Ten-Year Follow-Up of a Randomized Clinical Trial of Total Thyroidectomy Versus Dunhill Operation Versus Bilateral Subtotal Thyroidectomy for Multinodular Non-toxic Goiter.

BACKGROUND: The aim of this study was to validate in a 10-year follow-up the initial outcomes of various thyroid resection methods for multinodular non-toxic goiter (MNG) reported in World J Surg 2010;34:1203-13. MATERIALS AND METHODS: Six hundred consenting patients with MNG were randomized to three groups of 200 patients each: total thyroidectomy (TT), Dunhill operation (DO), bilateral subtotal thyroidectomy (BST). Obligatory follow-up period of 60 months was extended up to 120 months for all the consenting patients. The primary outcome measure was the prevalence of recurrent goiter and need for revision thyroid surgery. The secondary outcome measure was the cumulative postoperative and post-revision morbidity rate. RESULTS: The primary outcomes were twice as inferior at 10 years when compared to 5-year results for DO and BST, but not for TT. Recurrent goiter was found at 10 years in 1 (0.6%) TT versus 15 (8.6%) DO versus 39 (22.4%) BST (p < 0.001), and revision thyroidectomy was necessary in 1 (0.6%) TT versus 5 (2.8%) DO versus 14 (8.0%) BST patients (p < 0.001). Any permanent morbidity at 10 years was present in 5 (2.8%) TT patients following initial surgery versus 7 (4.0%) DO and 10 (5.7%) BST patients following initial and revision thyroidectomy (nonsignificant differences). At 10 years, 23 (11.5%) TT versus 25 (12.5%) DO versus 26 (13.0%) BST patients were lost to follow-up. CONCLUSIONS: Total thyroidectomy can be considered the preferred surgical approach for patients with MNG, as it abolishes the risk of goiter recurrence and need for future revision thyroidectomy when compared to more limited thyroid resections, whereas the prevalence of permanent morbidity is not increased at experienced hands. REGISTRATION NUMBER: NCT00946894 ( http://www.clinicaltrials.gov ).

The Overwhelming Majority but not All Motor Fibers of the Bifid Recurrent Laryngeal Nerve are Located in the Anterior Extralaryngeal Branch.

BACKGROUND: Few small studies reported that motor fibers are located exclusively in the anterior branch of the bifid recurrent laryngeal nerve (RLN). The aim of this study was to investigate the location of the motor fibers to the intrinsic muscles of the larynx among the bifid RLNs, and assess the prevalence of RLN injury with respect to nerve branching in a pragmatic trial. METHODS: This was a prospective cohort study of 1250 patients who underwent total thyroidectomy with intraoperative neural monitoring. The primary outcome was the position of the motor fibers in the bifid nerves. Adduction of the vocal folds was detected by the endotracheal tube electromyography and abduction by finger palpation of muscle contraction in the posterior cricoarytenoid. The secondary outcomes were the prevalence of the RLN branching and the prevalence of RLN injury in bifid versus non-bifid nerves. RESULTS: The bifid RLNs were identified in 613/2500 (24.5%) nerves at risk, including 92 (7.4%) patients with bilateral bifurcations. The motor fibers were present exclusively in the anterior branch in 605/613 (98.7%) bifid nerves, and in both the RLN branches in 8/613 (1.3%) bifid nerves. Prevalence of RLN injury was 5.2 versus 1.6% for the bifid versus non-bifid nerves (p < 0.001), odds ratio 2.98 (95% confidence interval 1.79-4.95; p < 0.001). CONCLUSIONS: The motor fibers of the RLN are located in the anterior extralaryngeal branch in the vast majority of but not in all patients. In rare cases, the motor fibers for adduction or abduction are located in the posterior branch of the RLN. As the bifid nerves are more prone to injury than non-branched nerves, meticulous dissection is recommended to assure preservation of all the branches of the RLN during thyroidectomy.

Trends in Prevalence of Thyroid Cancer Over Three Decades: A Retrospective Cohort Study of 17,526 Surgical Patients.

INTRODUCTION: Thyroid cancer (TC) incidence has been increasing in recent years. The aim of this study was to investigate our institution-based estimates of operative volumes for TC over the last three decades. MATERIALS AND METHODS: This was a retrospective cohort study of patients undergoing thyroid surgery at our institution. Patient characteristics were reviewed in three subgroups: Group I (treated in 1981-1986), Group II (treated in 1987-2002), and Group III (treated in 2003-2012). RESULTS: TC was diagnosed in 1578/17,526 (9.0%) thyroid operations. Incidence of TC increased from 3.7% in Group I to 10.4% in Group III (p < 0.001). Incidence of papillary TC increased form 40.6% in Group I to 81.3% in Group III (p < 0.001). In the latter group, 23.5% of all papillary TCs were diagnosed in patients with Hashimoto's disease. Meanwhile, incidence of anaplastic TC decreased from 16.2% in Group I to 2.1% in Group III patients (p < 0.001). pT1 tumors were diagnosed in 8.1% Group I and 54.8% Group III (p < 0.001), whereas pT4 tumors were identified in 40.5% Group I, 2.4% Group II, and 0.84% Group III subjects (p < 0.001). pT3 tumors were found in 51.6% Group I, whereas multifocal papillary TCs were found in 15.7% Group III patients, the latter with a higher prevalence of pN1 stage (p < 0.001). CONCLUSIONS: The following trends in surgical volume for TC were identified throughout the study period: a fivefold increase of thyroid operations for TC, a threefold increase in incidence of papillary TC, and an eightfold decrease in incidence of anaplastic TC. It is of interest that a significant increase in incidence of multifocal papillary TC in young female patients with Hashimoto's disease was found over time.

Subtotal parathyroidectomy for secondary renal hyperparathyroidism: a 20-year surgical outcome study.

AIM: The aim of this study was to evaluate the outcomes of surgery for patients with secondary renal hyperparathyroidism (rHPT). METHODS: This is a retrospective cohort study. Our institutional database was searched for eligible patients treated in 1995-2014. The inclusion criterion was initial parathyroidectomy for rHPT. Clinical and follow-up data were analyzed to estimate the cure rate (primary outcome), and morbidity (secondary outcome). RESULTS: The study group comprised 297 patients (154 females, age 44.5 ± 13.7 years, follow-up 24.6 ± 10.5 months), including 268 (90.2 %) patients who had underwent subtotal parathyroidectomy, and 29 (9.8 %) who had had incomplete parathyroidectomy. Intraoperative iPTH assay was utilized in 207 (69.7 %) explorations. Persistent rHPT occurred in 12/268 (4.5 %) patients after subtotal parathyroidectomy and 5/29 (17.2 %) subjects after incomplete parathyroidectomy (p = 0.005). The patients operated on with intraoperative iPTH assay had a higher cure rate than non-monitored individuals, 201/207 (97.1 %) vs. 79/90 (87.8 %), respectively (p = 0.001). In-hospital mortality occurred in 1/297 (0.3 %) patient. The hungry bone syndrome occurred in 84/268 (31.3 %) patients after subtotal parathyroidectomy and 2/29 (6.9 %) subjects after incomplete parathyroidectomy (p = 0.006). Transient recurrent laryngeal nerve paresis occurred in 14/594 (2.4 %) and permanent in 5/594 (0.8 %) nerves at risk. CONCLUSIONS: Subtotal parathyroidectomy is a safe and efficacious treatment for patients with rHPT. Utilization of intraoperative iPTH assay can guide surgical exploration and improve the cure rate.

Randomized clinical trial of posterior retroperitoneoscopic adrenalectomy versus lateral transperitoneal laparoscopic adrenalectomy with a 5-year follow-up.

OBJECTIVE: To test if posterior retroperitoneoscopic adrenalectomy (PRA) is superior to lateral transperitoneal laparoscopic adrenalectomy (LTLA). BACKGROUND: Most popular LTLA has been recently challenged by an increasing popularity of PRA, which is believed by many surgeons (not evidence-based) as superior to LTLA in the treatment of small and benign adrenal tumors. METHODS: Participants were assigned randomly to PRA or LTLA and followed for 5 years after surgery. The primary endpoint was the duration of surgery. Secondary endpoints were blood loss, conversion rate, postoperative recovery, morbidity, and costs. RESULTS: Sixty-five patients were included, of whom 61 (PRA 30, LTLA 31) completed the 5-year follow-up. The following differences were identified in favor of PRA vs LTLA: shorter duration of surgery (50.8 vs 77.3 minutes), lower intraoperative blood loss (52.7 vs 97.8 mL), diminished pain intensity within 48 hours postoperatively, lower prevalence of shoulder-tip pain (3.0% vs 37.5%), shorter time to oral intake (4.4 vs 7.3 hours), shorter time to ambulation (6.1 vs 11.5 hours), shorter length of hospital stay, and lower cost (1728 € vs 2315 €), respectively (P<0.001 for all). No differences were noted in conversion rate or morbidity except for herniation occurring more often after LTLA than PRA (16.1% vs 0%, P=0.022) and need for hernia repair (12.9% vs 0%, P=0.050), respectively. CONCLUSIONS: Both approaches were equally safe. However, outcomes of PRA operations were superior to LTLA in terms of shorter surgery duration, lower blood loss, lower postoperative pain, faster recovery, improved cost-effectiveness, and abolished risk of surgical access site herniation. REGISTRATION NUMBER: NCT01959711 (http://www.clinicaltrials.gov).

Intraoperative nerve monitoring can reduce prevalence of recurrent laryngeal nerve injury in thyroid reoperations: results of a retrospective cohort study.

BACKGROUND: The prevalence of recurrent laryngeal nerve (RLN) injury is higher in repeat than in primary thyroid operations. The use of intraoperative nerve monitoring (IONM) as an aid in dissection of the scar tissue is believed to minimize the risk of nerve injury. The aim of this study was to examine whether the use of IONM in thyroid reoperations can reduce the prevalence of RLN injury. METHODS: This was a retrospective cohort study of patients who underwent thyroid reoperations with IONM versus with RLN visualization, but without IONM. The database of thyroid surgery was searched for eligible patients (treated in the years 1993-2012). The primary outcomes were transient and permanent RLN injury. Laryngoscopy was used to evaluate and follow RLN injury. RESULTS: The study group comprised 854 patients (139 men, 715 women) operated for recurrent goiter (n = 576), recurrent hyperthyroidism (n = 36), completion thyroidectomy for cancer (n = 194) or recurrent thyroid cancer (n = 48), including 472 bilateral and 382 unilateral reoperations; 1,326 nerves at risk (NAR). A group of 306 patients (500 NAR) underwent reoperations with IONM and 548 patients (826 NAR) had reoperations with RLN visualization, but without IONM. Transient and permanent RLN injuries were found respectively in 13 (2.6 %) and seven (1.4 %) nerves with IONM versus 52 (6.3 %) and 20 (2.4 %) nerves without IONM (p = 0.003 and p = 0.202, respectively). CONCLUSIONS: IONM decreased the incidence of transient RLN paresis in repeat thyroid operations compared with nerve visualization alone. The prevalence of permanent RLN injury tended to be lower in thyroid reoperations with IONM, but statistical validation of the observed differences requires a sample size of 920 NAR per arm.

Nodal recurrence in the lateral neck after total thyroidectomy with prophylactic central neck dissection for papillary thyroid cancer.

PURPOSE: The aim of this study was to examine risk factors for nodal recurrence in the lateral neck (NRLN) in patients with papillary thyroid cancer (PTC) who underwent total thyroidectomy with prophylactic central neck dissection (TT + pCND). METHODS: This was a retrospective cohort study of patients with PTC who underwent TT + pCND. Data of all patients treated over a 10-year period (between 1998 and 2007) were analysed. The primary outcome was prevalence of NRLN within the 5-year follow-up after initial surgery. Predictors of NRLN were determined in the univariable and multivariable analysis. RESULTS: Of 760 patients with PTC included in this study, 44 (6.0 %) developed NRLN. In the univariable analysis, the following factors were identified to be associated with an increased risk of NRLN: positive/negative lymph node ratio ≥0.3 (odds ratio (OR) 14.50, 95 % confidence interval (CI) 7.21 to 29.13; p < 0.001), central lymph node metastases (OR 7.47, 95 % CI 3.63 to 15.38; p < 0.001), number of level VI lymph nodes <6 in the specimen (OR 2.88, 95 % CI 1.21 to 6.83; p = 0.016), extension through the thyroid capsule (OR 2.55, 95 % CI 1.21 to 5.37; p = 0.013), localization of the tumour within the upper third of the thyroid lobe (OR 2.35, 95 % CI 1.27 to 4.34; p = 0.006) and multifocal lesions (OR 1.85, 95 % CI 1.01 to 3.41; p = 0.048). CONCLUSIONS: Central lymph node metastases together with positive to negative lymph node ratio ≥0.3 represent the strongest independent prognostic factors for the PTC recurrence in the lateral neck.

Risk of lymph node metastases in multifocal papillary thyroid cancer associated with Hashimoto's thyroiditis.

AIMS: The aim of this study was to evaluate the risk factors of lymph nodes metastases (LNM) in patients with papillary thyroid cancer (PTC) and coexisting Hashimoto's thyroiditis (HT). PATIENTS AND METHODS: This was a retrospective cohort study of patients with PTC and HT who had undergone total thyroidectomy (TT) with central neck dissection (CND) over an 11-year period (between 2002 and 2012). Pathological reports of all eligible patients were reviewed. Multivariable analysis was performed to identify risk factors of LNM. RESULTS: During the study period, PTC was diagnosed in 130 patients with HT who had undergone TT with CND (F/M ratio = 110:20; median age, 52.4 ± 12.7 years). Multifocal lesions were observed in 28 (21.5 %) patients. LNM were identified in 25 of 28 (89.3 %) patients with multifocal PTC and HT versus 69 of 102 (67.5 %) patients with a solitary focus of PTC and HT (p = 0.023). In multivariable analysis, multifocal disease was identified as an independent risk factor for LNM (odds ratio, 3.99; 95 % confidence interval, 1.12 to 14.15; p = 0.033). CONCLUSIONS: Multifocal PTC in patients with HT is associated with an increased risk of LNM. Nevertheless, the clinical importance of this finding needs to be validated in well-designed prospective studies.

Clinical validation of NerveTrend versus conventional i-IONM mode of NIM Vital in prevention of recurrent laryngeal nerve events during bilateral thyroid surgery: A randomized controlled trial.

BACKGROUND: The aim of this study was to test the hypothesis that use of NerveTrend™ mode of intermittent neuromonitoring (i-IONM) during thyroidectomy may identify and prevent impending recurrent laryngeal nerve (RLN) injury. METHODS: A randomized clinical trial. The primary outcome was prevalence of RLN injury on postoperative day 1. In NerveTrend™ group the i-IONM stimulator was used for trending of amplitude and latency changes from initial vagal electromyographic baseline to tailor surgical strategy. RESULTS: Some 264 patients were randomized into the intervention versus the control group, 132 patients each. RLN injury was found on postoperative day 1 in 5/264 (1.89%) nerves at risk (NAR) versus 12/258 (4.65%) NAR whereas staged thyroidectomy was used in 0/132 (0.00%) versus 6/132 (4.54%) patients (p = 0.067 and p = 0.029, respectively). CONCLUSION: The use of NerveTrend™ mode resulted in tendency towards reduced RLN injury on postoperative day 1 and significant decrease of need for a staged thyroidectomy.

Coexistence of papillary thyroid cancer with Hashimoto thyroiditis.

AIMS: Conflicting data have been reported with regard to Hashimoto thyroiditis (HT) and risk of malignancy. The aim of this study was to evaluate coexistence of papillary thyroid cancer (PTC) with HT. PATIENTS AND METHODS: This is a retrospective cohort study in which HT was diagnosed in 452 (F/M ratio = 405:47, median age 53.5 ± 12.1 years) of 7,545 patients qualified for thyroidectomy throughout the years 2002 to 2010. Pathological reports were reviewed to identify prevalence of PTC in HT vs. non-HT patients. RESULTS: PTC was diagnosed in 106 of 452 (23.5 %) HT patients vs. 530 of 7,093 (7.5 %) non-HT patients (p < 0.001). Metastases to level VI lymph nodes were observed in 81 of 106 (76.4 %) patients with PTC in HT vs. 121 of 530 (22.8 %) patients with PTC in non-HT disease (p < 0.001). CONCLUSIONS: HT was associated with a threefold increase of PTC prevalence as compared to other non-HT thyroid diseases, and the spread of PTC to level VI lymph nodes was four times more frequent in HT than in non-HT patients.

[Staging of thyroid cancer--comparison of cases diagnosed preoperatively versus incidentally after surgery for benign goiter]. / Porównanie stopnia zaawansowania raka tarczycy rozpoznanego przedoperacyjnie i przypadkowo po operacji wola nienowotworowego.

INTRODUCTION: The aim of this study was to compare staging of incidentally diagnosed thyroid cancer (TC) to staging of preoperatively suspected TC. METHODS: This was a retrospective study of 224 patients who underwent surgery for primary TC between 2009 and 2011. Clinical and pathological data included in the TNM and AJCC staging system (7th edition, 2010) were analysed. Staging of incidentally diagnosed TC was compared to staging of preoperatively suspected TC. RESULTS: Suspicion of TC was made before surgery in 57.6% patients, and in 42.4% patients TC was diagnosed postoperatively. Papillary TC was predominant and followed by follicular TC, which were suspected in 88.4% and 4.7% of patients before surgery, and were diagnosed in 77.9% and 16.8% of patients postoperatively (p=0.035 and p<0.001, respectively). Preoperatively diagnosed TC was predominant in patients below 45 years of age (64.3% vs. 25.3%; p<0.001), was at lower stage at the diagnosis (according to AJCC in stage I : 42.6% vs. 67.4%; p<0.001; in stage II: 6.2% vs. 12.6%; p=0.095; in stage III: 38.0% vs. 16.8%; p<0.001; in stage IV: 13.2% vs. 3.2%; p=0.009, respectively), and it was more common multicentric (29.5% vs. 9.5%; p<0.001) than incidental TC. CONCLUSIONS: Approximately 40% of cases of TC is diagnosed incidentally based on postoperative pathology report. Incidental TC is predominant below age 45 years, is revealed with early-stage more common than TC diagnosed preoperatively, and occurs multicentric less frequently.

Recommendations for modern perioperative care for elective surgery: consensus of panel of exerts.

INTRODUCTION: Correct surgical technique and perioperative care are two factors that can reduce the number of complications, improve treatment outcomes and shorten the length of hospital stay. The introduction of enhanced recovery protocols has changed the approach to patient care in some centers. However, there are significant differences among centers, and in some the standard of care has remained unchanged. AIM: the goal of the panel was to develop recommendations for modern perioperative care in accordance with current medical knowledge in order to reduce the number of complications associated with surgical treatment. An additional goal was to optimize and standardize perioperative care among Polish centers. MATERIALS AND METHODS: the development of these recommendations was based on a review of the available literature from the PubMed, Medline and Cochrane Library databases from January 1, 1985 to March 31, 2022, with particular emphasis on systematic reviews and clinical recommendations of recognized scientific societies. Recommendations were formulated in a directive form and were assessed using the Delphi method. RESULTS AND CONCLUSIONS: 34 recommendations for perioperative care were presented. They cover aspects of pre-, intra- and post-operative care. Implementation of the presented rules allows to improve the results of surgical treatment.

Randomized controlled trial of visualization versus neuromonitoring of the external branch of the superior laryngeal nerve during thyroidectomy.

BACKGROUND: Injury to the external branch of the superior laryngeal nerve (EBSLN) during thyroidectomy results in a lowered fundamental frequency of the voice and deteriorated voice performance in producing high-frequency sounds. It remains unclear if the use of intraoperative nerve monitoring (IONM) can improve the clinical outcome of thyroidectomy in terms of preserved individual voice performance. This study was designed to test that hypothesis. METHODS: A total of 210 consenting female patients planned for total thyroidectomy were randomly assigned to two groups equal in size (n = 105): visual inspection of the EBSLN and RLN vs. this plus additional EBSLN and RLN monitoring. The primary outcome was the identification rate of the EBSLN. The secondary outcomes included: anatomical variability of the EBSLN according to the Cernea classification and changes in postoperative voice performance. Voice assessment included pre- and postoperative videostrobolaryngoscopy and an analysis of maximum phonation time (MPT), voice level (VL), fundamental frequency (Fo), and voice quality rating on the GRBAS scale. RESULTS: The following differences were found for operations without vs. with IONM: identification rate of the EBSLN was 34.3 % vs. 83.8 % (p < 0.001), whereas a 10 % or higher decrease in phonation parameters was found in 10 % vs. 2 % patients for MPT (p = 0.018), 13 % vs. 2 % for VL (p = 0.003), and 9 % vs. 1 % for Fo (p = 0.03), a change in the GRBAS scale > 4 points in 7 % vs. 1 % (p = 0.03), and temporary RLN injury was found in 2 % vs. 1 % (p = 0.56), respectively. CONCLUSIONS: The use of IONM significantly improved the identification rate of the EBSLN during thyroidectomy, as well as reduced the risk of early phonation changes after thyroidectomy.

Prognostic factors in differentiated thyroid cancer--a 20-year surgical outcome study.

AIMS: The aim of this study was to determine prognostic factors in patients operated on for well-differentiated thyroid cancer (WDTC). PATIENTS AND METHODS: A retrospective cohort study of patients with WDTC treated at our institution between 1989 and 1991 (n = 97; mean age 52.3 years, 78 females, follow-up 124.6 ± 75.1 months) was made. Multivariate analysis was performed including: age, gender, size of primary tumor, location and number of foci in thyroid tissue, clinical stage, thyroid capsule infiltration, tumor histological type, extent of surgery, prognosis based on the AGES and MACIS scores, and tumor proliferative activity based on determination of proliferating cell nuclear antigen (PCNA) and Ki-67 expression in tumor tissue and nodal metastases. RESULTS: The multivariate analysis showed increased relative risk (RR) of death for: age above 60 years (7.39; p < 0.001), pTm (2.94; p = 0.002), pT3 (11.83; p < 0.001), and pN1 (4.11; p < 0.001). Total thyroidectomy decreased RR of death (0.39; p = 0.023) when compared to more limited resections. Moderate and high PCNA index was associated with 48.3% and 87.5% mortality, respectively, while Ki-67 index was associated with the highest mortality rate (76%) in the group of medium values. CONCLUSIONS: Despite good prognosis in WDTC, factors that most significantly affect overall survival rate include age, size of primary lesion and multifocal disease, presence of nodal metastases, and extent of primary surgery.

Diagnosis and treatment of thyroid cancer in adult patients - Recommendations of Polish Scientific Societies and the National Oncological Strategy. 2022 Update [Diagnostyka i leczenie raka tarczycy u chorych doroslych - Rekomendacje Polskich Towarzystw Naukowych oraz Narodowej Strategii Onkologicznej. Aktualizacja na rok 2022].

The guidelines Thyroid Cancer 2022 are prepared based on previous Polish recommendations updated in 2018. They consider international guidelines - American Thyroid Association (ATA) 2015 and National Comprehensive Cancer Network (NCCN); however, they are adapted according to the ADAPTE process. The strength of the recommendations and the quality of the scientific evidence are assessed according to the GRADE system and the ATA 2015 and NCCN recommendations. The core of the changes made in the Polish recommendations is the inclusion of international guidelines and the results of those scientific studies that have already proven themselves prospectively. These extensions allow de-escalation of the therapeutic management in low-risk thyroid carcinoma, i.e., enabling active surveillance in papillary microcarcinoma to be chosen alternatively to minimally invasive techniques after agreeing on such management with the patient. Further extensions allow the use of thyroid lobectomy with the isthmus (hemithyroidectomy) in low-risk cancer up to 2 cm in diameter, modification of the indications for postoperative radioiodine treatment toward personalized approach, and clarification of the criteria used during postoperative L-thyroxine treatment. At the same time, the criteria for the preoperative differential diagnosis of nodular goiter in terms of ultrasonography and fine-needle aspiration biopsy have been clarified, and the rules for the histopathological examination of postoperative thyroid material have been updated. New, updated rules for monitoring patients after treatment are also presented. The updated recommendations focus on ensuring the best possible quality of life after thyroid cancer treatment while maintaining the good efficacy of this treatment.

Total thyroidectomy for benign thyroid disease: is it really worthwhile?

OBJECTIVE: To compare the outcomes of bilateral subtotal (BST) versus total thyroidectomy (TT) for benign bilateral thyroid disease (BBTD). BACKGROUND: The extent of thyroid resection in benign goiter is controversial. Potential advantages of TT over BST may include: one-stage removal of incidental thyroid cancer, and a lower risk for goiter recurrence. However, these potential advantages should outweigh the risk of morbidity. METHODS: A retrospective cohort study was conducted of 8032 patients with BBTD operated in a single institution. Patients in Group A underwent BST (1999-2004, n = 5214; follow-up 72.3 ± 12.4 months), whereas patients in Group B underwent TT (2005-2009, n = 2918; follow-up 36.3 ± 10.6 months). Data were collected prospectively. The analysis included: prevalence of incidental thyroid cancer, recurrent goiter, need for completion thyroidectomy, and morbidity. RESULTS: Incidental thyroid cancer was found in 406 (5.00%) patients. One hundred twelve (2.15%) BST versus 3 (0.10%) TT patients required completion thyroidectomy (P < 0.001). Recurrent goiter was diagnosed in 364 (6.99%) BST patients and 165 (45.33%) required reoperation versus 0% after TT (P < 0.001). The prevalence of transient and permanent hypoparathyroidism was 2.70% and 0.15% versus 13.12% and 0.10% (BST vs. TT, P < 0.001 and P = 0.65, respectively). The prevalence of temporary and permanent RLN injury was 2.30% and 0.71% versus 2.60% versus 0.69% (BST vs. TT, respectively; nonsignificant). CONCLUSIONS: Compared to TT, BST resulted in a significantly higher rate of completion thyroidectomy for incidentally diagnosed thyroid cancer and need for redo surgery for recurrent goiter. The extent of surgical resection had no significant impact on the prevalence of permanent complications. REGISTRATION NUMBER: NCT01273714 (http://www.clinicaltrials.gov).

[Prevalence of metastatic lymph nodes in the central compartment of the neck following prophylactic clearance for papillary thyroid cancer]. / Ocena czestosci przerzutów raka brodawkowatego tarczycy do wezlów chlonnych kompartmentu centralnego szyi u chorych poddawanych profilaktycznej limfadenektomii.

INTRODUCTION: Clinical suspicion of regional lymph nodes' involvement is present in approximately 10% of patients with papillary thyroid cancer (PTC). Nevertheless, among the remaining 90% of individuals staged pre-, or intraoperatively as node negative, some cases of metastatic lymph nodes from PTC are found on final pathological report. Both quality of life and survival can be influence by eventual nodal recurrence in this group of patients. AIMS: To evaluate the prevalence of metastatic lymph nodes in patients with PTC in stage cT1-3NxMx undergoing prophylactic central compartment lymph nodes' clearance, and to assess associated morbidity. METHODS: Clinical database of patients with thyroid cancer undergoing surgery in 2009 and 2010 was retrospectively analyzed. 116 (78.9%) patients with PTC, with pre-, or intraoperatively not suspected lymph nodes were identified. Total extracapsular thyroidectomy with one-stage prophylactic bilateral level VI lymph nodes clearance was performed in all patients. The numbers of excised and metastatic lymph nodes within the surgical specimen were analyzed. In addition, surgical morbidity was evaluated. RESULTS: Metastatic level VI lymph nodes' involvement was found in 22 of 116 (19%) patients. Mean number of lymph nodes within the surgical specimen was 4.5 +/- 3.3 (1-17, median 4). Mean number of 1 +/- 2 metastatic lymph nodes were identified (0-7, median 1). Transient vs. permanent hypoparathyroidism was found in 31 (26.7%) vs. 2 (1.7%) and temporary vs. permanent recurrent laryngeal nerve injury was found in 7 (3.0%) vs. 2 (0.9%) of 232 nerves at risk. CONCLUSIONS: One fifth of PTC patients with clinically and intraoperatively non-suspected lymph nodes within the central compartment are positive for metastatic nodal de- posits in surgical specimen following prophylactic level VI clearance.

Training Courses in Laryngeal Nerve Monitoring in Thyroid and Parathyroid Surgery- The INMSG Consensus Statement.

Intraoperative neural monitoring (IONM) is now an integral aspect of thyroid surgery in many centers. Interest in IONM and the number of institutions that perform monitored thyroidectomies have increased throughout the world in recent years. For surgeons considering the introduction of IONM in their practice, specific training in IONM devices and procedures can substantially shorten the learning curve. The International Neural Monitoring Study Group (INMSG) has been at the forefront of IONM technology and procedural adoption since the introduction of neural monitoring in thyroid and parathyroid surgery. The purpose of this document is to define the INMSG consensus on essential elements of IONM training courses. Specifically, this document describes the minimum training required for teaching practical application of IONM and consensus views on key issues that must be addressed for the safe and reliable introduction of IONM in surgical practice. The intent of this publication is to provide societies, course directors, teaching institutions, and national organizations with a practical reference for developing IONM training programs. With these guidelines, IONM will be implemented optimally, to the ultimate benefit of the thyroid and parathyroid surgical patients.

Five-year follow-up of a randomized clinical trial of unilateral thyroid lobectomy with or without postoperative levothyroxine treatment.

BACKGROUND: The aim of this study was to compare the prevalence of recurrent nodular goiter in the contralateral thyroid lobe among patients after unilateral thyroid lobectomy for unilateral multinodular goiter (MNG) receiving versus not receiving postoperative prophylactic levothyroxine (LT4) treatment. METHODS: From January 2000 through December 2003, 150 consenting patients underwent a unilateral thyroid lobectomy for unilateral MNG at our institution. They were randomized to two groups with 75 patients in each group. Patients in group A received prophylactic LT4 treatment postoperatively (dose range 75-125 microg/day to maintain thyroid-stimulating hormone values below 1.0 mU/L), whereas patients in group B received no postoperative LT4 treatment. All the patients underwent ultrasonographic, cytologic, and biochemical follow-up for at least 60 months postoperatively. The primary outcome was the prevalence of recurrent goiter in the contralateral thyroid lobe. The secondary outcome was the reoperation rate for recurrent goiter. The outcomes were stratified according to individual iodine metabolism status assessed by urinary iodine excretion. RESULTS: During the 5-year follow-up, among patients receiving vs. not receiving LT4, recurrent goiter within the contralateral thyroid lobe was found in 1.4% vs. 16.7% of patients, respectively (p = 0.001). Moreover, 1.4% vs. 8.3%, respectively, of patients receiving vs. not receiving LT4 required contralateral thyroid lobe surgery (p = 0.05). LT4 decreased the recurrence rate among iodine-deficient patients (3.4% vs. 36%, respectively; p = 0.002) but not among iodine-sufficient patients (0% vs. 6.4%, respectively; p = 0.09). CONCLUSIONS: Prophylactic LT4 treatment significantly decreased the recurrence rate of nodular goiter in the contralateral thyroid lobe and the need for completion thyroidectomy, mostly among patients with iodine deficiency.

Five-year follow-up of a randomized clinical trial of total thyroidectomy versus Dunhill operation versus bilateral subtotal thyroidectomy for multinodular nontoxic goiter.

BACKGROUND: The extent of thyroid resection in multinodular nontoxic goiter (MNG) is controversial. The aim of the present study was to evaluate results of various thyroid resection modes, with special emphasis put on the recurrence rate and morbidity rate, in a 5-year follow-up. MATERIALS AND METHODS: From 01/2000 through 12/2003, 600 consenting patients with MNG qualified for thyroidectomy at our institution were randomized to three groups equal in size, n = 200 in each. Patients in group A underwent total thyroidectomy (TT); patients in group B underwent Dunhill operation (DO), whereas patients in group C underwent bilateral subtotal thyroidectomy (BST). All patients were subjected to ultrasonographic, cytological, and biochemical follow-up at least for 60 months postoperatively. The primary outcome measure was prevalence of recurrent goiter and need for redo surgery. The secondary outcome measure was the postoperative morbidity rate (hypoparathyroidism and recurrent laryngeal nerve injury). RESULTS: Recurrent goiter was found in 0.52% TT versus 4.71% DO versus 11.58% BST (p = 0.01 for TT versus DO, p = 0.02 for DO versus BST, p < 0.001 for TT versus BST), and completion thyroidectomy was necessary in 0.52% TT versus 1.57% DO versus 3.68% BST (p = 0.03 for TT versus BST). Transient postoperative hypoparathyroidism was present in 10.99% versus 4.23% versus 2.1% (p = 0.007 for TT versus DO, p < 0.001 for TT versus BST), whereas the recurrent laryngeal nerve injury rate was 5.49% and 1.05% TT versus 4.23% and 0.79% DO versus 2.1% and 0.53% BST (transient and permanent, respectively; p = 0.007 for transient events TT versus BST). CONCLUSIONS: Total thyroidectomy can be regarded as the procedure of choice for patients with MNG. It is associated with a significantly lower incidence of goiter recurrence and less frequent need for completion thyroidectomy than other more limited thyroid resections. However, TT involves a significantly higher risk of postoperative transient but not permanent hypoparathyroidism and recurrent laryngeal nerve paresis.