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Background: Primary hyperparathyroidism (PHPT) is a common endocrine disorder. In the last few decades, the introduction of Rapid Intraoperative Parathyroid Hormone (ioPTH) monitoring has allowed to ensurance of the excision of all hyperfunctioning parathyroid tissues, reducing the risks of persistent and recurrent PHPT. However, the use of ioPTH is still debated among endocrine surgeons., Material and Methods: The objective of this systematic review and meta-analysis was to assess if ioPTH monitoring is able to reduce the incidence of persistent or recurrent PHPT. A systematic literature search was performed using PubMed, Scopus, ISI-Web of Science and Cochrane Library Database. Prospective and retrospective studies addressing the efficacy of ioPTH monitoring were included in the systematic review and meta-analysis. The random-effects model was assumed to account for different sources of variation among studies. The overall effect size was computed through the inverse variance method. Heterogeneity across studies, possible outlier studies, and publication bias were evaluated., Results: A total of 28 studies with 13,323 patients were included in the quantitative analysis. The incidence of operative failure was 3.2% in the case group and 5.8% in the control group. After excluding three outlier studies, the quantitative analysis revealed that ioPTH reduced significantly the incidence of postoperative persistent or recurrent PHPT. (Risk Difference = -0.02; CI = -0.03, -0.01; p < 0.001). There was no evidence of heterogeneity among the studies (Q = 19.92, p = 0.70; I 2  = 0%). The analysis of several continuous moderators revealed that the effectiveness of ioPTH was larger in studies with lower preoperative serum calcium values and higher incidences of multiple gland disease., Conclusion: ioPTH monitoring is effective in reducing the incidence of persistent and recurrent PHPT. Its routine use should be suggested in the next guidelines regarding management of PHPT., (Copyright © 2021 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: The aim of this study was to evaluate the diagnostic accuracy of intraoperative neuromonitoring (IONM) in predicting postoperative nerve function during thyroid surgery and its consequent ability to assist the surgeon in intraoperative decision making., Materials and Methods: A total of 2365 consecutive patients were submitted to thyroidectomy by the same surgical team. Group A included 1356 patients (2712 nerves at risk) in whom IONM was utilized, and Group B included 1009 patients (2018 nerves at risk) in whom IONM was not utilized., Results: In Group A, loss of signal (LOS) was observed in 37 patients; there were 29 true positive, 1317 true negative, 8 false positive, and 2 false negative cases. Accuracy was 99.3%, positive predictive value was 78.4%, negative predictive value was 99.8%, sensitivity was 93.6%, and specificity was 99.4%. A total of 29 (2.1%) cases of unilateral paralysis were observed, 23 (1.7%) of which were transient and 6 (0.4%) of which were permanent. Bilateral palsy was observed in two (0.1%) cases requiring a tracheostomy. In Group A, 31 (2.3%) injuries were observed, 25 (1.8%) of which were transient and 6 (0.4%) of which were permanent. In Group B, 26 (2.6%) unilateral paralysis cases were observed, 20 (2%) of which were transient and 6 (0.6%) of which were permanent; bilateral palsy was observed in 2 (0.2%) cases. In Group B, 28 (2.8%) injuries were observed, 21 (2.1%) of which were transient and 7 (0.7%) of which were permanent. Differences between the two groups were not statistically significant., Conclusions: Our results show that IONM has a very high sensitivity and negative predictive value, but also good specificity and positive predictive value. For these reasons, in selected patients with LOS, the surgical strategy should be reconsidered. However, patients need to be informed preoperatively about potential strategy changes during the planned bilateral surgery. Future larger and multicenter studies are needed to confirm the benefits of this therapeutic strategy., (Copyright © 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: The aim of the present study was to assess the clinical applicability of the TIR3A category in managing thyroid nodules, to examine the malignancy rates of TIR 3A and TIR 3B nodules, and to suggest management guidelines for these nodules., Materials and Methods: Thyroid cytologies performed in patients referred to our Department between January 2014 and August 2016 were classified according to the guidelines published by the SIAPEC. 102 cases were included in this retrospective study and were divided into two groups: 19 TIR3A were included in group A and 83 TIR3B in group B., Results: In group A, malignancy was diagnosed in 4 (21.1%) cases, papillary thyroid cancer was found in 3 patients and follicular thyroid cancer in 1; one case was classified as microcarcinoma, in two cancer was multicentric and bilateral and in one central node metastases were observed. In Group B malignancy was diagnosed in 48 (57.8%) patients, papillary thyroid cancer was found in 36 patients and follicular cancer in 12; microcarcinoma was observed in 25 cases, 12 were unilateral multicentric and 7 bilateral multicentric; in 3 cases central node metastases were present., Conclusion: Thyroid nodules with TIR3A cytology have a lower risk of malignancy than TIR3B cases, for which the new SIAPEC classification has proved accurate and effective. Malignancy rates in nodules with TIR3A cytology are higher than expected, although the real and accurate definition of the risk is extremely difficult. The recommendation to perform an accurate follow-up and repeat the fine-needle aspiration still appears the best option. For better management of patients with TIR3A cytology a careful assessment of risk factors and ultrasound characteristics is always needed. Further multicenter studies with longer follow-up are needed to better define the efficacy of this classification, the actual cancer risk, and the best management of these lesions., (Copyright © 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Introduction: The aim of this retrospective study was to investigate clinical and pathologic characteristics of differentiated thyroid cancer (DTC) in patients ≥75 years and to analyze results of surgical treatment in this age group., Methods: The clinical records of patients submitted to total thyroidectomy between 2009 and 2014 with histopathological diagnosis of DTC were analyzed. Patients were divided into 3 groups: patients ≤64 years were included in group A, those between 65 and 74 in B and those ≥75 years in C., Results: Classic papillary thyroid cancer was more frequent in group A, whereas follicular variant of papillary carcinoma, tall cell and follicular carcinoma were more frequent in C. Multicentric and locally invasive tumors were more frequent in group C; younger patients (group A) showed higher incidence of node metastases (12.54% in group A, 6.33% in B and 7.89% in C). Postoperative stay was significantly longer in group C (3.13 ± 1.28 days vs 2.55 ± 1.27 vs 2.89 ± 1.27; p < 0.001). Transient hypoparathyroidism was more frequent in groups A and B compared with C (29.26% vs 19.71% vs 18.42%; p 0.033) whereas transient recurrent laryngeal nerve palsy was more frequent in group C compared with A and B (2.63% vs 0.16% vs 2.11% p 0.009)., Conclusions: In aging patients DTC show a worse prognosis compared with younger patients due to higher incidence of more aggressive histotypes but also to a significant diagnostic delay. Total thyroidectomy is safe when surgical operation is performed by skilled surgeons. Age alone does not exclude surgical option., (Copyright © 2016 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Parathyroid carcinoma is a rare malignancy representing less than 1% of primary hyperparathyroidism cases. Its management is controversial due to lack of large-scale, multicentric studies. We report 8 new cases of parathyroid carcinoma and review the literature. Preoperative diagnosis of carcinoma was possible in 2 (25%) cases. Unclear surgical margins were present in 5 (62.5%) patients; 4 of them underwent subsequent re-exploration and ipsilateral hemithyroidectomy, in one case associated to central lymph node dissection. Recurrent disease is reported in 2 (25%) patients. Considering the high incidence of local recurrence in case of unclear surgical margins, a re-exploration with ipsilateral hemithyroidectomy is indicated in these patients. A neck dissection should be performed only in case of clinically involved lymph nodes, avoiding prophylactic lymphectomy. An aggressive approach is indicated in case of local or distant recurrence to reduce hypercalcemia., (Copyright © 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.)

Introduction: Despite the increasingly broad use of intraoperative neuromonitoring, review of the literature and clinical experience confirms there is little uniformity in application of and results across different centers. The aim of this study was to evaluate the ability of intraoperative neuromonitoring with a standardized evaluation of the signals to predict the postoperative functional outcome and its role in reducing the postoperative recurrent nerve palsy rates., Methods: 2365 consecutive patients underwent thyroidectomy by a single surgical team: in 1356 patients (group A) with intraoperative neuromonitoring, in 1009 (Group B) without it., Results: In group A a loss of signal was observed in 37 cases: we had 29 true positive cases, 1317 true negative, 8 false positive, and 2 false negative. Accuracy was 99.26%, positive predictive value 78.38%, negative predictive value 99.85%, sensitivity 93.55%, and specificity 99.4%. 29 unilateral nerve paralysis were observed (2.13%), 23 (1.69%) transient and 6 (0.44%) permanent. In group B 26 unilateral paralysis were observed (2.57%), 20 (1.98%) transient and 6 permanent (0.59%) Differences were not statistically significant., Conclusions: Intraoperative neuromonitoring is highly predictive of the postoperative nerve function. We obtained a very high sensitivity and negative predictive value, but also a good specificity and positive predictive value. For these reasons, in selected patients with loss of signal, the surgical strategy can be reconsidered. On the other hand, this study failed to demonstrate a statistically significant decrease in the nerve paralysis rate. Further studies are needed to better evaluate the real benefit of this technique., (Copyright © 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.)

Introduction: Over the last decades, mini-invasive surgery has become increasingly common for treatment of primary hyperparathyroidism; such approach requires preoperative localization of a suspected parathyroid adenoma. Neck ultrasound (US) and technetium-99 m sestamibi (MIBI) scan are the main imaging studies used for this purpose. The aim of the present study is to evaluate what pre- and post-operative factors may alter the reliability of localization studies., Methods: A retrospective analysis on 212 patients with preoperative diagnosis of primary hyperparathyroidism was conducted. Data collected included demographic data, preoperative workup, operative findings and follow-up. Univariate logistic regression was performed on pre- and postoperative variables., Results: US sensitivity was 62.4% and MIBI sensitivity 78.9%. Cure rate after parathyroidectomy was 98.1%. Univariate logistic regression demonstrated that US sensitivity was impaired by lower levels of serum calcium (p < 0.0001), multi-gland disease (p = 0.011) and co-existence of thyroid disease (p = 0.001); MIBI sensitivity was impaired by lower levels of serum calcium (p = 0.001) and multi-gland disease (p < 0,0001)., Conclusions: Mild hypercalcaemia, multi-gland disease and co-existing thyroid disease are the main factors affecting sensitivity of preoperative imaging studies. In such patients a mini-invasive approach is possible but the use of intraoperative PTH monitoring is mandatory to reduce the risk of unsuccessful surgery., (Copyright © 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.)

Introduction: Anticoagulants and antiplatelet agents are well-known risk factors for post-operative bleeding. The aim of this prospective, randomized pilot study was to evaluate the effectiveness of a topical haemostatic agent, namely TachoSil, for the prevention of postoperative bleeding in patients on antithrombotic therapy undergoing thyroidectomy. Perioperative management and some distinctive aspects of cervical haematomas were also discussed., Methods: Between January 2012 and May 2014, all patients taking vitamin K antagonists (VKAs) or acetyl salicylic acid (ASA) scheduled for total thyroidectomy were enrolled and randomly allocated to group 1 (standard haemostasis) and group 2 (standard haemostasis + TachoSil). Antithrombotic drugs were always suspended prior to surgery and, when indicated, replaced by bridging anticoagulation with low-molecular-weight heparin. The primary endpoint was the incidence of postoperative cervical haematomas., Results: A total of 70 patients were included in the study, representing 8.5% (70/820) of all patients who underwent thyroidectomies in the same period. The overall rate of post-operative cervical haematoma was 7.1% (5/70) and reached 14.8% (4/27) in patients on VKA therapy. All but one occurred more than 24 h after surgery (32nd hour, 8th, 10th, and 13th days). Group 1 (37 patients) and group 2 (33 patients) were well-matched according to clinical and demographic features. Postoperative haematoma was observed in 2/37 patients (5.4%) recruited in the Group 1 and 3/33 patients (9.1%) recruited in the Group 2 (P = 0.661)., Conclusions: Patients taking antithrombotic drugs represent a major problem in thyroid surgery. The incidence of bleeding after thyroidectomy is significantly high and the use of TachoSil do not seem effective in preventing its occurrence. However, larger multicenter study is needed to confirm these results., (Copyright © 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.)

Introduction: The aim of this retrospective study was to evaluate the ability of intraoperative neuromonitoring to predict the postoperative functional outcome and its role in reducing the postoperative recurrent laryngeal nerve palsy rate during thyroidectomy for thyroid malignancy., Methods: Between June 2007 and March 2013, 656 consecutive patients with thyroid cancer underwent thyroidectomy by a single surgical team. We compared 357 patients who have had neuromonitoring (Group A) to 299 patients who have undergone surgery with nerve visualization alone (group B)., Results: In group A 7 recurrent laryngeal nerve paralysis were observed (1.96%), 6 (1.68%) transient and 1 (0.28%) permanent; a bilateral recurrent laryngeal palsy was observed in 1 of the 7 cases (0.28%). In group B 6 recurrent laryngeal nerve paralysis were observed (2.01%), 5 (2.01%) transient and 1 permanent (0.33%); bilateral palsy was observed in 1 of the 6 cases (0.33%). Differences were not statistically significative., Conclusions: Routine visual nerve identification remains the gold standard of recurrent laryngeal nerve management in surgery for thyroid cancer. Intraoperative neuromonitoring is safe, effective, reliable, and easy to perform in excluding postoperative recurrent laryngeal palsy. It helps to identify the nerve in thyroid cancer, but it did not decrease the injuries compared with visualization alone in this study; however, its use can change the operative strategy in order to prevent the risk of bilateral damage in case of signal loss. Future studies are needed to evaluate the benefit of intraoperative neuromonitoring in thyroidectomy for thyroid cancer., (Copyright © 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.)

Introduction: The objective of this retrospective study was to investigate clinical and pathologic characteristics of differentiated thyroid cancer in elderly patients and to evaluate the results of surgical treatment in this age group., Methods: The clinical records of patients who underwent total thyroidectomy between 2002 and 2012 with histopathological diagnosis of differentiated thyroid cancer were analyzed. Patients were divided into two groups: those 65 years old or older were included in group A (101), those younger in group B (354)., Results: The mean surgical time was 100.9 ± 30.5 min in group A and 100.7 ± 27.6 in B. Postoperative stay was significantly longer in group A (2.8 ± 1.5 days vs 2.4 ± 0.7; p < 0.01). Classic papillary carcinoma was more frequent in group B, whereas follicular variant of papillary carcinoma and tall cell carcinoma in A. In group B node metastases were nearly twice. In Group A transient hypoparathyroidism occurred in 25 patients (24.8%), permanent hypoparathyroidism in 4 (4%), hematoma in 6 (5.9%), recurrent nerve palsy in 2 (2%), and wound infection in 2 (2%). In group B transient and permanent hypoparathyroidism occurred in 48 and 7 patients respectively (13.6% and 2%), hematoma in 4 (1.1%), recurrent nerve palsy in 5 (1.4%), and wound infection in 1 (0.3%)., Conclusions: Differentiated thyroid carcinoma is more aggressive in elderly patients for biological causes connected to age and to histotype but also for the diagnostic delay. Thyroid surgery in elderly patients is safe when the procedure is carried out by experienced staff. Total thyroidectomy is the surgical operation of choice., (Copyright © 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.)