Wojciech Cichoń and Stanisław Cichoń
Current Options in the Surgical Management of Hyperparathyroidism
Stanisław Cichoń and Marcin Barczyński
Endocrine Surgery on the Verge of the 21th Century
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.
Wojciech Cichoń, Grzegorz Walencik, Wojciech Gierczak, Krzysztof Aksędowski, Jerzy Bucki and Stanisław Cichoń
Increasing number of surgical subspecialities causes general surgeons have little experience with more complex procedures as total thyroidectomy.
The aim of the study was to present the outcome of total thyroidectomy following its implementation in a district hospital where such procedure has not been performed previously.
Material and methods. 293 patients were operated on for goiter between 01.10.2008 and 30.09.2011 in the District Hospital in Proszowice by one contracted endocrine surgeon. Hemithyroidectomy was performed in 75 (23.7%) patients and total thyroidectomy in 191 (76.3%) patients for multinodular goiter and only the latter group was subjected for further analysis.
Results. There were no bilateral recurrent laryngeal nerve palsy. A unilateral transient recurrent laryngeal nerve palsy occured in 6 patients (3.1%; 1.5% per risk) and postoperative hypocalcemia in 29 (15.7%) patients. 2 (1%) patients required wound revision due to a postoperative bleeding. Postoperative pathology revealed in 12 (6.2%) patients differentiated thyroid cancer.
Conclusions. 1. Total thyroidectomy in a district hospital is still a safe way to operate on thyroid for nonmalignant disorders with low number of complications. 2. Total thyroidectomy is a definite surgical treatment in patients diagnosed by postoperative pathology with differentiated thyroid cancer.
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
Aleksander Konturek, Marcin Barczyński, Stanisław Cichoń, Ryszard Anielski, Wojciech Cichoń, Jerzy Jamski, Jacek Jonkisz and Paweł Orlicki
Ultrasonic Scalpel Versus Classic Procedures with Limited Access in Thyroid Gland Surgery
The aim of the study was to demonstrate the advantages of employing the ultrasonic scalpel in maintaining appropriate intraoperative hemostasis as compared with traditional methods of thyroid vessel ligation and coagulation
Material and methods. Between December 2003 and May 2006, 2410 patients were managed for various thyroid diseases at the Department of Endocrine Surgery. In the presented group, 179 procedures that employed minimally invasive surgical techniques including 101 operations in which US was used to secure the thyroid vessels (group A) and 78 operations in which the superior thyroid vessels were clipped and subjected to bipolar coagulation without US (group B) were performed. Both groups were similar with respect to gender, age, indications for surgery and mean thyroid volume. Statistical analysis included mean operative time, postoperative blood loss, scar length and cosmetic satisfaction assessed on visual-analogue scale (VAS) at 1 month following surgery.
Results. Mean operative time was significantly greater in group B vs A (54.5±14.2 vs 35.4±8.7 min, respectively; t-test; p<0.001). Mean postoperative blood loss was significantly higher in group B vs A (32.8±13.0 vs 12.9±5.7 ml, respectively; t-test; p<0.001). One case of transient paralysis of the recurrent laryngeal nerve and two instances of postoperative drop in calcium concentration values below the normal range was observed. The mean scar length at 1 month following surgery was significantly longer in group B vs A (21.5±1.9 vs 15.6±1.4 mm, respectively; t-test; p<0.001). Cosmetic satisfaction was significantly lower in group B vs. A patients (81.9±5.4 vs 88.9±9.7pts, respectively; t-test; p<0.001).
Conclusion. The use of an ultrasonic scalpel in thyroid surgery reduces the mean operative time, achieves good hemostasis and improves cosmetic results without increasing the risk of morbidity
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.
Wojciech Cichoń, Aleksander Konturek, Ryszard Anielski, Marcin Barczyński, Anna Gierada, Paweł Orlicki and Stanisław Cichoń
Hypocalcemia After Thyroid Surgery Single-Center Experience Based on 987 Patients Operated on for Various Thyroid Diseases Within One Year
The aim of the study was to compare the extent of surgery in removal of thyroid tissue and serum calcium values postoperatively.
Material and methods. Between January 1 and December 31, 2005, 987 patients were operated on at our department due to various thyroid disorders. Patients with anaplastic, medullary and high-stage highly-differentiated (TNM>T3, N0, M0) thyroid carcinomas, as well as reoperated individuals, were excluded from the investigation. The patients were divided into three groups, depending on their serum calcium values; thus, the authors distinguished groups with mild (2.0-2.19 mmol/l), moderate (1.8-1.99 mmol/l) and severe hypocalcemia (<1.8 mmol/l). Differences between the groups were assessed by statistical methods (the t-Student's test and the X 2 test - the STATISTICA software). The value of p<0.05 was accepted as statistically significant.
Results. Of 987 surgical patients, 63 (6.4%) were found to have symptomatic or asymptomatic hypocalcemia. The group included 61 females and two males, their mean age being 50.1±12 years. The intensity of clinical symptoms of hypoparathyroidism was positively correlated with serum calcium values and the said symptoms were most clearly seen in patients classified as belonging to group 3 (Ca<1.8 mmol/l). The most common surgically treated thyroid disease was non-toxic nodular goiter. Hypocalcemia was the most frequent finding in patients operated on due to thyroid carcinoma. In all patients with a mild form of hypocalcemia, the onset of clinical symptoms occurred on postoperative day 2. As it follows from the analysis, there were no statistically significant differences in hypocalcemia prevalence between patients subjected to bilateral exposure of the thyroid lobes and subtotal vs. total thyroidectomy (6 (6.1%) vs 24 (7.1%) patients). On the other hand, a statistically significant difference between the lower prevalence rate of hypocalcemia in unilateral procedures (p<0.001) as compared to bilateral neck explorations (4 (1.4%) vs 59 (8.4%) patients) seems to be logical and physiologically justified. In addition, an element that was found to affect the level of calcium deficit was the number of parathyroid glands identified "in situ". Hence, the prevalence of hypocalcemia increased with a decrease in the number of identified parathyroids (p<0.05). In hypocalcemic patients, hospitalization time ranged from 3 to 11 days, with a mean time of 5.3 days as compared to 3 days in patients without complications. Six months after the surgery and pharmacotherapy, no clinical and biochemical signs of hypocalcemia were noted in the above described group.
Conclusions. The risk of hypocalcemia following thyroid surgery is higher in bilateral neck explorations. There are no statistically significant differences in postoperative hypocalcemia between patients subjected to bilateral subtotal vs. total thyroidectomies.
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.