Stanisław Cichoń and Marcin Barczyński
Krzysztof Pragacz and Marcin Barczyński
Intraoperative neuromonitoring facilitates identification of the recurrent laryngeal nerves (RLN) and allows for predicting their postoperative function. Nevertheless, the outcome of thyroid surgery monitoring is affected by both the experience of the operator and his mastering of the technique.
The aim of the study was the assessment of the learning curve for intraoperative RLN neuromonitoring.
Material and methods. The prospective analysis included 100 consecutive thyroid operations performed by a single surgeon during implementation of RLN neuromonitoring in a district surgical ward in Staszów. RLN neuromonitoring was performed in keeping with the recommendations of the International Neural Monitoring Study Group using a C2 NerveMonitor (Inomed, Germany). The outcomes of initial 50 procedures (group I: 08/2012-07/2013) were compared with the results of subsequent 50 operations (group II: 08/2013-07/2014). The evaluation included demographic and intraoperative data along with predictive value of the method and complications.
Results. In group II as compared to group I, a significant reduction of operative time was noted (102.1±19.4 vs 109.9±19; p=0.045), along with an increased percentage of identified RLNs (99% vs 89.2%; p=0.006), a decreased percentage of correction-requiring technical errors (8% vs 24%; p=0.029), an improved negative predictive (99% vs 89.3%; p<0.001) and positive value (75% vs 55.6%; p<0.001), as well as a decreased percentage of RLN injuries (3% vs 14%; p=0.006).
Conclusions. Mastering the technique of intraoperative RLN neuromonitoring in thyroid surgery requires the surgeon to perform independently approximately 50 monitored procedures, what allows for achieving the predictive value of the method that is comparable to outcomes published by referral centers.
Jakub Kenig, Piotr Richter and Marcin Barczyński
The umbilical area can present with a variety of signs associated with an intra abdominal malignancy. An umbilical/paraumbilical hernia might itself be a sign of an internal malignancy. The correlation between the presence of an umbilical/paraumbilical hernia and an intra abdominal malignancy has been previously based only on case reports. The aim of the study was to evaluate the significance of an umbilical/paraumbilical hernia as a symptom of an intraabdominal malignancy. Material and methods. A retrospective analysis was performed; review of the medical records of 145 patients (113 female and 32 male; mean age 66.4±11.9) with an umbilical/paraumbilical hernia treated during the period of 2005-2013. Twenty-three patients (15.9%) were diagnosed with an intra abdominal malignancy; 34% were in the age group over 75 years of age. Results. The most common malignancies were: colorectal cancer, followed by pancreatic cancer, and cancers of the adnexa and kidneys. The patients with a concomitant malignancy identified were significantly older than those without a malignancy. In 65% of patients, the diagnosis was made postoperatively. Logistic regression analysis demonstrated that age, the presence of preoperative symptoms, anemia, and weight loss were independent risk factors for concomitant abdominal cancer. Conclusion. The findings of this study support intensive preoperative diagnostic evaluation of elderly patients that are qualified for surgery for an umbilical/paraumbilical hernia. This is particularly important because most of these patients had a small/medium hernia orifice, which did not allow for accurate manual abdominal exploration. Currently, the routine preoperative diagnostic evaluation is often insufficient for an accurate diagnosis
Marcin Barczyński, Stanisław Cichoń, Aleksander Konturek, Wojciech Cichoń and Wojciech Wierzchowski
Comparison of Two Techniques of Minimally Invasive Parathyroidectomy: Video-Assisted (MIVAP) and open (OMIP)
The aim of the study was to recapitulate the experience of the authors in the employment of two minimally invasive parathyroidectomy (MIP) techniques: video-assisted according to Miccoli (MIVAP) and open according to Udelsmann (OMIP) as the procedure of choice in primary hyperparathyroidism resulting from parathyroid adenomas.
Material and methods. The investigation included 168 patients qualified for MIP between December 2002 and April 2007, diagnosed as primary hyperparathyroidism and presenting with a single parathyroid adenoma detected in at least one imaging examination (USG and/or 99m Tc-MIBI subtraction scintigraphy). In group A (n=100), the procedures were performed employing the MIVAP technique with intraoperative serum parathormon determinations (IOPTH), while in group B (n=68), the OMIP technique was used in combination with IOPTH. The analysis included surgical indications, the course of the procedure, the validity of intraoperative histopathology in identifying multiglandular disease, the validity of IOPTH in selection of an appropriate extent of neck exploration, and the surgical outcome.
Results. Postoperative normocalcemia was achieved in 99% vs 100% of patients, respectively (A vs. B). In nine patients subjected to MIP, intraoperative IOPTH allowed for detection of multiglandular disease. IOPTH proved to be significantly more effective in identification of patients with multiglandular disease as compared to intraoperative examination of a single resected parathyroid gland, which had been demonstrated by imaging studies to be a single adenoma (the accuracy of 98.8% vs. 92.8%, respectively). The conversion rate was 5% and 5.8%, respectively (A vs B). A significantly higher percentage of visualized recurrent laryngeal nerves was noted in group A vs B (88% vs 66%, respectively), although the prevalence of transient recurrent laryngeal nerve palsy was similar in both groups (1% vs 2.9%). The investigators also observed a decrease in pain-associated complaints (by the mean value of 25%) and a decreased demand for analgesic drugs (by the mean value of 50%) on the first postoperative day. Satisfaction of the cosmetic effect was higher in the first postoperative month in group A vs B, although the difference became non-significant after 6 months.
Conclusions. Both techniques, MIVAP, as well as OMIP, are highly effective in surgical treatment of patients with primary hyperparathyroidism caused by a single adenoma. However, the use of IOPTH is necessary when the results of preoperative localization examinations are not complementary in order to minimize the risk of inadvertently missing multiglandular disease. The advantage of MIVAP consists in easier identification of the recurrent laryngeal nerve, a decreased pain and decreased demand for analgesic drugs after the surgery, as well as a better cosmetic effect in the early postoperative period resulting from a smaller scar size.
Marcin Barczyński, Aleksander Konturek, Małgorzata Stopa, Filip Gołkowski, Alicja Hubalewska-Dydejczyk, Stanisław Cichoń and Wojciech Nowak
Bilateral Neck Exploration with Intraoperative iPTH Assay in the ERA of Minimaly Invasive Parathyroidectomy
At present, the majority of patients with sporadic primary hyperparathyroidism (pHPT) qualify to minimally invasive parathyroidectomy (MIP). Nevertheless, in some patients, especially those with multiglandular parathyroid disease, achieving normocalcemia necessitates bilateral neck exploration (BNE).
The aim of the study was evaluation of current indications for BNE and results obtained employing this method in an endocrine surgery referral center.
Material and methods. A prospective analysis included 385 patients with pHPT qualified to parathyroidectomy (300 to MIP and 85 to BNE procedures) in the period between 12/2002 and 05/2008. Prior to the procedure, all the patients underwent preoperative imaging diagnostic studies (scintiscans of the parathyroids and ultrasound of the neck). Intraoperative parathormone assay was carried out in the course of all the operations. Indications for BNE and therapeutic results were evaluated.
Results. The most common indication for BNE was lack of preoperative location of a parathyroid adenoma in imaging studies aiming either at lateralization or regionalization (49.4%), followed by concomitant thyroid pathology that required surgical treatment (23.5%), MEN 1 syndrome (12.9%), long-term lithium therapy (5.9%), refusal of the patient to grant informed consent to a minimally invasive parathyroidectomy (5.9%) and MEN 2A syndrome (2.4%). In the discussed group, 31 subtotal parathyroidectomies were performed, along with ten resections of two parathyroid adenomas and 44 resections of single parathyroid adenomas. Intraoperative iPTH assay affected the extent of parathyroid tissues resection in eight (9.4%) cases. One case of persistent and one case of recurrent hyperparathyroidism were noted in the follow-up of mean 37.4 ± 19.4 months postoperatively.
Conclusions. In an endocrine surgery referral center, BNE is a procedure of choice in patients suspected of multiglandular parathyroid disease (MEN 1 and 2A, familial pHPT, long-term lithium therapy), in cases when a pathological parathyroid has not been located preoperatively and in patients which refuse their consent to MIP. Supplementing BNE with intraoperative iPTH assay allows for maintaining the highest quality of surgical treatment.
Marcin Barczyński, Aleksander Konturek, Stanisław Cichoń, Filip Gołkowski and Alicja Hubalewska-Dydejczyk
Posterior Retroperitoneoscopic Adrenalectomy - Clnical Evaluation of the Method Based on the Four-Year Experience
The aim of the study was to present the authors' four-year experience in employing posterior retroperitoneoscopic adrenalectomy according to Walz (PRA) in surgical treatment of adrenal tumors up to 6 cm in size.
Material and methods. A prospective analysis included 83 procedures of unilateral PRA (40 rightsided and 43 left-sided adrenalectomies) performed in patients (the M:F ratio = 22:61; mean age 58.1±10.3 years; mean tumor size 41±14 mm) operated on in the Department in the period from January 2004 to December 2007. Indications for surgery included: glucocorticoid adenomas (10), aldosteronomas (18), pheochromocytomas (16) and hormonally inactive adrenal cortex tumors (39). The operators used the PRA surgical technique according to Walz. The learning curve was evaluated taking into consideration the operative time, percentage of conversions and complications. The statistical analysis assessed the correlation between the operative time and body mass index (BMI), location and size of the tumor and its hormonal activity. The results of surgical treatment employed in patients with hormonally active tumors were evaluated in a 6-month follow-up.
Results. The mean operative time was 73.7±22.3 min. A single conversion (1.2%) was required, as well as a single early reoperation (1.2%) due to bleeding. Following the initial 20 operations with the mean operative time of 86.5±34.6 min, the mean operative time of the remaining 63 procedures was 69.7±14.9 min (p=0.046) and did not exceed 90 min in any case. No correlation was noted between the operative time and BMI, tumor location and size. The procedures performed in patients with pheochromocytomas were not significantly longer in comparison to operations in hormonally inactive adrenocortical adenomas. Normalization of arterial blood pressure was achieved in all the patients with pheochromocytomas, aldosteronomas and subclinical glucocorticoidism aged below 50 years and with less than one-year history of secondary hypertension.
Conclusions. Despite its seeming complexity resulting from operating in an "upside down" surgical field, the PRA surgical technique is easy to master and safe, also during the learning period. After the surgeon has performed approximately 20 operations, the operative time does not exceed 90 min. PRA is worthy of recommending in the case of adrenal tumors qualified for surgical treatment and not exceeding 6 cm in size.
Marcin Barczyński, Alicja Hubalewska-Dydejczyk, Aleksander Konturek, Anna Sowa-Staszczak and Stanisław Cichoń
Minimally Invasive Radio-Guided Reoperative Surgery with Intraoperative ipth Assay in Primary Hyperparathyroidism
The aim of the study was to present the experience of the authors in employing minimally invasive radio-guided parathyroid reoperative surgery (MIRP) combined with intraoperative iPTH assay (IOPTH) in persistent and recurrent primary hyperparathyroidism (PHP) and in patients with a history of thyroidectomy.
Material and methods. A prospective analysis included the results of 12 reoperations performed employing the minimally invasive method using an intraoperative hand-held gamma camera (Gamma Finder II) following IV administration of 10 mCi 99mTc-MIBI, combined with IOPTH (Future Diagnostics) in six patients with persistent PHP, one patient with recurrent PHP and five patients after subtotal strumectomies without planned parathyroidectomies (F: M = 10 : 2; mean age 54±10.7 years; mean preoperative iPTH concentration 233.3±80.6 ng/L). Prior to surgery, all the patients had been subjected to diagnostic imaging studies (parathyroid scintiscans, USG of the neck, in selected cases, SPECT and CT of the neck and mediastinum). The validity of MIRP and IOPTH in minimizing the extent of intraoperative neck exploration was assessed. Therapeutic results were evaluated in six-month postoperative follow-up.
Results. All the patients were cured. The mean incision length was 3.5±0.5 cm. The mean operative time was 49±10 min. All the patients had a single parathyroid adenoma (in five cases - in the tracheoesophageal groove, in 3 - in the retroesophageal region in the neck, in one - in the retroesophageal region in the superior posterior mediastinum, in one - in the thyrothymic ligament and in two - in the thymus). The mean ratio of adenoma to background neck radioactivity was 25.7±5.4%. The mean iPTH concentration 10 min after adenoma resection was 38.5±17.4 ng/L. No postoperative complications were noted. In six-month postoperative follow-up, all the patients demonstrated normal serum calcium values.
Conclusions. MIRP has proven to be highly successful in reoperations in patients with PHP. The procedure performed using a hand-held gamma camera allows for a safe execution of a minimally invasive procedure focused on resection of a single parathyroid adenoma, eliminating the need for bilateral neck exploration, which is extensive, time-consuming and associated with a higher risk of damaging the recurrent laryngeal nerve and normal parathyroids.
Stanisław Cichoń, Ryszard Anielski, Aleksander Konturek, Marcin Barczyński, Wojciech Cichoń and Paweł Orlicki
Total Thyroidectomy in Multinodular Non-Neoplastic Goiter
The aim of the study was to describe the experience of the authors in performing total thyroidectomies in patients referred to surgical treatment with the diagnosis of non-neoplastic multinodular goiter.
Material and methods. Over a period of 6 years (2000-2005), 4999 surgical procedures were performed in patients diagnosed as having non-neoplastic goiter at our department. Thus, the analysis does not include patients operated on due to carcinoma of the thyroid, diagnosed either pre- or intraoperatively, or individuals with recurrent goiter. Total thyroidectomies were performed in 408 (8.16%) patients. Subtotal thyroidectomies, i.e. a total lobectomy involving one, dominant thyroid lobe and combined with a subtotal resection of the contralateral lobe, were done in 1251 (25.02%) individuals. In patients with lesions involving one thyroid lobe only, the operators performed a total resection of the affected lobe, while leaving the normal, contralateral lobe without any surgical intervention. Such a procedure was performed in 89 (1.78%) individuals. In very few cases, the operation consisted of a subtotal unilateral lobectomy; such a treatment modality was employed in 39 (0.78%) patients. The predominantly performed procedure employed in 3212 (64.1%) patients was subtotal bilateral lobectomy of the thyroid gland. The patients were divided into groups according to the type of surgery performed. The groups were then compared for clinical diagnosis and the prevalence of early and late postoperative complications. The Student-t test was employed to calculate the probability and confidence interval values.
Results. Among surgical patients not suspected of thyroid carcinomas, neoplastic lesions were, nevertheless, confirmed by postoperative histopathology in 310 (6.2%) individuals. As shown in the presented data, increased extent of the procedure was associated with thyroid carcinoma, diagnosed only by postoperative histopathology an increased number of complications, among which the most common was hypocalcemia.
Conclusions. 1. Total thyroidectomy may be a preferred method for treating bilateral multinodular goiter; when performed by an experienced endocrine surgeon, it is associated with a low percentage of postoperative complications. 2. Total thyroidectomy in bilateral multinodular goiters lead to a decreased number of secondary operations in patients.
Aleksander Konturek, Marcin Barczyński, Stanisław Cichoń, Ryszard Anielski, Wojciech Cichoń, Jacek Jonkisz and Paweł Orlicki
Total Thyroidectomy in Treatment of Graves' Ophthalmopathy
The aim of the study. The present report is an attempt at answering the question regarding the ocular status in the course of thyroid ophthalmopathy following surgical treatment. A retrospective analysis included a group of patients presenting with various ophthalmologic symptoms in the course of Graves' disease. The analysis focused on the clinical ophthalmologic status determined based on eye examinations and determinations of the level of thyroid stimulating hormone receptor antibody (TRAb), as well as on changes in the above parameters in pre and postoperative examinations.
Material and methods. Between January 2005 and December 2006, 61 patients were managed surgically for Graves' disease. The group consisted of 53 (86.9%) females and eight (13.1%) males. Their mean age was 45.5±12 years, with the range of 18 to 71 years. Prior to surgery, the mean duration of pharmacotherapy was 27.3 months, with the range of 3-120 months. The severity of the disease was determined using the NOSPECS classification and the resultant ophthalmopathy index according to Donaldson. Ocular symptoms were assessed prior to treatment and subsequently at 3, 6 and 12 months after thyroidectomy. Determinations of TSH, fT4 and antithyroid antibodies TRAb were done in all the patients before and 12 months after surgical treatment. In the present investigations, determinations of the thyroid stimulating hormone receptor antibody (TRAb) levels were done by radioimmunoassay.
Results. All the 61 patients were treated surgically. The following procedures were performed: total thyroidectomies in 35 (57.4%) patients, the so-called Dunhill operations (total lobectomy plus subtotal resection of the contralateral side) in 14 (23%), and subtotal bilateral lobectomies in 12 (19.6%) subjects. Determinations of thyroid stimulating hormone receptor antibody TRAb levels were done preoperatively in 61 (100%) patients and postoperatively in 54 (88.5%) individuals. In the present series, preoperative TRAb values were significantly elevated (>2 IU/L) in as many as 56 (91.8%) patients. After the surgery, TRAb normalized in 35 (57.4%) patients (<1 IU/L - absent) from 9.14±10.7 to 0.95±0.45 IU/L (p<0.001, test t). The differences are statistically significant. Borderline antibody values (between 1 and 2 IU/l) were noted in 5 (8.1%) patients before and in 18 (29.5%) after the procedure. The ophthalmologic assessment based on the Donaldson ophthalmopathy index, which combines scores awarded while evaluating five classes (soft tissues, degree of exophthalmus, oculomotor muscle status, corneal status, visual acuity) included 54 (88.5%) of 61 patients. The value of the index changed in the entire investigated group, what was manifested in a statistically significant decrease in the ophthalmopathy index from 6.1±2.32 prior to treatment to 3.31±2.09 after the surgery (p<0.001, test t). Deterioration of the general ocular status as confirmed by the initial ophthalmopathy index was confirmed by ophthalmology in five patients. Subjective complaints of deteriorated vision were reported by three patients
Conclusions. The use of ultrasonic scalpel in thyroid surgery a reduction of mean operating time, achieving good hemostasis and improved cosmetic results without increased risk of morbidity
Marcin Barczyński, Aleksander Konturek, Małgorzata Stopa, Alicja Hubalewska-Dydejczyk, Piotr Richter and Wojciech Nowak
Clinical Value of Intraoperative Neuromonitoring of the Recurrent Laryngeal Nerves in Improving Outcomes of Surgery for Well-Differentiated Thyroid Cancer
The recurrent laryngeal nerve (RLN) is particularly prone to injury during thyroidectomy in case of extralaryngeal bifurcation being present in approximately one-third of patients near the inferior thyroid artery or ligament of Berry. Meticulous surgical dissection in this area may be additionally facilitated by the use of intraoperative neuromonitoring (IONM) to assure safe and complete removal of thyroid tissue.
The aim of the study was to verify the hypothesis that meticulous surgical technique of tissue dissection in the area of the posterior surface of the thyroid capsule and adjacent RLN may be additionally facilitated by intraoperative neuromonitoring (IONM), and may contribute to increasing the safety and radicalness of total thyroidectomy in patients with well-differentiated thyroid cancer.
Material and methods. The outcomes of total thyroidectomy with level VI lymph node clearance for well-differentiated thyroid cancer (WDTC; pT1-3, N0-1, Mx) were retrospectively compared between 151 patients undergoing surgery with IONM (01/2005-06/2009) and 151 patients undergoing surgery without IONM (2003-2004). RLN morbidity (calculated for nerves at risk) was assessed by videolaryngoscopy or indirect laryngoscopy (mandatory before and after surgery and at 12-month follow-up). The anatomical course of the extralaryngeal segment of RLNs were analyzed in detail in each operation. Thyroid iodine uptake (131I) was measured during endogenous TSH stimulation test a week before radioiodine therapy.
Results. Among patients operated with vs. without IONM, the early RLN injury rate was 3% vs. 6.7% (p=0.02), including 2% vs. 5% (p=0.04) of temporary nerve lesions, and 1% vs. 1.7% of permanent nerve events (p=0.31), respectively. Extralaryngeal RLN bifurcation was identified in 42 (27.8%) vs. 25 (16.6%) of patients operated with vs. without IONM, respectively (p=0.001). Mean I-131 uptake following total thyroidectomy with vs. without IONM was 0.67 ± 0.39% vs. 1.59 ± 0.69% (p<0.001). 131I uptake lower than 1% was found in 106 (70.2%) vs. 38 (25.2%) patients operated with vs. without IONM, respectively (p<0.001).
Conclusions. Most patients with WDTC who undergo total thyroidectomy have a small amount of residual thyroid tissue. The use of IONM may improve the outcomes of surgery among these patients by both increasing the completeness of total thyroidectomy and significantly reducing the prevalence of temporary RLN injury. The possible mechanism of this improvement is the aid in dissection at the level of the Berry's ligament offered by IONM which enhances the surgeon's ability to identify a branched RLN, and allows for reduction of traction injury and neuropraxia of the anterior branch of bifid nerves.