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Laryngeal ultrasound (US) is becoming widely accepted for assessing true vocal fold immobility (TVFI), a potential complication of laryngeal and thyroid surgery. The objective of this project is to perform a systematic review and meta-analysis of pooled evidence surrounding laryngeal US as a modality for diagnosing TVFI in adults at risk for the condition in comparison to laryngoscopy as a gold standard. Medical subject heading terms were used to search MEDLINE, Embase, Google Scholar, Web of Science, and the Cochrane Library for relevant citations from January 1, 2000, to June 30, 2020. Studies were included if they involved patients 16 years and older, where laryngeal US was compared to laryngoscopy for TVFI. Studies were excluded if there were insufficient data to compute a sensitivity/specificity table after attempting to contact the authors. Case reports, and case series were also excluded. The initial search returned 1357 citations. Of these, 109 were selected for review utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Thirty citations describing 6033 patients were included in the final meta-analysis. A bivariate random effects meta-analysis was performed, revealing a pooled sensitivity for laryngeal US of 0.95 (95% confidence interval [CI] 0.88-0.98), a specificity of 0.99 (95% CI 0.97-0.99), and a diagnostic odds ratio of 1328.2 (95% CI 294.0-5996.5). The area under the curve of the hierarchical summary receiver operating characteristic curve was 0.99 (95% CI 0.98-1.00). Laryngeal US demonstrates high sensitivity and specificity for detecting VFI in the hands of clinicians directly providing care to patients.

Transcutaneous laryngeal ultrasound (TLUSG) is an innovative, non-invasive tool in detecting post-thyroidectomy vocal cord palsy (VCP). However, TLUSG failed to detect about 6–15% laryngoscopic examination (LE)-confirmed VCP. It is unclear whether the outcome of patients with VCP missed by TLUSG [false negative (FN)] is different from those with VCP diagnosed by TLUSG [true positive (TP)]. Therefore, this study aimed to compare the clinical outcome and prognosis between patients with FN results and TP results. Over 46 months, all consecutive patients undergoing thyroidectomy or endocrine-related neck procedure were recruited. They underwent pre-operative and post-operative voice assessments on symptoms, voice-specific questionnaire [voice handicap index questionnaire (VHI-30)], TLUSG and LE. For patients with post-operative vocal cord palsy, reassessment LE would be arranged at second, fourth, sixth and twelfth months post-operatively until VCP recovered. In total, 1196 patients, including 74 post-thyroidectomy VCP, were recruited. For those with assessable vocal cords (VC), 58 VCP were correctly diagnosed by TLUSG (TP) and 10 VCP were missed by TLUSG (FN). Sensitivity and specificity of detecting a VCP by TLUSG were 85.3% and 94.7%, respectively. VHI-30 score was significantly increased after operation in TP group [31 (range − 6–105), p

I have read with interest on the article by Wu et al . “Transcutaneous Recording during Intraoperative Neuromonitoring in Thyroid Surgery” published in Thyroid (1). The article is well written and innovative. It introduced and test the feasibility of a transcutaneous electrode on recording intra-operative neuro-monitoring (IONM) signal in an in-vivo study.

Hypothyroidism is a common sequel after a hemithyroidectomy. Although various risk factors leading to hypothyroidism have been reported, the effect of the contralateral lobe’s volume has been understudied. This study aimed to examine the association between the preoperative contralateral lobe’s volume and the risk of postoperative hypothyroidism. During a 2-year period, 150 eligible patients undergoing a hemithyroidectomy were evaluated. The volume of the contralateral nonexcised lobe was estimated preoperatively by independent assessors on ultrasonography using the following formula: width (in cm) × depth (in cm) × length (in cm) × (π/6), adjusted for the body surface area (BSA). Postoperative hypothyroidism was defined as serum thyroid-stimulating hormone (TSH) exceeding 4.78 mIU/L. Any significant characteristics in the univariate analysis were entered into the multivariate analysis to determine independent factors. After a mean follow-up period of 53.5 ± 9.4 months, 44 patients (29.3 %) experienced postoperative hypothyroidism, and 10 of these patients required thyroxine replacement. Hypothyroidism was associated with a higher preoperative TSH level (p < 0.001), a smaller BSA-adjusted volume (p < 0.001), fewer ipsilateral nodules (p = 0.037), and the presence of thyroiditis (p = 0.050). After adjustment for thyroiditis, preoperative TSH (p < 0.001), number of ipsilateral nodules (p = 0.048), and BSA-adjusted volume (p < 0.001) were independent factors for hypothyroidism. Patients with a BSA-adjusted volume smaller than 3.2 ml had a threefold greater hypothyroidism risk than those with a BSA-adjusted volume of 3.2 ml or more (p < 0.001). A significant inverse association between the preoperative contralateral lobe’s volume and hypothyroidism risk was observed after hemithyroidectomy. Together with a higher preoperative TSH level and fewer ipsilateral nodules, a smaller BSA-adjusted volume measured by preoperative ultrasonography independently predicted hypothyroidism.

Patients with hoarseness of voice, previous neck operation, or suspicion of malignancy are at high risk of having pre-thyroidectomy vocal cord (VCP) palsy. Therefore, vocal cord (VC) functions should be evaluated before surgery. This study aimed to evaluate the accuracy of hoarseness, a voice-related questionnaire (Voice Handicap Index [VHI]-30), and transcutaneous laryngeal ultrasound (TLUSG) in diagnosing VCP, as well as the role of TLUSG in the evaluation of high-risk patients.A total of 1000 patients undergoing thyroidectomy or other endocrine-related neck procedures were prospectively included. Symptoms of hoarseness, the VHI-30 score, and TLUSG were evaluated. Validation laryngoscopies were performed by a separate endoscopist after performing TLUSG. All the assessments were performed one to seven days before surgery. The findings of hoarseness, the VHI-30 score, and TLUSG were correlated with laryngoscopic findings to evaluate the diagnostic accuracy.Of 1000 patients, nine preoperative VCP were diagnosed with laryngoscopy. Sensitivity in detecting VCP by hoarseness, the VHI-30 score, and TLUSG were 33.3%, 62.5%, and 88.9%, respectively. A total of 342 patients were considered as high risk, and eight preoperative VCP were confirmed with laryngoscopy. Despite it not being possible to visualize the VCs in 26 (7.7%) patients, TLUSG had a higher accuracy in detecting VCP than the VHI-30 did (96.8% vs. 74.2%; p 0.001). If patients had been selected who were unassessable or who had had VCP on assessment for confirmatory laryngoscopy, TLUSG saved more patients from laryngoscopic examinations than the VHI-30 did (87.7% vs. 71.3%; p 0.001). A history of neck operation and suspicion of malignancy did not affect the assessment by TLUSG (p 0.05).TLUSG is a feasible, non-invasive, and sensitive tool in detecting VCP in high-risk patients. It has safely precluded 87.7% high-risk patients from laryngoscopy. TLUSG should be incorporated as a part of the ultrasound examination of the thyroid.

Pancreatic neuroendocrine tumours (PNETs) are rare. They are generally accepted to be slow-growing and have an indolent course. These tumours can be non-functioning or functioning, consisting of a biochemically heterogeneous group of tumours including insulinomas, gastrinomas, carcinoids and glucagonomas. Although surgery remains the mainstay of treatment, controversy still exists especially for non-functioning tumours

It remains uncertain whether a parathyroid gland (PG) that appears darkened or severely bruised but still has an attached vascular pedicle should be left in situ or taken out and auto-transplanted following total thyroidectomy. Our study aimed to examine the impact of discolored PGs (DPGs) on short- and long-term hypoparathyroidism.One hundred and three patients who underwent total thyroidectomy with 4 clearly identified PGs were analyzed. Location (superior/inferior) and color of each PG were recorded. Patients without DPG were grouped into I while those with 1-2 DPGs and ≥3 DPGs were grouped into II and III, respectively. Transient hypoparathyroidism meant adjusted Ca2.00 mol/L 24 h after surgery and/or need for supplements. Protracted hypoparathyroidism meant a subnormal PTH at 4-6 weeks and/or supplements6 weeks. Permanent hypoparathyroidism meant supplements ≥1 year.Relative to I, group III had greater adjusted Ca drop at postoperative 1-h (p = 0.012), 24-h (p 0.001) and lower day-1 PTH (p = 0.015). Having ≥3 DPGs (OR 14.00, 95 % CI 1.575-124.474, p = 0.018) was an independent factor of transient hypoparathyroidism. However, permanent hypoparathyroidism rate was higher than in group I than II (p = 0.019). Eight patients (25.8 %) in group I had undetectable day-1 PTH, while none in group III had undetectable day-1 PTH. Graves' disease/toxic goiter (OR 15.166, 95 % CI 2.594-88.661, p = 0.003) and excised gland weight (OR 1.028, 95 % CI 1.010-1.046, p = 0.003) were independent factors of ≥3 DPGs.PG discoloration is associated with transient hypoparathyroidism while normal colored PG with seemingly adequate blood supply does not always imply functionally normal gland. These findings highlights the need for a real-time intraoperative method to assess PG viability.

Transcutaneous laryngeal ultrasonography (TLUSG) is a promising alternative to laryngoscopy in vocal cords (VCs) assessment which might be challenging in the beginning. However, it remains unclear when an assessor can provide proficient TLUSG enough to abandon direct laryngoscopy . Eight surgical residents (SRs) without prior USG experience were recruited to determine the learning curve. After a standardized training program, SRs would perform 80 consecutive peri-operative VCs assessment using TLUSG. Performances of SRs were quantitatively evaluated by a composite performance score (lower score representing better performance) which comprised total examination time (in seconds), VCs visualization, and assessment accuracy. Cumulative sum (CUSUM) chart was then used to evaluate learning curve. Diagnostic accuracy and demographic data between every twentieth TLUSG were compared. 640 TLUSG examinations had been performed by 8 residents. 95.1% of VCs could be assessed by SRs. The CUSUM curve showed a rising pattern (learning phase) until 7th TLUSG and then flattened. The curve declined continuously after 42nd TLUSG (after reaching a plateau). Rates of assessable VCs were comparable in every twentieth cases performed. It took a longer time to complete TLUSG in 1st-20th than 21st-40th examinations. (45 vs. 32s, p = 0.001). Although statistically not significant, proportion of false-negative results was higher in 21st-40th (2.5%) than 1(st)-20th (0.6%), 41(st)-60th (0.7%), and 61(st)-80th (0.7%) TLUSG performed. After a short formal training, surgeons could master skill in TLUSG after seven examination and assess vocal cord function consistently and accurately after 40 TLUSG.

Although 18F-fluorodeoxyglucose (FDG) positron emission tomography combined with computed tomography (PET/CT) is a potentially powerful, non-invasive imaging tool in differentiating adrenal metastasis from benign disease, some adenomas also exhibit high FDG uptake, therefore mimicking metastasis (i.e., false positives). We aimed to evaluate the accuracy of FDG-PET/CT based exclusively on histology and to identify risk factors for adrenal metastasis. Among the 289 consecutive patients who underwent adrenalectomy, 39 (78.0 %) patients had suspected solitary adrenal metastasis and had a positive preoperative FDG-PET/CT. The FDG-PET/CT findings were correlated with the histology of the excised adrenal gland. To identify risk factors for adrenal metastasis, characteristics were compared between patients with histologically proven adrenal metastasis and those without. Youden’s index was used to calculate the optimal cut-off value for predicting adrenal metastasis. Histology of the excised adrenal tumor confirmed adrenal metastasis in 28/39 (71.8 %) patients while non-metastatic lesions comprised mostly benign adrenal cortical adenoma (n = 10) and one non-functional pheochromocytoma. Therefore, the overall false-positive rate of FDG-PET/CT was 28.2 %. History of primary lung malignancy [odds ratio (OR) (95 % CI) 20.00 (1.01–333.3), p = 0.049] and SUVmax > 2.65 [OR (95 % CI) 31.606 (2.46–405.71), p = 0.008] were independent risk factors for adrenal metastasis. Single adrenal uptake on FDG-PET/CT in suspected solitary adrenal metastasis was associated with a high false-positive rate (28.2 %). Risk factors associated with adrenal metastasis included a history of known primary lung malignancy and a SUVmax > 2.65 at the adrenal lesion of interest on FDG-PET/CT. Based on these findings, a new algorithm was constructed.

Introduction During examination of the vocal cords (VC) using transcutaneous laryngeal ultrasonography (TLUSG), 3 sonographic landmarks (namely, false VC [FC], true VC [TC], and arytenoids [AR]) are often seen. However, it remains unclear which landmark provides a more reliable assessment and whether seeing more landmarks improves the diagnostic accuracy and reliability. Methods We evaluated prospectively 245 patients from 2 centers. One assessor from each center performed all TLUSG examinations and their findings were validated by direct laryngoscopy. All 3 sonographic landmarks were routinely visualized whenever possible. The rate of visualization and diagnostic accuracy between the 3 landmarks were compared. Results Eighteen patients suffered postoperative VC palsy (VCP). Both centers had comparable visualization or assessability rate of ≥1 sonographic landmark (94.9 and 95.3%; P = 1.000) and 100% sensitivity on postoperative TLUSG. The rates of FC, TC, and AR visualization were 92.7%, 36.7%, and 89.8%, respectively. The sensitivity, specificity, and diagnostic accuracy and the proportion of true positives, false positives, and true negatives between using 1, 2, landmarks and 3 landmarks were comparable (P > .05). Conclusion Each sonographic landmark had similar reliability and diagnostic accuracy. Identifying all 3 sonographic landmarks was not mandatory and visualizing normal movement in one of the sonographic landmarks would be sufficient to exclude VCP.

Although transcutaneous laryngeal ultrasound (TLUSG) is an excellent, noninvasive way to assess vocal cord (VC) function after thyroidectomy, some patients simply have “un-assessable” or “inaccurate” examination. Our study evaluated what patient and surgical factors affected assessability and/or accuracy of postoperative TLUSG. Five hundred eighty-one consecutive patients were analyzed. All TLUSGs were done by one operator using standardized technique, whereas direct laryngoscopies (DL) were done by an independent endoscopist to confirm TLUSG findings. Their findings were correlated. TLUSG was “unassessable” if ≥1 VC could not be clearly visualized, whereas it was “inaccurate” if the TLUSG and DL findings were discordant. Demographics, body habitus, neck anthropometry, and position of incision were correlated with assessability and accuracy of TLUSG. Twenty-nine (5.0 %) patients had “unassessable” VCs; among the “assessable” patients, 29 (5.3 %) patients had “inaccurate” TLUSG. More than one-third (38.5 %) of VC palsies (VCPs) were “inaccurate.” Older age (odds ratio [OR] = 1.055, 95 % confidence interval [CI] 1.016–1.095, p = 0.005), male sex (OR = 13.657, 95 % CI 2.771–67.315, p = 0.001), taller height (OR = 1.098, 95 % CI 1.008–1.195, p = 0.032), and shorter distance from cricoid cartilage to incision (OR = 0.655, 95 % CI 0.461–0.932, p = 0.019) were independent factors for “unassessable” VCs, whereas older age (OR = 1.028, 95 % CI 1.001–1.056, p = 0.040) was the only factor of incorrect assessment. Older age, male sex, tall in height, and incision closer to the thyroid cartilage were independent contributing factors for unassessable VCs, whereas older age was the only contributing factor for inaccurate postoperative TLUSG. Because more than one-third of VCPs were actually normal, patients labeled as such on TLUSG would benefit from laryngoscopic validation.

Prophylactic central neck dissection (pCND) at the time of the total thyroidectomy (TT) remains controversial in clinically nodal-negative (cN0) papillary thyroid carcinoma. Our study was designed to examine the predictive factors and pattern of locoregional recurrence (LRR) after pCND in the context of the postoperative stimulated Tg (sTg) level. A total of 341 patients who underwent TT and unilateral pCND were analyzed. Patients with an identifiable lesion on ultrasonography or whole-body scan within 6 months of surgery were excluded. LRR was defined as an identifiable lesion on USG, which was later confirmed by cytology/histology. Preablation sTg level was taken 2 months after surgery, whereas postablation sTg level was taken 8 months after surgery. Cox regression was used in the univariate and multivariate analyses to identify significant independent factors for LRR. After a follow-up of 66.6 ± 38.6 months, 14 (4.1 %) suffered from LRR. The duration to first LRR was 36.4 ± 21.7 months. The estimated 5- and 10-year LRR rates were 5.1 and 6.1 %, respectively. Of these 14 LRR, 3 (21.4 %) involved the central compartment alone, 9 (64.3 %) involved the lateral compartment alone, and 2 (14.3 %) involved both central and lateral compartments. After adjusting for other clinicopathological factors, postablation sTg level ≥ 1 µg/L (hazard ratio 265.109, 95 % confidence interval 1.132–62075.644, p = 0.045) was the only independent predictor of LRR. Annualized risk of LRR after pCND was approximately 1 % in the first 5 years and 0.2 % in the subsequent 5 years. Most (78.6 %) LRRs involved the lateral compartment. Postablation sTg ≥ 1 µg/L significantly predicted risk of LRR.

Although routine laryngeal examination (RLE) after thyroidectomy may cost more than selective laryngeal examination (SLE), it permits earlier detection and treatment of vocal cord palsy (VCP) and so may be cost-saving in the longer term. We compared the 2-year cost-effectiveness between RLE and SLE with RLE performed at 2 weeks (SLE-2w), 1 month (SLE-1m), and 3 months (SLE-3m) after thyroidectomy in the institution’s perspective. Our case definition was a hypothetical 50-year-old woman who underwent an elective total thyroidectomy for a benign multinodular goiter. A decision-analytic model was constructed to compare the estimated cost-effectiveness between RLE, SLE-2w, SLE-1m, and SLE-3m after a 2-year period. Outcome probabilities, utilities, and costs were estimated from the literature. The threshold for cost-effectiveness was set at US$50,000/quality-adjusted life-year. Sensitivity and threshold analyses were used to examine model uncertainty. RLE was not cost-effective because its incremental cost-effectiveness ratio to SLE-2w, SLE-1m, and SLE-3m were US$302,755, US$227,883 and US$247,105, respectively. RLE was only cost-effective when the temporary VCP rate increased >42.7 % or when the cost of RLE equaled zero. Similarly, SLE-2w was only cost-effective to SLE-3m when dysphonia for temporary VCP at 3 months increased >39.13 %, dysphonia for permanent VCP at 3 months increased >50.29 %, or dysphonia without VCP at 3 months increased >42.69 %. However, none of these scenarios appeared clinically likely. In the institution’s perspective, RLE was not cost-effective against the other three SLE strategies. Regarding to the optimal timing of SLE, SLE-3m appears to be a reasonable and acceptable strategy because of its relative low overall cost.

Background The purpose of this study was to compare surgical outcomes between those patients who underwent open thyroidectomy with and without neck extension. Methods One hundred eighty patients were randomized into 2 groups, with neck extension (group I) and without neck extension (group II). Outcomes included pain score on postoperative day 0, day 1, and the first clinic visit, operating time, blood loss, recurrent laryngeal nerve (RLN) injury, and hypoparathyroidism. Results Pain scores in group II were significantly lower on postoperative day 1 (2.38 vs 3.08; p = .022) and at the first clinic visit (0.57 vs 0.78; p = .026). There was a significant direct correlation between degree of neck extension and pain score on day 1 (p = .159 and p = .033). Other outcomes seemed comparable. However, the overall RLN injury rate was not significantly different between the 2 groups (5.3% vs 2.0%; p = .212). Conclusion Compared to group I, pain on postoperative day 1 and at the first visit in group II were significantly less, but both groups had similar overall RLN injury rate. © 2014 Wiley Periodicals, Inc. Head Neck 37: 407–412, 2015

Introduction Transcutaneous laryngeal ultrasonography (TLUSG) is a promising alternative to direct laryngoscopy in assessing perioperative vocal cord function. This study sought to evaluate the accuracy of TLUSG in assessing vocal cord function. Methods Altogether, 204 patients underwent TLUSG and direct laryngoscopy before and after elective thyroidectomy. For both examinations, vocal cord movements were independently graded. Grade I meant both vocal cords had normal movement; grade II meant ≥1 vocal cord had decreased movement; and grade III meant ≥1 vocal cord had no movement. Grade II or III on direct laryngoscopy was defined as vocal cord paresis or palsy (VCP). To assess accuracy, TLUSG findings were correlated with direct laryngoscopy findings. Results No patient had preoperative VCP, and 17 had unilateral postoperative VCP. The overall postoperative VCP rate was 5.1%. TLUSG failed to assess VCs in 11 (5.4%) postoperative patients. Of these, 2 had VCP and 9 had no VCP on direct laryngoscopy. Postoperative TLUSG had a sensitivity, specificity, positive predictive value, and negative predictive value of 93.3%, 97.8%, 77.8%, and 99.4%, respectively. Of the 175 patients with grade I on TLUSG, only 1 ( Conclusion TLUSG is a promising, noninvasive tool for selecting patients to undergo direct laryngoscopy before and after thyroidectomy.

Despite gaining popularity, robotic-assisted thyroidectomy (RT) remains controversial. This systematic review and meta-analysis is aimed at comparing surgically-related complications between RT and conventional open thyroidectomy (OT).A systematic review of the literature was performed to identify studies comparing surgically-related outcomes between RT and OT. Studies that compared ≥ 1 surgically-related outcomes between RT and OT were included. Outcomes included operating time, blood loss, complications, and hospital stay. Meta-analysis was performed using a fixed-effects model.Eleven studies were eligible but none were randomized controlled trials. Of the 2,375 patients, 839 (35.3 %) underwent RT, while 1,536 (64.7 %) underwent OT. RT was significantly associated with longer operating time (p0.001), hospital stay (p = 0.023) and higher temporary recurrent laryngeal nerve (RLN) injury (p = 0.016). Although there was no correlation between the number of RTs reported in the study and the rate of temporary RLN injury (p = -0.486, p = 0.328, respectively), routine perioperative laryngoscopy was performed in only 2 of 11 studies. Blood loss (p = 0.485), temporary (p = 0.333) and permanent (p = 0.599) hypocalcemia, hematoma (p = 0.602), and overall morbidity (p = 0.880) appeared comparable. Two (0.2 %) brachial plexus injuries in RT were reported in one study.Relative to OT, RT was associated with significantly longer operating time, longer hospital stay, and higher temporary RLN injury rate but comparable permanent complications and overall morbidity. Given some of the limitations with the literature and the potential added surgical risks and morbidity in RT, application of the robot in thyroid surgery should be carefully and thoroughly discussed before one decides on the procedure.

Although reoperative surgery in the central compartment (RCND) is indicated for bulky or progressive persistent/recurrent papillary thyroid carcinoma (PTC), its associated morbidity and disease outcomes remain unclear. We evaluated RCND outcomes by comparing them with those of patients who underwent primary central neck dissection (CND).After matching for age, sex, tumor size, and initial tumor stage, the morbidity and outcomes of 50 consecutive patients who underwent RCND were compared with data from 75 patients who underwent primary therapeutic CND during the same period. Matching was performed blind to the morbidity and disease outcome of each patient. A stimulated thyroglobulin (sTg)2 ng/ml was considered undetectable.Relative to primary CND, the incidence of extranodal extension (p = 0.010) and size of metastatic lymph nodes (p0.001) were significantly greater in the RCND group. Postoperative hypoparathyroidism and vocal cord palsy rates were comparable in the groups. There were two esophageal injuries in the RCND group and none in the primary CND group. The secondary CND group achieved a significantly lower undetectable postablation sTg rate (12.0 vs. 52.0 %, p = 0.001) and worse 10-year disease-free survival (35.6 vs. 91.8 %, p = 0.001) and cancer-specific survival (82.0 vs. 98.5 %, p = 0.001) than the primary CND group.Although RCND for persistent/recurrent PTC was performed with morbidity comparable to that seen with primary CND, it was associated with some serious complications. Short- and long-term disease control appeared moderate with approximately one-tenth of patients having an undetectable sTg level 6 months after ablation and one-third remaining clinically disease-free after 10 years.

Prophylactic central neck dissection (pCND) at the time of total thyroidectomy (TT) remains controversial in clinically node-negative (cN0) papillary thyroid carcinoma (PTC). Despite occult central lymph node metastases being common, it is unclear if removing these metastases initially would reduce future locoregional recurrence (LRR). This systematic review and meta-analysis aimed at comparing the short-term LRR between patients who underwent TT with pCND and those who underwent TT alone.A systematic review of the literature was performed to identify studies comparing LRR between patients with PTC who underwent TT + pCND (group A) and those who underwent TT alone (group B). Inclusion criteria were cN0 patients, with each comparative group containing10 patients, and with the number of LRR and mean follow-up duration available. The pooled incidence rate ratio (IRR) was used for calculating the LRR rate between the two groups. Other parameters evaluated included postoperative radioiodine (RAI) ablation, surgically related complications, and overall morbidity. Meta-analysis was performed using a fixed-effects model.Fourteen studies matched the selection criteria. Of the 3331 patients, 1592 (47.8%) belonged to group A, while 1739 (52.2%) belonged to group B. Relative to group B, group A was significantly more likely to have postoperative RAI ablation (71.7% vs. 53.1%; odds ratio [OR] = 2.60 [95% confidence interval (CI) = 2.12-3.18]), temporary hypocalcemia (26.0% vs. 10.8%; OR = 2.56 [CI = 2.04-3.21]), and overall morbidity (33.2% vs. 17.7%; OR = 2.12 [CI = 1.75-2.57]). When temporary hypocalcemia was excluded, overall morbidity was similar between the two groups (7.3% vs. 6.8%; OR = 1.07 [CI = 0.78-1.47]). Group A had a significantly lower risk of LRR than group B (4.7% vs. 8.6%; IRR = 0.65 [CI = 0.48-0.86]).Group A was more likely to have postoperative RAI ablation, temporary hypocalcemia, and overall morbidity than group B. Temporary hypocalcemia was the major surgical morbidity in pCND and, when excluded, the overall morbidity appeared similar between the two groups. Although our meta-analysis would suggest that those who undergo TT + pCND may have a 35% reduction in risk of LRR than those who undergo TT alone in the short term (5 years), it remains unclear how much of this risk reduction is related to increased use of RAI ablation and potential selection bias in some of the studies examined.

The issue of whether an involved but functioning recurrent laryngeal nerve (RLN) should be shaved or resected in locally advanced papillary thyroid carcinoma (PTC) remains controversial. Our study aimed to compare the early and late outcomes between those who underwent shaving and those who underwent resection and also to identify independent prognostic factors in this subset of patients. Of the 77 patients with 1 RLN involved by PTC, 39 (50.6 %) underwent RLN preservation (group I) while 38 (49.4 %) underwent RLN resection (group II). Early and late vocal cord function (as assessed by flexible laryngoscopy) and disease status were compared between the 2 groups. A multivariate Cox proportional hazards model was carried out to identify independent factors. Baseline characteristics were comparable between the 2 groups. Although temporary vocal cord palsy rate was similar between the 2 groups (p = 0.532), 5 patients in group II (13.2 %) suffered temporary bilateral vocal cord palsies with 1 requiring a tracheostomy lasting for 1 month. After a median follow-up of 113.8 months, 1 patient from each group developed new onset vocal cord palsy. Presence of distant metastases (hazard ratio [HR] = 5.892, 95 % CI = 1.971–17.604, p = 0.001) and incomplete surgical resection in non-RLN concomitant sites (HR = 2.491, 95 % CI = 1.181–5.476, p = 0.024) were the 2 independent predictors for a poor cancer-specific survival. Our data suggested that shaving could preserve the normal functionality in most of the involved RLNs (>90 %) in the short to medium term. In the presence of distant metastases or incomplete resection in other non-RLN concomitant sites, the argument for shaving over resection appears even stronger.

Although previous studies have suggested that low preoperative 25-hydroxyvitamin D (25-OHD) is a risk factor for hypocalcemia after total thyroidectomy, the impact of preoperative 25-OHD on calcium (Ca)/parathyroid hormone (PTH) kinetics in the immediate postoperative period remains unclear. The study compared the postoperative Ca/PTH kinetics between different preoperative 25-OHD levels.A total of 281 patients who underwent a total thyroidectomy were analyzed. Serum Ca was measured preoperatively within 1 h after surgery (Ca-D0) and on the following morning (Ca-D1). Preoperative 25-OHD was also measured after overnight fasting while postoperative PTH was checked at skin closure on day 0 (PTH-D0) and on the following morning on day 1 (PTH-D1). The Ca/PTH kinetics were compared between three groups (group I: preoperative 25-OHD10 ng/mL; group II: 25-OHD = 10-20 ng/mL; group III: 25-OHD20 ng/mL).Group I had significantly lower preoperative Ca (p = 0.016) and Ca-D0 (p = 0.036) but higher PTH-D1 (p = 0.015) than groups II and III. PTH-D0, Ca-D1, and the rate of clinically significant hypocalcemia were similar in the three groups. Group I had a significantly smaller Ca drop (-0.02 vs. 0.01 and 0.02 mmol/L, p = 0.011) and a tendency for a significantly smaller PTH drop (0.4 vs. 0.5 and 1.0 pmol/L, p = 0.073) than groups II and III. PTH-D1 (OR = 1.550) and 25-OHD (OR = 0.958) were independent factors for Ca drop from day 0 to day 1.Although group I began with lower serum Ca, those patients tended to have a greater PTH response to Ca drop and so preoperative 25-OHD did not significantly affect the overall Ca kinetics from preoperative to day 1.

Both ultrasonic coagulation (Harmonic Scalpel) (HS) and bipolar coagulation (Ligasure) (LS) are new energy devices commonly used in open thyroidectomy. This systematic review aimed at comparing the efficacy and surgical outcomes of total thyroidectomy (TT) between HS and. LS. A systematic review of the literature was performed to identify studies comparing HS and LS. Intraoperative outcomes, surgically related complications, overall morbidity, and hospital stay were evaluated. Meta-analysis was performed using a fixed-effects model. There were 8 studies that matched the selection criteria. Of the 963 patients who underwent TT, 433 (45.0 %) used HS (HS group) while 530 (55.0 %) used LS (LS group). Compared with LS, the HS group had significantly less volume of blood loss by 2.22 ml (95 % CI = 0.26–4.23 ml) (standardized mean difference [SMD] = −0.2, 95 % CI = −0.38 to −0.02) and reduced total operating time by 3.32 minutes (95 % CI = 1.62–5.03 minutes) (SMD = −0.28, 95 % CI = −0.42 to −0.15). There was no significant difference in temporary postoperative hypocalcemia (OR = 1.29, 95 % CI = 0.88–1.90), permanent postoperative hypocalcemia (OR = 1.45, 95 % CI = 0.23–9.26), temporary recurrent laryngeal nerve (RLN) injury (OR = 1.34; 95 % CI = 0.66–2.71), permanent RLN injury (OR = 1.00; 95 % CI = 0.25–4.03), hematoma (OR = 1.00; 95 % CI = 0.3–3.31), overall morbidity (OR = 1.21, 95 % CI = 0.87–1.69), and hospital stay (SMD = −0.03; 95 % CI = −0.07 to 0.01). Compared with LS, using HS in TT significantly reduced the volume of blood loss and operating time. However, the clinical significance of these findings remained questionable because the overall mean difference appeared small. There was no significant difference in the rate of complications, overall morbidity, and hospital stay between the two devices.

Introduction Use of intra-operative neuro-monitoring (IONM) during high-risk thyroidectomy has been suggested to decrease the rate of recurrent laryngeal nerve (RLN) palsy. However, current evidences were mixed and there was no large-scale study concluding its benefit. We evaluated the role of IONM in reducing RLN palsy during high-risk thyroidectomy and identified which high-risk subgroup would be most benefited. Methods A systemic review was performed to identify studies comparing the use of IONM and visual identification of RLN alone (VA) during high-risk thyroidectomy, namely re-operation, thyroidectomy for malignancy, thyrotoxicosis or retrosternal goitre. Rate of RLN palsy was presented in terms of number of nerve-at-risk (NAR). Meta-analysis on overall high-risk thyroidectomy and subgroups were performed using fixed or random-effects model. Results Ten articles were eligible for final analysis. There were 4460 NARs in VA group and 6155 NARs in IONM group. Comparing to VA, IONM had lower rate of overall [4.5% vs. 2.5%, Odd ratio (OR): 1.40, 95% confidence interval (CI): 1.12–1.79, p = 0.003] and temporary [3.9% vs. 2.4%; OR: 1.47, 95% CI: 1.07–2.00, p = 0.016] RLN palsy in overall high-risk thyroidectomies. On subgroup analysis, although numbers of NARs were less than minimal numbers required for a statistical powered study (2.1%–72.7%), use of IONM decreased the rate of overall RLN palsy during re-operation (7.6% vs. 4.5%, OR: 1.32, p = 0.021) and temporary RLN palsy during thyroidectomy for malignancy (3.1% vs. 1.6%, OR: 1.90, p = 0.026). Use of IONM tended to have a lower rate of overall RLN palsy during thyroidectomy for malignancy than VA alone. (3.5% vs. 2.1%, p = 0.050). Conclusions Selective use of IONM during high-risk thyroidectomy decreased the rate of overall RLN palsy. IONM should be applied during re-operative thyroidectomy and thyroidectomy for malignancy.

Since the first report of endoscopic subtotal parathyroidectomy in 1996, a variety of endoscopic surgical approaches has been reported. These endoscopic approaches include the minimally-invasive video-assisted thyroidectomy (MIVAT), the endoscopic lateral approach, the lateral mini-incision approach, the anterior/chest (hybrid) approach, the transaxillary approach, the axillo-breast approach, the post-auricular and axillary approach, and other novel experimental approaches. Some of these approaches could be done with the assistance of the da Vinci robot (i.e. robotic-assisted thyroidectomy). For simplification, these approaches could be categorized into the cervical/direct approach and the extra-cervical/indirect approach. Each technique or approach has its own benefits and weaknesses. Currently, there is no preferred approach in the literature and the choice seems to be determined by the surgeon’s own experience and the patient’s preference. In our experience, the transaxillary approach was a technically more challenging procedure and was associated with longer hospital stay, longer operating time, more immediate pain, and increased overall RLN injury and morbidity than MIVAT. The 6-month scar appearance and patient satisfaction were similar between the two procedures.

Background. Because patients with differentiated thyroid carcinoma (DTC) presenting with distant metastasis (DM) have a particularly poor prognosis, examining the prognostic factors in this group is essential. We aimed to evaluate the prognostic factors affecting cancer-specific survival (CSS) in DTC patients presenting with DM. Methods. Of the 1227 DTC patients, 51 (4.2 %) presented with DM at diagnosis. All patients underwent a total thyroidectomy, followed by radioiodine (RAI) ablation and postablation whole body scan (WBS). Patients were considered to have an osseous metastasis if one of the metastatic sites involved a bone, while RAI avidity was determined by any visual uptake in a known metastatic site on the first WBS. Factors predictive of CSS were determined by univariate and multivariate analyses by the Cox proportional hazard model. Results. In univariate analysis, older age (relative risk [RR] 1.050, 95 % confidence interval [CI] 1.010–1.091, P = 0.014), DM discovered before WBS (RR 3.401, 95 % CI 1.127–10.309, P = 0.030), follicular thyroid carcinoma (RR 3.095, 95 % CI 1.168–8.205, P = 0.025), osseous metastasis (RR 4.695, 95 % CI 1.379–15.873, P = 0.013), non-RAI avidity (RR 3.355, 95 % CI 1.280–8.772, P = 0.014), and external beam radiotherapy to DM (RR 3.241, 95 % CI 1.093–9.614, P = 0.034) were significant poor prognostic factors for CSS. In the multivariate analysis, after adjusting for other factors, osseous metastasis (RR 6.849, 95 % CI 1.495–31.250, P = 0.013) and nonRAI avidity (RR 7.752, 95 % CI 2.198–27.027, P = 0.001) were the two independent poor prognostic factors for CSS. Older age almost reached statistically significance (RR 1.055, 95 % CI 0.996–1.117, P = 0.068). Conclusions. DTC patients presenting with DM accounted for 4.2 % of all patients. Because osseous metastasis and RAI avidity were independent prognostic factors, future therapy should be directed at improving the treatment efficacy of osseous and/or non-RAI-avid metastases. Differentiated thyroid carcinoma (DTC) accounts for over 90 % of all follicular cell–derived thyroid malignancies and comprises two distinct histological types, papillary thyroid carcinoma and follicular thyroid carcinoma. 1 Despite the rising incidence, its prognosis remains excellent, with a 10-year cancer-specific survival (CSS) of up to 90 %. 2,3 However, up to 9 % of DTC patients present with distant metastasis (DM) at the time of diagnosis. 4 Unlike the rest of the group, this specific group carries a far worse prognosis. 2 In fact, this group accounts for much of the overall cancer-specific deaths. 2,3

Background. The efficacy of reoperative cervical neck dissection (RND) in achieving biochemical complete remission (BCR) (or postreoperation stimulated thyroglobulin [sTg] of \0.5 ng/mL) remains unclear in persistent/recurrent papillary thyroid carcinoma (PTC). We hypothesized that lower postablation sTg levels would indicate a higher rate of BCR after RND. Our study examined the association between postablation sTg and BCR after one or more RNDs. Methods. Of 199 patients who underwent RND, 81 patients were eligible. The postablation sTg levels (B2 and [2 ng/mL) were correlated with the postreoperation sTg levels after RNDs. Patients’ clinicopathological characteristics, operative findings, and subsequent RNDs were compared between those with BCR after RNDs and those without. Results. Those with postablation sTg levels of B2 ng/mL had significantly higher BCR rate after the first RND (77.8 vs. 5.6 %, p \ 0.001), overall BCR after one or more RNDs (77.8 vs. 9.3 %, p \ 0.001), and better 5-year recurrence-free survival after the first RND (80.0 vs. 60.1 %, p = 0.049) than those with postablation sTg levels of [2 ng/mL. Overall BCR gradually decreased after each subsequent RND. Postablation sTg significantly correlated with postreoperation sTg (q = 0.509, p \ 0.001). After adjusting for the number of metastatic lymph nodes excised at first RND and presence of extranodal extension, postablation sTg of B 0.2 ng/mL was the only independent factor for BCR after one or more RNDs (odds ratio 37.0, 95 % confidence interval 5.68–250.0, p = 0.001). Conclusions. Only a third of patients who underwent one or more RNDs for persistent/recurrent PTC had BCR afterward. Postablation sTg level was an independent factor for BCR. Completeness of the initial operation is important for the subsequent success of RND.

Background Although some studies have suggested that low preoperative 25-hydroxyvitamin D (25-OHD) levels may increase the risk of hypocalcemia and decrease the accuracy of single quick parathyroid hormone in predicting hypocalcemia after total thyroidectomy, the literature remains scarce and inconsistent. Our study aimed to address these issues. Methods Of the 281 consecutive patients who underwent a total/completion total thyroidectomy, 244 (86.8 %) did not require any oral calcium and/or calcitriol supplements (group 1), while 37 (13.2 %) did (group 2) at hospital discharge. 25-OHD level was checked 1 day before surgery, and postoperative quick parathyroid hormone (PTH) was checked at skin closure (PTH-SC). Postoperative serum calcium was checked regularly. Hypocalcemia was defined by the presence of symptoms or adjusted calcium of

Background Determinants for adequate lymph node yield (LNY) in prophylactic central neck dissection (pCND) for papillary thyroid carcinoma (PTC) remain unclear. We aimed to determine factors affecting LNY in pCND. Methods Of 230 patients, 109 (47.4%) had total thyroidectomy and unilateral pCND. A specimen of ≥6 central lymph nodes (CLNs) was considered adequate. Factors such as patient clinicopathologic features, specimen dimensions, and pathologists' experience were compared between those with LNY

Background Differentiated thyroid cancer survivors are at increased risk of nonsynchronous second primary malignancy, but the cause remains unclear. This study aimed to evaluate the association between radioiodine therapy and risk of nonsynchronous second primary malignancy and to examine whether the risk of nonsynchronous second primary malignancy in differentiated thyroid cancer survivors treated with radioiodine therapy is increased relative to the general population. Methods Among 895 radiation-naive patients with differentiated thyroid cancer, 643 (71.8%) received ≥1 course of radioiodine therapy (radioiodine therapy–positive group) and 252 (28.2%) received no radioiodine therapy (radioiodine therapy–negative group). After a median follow-up of 93.5 months (range, 23.4–570.8), 64 (7.2%) patients developed ≥1 nonsynchronous second primary malignancy. Potential risk factors for nonsynchronous second primary malignancy were entered into a multivariable regression model and cancer incidence in the radioiodine therapy–positive and –negative groups were compared to that of the general population by estimating the standardized incidence ratios. Results The 20-year cumulative nonsynchronous second primary malignancy risk in radioiodine therapy–positive group was significantly higher than radioiodine therapy–negative group (13.5% vs 3.1%; P = .015). Cumulative radioiodine therapy activity of 3.0 to 8.9 GBq (relative risk, 2.77; 95% CI, 1.079–7.154; P = .034) was the only independent risk factor for nonsynchronous second primary malignancy after adjusting for age, sex, period of differentiated thyroid cancer diagnosis, and stage of differentiated thyroid cancer. For females, the standardized incidence ratio in the radioiodine therapy–positive group was 1.54 (95% CI, 1.11–2.08) and in the radioiodine therapy–negative group it was 0.92 (95% CI, 0.37–1.90). Conclusion Differentiated thyroid cancer female survivors treated by radioiodine therapy appeared to be at elevated risk of nonsynchronous second primary malignancy when compared to the general population and this risk was not apparent in those not previously treated by radioiodine therapy.

BACKGROUND: Prophylactic central neck dissection (CND) remains controversial in papillary thyroid carcinoma (PTC). Because postsurgical stimulated thyroglobulin (sTg) level is a good surrogate for recurrence, the study aimed to evaluate the impact of prophylactic CND on preablative and postablative sTg levels after total thyroidectomy. METHODS: Of the 185 patients retrospectively analyzed, 82 (44.3%) underwent a total thyroidectomy and prophylactic CND (CND-positive group) while 103 (55.7%) underwent total thyroidectomy only (CND-negative group). All patients had no preoperative or intraoperative evidence of lymph node metastases. Clinicopathological characteristics, postoperative outcomes, and preablative and postablative sTg levels were compared between the two groups. Preablative sTg level was taken at the time of radioiodine ablation, while postablative sTg level was taken 6 months after ablation. A multivariable analysis was conducted to identify factors for preablative athyroglobulinemia (sTg, published_or_final_version, Springer Open Choice, 21 Feb 2012

Background. The prognostic significance of size of central lymph node metastasis (CLNM) in papillary thyroid carcinoma (PTC) remains unknown. Because postsurgical detectable stimulated thyroglobulin (DsTg) after radioiodine ablation may imply persistent or recurrent disease, we evaluated the association between size of CLNM and rate of DsTg in patients with PTC who underwent unilateral prophylactic central neck dissection. Methods. To be eligible for analysis, the prophylactic central neck dissection specimen with \3 central lymph nodes (CLNs) or size of CLNM C1 cm as measured under the microscope was excluded. Of 132 specimens, 89 (67.4 %) were eligible. Forty patients (44.9 %) had no metastasis or pN0, 20 (22.5 %) had micrometastasis (\2 mm) or pN1mic and 29 (32.6 %) had macrometastasis (C2 mm) or pN1mac. Postablation sTg level was measured 9 months after surgery. A multivariable analysis was conducted to identify independent factors for postablation DsTg. Results. Larger-sized CLNM correlated significantly with younger age (p = 0.028), greater number of CLN retrieved (p = 0.016), greater number of metastatic CLN excised (p \ 0.001), higher metastatic CLN ratio (p = 0.006) and postablation sTg level (p = 0.012). In the multivariable analysis, after adjusting for tumor size and metastatic CLN ratio, size of CLNM was an independent predictor of postablation DsTg (odds ratio 1.56, 95 % confidence interval 1.09–2.24, p = 0.015). Relative to pN0, the odds ratios for postablation DsTg in pN1mic and pN1mac were 2.53 (95 % confidence interval 0.35–19.00, p = 0.351) and 5.81 (95 % confidence interval 1.22–27.70, p = 0.027), respectively. Conclusions. Size of CLNM was an independent factor for DsTg 9 months after surgery. Patients with pN1mac were almost 6 times more likely to have postablation DsTg than those with pN0 or pN1mic.

An increasing elderly population, a rising incidence of differentiated thyroid carcinoma (DTC), and a rising incidence of benign nodular disease with age are all contributing to a rise in thyroid operations for the elderly. Literature review on the outcome and safety of thyroid surgery in elderly patients has been filled with conflicting results and this subject remains controversial. Although most single-institution studies conducted by high-volume surgeons did not find significant differences of complication rates in elderly when compared with younger cohorts, they often lacked the power necessary to identify subtle differences and suffered from various selection and referral biases. Recent evidence from large population-based studies concluded that thyroid surgery in the elderly was associated with higher complication rates. One of the major contributing factors for the increased complication rate was because most elderly patients suffered from many preexisting comorbidities. Therefore, elderly patients who have abnormal thyroid findings should complete a thorough preoperative workup and better postoperative care after undergoing any thyroid surgery. Furthermore, these high-risk patients would benefit if they could be referred to high-volume, specialized surgical units early. In this systemic review, we aimed to evaluate different issues and controversies in thyroidectomy for elderly patients.

Intraoperative nerve stimulation (IONS) could potentially reduce the incidence of recurrent laryngeal nerve (RLN) injury in thyroidectomy. The current study aimed at demonstrating the technical feasibility of using IONS in gasless, transaxillary endoscopic thyroidectomy (GTET) and robotic-assisted thyroidectomy (RAT) with conventional nerve stimulator probe and comparing the overall accuracy between two different nerve stimulation techniques, namely the direct RLN stimulation and the indirect stimulation via the vagus nerve (VN group), in predicting postoperative RLN function.From 2009 to 2010, 60 (17.1%) patients underwent endoscopic thyroidectomy using IONS. Thirty-three (55.0%) patients had direct intraoperative RLN stimulation (RLN group), whereas 27 (45.0%) patients had stimulation to the VN (VN group). Total number of nerves at risk was 76. The results of IONS were confirmed by the postoperative vocal cord movement on laryngoscopy.Patient demographics, surgical indications, resection type, size of dominant nodule, excised gland weight, and final pathology were similar between the two groups. The number of vocal cord palsies in the RLN and VN groups was 3 (7.3%) and 2 (5.7%), respectively. Compared with the VN group, the RLN group had a significantly lower percentage of true negatives (78.0% vs. 94.3%, P=.045) and higher percentage of false positives (14.6% vs. 0.0%, P=.018). Overall accuracy was higher in the VN group.The current study demonstrated the technical feasibility of using conventional open-nerve stimulator probe in both GTET and RAT. Indirect stimulation via the VN produced more reliable and accurate IONS test results than direct RLN stimulation.

Background: Prognostic significance of metastatic central lymph node ratio (CLNR) in papillary thyroid carcinoma (PTC) remains unknown. Because postsurgical detectable stimulated thyroglobulin (DsTg) after radioiodine ablation may imply persistent or recurrent disease, we evaluated the association between CLNR and rate of DsTg in patients with PTC who underwent unilateral prophylactic central neck dissection. Methods: To be eligible for analysis, the prophylactic central neck dissection specimen had to contain ≥3 central lymph nodes (CLNs) with ≥1 harboring metastasis. Of 129 specimens, 51 (39.5%) were eligible. CLNR was calculated as follows: (number of metastatic CLNs/number of CLNs retrieved) × 100. They were categorized into group 1 (CLNR 66.67%) (n = 22). Postablation sTg level was measured 6 months after radioiodine ablation. A multivariate analysis was conducted to identify factors for postablation DsTg. Results: Young age, palpable neck swelling, large tumor size, advanced tumor, node, metastasis system (TNM) stage, and large number of metastatic CLNs were significantly associated with high CLNR (P, published_or_final_version, Springer Open Choice, 21 Feb 2012

BACKGROUND: Patients with eucalcemic parathyroid hormone elevation (ePTH) after parathyroidectomy for primary hyperparathyroidism (HPT) may be at risk of recurrence. We aimed to examine risk factors, trend of PTH level, and outcome of patients with ePTH 6 months after parathyroidectomy. METHODS: A total of 161 primary HPT were analyzed. The 6-month postoperative calcium and PTH levels were obtained. ePTH was defined as an elevated PTH level in the presence of normocalcemia. At 6 months, 98 had eucalcemic normal PTH and 63 (39.1%) had ePTH. Perioperative variables, PTH trend, and outcome were compared between 2 groups. Multivariable analyses were performed to identify independent preoperative and operative/postoperative risk factors for ePTH. RESULTS: Among preoperative factors, advanced age (odds ratio [OR] = 1.042, P = .027) and low 25-hydroxyvitamin D(3) (25OHD(3)) (OR = 1.043, P = .009) were independently associated with ePTH, whereas among operative/postoperative factors, high 10-min intraoperative PTH level (OR = 1.015, P = .040) and high postoperative 3-month PTH (OR = 1.048, P < .001) were independently associated with ePTH. After a mean follow-up of 38.7 months, recurrence rate was similar between the 2 groups (P = 1.00). In the first 2 postoperative years, 75 (46.6%) had ePTH on at least 1 occasion and 8 (5.0%) had persistently ePTH on every occasion. CONCLUSIONS: Advanced age, low 25OHD(3), high 10-min intraoperative PTH, and high postoperative 3-month PTH were independently associated with ePTH at 6-month. Although 39.1% of patients had ePTH at 6 months, more than 50% had at least 1 ePTH within the first 2 years of follow-up. Recurrence appeared similar between those with or without ePTH at 6 months., published_or_final_version, Springer Open Choice, 21 Feb 2012

Background Because the fluorescent light intensity on an indocyanine green fluorescence angiography reflects the blood perfusion within a focused area, the fluorescent light intensity in the remaining in situ parathyroid glands may predict postoperative hypocalcemia risk after total thyroidectomy. Methods Seventy patients underwent intraoperative indocyanine green fluorescence angiography after total thyroidectomy. Any parathyroid glands with a vascular pedicle was left in situ while any parathyroid glands without pedicle or inadvertently removed was autotransplanted. After total thyroidectomy, an intravenous 2.5 mg indocyanine green fluorescence angiography was given and real-time fluorescent images of the thyroid bed were recorded using the SPY imaging system (Novadaq, Ontario, Canada). The fluorescent light intensity of each indocyanine green fluorescence angiography as well as the average and greatest fluorescent light intensity in each patient were calculated. Postoperative hypocalcemia was defined as adjusted calcium Results The fluorescent light intensity between discolored and normal-looking indocyanine green fluorescence angiographies was similar ( P = .479). No patients with a greatest fluorescent light intensity >150% developed postoperative hypocalcemia while 9 (81.8%) patients with a greatest fluorescent light intensity ≤150% did. Similarly, no patients with an average fluorescent light intensity >109% developed PH while 9 (30%) with an average fluorescent light intensity ≤109% did. The greatest fluorescent light intensity was more predictive than day-0 postoperative hypocalcemia ( P = .027) and % PTH drop day-0 to 1 ( P Conclusion Indocyanine green fluorescence angiography is a promising operative adjunct in determining residual parathyroid glands function and predicting postoperative hypocalcemia risk after total thyroidectomy.

To assess vocal cord (VC) movement with transcutaneous laryngeal ultrasound (TLUSG), three maneuvers, namely passive (quiet respiration), active (phonation), and Valsalva maneuvers have been described. It remains unclear which maneuver or using more maneuvers provides better visualization and assessment accuracy. We prospectively evaluated 342 post-thyroidectomy patients from two centers. They underwent TLUSG with direct laryngoscopic (DL) validation afterwards. During TLUSG, patients were instructed to perform all three maneuvers (passive, active, and Valsalva). VC visualization rate and accuracy between three maneuvers were compared. Visualization rate tended to be higher in Valsalva maneuver than that in other two maneuvers (92.1% vs. passive: 91.5%; active: 89.8%). While 19 patients had post-operative VC palsy, passive maneuver had lower test specificity than active (94.3 vs. 97.6%, p = 0.01) and Valsalva maneuvers (94.3 vs. 97.4%, p = 0.02). In assessable VCs, passive maneuver has a higher ability to differentiate between mobile VCs and VC palsy (Area under ROC curve--passive: 0.942, active: 0.863, Valsalva: 0.893). TLUSG with more maneuvers did not improve sensitivity or specificity. On applying TLUSG as a screening tool (i.e., only selected patient with "unassessable" VCs or VCP on TLUSG for DL), Valsalva maneuver (85.96%) saved more patients from DL than passive (81.87%) or active (84.81%) maneuver. Passive maneuver has a higher ability to differentiate VC palsy from normal. Using TLUSG as a screening tool, Valsalva was the preferred maneuver as it was more specific, had high visualization rate, and saved more patients from DL.

Bilateral pheochromocytoma (PHEO) is more frequently found in patients with multiple endocrine neoplasia 2A carrying a RET germline mutation located in codon 634 (C634). However, it is unclear whether different amino acid substitutions within C634 cause differences in bilateral PHEOs expression. We aimed to answer this by pooling data from two Asian institutions. Sixty-seven patients had confirmed C634 germline mutation. Age-dependent penetrance of bilateral PHEO was calculated from date of birth to the date when bilateral PHEO was first diagnosed or when the contralateral gland became a PHEO (if the patient already had one adrenal gland removed). Age-dependent penetrance was estimated by the Kaplan–Meier method and compared by log-rank test. The 4 different amino acid substitutions included C634R (arginine) (n = 19, 28.4 %), C634Y (tyrosine) (n = 36, 38.8 %), C634G (glycine) (n = 4, 6.0 %), and C634W (tryptophan) (n = 8, 11.9 %). The age-related penetrance of PHEO was similar between C634R, C634Y, C634G, and C634W (by age 40, 69.8, 55.2, 25.0, and 56.2 %, respectively) (p = 0.529). However, the age-related penetrance of bilateral PHEO in C634R was significantly higher than C634Y (by age of 40, 59.3 % vs. 25.2 %, p = 0.046) or C634Y, C634G, and C634W combined (59.3 % vs. 21.5 %, p = 0.024). Nevertheless, the accumulative risk of bilateral PHEOs across all four C634 mutations almost approached 100 % over time. The accumulative risk of bilateral PHEOs almost reached 100 % but its onset was significantly earlier in C634R mutation. These findings implied that those with C634R mutation might benefit from earlier screening of contralateral PHEO than other C634 mutations after an unilateral adrenalectomy.

Although an age cutoff of 45 years has often been adopted to stratify cancer risk in papillary thyroid carcinoma (PTC), both cancer-specific survival (CSS) and disease-specific survival (DFS) continue to worsen beyond this cutoff. This study aimed to determine whether advanced age (i.e.,60 years) at diagnosis was an independent predictor of CSS and DFS in older (≥45 years) patients.This study analyzed 407 PTC patients with a minimal follow-up period of 7 years. Standard protocol was followed. Both CSS and DFS were estimated using the Kaplan-Meier method and compared with the log-rank test. Variables shown to be significant by the log-rank test were entered into the Cox regression analysis.During a median follow-up period of 15.1 years, 51 patients (12.5 %) died of PTC, whereas 80 (20.5 %) experienced at least one recurrence. For CSS, age beyond 60 years (hazard ratio [HR], 3.027; 95 % confidence interval [CI] 1.369-6.690; p = 0.006), tumor size greater than 4 cm (HR 2.043; 95 % CI 1.141-4.255; p = 0.049), central nodal metastases (HR 2.726; 95 % CI 1.198-6.200; p = 0.017), lateral nodal metastases (HR 5.247; 95 % CI 2.987-9.216; p 0.001), and distant metastases (HR 4.297; 95 % CI 1.726-2.506; p = 0.002) were independent predictors. For DFS, only tumor size greater than 4 cm (HR 1.733; 95 % CI 1.030-3.058; p = 0.049), central nodal metastases (HR 2.362; 95 % CI 1.010-5.523; p = 0.047), and lateral nodal metastases (HR 4.383; 95 % CI 2.388-8.042; p 0.001) were independent predictors.Advanced age was an independent predictor of CSS, and cancer-related death risk showed a continuing increase beyond the age of 60 years. However, advanced age was not an independent predictor of DFS. Therefore, having another age cutoff appears justifiable for stratifying risk of cancer-related death but less justifiable for disease recurrence. Tumor size as well as central and lateral nodal metastases independently predicted CSS and DFS.

Preoperative neutrophil to lymphocyte ratio (NLR) might be prognostic in papillary thyroid carcinoma (PTC). Given the controversy of prophylactic central neck dissection (pCND) in clinically nodal-negative (cN0) PTC, our study evaluated whether preoperative NLR predicted disease-free survival (DFS) and occult central nodal metastasis (CNM) in cN0 PTC.A total of 191 patients who underwent pCND were analyzed. Complete blood counts with differential counts were taken before operation. NLR was calculated by dividing preoperative neutrophil count with lymphocyte count. Patients were categorized into NLR tertiles: first (NLR1.93; n = 63), second (NLR = 1.93-2.79; n = 64), and third tertile (NLR2.79; n = 64). Four other patient types, namely, benign nodular goiter, clinically nodal-positive (cN1) PTC, poorly differentiated thyroid carcinoma, and anaplastic thyroid carcinoma (ATC), were used as references.Age at operation (p0.001) and tumor size (p = 0.037) significantly increased with higher NLR. First tertile had significantly more TNM stage I tumors (p = 0.01) and lowest MACIS score (p = 0.002). Tumor size [hazard ratio (HR) 1.422, 95% confidence interval (CI) 1.119-1.809, p = 0.004] and multicentricity (HR = 2.545, 95% CI 1.073-6.024, p = 0.034) independently predicted DFS, whereas old age [odds ratio (OR) 1.026, 95% CI 1.006-1.046, p = 0.009), male (OR 2.882, 95% CI 1.348-6.172, p = 0.006), and large tumor (OR 1.567, 95% CI 1.209-2.032, p = 0.001) independently predicted occult CNM. NLR was not significantly associated with DFS or occult CNM. ATC had significantly higher NLR than cN1 PTC (7.28 vs. 2.74, p0.001).Although a higher NLR may imply a poorer tumor profile, it was not significantly associated with a worse DFS or higher risk of occult CNM in cN0 PTC. Perhaps, future research should focus on the prognostic value in other thyroid cancer types with a poorer prognosis.

Objective. Thyrotoxic periodic paralysis (TPP) is a potentially life-threatening complication of Graves' disease (GD). The present study compared the long-term efficacy of antithyroid drugs (ATD), radioactive iodine (RAI), and surgery in GD/TPP. Methods. Sixteen patients with GD/TPP were followed over a 14-year period. ATD was generally prescribed upfront for 12-18 months before RAI or surgery was considered. Outcomes such as thyrotoxic or TPP relapses were compared between the three modalities. Results. Eight (50.0%) patients had ATD alone, 4 (25.0%) had RAI, and 4 (25.0%) had surgery as primary treatment. Despite being able to withdraw ATD in all 8 patients for 37.5 (22-247) months, all subsequently developed thyrotoxic relapses and 4 (50.0%) had ≥1 TPP relapses. Of the four patients who had RAI, two (50%) developed thyrotoxic relapse after 12 and 29 months, respectively, and two (50.0%) became hypothyroid. The median required RAI dose to render hypothyroidism was 550 (350-700) MBq. Of the 4 patients who underwent surgery, none developed relapses but all became hypothyroid. Conclusion. To minimize future relapses, more definitive primary treatment such as RAI or surgery is preferred over ATD alone. If RAI is chosen over surgery, a higher dose (>550 MBq) is recommended., published_or_final_version

The purpose of this study was to compare surgical outcomes between those patients who underwent open thyroidectomy with and without neck extension.One hundred eighty patients were randomized into 2 groups, with neck extension (group I) and without neck extension (group II). Outcomes included pain score on postoperative day 0, day 1, and the first clinic visit, operating time, blood loss, recurrent laryngeal nerve (RLN) injury, and hypoparathyroidism.Pain scores in group II were significantly lower on postoperative day 1 (2.38 vs 3.08; p = .022) and at the first clinic visit (0.57 vs 0.78; p = .026). There was a significant direct correlation between degree of neck extension and pain score on day 1 (p = .159 and p = .033). Other outcomes seemed comparable. However, the overall RLN injury rate was not significantly different between the 2 groups (5.3% vs 2.0%; p = .212).Compared to group I, pain on postoperative day 1 and at the first visit in group II were significantly less, but both groups had similar overall RLN injury rate.

Routine preoperative laryngeal examination remains controversial. We aimed to assess the utility of preoperative routine flexible laryngoscopy (FL) by looking at the incidence, clinical significance and predictors for preoperative vocal cord paresis (VCP) and incidental laryngopharyngeal conditions (LPC) in our consecutive cohort. A total of 302 patients underwent laryngeal examination by an independent otorhinolaryngologist and were specifically asked about voice/swallowing symptoms suggestive of VCP 1 day before surgery. As well as vocal cord (VC) mobility, the naso-pharynx and larynx were examined using FL. Any VCP and/or LPC was recorded. VCP was defined as reduced or absent movement in one or more VC. An LPC was considered clinically significant if the ensuing thyroidectomy was changed or deferred. Seven (2.3 %) patients had preoperative VCP, while an additional seven patients had an incidental LPC. Of the seven VCPs, five were caused by previous thyroidectomy, while two were caused by a benign goitre. The incidence of asymptomatic VCP in a previously non-operated cohort was 1/245 (0.41 %). Voice/swallowing symptoms (p = 0.033) and previous thyroidectomy (p

Oral calcium and calcitriol are often prescribed after total thyroidectomy to avoid biochemical and/or symptomatic hypocalcemia. We aimed to identify independent perioperative factors that correlated with the duration of calcium and/or calcitriol supplementation after total thyroidectomy. Of 271 eligible patients, 48 (17.7 %) required calcium and/or calcitriol supplements on discharge. Patients were gradually weaned from the supplementation by one surgeon according to a biweekly algorithm based on serum calcium (Ca). Duration of supplementation was calculated from the date of operation to the date of ceasing all supplementation without biochemical hypocalcemia (i.e., serum adjusted Ca ≥8.44 mg/dL). The Cox regression analysis was performed to identify independent perioperative factors for duration of supplementation. The best cut-off value for these independent factors was determined by the receiver characteristic curve. In the multivariate analysis, parathyroid hormone (PTH) at skin closure (PTH-SC) (RR 1.742, 95 % CI 1.080–2.810) and on postoperative day 1 adjusted Ca (Ca-D1) (RR 77.526, 95 % CI 3.600–1669.57) were the only two independent determinants for shorter duration before ceasing all supplementation. The best cut-off values in predicting supplementation ≥6 months for PTH-SC and Ca-D1 were 7.08 pg/mL (sensitivity = 100 %, specificity = 60.5 %, PPV = 40.0 % and NPV = 100 %) and 7.88 mg/dL (sensitivity = 90.0 %, specificity = 55.3 %, PPV = 34.6 % and NPV = 95.5 %), respectively. Both PTH-SC and Ca-D1 were independently associated with the duration of supplementation after total thyroidectomy. Almost all patients with PTH-SC ≥7.08 pg/mL or Ca-D1 ≥7.88 mg/dL did not require supplementation ≥6 months whereas about one third of patients with PTH-SC

Metastatic disease to regional lymph nodes (LNs) is common in papillary thyroid carcinoma (PTC). LN dissection is increasingly performed as part of the surgical management of PTC. The role of prophylactic central neck dissection (pCND) in PTC is unclear. There is limited evidence to support a routine pCND in clinical setting for nodal negative (cN0) PTC. The aim of this review was to examine the pros and cons of prophylactic neck dissection in cN0 PTC. In summary, the advantages of pCND are: removal of the central LNs that potentially harbor micro-metastases, more accurate staging of disease in order to plan more individualized management, reducing the need for re-operation to remove the metastatic LNs which have developed later and possible improvement in overall survival. The disadvantages are: an extensive surgery but lack of evidence of survival benefit, higher incidence of complications with little impact on local recurrence rate, possibility of over treating in cN0 patients and it does not sound like a cost effective approach in the management of small thyroid cancer. Considering low frequency of permanent morbidity, some authors believe that prophylactic neck dissection is safe in experienced hands even though its prognostic benefit has yet to be demonstrated.

Successful thermal ablation using radiofrequency has been reported in various tumors including liver or kidney tumors. Nonsurgical minimally invasive ablative therapy such as radiofrequency ablation (RFA) has been reported to be a safe and efficient treatment option in managing symptomatic cold thyroid nodules or hyperfunctioning thyroid nodules. Pressure and cosmetic symptoms have been shown to be significantly improved both in the short and long terms after RFA. For hyperfunctioning thyroid nodules, RFA is indicated for whom surgery or radioiodine are not indicated or ineffective or for those who refuse surgery or radio-iodine. Improvement of thyroid function with decreased need for antithyroid medications has been reported. Complication rate is relatively low. By reviewing the current literature, we reported its efficacy and complications and compared the efficacy of RFA relative to other ablative options such as ethanol ablation and laser ablation. © 2013 Kai-Pun Wong and Brian Hung-Hin Lang., published_or_final_version

Background The gasless, transaxillary endoscopic thyroidectomy (GTET) and minimally invasive video-assisted thyroidectomy (VAT) are both well-recognized endoscopic thyroid procedures, but how their postoperative outcomes are compared remains unclear. The present study was designed to compare surgical morbidities/complications and scar appearance between GTET and VAT at our institution. Methods Of the 141 patients eligible for endoscopic thyroidectomy, 96 (68.1 %) underwent GTET and 45 (31.9 %) underwent VAT. Patient demographics, indications, operative findings, pain scores on days 0 and 1, and surgical morbidities were compared between the two groups. At 6 months after surgery, all patients were asked about their satisfaction on the cosmetic result by giving a score (Patient Satisfaction Score or PSS) and their scar appearance was assessed by the 11 domains in the Patient and Observer Scar Assessment Scale (POSAS). Results GTET was associated with a significantly longer operating time (84 vs. 148 min, p = 0.005), higher pain scores on days 0 and 1 (2.9 vs. 2.3, p = 0.042 and 2.2 vs. 1.7, p = 0.033, respectively), overall recurrent laryngeal nerve (RLN) injury (6.3 vs. 0 %, p = 0.043), and overall morbidity rates (12.5 vs. 2.2 %, p = 0.049) than VAT. The actual individual score for the 11 domains in POSAS and for PSS remained similar between the two groups. They remained similar even when patients with morbidity were excluded. Conclusions GTET was a technically more challenging procedure and was associated with longer hospital stay, longer operating time, more immediate pain, and increased overall RLN injury and morbidity than VAT. The 6-month POSAS and PSS were similar between the two procedures.

Determinants for adequate lymph node yield (LNY) in prophylactic central neck dissection (pCND) for papillary thyroid carcinoma (PTC) remain unclear. We aimed to determine factors affecting LNY in pCND.Of 230 patients, 109 (47.4%) had total thyroidectomy and unilateral pCND. A specimen of ≥ 6 central lymph nodes (CLNs) was considered adequate. Factors such as patient clinicopathologic features, specimen dimensions, and pathologists' experience were compared between those with LNY 6 (n = 52) and LNY ≥ 6 (n = 57). A multivariate analysis was conducted to identify independent factors for LNY ≥ 6.Age, sex, presentation, body mass index, tumor characteristics, TNM stages, MACIS score, and pathologist's experience were not significant determinants for LNY ≥ 6. In the univariate analysis, the length (P = 0.021), width (P = 0.047), thickness (P = 0.024), and pN1a (P = 0.042) were significant determinants but in the multivariate analysis, the length (OR = 1.486 (95% CI: 1.053-2.097), P = 0.024) was the only independent factor for LNY ≥ 6. Postoperative vocal cord palsy, hypoparathyroidism, stimulated thyroglobulin and recurrences were similar between LNY6 and ≥ 6.Length (or the longest measured dimension) of the fresh CLN specimen was the only factor assuring LNY ≥ 6. Surgical complications and short-term outcomes appeared similar between LNY6 or ≥ 6.