND: Although in the last decade several studies have addressed the protective role of black and green tea on several diseases, including cancer, there are only few and controversial studies on the effect of tea on benign and malignant thyroid diseases. METHODS: An age and gender group matched case-control study conducted in Athens, Greece, was designed. 113 Greek patients with histologically confirmed thyroid cancer and 286 patients with benign thyroid diseases along with 138 healthy controls were interviewed with a pre-structured questionnaire in person by trained interviewers. RESULTS: An inverse association between chamomile tea consumption and benign/malignant thyroid diseases was found (P < 0.001). The odds of chamomile tea consumption, two to six times a week, after controlling for age, gender and BMI, were 0.30 (95% CI: 0.10-0.89) and 0.26 (95% CI: 0.12-0.5) for developing thyroid cancer and benign thyroid diseases, respectively when compared with not consumption. The duration of consumption was also inversely associated with the diseases. Thirty years of consumption significantly reduced the risk of thyroid cancer and benign thyroid diseases development by almost 80%. Similar, although weaker protective association, was found for sage and mountain tea. Adjustment for smoking, alcohol and coffee consumption did not alter the results. CONCLUSIONS: Our findings suggest for the first time that drinking herbal teas, especially chamomile, protects from thyroid cancer as well as other benign thyroid diseases.

Music meets surgery: two sides to the art of "healing".

BACKGROUND: The effect of music in the operating room is not fully understood. Through a systematic review the authors aim to give a conceptual presentation of the effect that music has on the pre- and postoperative course of surgical patients and on the effectiveness of the surgical work performed by both physicians and staff. METHODS: The search was conducted both on the basis of the Medical Subject Headings (MeSH) tree and as a text search using the Medline database (1946 to December 2011). The main search heading was "music in operating room" with the accessory keyword "surgery." The selection criteria specified the English language and the availability of abstracts or full-text articles. From 85 articles listed with the corresponding search, 28 were relevant and enrolled for the review. RESULTS: Patients exhibit lower anxiety levels before and during surgery when hearing music and a significant reduction in analgesia and sedation requirements has been observed. Music was found to reduce the heart rate, blood pressure, and muscle effort of surgeons while at the same time increasing the accuracy of surgical tasks. Surgeons who played a musical instrument were found to perform surgical tasks faster. On the other hand, anesthesiologists report that music is associated with difficulties communicating and offering a stable level of sedation. The most appropriate music in the operating room seems to be the classical type. CONCLUSIONS: Music in the operating room can have beneficial effects on patients by decreasing stress, anxiety, and the demand for analgesic and anesthetic drugs. For the surgical staff, music is considered to be distracting. For the surgeon, music can increase the speed and accuracy of task performance.

Patient attitudes toward transaxillary robot-assisted thyroidectomy.

BACKGROUND: The transaxillary robot-assisted technique constitutes an acceptable treatment option for patients requiring thyroidectomy. However, patients' attitudes toward this new technique have not yet been analyzed. METHODS: A sample of 596 randomly selected patients who underwent thyroidectomy between January 2000 and March 2010 was assessed. We evaluated patients' attitudes toward transaxillary robot-assisted thyroidectomy, taking into account the validated Patient Scar Assessment Questionnaire, the SF-36 Health Survey Questionnaire, and 11 sociodemographic and surgical patient characteristics. RESULTS: Only 11.6 % of the patients would prefer to have been treated with the transaxillary method. Most patients had concerns that it would be a more painful procedure (39.2 %), and they expressed satisfaction with the existing esthetic outcome (29.1 %); other concerns were that the robotic approach would be of longer duration (25.4 %) and at higher cost (15.5 %). Nevertheless, the worse the appearance of the neck scar the more preferable is the new method (p = 0.025), a result that holds true irrespective of patients' physical health, the invasive procedure attained (conventional or minimal), and the presence of postoperative complications, among other characteristics. Patients diagnosed with a benign or uncertain neoplasm (p = 0.022) and younger patients (p = 0.003) held a more positive view of the new method. CONCLUSIONS: Patients who have undergone conventional thyroidectomy via the usual neck incision do not express a preference for the transaxillary method. The reasons given include various perceived disadvantages of the robotic procedure (increased pain, longer operative times, and higher cost). Younger patients, patients with poor appearance of their neck scar, and patients with benign thyroid pathology seem to hold a more positive attitude toward the robotic approach.

Evaluation of the effect of Mozart music on pain and respiratory rate after thyroidectomy.

PURPOSE: Pain has always been a major concern in postoperative care. The aim of this study was to assess the impact of Mozart music on postoperative pain and physiological parameters in patients who underwent total thyroidectomy. METHODS: Patients scheduled for total thyroidectomy were randomly assigned to a music group or a control group. The music intervention was applied immediately after surgery, whereas the control group received only usual care. Measurements of pain perception and physiological parameters were performed before, during, and after the music intervention in the music group and at the same time points in the control group. Pain was evaluated with the visual analog scale. RESULTS: In a study population of 50 patients, a higher rate of decrease in pain was observed in the music group after the first 10 min of the music intervention compared to the control group (estimate = - 1.329; 95% CI [- 2.490, - 0.169]). Music also reduced respiratory rate by 1.31 rates/min more in the music group than in the control group at every assessment point (95% CI [- 2.171, - 0.451]). Changes in the remaining physiological parameters were not statistically significant between the music and the control group and within each group. CONCLUSION: This study suggests that the use of music during immediate postoperative care after thyroidectomy could accelerate pain relief and lead to a greater decline of respiratory rate compared to that achieved in usual care. TRIAL REGISTRATION NUMBER: NCT04699084, 30/12/2020.

Gasless transaxillary robotic versus endoscopic thyroidectomy: exploring the frontiers of scarless thyroidectomy through a preliminary comparison study.

BACKGROUND: Robot-assisted thyroidectomy has been associated with lengthy operative times due to fussy robot preparation and docking maneuvers. The authors propose an endoscopic transaxillary approach using a novel platform, comparing its results with those of the former approach. METHODS: Eight patients (6 females and 2 males; mean age, 38.8 years) with a favorable body habitus (mean body mass index [BMI], 23.4 kg/m(2)) underwent robot-assisted thyroidectomy through a gasless transaxillary approach using the da Vinci S system. Another four female patients (mean age, 31 years) underwent an endoscopic procedure. The patients' demographic data, operative time, complications, hospital stay, postoperative visual analog pain score (VAPS), and costs were compared. RESULTS: Three lobectomies, two near-total thyroidectomies, two total thyroidectomies, and one total thyroidectomy with lateral lymph node dissection were performed in the robotic group. Two lobectomies and two near total thyroidectomies were performed in the endoscopic group. The mean diameter of the largest nodule in the robotic series was 26.5 mm compared with 42.5 mm in the endoscopic group. The mean total operative time was 211 min for the robotic series compared with 160 min for the endoscopic series. There was one temporary recurrent laryngeal nerve paralysis in the robotic group. Two patients in the robotic group exhibited transient symptomatic hypocalcemia compared with one patient in the endoscopic group. Hypoesthesia in the flap dissection area was experienced by three patients in the robotic group and two patients of the endoscopic group. The mean hospital stay was 1.5 days (range 1-3 days) in both groups. The postoperative VAPS also was similar in the two groups (3.1 vs 2.8). The cost was significantly less for the endoscopic approach. CONCLUSIONS: The preliminary comparison in this study shows that both approaches are safe and feasible, with similar results. They also afford an excellent view of the critical neck anatomy that allows precise tissue handling and dissection. However, the endoscopic approach results in a significantly faster and more convenient thyroidectomy.

Impact of posterior retroperitoneoscopic adrenalectomy in a tertiary care center: a paradigm shift.

BACKGROUND: Posterior retroperitoneoscopic adrenalectomy has substituted its anterior laparoscopic counterpart as the treatment of choice in the management of adrenal tumors at the authors' institution. The authors present their comparative results between these operative techniques, demonstrating the reasons for this change. METHODS: From May 2008 to September 2010, 30 patients underwent posterior retroperitoneoscopic adrenalectomy. Operative time, complications, hospital stay, postoperative pain, and cost were compared with those of 30 selected laparoscopic control subjects treated from 2005 to 2010. Statistical analysis was based on Chi-square, the Mann-Whitney U test, the independent-samples t-test, and the Wilcoxon matched pairs test, as appropriate. RESULTS: The median tumor size was 3.8 cm (range, 1.5-8.0 cm) in the retroperitoneoscopic group and 4.9 cm (range, 2.4-8.0 cm) in the laparoscopic group. The median operative time was similar between the two groups (90.0 min; range, 60-165 min vs. 77.5 min; range, 55-120 min; P = 0.138). It was, however, significantly reduced after the 20th case (97.5 min; range, 80-165 min vs. 70 min; range, 60-110 min; P < 0.001) in the retroperitoneoscopic group. The median visual analog pain scores were significantly lower in the retroperitoneoscopic group on both the first and the third postoperative days, respectively (1; range, 0-1 vs. 4; range, 3-6; P < 0.001 and 0; range, 0-1 vs. 3; range, 2-6; P < 0.001). The median postoperative hospital stay also was shorter in the retroperitoneoscopic group (2 days; range, 2-3 days vs. 4 days; range, 3-6 days; P < 0.001). The cost of the posterior approach was significantly less than that of the laparoscopic technique (P < 0.001). CONCLUSIONS: Posterior retroperitoneoscopic adrenalectomy compared with laparoscopic adrenalectomy was safe, fast, and vastly superior in terms of postoperative pain and hospital stay in this series. Because of the ability to reproduce such excellent operative results, the impressive patient recovery, and the significantly reduced operative cost, the authors suggest that the retroperitoneoscopic approach should become the method of choice in minimally invasive adrenal surgery.

Primary pigmented nodular adrenocortical disease: a case report in a 7-year-old girl.

Primary pigmented nodular adrenocortical disease (PPNAD) is a rare cause of Cushing syndrome in children, often occurring in association with Carney complex. We report a case of Cushing syndrome due to isolated non-familial PPNAD. The child presented with typical clinical characteristics, growth retardation and obesity. Liddle's test was positive but micronodular appearance was not evident on CT scan and MRI; selective venous sampling revealed higher cortisol concentrations in the right adrenal vein. The patient underwent a laparoscopic right adrenalectomy. Postoperatively, hypercortisolism signs disappeared but after the second year a slight increase in urinary cortisol was noted and the patient developed osteopenia. Although significant catch-up growth occurred postoperatively, height did not normalize over the next 2 years. When she entered puberty, treatment with a luteinizing-hormone-releasing hormone agonist was initiated and growth hormone was added. Almost 5 years later a left adrenalectomy was also performed. Thereafter, complete disease remission was observed, the patient's growth accelerated and her osteopenia reversed.

Efficacy and safety of radiofrequency ablation in the treatment of low-risk papillary thyroid carcinoma: a review.

Ultrasound-guided radiofrequency ablation (RFA) has recently been used for the treatment of thyroid carcinomas. In this study, we aimed to evaluate the efficacy and safety of RFA for treating low-risk papillary thyroid carcinomas (PTCs). We searched the MEDLINE and the SCOPUS databases up to December 29, 2020, for studies assessing the efficacy and safety of RFA in the management of low-risk PTCs. Data on volume reduction ratio (VRR), complete disappearance, carcinoma recurrence, and complication frequency were collected. Thirteen studies with a total of 1389 patients and 1422 tumors were included in the synthesis of this study. Mean VRR varied between 47.8 and 100%, with most studies reporting a ratio of 98.5-100%. The ratio of complete disappearance ranged between 33.7 and 100%, although studies with a prolonged follow-up period reported a frequency of 56-100%. The tumor progression/recurrence frequency was 0-4.5%. Complications occurred in 45 patients (3.2%). Mild-moderate pain and cervical discomfort were the most common complications and no life-threatening complications were reported. Based on these data, we suggest that ultrasound-guided RFA can serve as an efficacious and safe alternative for the treatment of low-risk PTC in patients who are unable or unwilling to receive surgical therapy.

Long-standing hypercalcemia in a 78-years old woman.

A 78 years-old woman was found with worsening hypercalcemia, osteopenia and memory loss during the past 2 years. Multiple, repeated imaging studies failed to reveal the etiology of the primary hyperparathyroidism. Bilateral neck exploration revealed a 4.5 × 2.3 cm right superior parathyroid adenoma in an ectopic position.

Anthropometric characteristics and mammographic parenchymal patterns in post-menopausal women: a population-based study in Northern Greece.

OBJECTIVE: To examine the effects of various anthropometric determinants on mammographic patterns at postmenopausal ages, accounting for reproductive differences. METHODS: Mammograms from 900 post-menopausal women classified into high- (P2/DY) versus low-density (N1/P1) groups using the Wolfe criteria were associated with changes in body figure, reported and measured height and weight, body mass index, hip, waist and chest circumferences, chest/hip ratio, waist/hip ratio (WHR), breast size, and leg length. Reproductive factors included ages at menarche, first pregnancy and menopause, years since menopause, parity, and breast feeding duration. The study was nested within a large cross-sectional survey of a population-based breast cancer screening program in Northern Greece. RESULTS: Increasing chest circumference (p = 0.002), change in body build during adulthood to a heavier profile (p = 0.04), and heavy somatotype at age 18 (p = 0.007) were the anthropometric determinants significantly associated with low-density mammographic patterns. CONCLUSIONS: Chest circumference as a measure of upper body fat adiposity appears to be a stronger determinant of mammographic patterns than body fat distribution (measured as WHR). A heavy body build in adulthood is associated with decreased mammographic density. Further studies are necessary to confirm our results, ideally prospective cohorts, looking at the effect of anthropometric determinants on mammographic pattern changes over time and breast cancer risk.

Reinforcement does not necessarily reduce the rate of staple line leaks after sleeve gastrectomy. A review of the literature and clinical experiences.

BACKGROUND: Laparoscopic sleeve gastrectomy (SG) is an accepted bariatric procedure, with an advantaged by a low complication rate. A feared complication is stapler line leak. Buttressing materials have been suggested as a means of reducing staple line leak rates. We analyzed the leak rates from published series to help in demonstrating a potential cause. METHODS: The study was institutional review board (IRB) approved retrospectively. A Medline search using the key words sleeve gastrectomy and bariatric surgery obtained 54 articles. Attention was restricted to 11 articles written in English that listed numbers of gastrectomy procedures and leaks. Poisson regression assessed the possibility that patients who received buttressing materials had a reduced rate of leaks. RESULTS: Thirty-five patients were evaluated from Greece (15) and the United States (20); two patients developed staple line leaks that appeared to be related to problems associated with buttressing materials. Eleven prior studies and the present series yielded 1,589 procedures, 15 (0.94%) of which were complicated by leaks. The leak rate for patients who were known to have received reinforcement of some sort was 1.45 (95% confidence interval 0.41-3.43) times that for other patients. To detect a difference between 1% and 0.5% as statistically significant in 80% of cases, with a two tailed test and alpha set at 0.05, would require 9,346 procedures. CONCLUSIONS: There is no reason to believe, at this point, that reduction in leak rates occur because reinforcement is used. Because the leak rate is small, the routine reinforcement of the staple line after sleeve gastrectomy is questionable at best, although a decrease in hemorrhage has been reported.