Preferential Use of Total Thyroidectomy without Prophylactic Central Lymph Node Dissection for Early-Stage Papillary Thyroid Cancer: Oncologic Outcomes in an Integrated Health Plan.

CONTEXT: The oncologic benefit of prophylactic central lymph node dissection (pCLND) in node-negative papillary thyroid cancer has been debated. OBJECTIVE: To determine the use of pCLND in an integrated health care system and to evaluate recurrence in the cohort. DESIGN: Retrospective cohort study of patients with clinically node-negative papillary thyroid cancer who underwent total thyroidectomy with or without pCLND in Kaiser Permanente Southern California Region hospitals between January 1996 and December 2008. Chart review of all patients was performed to collect demographic data, tumor features, stage, and recurrences. MAIN OUTCOME MEASURES: Proportion undergoing pCLND and recurrence rate of papillary thyroid cancer. RESULTS: There were 864 patients identified (mean age, 46.1 years). Almost all patients had total thyroidectomy alone, and 34 (3.9%) underwent pCLND. The TNM (tumor, node, metastasis) stages for the 2 groups were not significantly different (p = 0.18). Overall recurrence was 24 (2.8%). There were 23 (2.8%) recurrences in the no-pCLND group and 1 (2.9%) recurrence in the pCLND group (p = 0.95). The rate of recurrence in the central neck compartment in those without pCLND was 1.1% and 0% in the pCLND group (p = 0.54). The recurrence rate in the lateral neck compartment in the no-pCLND group was 2.2%, and this rate was 2.9% in the pCLND group (p = 0.76). The no-pCLND group had a recurrence-free survival rate of 96.4% at 10 years vs 96.8% in the pCLND patients (p = 0.80). CONCLUSION: Presently, routine pCLND is difficult to advocate in our medical system.

Thoracoscopic versus open repair of tracheoesophageal fistulas and rates of vocal cord paresis.

BACKGROUND/PURPOSE: The purpose of this study was to investigate the rates of vocal cord paresis/paralysis (VCP) in patients treated for esophageal atresia (EA) with and without fistula performed thoracoscopically versus open. METHODS: A retrospective review of EA cases performed from 2008 to 2014 in an integrated health care system was performed. RESULTS: A total of 31 cases of EA were performed by 6 surgeons at 4 different institutions. Seventeen cases were performed thoracoscopically, whereas 14 cases were performed open. In the thoracoscopic group, the average gestational age (weeks) of the patient was significantly higher 38.3 vs. 35.2 (p=0.016) as well as the average birth weight (grams) 2843 vs. 2079 (p=0.005). There was no difference in the postoperative length of stay, rates of anastomotic stricture, leak, or tracheomalacia. There were 10 cases of vocal cord paresis, 9 from the thoracoscopic group and one from the open group (p=0.007). Of the 10 cases of VCP, 6 were unilateral (left sided) and 4 were bilateral. Of the 10 cases, 6 resolved, 2 resulted in permanent paralysis, and 2 are currently still being evaluated. CONCLUSIONS: Thoracoscopic repair of EA appears to have higher rates of VCP. The results are thought to be from thoracoscopic dissection of the esophagus high into the thoracic inlet.