Usefulness of PET-CT scan in recurrent thyroid cancer.

The aim of this paper is to discuss the risk of recurrence in patients with differentiated thyroid cancer and emphasize the importance of risk-group stratification, early recurrence identification and application of new imaging modalities, what is the PET-CT. Moreover, follow-up of patients with thyroid carcinoma should be carried out by specialized teams throughout life. Therefore, interdisciplinary case discussions in tumor conferences may improve the use of multimodal therapy especially in patients with poorly differentiated thyroid carcinomas. After baseline follow-up, if there is a suspicion of thyroid carcinoma, early PET-CT should be used for early detection and appropriate planning. Fortunately, due to the good localization possibility, the PET-CT enables a focused surgical procedure with avoidance of an unnecessary tumor search and thereby a reduction of the risk of injury of neighboring structures which is a concern with reoperative neck surgery.

Platysmal Lineaments of the Neck With Emphasis on Endoscopic Endocrine Surgery.

BACKGROUND: In endoscopic neck endocrine surgery, the subplatysmal plane is an anatomic key structure that must be identified and preserved, to progress with the dissection. We define the prevalence of platysma, in the intermediate plane of the anterior cervical region, and evaluate potential statistical correlations with clinical and pathologic variables. MATERIALS AND METHODS: The study included patients who had thyroid surgery. Morphologies, asymmetry, and patterns of the platysma were described. The analysis of the different considered variables was quantitative and qualitative, using multiple data reports. RESULTS: A total of 23 men and 90 women, aged 19 to 70 (median 41±19) years constituted the study cohort. Their neck circumference and height were 388.5±45 mm (334 to 479 mm) and 200±30 mm (160 to 270 mm), respectively. The hemi-platysmal muscle was bilaterally identified in 109 (96.4%). The mean platysmal thickness was 2.7±1.7 mm (range: 0.7 to 8.2 mm). The intermediate plane between the platysmal muscles was classified into 4 types, depending on the muscle features in the midline: Type A: the left and right platysmal fibers were interlaced with each other in the midline (7%); type B: the platysmal fibers were disconnected by <1 cm (27%); type C: between 1 and 3 cm (52%); and type D separated >3 cm (14%). CONCLUSIONS: We provide descriptive characteristics of the cervical platysma. A better understanding of the anatomic variability in cervical platysma may be useful in performing a more accurate dissection in endoscopic endocrine neck surgery.

Human cadaveric model for studying the preservation of mental nerve during transoral endoscopic thyroidectomy.

PURPOSE: Mental nerve (MN) injury can be caused by transoral endoscopic thyroidectomy vestibular approach (TOETVA). The purpose of this experimental study was to determine the location and distribution pattern of MN structures in relation to oral vestibular incisions. METHODS: Ten cadaver specimens were included, yielding a total of 20 MNs. The difference between standard 10-mm TOETVA median incision and modified incision (i.e. lower and perpendicular) was compared. RESULTS: All 20 MNs were successfully dissected and presented as bifid (100%), lateral toward medial direction. The branches of MNs were equally distributed into both right and left sides. Standard lateral 5-mm vestibular incisions did not determine any division of MN branches. Two left MNs (25%) and one right MN (12.5%) were injured by standard median vestibular incision. Using a more inferiorly positioned and a vertical median incision, the integrity of MN branches was preserved. CONCLUSIONS: Standard lateral 5-mm vestibular incisions are safe for determining MN integrity. The 10-mm median vestibular incision divided the medial ramifications of MN at a rate of 12-25%. These may result in MN ipsilateral or bilateral paralysis. Hence, it is recommended to locate the median incision more inferiorly or vertically.

How to Avoid and Manage Mental Nerve Injury in Transoral Thyroidectomy.

Transoral endoscopic thyroidectomy by vestibular approach (TOETVA) represents an innovative and scarless technique for thyroid surgery. The procedure is conducted via a three-port technique at the oral vestibule using a 10mm port for the 30° endoscope and two additional 5mm ports for the dissecting and coagulating instruments. Patients meeting the following criteria can be considered as candidates for TOETVA: (a) an ultrasonographically (US) estimated thyroid diameter =10cm; (b) US-estimated gland volume =45mL; (c) nodule size =50mm; (d) presence of a benign tumor, such as a thyroid cyst or a single- or multinodular goiter; (e) Bethesda 3 and/or 4 categories, and (f) papillary microcar-cinoma without the evidence of metastasis. Beyond the classic complications of thyroid surgery, namely cervical hematoma, recurrent laryngeal nerve injury and hypoparathyroidism, novel consequences can occur as mental nerve (MN) injury. In this paper, leading experts in the field report on their current clinical experience with the TOETVA approach for thyroid gland surgery, with emphasis given to tips and tricks to avoid and manage MN injury.

Patient and Surgeon Candidacy for Transoral Endoscopic Thyroid Surgery.

The transoral thyroidectomy (TT) is a feasible novel surgical procedure that does not need visible incisions, a truly cutaneous scar-free surgery. Inclusion criteria are (a) patients who have a ultrasonographically (US) estimated thyroid diameter not larger than 10 cm, (b) US estimated gland volume ≤45 mL, (c) nodule size ≤50 mm, (d) a benign tumor, such as a thyroid cyst, single-nodular goiter, or multinodular goiter, (e) follicular neoplasm, and (f) papillary microcarcinoma without evidence of metastasis. The procedure is carried out through a three-port technique placed at the oral vestibule; one 10-mm port for a 30° endoscope and two additional 5-mm ports for dissecting and coagulating instruments. CO2 insufflation pressure is set at 6 mmHg. An anterior cervical subplatysmal space is created from the oral vestibule down to the sternal notch, laterally to the sternocleidomastoid muscle medial edges. TT is done fully endoscopically using conventional endoscopic instruments.

New Paradigms for Neural Monitoring in Thyroid Surgery.

Intraoperative neuromonitoring (IONM) in thyroid gland surgery provides real-time feedback to the endocrine surgeon regarding the electrophysiological consequences of surgical manipulation of the laryngeal nerves. The goal of monitoring modalities is to detect surgical or physiological insults to the recurrent laryngeal nerve (RLN) while they are still reversible or, in cases where prevention is not an option, to minimize the damage done to these structures during thyroidectomy. In recent decades, monitoring of the RLN has become a fundamental part of endocrine surgery. IONM is a feasible procedure in both open and endoscopic, robotic thyroidectomy. Experts in IONM have organized a working group of general, endocrine, head and neck ENT surgeons and endocrinologists (International Neural Monitoring Study Group; INMSG) to develop standards for practicing this technique in endoscopic and robotic thyroidectomy. This paper presents recent clinical and research experience with intraoperative neural monitoring for thyroid gland surgery.

How does neural monitoring help during thyroid sugery for Graves' disease?

We evaluate the role of intraoperative neuromonitoring (IONM) in thyroidectomy performed for Graves' disease (GD) with an emphasis on recurrent laryngeal nerve (RLN) management and completeness of resection. The study is a retrospective series comprising 55 thyroidectomy (control group) versus 82 procedures with intermittent IONM (I-IONM) and 72 by means of continuous IONM (C-IONM). In the control group the laryngeal nerves have been identified by visualization solely. In the I-IONM group both vagal nerve (VN) and RLN have been localized and monitored during thyroid resection. C-IONM was achieved with a vagal stimulation probe. I-IONM group had shorter operating times (P = 0.032). RLN morbidity, meaning palsy rate, was 2.7% in the C-IONM group, 3.6% in I-IONM and 5.4% in the control group (P = 0.058). The proportion of complete procedures (total or near total resections) were significantly higher using monitoring technology (P = 0.049). Persistent positive serum TBII values were found in 25 (45%), 25 (30%) and 20 (27%) patients at 12 months in the control, I-IONM and C-IONM groups respectively (P = 0,04). IONM is an effective technology in GD patients.

Limitations of Continuous Neural Monitoring in Thyroid Surgery.

Continuous intraoperative neuromonitoring is currently the gold standard technique available to prevent recurrent laryngeal nerve injuries. It significantly reduces the complication rate compared with intermittent intraoperative neuromonitoring, and represents significant progress in thyroid surgery, particularly in cases of more difficult dissections. There are, however, some technological and interpretative limits related to the lack of standardization of continuous intraoperative neuromonitoring and the prolonged length of time employed in the surgical positioning of the probe, despite various proposed approaches to the vagal nerve. Nonetheless, this method can be considered a safe and modern approach to thyroid surgery that reduces post-surgical complications and provides useful information.

Postoperative Bleeding after Thyroid Surgery: Care Instructions.

Prospective studies on the incidence, etiology, and prognosis of well-characterized patients with bleeding after thyroid surgery are lacking. Bleeding after thyroid surgery cannot be predicted or prevented even if risk factors are known in every single procedure, which enhances the im-portance of the following issues: (a) meticulous hemostasis and surgical technique; (b) coopera-tion with the anesthesiologist, i.e., controlling the Valsalva maneuver, adequate blood pressure at the end of the operation as well as at extubation phase and (c) in case of bleeding, a prompt management to guarantee a better outcome. This requires an intensive postoperative clinical monitoring of patients, ideally, in a recovery room with trained staff for at least 4-6 h. Early recognition of postoperative bleeding with immediate intervention is the key to the management of this complication.