Complicaciones de la tiroidectomía total / Complications of total Thyroidectomy

La tiroidectoimía total es realizada con relativa frecuencia para el tratamiento tanto de patología maligna como en casos específicos de patología benigna de la glándula tiroides. La cifra de complicaciones varía en las distintas series publicadas. El objetivo de este trabajo es determinar las características y el porcentaje de complicaciones postoperatorias de la tiroidectomía total....La tiroidectomía total, realizada por cirujanos entrenados en la especialidad, es un procedimiento seguro y con una morbilidad aceptable

Malignant meningioma of the scalp.

A nodule from the scalp of a 14-year-old boy was diagnosed by light and electron microscopy as a meningioma. There was no evidence of an intracranial lesion or involvement of the bone of the skull. The tumor was excised but recurred and metastasized to lung and chest wall.

Total reconstruction of the hypopharynx and cervical esophagus: a 20-year experience.

We have reviewed 145 patients who underwent 148 total reconstructions of the hypopharynx and cervical esophagus between 1970 and 1989. The types and numbers of reconstruction included 45 deltopectoral (DP) flaps, 35 musculocutaneous (MC) flaps, 19 colon interpositions, 23 gastric transpositions, and 26 free jejunal transfers. Median hospitalization was 51 days for DP flaps, 24 days for MC flaps, 28 days for colon, 30 days for gastric, and 14 days for jejunum. Median resumption of oral intake was 92 days for DP flaps, 19 days for MC flaps, 12 days for colon, 13 days for gastric, and 9 days for jejunum. Functional failure, defined as the inability to maintain adequate nutrition without tube feedings, was 40% for MC flaps, 42% for colon interposition, 17% for gastric transposition, and 20% for free jejunal transfer. Microvascular free jejunal transfer has become our method of choice for reconstruction of the hypopharynx and cervical esophagus. Gastric transposition is an alternative when resection of the thoracic esophagus is necessary.

Prognostic variables in parotid gland cancer.

We performed a retrospective review of 178 previously untreated patients with primary malignant neoplasms of the parotid gland treated at our institution between 1960 and 1985. Patients were followed up for a median of 7.5 years. Fifty-nine percent underwent surgery alone, and 40% underwent surgery and radiation therapy. Univariate and multivariate analyses established the prognostic influence of cancer stage, cancer grade, histologic type, presence of lymphatic invasion, perineural invasion, tumor size, extension beyond the parotid gland fascia, cervical adenopathy, quality of margins, and patient age and gender. Survival was influenced most by tumor grade, tumor size, presence of positive cervical lymph nodes, and facial nerve invasion. The risk of local-regional recurrence was most affected by cervical adenopathy and tumor size. Distant metastases were predicted by tumor grade and size. At last contact, 39% of patients were alive and free of disease, while 26% had died of the disease. We analyzed the optimal surgical procedure and the rationale for the selection of combined treatment.

Mucosal melanoma of the head and neck.

Forty-two patients with mucosal melanoma of the head and neck were treated at the M. D. Anderson Cancer Center from 1944-1989. Their records were evaluated regarding: location of the primary, stage of the disease at presentation, type of treatment, location of recurrences, and overall survival. These patients received the majority of their therapy at M. D. Anderson Cancer Center. The treatment consisted of surgery, radiotherapy, chemotherapy, immunotherapy, or a combination of these. The 5-year survival rate was 40%. Twenty-four of 27 patients who died with metastatic melanoma had local or regional disease concomitantly. Forty percent of patients were free of disease at 5 years; however, only 26% had long-term survival. Although the majority of patients eventually succumbed to their disease, local and regional control was obtained initially in 92% of the group. These data indicate that prolonged survival is possible with mucosal melanoma of the head and neck; however, recurrence or metastasis remain possible many years after the initial diagnosis.

Electrosurgical dissection to reduce blood loss in head and neck surgery.

We prospectively determined the intraoperative blood loss in 250 patients who underwent major head and neck surgical procedures over a 13-month period to demonstrate the efficacy of electrosurgical dissection for reducing blood loss and to determine those factors predictive of the need for blood replacement. Transfusions were required in 30 (12%) of the 250 patients, and a total of 66 units of packed red blood cells was administered. Two patients were transfused preoperatively, 16 patients intraoperatively, and 14 patients postoperatively. Factors predicting the necessity for blood replacement included the patient's preoperative hematocrit level, intraoperative blood loss, the duration and type of procedure, and the surgeon's level of experience. The principles of electrosurgical dissection are discussed.

Minor salivary gland tumors of the lip and buccal mucosa.

Between 1944 and 1985, 50 patients with minor salivary gland tumors of the lip and buccal mucosa were treated at M.D. Anderson Cancer Center: 19 with lip and 31 with buccal mucosa tumors. The male-to-female ratios were 2.8:1 for lip and 1:2.9 for the buccal mucosa tumors. Patient age at presentation ranged from 18 to 98 years with a median of 55 years. Treatment consisted of surgery alone for 28 patients, radiotherapy in 9 patients, and combined therapy for 13. Adenoid cystic carcinoma was the predominant histologic type, accounting for 21 (42%) tumors. Risk for recurrence was influenced by histology, the presence of perineural invasion, and the location of the primary tumor. Six patients developed recurrent disease; all six had adenoid cystic carcinoma. The therapeutic approach and the rationale for combined treatment of these neoplasms are discussed.

Wound prophylaxis with metronidazole in head and neck surgical oncology.

Anaerobic organisms are thought to be an important source of wound infection in head and neck oncologic surgery. Antibiotic prophylaxis consisting of agents specific for anaerobes combined with broad-spectrum agents that provide coverage for other well-recognized pathogens should be an effective combination regimen for this group of patients. We conducted a prospective, randomized study comparing the efficacy of prophylaxis using combination of metronidazole and cefazolin-designated group A, to prophylaxis using cefazolin alone-group B, for patients undergoing oncologic procedures of the head and neck. The rate of wound infection in the cefazolin-metronidazole group (158 patients) was 9.5%, compared with 18.6% in the cefazolin group (172 patients) (p = 0.03). Patients undergoing clean procedures had a 4.9% infection rate overall, compared with 17.9% for clean-contaminated procedures, and 33.3% for contaminated procedures. The average length of hospitalization was 20.7 days for patients who developed infections, compared with 8.9 days for patients without infection. Anaerobic organisms were cultured in 12 of 26 patients, ten of whom did not receive metronidazole. The lower rate of wound infection among patients who received metronidazole suggests that anaerobic organisms are an important source of wound infection in head and neck oncologic surgery. Chemoprophylaxis for these patients should, therefore, include specific anaerobic coverage in addition to the broad-spectrum agents that cover the more familiar aerobic organisms.

Continuous cisplatin (24-hour) and 5-fluorouracil (120-hour) infusion in recurrent head and neck squamous cell carcinoma.

Cisplatin and 5-fluorouracil (5-FU) has been reported to be one of the most active chemotherapeutic regimens in recurrent head and neck squamous cell carcinoma. In this study, 21 patients with recurrent head and neck squamous cell carcinoma received a combination of cisplatin given as a 100 mg/m2 continuous infusion over 24 hours and 5-FU given as a 1000 mg/m2 24-hour continuous infusion for 120 hours. Toxicity was evaluated in all patients, and response and survival were evaluated 20 patients. There were two complete remissions (10%) and three partial remissions (15%) for a major response of 25%. Overall survival for the complete responders was 79+ and 61+ weeks, respectively. Median survival for all patients was 36 weeks. Toxicity consisted of moderate to severe nausea and vomiting in 14 patients (66%), mucositis in 14 patients (66%), granulocytopenia of less than 1000/microliter in 11 patients (52%), objective peripheral neuropathy in one patient (4.7%), and nephrotoxocity in one patient (4.7%). We conclude that the efficacy of 24-hour cisplatin infusion and 120-hour 5-FU infusion in the treatment of recurrent head and neck squamous carcinoma is not superior to the efficacy of single agent trials reported in the literature.

The folded trapezius flap for through-and-through cheek defects.

A through-and-through defect of the cheek is a reconstructive challenge--functionally, technically, and cosmetically. The goal of reconstruction is to reliably and expediently bridge a poorly vascularized gap with healthy tissue. Since 1979, five patients have undergone folded trapezius flap reconstruction of the cheek. Despite a history of radiation in four of the five, all flaps have healed and complications have been minimal. The key to success seems to be careful attention to the venous drainage. This technique provides a one-stage reconstruction of a difficult surgical defect.

Pharyngeal carcinoma and natural killer cell activity.

An evaluation of natural killer cell activity was performed in 42 patients with pharyngeal carcinoma. Compared with age- and sex-matched control subjects, the cancer patients expressed significantly lower cytotoxicity against K562 target cells (68 +/- 8 lytic units versus 99 +/- 8 lytic units, p less than 0.01), with 52 percent of the patients expressing deficient activity (below 1 standard deviation of the mean activity of the control population). The probability of deficient activity was greater in these patients than observed in patients with cancer of other head and neck sites. Although natural killer cell activity was lower in patients who drank alcohol or had nodal metastases, no single clinical factor was predictive of deficient cytotoxic response. Prospective longitudinal evaluation (mean = 12 months) of these pharyngeal cancer patients demonstrated that deficient natural killer cell activity measured before treatment identified a population with a significantly increased risk for the development of distant metastases. Distant metastases developed in 7 of 18 patients (39 percent) with deficient natural killer cell activity. In contrast, none of the 16 patients with normal natural killer cell function had evidence of distant disease at last follow-up (p less than 0.01). Deficient natural killer cell activity exists in patients with pharyngeal cancer and is an independent marker for the subsequent development of distant metastases.

Cancer of the minor salivary glands of the larynx.

Minor salivary gland carcinomas of the larynx are rare and few large series have been reported from a single institution. Eighteen patients were treated for this disease at M.D. Anderson Hospital between 1944 and 1982. Of these, 8 patients had adenoid cystic carcinoma and 10 had poorly differentiated adenocarcinoma. Characteristically these tumors presented as predominantly submucosal masses in the supraglottic or subglottic regions. Surgery was the primary treatment modality used in most cases. The average 2 and 5 year survival rates for patients with this disease were 70.6 percent and 42.8 percent, respectively. Although the 5 year survival rates were comparable between the adenocarcinoma and cystic carcinoma groups, adenocarcinoma was a more rapidly lethal disease than adenoid cystic carcinoma. Salvage after recurrence was seldom possible, although local and regional control could usually be achieved. Distant metastases remain the principal cause of treatment failure.

Total reconstruction of the hypopharynx and cervical esophagus.

Patients with extensive circumferential tumors of the hypopharynx and those with carcinomas of the cervical esophagus usually require resection of a cylindrical segment of the upper digestive tube. These patients present similar difficulties of reconstruction and also share a very poor prognosis. At times, the same complicated technical effort is required for palliation and definitive cure alike. From 1970 through 1982 at the University of Texas-M.D. Anderson Hospital at Houston, 78 patients underwent complete resection of the hypopharynx (54 patients) or the cervical esophagus (24 patients) for advanced malignant tumors. Seventy-three tumors were squamous cell carcinomas, and the remaining 5 were cancers that originated in the salivary gland. These large tumors were not staged according to the TNM system, since they frequently involved two different anatomic structures and a precise clinical assessment was not always possible. The only criterion for inclusion of patients in this series was the need to replace the entire pharynx or cervical esophagus after removal of the cancer. Of the 78 patients, 64 received their entire treatment at our institution, and of this group, 44 patients had only one surgical procedure. All patients in the series had circumferential resection as the final surgical step at our institution. The types of repair used in this group of patients were a cutaneous flap or graft in 44 patients, a colon bypass in 16 patients, a lateral trapezius musculocutaneous flap in 9 patients, and a pectoralis major musculocutaneous flap in 6 patients. In three additional patients, the reconstruction was initially delayed for various reasons and was ultimately abandoned. Technical considerations and a detailed analysis of the complications and palliative value of each procedure are presented. The merit of these procedures is judged according to the quality and the length of the patient's survival. Although the degree of palliation varies considerably according to the technique used, the survival rates were similar in all cases, the average being 43 percent at 5 years after the first treatment attempt and 27 percent at 5 years after the surgical resection that required a complete circumferential reconstruction.

The treatment of differentiated carcinoma of the thyroid gland. Selective management?

Two hundred thirty patients with differentiated carcinoma of the thyroid gland received definitive treatment at the University of Texas M. D. Anderson Hospital and Tumor Institute (MDAH), Houston, from January 1960 through December 1975. Two thirds of these patients were women, and 127 of these female patients (55%) had not had any previous treatment. The mean follow-up period was 11.8 years. The vast majority of patients (80%) had mixed papillary and follicular cancers; 104 patients were seen with cervical metastases. Overall absolute survival was 72.6%. The prognosis was more favorable in the female patients and those persons who were treated solely at MDAH. In 4.4% of those patients treated with a total thyroidectomy, the cancer recurred locally. Of those whose operation was only a lobectomy, local recurrence developed in 10.7%. Several adverse prognostic factors were identified in this group of patients. This analysis would suggest the need for a more selective approach to the surgical treatment of this disease. Differentiated cancer of the thyroid gland affects a heterogeneous group of patients and also appears with varied clinical and anatomic manifestations.

Postoperative irradiation in malignant epithelial tumors of the parotid.

From 1954 through 1979, 77 patients with malignant tumors of the parotid gland were referred from the Department of Head and Neck Surgery for postoperative irradiation. The analysis has been made by grouping the patients according to the estimated amount of disease left after the surgical procedure and by the histological types. There were no local failures in the low-grade tumors, and there were 6 in the 63 patients with high-grade tumors. With gross residual disease or potential residual disease the patients received slightly higher doses than those without. Although there were only 6 failures in the various histological types, there was perhaps a trend to more failures in the adenocarcinomas. There was no difference in the failure rates in patients having had a total resection of the facial nerve or partial resection or no resection. The preferred treatment has been a combination of 20 MeV photons and 18 MeV electrons. Five neck failures were essentially a result of lack of elective irradiation of the neck. Severe complications appeared only in the patients irradiated either for gross residual disease or excision of a recurrence with a high risk of widespread microscopic residual disease.

Clinical effects of closed suction drainage on wound healing in patients with head and neck cancer.

This study was undertaken to determine what optimal levels of suction pressure were necessary to provide good drainage volume and obliteration of any dead space and also to determine the prevalence of clotting and complications secondary to various levels of suction pressure. The patients were grouped by their degree of nutritional depletion, prior radiation exposure, the types of surgical procedures undergone, and the results of tests using four levels of suction pressure. Three of the suction pressure values were obtained with a wall suction and one was obtained using a portable closed system. All wall suction pressure levels were certainly comparable with the portable unit. However, the portable unit provided continuous suction pressure when the patients were ambulatory and was not associated with any statistically significant increase in wound complications or equipment failure.