Routine bilateral neck exploration and four-gland dissection remains unnecessary in modern parathyroid surgery.

OBJECTIVE: Recent advances in preoperative imaging techniques and intraoperative parathyroid hormone (ioPTH) assays have made single-gland, minimally invasive parathyroidectomy (MIP) the preferred treatment option for most patients with primary hyperparathyroidism (pHPT). Despite this evolution, a recommendation for bilateral neck exploration (BNE) with four-gland dissection in all patients has recently been advocated by a parathyroid surgical group. The current study compares the long-term outcomes of MIP with those of conventional BNE with four-gland dissection in patients with pHPT. METHODS: In order to objectively assess a recommendation in the literature that universal BNE with four-gland dissection is advisable, all patients undergoing an initial MIP with ioPTH assessment for pHPT in a tertiary endocrine practice during a 10-year period were reviewed. The cure rates from this procedure were compared with published results of conventional BNE with four-gland dissection. RESULTS: Of the 561 patients undergoing parathyroidectomy during the study period, 337 had initial surgery for pHPT; 282 of these patients met inclusion criteria and 212 had sufficient follow-up data available. A single adenoma was identified in 87.3% of cases. Preoperative imaging studies were co-localizing in 148 (69.8%), and 127 (85.8%) of these patients with co-localizing imaging required only single-gland surgery. Imaging studies did not co-localize in 49 patients, yet 32 (65.3%) of these patients were still cured with unilateral surgery. The cure rate for patients undergoing MIP was 98.6%, with a long-term recurrence rate of <2%. CONCLUSION: When coupled with the ioPTH assay, patients with at least one preoperative localizing study can undergo MIP and anticipate a cure rate of 99%, which is as good as or better than the published rates for conventional BNE with four-gland dissection. With unilateral surgery, the risks of permanent hypoparathyroidism and airway obstruction from bilateral vocal fold paralysis are completely eliminated. Therefore, despite recommendations to the contrary, most patients with pHPT should not have a planned four-gland exploration. LEVEL OF EVIDENCE: III or IV.

Baseline intraoperative intact parathyroid hormone levels in parathyroid surgery.

BACKGROUND: We sought to evaluate the relationship between the preoperative core-laboratory parathyroid hormone (CL-PTH) level and the baseline intraoperative PTH (IOPTH) level and assess the impact of any differences on clinical decision making in consecutive surgical patients with primary hyperparathyroidism undergoing parathyroidectomy. METHODS: The CL-PTH and baseline IOPTH levels were compared. The influence of relying on either the CL-PTH or baseline PTH levels for intraoperative decision making was determined. RESULTS: Data were available for 316 patients. Baseline IOPTH measurements were usually higher than the CL-PTH (247 patients; 78.2%) measurements, with a mean difference of 68.2 pg/mL (P < .001). Using the CL-PTH as a surrogate for the baseline parathyroid hormone (PTH) would have prolonged the operation in 23 patients (7.3%). CONCLUSION: Baseline point-of-care IOPTH levels were higher than the preoperative CL-PTH levels in >75% of patients undergoing parathyroidectomy. Using the CL-PTH in lieu of an IOPTH baseline value would prolong the operation in some patients.

Outpatient thyroidectomy is safe in the elderly and super-elderly.

OBJECTIVES: 1) Determine the safety of outpatient thyroidectomy in the geriatric patient population. 2) Analyze the risk of postoperative complications from thyroid surgery in patients aged over 65 years (elderly) and aged over 80 years (super-elderly) undergoing ambulatory thyroidectomy compared to patients aged 21 through 40 years. STUDY DESIGN: A retrospective analysis of consecutive patients undergoing thyroidectomy between January 2008 and July 2015 at a tertiary academic institution. METHOD: Patients were stratified by age, and three subsets within this population were considered and analyzed further: youthful/control (aged 21-40 years), elderly (aged 65-79 years), and super-elderly (≥ 80 years). Patient demographics, surgical and pathological data, admission status, complication, and readmission rates were recorded. RESULTS: A total of 1,429 thyroidectomies were accomplished; of these, 1,207 (84.5%) were outpatient operations. Among the outpatients, 85.2% were female, 14.1% were male, and the mean age was 50.3 ± 15.2 years. The control (youthful) group was comprised of 328 patients with a mean age of 33.3 years; the elderly group of 201 patients had a mean age of 70.3 years; and 16 patients in the super-elderly group had a mean age 82.7 years. The complication rates (5.2%, 5.0%, and 6.3%, respectively; P = 0.98) and re-admission rates (1.5%, 1.5%, and 0.0%, respectively; P = 0.89) were not different among these groups. CONCLUSION: Outpatient thyroid surgery is as safe in appropriately selected elderly and super-elderly patients as it is in a control group of youthful patients. Therefore, age should not be a contraindication to conducting thyroidectomy on an ambulatory basis. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:290-294, 2018.

Aesthetics in Thyroid Surgery: The Patient Perspective.

Objectives To define characteristics that influence patient perceptions of thyroidectomy scar cosmesis. Study Design Prospective cohort study. Setting Tertiary endocrine surgery practice in an academic medical center. Subjects and Methods Institutional review board-approved trial in which 136 subjects were recruited from a population of patients being seen for either thyroid or sinus surgery and evaluated standardized photographs, superimposed with computer-generated thyroidectomy scars of varying lengths (2, 4, and 6 cm) and widths (1 and 2 mm), and graded their perception of the scars using the observer scar assessment scale (OSAS) domains of the patient and observer scar assessment scale. Results There were 69 subjects in the thyroid group and 67 in the nonthyroid group. Controlling for width, longer scars were perceived as worse than shorter scars; controlling for length, thicker scars were perceived as worse than thinner scars ( P < .01). Beyond 2 cm, thick scars were judged to be worse than thin scars, even when they were shorter. There was no difference in the mean overall OSAS scores between surgery, sex, or age groups. Nonwhites tended to judge scars as being worse than whites did ( P < .01). Conclusion As expected, patients of all demographics prefer shorter scars compared with longer scars and thinner scars over thick scars. Ethnic differences in scar perception were identified and deserve additional study. Surgeons should endeavor to perform thyroid surgery through the smallest incision that allows the operation to be performed safely to minimize the cosmetic impact of the operation.

Persistently elevated parathyroid hormone after successful parathyroid surgery.

OBJECTIVES/HYPOTHESIS: Explore potential causes of persistently elevated parathyroid hormone levels after curative parathyroidectomy in patients with primary hyperparathyroidism due to single gland disease. STUDY DESIGN: Case series with planned data collection. METHODS: An analysis was undertaken of 314 patients with primary hyperparathyroidism undergoing parathyroid surgery in a tertiary academic practice between January 2009 and April 2013. There were 187 patients with single-gland disease; 68 failed to meet inclusion criteria, resulting in a study population of 119 patients. Preoperative parathyroid hormone, calcium, ionized calcium, 25-OH-vitamin D, creatinine, and glomerular filtration rate values were determined, along with postoperative calcium, ionized calcium, and parathyroid hormone levels. Patients were divided into two groups based on their postoperative parathyroid hormone values: elevated parathyroid hormone and normal parathyroid hormone. RESULTS: Thirty (25.2%) patients achieved postoperative normocalcemia but had elevated parathyroid hormone levels. This group had significantly higher preoperative levels of parathyroid hormone (P =.002) and creatinine (P =.007), and a lower glomerular filtration rate (P =.002) than patients with normal postoperative parathyroid hormone levels. The preoperative 25-OH-vitamin D level was not significantly associated with an elevated parathyroid hormone (odds ratio [OR]: 1.56). Preoperative impaired renal function, specifically an abnormal glomerular filtration rate (OR: 12.8), was significantly associated with an elevated parathyroid hormone. CONCLUSIONS: Parathyroid hormone remains elevated in 25% of patients who are cured (eucalcemic) after surgery for primary hyperparathyroidism. This phenomenon was associated with higher preoperative parathyroid hormone levels and impaired renal function rather than low 25-OH-vitamin D levels. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:1720-1723, 2017.

Remote Access Robotic Facelift Thyroidectomy: A Multi-institutional Experience.

BACKGROUND: Robotic facelift thyroidectomy (RFT) was developed as a new surgical approach to the thyroid gland using a remote incision site. Early favorable results led to this confirmatory multi-institutional experience. METHODS: Prospectively collected data on consecutive patients undergoing RFT in five North American academic endocrine surgical practices were compiled. Surgical indications, operative times, final pathology, nodule size, complications, and postoperative management (drain use and length of hospital stay) were evaluated. RESULTS: A total of 102 RFT procedures were undertaken in 90 patients. All but one of the patients (98.9 %) were female, and the mean age was 41.9 ± 13.1 years (range 12-69 years). The indication for surgery was nodular disease in 91.2 % of cases; 8.8 % were completion procedures performed for a diagnosis of cancer. The mean size of the largest nodule was 1.9 cm (range 0-5.6 cm). The mean total operative time for a thyroid lobectomy was 162 min (range 82-265 min). No permanent complications occurred. There were 4 cases (3.9 %) of transient recurrent laryngeal nerve weakness, no cases of hypocalcemia, and 3 (2.9 %) hematomas. There were no conversions to an anterior cervical approach. The majority of patients were managed on an outpatient basis (61.8 %) and without a drain (65.7 %). CONCLUSIONS: RFT is technically feasible and safe in selected patients. RFT can continue to be offered to carefully selected patients as a way to avoid a visible cervical scar. Future prospective studies to compare this novel approach to other remote access approaches are warranted.

Outpatient thyroid surgery: Safety of an optimized protocol in more than 1,000 patients.

OBJECTIVES: Outpatient thyroid surgery is becoming increasingly common. The aim of this study was to clarify the principles for safe outpatient thyroid surgery and review our outcomes with the use of a protocol for outpatient thyroidectomy in a large patient cohort. STUDY DESIGN: A systematic analysis of a prospectively maintained database of outcomes of thyroidectomy in a tertiary endocrine surgery practice. SETTING: Academic medical center. SUBJECTS AND METHODS: A protocol for outpatient thyroidectomy was conceived and refined over 3 years. A prospective analysis of all thyroidectomies accomplished by a single surgeon who used this protocol from May 2006 to November 2013 was then undertaken. Patient demographics, operative and pathologic data, admission status, complications, and readmission rates were recorded. RESULTS: A total of 1,311 thyroidectomy procedures were performed during the study period, of which 1,026 (78.3 %) were conducted on an outpatient basis. The readmission rate for outpatients was 0.9%, with only 1 readmission in the last 200 procedures. Inpatients (which included patients in the 23-hour "observation" category) were readmitted more often than outpatients (3.5% vs 0.9%, P < .01). Outpatient management increased steadily throughout the study period (from 59.7% to 92.3%, P < .01), despite a larger mean nodule size and a greater rate of malignancy over time. There were no changes in the complication rate across the study timeframe except for the incidence of temporary hypocalcemia, which decreased over time (P < .01). CONCLUSION: Outpatient thyroid surgery is safe in appropriately selected patients using an optimized and systematic protocol.

Reoperative Parathyroidectomy: Overly Descended Superior Adenoma.

OBJECTIVES: To identify the importance of the ectopic, overly descended superior parathyroid adenoma variant and its prevalence in primary and reoperative parathyroid surgery and the implications for successful initial parathyroidectomy. STUDY DESIGN: Case series with planned data collection. SETTING: Tertiary endocrine surgery practice in an academic medical center. SUBJECTS AND METHODS: An analysis was undertaken of 561 consecutive patients undergoing parathyroid surgery in a tertiary endocrine surgery practice from March 2004 to April 2013. There were 270 patients who had curative primary or reoperative surgery for single-gland parathyroid adenomas during this time. Clinical records, imaging studies, operative reports, and pathology findings were evaluated, and cases from a subset of patients who had an ectopic, overly descended superior parathyroid adenoma were further analyzed. The prevalence of this entity in primary and revision surgeries was calculated. RESULTS: Among the 270 patients with single-gland parathyroid adenomas, there were 251 primary operations and 19 reoperative procedures referred from outside institutions. An ectopic, overly descended superior parathyroid adenoma was present in 23 (9.2%) primary cases and 4 (21.1%) reoperative cases. CONCLUSION: An overly descended superior parathyroid adenoma is frequently encountered during primary parathyroid surgery. It is more than twice as common in reoperative parathyroidectomy, reflecting the propensity to be missed at the first exploration. Recognition and proper treatment of this entity at the initial operation will reduce the need for revision surgery.

Robotic facelift thyroid surgery.

Techniques for thyroid surgery have advanced dramatically over the past two decades, driven by a better understanding of thyroid physiology, anatomy, and perioperative management strategies. Improvements in surgical technology have permitted surgeons to perform minimally invasive surgery associated with less dissection, decreased pain, smaller anterior cervical incisions, and most importantly a faster recovery. The advent of robotic surgical technology has allowed the development of remote access thyroidectomy for select patients who wish to avoid a visible cervical incision completely. The robotic facelift thyroidectomy (RFT) approach also offers the advantage of outpatient surgery without the need for postoperative drainage. A growing body of evidence supports the safety and efficacy of the approach, and as a result the technique is now being performed at several centers around the world.

Continuous Vagal Nerve Monitoring is Dangerous and Should not Routinely be Done During Thyroid Surgery.

INTRODUCTION: Laryngeal nerve monitoring has been increasingly embraced as a mechanism for mitigating the risk of nerve damage during thyroid and parathyroid surgery. Vagal nerve monitoring has recently been introduced as a potentially increased level of nerve integrity scrutiny. We sought to define the risks and benefits of this technology in a prospective analysis of a series of patients undergoing neck endocrine surgery. SETTING: High-volume academic endocrine surgery practice. METHODS: A prospective, non-controlled trial of continuous vagal nerve monitoring (CVNM) in a projected cohort of 20 non-randomly selected patients undergoing thyroid and parathyroid surgery was planned. A commercially available nerve monitoring system with automatic periodic stimulation was utilized for both laryngeal nerve monitoring and CVNM. Demographic data were obtained, and outcome variables included surgical procedures performed, pathology, complications, incremental time required to achieve CVNM, and benefits of monitoring and stimulation. RESULTS: The patient accrual was aborted after 9 surgeries (12 nerves monitored) because of two serious adverse events (hemodynamic instability and reversible vagal neuropraxia attributable to the monitoring apparatus). No other complications occurred. The time to establish monitoring ranged from 3 to 26 min, with a median of 6 min (representing 2.9-12.2 % of the total surgical procedural time). The stimulation clamp became dislodged 11 times in 5 cases and was replaced in 7 of those instances. Benefits of CVNM included recognition of reduced amplitude and increased nerve latency in two patients. CONCLUSIONS: We report the first evidence that CVNM may cause serious patient harm. This novel approach is invasive and threatens patient safety. Although it may occasionally provide meaningful information, the risk-benefit ratio does not favor widespread adoption.

Six-Year Experience With Endoscopic Thyroidectomy: Outcomes and Safety Profile.

BACKGROUND: Though minimally invasive video-assisted thyroidectomy (MIVAT) offers many advantages over traditional thyroid surgery, its adoption in North America has been limited. This study analyzes the largest series of MIVAT in North America to explore its safety. METHODS: A prospectively maintained database of all patients undergoing thyroid surgery by a single surgeon from 2003 to 2011 at an academic tertiary care medical center was evaluated. Demographic information, surgical and pathologic data, and postoperative outcomes were analyzed. RESULTS: Beginning in 2005, a total of 260 MIVATs were performed during the study period. Outpatient surgery was accomplished in 234 MIVATs (90%). MIVAT patients were predominantly young (46.8±14.8 years vs 52.4±14.6 years for conventional thyroidectomy) and female (88.5% vs 75.5% for conventional thyroidectomy). There were no cases of permanent hypoparathyroidism or permanent recurrent laryngeal nerve dysfunction. Observed complications included transient recurrent laryngeal nerve dysfunction (n=10; 3.8%), cellulitis (n=1; 0.4%), and temporary hypocalcemia (n=6; 2.3%). The overall complication rate for MIVAT (6.5%) was lower than the overall complication rate in conventional thyroidectomy (18.5%, P<.0001). CONCLUSION: MIVAT can be performed safely with a low complication profile in a high-volume practice. The safety of MIVAT represented by this experience supports broader adoption across surgical practices.

Incision Planning in Thyroid Compartment Surgery: Getting it Perfect.

OBJECTIVE: This study evaluated changes in thyroid compartment incision site locations with patient positioning to define a reliable method for placing the scar in the optimal vertical location. METHODS: The optimal incision location was marked with the patient sitting upright before surgery. The distance from the sternal notch to this mark was measured with the patient in the upright, supine, and final surgical positions. RESULTS: Complete data were available for 104 procedures. The mean distances from the sternal notch to the incision site were 4.8, 21.5, and 31.9 mm in the sitting, supine, and surgical positions, respectively. Each of these distances were significantly different from one another (P<.0001) and were independent of patient age, sex, body mass index (BMI), or height. CONCLUSIONS: Cutaneous cervical landmarks migrate significantly during patient positioning. Marking the thyroid compartment incision site while the patient is in an upright position results in a more predictable final scar location.

Contemporary surgical techniques.

Recent technologic advances have engendered alternative and innovative approaches to thyroid surgery aimed at reducing cosmetic sequelae. Minimally invasive techniques via small anterior cervical incisions hidden in natural skin creases and remote access approaches that eliminate anterior neck incisions entirely have emerged as viable options for patients who regard cosmesis as a priority. The safe application of these techniques to both benign and malignant thyroid disease has been evaluated.

Alternative approaches to the thyroid gland.

Advances in surgical technology and patient-driven demands have fueled exploration into methods to improve cosmetic outcomes in thyroid surgery. This exploration has produced 2 fundamentally different pathways for reducing the visible thyroidectomy scar. Minimally invasive anterior cervical approaches use small incisions hidden in natural skin creases and reduce the overall extent of dissection required to remove the thyroid. Remote access approaches remove the incision from the anterior neck completely but require more extensive dissection to access the thyroid compartment.

Endoscopic thyroidectomy is safe in patients with a high body mass index.

BACKGROUND: Obesity is associated with a number of medical comorbidities and is considered a risk factor for surgical complications. However, the impact of obesity on the safety of minimally invasive video-assisted thyroidectomy (MIVAT) has not been well defined. We sought to determine the relationship between obesity and the risk of complications in patients undergoing MIVAT. METHOD: A prospectively maintained database of all thyroid surgeries performed from January 2006 through June 2012 was searched and all cases of MIVAT were identified. Patients were stratified into three body mass index (BMI) groups according to the National Institutes of Health classification for obesity: normal (BMI ≤ 24.9 kg/m(2)), overweight (BMI 25-29.9 kg/m(2)) and obese (BMI ≥ 30 kg/m(2)). The total number of complications was compared among the three groups, and MIVAT patients were also compared to a cohort of patients undergoing conventional thyroid surgery. RESULTS: There were 233 MIVATs performed on 223 patients. The mean overall BMI for the study population was 25.4 kg/m(2). There were 123 procedures (52.8%) in the normal group, 76 procedures (32.6%) in the overweight group, and 34 procedures (14.6%) in the obese group. Complications included 1 case of cellulitis (0.4%), 6 cases of temporary hypocalcemia (2.6%), and 6 cases of transient vocal fold paresis (2.6%). No patients suffered permanent hypocalcemia or a permanent recurrent laryngeal nerve injury. There were 9 complications in the normal group (7.3%), 4 complications in the overweight group (5.3%), and no complications in the obese group. Due to the low number of complications in this series, the overweight and obese groups were combined into a high BMI group for further analysis. Statistical analysis using simple logistic regression models revealed that there was no significant difference in the number of complications in patients with a high BMI compared with patients with a normal BMI (odds ratio [OR] 0.48 [confidence interval (CI) 0.14-1.63], p=0.2). The MIVAT group had fewer overall complications than the conventional thyroidectomy group. CONCLUSIONS: Overweight and obese patients undergoing MIVAT in this series were not at an increased risk for surgical complications. The MIVAT procedure may be considered safe in patients with a high BMI, who may derive particular benefit from a minimally invasive approach.