RESUMO
The risk of hypoparathyroidism and hypocalcemia is a critical concern in thyroid surgery. Preserving parathyroid gland vascularization during surgery is essential for effective prevention. Preoperative and postoperative management, including calcium and Vitamin D supplementation, is paramount. Measurement of parathyroid hormone levels after surgery is the best predictor of hypoparathyroidism. This guideline offers recommendations for the prevention, diagnosis, and treatment of acute hypoparathyroidism and hypocalcemia after thyroid surgery.
RESUMO
Introduction: Thyroid cancer, considered one of the most frequent malignant tumors of the endocrine system, accounts for 80%-90% of cases. The most common histological type observed in most studies is papillary cancer. Objective: To determine the frequency of thyroid cancer in patients undergoing total thyroidectomy at the Otorhinolaryngology Department of the Hospital de Clínicas between the period 2018-2022. Methodology: This retrospective study included 260 patients treated during the study period. Data were obtained from the patients' medical records, and sociodemographic and clinical variables related to thyroid cancer were analyzed. Data were analyzed with the SPSS v25 program, using descriptive statistics. Results: The frequency of thyroid cancer was 48.1%. The mean age of the cancer patients was 42.10±13.10 years. A higher frequency was observed in females 34.2%, n=89) and among those aged 25-44 years 20.0%, n=52). The most frequent were papillary (36.9%), follicular (2.7%), medullary (1.5%), and anaplastic (1.2%) types. Discussion: The frequency of thyroid cancer is high; it is more common in women and as age increases.
Introducción: El cáncer de tiroides, considerado uno de los tumores malignos más frecuentes del sistema endocrino, representa entre el 80% y el 90% de los casos. El tipo histológico más común observado en la mayoría de los estudios es el cáncer papilar. Objetivo: Determinar la frecuencia de cáncer de tiroides en pacientes sometidos a tiroidectomía total en la Cátedra y Servicio de Otorrinolaringología del Hospital de Clínicas durante el período 2018-2022. Metodología: se realizó un estudio retrospectivo con un total de 260 pacientes atendidos en el período de estudio. Los datos fueron tomados de las historias clínicas de los pacientes, en el cual se analizan variables sociodemográficas y clínicas relacionadas con el cáncer de tiroides. Los datos se analizaron con el programa SPSS v25, mediante estadística descriptiva. Resultados: La frecuencia del cáncer de tiroides fue del 48.1%. El promedio de edad de los pacientes con cáncer fue de 42.10±13.10 años. se observó una mayor frecuencia en las personas del sexo femenino 34.2% (n=89) y entre quienes tuvieron de 25-44 años 20.0% (n=52). El más frecuente fue el tipo papilar 36.9%, el folicular 2.7%, el medular 1.5% y el anaplásico 1.2%. Discusión: la frecuencia de cáncer de tiroides es alta, es más frecuente en las mujeres y a medida que aumenta la edad.
RESUMO
Introduction Despite the evidence against drain placement after thyroidectomy, there is a lack of consensus on drain use in patients with substernal goiter. Objective To assess the factors that increase the likelihood of drain placement and its impact on postoperative hematoma and other 30-day complications among adult patients undergoing thyroidectomy for substernal goiter. Methods A retrospective cohort study that used data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Adult patients (aged ≥ 18 years) who underwent elective thyroidectomy for substernal goiter from 2016 to 2020 were included. Cases with closed suction neck drains placed upon completion of surgery were included in the drain group, and the remaining cases formed the nondrain group. Results A total of 1,229 patients were included (46.5% with drain placement). The factors that increased the likelihood of drain placement included body mass index (BMI) ≥ 30 kg/m 2 , score between 3 and 5 on the American Society of Anesthesiologists (ASA) physical status classification, sternal split/transthoracic surgical approach, operative time ≥ 90 minutes, and surgery conducted by otolaryngologists. Patients with clean-contaminated or contaminated wound classifications were less likely to be submitted to drain placement. In addition, drain use had no impact on postoperative hematoma formation but was found to independently increase the risk of prolonged length of hospital stay. Conclusion Thyroidectomy without drain placement might be safe for substernal goiter. However, this decision should be individualized for each patient. Level Of Evidence: 3.
RESUMO
Unilateral vocal cord paralysis is frequently observed in patients who undergo thyroid surgery. This study explored the correlation between acoustic voice analysis (objective measure) and Voice Handicap Index (VHI, a self-assessment tool). One hundred and forty patients who had thyroid surgery with or without postoperative unilateral vocal cord paralysis (PVCP and NPVCP) were included. The patients were evaluated by the VHI and Dysphonia Severity Index (DSI) tools. VHI scores were significantly higher in PVCP patients than in NPVCP patients. Jitter (%) and shimmer (%) were significantly increased, whereas DSI was significantly decreased in PVCP patients. Receiver operating characteristics curve revealed that VHI scores were associated with the diagnosis of PVCP, of which VHI total score yielded an area under the curve (AUC) of 0.81. Among acoustic parameters, DSI was highly associated to PVCP (AUC=0.82, 95%CI=0.75 to 0.89). Moreover, we found a correlation between VHI scores and voice acoustic parameters. Among them, DSI had a moderate correlation with functional and VHI scores, as suggested by an R value of 0.41 and 0.49, respectively. VHI scores and acoustic parameters were associated with the diagnosis of PVCP.
RESUMO
Resumen Objetivo: La lesión del nervio laríngeo recurrente es una grave complicación en cirugía tiroidea. El propósito del presente estudio es analizar la utilidad de la neuromonitorización vagal continua intraoperatoria en un hospital terciario. Materiales y Método: Estudio observacional, analítico y retrospectivo que recoge pacientes intervenidos de cirugía tiroidea con neuromonitorización en un período de 14 meses. La pérdida de señal se define como amplitud final nerviosa < 100 ^V, realizándose laringoscopia postquirúrgica ante la sospecha de lesión nerviosa. El análisis estadístico se realizó con el programa SPSS® V25,0, con p < 0,05. Resultados: Se incluyeron 120 pacientes intervenidos, registrándose en el 24,2% pérdida de señal. Factores de riesgo para lesión fueron bocio intratorácico (OR 5,31; IC 95% 1,56-17,99; p = 0,007), cirugía cervical previa (OR 5,76; IC 95% 0,64-51,97; p = 0,119) y patología maligna (OR 1,44; IC 95% 0,16-12,79; p = 0,743). Fue posible el cambio de estrategia quirúrgica en 7 casos. En el seguimiento posterior se cuantificó parálisis recurrencial transitoria en 27 pacientes y permanente en 4. Discusión: La neuromonitorización parece reducir la incidencia de parálisis laríngea porque aumenta la seguridad en la identificación del nervio recurrente y reduce su manipulación durante la cirugía. Conclusiones: La neuromonitorización intraoperatoria es útil para identificar el nervio laríngeo recurrente y advierte del riesgo potencial de lesión, permitiendo cambiar la estrategia quirúrgica para evitar la parálisis bilateral de cuerdas vocales.
Aim: Recurrent laryngeal nerve injury is a serious complication in thyroid surgery. The purpose of the present study is to analyze the use of intraoperative continuous vagal neuromonitoring in a tertiary hospital. Materials and Method: Observational, analytical and retrospective study that includes patients who underwent thyroid surgery with neuromonitoring in a period of 14 months. Loss of signal is defined as final nerve amplitude < 100 ^V, and postsurgical laryngoscopy is performed due to suspicion of nerve injury. Statistical analysis was performed with the SPSS® V25.0 program, with p < 0.05. Results: 120 operated patients were included, registering loss of signal in 24.2%. Risk factors for injury were intrathoracic goiter (OR 5.31; 95% CI 1.56-17.99; p = 0.007), previous cervical surgery (OR 5.76; 95% CI 0.64-51.97; p = 0.119) and malignant pathology (OR 1.44; 95% CI 0.16-12.79; p = 0.743). A change in surgical strategy was possible in 7 cases. In the subsequent follow-up, transient recurrent paralysis was quantified in 27 patients and permanent in 4. Discussion: Neuromonitoring seems to reduce the incidence of laryngeal paralysis because it increases the security in the identification of the recurrent nerve and reduces its manipulation during surgery. Conclusions: Intraoperative neuromonitoring is useful to identify the recurrent laryngeal nerve and warns of the potential risk of injury, allowing to change the surgical strategy to avoid bilateral vocal cord paralysis.
Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Nervo Laríngeo Recorrente/patologia , Glândula Tireoide/cirurgia , Nervo Vago , Análise Multivariada , Estudos Retrospectivos , Monitorização IntraoperatóriaRESUMO
Involvement of the thyroid gland by tuberculosis is very rare and is usually secondary to disseminated infection. Very few cases of primary thyroid tuberculosis have been described even in countries with a high incidence of this disease. We present the case of a Spanish patient operated for a suspicious thyroid nodule that was finally diagnosed as primary thyroid tuberculosis.
La afectación de la glándula tiroidea por tuberculosis es muy rara y generalmente es secundaria a una enfermedad diseminada. Se han descrito muy pocos casos de tuberculosis tiroidea primaria incluso en paises con alta incidencia de esta enfermedad. Presentamos el caso de una paciente española operada por un nódulo tiroideo sospechoso que fue finalmente diagnosticado como tuberculosis tiroidea primaria.
Assuntos
Glândula Tireoide , Tuberculose , Humanos , Incidência , Glândula Tireoide/diagnóstico por imagem , Glândula Tireoide/cirurgiaRESUMO
BACKGROUND: Well-established conventional thyroidectomy has satisfactory outcomes; however, robotic and endoscopic thyroid surgery can avoid visible anterior neck scars. Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is the most recent of these techniques. METHODS: This was a retrospective review of 412 patients who underwent TOETVA from 2017 to 2020 in 13 Brazilian centers. RESULTS: The study included 359 (87.1%) females and 53 (12.9%) males, with a mean age of 40 years. There were 231 (56.1%) total thyroidectomies. The conversion rate was 0.7%. The transient vocal cord palsy rate was 7.6% (30 patients). Temporary and persistent hypocalcemia rates were 4.0% and 0.8%, respectively. There were two cases of infection (0.5%). DISCUSSION: This is a large multi-institute TOETVA study, with one of the largest cohorts published to date that; despite its retrospective nature and selection bias, reached outcomes comparable to previously reported series, this study reinforced safeness, feasibility, and nationwide reproducibility for this technique.
Assuntos
Cirurgia Endoscópica por Orifício Natural , Tireoidectomia , Adulto , Feminino , Humanos , Masculino , Cirurgia Endoscópica por Orifício Natural/efeitos adversos , Reprodutibilidade dos Testes , Estudos Retrospectivos , Glândula Tireoide , Tireoidectomia/efeitos adversosRESUMO
Objectives Thyroid cancer is the most common endocrine neoplasm in childhood. There are few studies characterizing pediatric population in Colombia. We intend to detail the clinical, histological characteristics, BRAFV600E mutational status and NIS (sodium-iodine symporter) expression of children with papillary thyroid carcinoma (PTC) managed at Hospital de La Misericordia. Methods Medical records of the Department of Pediatric Surgery and Pathology from 2009 to 2018 were scrutinized in search of cases of differentiated thyroid carcinoma. A descriptive analysis was made. Paraffin embedded tumoral tissue was recovered to assess BRAF V600E mutational status by PCR and NIS expression by immunohistochemistry. Results Sixteen patients were selected, 81.2% were girls. Average age of presentation was 11.8 years. Only one patient had previous radiation exposure. Most frequent symptom was cervical adenopathy with a mean time of 29.2 weeks before diagnosis. 93.7% underwent total thyroidectomy and lymphadenectomy. 62.5% were PTC combining both classic and follicular pattern. 6.25% cases had BRAFV600E mutation and 25% showed NIS focal reactivity. Conclusions We found greater female predominance, lower percentage of risk factors described and a high percentage of patients requiring aggressive surgical treatment. We consider important to contemplate thyroid cancer as a differential diagnosis of cervical lymph node enlargement in children. Diagnosis can be challenging in benign and indeterminate categories of the FNA cytology and biomolecular profiles such as BRAF and NIS could be determinant in guiding treatment. More studies with larger sample size, complete genetic analysis, evaluation to iodine response and long term follow up are required.
Assuntos
Proteínas Proto-Oncogênicas B-raf/genética , Simportadores/genética , Câncer Papilífero da Tireoide , Neoplasias da Glândula Tireoide , Adolescente , Idade de Início , Substituição de Aminoácidos/genética , Criança , Colômbia/epidemiologia , Feminino , Regulação Neoplásica da Expressão Gênica , Ácido Glutâmico/genética , Humanos , Incidência , Masculino , Mutação de Sentido Incorreto , Prognóstico , Simportadores/metabolismo , Câncer Papilífero da Tireoide/diagnóstico , Câncer Papilífero da Tireoide/epidemiologia , Câncer Papilífero da Tireoide/genética , Câncer Papilífero da Tireoide/cirurgia , Neoplasias da Glândula Tireoide/diagnóstico , Neoplasias da Glândula Tireoide/epidemiologia , Neoplasias da Glândula Tireoide/genética , Neoplasias da Glândula Tireoide/cirurgia , Tireoidectomia/métodos , Tireoidectomia/estatística & dados numéricos , Resultado do Tratamento , Valina/genéticaRESUMO
PURPOSE OF REVIEW: To explore the advances in robotic head and neck surgery (HNS) beyond TORS. RECENT FINDINGS: Although limited, the current literature corroborates the safety of robotic neck surgery, revealing similar surgical/oncologic outcomes, except longer operative time and superior cosmesis. In most of the remote thyroid approaches, use of robotic-assisted surgery is essential. However, for the recently popularized transoral approach, endoscopic technique has been preferred by most surgeons, due to longer operative time in robotic-assisted technique. On the other hand, retroauricular approach has been considered the standard for comprehensive/selective robotic neck dissections. Robotic technology has an increasing role in HNS. Robotic neck dissection has shown encouraging results, being routinely used in some centers around the globe. Robotic thyroid surgery, although safe when well applied, has lost ground to endoscopic transoral thyroidectomy. In the future, more evolved robotic systems could improve multiple areas of HNS.
Assuntos
Esvaziamento Cervical/métodos , Procedimentos Cirúrgicos Robóticos/tendências , Tireoidectomia/métodos , Endoscopia , Humanos , Duração da Cirurgia , Neoplasias da Glândula Tireoide/cirurgiaRESUMO
INTRODUCTION: In patients with unresectable Differentiated thyroid cancer (DTC), the use of external beam radiation therapy (EBRT), leads mostly to palliation. Our aim is to define the role of upfront EBRT, followed or not by salvage surgery, on Progression-free survival (PFS) or Overall survival (OS) in patients with DTC. METHODS: This is a cohort study of patients with initially unresectable DTC who received EBRT. Cohort A received EBRT followed by rescue surgery and cohort B, EBRT only. The Kaplan-Meier method and Cox model were employed for survival analysis. RESULTS: Thirty-three patients were included; 69.6% females and 30.3% males. Mean age was 60.6 and mean tumor diameter was 10.4 cm; 17 and 16 patients were included in cohorts A and B, respectively. Belonging to cohort A (Hazard ratio [HR] 0.177, 95% CI 0.05-0.7) and use of intensity modulated radiotherapy (HR 0.177, 95% CI 0.03-1.08) were associated to better PFS, while high-risk histopathology (HR 6.6, 95% CI 0.9-50) and EBRT dose (HR 1.05, 95% CI 1.01-1.08) were independently associated with lower PFS. Patients from cohort A (HR 0.061, 95% CI 0.01-0.3) had improved OS, while high-risk histopathology (HR 5.7, 95% CI 1.1-28.6) and EBRT dose (HR 1.05, 95% CI 1.01-1.09) were independently associated to worse OS. CONCLUSION: EBRT, and when feasible, salvage surgery, should be an integral part of the therapeutic strategy in initially unresectable DTC.
RESUMO
Cuando un nódulo tiroideo muestra características ecográficas sospechosas de malignidad (informada con clasificación T-RADS) casi no se discute que debe completarse el diagnóstico con una punción aspirativa con aguja fina (PAAF) (informada con sistema Bethesda). Pero cuando la ecografía sólo muestra características consideradas de benignidad, la indicación de PAAF es cuestionable y debe ser justificada. ¿Podrá la clasificación T-RADS determinar eficientemente cuáles nódulos tiroideos requieren una PAAF y cuáles no? Esta decisión está vinculada a determinar si un paciente deberá ser sometido o no a una cirugía tiroidea. Objetivo: Analizar la capacidad de la clasificación T-RADS, con y sin el agregado de sistema Bethesda para optimizar el diagnóstico de patología tiroidea. Material y métodos: se incluyeron 139 nódulos que requirieron cirugía, previamente evaluados con ecografía y con PAAF. Fueron realizadas por un mismo operador las ecografías (SMB), las punciones (OBM) y las cirugías (JLN). Se homogeneizaron las definiciones: T-RADS II-III-IVa y Bethesda II-III: Baja sospecha de malignidad; T-RADS IVb-V-VI y Bethesda IV-V-VI: Alta sospecha de malignidad. Conslusiones: se comprobó que cuando las características ecográficas de un nódulo tienen baja sospecha de malignidad (T-RADS II-III-IVa), indicar una PAAF no aporta al diagnóstico en forma estadísticamente significativa. Cuando la ecografía indica alta sospecha de malignidad (T-RADS IVb-V-VI), la realización de una PAAF incrementa significativamente la certidumbre del diagnóstico (AU)
When a thyroid nodule shows ultrasonographic characteristics of malignancy suspicion (informed with T-RADS classification), almost nobody discusses to complete diagnosis with a fine needle aspiration biopsy (FNAB) (informed with Bethesda system). But when ultrasonography only shows characteristics compatible with benignity, a FNAB indication is questionable and that must be justified. Could T-RADS classification efficiently identify which nodule requires a FNAB and which does not? That decision will linked to which patients should be undergo a thyroid surgery. Objective: to analyze T-RADS capability with and without Bethesda system to optimize the diagnosis of thyroid pathology. Material and methods: a total of 139 nodules which required surgery were included. They were previously evaluated with ultrasonography and FNAB. A same operator classified the T-RADS (SMB), the Bethesda system (OMB) and performed the surgeries (JLN). For this work, definitions were homogenized as follows: T-RADS II-III-IVa and Bethesda II-III: Low suspicion of malignancy; T-RADS IVb-V-VI and Bethesda IV-V-VI: High suspicion of malignancy. Conclusions: the evidence suggested that when a thyroid nodule shows low suspicion of malignancy by ultrasonography (T-RADS II-III-IVa), the indication of a FNAB did not add statistically significant diagnostic benefit. When a thyroid nodule shows high suspicion of malignancy (T-RADS IVb-V-VI), a FNAB added significant diagnostic accuracy (AU)
Assuntos
Humanos , Masculino , Feminino , Adulto , Nódulo da Glândula Tireoide/diagnóstico por imagem , Ultrassonografia Doppler/métodos , Doenças da Glândula Tireoide/diagnóstico por imagem , Biópsia por Agulha , Neoplasias da Glândula Tireoide/cirurgia , Neoplasias da Glândula Tireoide/diagnóstico por imagem , Diagnóstico por Imagem , Estudos TransversaisRESUMO
BACKGROUND: Technological advances in the last decades allowed significant evolution in head and neck surgery toward less invasive procedures, with better esthetic and functional outcomes, without compromising oncologic soundness. Although robotic thyroid surgery has been performed for some years now and several published series reported its safety and feasibility, it remains the center of significant controversy. This study shows the results of a case series of robotic thyroid surgery, combined or not with robotic neck dissection. METHODS: A retrospective cohort including 48 cases of robotic thyroid surgery with or without neck dissection, using retroauricular or combined approaches, performed in a tertiary cancer center, comprised the study. RESULTS: Between 2015 and 2017, we performed 2,769 thyroid surgical procedures, of which 48 (1.7%) were robot-assisted, in 46 patients [26 hemithyroidectomies, 7 total thyroidectomies, and 12 total thyroidectomies (or totalization) with selective neck dissection (SND) II-VI; and 3 neck dissections for thyroid carcinoma]. There were 43 (89.6%) women, and the median age was 35 years. The mean hospital stay was 1.9 days. In 3 (6.2%) cases, drains were not placed (hemithyroidectomies), whereas the other 45 (93.8%) cases had a mean drain stay of 4.4 days (range, 1-9 days). The console time (robotic thyroid resection and neck dissection) ranged from 11 to 200 min (mean 66.1 min; median 40 min), and the total operating room time ranged from 80 to 440 min (mean 227.9 min; median 170 min). Three (6.2%) patients had transient vocal cord paresis. Transient hypocalcemia was reported in three cases (6.2%). There were 30 carcinomas (62.5%), and the mean number of retrieved lymph nodes (LNs) (considering only cases that included robotic neck dissection) was 27.2 (range, 17-40). The mean follow-up time was 17.4 months (range, 1.4-31.9 months), and no recurrence was diagnosed. CONCLUSIONS: The quality outcomes and complication rates are comparable to the conventional approaches. Therefore, robotic thyroidectomy can be an option for selected patients that are motivated to avoid a visible neck scar, treated in high-volume centers. For the patients who require lateral neck dissection, the retroauricular robotic approach could be even more attractive, especially for young patients.
RESUMO
Antecedentes: el papel del estudio patológico intraoperatorio (EPI) en cirugía tiroidea ha sido discutido largamente y es todavía motivo de controversia. Objetivo: estimar los resultados del EPI en el diagnóstico de malignidad, su relación con la biopsia por punción-aspiración preoperatoria con aguja fina (PAAF) y el estudio patológico diferido (EPD), así como su contribución al cambio en la estrategia quirúrgica en cirugía tiroidea. Material y métodos: revisión retrospectiva de las historias clínicas de 773 pacientes operados por patología tiroidea entre enero de 2014 y diciembre de 2015. En todos se efectuó EPI y EPD; a 686 (89%) pacientes también se les efectuó la biopsia por PAAF preoperatoria. Resultados: los resultados del EPI fueron benigno en 215 pacientes (27,8%), maligno en 419 (54,2%) y no definitivo en 139 (18,0%). Cuando estos resultados fueron comparados con la EPD se encontraron 19 casos (8,8%) de falsos negativos y 4 (0,95%) de falsos positivos. Considerando solo los resultados definitivos, el EPI tuvo sensibilidad 95%, especificidad 98%, valor predictivo positivo 99%, valor predictivo negativo 91% y exactitud 91%. Cuando se comparó el EPI con la PAAF preoperatoria, los valores de sensibilidad más bajos (44%) correspondieron a las categorías de Bethesda III y IV. El EPI influyó en la estrategia quirúrgica en 95 pacientes (12,28%): en 53 (6,8%), la hemitiroidectomía cambió a tiroidectomía total; en 37 (4,8%), el diagnóstico de metástasis ganglionares permitió realizar un vaciamiento modificado de cuello, y en 5 (0,6%) ocurrieron ambas situaciones. Conclusión: el EPI tuvo altos valores de utilidad diagnóstica cuando se compararon con el EPD. También se correlacionó con la PAAF preoperatoria, pero tuvo menos utilidad en las categorías Bethesda III y IV. El EPI contribuyó a cambiar la decisión de técnica quirúrgica en un grupo de pacientes y evitar una segunda operación.
Background: the role of intraoperative pathologic evaluation (IPE) in thyroid surgery has largely been discussed and it is still controversial. Objective: to estimate the results of IPE in diagnosis of malignancy, its correlation with preoperative fine needle aspiration (FNA) biopsy and permanent pathologic evaluation (PPE), and its contribution to change surgical strategy in thyroid surgery. Materials and methods: retrospective chart review of 773 patients operated on for thyroid disease between January 2014 and December 2015. All patients underwent IPE and PPE; 686 (89%) patients had also preoperative FNA biopsy. Results: IPE resulted benign in 215 patients (27.8%), malignant in 419 (54.2%) and non definitive in 139 (18.0%). When these results were compared with PPE, 19 cases were false negative (8.8%) and 4 false positive (0.95). Considering only definitive results, IPE had sensitivity 95%, specificity 98%, positive predictive value 99%, negative predictive value 91% and accuracy 91%. When IPE was compared with preoperative FNA biopsy, lowest values of sensitivity (44%) corresponded with Bethesda categories III and IV. IPE influenced surgical strategy in 95 patients (12.28%): in 53 (6.8%) hemithyroidectomy changed to total thyroidectomy, in 37 (4.8%) lymph node metastases diagnosis allowed to perform modified neck dissection, and in 5 (0.6%) both situations occurred. Conclusion: IPE had high values of diagnostic utility when compared with PPE. It also correlated with preoperative FNA biopsy, but had less utility in Bethesda categories III and IV. IPE contributed to change surgical technical decision in a subset of patients and avoid a second operation.
Assuntos
Humanos , Feminino , Adolescente , Adulto , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Adulto Jovem , Glândula Tireoide/patologia , Tireoidectomia , Biópsia por Agulha/métodos , Neoplasias da Glândula Tireoide , Carcinoma Papilar/diagnóstico , Estudos Retrospectivos , Carcinoma Medular/diagnósticoRESUMO
The external branch of the superior laryngeal nerve (EBSLN) innervates the cricothyroid muscle (CTM) to promote lengthening and thinning of the vocal fold, thus increasing voice pitch. The close relation with the superior thyroid vessels (STV) puts the EBSLN in risk every time the superior pole of the thyroid is dissected. It travels downward to innervate the CTM, lateral to the thyroid cartilage and to the inferior pharyngeal constrictor muscle (IPCM), being eventually covered by this muscle fibers as it approaches its entry point. During its descending course, the EBSLN curves and crosses the STV posteriorly. The lower this crossing occurs in the neck, the higher the risk of surgical damage to the nerve by transection, traction, entrapment, thermal damage or disrupted blood supply. The chances of surgical trauma are also increased by size and weight of the specimen, shorter neck length and non-white ethnicity. Voice changes following thyroid surgery are common and multifactorial. The actual rate of vocal impairment due to EBSLN injury is unclear, since changes to the everyday speaking voice can be minimal and laryngeal findings are usually subtle and controversial. CTM electroneuromyography (EMG) is the most accurate tool to diagnose abnormal EBSLN conductivity, but it is technically difficult and barely applicable in routine practice. Recommended approaches to prevent injury include: (I) individual distal ligature of the STV by the thyroid capsule; (II) visual identification of the nerve and its trajectory and (III) electrostimulation with either observation of CTM twitch or intraoperative nerve monitoring (IONM) via dedicated endotracheal tube electrodes. There is accumulating evidence that a combination of visual and standardized electrophysiological EBSLN identification with meticulous division of the STV improves preservation rates. IONM bears the additional benefits of prognostication, quantification and documentation of neural function once it allows intraoperative laryngeal EMG.
RESUMO
El trabajo repasa la evolución histórica en el entendimiento y en el manejo de la cirugía tiroidea. Describe los orígenes de esta cirugía y su ejecución, mucho antes de que se entendiera el funcionamiento de la glándula. Enumera los personajes más trascendentes de esta historia y cómo otras técnicas aplicadas en la cirugía oncológica general se adaptaron a la cirugía de cabeza y cuello. Se mencionan las innovaciones tecnológicas en cirugía tiroidea.
This work reviews the historical evolution of thyroid surgery, its understanding and management. It mentions the origins of this surgical procedure and its execution well before the understanding of the glandular function. The leading persons in this historical field are enumerated; and a review is made of how other techniques applied in surgical oncology were adapted in head and neck surgery. Technological innovations in thyroid surgery are enumerated.
Assuntos
Humanos , Técnicas e Procedimentos Diagnósticos/tendências , Literatura de Revisão como Assunto , Neoplasias da Glândula Tireoide/história , Neoplasias da Glândula Tireoide/cirurgia , Endocrinologia/história , História da Medicina , Desenvolvimento TecnológicoRESUMO
Minimally invasive surgery is rapidly expanding its role in almost all of the surgical sub-specialties. There is also a growing demand of this service as patients became more and more concerned about cosmesis in addition to their original surgery. Although its role in thyroid surgery has already been proven earlier; but it is not yet accepted as a routine approach amongst many thyroid surgeons. There is no reported case of laparoscopic thyroid surgery in the English literature from the Caribbean. We are reporting our first clinical experience in performing laparoscopic thyroid surgery in the Caribbean with a successful outcome.
RESUMO
In the last three decades, otolaryngology and head and neck oncological surgery have shown remarkable progress with the development of several modalities of endoscopic-assisted minimally invasive surgeries. More recently, the Da Vinci robotic surgery system has promoted the development of several surgical approaches with less morbidity and better cosmetic results, including the transaxillary and retroauricular approaches for thyroid surgery and neck dissections. In South America, there are several shortcomings regarding financial resources as well as the lack of support for innovation leading to a significant delay in adoption of numerous technological advances in medical practice. Despite these obstacles, we obtained training in transoral robotic surgery and neck procedures, and then decided to implement neck endoscopic and robotic surgery at our institution. We developed a collaborative training program with Yonsei University that, together with several local measures, allowed for a safe implementation. From June 2014 to December 2016, we have performed a total of 121 retroauricular neck surgeries, of which 65 were robotic-assisted and 56 were endoscopic assisted procedures, with a complication rate that seems to be comparable to conventional procedures in our experience and a smooth learning curve. Safety compliance has been continuously assessed. Aiming to develop and disseminate these techniques, we have ongoing collaborative work with Yonsei University faculty, to continue increasing our clinical experience, and we are now preparing the group and infrastructure to establish a local training program for South American surgeons. We have been presenting our results at national and international medical meetings and started to publish the preliminary results in peer reviewed medical journals. The emphasis is that a retroauricular approach is a therapeutic option to be considered, especially for young patients. Media exposure has been avoided so far. As expected, resistance by our peers is still present and much more work is needed to overcome it, including the generation of data on the outcomes and a critical analysis of the advantages and disadvantages of endoscopic and robotic neck surgery.
RESUMO
BACKGROUND: Parathyroid gland (PG) identification during thyroid and parathyroid surgery is challenging. Accidental parathyroidectomy increases the rate of postoperative hypocalcaemia. Recently, autofluorescence with near infrared light (NIRL) has been described for PG visualization. The aim of this study is to analyze the increased rate of visualization of PGs with the use of NIRL compared to white light (WL). MATERIALS AND METHODS: All patients undergoing thyroid and parathyroid surgery were included in this study. PGs were identified with both NIRL and WL by experienced head and neck surgeons. The number of PGs identified with NIRL and WL were compared. The identification of PGs was correlated to age, sex, and histopathological diagnosis. RESULTS: Seventy-four patients were included in the study. The mean age was 48.4 (SD ±13.5) years old. Mean PG fluorescence intensity (47.60) was significantly higher compared to the thyroid gland (22.32) and background (9.27) (p < 0.0001). The mean number of PGs identified with NIRL and WL were 3.7 and 2.5 PG, respectively (p < 0.001). The difference in the number of PGs identified with NIRL and WL and fluorescence intensity was not related to age, sex, or histopathological diagnosis, with the exception of the diagnosis of thyroiditis, in which there was a significant increase in the number of PGs visualized with NIRL (p = 0.026). CONCLUSION: The use of NIRL for PG visualization significantly increased the number of PGs identified during thyroid and parathyroid surgery, and the differences in fluorescent intensity among PGs, thyroid glands, and background were not affected by age, sex, and histopathological diagnosis.
Assuntos
Pescoço/diagnóstico por imagem , Glândulas Paratireoides/diagnóstico por imagem , Paratireoidectomia , Espectroscopia de Luz Próxima ao Infravermelho , Glândula Tireoide/diagnóstico por imagem , Tireoidectomia , Adulto , Feminino , Humanos , Período Intraoperatório , Masculino , Pessoa de Meia-Idade , Pescoço/cirurgia , Glândulas Paratireoides/cirurgia , Estudos Retrospectivos , Espectroscopia de Luz Próxima ao Infravermelho/métodos , Glândula Tireoide/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND: Intraoperative neuromonitoring of the recurrent laryngeal nerve in thyroid surgery facilitates the identification of anatomical structures in cervical endocrine surgery reducing the frequency of vocal cord paralysis. OBJECTIVE: To study the normal electrophysiological values of the vague and recurrent laryngeal nerves before and after thyroid surgery. To compare rates of injury of recurrent nerve before and after the introduction of the intraoperative neuromonitoring in thyroid surgery. MATERIAL AND METHODS: An observational, descriptive and prospective study in which a total of 490 patients were included. Between 2003-2010, surgery was performed on 411 patients (703 nerves at risk) with systematic identification of recurrent laryngeal nerves. Between 2010-2011 neuromonitorization was also systematically performed on 79 patients. RESULTS: Before the introduction of intraoperative neuromonitoring of 704 nerves at risk, there were 14 recurrent laryngeal nerve injuries. Since 2010, after the introduction of the intraoperative neuromonitoring in thyroid surgery, there has been no nerve injury in 135 nerves at risk. CONCLUSIONS: We consider the systematic identification of the recurrent laryngeal nerve is the 'gold standard' in thyroid surgery and the intraoperative neuromonitoring of nerves can never replace surgery but can complement it.
Assuntos
Complicações Intraoperatórias/prevenção & controle , Monitorização Neurofisiológica Intraoperatória , Traumatismos do Nervo Laríngeo Recorrente/prevenção & controle , Nervo Laríngeo Recorrente/fisiologia , Tireoidectomia , Nervo Vago/fisiologia , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Traumatismos do Nervo Laríngeo Recorrente/epidemiologiaRESUMO
Introducción: El objetivo del tratamiento del carcinoma diferenciado de tiroides con invasión traqueal es resecar satisfactoriamente la enfermedad conservando las funciones. Caso clínico: Mujer de 27 años, con masa tiroidea con compromiso traqueal evidenciado por tomografía computarizada. Se efectuó tiroidectomía total, linfadenectomía central y selectiva II-V bilateral, resección segmentaria y anastomosis traqueal. En el postoperatorio presentó dehiscencia de la anastomosis, requiriendo traqueostomía. Posteriormente, se efectuó traqueoplastia con evolución favorable. Discusión: La resección traqueal segmentaria es de elección en casos de compromiso local sin enfermedad a distancia. La traqueoplastia permite obtener un resultado funcional satisfactorio en estos casos en centros de alto volumen.
Introduction: The aim of surgery in well-differentiated thyroid cancer with tracheal invasion is to remove all the tumour while preserving functional structures. Clinical case: A 27 year old female presented with a thyroid mass with tracheal invasion on the computed tomography. She underwent total thyroidectomy, bilateral central compartment and selective II-V neck dissection, and tracheal resection with end-to-end anastomosis. She subsequently had anastomotic dehiscence, which required a tracheostomy. Tracheoplasty was later performed with good functional results. Discussion: Segmentary tracheal resection is the procedure of choice in differentiated thyroid cancer with local invasion and with no distant disease. Tracheoplasty, performed in highvolume centres, leads to a satisfying functional outcome.