Assessment of diagnostic capacity and decision-making based on the 2015 American Thyroid Association ultrasound classification system.

BACKGROUND: This study evaluates the American Thyroid Association (ATA) ultrasound (US) classification system for the initial assessment of thyroid nodules to determine if it indeed facilitates clinical decision-making. AIM: To perform a systematic review and meta-analysis of the diagnostic value of the ATA US classification system for the initial assessment of thyroid nodules. METHODS: In accordance with the PRISMA statement for diagnostic test accuracy, we selected articles that evaluated the 2015 ATA US pattern guidelines using a diagnostic gold standard. We analyzed these cases using traditional diagnostic parameters, as well as the threshold approach to clinical decision-making and decision curve analysis. RESULTS: We reviewed 13 articles with 8445 thyroid nodules, which were classified according to 2015 ATA patterns. Of these, 46.62% were malignant. No cancer was found in any of the ATA benign pattern nodules. The Bayesian analysis post-test probability for cancer in each classification was: (1) Very-low suspicion, 0.85%; (2) Low, 2.6%; (3) Intermediate, 6.7%; and (4) High, 40.9%. The net benefit (NB), expressed as avoided interventions, indicated that the highest capacity to avoid unnecessary fine needle aspiration biopsy (FNAB) in the patterns that we studied was 42, 31, 35, and 43 of every 100 FNABs. The NB calculation for a probability threshold of 11% for each of the ATA suspicion patterns studied is less than that of performing FNAB on all nodules. CONCLUSION: These three types of analysis have shown that only the ATA high-suspicion diagnostic pattern is clinically useful, in which case, FNAB should be performed. However, the curve decision analysis has demonstrated that using the ATA US risk patterns to decide which patients need FNAB does not provide a greater benefit than performing FNAB on all thyroid nodules. Therefore, it is likely that a better way to approach the assessment of thyroid nodules would be to perform FNAB on all non-cystic nodules, as the present analysis has shown the ATA risk patterns do not provide an adequate clinical decision-making framework.

Regional Node Distribution in Papillary Thyroid Cancer with Microscopic Metastasis.

BACKGROUND: Optimal neck lymphadenectomy in patients with papillary thyroid cancer (PTC) and microscopic lymph node metastasis needs to be defined in order to aid surgeons in their decision about the best way to proceed in these cases. METHODS: Patients who underwent total thyroidectomy and lymphadenectomy at levels IIa to VI were divided into two groups: Group 1 (G1) with macroscopic metastasis detected before surgery and Group 2 (G2) with microscopic metastasis detected in sentinel node during surgery. Odds ratio (OR) was computed for age, sex, tumor size, multicentricity, capsular invasion, vascular/lymphatic permeation, and nodes with metastasis. RESULTS: Primary tumor size was (G1 versus G2, respectively) 3.8 cm versus 1.98 cm (P<0.001); only lymphatic permeation was correlated to an increase in metastasis in lymph nodes 65.4% versus 25% (OR=5.6, p<0.001); metastatic frequency by region was IIa 18.5% versus 1.5%, III 24.3% versus 9.9%, IV 17.4% versus 18.1%, and VI 25.9% versus 71,2%. Metastasis to level V was found only in G1. CONCLUSION: Selective lymphadenectomy at levels III, IV, and VI is optimal for PTC patients without preoperative evidence of lymph node disease, but who present with lymph node microscopic metastasis in an intraoperative assessment.

Safety and Cost-Effectiveness in Thyroidectomy Using the HARMONIC Scalpel Compared to Traditional Hemostasis: A Controlled Clinical Assay.

INTRODUCTION: The aim of this clinical control trial is to analyze the cost-effectiveness and to understand the efficacy of the HARMONIC FOCUS®+ (Ethicon Inc., Somerville, New Jersey) scalpel as the only system to cut and coagulate in thyroidectomy. MATERIALS AND METHODS: One hundered patients of the thyroid clinic of the Mexico City General Hospital were included. All patients underwent surgery and were divided into two randomized groups. In Group 1, the HARMONIC scalpel was the only device used for cut and coagulate (50 patients), and in Group 2 clamp, tie, and electrocautery (50 patients) were used. Surgical bleeding, operative time, complications, diagnosis, thyroid size, and hospital stay were evaluated in both groups. The statistical analysis was done using central trend measurements, Student's t-, chi-squared, and Fisher's exact test, with a significance level of p < 0.05. The cost-effectiveness analysis was completed by determining the total cost of the surgical procedure per hour in US dollars, and the evolution to compare efficacy will be the number of re-interventions due to postoperative bleeding. RESULTS: The use of the HARMONIC scalpel in thyroid surgery had the same results as the traditional method when comparing complications, reoperation, hospital stay, and hypoparathyroidism. In total thyroidectomy patients, the bleeding in Group 1 was 55.16ml ( ± 32.97) and 85.4ml ( ± 69.41) in Group 2 , p=0.034. Operative time in Group 1 was 74.6 minutes (± 23.39) and 104.09 minutes (± 34.66) in Group 2, p= 0.0001. In both groups, there were no statistical differences in lobectomy. Cost-effectiveness analysis implies an adequate hemostasis if we are using a hemostatic device, and above all, the avoidance of a re-intervention due to hematoma, and the cost-effectiveness with regard to the re-intervention as a result of a hematoma implies that $161 US more is spent for each re-intervention. CONCLUSION: The utilization of the HARMONIC scalpel device is similar to the traditional technique of ligature and knots as far as cost-effectiveness is concerned, due to the fact that the greater expense of the device is compensated by the lower expense in time and surgical re-intervention.

Efficacy of Intraoperative Neuro-Monitoring to Localize the External Branch of the Superior Laryngeal Nerve.

BACKGROUND: This study investigated whether visual localization of the external branch of the superior laryngeal nerve (EBSLN) coincides with its localization via intraoperative neuro-monitoring (IONM) during thyroidectomy and whether its use influences the frequency of injuries. METHODS: A prospective, comparative, cross-sectional, observational study was performed in 240 superior thyroid poles. The metrics were visual identification of the EBSLN and its corroboration with IONM. The frequency of EBSLN injuries was also determined. Statistical analysis was achieved via kappa and chi-square tests, as well as odds ratios (OR). RESULTS: Of the 240 superior thyroid poles, IONM identified 234 (97.5%) EBSLN, whereas 190 (79.1%) were identified visually: OR = 10.35 [CI 4.37-24.65] p < 0.0001. Of the 190 EBSLN identified visually, 150 were confirmed through IONM. Indeed, their structure corresponded to an EBSLN to yield a kappa with a linear weighting value of 0.362. The standard error was 0.0467 [CI 0.2686-0.4554], indicating a fair agreement between the visual and IONM classification. CONCLUSION: IONM identified 97.5% of EBSLN cases. It was higher than the visual identification. There were no injuries to EBSLN identified through IONM.

Calidad de vida en pacientes operados de plastía inguinal mediante short form 36 (SF-36) / Quality of life in patients subjected to inguinal hernioplasty assessed through the short form 36 (SF-36)

Objetivo: Demostrar la autopercepción de los pacientes en su calidad de vida antes y después de operados de plastía inguinal en un hospital de tercer nivel de atención del sector salud, mediante el cuestionario de salud SF-36. Sede: Hospital General de México. Diseño: Estudio prospectivo, longitudinal, comparativo y observacional. Análisis estadístico: Medidas de tendencia central, prueba de rangos de Wilcoxon y modelo lineal general. Pacientes y métodos: Se incluyeron 67 pacientes a quienes se les realizó plastía inguinal con técnica de Lichtenstein, del día 1 de marzo al 31 de mayo de 2012, aplicando el cuestionario SF-36 un día previo al procedimiento quirúrgico y a los 3 meses posteriores a éste. Resultados: Se conformó el grupo con 64 hombres y 3 mujeres, con edad promedio de 44.73 (DE ± 13.2). Sin importar el tipo de hernia (clasificación de Nyhus), todos los pacientes percibieron una mejoría significativa en su calidad de vida (p <0.05). Los pacientes con menos de un año de síntomas ocasionados por la hernia inguinal no percibieron mejoría en su calidad de vida (p >0.05). Los casos con síntomas por más de 1 año manifestaron una mejoría significativa en su calidad de vida (p <0.05). Conclusiones: Los pacientes con más de un año de evolución de la hernia inguinal fueron los que percibieron mayor mejoría en su calidad de vida (SF-36) después de la cirugía.

Objective: To demonstrate self-perception of patients regarding their quality of life before and after inguinal plasty in a third level health care hospital of the health sector, by means of the SF-36 health questionnaire. Setting: Hospital General de México, Mexico City. Design: Prospective, longitudinal, comparative and observational study. Statistical analysis: Central tendency measures, Wilcoxon ranks tests and general linear model. Patients and methods: We included 67 patients, in whom inguinal plasty was performed with the Lichtenstein technique between March 1st and May 31st 2012, applying the SF-36 questionnaire one day before and 3 months after surgery. Results: The group consisted of 64 men and 3 women, average age of 44.73 (SD ± 13.2). Regardless of the type of hernia (Nythus classification), all patients perceived a significant improvement in their quality of life (p <0.05). Patients with less than 1 year with symptoms caused by the inguinal hernia did not perceive an improvement in the quality of life (p >0.05). Those cases with more than 1 year with symptoms perceived a significant improvement in their quality of life (p <0.05). Conclusions: Those patients with more than one year of evolution with the inguinal hernia were the ones to perceive the best improvement in their quality of life (SF-36) after surgery.

Precisión diagnóstica de la escala RIPASA para el diagnóstico de apendicitis aguda: análisis comparativo con la escala de Alvarado modificada / Diagnostic accuracy of the RIPASA Score for the diagnosis of acute appendicitis: comparative analysis with the modified Alvarado Score

Objetivo: Evaluar en forma comparativa la escala de Alvarado modificada y la escala RIPASA, para conocer su utilidad en el diagnóstico de apendicitis aguda en un hospital de tercer nivel de atención del sector salud. Sede: Hospital General de México. Diseño: Estudio prospectivo, transversal, comparativo y observacional. Análisis estadístico: Medidas de tendencia central, análisis para pruebas diagnósticas (sensibilidad, especificidad, valores predictivos, likelihood ratio o coeficiente de probabilidad) y curva ROC. Pacientes y métodos: De acuerdo al cálculo de tamaño de muestra se estudiaron 70 pacientes, que ingresaron al Servicio de Urgencias del Hospital General de México con síndrome doloroso abdominal sugestivo de apendicitis aguda, se les realizaron estudios de laboratorio y gabinete. Aplicando en forma simultánea las escalas de Alvarado modificada y la RIPASA. Se anotaron hallazgos clínicos, quirúrgicos e histopatológicos del apéndice. Resultados: La escala de Alvarado presentó una sensibilidad de 89.5% y especificidad de 69.2%, la RIPASA presentó una sensibilidad de 91.2% y especificidad de 84.6%. El área bajo la curva ROC de la escala RIPASA fue de 0.93, superior a la de Alvarado de 0.89. Si la decisión quirúrgica se hubiera realizado con base en la escala de Alvarado, las apendicectomías negativas se hubieran presentado en 18.3% pacientes, y con RIPASA disminuirían a 15.7%. Conclusiones: Ambas escalas presentaron buena sensibilidad para el diagnóstico de apendicitis aguda. La escala RIPASA presentó mejor especificidad y valores predictivos, con menor probabilidad de apendicectomías negativas. La escala RIPASA presenta mayor exactitud diagnóstica que la de Alvarado.

Objective: To assess comparatively the Modified Alvarado and the RIPASA scores, to know their usefulness in the diagnosis of acute appendicitis in a third level health care hospital. Setting: General Hospital of Mexico. Design: Prospective, cross-sectional, comparative, and observational study. Statistical analysis: Central Tendency Measures, analyses for diagnostic tests (specificity, sensitivity, predictive values, likelihood ratio) and ROC curve. Patients and methods: According to the established sample size, we studied 70 patients that were admitted at the Emergency Ward of the General Hospital of Mexico, with abdominal pain syndrome suggestive of acute appendicitis. Laboratory and imaging studies were performed. The modified Alvarado and RIPASA scores were applied simultaneously. Clinical, surgical, and histopathological findings were recorded. Results: The Alvarado score presented a sensitivity of 89.5% and a specificity of 69.2%, whereas RIPASA presented a sensitivity of 91.2% and specificity of 84.6%. The area under the ROC curve for the RIPASA score was 0.93, higher than that of the Alvarado with 0.89. If surgical decision had been based on the Alvarado score, negative appendicectomies would have been encountered in 18.3% of patients, and with RIPASA they would have diminished to 15.7%. Conclusions: Both scores presented a good sensitivity for the diagnosis of acute appendicitis. RIPASA presented better specificity and predictive values, with a lower likelihood of negative appendicectomies. The RIPASA score had a better diagnostic accuracy than the Alvarado score.

Inguinodinia en postoperados de plastía inguinal con técnica de Lichtenstein con resección versus preservación del nervio ilioinguinal ipsilateral / Inguinodynia in patients after inguinal hernioplasty with the Lichtenstein technique with resection versus preservation of the ipsilateral ilioinguinal nerve

Objetivo: Evaluar la inguinodinia en pacientes postoperados de plastía inguinal tipo Lichtenstein, comparando la sección contra la preservación de nervio ilioinguinal. Sede: Clínica de Hernias del Servicio de Cirugía General del Hospital General de México. Diseño: Ensayo clínico controlado, doble ciego. Análisis estadístico: Prueba de Wilcoxon y U de Mann-Whitney. Material y métodos: A 40 pacientes se les realizó plastía tipo Lichtenstein; aleatoriamente, en 18 se seccionó el nervio ilioinguinal y en 22 se preservó. Se evaluó la sensibilidad cutánea pre y postoperatoria, con escala visual análoga para la intensidad del dolor, con el fin de determinar si la sección del nervio ilioinguinal disminuye o no la intensidad del dolor y la presentación de inguinodinia postoperatoria. Resultados: Hubo diferencia significativa en cuanto a reducción del dolor a favor de los pacientes en que se seccionó el nervio a partir de 24 horas del postoperatorio (p < 0.001) y a los 60 días del postoperatorio (p < 0.0001), sin presentarse inguinodinia, alodinia, ni molestias por la hipoestesia o anestesia. Conclusión: La sección del nervio ilioinguinal durante la reparación de la hernia inguinal con la técnica de Lichtenstein disminuye el dolor postoperatorio en forma óptima, sin alterar en forma importante la sensibilidad superficial y además evita la inguinodinia.

Empleo de la presión negativa en el tratamiento de heridas complicadas: Reporte de seis casos / Use of negative pressure for the treatment of complicated wounds: Report of six cases

Objetivo: Conocer la utilidad de un sistema de terapia basado en presión negativa tópica, aplicado en la herida quirúrgica complicada. Sede: Servicio de Cirugía General, hospital de tercer nivel de atención. Diseño: Estudio piloto, prospectivo, longitudinal y descriptivo. Análisis estadístico: Medidas de tendencia central. Pacientes y métodos: Se presentan seis pacientes postoperados, con herida quirúrgica abierta, complicada. Todos con infección demostrada por cultivo y con salida de material purulento, tres pacientes con abdomen abierto por sepsis abdominal, uno con lesión torácica postraumática, uno con muñón de amputación supracondílea infectado y el último paciente con herida quirúrgica complicada posterior a dermolipectomía; todos ellos con tratamientos previos sobre la herida quirúrgica antes de aplicar la presión negativa. Se incluyeron pacientes consecutivos que presentaban: herida complicada, infectada, con estancia hospitalaria prolongada, quienes no presentaban progreso con el tratamiento médico tradicional. Resultados: El tiempo de aplicación de la presión negativa para los seis pacientes estuvo entre 6 y 26 días, con evolución satisfactoria, obteniéndose la mejoría deseada de la herida quirúrgica y de la cavidad abdominal. En los tres pacientes con abdomen abierto y tratamiento previo con bolsa de Bogotá, se pudo cerrar la cavidad abdominal entre los 14 y los 26 días posteriores al tratamiento con presión negativa; en los otros tres pacientes, con lesiones más superficiales, el cierre de la herida se logró entre el sexto y el décimo cuarto día. En todos hubo seguimiento mayor a cinco meses, conservándose la herida cerrada, sin alteraciones. Conclusión: La terapia de presión negativa fue útil en el tratamiento de pacientes con heridas quirúrgicas complicadas y/o en el tratamiento de pacientes con abdomen abierto en sustitución de la bolsa de Bogotá. Del 100% de días de estancia hospitalaria, el 30% fue con terapia basado en presión negativa tópica.

Objective: To know the usefulness of a therapy system based on negative pressure topically applied on a complicated surgical wound. Setting: General Surgery Service, third level health care hospital. Design: Pilot study, prospective, longitudinal and descriptive. Statistical analysis: Central tendency measures. Patients and methods: We present six post-operated patients with open complicated surgical wounds. All with infection demonstrated by culture and output of purulent material: three patients with open abdomen due to abdominal sepsis, one with post-traumatic thoracic injury, one with an supracondyle infected stump, and the last with complicated surgical wound due to dermolipectomy, all of them with treatments of the surgical wound before applying negative pressure. We included consecutive patients coursing with complicated infected wounds, prolonged in-hospital stay, and who did not improve with traditional medical treatment. Results: The time of negative pressure application for the six patients ranged from 6 to 26 days, with satisfactory evolution, obtaining the expected improvement of the surgical wound and the abdominal cavity. In the three patients with open abdomen and previous treatment with Bogota pouch, the abdominal cavity could be closed between 14 and 26 days of negative pressure treatment; in the other three patients with more superficial wounds, closure of the wound was achieved between the 6th and 14th day. All patients were followed for more than 5 months, the wound remained closed and without any alterations. Conclusion: Negative pressure therapy was useful in the treatment of patients with complicated surgical wounds and/or treatment of open abdomen substituting the Bogota pouch. Of the 100% of in-hospital stay days, 30% corresponded to topically applied negative pressure therapy.

[Dyspareunia after total abdominal hysterectomy. Anatomical relation]. / Dispareunia post-histerectomía total abdominal. Relación anatómica.

BACKGROUND: We undertook this study to determine whether anatomic changes after total abdominal hysterectomy are a cause of dyspareunia in premenopausal women. METHODS: This is a comparative, prospective and longitudinal study in 50 premenopausal women with benign uterine disease without dyspareunia treated with total abdominal hysterectomy. Primary variable was presence of postsurgical dyspareunia. Secondary variables are presurgical and assessment 3 months after surgery of left, right, anterior and posterior vaginal longitude (VLL, VRL, VAL and VPL, respectively) expressed in centimeters, as well as of the vaginal volume (VV). Statistical analysis for mean, central tendency and t-test. Group 1 (G1) is comprised of patients with postsurgical dyspareunia and Group 2 (G2) is comprised of patients without dyspareunia. RESULTS: In G1, three patients (mean age: 42 years) had dyspareunia, pre- and postsurgical mean values were VV 146.6 and 100, VLL 8 and 7.3, VPL 9.16 and 7.3, VLL 8 and 7.3, VRL 8 and 7.3. In G2, 47 patients (mean age: 40.36 years) were without dyspareunia, pre- and postsurgical values were VV 150.6 and 121.57, VLL 8.81 and 8.12, VPL 9.7 and 8.69, VLL 9.24 and 8.3, VRL 9.28 and 8.33. We did not find significant differences between the groups. Two of the three patients with dyspareunia had a vaginal granuloma, but the third case did not show an anatomical cause. CONCLUSIONS: There is no relationship between total abdominal hysterectomy in premenopausal women and anatomical vaginal changes after surgery as assessed by vaginal volume and longitude. Presence of vaginal granuloma was responsible for dyspareunia in 4% of cases. Dyspareunia was found in 2% of premenopausal women without posthysterectomy anatomical cause.

Dispareunia post-histerectomía total abdominal: relación anatómica / Dyspareunia after total abdominal hysterectomy: anatomical relation

Objetivo: conocer si los cambios anatómicos poshisterectomía total abdominal producen dispareunia en pacientes premenopáusicas. Material y métodos: estudio comparativo, prospectivo, longitudinal, de 50 pacientes premenopáusicas sometidas a histerectomía total abdominal por enfermedad uterina benigna sin dispareunia prequirúrgica. Se realizaron valoraciones pre y posperatorias del volumen vaginal y de las longitudes vaginales izquierda, derecha, anterior y posterior. El análisis estadístico se llevó a cabo por medidas de tendencia central y prueba t, agrupando a las pacientes en dos grupos: con dispareunia posoperatoria (grupo I) y sin dispareunia posoperatoria (grupo II). Resultados: grupo I, tres pacientes con los siguientes valores preoperatorios y posoperatorios: volumen vaginal de 146.6 y 100 cm3, longitud vaginal anterior de 8 y 7.3 cm, posterior de 9.16 y 7.3 cm, izquierda de 8 y 7.3 cm, y derecha de 8 y 7.3 cm. Grupo II, 47 pacientes con los siguientes valores preoperatorios y posoperatorios: volumen vaginal de 150.6 y 121.6 cm3, longitud vaginal anterior de 8.81 y 8.12 cm, posterior de 9.7 y 8.69 cm, izquierda de 9.24 y 8.3 cm, y derecha de 9.28 y 8.33 cm. Entre los grupos no encontramos diferencias estadísticamente significativas en volumen ni longitudes vaginales. En dos casos con dispareunia se encontró granuloma en cúpula vaginal que remitió con la resección; en otro no hubo implicación anatómica Conclusiones: no existió relación entre la dispareunia y los cambios de volumen y longitudes vaginales poshisterectomía. El granuloma en la cúpula vaginal fue responsable de 4 % de dispareunia. La dispareunia poshisterectomía total abdominal en paciente premenopáusicas sin causa anatómica aparente se presentó en 2 %.

BACKGROUND: We undertook this study to determine whether anatomic changes after total abdominal hysterectomy are a cause of dyspareunia in premenopausal women. METHODS: This is a comparative, prospective and longitudinal study in 50 premenopausal women with benign uterine disease without dyspareunia treated with total abdominal hysterectomy. Primary variable was presence of postsurgical dyspareunia. Secondary variables are presurgical and assessment 3 months after surgery of left, right, anterior and posterior vaginal longitude (VLL, VRL, VAL and VPL, respectively) expressed in centimeters, as well as of the vaginal volume (VV). Statistical analysis for mean, central tendency and t-test. Group 1 (G1) is comprised of patients with postsurgical dyspareunia and Group 2 (G2) is comprised of patients without dyspareunia. RESULTS: In G1, three patients (mean age: 42 years) had dyspareunia, pre- and postsurgical mean values were VV 146.6 and 100, VLL 8 and 7.3, VPL 9.16 and 7.3, VLL 8 and 7.3, VRL 8 and 7.3. In G2, 47 patients (mean age: 40.36 years) were without dyspareunia, pre- and postsurgical values were VV 150.6 and 121.57, VLL 8.81 and 8.12, VPL 9.7 and 8.69, VLL 9.24 and 8.3, VRL 9.28 and 8.33. We did not find significant differences between the groups. Two of the three patients with dyspareunia had a vaginal granuloma, but the third case did not show an anatomical cause. CONCLUSIONS: There is no relationship between total abdominal hysterectomy in premenopausal women and anatomical vaginal changes after surgery as assessed by vaginal volume and longitude. Presence of vaginal granuloma was responsible for dyspareunia in 4% of cases. Dyspareunia was found in 2% of premenopausal women without posthysterectomy anatomical cause.

Importance of the intraoperative identification of the external branch of the superior laryngeal nerve during thyroidectomy: electromyographic evaluation.

OBJECTIVE: To establish the frequency and degree of postthyroidectomy injury of the external branch of the superior laryngeal nerve (EBSLN) by means of electromyography and to assess whether intraoperative identification of the nerve and the presence of malignancy influence morbidity. PATIENTS AND METHODS: Prospective, randomized, blind study. Comparison of 100 superior thyroid poles subjected to surgery because of benign and malignant disease, divided in three groups: G1, thyroidectomies, without searching for the EBSLN; G2, thyroidectomies, searching for the EBSLN; G3, Control, lobes, contralateral to the lobectomy, not surgically manipulated. The electromyographic function of the EBSLN was assessed in all cases, classifying the degree of injury and clinically assessing its function. Central tendency measures were used, as well as X (2) and multiple variance analysis. RESULTS: In G1, with 50 dissections of the superior pole, 25 injuries were found in 15 patients (10 bilateral and 5 unilateral). In G2, EBSLN injury was found after 13 explorations of the superior pole in 8 patients (5 bilateral and 3 unilateral). G3 patients did not present EBSLN injury. X (2) among groups and degree of injury revealed that intraoperative identification of the EBSLN decreases its injury. No evidence were found that injury frequency is increased by the presence of thyroid malignancy, extracapsular infiltration, or size of tumor. Clinical manifestations of hoarseness were present in 14% of G1 patients and 8% of G2 patients. DISCUSSION: The rate of EBSLN injury increased when not exploring and/or identifying it expressly. The presence of cancer, extracapsular extension, or size of the thyroid tumor exerted no influence on the frequency of injury; localization of the nerve was the only factor affecting injury. Hoarseness correlated with the degree of injury. CONCLUSION: EBSLN must be localized expressly to decrease the risk of injury.

Combined use of fine-needle aspiration biopsy, MIBI scans and frozen section biopsy offers the best diagnostic accuracy in the assessment of the hypofunctioning solitary thyroid nodule.

PURPOSE: The probability of malignancy is increased in hypofunctioning solitary thyroid nodules (HFNs). Fine-needle aspiration biopsy (FNA), (99m)Tc-methoxyisobutylisonitrile (MIBI) and frozen section biopsy (FS) have limited independent diagnostic accuracy for the differential diagnosis of HFNs. The goal of this study was to assess the accuracy of the three independent diagnostic methods in distinguishing between benign and malignant disease. METHODS: A total of 130 patients with an HFN on the (99m)Tc-pertechnetate scan were included in this study. FNA, MIBI scans, FS, thyroidectomy and histological analysis of surgical specimens for final diagnosis were performed in all patients. RESULTS: Of the 130 patients, 80 (61.54%) had benign lesions and 50 (38.46%), malignant lesions. FNA was diagnostic in 78/130 (60%) patients and non-diagnostic in 52/130 (40%) patients. None of the patients with a negative MIBI scan had a final histological diagnosis of malignancy, and MIBI scans were negative in 38.46% of patients with non-diagnostic FNA results. FS was diagnostic in 104/130 (80%) patients and non-diagnostic in 26/130 (20%) patients. Sensitivity, specificity, positive and negative predictive values and positive and negative likelihood ratios were 81.3%, 97.8%, 96%, 88%, 36.95 and 0.19 respectively for FNA; 100%, 61.3%, 61.7%, 100%, 2.58 and 0 respectively for MIBI; and 80.5%, 100%, 100%, 89%, 0 and 0.2 respectively for FS. Use of both MIBI scans and FS in patients with non-diagnostic FNA rendered a specificity and sensitivity of 100%. CONCLUSION: MIBI scans exclude malignancy in a significant proportion of patients with non-diagnostic FNAs (38% in this study). Cystic nodules with a positive MIBI scan should be further investigated even when the FNA result indicates a benign lesion. Combined use of FNA, MIBI and FS offers the best diagnostic accuracy.

Clinical course of insular thyroid carcinoma.

BACKGROUND: To present the clinical picture and outcome of poorly differentiated insular-type thyroid carcinoma (ITC) compared with papillary thyroid carcinoma (PTC) in a Mexican population in order to demonstrate their different biological behavior. MATERIAL/METHODS: Retrospective, transversal study comparing ITC (G1) with PTC (G2). Assessed variables were: age, gender, size of tumor, previous history of thyroid disease, and outcome. The recurrence/death risk was established according to the MACIS, De GROOT, and AMES classifications. Statistical analysis was made by means of central tendency measures, the Kaplan-Meier method, Cox-Mantel's log-rank, Student's t, and chi-square tests. RESULTS: Both groups were classified based on a high or low risk for thyroid neoplasms. G1 had 13 patients, tumor volume was 78 cm3, 7 cases presented metastases at the time of admittance, five had antecedents of goiter. Average follow-up time was 23 months. G2 had seventy-one patients, tumor volume was 42 cm3, and follow-up time of 44 months. Kaplan-Meier revealed a lower survival in Group 1 than Group 2, statistically significant by the Cox-Mantel log-rank test. A significant statistical difference existed regarding survival and the presence of metastases: G1 (61%) and G2 (53.8%). No statistical difference was found between tumor size. CONCLUSIONS: ITC is more aggressive than PTC. It occurs in the 6th decade of life, with antecedents of long-standing goiter, and has a high recurrence, metastasis and mortality frequency.

Risk of injury to the external branch of the superior laryngeal nerve in thyroidectomy.

OBJECTIVE: To establish in the Mexican population with thyroid disease the risk of injury to the external branch of the superior laryngeal nerve (EBSLN) based on its anatomical position. STUDY DESIGN: Non-randomized comparative clinical trial. METHODS: Seventy-three patients subjected to thyroidectomy because of thyroid nodule in which the EBSLN was identified and classified. The dependent variable was Cernea's classification of the EBSLN, and the independent variables were weight (in grams) of the nodule, side studied, gender, and age. For statistical analysis, chi2 test, Fisher's Exact test, and analysis of multiple variables (analysis of variance) were used. RESULTS: We studied 73 patients; 64 (87.62%) were women and 9 (12.38%) were men (average age, 39.3 years [age range, 17-73 y]; median age, 40 y; mode, 40 y; SD +/- 23.4 y). Regarding location of the EBSLN, for pathological lobes, 78.1% were located in a high-risk position and for nonpathological lobes, 72.7%. Comparative analysis between sides and relation between weight and classification revealed no statistical significance. CONCLUSION: The frequency of high-risk position for EBSLN lesion in our milieu was higher than that reported in series from other countries and races.

Causes for early reintervention after thyroidectomy.

BACKGROUND: The purpose of our study was to ascertain the causes for early reintervention after thyroidectomy performed by a surgical team using a systematized surgical technique. MATERIAL/METHODS: We analyzed 1131 patients, 939 (83.1%) women and 192 (16.9%) men, average age 38.7 years (range 12 to 79). Of these patients, there were 675 hemithyroidectomies with isthmusectomy (59.74%), 189 subtotal thyroidectomies (16.71%), and 267 total thyroidectomies, alone or with regional lymphatic dissection at levels VI and VII (23.55%). Statistical analysis was performed by main tendency measures and chi square (chi-squared) for comparison of two independent samples; the dependent variable was the rate of early reintervention, while the independent variables included causes, time of presentation, hormonal functional state and extent of surgery. RESULTS: Early reintervention was necessary in 11 cases (0.97%). 9 were due to hematoma (0.79%) resolved with drainage and hemostasis, and two (0.18%) due to acute respiratory failure (ARF) caused by laryngeal edema, resolved by tracheostomy. Analysis based on diagnosis, extent of surgery and functional state failed to reveal statistically significant differences. The maximum time presentation of complications was 6 hours. CONCLUSIONS: The most intense postoperative monitoring is necessary during the first six hours. The low frequency of early reintervention and the appearance of complications in less than 8 hours enable thyroid surgery to be performed on a short-stay basis with adequate safety margins.

Comportamiento clínico del cáncer papilar de tiroides durante el embarazo: momento óptimo para su tratamiento / Papilary thyroid cancer with pregnancy and the optimal time to treatment

Objetivo: analizar el comportamiento clínico y evolución del cáncer papilar de tiroides y embarazo en población mexicana, así como determinar el momento óptimo de su tratamiento. Material y método: estudio de cohorte analítico, en dos grupos: uno (G1) de seis pacientes con cáncer papilar de tiroides y embarazo, otro (G2) de 24 pacientes con cáncer papilar de tiroides no embarazadas y con el mismo rango de edad, estadificación pronóstica de AMES. MACIS, tratamiento y tiempo de seguimiento. Las variables estudiadas fueron estadio inicial, tiempo de evolución, frecuencia de recidiva local, regional, a distancia y mortalidad. El análisis se realizó por medio de estadística descriptiva e inferencial, X2 y prueba t. Resultados: ambos grupos no tuvieron diferencia estadística entre edad, clasificación clínico/pronósticas, recurrencia local, regional o a distancia así como supervivencia con un seguimiento promedio de 83 (33 a 240) y 88 (12 a 288) meses en promedio para G1 y G2. Sólo se encontró diferencia en la presentación clínica con 100 por ciento del G1 metástasis regionales vs. 12.5 por ciento del G2 al diagnóstico que no impactaron en la evolución final. Conclusión: una embarazada con cáncer papilar de tiroides podrá esperar al término natural del embarazo y posteriormente realizar el tratamiento adecuado del cáncer.

Frecuencia de la patología quirúrgica tiroidea / Frequency of the thyroid pathology

Introducción: Una pieza importante en el diagnóstico, tratamiento, pronóstico y prevención de la patología quirúrgica tiroidea es conocer la frecuencia de la misma. Objetivo: Determinar la frecuencia actual de la patología quirúrgica tiroidea. Material y métodos: Estudio descriptivo, transversal no comparativo en 1,038 pacientes intervenidos quirúrgicamente por patología tiroidea de 1992 a 1996. Fueron recopilados los siguientes datos: diagnóstico histopatológico (variable dependiente), así como sexo, edad y presentación clínica (variables independientes); los cuales fueron analizados por medidas de tendencia central. Resultados: El predomino del sexo femenino fue de 15:1 y edad promedio de 39.9 años. El cáncer representó el 20.1 por ciento, siendo el más frecuente el papilar (85.2 por ciento), seguido por el medular (6.7 por ciento). El bocio eutiroideo representó el 39.1 por ciento, siendo el nodular el más común 87.1 por ciento. Los adenomas representaron el 6.2 por ciento, el más frecuente folicular (86 por ciento). Los padecimientos autoinmunes que requirieron cirugía para diagnóstico y tratamiento representaron el 34.6 por ciento. La presentación clínica más frecuente fue el nódulo tiroideo con 60.7 por ciento y, de éstos, el cáncer representó el 33 por ciento. Conclusiones: 1) El predomino femenino se ha incrementado. 2) La presentación clínica más frecuente es nódulo tiroideo. 3) La frecuencia de cáncer en nódulo tiroideo es de 33 por ciento. 4) El cáncer medular tiene un incremento en su frecuencia.

Vigilancia epidemiológica de infección del sitio operatorio superficial: estudio comparativo de tres años / Superficial surgical site infection epidemiologic surveillance: a three year comparative study

Objetivo: comparar el número de infecciones del sitio operatorio superficial de 1,930 pacientes, divididos en tres grupos a quienes se siguió vigilancia epidemiológica. Sede: Unidad 305 del Hospital General de México. Diseño: estudio prospectivo, longitudinal, comparativo de tres grupos de operados: el grupo uno del año 1995, el dos de 1996 y el tres de 1997. Método: se registraron todos los casos, sin excluir ninguno, se clasificaron por el método tradicional basado en heridas limpias, limpias contaminadas, contaminadas y sucias. El análisis estadístico fue por Ji cuadrada y cuadros de contingencia. Resultados: hubo reducción del porcentaje de infecciones, del sitio operatorio superficial, con valor estadístico, en heridas limpias, en el grupo dos comparado contra el grupo uno, lo mismo ocurrió en el grupo tres comparado con el dos y contra el uno. En este trabajo se mostró reducción gradual del número de infecciones en heridas limpias en años sucesivos, a expensas de descenso de la flora fecal. Las infecciones fueron más comunes en mayores de 40 años de edad. La mejoría en las cifras de infecciones fue mejor en el turno matutino.

Biopsia por aspiración con aguja fina en nódulo tiroideo. Apoyo del citopatólogo en la obtención de la muestra / Fine needle aspiration of thyroid nodule. The support of the citopathologyst on the sample obtention

Introducción: La biopsia por aspiración con aguja fina (BAAF) es un método simple, rápido y económico, evalúa la naturaleza de un nódulo tiroideo, eliminando la necesidad de remoción quirúrgica al establecer un diagnóstico citológico. Objetivo: Determinar si la presencia del citopatólogo en la obtención de la BAAF disminuye el número de muestras inadecuadas y si esto influye sobre la decisión terapéutica. Pacientes y métodos: Se realizaron 151 BAAF en nódulo tiroideo. Los pacientes fueron distribuidos en dos grupos: Grupo I biopsias practicadas sin la intervención del citopatólogo y el grupo II con la intervención de un citopatólogo. Resultados: Grupo I: 75 pacientes (88 por ciento mujeres) con edad promedio 45.3 años. Diecisiete biopsias fueron inadecuadas. El 77.3 por ciento de las BAAF con diagnóstico inicial benigno, 56.9 por ciento fueron correctos. En cáncer, la BAAF detectó el 63.6 por ciento de los casos. El tiempo promedio de diagnóstico fue de 14 días. Grupo II: 76 pacientes (84.2 por ciento mujeres), edad promedio 41.9 años. Siete biopsias fueron inadecuadas. El 90.8 por ciento de las BAAF con diagnóstico inicial benigno, 68.1 por ciento fueron correctos. En cáncer, la BAAF detectó 55.5 por ciento de los casos. El tiempo promedio de diagnóstico fue de tres días. Conclusiones: La evaluación inmediata del material obtenido en la BAAF disminuye el número de muestras inadecuadas, lo cual mejora la certeza diagnóstica y la decisión terapéutica.