Post Thyroidectomy Assessment of Intact Parathyroid Hormone for Early Prediction of Hypocalcaemia

Background: As the half-life of intact parathyroid hormone (iPTH) is very low, it reflects parathyroid insufficiency within minutes to hours after total thyroidectomy. Therefore, iPTH level assessment in the postoperative period can be used to predict the development of hypocalcaemia. The optimal time point to measure serum iPTH is important for the accurate prediction of hypocalcaemia. Aim: This paper aims to evaluate the ability of iPTH as an early predictive marker of hypocalcaemia and determine which time iPTH is more able to predict postoperative hypocalcaemia. Method: This prospective observational study was conducted in the Department of Otolaryngology-Head & Neck Surgery, BSMMU, Dhaka, from July 2020 to December 2021, with 67 patients who underwent total thyroidectomy. iPTH levels were measured on the day before the operation and at 1 hour, 4 hours, and 24 hours after the operation. S.calcium levels were measured on the day before the operation and 1st postoperative day. All the data were compiled and sorted properly and were analyzed statistically. Results: Postoperative hypocalcaemia developed in 18 cases, with an incidence of 26.9%. Pearson correlation showed a significant correlation between postoperative iPTH at 1 hr, 4 h, and 24 hr with 1st postoperative calcium value. The Receiver operating characteristic (ROC) curve was processed for the postoperative iPTH at 1 hr, 4 h, and 24 hr. The sensitivity, specificity, cut-off value, and mean AUC found 93.9%, 94.4%, ≤14.0, 0.988;95.9%, 94.4%, ≤09.5, 0.993 and 91.8%, 94.4%, ≤11.0, 0.993 respectively. Conclusion: iPTH can be used as an early predictor of post-thy-roidectomy hypocalcaemia. 4 hr iPTH showed more sensitivity and specificity for a cut-off value near the laboratory reference range.

Thyroidectomy: Frequency and Indications in the General Surgery Department of the Hôpital National Ignace Deen/CHU de Conakry

Introduction: Thyroidectomy is a surgical procedure to remove all or part of the thyroid gland. The aim of this study was to report the results of thyroidectomy in the general surgery department of the Hôpital national Ignace Deen/CHU de Conakry. Methodology: This was a retrospective study, of seven (07) years (January 1, 2016 - August 31, 2023), in the General Surgery Department of the Ignace Deen National Hospital-CHU in Conakry. We included all records of patients admitted and operated on for thyroidectomy and with up-to-date medical records. The variables were epidemiological, clinical and therapeutic. Results: During the study period, we recorded 3221 cases of surgery, including 40 thyroidectomies (1.24% of cases). The average age was 42.4 years. Women were the most represented, with a sex ratio of 0.16. The reason for consultation was anterior cervical swelling in 86% (n = 25) of cases, followed by signs of cervical compression 21% (n = 6) and signs of thyrotoxicosis 31% (n = 9). Indications for thyroidectomy were dominated by homogeneous goitres in 69% (n = 20) of cases, basedow’s disease in 20.7% (n = 6) and nodular goitres in 6.9% (n = 2) of cases. The surgical procedures were lobo-isthmectomies in 72.4% (n = 21), subtotal thyroidectomies 13.8% (n = 4), total thyroidectomies 10.3% (n = 3). Postoperative follow-up was straightforward in 69% (n = 20). Complications included haemorrhage in 20.7% (n = 6) and recurrence in 6.9% (n = 2). The average hospital stay was 7 days. Conclusion: Thyroidectomy is a relatively frequent surgical procedure in our department. Indications are dominated by homogeneous goitres. Morbidity is related to hemorrhage. Rigorous hemostasis could improve the quality of thyroidectomy.

Asymptomatic carbon dioxide embolism during transoral vestibular thyroidectomy:A case report

BACKGROUND Endoscopic thyroidectomy has obvious advantages over conventional surgical techniques in terms of postoperative cosmetic outcome.Although the incidence of carbon dioxide embolism(CDE)during endoscopic thyroidectomy is very low,it is potentially fatal.The clinical manifestations of CDE vary,and more attention should be paid to this disorder.CASE SUMMARY A 27-year-old man was scheduled for thyroidectomy by the transoral vestibular approach.The patient had no other diseases or surgical history.During the operation,he developed a CDE following inadvertent injury of the anterior jugular vein.The clinical manifestation in this patient was a transient sharp rise in end-tidal carbon dioxide,and his remaining vital signs were stable.In addition,loud coarse systolic and diastolic murmurs were heard over the precordium.The patient was discharged on day 4 after surgery without complications.CONCLUSION A transient sharp rise in end-tidal carbon dioxide is considered a helpful early sign of CDE during endoscopic thyroidectomy.

Potential protection of indocyanine green on parathyroid gland function during near-infrared laparoscopic-assisted thyroidectomy: A case report and literature review

BACKGROUND In recent decades,significant advances have been made in protecting the parathyroid glands and recurrent laryngeal nerves during thyroidectomy.However,reliable and convenient technical means are still lacking.In this study,the reliability,safety and feasibility of near-infrared(NIR)laparoscopyassisted thyroid lobectomy with isthmectomy and prophylactic central lymph node dissection(CLND)were reported.CASE SUMMARY A 63-year-old female patient with a free previous medical history,was admitted to our department due to multiple thyroid nodules.Ultrasonic examination suggested diffuse thyroid changes and one thyroid nodule in the right upper lobe with the largest diameter of 1.5 cm adjacent to the trachea and Breast Imaging Reporting and Data System grade 4B.Imaging examination of the neck showed no obvious enlarged lymph nodes.Fine needle aspiration biopsy suggested a papillary thyroid carcinoma.Combined with thyroid function examination,the patient was diagnosed with papillary thyroid carcinoma and Hashimoto's thyroiditis.Considering the risk of invading the capsule and the patient's extreme anxiety,a right thyroid lobectomy with isthmectomy and prophylactic CLND was planned.No significant abnormalities were found during preoperative examinations,except for an increased thyroid stimulating hormone level.The patient underwent NIR laparoscopy-assisted thyroid lobectomy with isthmectomy and prophylactic CLND.During the operation,two right parathyroid glands(PGs)adjacent to the thyroid gland capsule and the right recurrent laryngeal nerve(RLN)were examined by indocyanine green(ICG)fluorescence using a NIR fluorescence camera,and the PGs and RLN were reliably preserved.Considering the ICG-positive PG,prophylactic CLND was performed.The postoperative parathyroid hormone level was in the normal range and no significant hypocalcemia symptoms were observed.CONCLUSION During NIR laparoscopy-assisted thyroidectomy,ICG fluorescence may aid PG identification and protection.

Thyroidectomy for Massive Goiter Weighing more than 500 Grams. Technical Difficulties, Complications and Management. Review

Background: Multinodular goiter is a relatively common thyroid disorder with a marked female preponderance. Most of these goiters weigh less than 100 grams with those weighing more than 500 grams being exceptional. The massively expanding goiter due to the strategic anatomic location of thyroid gland, in addition to being cosmetically disfiguring can seriously compromise the patency of the trachea and oesophagus. Thyroidectomy for such goiters is a surgical challenge due to the possible association of tracheomalacia, retrosternal extension, skin involvement and the difficulty in intubation and dissection of the thyroid gland due to distorted and displaced anatomy. Material and methods: While presenting 2 patients who underwent thyroidectomy for glands weighing more than 500 grams, the literature is reviewed to analyze the technical difficulties and approach in such patients and the frequently encountered complications in them and their management. Results: A review of the literature revealed an additional 7 cases of patients who had undergone thyroidectomy for glands weighing more than 500 grams. Massively enlarged goiter was often associated with tracheomalacia, tracheal stenosis and retrosternal extension. Difficulty during surgery was most often encountered in establishing the airway and in exposure of the gland particularly when the skin was involved. The predominant postoperative complications were related to respiratory distress as a consequence of tracheomalacia and tracheal stenosis. Conclusion: In spite of the technical challenge related to the airway, and thyroidectomy, surgery continues to be the best option in experienced hands due to its distinct advantage of its immediate effect and complete resolution of compressive symptoms.

Optimum Timing and Complication of Completion Thyroidectomy for Differentiated Thyroid Cancer

Background: Despite improved preoperative diagnostics, incidental postoperative detection of differentiated thyroid cancer in the final histology is still common. In most of these cases, completion thyroidectomy is recommended by national and international guidelines, although secondary surgery is associated with an increased operative risk. The optimal timing of completion thyroidectomy is still controversial. Patients and Methods: The patients admitted to surgical oncology department, SECI, with diagnosis of differentiated thyroid cancer;during the period from January 2008 to December 2015;were rewired for age, sex, type of 1st operation, histopathological result, type of 2nd operation and time interval between the 2 operation, complication of 2nd operation and morbidity. 118 patients underwent completion thyroidectomy;those patients were divided according to timing of completion operation into 3 groups: Group A is from one week to 3 months and include 64 patients;Group B is from 3 - 6 months and include 30 patients;Group C is more than 6 months and include 24 patients. Clinical complications and oncologic outcomes were analyzed. The mean follow-up was 80 ± 10 months. Result: we record 118 patients under completion thyroidectomy. Ages range from 79 to 13 years. Papillary thyroid cancer were 96 and follicular thyroid cancer were 22. The overall rates of transient and persistent postoperative hypocalcemia were 19.5% and 4.2%, respectively. The rates of persistent hypocalcemia were found in group A and B but not in group C. Transient or persistent vocal cord paresis was observed in 9 (7.6%) and 3 patients (2.5%). The incidence of persistent vocal cord paresis (VCP) was significantly higher in groups A and B than in group C. There was no significant difference regarding survival among the 3 groups;however recurrence is higher in group A. Conclusion: Considering perioperative morbidity and oncologic outcomes, completion thyroidectomy should be performed at least 3 to 6 months after primary surgery.

Clinical Use of a Drain Incision Placed Below and Bilaterial to Near Total Thyroidectomy Incision

Objective： To design a new draining method for near total thyroidectomy at the lower two sides of the neck. Methods： Near total thyroidectomies in 63 cases were performed with new drain incisions at the lower two sides of the neck between December 1998 and July 2004. Results： All the draining operative procedures were performed smoothly, and all produced cosmetic scars were effective. The mean amount drained was 38 ml （minimum 10 ml, maximum 120 ml） and no patient developed wound infection. Conclusion： The drain incision for near total thyroidectomy placed at the lower sides of the neck results in a cosmetic scar which is easily covered by the collar, and was safe and effective. We thereby recommend the use of this drain incision for near total thyroidectomy.

Thromboelastographic Profile of Patients with Hyperparathyroidism Secondary to Chronic Kidney Failure Submitted to Total Parathyroidectomy

Coagulopathy in surgical patients can cause perioperative complications, as both bleeding and thromboembolic events increase surgical morbimortality. The recognition of preexisting disorders and the understanding of the dynamic changes in hemostasis during surgery are prerequisites of safe patient management. The perioperative management of patients with chronic kidney failure is a huge challenge due to both the hypercoagulable state and increased risk of bleeding. Classic laboratory exams performed for the evaluation of blood clotting seem insufficient regarding the determination of the risk of bleeding and thrombosis in surgical patients. As patients with chronic kidney failure develop secondary hyperparathyroidism, the aim of the present study was to describe a case series and correlate the perioperative thromboelastographic profile of patients with chronic kidney failure submitted to parathyroidectomy with their secondary hyperparathyroidism.

Fluctuation of Corrected Serum Calcium Levels Following Partial and Total Thyroidectomy

Objectives: To identify any fluctuation of corrected serum calcium levels and to determine the presence of sub-clinical hypocalcaemia following partial and total thyroidectomy with preservation of at least two parathyroid glands. Design: A prospective study. Setting: Tertiary Head & Neck referral unit. Patients: Eighty five patients undergoing partial or total thyroidectomy with or without laryngectomy from April 2003 to April 2009 were included in the study. Corrected serum calcium levels (CCSL) were noted preoperatively and postoperatively on day 1, day 7 and 6 months. Results: Forty six patients underwent hemi-thyroidectomy (HT), 29 underwent total thyroidectomy (TT) and 10 underwent total thyroidectomy with laryngectomy (TTL). Nine (19.56%) patients in the HT group, 6 (24.14%) in the TT group and 3 (30.0%) in the TTL group developed hypocalcaemia postoperatively which was most significant on 1st postoperative day. This improved by 7th postoperative day in each group when the change in calcium levels became statistically insignificant. Six patients (3 patients had HT, 2 had TT and 1 had TTL) developed sub-clinical mild hypocalcaemia which was persistent at 6 months follow-up. Conclusion: The most significant changes in corrected serum calcium levels occur within first 24 hours after thyroid surgery. Thereafter most patients return to normocalcaemia within a seven-day period. Despite preservation of parathyroid glands there is a subgroup of patients who develop sub-clinical hypocalcaemia which persists even at six months but does not require treatment.

Total Thyroidectomy in Multinodular Goiter: An African Experience

Introduction: Total thyroidectomy is an operation that involves the surgical removal of the whole thyroid gland, with the preservation of the parathyroid glands. The aim of the present study was to assess the complication rates of total thyroidectomy on benign indication and first-time thyroid surgery and investigate the early outcome after opotherapy. Materials and Methods: In this retrospective study, patients who underwent total thyroidectomy for benign multinodular goiter in the department of thoracic surgery in our Hospital from January 2012 to December 2014 were included. In postoperative time, we evaluated surgical complication, histopathological examination and opotherapy. Results: A total 53 patients underwent total thyroidectomy for multmodular goiter;they were 49 (92.45%) bilateral and 4 (7.55%) unilateral (recurrence). The mean age was 47 years and mean diameter of goiter was 10.75 cm. Among the patients 88.68% were females and 11.32% were male. Preoperative hormonal statuses were (70%) in euthyroid and (30%) hyperthyroid following surgery complications like transient laryngeal nerve palsy (3.77%), transient hypocalcemia (7.55%), hematoma (1.9%) and wound infection (1.9%). On histopathological examination of the surgical specimen, 5.7% were reported to be malignant. Six month following surgery 92.45% of patients was a good hormonal balance. Conclusion: Total thyroidectomy for multinodular goiter has a low morbidity and mortality;this procedure olves both the problem of recurrence of disease and reintervention. The opotherapy is doable with a good hormonal balance.

Horner’s Syndrome after Thyroidectomy: Two Cases Report

Background: Horner’s syndrome is defined as a combination of a series of symptoms following the injury of oculosympathetic pathway. This dysfunction is usually acquired during cervical surgery but rarely triggered by thyroid-surgery. Case Presentation: Here we present two cases secondary to thyroidectomy. Two young female patients, both diagnosed as tumor in left lobe of thyroid, had Horner’s syndrome after surgery. Fortunately, Horner’s syndrome was relieved after steroid treatment. Conclusions: Indirect mechanism involved in the lesion and the direct factor with mistaken section of nerve fibers may be responsible for Horner’s syndrome. Besides, Horner’s syndrome after thyroid surgery may be revisable after oral steroid treatment.

Classic clamp-and-tie total thyroidectomy for large goiters in the modern era:To drain or not to drain?

AIM: To evaluate the role of drains in clamp-and-tie total thyroidectomy(c TT) for large goiters. METHODS: A hundred patients were randomized into group D(drains maintained for 24 h) and ND(no drains). We recorded epidemiological characteristics, thyroid pathology, hemostatic material, intraoperative events, operative time and difficulty, blood loss, biochemical and hematological data, postoperative vocal alteration and pain, discomfort, complications, blood in drains, and hospitalization.RESULTS: The groups had comparable preoperative characteristics, pathology, intraoperative and postoperative data. Hemostatic material was used in all patients of group ND. Forty patients in group D and 9 in ND felt discomfort(P < 0.001). CONCLUSION: Drains in c TT for large goiters give no advantage or disadvantage to the surgeon. The only "major disadvantage" is the discomfort for the patient. Inversely, drains probably influence surgeons' serenity,especially when c TT is performed in nonspecialized departments.

Analysis of the Effect of Anesthetics Comprising of Remifentanil Combined with Propofol During Thyroidectomy

Objective:To analyze the anesthetic effect of remifentanil combined with propofol during thyroidectomy.Methods:A total of 70 patients who underwent thyroidectomy during November 2018 to November 2019 in Chongqing Eleventh People’s Hospital were selected and recruited.These patients were divided into control group and observation group by random number table method.Each group consisted of 35 patients.The patients in the control group was given intravenous anesthesia comprising of propofol combined with intermittent fentanyl anesthesia,whereas the patients in the observation group was given intravenous anesthesia comprising of remifentanil combined with propofol.Results:The heart rate and mean arterial pressure of the observation group after anesthesia for 30 minutes were lower than those of the control group,and the differences were statistically significant(P<0.05).The total incidence of adverse reactions in the observation group was lower than that of the control group,and the differences were statistically significant(P<0.05).Conclusion:Remifentanil combined with propofol is effective in thyroidectomy.This combination can reduce the risk of adverse reactions and maintain stable hemodynamic parameters.

Therapeutic Management in Proximal Tracheal Rupture during Total Thyroidectomy

Tracheal disruption is a life-threatening rare complication of total thyroidectomy that it should be prevented. The own-patient risk factors, procedure of tracheal intubation and a meticulous surgical technique are three main keys to keep in mind. Both medical and surgical management of this injury depends on its size, location and patient’s symptoms although neither of them prevents late complications. An early diagnosis could improve with prognosis although it is mandatory to perform either respiratory functional or imaging study in order to assume its healing. When the tracheal laceration is diagnosed during the surgery, we should take care with a continuous monitoring of the patient’s vital signs. A good oxygenation will be succeeded in high volume and low pressure with endotracheal tube distal to the lesion. We advice placing a tube drain near the disruption to prevent emphysema and an early extubation to avoid an ischaemic damage of the mucosa. A postoperative suspicion of tracheal rupture could demand reintubation with the patient in full relaxation and an examination by CT-scan or fiberscope before deciding a simple supportive therapy. We present our therapeutic experience in a female patient who suffered from tracheal injury during total thyroidectomy and describe a review of literature.

Assessment of Laryngeal Mask Airway in General Anesthesia during Thyroidectomy without Applying Miorelaxants

The selective approach of anesthesia has a crucial role in the surgical treatment of thyroid diseases.Anesthesia during the insertion of a laryngeal mask airway is an alternative instead of endotracheal tube,hence this is a novel period in anesthesiology.

Evaluation of the Morbidity and Complications of Total Thyroidectomy: Systematic Literature Review

This scientific problem is aiming to talk about the evaluation of morbidity and complications of total thyroidectomy. The presented review was conducted by searching in Medline, Embase, Web of Science, Science Direct, BMJ journal, and Google Scholar for, researches, review articles, and reports, published over the past years, which was searched up to June 2021 for published and unpublished studies and without language restrictions. If limitless lookup had comparable findings, we randomly chosen one or two to keep away from repetitive results. Based on the findings and effects of this review, the success of total thyroidectomy will beautify if we furnish large cognizance to advances in intervention, developing new methods and education. Surgeon responsiveness, nursing training will aid too in accomplishing this goal.

Efficacy of minimally invasive video-assisted thyroidectomy for completion thyroidectomy

Objective:Minimally invasive video-assisted thyroidectomy(MIVAT)is among the most common alternatives to conventional open thyroidectomy.Previous reports have shown it to be safe and effective in patients without neck surgery history.However,this contraindication has been called into question in more recent small series.This study aims to evaluate the efficacy and safety of MIVAT in patients with prior neck surgery.Methods:We retrospectively reviewed the data of 178 patients who underwent completion thyroidectomy in the Department of Otolaryngology-Head and Neck Surgery at Loma Linda University Medical Center between July 2004 and July 2017.Patients were divided into MIVAT group and Conventional group based on method of surgery,and analysis with two sample tests of proportions was carried out as appropriate.Results:Patients in MIVAT group had significantly shorter operative time(74.1±26.4 min vs.99.0±49.3 min,p<0.001),less estimated blood loss(19.5±15.0 mL vs.39.0±65.9 mL,p¼0.002),smaller incision size(3.5±1.1 cm vs.6.2±2.2 cm,p<0.001),and a lighter thyroid weight(7.5±5.2 g vs.20.5±31.1 g,p<0.001).The average length of stay was a half day longer,and post-operative admission was higher(78.8%vs.51.7%,p¼0.005)in MIVAT group,while most was for routine 23-hour observation(63.6%vs.35.9%,p¼0.009).There were no differences in complications.Conclusion:MIVAT is feasible for re-operative patients with equivalent or superior outcomes to those of conventional thyroidectomy,and no significant difference in the incidences of common postoperative complications.

Application of inflation fluid containing ropivacaine hydrochloride in endoscopic thyroidectomy on stress response and pain mediators

Objective:To study the effect of the application of inflation fluid containing ropivacaine hydrochloride in endoscopic thyroidectomy on stress response and pain mediators. Methods:128 patients receiving endoscopic thyroidectomy in our hospital between November 2015 and November 2016 were selected and randomly divided into two groups (n=64), observation group of patients received the inflation fluid containing ropivacaine hydrochloride as the inflating medium during endoscopic thyroidectomy and control group of patients received saline inflation fluid as the inflating medium during endoscopic thyroidectomy. Serum was collected before and after operation respectively to determine the levels of stress response-related hormones and pain-related mediators. Results:Serum adrenocorticotropic hormone (ACTH), cortisol (Cor), norepinephrine (NE), epinephrine (E), renin (PRA), angiotensin-2 (ANG-2), aldosterone (ALD), dynorphin (DYN),β-endorphin (β-EP), nitric oxide (NO) and substance P (SP) levels of both groups after operation were significantly higher than those before operation (P<0.05), and serum ACTH, Cor, NE, E, PRA, ANG-2, ALD, DYN,β-EP, NO and SP levels of observation group after operation were significantly lower than those of control group (P<0.05). Conclusions:The application of inflation fluid containing ropivacaine hydrochloride in endoscopic thyroidectomy can reduce the postoperative stress response and suppress pain mediator secretion.

Thyroidectomy under Local Anaesthesia: A Viable Option in a Resource Limited Community

Background: In most centers worldwide, thyroidectomy is performed under general anaesthesia as a result of advances in anaesthetic technique, consideration for patients’ safety and surgeons’ convenience. However, in some developing countries such as Nigeria, facilities and expertise for general anaesthesia are not equitably distributed. As such, they are not available in some health centers especially in the rural communities. Hence, the need to explore other suitable alternatives such as operating under local anaesthesia. Aim: This study aims to highlight the feasibility and safety of thyroidectomy under local anaesthesia at a surgical outreach in a rural community in Nigeria. Patients and Methods: The study site was conducted at Bethany Medical Centre, Gboko, Benue State, Nigeria. It was a one-week surgical outreach. Neck infiltration with local anaesthesia was carried out using 2% xylocaine with adrenaline 1:200,000 and a standard open technique was used to carry out all thyroidectomies. Results: Out of seventy (70) patients that presented during the study period, 31 (44.3%) met the inclusion criteria and were operated within the seven (7) days period. There were 3 (10.7%) males and 28 (89.3%) females. There ages ranged between 22 to 65 years, average was 43 years. The average duration of surgery was 90 minutes, and 3 days’ hospital stay. Those followed up two weeks post-operation recuperated well with no notable complications. Conclusion: Thyroidectomy under local anaesthesia is safe and feasible in our rural communities and in selected cases can be a suitable alternative to general anaesthesia.

Modern internet search analytics and thyroidectomy:What are patients asking?

Objectives:Thyroidectomy is among the most commonly performed head and neck surgeries,however,limited existing information is available on topics of interest and concern to patients.Study Design:Observational.Setting:Online.Methods:A search engine optimization tool was utilized to extract metadata on Google‐suggested questions that“People Also Ask”(PAA)pertaining to“thyroidectomy”and“thyroid surgery.”These questions were categorized by Rothwell criteria and topics of interest.The Journal of the American Medical Association(JAMA)benchmark criteria enabled quality assessment.Results:A total of 250 PAA questions were analyzed.Future‐oriented PAA questions describing what to expect during and after the surgery on topics such as postoperative management,risks or complications of surgery,and technical details were significantly less popular among the“thyroid surgery”group(P<0.001,P=0.005,and P<0.001,respectively).PAA questions about scarring and hypocalcemia were nearly threefold more popular than those related to pain(335 and 319 vs.113 combined search engine response page count,respectively).The overall JAMA quality score remained low(2.50±1.07),despite an increasing number of patients searching for“thyroidectomy”(r(77)=0.30,P=0.007).Conclusions:Patients searching for the nonspecific term“thyroid surgery”received a curated collection of PAA questions that were significantly less likely to educate them on what to expect during and after surgery,as compared to patients with higher health literacy who search with the term“thyroidectomy.”This suggests that the content of PAA questions differs based on the presumed health literacy of the internet user.