Abstract
Background
Intraoperative nerve monitoring (IONM) is used increasingly in thyroid surgery to prevent recurrent laryngeal nerve (RLN) injury, despite lack of definitive evidence. This study ...analysed the United Kingdom Registry of Endocrine and Thyroid Surgery (UKRETS) to investigate whether IONM reduced the incidence of RLN injury.
Methods
UKRETS data were extracted on 28 July 2018. Factors related to risk of RLN palsy, such as age, sex, retrosternal goitre, reoperation, use of energy devices, extent of surgery, nodal dissection and IONM, were analysed. Data with missing entries for these risk factors were excluded. Outcomes of patients who had preoperative and postoperative laryngoscopy were analysed.
Results
RLN palsy occurred in 4.9 per cent of thyroidectomies. The palsy was temporary in 64.6 per cent and persistent in 35.4 per cent of patients. In multivariable analysis, IONM reduced the risk of RLN palsy (odds ratio (OR) 0.63, 95 per cent confidence interval (CI) 0.54 to 0.74, P < 0.001) and persistent nerve palsy (OR 0.47, 0.37 to 0.61, P < 0.001). Outpatient laryngoscopy was also associated with a reduced incidence of RLN palsy (OR 0.50, 0.37 to 0.67, P < 0.001). Bilateral RLN palsy occurred in 0.3 per cent. Reoperation (OR 12.30, 2.90 to 52.10, P = 0.001) and total thyroidectomy (OR 6.52, 1.50 to 27.80; P = 0.010) were significantly associated with bilateral RLN palsy.
Conclusion
The use of IONM is associated with a decreased risk of RLN injury in thyroidectomy. These results based on analysis of UKRETS data support the routine use of RLN monitoring in thyroid surgery.
Based on analysis of United Kingdom Registry of Endocrine and Thyroid Surgery data, recurrent laryngeal nerve (RLN) palsy occurred in 4.9 per cent of thyroidectomies. RLN monitoring reduced the risk of overall RLN palsy (odds ratio (OR) 0.63, 95 per cent CI 0.54 to 0.74; P <0.001) and persistent RLN palsy (OR 0.47, 0.37 to 0.61; P <0.001) in multivariable analysis. These results support the routine use of RLN monitoring in thyroid surgery.
IONM reduces RLN
Post-thyroidectomy haemorrhage occurs in 1-2 per cent of patients, one-quarter requiring bedside clot evacuation. Owing to the risk of life-threatening haemorrhage, previous British Association of ...Endocrine and Thyroid Surgeons (BAETS) guidance has been that day-case thyroidectomy could not be endorsed. This study aimed to review the best currently available UK data to evaluate a recent change in this recommendation.
The UK Registry of Endocrine and Thyroid Surgery was analysed to determine the incidence of and risk factors for post-thyroidectomy haemorrhage from 2004 to 2018.
Reoperation for bleeding occurred in 1.2 per cent (449 of 39 014) of all thyroidectomies. In multivariable analysis male sex, increasing age, redo surgery, retrosternal goitre and total thyroidectomy were significantly correlated with an increased risk of reoperation for bleeding, and surgeon monthly thyroidectomy rate correlated with a decreased risk. Estimation of variation in bleeding risk from these predictors gave low pseudo-R2 values, suggesting that bleeding is unpredictable. Reoperation for bleeding occurred in 0.9 per cent (217 of 24 700) of hemithyroidectomies, with male sex, increasing age, decreasing surgeon volume and redo surgery being risk factors. The mortality rate following thyroidectomy was 0.1 per cent (23 of 38 740). In a multivariable model including reoperation for bleeding node dissection and age were significant risk factors for mortality.
The highest risk for bleeding occurred following total thyroidectomy in men, but overall bleeding was unpredictable. In hemithyroidectomy increasing surgeon thyroidectomy volume reduces bleeding risk. This analysis supports the revised BAETS recommendation to restrict day-case thyroid surgery to hemithyroidectomy performed by high-volume surgeons, with caution in the elderly, men, patients with retrosternal goitres, and those undergoing redo surgery.
Introduction
Hypoxic stress is a feature of rapidly growing thyroid tumours. Cancer progression is thought to be driven by a small population of tumour cells possessing stem cell properties. ...Hypoxia-inducible factors (HIFs) are important mediators of hypoxia. Both HIF-1alpha and HIF-2alpha have been reported to be expressed in thyroid cancers. There is growing evidence that the HIF pathway plays a significant role in the maintenance of thyroid cancer stem cells (CSC).
Methodology
We have isolated thyroid CSC from a papillary thyroid cancer-derived cell line (BCPAP) and an anaplastic thyroid cancer-derived cell line (SW1736) as side population (SP) cells (a putative stem cell population) and treated them with cobalt chloride (II) to induce hypoxia.
Results and discussion
We observed an increase in the SP of cells within the thyroid cancer cell lines following induction of hypoxia.
Introduction Multiple surgical approaches to the thyroid gland have been described via cervical or extracervical routes. Improved cosmesis, patient satisfaction, reduced pain (procedure dependent) ...and early discharge have all been reported for minimally invasive approaches with similar safety profiles and long-term outcomes to conventional surgery. This review summarises the current evidence base for improved cosmesis with minimally invasive cervical approaches to the thyroid gland compared with conventional surgery. Methods A systematic review was undertaken. The MEDLINE(®), Embase™ and Cochrane databases were searched for relevant articles. Results A total of 57 papers thyroid papers were identified. Of those, 20 reported some form of cosmetic outcome assessment. There were 6 randomised controlled trials with 412 patients (evidence level 2B), 7 cohort studies with 3,073 patients (level 3B) and 7 non-comparative case series with 1,575 patients (level 4). There was significant heterogeneity between studies in terms of wound closure technique, timing of scar assessment and scar assessment scales (validated and non-validated). Most studies performed early scar assessments, some using non-validated scar assessment tools. Conclusions Assessment of cosmesis is complex and requires rigorous methodology. Evidence from healing/remodelling studies suggests scar maturation is a long-term process. This calls into question the value of early scar assessment. Current evidence does not support minimally invasive surgical approaches to the thyroid gland if improved long-term cosmesis is the goal.
Background
The United Kingdom Registry of Endocrine and Thyroid Surgeons is a national database holding details on > 28,000 parathyroidectomies.
Methods
An extract (2004–2017) of the database was ...analysed to investigate the reported efficacy, safety and use of intra-operative surgical adjuncts in targeted parathyroidectomy (tPTx) and bilateral neck exploration (BNE) for adult, first-time primary hyperparathyroidism (PHPT).
Results
50.9% of 21,738 cases underwent tPTx. Excellent short-term (median follow-up 35 days) post-operative normocalcaemia rates were reported overall (tPTx 96.6%, BNE 94.5%,
p
< 0.05) and in image-positive cases (tPTx 96.7%, BNE 96%,
p
< 0.05). Intra-operative PTH improved overall normocalcaemia rates (tPTx 97.8% vs 96.3%, BNE 95% vs 94.4%: both
p
< 0.05). Intra-operative nerve monitoring reduced vocal cord (VC) dysfunction in image-positive tPTx, but not in BNE (97.8% vs 93.2%,
p
< 0.05). Complications were higher following BNE (7.4% vs 3.8%,
p
< 0.05), especially hypocalcaemia (5.3% vs 2%,
p
< 0.05). There was no difference in rates of subjective dysphonia following tPTx or BNE (2.4% vs 2.3%,
p
> 0.05), nor any difference in VC dysfunction when formally examined (4.9% vs 4.1%,
p
> 0.05).
Conclusions
In image-positive, first time, adult PHPT cases, tPTx is as safe and effective as BNE, with both achieving excellent short-term results with minimal complications.
Purpose
Categorize data to investigate the surgeon volume outcome relationship in thyroidectomies. Determine the evidence base for recommending a minimum number of thyroidectomies performed per year ...to maintain surgical competency.
Methods
Data on thyroid operations in the United Kingdom Registry of Endocrine and Thyroid Surgery (UKRETS) from 01/09/2010 to 31/08/2016 was analysed. The primary outcome measure was permanent hypoparathyroidism (PH). Recurrent laryngeal nerve palsy (RLN) and post-operative haematoma were also examined. Exclusion criteria included patient age > 85 or < 18 years, and surgeons contributing <10 operations. Data analysis was performed using general additive models and mixed effect logistic regression for PH and binary logistic regression for others.
Results
For PH 10313 bilateral thyroid operations were analysed. The Annual rate (AR,
p
= 0.012) and nodal dissection (
P
< 10
−7
) were significant factors. 25,038 thyroidectomies were analysed to investigate the effect of surgeon Volume on RLN palsy and haematoma. Age, retrosternal goitre, routine laryngoscopy, re-operation, nodal Dissection, bilateral thyroidectomy, RLN monitoring and surgeon volume were significantly associated with RLN palsy. Post-operative haematoma showed no significant correlation to surgeon volume. Categorisation of AR showed that PH and RLN palsy rates declined in surgeons performing >50 cases/year to a minimum of 3% and 2.6% respectively in highest volume AR group (>100 cases/year).
Conclusion
Surgeon annual operative volume is a factor in determining outcome from thyroid surgery. Results are limited by a high proportion of missing data, which could potentially bias the outcome, but tentatively suggests the minimum recommended number of thyroid operations / year should be 50 cases.
Highlights ► Rotarix associated with 59% reductions in severe gastroenteritis over 2 consecutive rotavirus seasons in South Africa. ► 3-dose Rotarix schedule was associated with the trend of being ...more immunogenic than a 2-doses. ► 3-dose Rotarix schedule was associated with higher efficacy estimate over two seasons than a 2-doses. ► The optimal dosing schedule of Rotarix in providing long-term protection in African children needs to be explored.
Calcitonin-negative medullary thyroid carcinoma is a rare, poorly understood primary neuroendocrine carcinoma of the thyroid characterised by classic medullary thyroid carcinoma morphology without ...raised serum calcitonin. A 24-year-old woman presented with a slow-growing, right-sided neck swelling. She underwent an ultrasound scan, cytopathological and histopathological examination, and tests for alternative diagnoses. The ultrasound showed a heterogeneous, hyperechoic nodule in the right thyroid lobe. Serum calcitonin was normal. Cytopathology and histopathology showed typical medullary thyroid carcinoma morphology but without calcitonin upon immunostaining and mRNA in situ hybridisation. A 'triple-negative' calcitonin-negative medullary thyroid carcinoma was diagnosed. A completion thyroidectomy with bilateral central lymph node dissection was performed. The patient remains well three-years post-surgery. When cytopathology suggests a medullary thyroid carcinoma, serum calcitonin, pro-calcitonin, carcinoembryonic antigen and calcitonin-gene-related peptide should be measured to identify cases of calcitonin-negative medullary thyroid carcinoma. They should also be measured post-treatment for monitoring purposes. This will aid future calcitonin-negative medullary thyroid carcinoma diagnoses and will inform prognostic stratification and influence treatment decisions.
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