[Non-functioning parathyroid cysts]. / Nefunktsional'nye kisty okoloshchitovidnykh zhelez.

OBJECTIVE: To study the features of clinical course, diagnosis and treatment of true non-functioning parathyroid cysts. MATERIAL AND METHODS: We retrospectively analyzed 18 patients with non-functioning true parathyroid cysts. Inclusion criteria: US-confirmed anechoic lesion of the neck without tissue component, cytological data on cystic lesion, high cystic parathyroid hormone and no laboratory signs of hyperparathyroidism. RESULTS: Non-functioning parathyroid cysts were asymptomatic and diagnosed accidentally after ultrasound of the neck. All patients were women aged 35-77 years. Four patients had cysts near the upper parathyroid glands, 14 patients - near the lower parathyroid glands. Of these, 2 ones had cysts below the level of the clavicle. Cyst volume was 4.3-110.3 cm3 (24.1±26.2 cm3). High cystic parathyroid hormone (2012.5±946.7 pg/ml) was observed in all patients. Simple aspiration was performed in 5 patients, aspiration with sclerotherapy - in 10 patients, cystectomy - in 3 patients. Recurrence was diagnosed in 1 patient after aspiration and 2 patients after sclerotherapy. CONCLUSION: No pathognomonic clinical and ultrasonic symptoms, as well as specific cytological data lead to misdiagnosis. Analysis of PTH in non-functioning parathyroid cysts is essential for diagnosis. Minimally invasive treatment is preferable for true parathyroid cysts. However, these approaches are not radical.

A contemporary analysis of the pre- and intraoperative recognition of multigland parathyroid disease.

BACKGROUND: Despite advances in biochemical and radiological identification of parathyroid gland enlargement, primary hyperparathyroidism (PHPT) due to sporadic multigland parathyroid disease (MGPD) remains a perioperative diagnostic dilemma. Failure to recognise MGPD pre- or intraoperatively may negatively impact surgical cure rates and result in persistent PHPT and ongoing patient morbidity. METHODS: We have conducted a comprehensive review of published literature in attempt to determine factors that could aid in reliably diagnosing sporadic MGPD pre- or intraoperatively. We discuss preoperative clinical features and examine pre- and intraoperative biochemical and imaging findings concentrating on those areas that give practicing surgeons and the wider multi-disciplinary endocrine team indications that a patient has MGDP. This could alter surgical strategy. CONCLUSION: Biochemistry can provide diagnosis of PHPT but cannot reliably discriminate parathyroid pathology. Histopathology can aid diagnosis between MGPD and adenoma, but histological appearance can overlap. Multiple negative imaging modalities indicate that MGPD may be more likely than a single parathyroid adenoma, but the gold standard for diagnosis is still intraoperative identification during BNE. MGPD remains a difficult disease to both diagnose and treat.

[Safe thyroidectomy for thyroid and parathyroid diseases]. / Puti osvoeniya bezopasnoi tekhniki tireoidektomii pri zabolevaniyakh shchitovidnoi i okoloshchitovidnykh zhelez.

OBJECTIVE: To offer the ways for safe thyroidectomy aimed at prevention of damage of recurrent laryngeal nerve in patients with thyroid and parathyroid diseases. MATERIAL AND METHODS: We analyzed postoperative outcomes after thyroidectomy in 342 patients aged 20-80 years. Topography of recurrent laryngeal nerves was studied on 20 laryngeal-tracheal complexes of deceased patients. Technique of visualization of various segments of recurrent laryngeal nerve was worked out. RESULTS AND DISCUSSION: Thyroidectomy was performed in 342 patients with thyroid and parathyroid diseases. Thyroidectomy was performed in accordance with recommendations described by F.W. Lahey, W.B. Hoover (1938) and H. Malcolm, M.D. Wheeler (1998). Location of recurrent laryngeal nerve varied in patients with nodular, retrosternal goiter and parathyroid gland adenoma. Comparison of intraoperative and morphological data on recurrent laryngeal nerve visualization showed possible risks of its damage during manipulations on thyroid gland, esophagus and trachea. Our study confirmed the need for visualization and mobilization of recurrent laryngeal nerve in all procedures on thyroid and parathyroid glands. Introduction of the described technique of thyroidectomy and training sessions for recurrent laryngeal nerve mobilization on laryngeal-tracheal complexes reduced postoperative incidence of phonation disorders from 21.6% to 0.98%. CONCLUSION: Thyroidectomy may be a safe procedure if surgeons are familiar with the details of surgical technique and prevent damage to adjacent structures.

Intraoperative near-infrared imaging of parathyroid glands: A comparison of first- and second-generation technologies.

BACKGROUND: Intraoperative near-infrared imaging (NIFI) of parathyroid glands (PG) by first-generation technology had limited image quality and depth penetration. Second-generation NIFI has recently been introduced. Our aim was to compare (1) capability to detect PG and (2) image quality between older and newer technologies. METHODS: Accurately detecting PG, as well as, quality of autofluorescence (AF) was compared between an older charge-coupled device (CCD) camera and a newer complementary metal-oxide semiconductor (CMOS). χ2 , t test, and analysis of variance were used for analysis. RESULTS: There were 300 patients who underwent parathyroidectomy (PTX) and/or thyroidectomy (THY) with NIFI, 200 with CCD, and 100 with CMOS. Although both NIFI technologies detected >94% of PG, CMOS was superior to CCD. Comparing AF quality, mean pixel intensity of PG compared with the background was higher with CMOS compared with CCD. When comparing PG detected by NIFI before visual identification by a surgeon, both CCD and CMOS had similar results (25% vs. 22%; p = .3). CONCLUSION: Both NIFI cameras were excellent at detecting PG. Second-generation NIFI (CMOS) displayed higher detection rates and AF intensity. Although surgeons identified majority of PG before NIFI detection, 25% of PG were identified with NIFI first, suggesting future advancements of this technology may expand its applications during parathyroid/thyroid operations.

Parathyroid 4D CT: What the Surgeon Wants to Know.

Parathyroid four-dimensional (4D) CT is an increasingly used and powerful tool for preoperative localization of abnormal parathyroid tissue in the setting of primary hyperparathyroidism. Accurate and precise localization of a single adenoma facilitates minimally invasive parathyroidectomy, and localization of multiglandular disease aids bilateral neck exploration. However, many radiologists find the interpretation of these examinations to be an intimidating challenge. The authors review parathyroid 4D CT findings of typical and atypical parathyroid lesions and provide illustrative examples. Relevant anatomy, embryology, and operative considerations with which the radiologist should be familiar to provide clinically useful image interpretations are also discussed. The most important 4D CT information to the surgeon includes the number, size, and specific location of candidate parathyroid lesions with respect to relevant surgical landmarks; the radiologist's opinion and confidence level regarding what each candidate lesion represents; and the presence or absence of ectopic or supernumerary parathyroid tissue, concurrent thyroid pathologic conditions, and arterial anomalies associated with a nonrecurrent laryngeal nerve. The authors provide the radiologist with an accessible and practical approach to performing and interpreting parathyroid 4D CT images, detail what the surgeon really wants to know from the radiologist and why, and provide an accompanying structured report outlining the key information to be addressed. By accurately reporting and concisely addressing the key information the surgeon desires from a parathyroid 4D CT examination, the radiologist substantially impacts patient care by enabling the surgeon to develop and execute the best possible operative plan for each patient. ©RSNA, 2020.

Role of ultrasound in the differentiation of parathyroid carcinoma and benign parathyroid lesions.

AIM: To identify the differences between ultrasound (US) features of parathyroid carcinoma (PC) and benign parathyroid (BP) lesions in patients with primary hyperparathyroidism (PHPT). MATERIAL AND METHODS: Twenty-one patients with PC and 64 consecutive patients with BP, whose diagnoses were confirmed at surgery, were enrolled from January 2013 to December 2018. The US features, demographic, clinical, and biochemical characteristics of the two groups were compared retrospectively. RESULTS: There are no significant differences between the patients with PC and BP regarding mean age or mean ionized calcium levels but differences were seen in sex distribution and mean parathyroid hormone (PTH) levels. On US imaging, PC significantly exhibited higher incidences of larger size and higher depth/width (D/W) ratio, heterogeneous echotexture, irregular shape, non-circumscribed margin, intra-nodular calcifications, indistinct border, cystic change, and the presence of suspicious lymph nodes compared to BP lesions. CONCLUSION: Preoperative ultrasonography is helpful to differentiate PC and BP. Patients with PC are differentiated from BP by their sex distribution, mean PTH levels, and major US characteristics: larger size, higher D/W ratio, heterogeneous echotexture, irregular shape, non-circumscribed margin, indistinct border, intra-nodular calcifications, cystic change, and the presence of suspicious lymph nodes.

Video-assisted neck surgery (VANS) using a gasless lifting procedure for thyroid and parathyroid diseases: "The VANS method from A to Z".

PURPOSE: To describe and evaluate our video-assisted neck surgery (VANS) method for thyroid and parathyroid diseases. METHODS: We describe in detail the VANS method for enucleation, lobectomy, total (nearly total) thyroidectomy, and lymph node dissection for malignancy and Graves' disease. In collaboration with the Japan Society of Endoscopic Surgery (JSES), we evaluated several aspects of this method. The JSES evaluated the method for working-space formation and surgical complications, whereas we examined the learning curve of the surgeons, and the cosmetic satisfaction of the patients and the degree of numbness and pain they experienced. We also asked patients who underwent conventional surgery whether they would have selected VANS had it been available. RESULTS: The working space for 81.5% of the procedures in Japan was created using the gasless lifting method. The learning curve, considering both blood loss and operating time, decreased after 30 cases. Both factors improved for tumors smaller than 5 cm in diameter. Over 60% of the patients who underwent conventional surgery stated that they would have selected VANS, had it been available. Postoperative pain was worse after conventional surgery than after VANS, but neck numbness after VANS was more frequent than expected. CONCLUSIONS: The VANS method is a feasible, safe, and cost-effective procedure with clear cosmetic advantages over conventional surgery.

A Long, Unnerving Road: Malpractice Claims Involving the Surgical Management of Thyroid and Parathyroid Disease.

BACKGROUND: Given their profound emotional, physical, and financial toll on patients and surgeons, we studied the characteristics, costs, and contributing factors of thyroid and parathyroid surgical malpractice claims. METHODS: Using the Controlled Risk Insurance Company Strategies' Comparative Benchmarking System database, representing ~30% of all US paid and unpaid malpractice claims, 5384 claims filed against general surgeons and otolaryngologists from 1995-2015 were reviewed to isolate claims involving the surgical management of thyroid and parathyroid disease. These claims were studied, and multivariable regression analysis was performed to identify factors associated with plaintiff payout. RESULTS: One hundred twenty-eight thyroid and parathyroid surgical malpractice claims were isolated. The median time from alleged harm event to closure of a malpractice case was 39 months. The most common associated complications were bilateral recurrent laryngeal nerve (RLN) injury (n = 23) and hematoma (n = 18). Complications led to death in 18 cases. Patient payout occurred in 33% of claims (n = 42), and the median cost per claim was $277,913 (IQR $87,343-$783,663). On multivariable analysis, bilateral RLN injury was predictive of patient payout (OR 3.58, p = 0.03), while procedure, death, and surgeon specialty were not. CONCLUSION: Though rare, malpractice claims related to thyroid and parathyroid surgery are costly, time-consuming, and reveal opportunities for early surgeon-patient resolution after poor outcomes.

Risk factors and prognosis of voice disorders after surgical treatment of thyroid and parathyroid diseases. / Faktory riska i prognozirovanie narushenii golosa posle khirurgicheskogo lecheniia zabolevanii shchitovidnoi i okoloshchitovidnykh zhelez.

AIM: To analyze risk factors and prognosis of voice disorders after surgical treatment of thyroid and parathyroid diseases. MATERIAL AND METHODS: There were 1272 patients who were operated in the endocrine surgery department for the period from January 1, 2016 to April 30, 2017. We studied the incidence of VF paresis, VF paralysis, and persistent dysphonia as clinical outcomes. Potential risk factors have to be analyzed were sex and age of patients, BMI, diagnosis, surgical technique, thyroid volume, experience of the surgeon and assistant, use of intraoperative neuromonitoring, etc. RESULTS: Significant relationships of risk factors with various complications of thyroid surgery were found. In logistic regression analysis, the independent predictors of complications were the following: 1) for VF paresis - extent of surgery and thyroid volume; 2) for VF paralysis - sex, extent of surgery and thyroid volume; 3) for persistent postoperative dysphonia - age and thyroid volume. CONCLUSION: The correlation of various risk factors with development of VF paresis, VF paralysis and persistent dysphonia were identified in patients undergoing thyroid and parathyroid surgery.

Current practice in the surgical management of parathyroid disorders: a United Kingdom survey.

PURPOSE: Surgery for primary hyperparathyroidism is undertaken by many specialties but predominantly endocrine and ear, nose and throat (ENT) surgeons. There is currently no consensus on the peri-operative management of primary hyperparathyroidism. We sought to determine current surgical practice and identify any inter-specialty variation in the United Kingdom (UK). METHODS: An online survey was disseminated to members of the British Association of Endocrine & Thyroid Surgeons (BAETS) in the UK. RESULTS: 78 surgeons responded (40 Endocrine, 37 ENT and 1 maxillofacial). 90% of surgeons used ultrasound and sestamibi for pre-operative localisation. Intraoperative frozen section (31%) and parathyroid hormone monitoring (41%) were the most common adjuncts used intraoperatively. 68% of surgeons did not use any wound drains. Nearly two-thirds of surgeons (64%) discharged patients from the clinic within 3 months, There were some significant differences (p < 0.05) in particular areas of practice between endocrine and ENT surgeons (%, p): use of single-photon emission computed tomography (SPECT) (Endocrine 25% vs. ENT 5%), preoperative laryngeal assessment (endocrine 58% vs. ENT 95%), intraoperative laryngeal nerve monitoring (endocrine 35% vs. ENT 68%), use of monopolar diathermy (endocrine 58% vs. ENT 22%), bipolar diathermy (endocrine 60% vs. 89%) and surgical ties (endocrine 48% vs. ENT 19%). CONCLUSION: Our study demonstrates some similarities as well as some notable differences in practice between endocrine and ENT surgeons, and therefore, highlights the need for national consensus with respect to some key areas in parathyroid surgery.

Parathyroid cysts: experience of a rare phenomenon at a single institution.

BACKGROUND: Parathyroid cysts are relatively uncommon lesions and are often misdiagnosed. We evaluate our experience in the diagnosis of and therapy to correct parathyroid cystic lesions. METHODS: We retrospectively reviewed a series of 32 patients with parathyroid cysts who were admitted to our department between July 2011 and November 2016. Clinical pathological features of the patients, including age, gender, location, size, ultrasonography, histopathology, surgery, and follow-up, were analyzed. RESULTS: There were 22 female and 10 male participants with a median age of 46.7 years old (27-76 years old). Only two cysts were found in the superior mediastinum. The rest were located under the lower pole of the thyroid. All of the patients underwent ultrasonography scans and serum parathyroid hormone (PTH) assays. Three patients had elevated serum PTH levels, and they were further scanned with Tc99m sestamibi as functional cysts. In 29 cases of nonfunctional cysts, 3 cases were preoperatively diagnosed by cystic aspiration with PTH detection. The rest were diagnosed by postoperative immunopathology. All of the patients underwent cystectomy, and 24 patients also underwent thyroidectomy. There was a significant difference in cyst diameter size between the cystectomy alone and cystectomy with thyroidectomy groups (4.0 ± 2.0 vs 1.5 ± 1.0 cm; p < 0.05). No participant experienced recurrence during the median 36 months of follow-up. CONCLUSIONS: Cystic lesions located under the lower pole of the thyroid gland should be considered to have originated at the parathyroid gland. Cystic aspiration with PTH detection or postoperative immunopathology can lead to a definitive diagnosis. Cystectomy is still a commonly used and effective treatment.

Intraoperative Identification of the Parathyroid Gland with a Fluorescence Detection System.

BACKGROUND: Intraoperative identification of the difficult-to-spot parathyroid gland is critical during surgery for thyroid and parathyroid disease. Recently, intrinsic fluorescence of the parathyroid gland was identified, and a new method was developed for intraoperative detection of the parathyroid with an original fluorescent detection apparatus. Here, we describe a method for intraoperative detection of the parathyroid using a ready-made photodynamic eye (PDE) system without any fluorescent dye or contrast agents. METHODS: Seventeen patients who underwent surgical treatment for thyroid or parathyroid disease at Kagoshima University Hospital were enrolled in this study. Intrinsic fluorescence of various tissues was detected with the PDE system. Intraoperative in vivo and ex vivo intrinsic fluorescence of the parathyroid, thyroid, lymph nodes and fat tissues was measured and analyzed. RESULTS: The parathyroid gland had a significantly higher fluorescence intensity than the other tissues, including the thyroid glands, lymph nodes and fat tissues, and we could identify them during surgery using the fluorescence-guided method. Our method could be applicable for two intraoperative clinical procedures: ex vivo tissue identification of parathyroid tissue and in vivo identification of the location of the parathyroid gland, including ectopic glands. CONCLUSION: The PDE system may be an easy and highly feasible method to identify the parathyroid gland during surgery.

Unusual presentations of enlarged parathyroid cysts: two case reports.

INTRODUCTION: Parathyroid cysts are infrequently encountered and have a variable presentation pattern depending on their size, location and secreting character. PATIENTS AND METHODS: We report two cases of parathyroid cysts characterized by their uncommon clinical presentation. RESULTS: In the first case the patient presented with a large cervical cystic mass without hypercalcemia, while in the second case, the patient experienced a hypercalcemic crisis associated with acute renal failure. The variable pattern of clinical manifestations is discussed. CONCLUSION: Parathyroid cysts are a rare entity. Surgical resection is the key to therapy when hyperparathyroidism or local compression are identified.

Robotic parathyroidectomy.

Robotic parathyroidectomy has recently been described. Although the procedure eliminates the neck scar, it is technically more demanding than the conventional approaches. This report is a review of the patients' selection criteria, technique, and outcomes.

Antimicrobial prophylaxis for the prevention of surgical site infection after thyroid and parathyroid surgery: a prospective randomized trial.

BACKGROUND AND OBJECTIVE: The effectiveness of antimicrobial prophylaxis (AMP) in the prevention of surgical site infection (SSI) following thyroid and parathyroid surgery remains uncertain. The objective of this prospective randomized controlled trial (Ito-RCT1) was to assess the effectiveness of AMP in clean neck surgery performed to treat thyroid and parathyroid disease. METHODS: Participants comprised patients scheduled for clean neck surgery for thyroid and parathyroid disease at Ito Hospital. Patients whose surgery included sternotomy or resection of the trachea, larynx, pharynx, or esophagus were excluded. AMP consisted of 2 g of piperacillin (PIPC) (group A, n = 541) or 1 g of cefazolin (CEZ) (group B, n = 541) administered intravenously immediately after endotracheal intubation. Patients in the control group (Group C, n = 1,082) did not receive AMP. RESULTS: Statistical analysis was performed to compare the AMP group (Group A + Group B) with the control group (Group C). Drug-induced acute reactions correlated to PIPC or CEZ did not occur in the AMP group. No significant differences in the postoperative incidence of liver or renal dysfunction were seen between the AMP and control groups. Postoperative incidence of urinary tract infection was significantly higher in the control group (p = 0.002). The incidence of SSI events was very low, with only 1 event (0.09 %) in the AMP group and 3 events (0.28 %) in the control group, and this difference between groups was not significant (p = 0.371). CONCLUSIONS: AMP is not necessary to prevent SSI after clean thyroid or parathyroid surgery.

Readability Assessment of Internet-Based Patient Education Materials Related to Parathyroid Surgery.

OBJECTIVES: Patient education is critical in obtaining informed consent and reducing preoperative anxiety. Written patient education material (PEM) can supplement verbal communication to improve understanding and satisfaction. Published guidelines recommend that health information be presented at or below a sixth-grade reading level to facilitate comprehension. We investigate the grade level of online PEMs regarding parathyroid surgery. METHODS: A popular internet search engine was used to identify PEM discussing parathyroid surgery. Four formulas were used to calculate readability scores: Flesch Reading Ease (FRE), Flesch-Kincaid Grade Level (FKGL), Gunning Frequency of Gobbledygook (GFOG), and Simple Measure of Gobbledygook (SMOG). RESULTS: Thirty web-based articles discussing parathyroid surgery were identified. The average FRE score was 42.8 (±1 standard deviation [SD] 16.3; 95% confidence interval [CI], 36.6-48.8; range, 6.1-71.3). The average FKGL score was 11.7 (±1 SD 3.3; 95% CI, 10.5-12.9; range, 6.1-19.0). The SMOG scores averaged 14.2 (±1 SD 2.6; 95% CI, 13.2-15.2; range, 10.7-21.9), and the GFOG scores averaged 15.0 (±1 SD 3.5; 95% CI, 13.7-16.3; range, 10.6-24.8). CONCLUSION: Online PEM on parathyroid surgery is written above the recommended sixth-grade reading level. Improving readability of PEM may promote better health education and compliance.

Systematic review and meta-analysis of wound drains after thyroid surgery.

BACKGROUND: Drainage after routine thyroid and parathyroid surgery remains controversial. However, there is increasing evidence from a number of randomized clinical trials (RCTs) suggesting no benefit from the use of drains. METHODS: A systematic review and meta-analysis was performed according to PRISMA guidelines. A literature search was carried out, and RCTs comparing the use of drains versus no drains in patients who underwent thyroid or parathyroid surgery were included. Trials including patients who underwent lateral neck dissection were excluded. Methodological quality was graded and data were extracted by independent reviewers. Risk ratio (RR) or mean difference (MD) with 95 per cent confidence interval (c.i.) was calculated and heterogeneity was assessed. RESULTS: Twenty-five RCTs were included in the meta-analysis comprising 2939 patients. There was no significant difference between the two groups in rate of reoperation for neck haematoma (RR 1·90, 95 per cent c.i. 0·87 to 4·14), ultrasound-assessed fluid volume on day 1 after surgery (MD 2·30 (95 per cent c.i. -0·73 to 5·34) ml), wound collection requiring intervention (RR 0·64, 0·38 to 1·09) or not (RR 0·93, 0·66 to 1·30), transient voice change (RR 2·33, 0·91 to 5·96) and persistent recurrent laryngeal nerve palsy (RR 1·67, 0·22 to 12·51). Length of hospital stay was significantly greater in the drain group (MD 1·25 (0·83 to 1·68) days), as were wound infection rates (RR 2·53, 1·23 to 5·21) and pain score measure using a visual analogue scale from 1 to 10 on day 1 after surgery (MD 1·46 (0·67 to 2·26) units). CONCLUSION: The results indicate that drain use after routine thyroid surgery does not confer a benefit to patients.

Changing trends in thyroid and parathyroid surgery over the decade: is same-day discharge feasible in the United Kingdom?

BACKGROUND: A recent British Association of Endocrine and Thyroid Surgeons consensus document suggested that day-case thyroidectomy is feasible in a small proportion of patients but has to be balanced against risks. Currently, there is no large reported series of same-day discharge in thyroid and parathyroid surgery from the UK. The aim of this study was to assess the outcomes of day-case thyroid and parathyroid surgery. METHODS: We conducted a retrospective study of patients who underwent thyroid or parathyroid surgery between January 2000 and December 2011 at Oxford University Hospitals. The end points analysed were complications in the form of bleeding, hypocalcaemia, wound infection, and seroma. RESULTS: A total of 2,102 patients (495 males and 1,607 females, age range = 13-90 years) underwent surgery for parathyroid (n = 776) or thyroid (n = 1,326) conditions. The operations included minimally invasive parathyroidectomy (MIP) (n = 331), open parathyroidectomy (n = 445), lobectomy (n = 687), isthmusectomy (n = 23), total thyroidectomy (n = 580) and thyroglossal cyst excision (n = 36). Routine arrangements were in place for consideration of same-day discharge for lobectomies, thyroglossal cyst surgery, and MIPs; lobectomies accounted for 63 % of same-day cases, followed by parathyroidectomy (35 %). Over the decade, day-case surgery increased from 4 to 17 % for thyroid surgery and from 20 to 40 % for parathyroid surgery. None of the 435 patients who had same-day discharge was readmitted for bleeding [confidence interval (CI) 0-0.6 %]. There was no 30-day mortality for the whole cohort. Complications in patients who underwent surgery in the whole cohort versus those who were discharged the same day were temporary hypocalcaemia (4 vs. 0.2 %), permanent hypocalcaemia (1 vs. 0.4 %), bleeding (0.4 vs. 0 %), seroma (0.3 vs. 0 %), and wound infection (0.3 vs. 0 %). CONCLUSION: Current protocols for thyroid or parathyroid surgery make same-day discharge feasible and safe in carefully selected patients.