Objective To compare the therapeutic effects between endoscopic thyroidectomy by anterior chest approach and modified Miccoli thyroidectomy. Methods Sixty patients with thyroid goiter were performed endoscopic thyroidectomy by anterior chest approach (endoscopic thyroidectomy by anterior chest approach group, n=30) and modified Miccoli thyroidectomy (modified Miccoli group, n=30) respectively. The operative time, the drainage volume, cosmetic benefit, the postoperative hospitalization time, the expenses of hospitalization and postoperative complications of two groups were compared. Results The operative time and the drainage volume after operation of endoscopic thyoidectomy by anterior chest approach group were significantly more than modified Miccoli group 〔(99.9±23.4) min vs. (74.0±29.6) min; (68.6±8.7) ml vs. (40.9±6.1) ml, respectively〕, Plt;0.05. The cosmetic benefit score of endoscopic thyoidectomy by anterior chest approach group was higher than that of modified Miccoli group 〔(4.7±0.2) points vs. (3.7±0.1) points〕, Plt;0.05. The postoperative hospitalization time and expenses of hospitalization were no significant differences between the two groups 〔(6.5±1.7) d vs. (5.5±0.9) d; (9 328.3±1 107.1) yuan vs. (8 568.2±1 032.3) yuan, respectively〕, Pgt;0.05. One case had transient hoarseness in 2 groups respectively, no other complications happened. Conclusions Modified Miccoli operation is both minimally invasive and cosmetic, but endoscopic thyroidectomy by anterior chest approach has better cosmetic benefit, which can release patients’ psychological trauma. The patients with specific cosmetic demand may choose endoscopic thyroidectomy by anterior chest approach.
Objective To investigate the clinical significance of visual identification and intraoperative neuromonitoring of recurrent laryngeal nerve (RLN) during thyroidectomy. Methods Totally 1 664 patients underwent thyroidectomy with RLN protection from January 2009 to December 2009 were included in this study, in which 1 447 cases were protected by visual identification only, and 217 complex thyroidectomy cases were protected by visual identification and intraoperative monitoring. Results By the “multisites, three steps” RLN exposure method, 1 417 cases （85.16%） were successfully recognized and the recognition time was (3.57±1.26) min. The recognition time in the rest 30 complex cases (2.07%) without intraoperative neuromonitoring was (17.02±5.48) min. By this method, the temporary RLN injury occurred in 23 cases (1.54%) and 15 cases (65.22%) recovered within 2 weeks. In patients undewent intraoperative neuromonitoring, the recognition rate was 100% (217/217) and recognition time was (2.18±0.67) min. The temporary RLN injury occurred in 4 cases (1.84%) and 3 cases (75.00%) recovered within 2 weeks. All temporary RLN injuries recovered within 1 month and no persistent RLN injury occurred. Conclusions Conventional visual identification can reduce the RLN injury, but not meet the needs of the RLN protection during complex thyroidectomy. The combination of visual identification and intraoperative neuromonitoring can further improve the recognition rate and shorten the recovery time of vocal cord dyskinesia.
ObjectiveTo investigate the risk factors of perioperative anaesthesia management in postoperative headache induced by thyroidectomy. MethodsA 1:1 age and operation time matched case-control design study was performed. General anesthesia patients for elective thyroidectomy with postoperative headache (case group, VAS score >4) and without postoperative headache (control group, VAS score ≤4) were recruited. Univariate and multivariate analyses were performed to analyze the risk factors of postoperative headache after 24 and 48 hours of operation by using SPSS 18.0 software. ResultsA total of 134 patients were included; of which, 67 were in the case group and the other 67 were in the control group. The results of univariate analysis showed that female and administration of flurbiprofen axetil might be the risk factors of postoperative headache. The further multivariate analysis showed that administration of flurbiprofen axetil was significantly associated with decreased postoperative headache (OR=0.387, 95%CI 0.185 to 0.811). ConclusionPerioperative anesthesia management has a certain influence on postoperative headache induced by thyroidectomy. The use of flurbiprofen axetil during operation could reduce the incidence rate of postoperative headache.
ObjectiveTo evaluate the value of parathyroid hormone (PTH) in predicting hypocalcemia at different time after thyroidectomy. MethodsThe literatures in CBM, WanFang, CNKI, VIP in Chinese, and OVID, PUBMED, EMBASE, and MEDLINE in English were searched. Hand searches and additional searches were also conducted. The studies of predicting hypocalcemia after thyroidectomy by detecting postoperative PTH at different time were selected, and the quality and tested the heterogeneity of included articles were assessed. Then the proper effect model to calculate pooled weighted sensitivity (SEN), specificity (SPE), positive likelihood ratio (LR+), and negative likelihood ratio (LR-) were selected. The summary receiver operating characteristic (SROC) curve was performed and the area under the curve (AUC) was computed. ResultsTwenty-three articles entered this systematic review, 21 articles were English and 2 articles were Chinese. Fifteen of 23 articles were designed to be prospective cohort study (PC) and 8 of 23 articles were retrospective study (Retro). These articles were divided into two groups. Group 1 was the studies of detecting postoperative PTH in 1 hour, which included 2 012 cases (494 of them occurred hypocalcemia). Group 2 was the studies of detecting postoperative PTH between 4-12 hours, which included 693 cases (266 of them occurred hypocalcemia). The publication bias of 2 groups were smaller that founded through the literature funnel. Meta analysis showed that in addition to merge SEN, between the 2 groups with merge SPE, LR+, LR-, and AUC differences were statistically significant (P < 0.01);the forecast effect of group 1 was better than group 2, and the AUC was the largest area when the PTH value in 1 hour after operation was below 16 ng/L. ConclusionDetection of postoperative PTH value is an effective method for predicting postoperative hypocalcemia. The 1 hour after operation for detecting PTH value below 16 ng/L to predict postoperative hypocalcemia have the best effect.
Objective To investigate the threshold value for postoperative parathyroid hormone （PTH） that can predict the development of symptomatic hypocalcemia. Methods The patients received total thyroidectomy and all the operations performed by the same team from June 2010 to December 2011 in the thyroid and breast group of department of general surgery，Xuanwu Hospital of Capital Medical University were enrolled in this prospective study. Serum PTH and calcium were tested at 1-hour postoperatively and thereafter every day during hospitalization. Symptoms of hypocalcemia were recorded. Receiver operator characteristic curve was plotted to test the value of PTH assay to predict symptomatic hypocalcemia. Results There were 45 consecutive patients recruited in this prospective study，9 （20.0%） patients remained normocalcemic and 36 （80.0%） patients developed hypocalcemia postoperatively. There were 19 （42.2%） patients who developed symptoms associated with hypocalcemia and needed calcium supplement. The postoperative PTHs for normocalcemic （n=9），asymptomatic （n=17），and symptomatic （n=19） hypocalcemia patients groups were （40.5±23.7） ng/L，（18.3±9.1） ng/L，and （7.6±4.2） ng/L，respectively （P＜0.001）. The PTH value less than 13.4 ng/L could easily predict who were at high risk to develop symptomatic hypocalcemia with sensitivity of 94.7% and specificity of 76.9%. Conclusions This study suggests that a 1-hour postoperative PTH level at 13.4 ng/L can identify those individuals at risk for developing symptomatic hypocalcemia. Therefore，we recommend early calcium supplementation for these patients to decrease their postoperative morbidity from symptomatic hypocalcemia.
ObjectiveTo observe the effect of dexmedetomidine combined with etomidate on the clinical safety and the tracheal extubation response after general anesthesⅠa in elderly patient undergoing thyroidectomy. MethodsFifty patients (aged between 65 and 75 years, ASAⅠor Ⅱ) scheduled for thyroid surgery between July 2012 and January 2013 were randomly divided into two groups:dexmedetomidine group (group D) and control group (group C) with 25 patients in each group. Group D received dexmedetomidine of 0.5 μg/(kg·h) through intravenous infusion after anesthesia induction, and the intravenous infusion was stopped five minutes before the end of surgery. Normal saline was infused at the same volume in group C at the same time. Patients were induced with etomidate at 0.2 mg/kg for anesthesia, and etomidate and remifentanil were used for the anesthesia maintenance during the operation. Heart rate (HR), systolic blood pressure SBP), diastolic blood pressure (DBP) and bispectral index (BIS) were recorded 5 (T1), 15 (T2) and 30 (T3) minutes after the beginning of the operation, and 15 (T4) and 5 (T5) minutes before the end of the operation. Moreover, the time of eye opening, time of extubation, the number of patients with restlessness and etomidate requirement were recorded. ResultsCompared with group C, HR and MAP at the time points of T2 and T5 in group D did not obviously change, but the number of restlessness patients in group D was significantly less than in group C (P<0.05). There was no statistically significant difference in time of eye opening and time of extubation between the two groups (P>0.05). Etomidate requirement in group D was[(8.6±2.1) μg/(kg·min)], which was significantly lower than that in group C[(14.4±3.4) μg/(kg·min)] (P<0.05). ConclusionDexmedetomidine combined with etomidate is efficient and safe for elderly patients undergoing thyroidectomy, and this method can effectively reduce cardiovascular responses to tracheal extubation, decrease the incidence of postoperative restlessness, and reduce the requirement of etomidate during the operation.
Objective To investigate the causes and treatment of recurrent laryngeal nerve （RLN） injury during the operation of thyroidectomy. Methods Clinical data of 48 patients that RLN were injured during thyroidectomy in and out of our hospital from Jun. 2003 to Mar. 2007 were reviewed. Results No patient died while operation and staying in hospital. There were 47 cases of unilateral RLN injury, 1 case of bilateral RLN injury; 21 cases （43.7%） were injured because of suture or scar adhesion, 13 cases （27.1%） were partly broken with formed scar, 14 cases （29.2%） were completely cut off; The locations of RLN injuries were closely adjacent to the crossing of the inferior thyroid artery and RLN in 13 cases （27.1%） and 35 cases （72.9%） were within 2 cm below the point of RLN entering into throat. The injured RLN were repaired surgically in 43 cases, among which 39 cases’ phonation and vocal cord movement were restored completely or had their vocal cord movement recovered partly; There were only 4 cases that the phonation and vocal cord movement were not recovered. Another 5 cases that did not take any repair did not recovered naturally. Conclusion The location of most RLN injuries caused by mechanical injury during thyroid surgery is closely adjacent to the entrance of RLN into throat. Early nerve exploratory operation should be performed once the RLN is injured, and the method of repair should be decided according to concrete conditions of injury．
ObjectiveTo explore the safety, effectiveness, and cosmetic advantage of endoscopic thyroidectomy for differentiated thyroid cancer in the cT1N0 stage. MethodsThe clinical data of 148 patients underwent thyroidectomy for the cT1N0 differentiated thyroid cancer in the First Affiliated Hospital of PLA General Hospital and the PLA General Hospital from September 2010 to September 2013 were analyzed retrospectively, including 36 patients by total endoscopic thyroidectomy (TET group), 41 patients by endoscopic-assisted thyroidectomy (EAT group), and 71 patients by open thyroidectomy (OT group). The intraoperative status, early complications, late complications, and cosmetic result were compared among these three groups. ResultsAll the procedures were accomplished successfully.①In the intraoperative status: The operation time of the TET group was significantly longer than that of the EAT group(P < 0.05)or OT group (P < 0.05), drainage on the first day after operation in the TET group was significantly more than that in the EAT(P < 0.05)or OT group (P < 0.05), the intraoperative bleeding of the TET group or EAT group was significantly less than that of the OT group (P < 0.05), there were no statistical significances in the total number of lymph nodes dissection and number of positive lymph nodes among three groups (P > 0.05).②In the early complications: The postoperative pain score of the TET group was significantly lower than that of the EAT group (P < 0.05)or OT group (P < 0.05), there were no statistical significances in the postoperative bleeding, seroma, infection, transient recurrent laryngeal nerve paralysis, or transient hypoparathyroidism among three groups (P > 0.05).③In the late complications: there was no statistical significance in the perpetual recurrent laryngeal nerve paralysis, perpetual hypoparathyroidism, or thyroid cancer relapse among three groups (P > 0.05).④The best cosmetic result was obtained by the patients underwent TET as compared with the patients underwent EAT(P < 0.05)or OT (P < 0.05). ConclusionsEndoscopic procedure has the same effectiveness and safety with open procedure for differentiated thyroid cancer in the cT1N0 stage, but endoscopic procedure has a better cosmetic result than that open procedure. Compared with EAT, TET has more advantages in the cosmetic result.
Objective To explore the clinical significance of exposure the recurrent laryngeal nerve（RLN） for preventing the RLN injury in thyroidectomy. Methods The data of 1 723 patients with thyroid diseases undergoing total or subtotal thyroidectomy from September 2006 to August 2011 were retrospectively reviewed. RLN were exposed in 914 cases, 1 203 RLNs were exposed（exposed group）. RLN were unexposed in 809 cases, 1 013 sides were cut（unexposed group）. To compare RLN injury rate after operation and recovery of vocal cord in 6 months after operation between the two groups. Results In exposed group, 11 cases had RLN injury, the rate of RLN lesion was 0.91%. In unexposed group, 21 cases had RLN injury, the rate of RLN lesion was 2.07%. The differences between the two groups had statistical significance（P＜0.05）. When six months after operation, 0 case and 13 cases in exposed group and unexposed group respectively occurred permanent RLN injury, the differences between the two groups had statistical significance（P＜0.01）. Conclusion Exposure of RLN in total and subtotal thyroidectomy can significant avoid RLN injury, especially RLN permanent injury.
OBJECTIVE In order to investigate the opportunity of repair and prognosis of recurrent laryngeal nerve injuries after thyroidectomy. METHODS Twelve cases with recurrent laryngeal nerve injuries after thyroidectomy were immediately and delayed operated on nerve repair and reinnervation. In immediate operation, 5 cases were repaired by direct recurrent laryngeal nerve suture, and 1 case was treated by transposition of the phrenic nerve to the recurrent laryngeal nerve and sutured the adductor branch to the branch of ansa cervicalis. In delayed operation, 3 cases were treated by anastomosis the main trunk of ansa cervicalis to the adductor branch of recurrent laryngeal nerve, and 3 cases were operated on neuromuscular pedicle to reinnervate posterior cricoarytenoid muscle. RESULTS Followed up 6 months, the effect was excellent in 1 case who was immediately operated by selective reinnervation of the abductor and adductor muscles of the larynx, better in 9 cases, and poor in 2 cases who were delayed operated over 12 months. CONCLUSION It can be concluded that the earlier reinnervation is performed, the better prognosis is.