The Usefulness of Intraoperative PTH as a Predictor for Successful Parathyroidectomy in Secondary Hyperparathyroidism

Introduction: Secondary hyperparathyroidism (SHPT) is a multisystemic syndrome that affects calcium and bone homeostasis in patients with chronic kidney disease (CKD). Despite medical treatment, 1–2% of patients require parathyroidectomy annually. The use of an intraoperative parathormone protocol (IOPTH) to predict cure is still in debate, due to the lack of standardized protocols, the use of different assays, and uneven PTH clearance. This study aimed to determine the diagnostic accuracy of an IOPTH in patients with SHPT for predicting successful surgery after parathyroidectomy.Methods: About 30 patients were enrolled. A prospective observational study (cohort) was performed in patients who were submitted to parathyroidectomy by an endocrine surgeon for SHPT. All were submitted to a bilateral neck exploration with a subtotal parathyroidectomy. Three IOPTH determinations were withdrawn: at anesthetic induction (PTH0), 15 min (PTH15), and 30 min (PTH30) after completion of gland resection. Another sample was taken 24 h after the procedure (PTH24), values <150 pg/mL defined a successful surgery, and patients were assigned to the success or failure group. IOPTH drop was analyzed to predict successful surgery with drops of 70 and 90% at 15 and 30 min, respectively.Results: A total of 26 patients were included, 19 patients were in the successful group. IOPTH showed a significant difference between groups in their absolute PTH15 and PTH30 values. A significant difference was also found in their PTH drop at 30 min (81 vs. 91%, p = 0.08). For predicting a successful surgery, having a PTH drop >90% at 30 min was the most significant factor [Odds Ratio (OR) 3.0 (1.5–4) IC 95%].Conclusions: This study points toward a stricter and staggered IOPTH protocol to predict a successful surgery. Our results suggest taking a PTH15 expecting a PTH drop of >90%. If this is not achieved, reexploration and a PTH30 sample are suggested to accurately predict success.

Parathyroid Imaging Practices for Primary Hyperparathyroidism Without Previous Operations Among Endocrine Surgery Program Directors

Background Attempts at preoperative localization of abnormal parathyroid gland(s) in primary hyperparathyroidism (pHPT) can be performed with a variety of modalities. Study utilization is surgeon-specific with highly variable opinions in parathyroid surgery. As more people are diagnosed with pHPT, the complexity of the disease has given rise to variation in management. This heterogeneity raises the question of the true clinical practice of imaging among individual endocrine surgeons. Methods To better understand the preoperative parathyroid imaging practices of endocrine surgeons, an email-based survey was disseminated to the program directors of 22 American Association of Endocrine Surgeons fellowship programs querying them on their initial diagnostic test of choice for pHPT. Clinical support team members from each respective program were subsequently contacted and answers were compared. Results Sixty-eight percent (15/22) of clinical team members recommended either an additional (12/15) or different imaging test (3/15) than what was recommended by their institution’s endocrine surgeon. The most common initial imaging test that was repeated by both the endocrine surgeon and clinical team member was neck ultrasound; 33% of clinical team members (7/22) responded concordantly to their surgeon with ultrasound as the initial recommendation. Discussion Significant variability exists in the preoperative approach to patients with hyperparathyroidism. Here, we demonstrate that inconsistency in preoperative imaging recommendations even extends to within an individual surgeon’s practice based on the impact of the clinical support team, highlighting the role for improved clinical protocols within an institution’s clinical team.

Case report of toxic multinodular goiter with neck compression

We present a case of a 62-year-old patient with multinodular substernal goiter and tracheal compression (up to 5 mm). The multinodular goiter was initially diagnosed 3 years before by a local endocrinologist. The patient had been suffering from difficulty of breathing and exertional dyspnea for two years. He consulted specialists in therapy, pulmonology, cardiology more than once. However, none of the clinicians was able to identify the cause of labored respiration. Eventually an endocrine surgeon diagnosed a case of the complicated multinodular goiter with the development of cervical compression syndrome and tracheal narrowing.Ultrasound study showed the diffuse enlargement of the thyroid gland mainly due to the large left lobe with a total volume of 132,5 cm3. Computed tomography showed the shift of trachea to the right because of its compression by the left lobe and the luminal narrowing up to 5 mm. The patient needed surgical intervention by life-saving indications. He underwent thyroidectomy. The postoperative period was uneventful, the patient did not complain about labored respiration and reported the improvement of physical activity. It is important to keep in mind that patients with multinodular goiter have the potential risk of developing cervical compression syndrome. Current case demonstrates that such patients should be examined by an endocrine surgeon as early as possible in order to perform timely elective surgery.

Initial Experience with Robotic Modified Radical Neck Dissection Using the da Vinci Xi System through the Bilateral Axillary Breast Approach

Objectives: The bilateral axillo-breast approach (BABA) to robotic thyroidectomy has been extended to modified radical neck dissection (MRND). This study assessed outcomes in patients who underwent robotic MRND through BABA using the da Vinci Xi system. Methods: The medical records of 40 patients who underwent total thyroidectomy, bilateral central neck dissection and MRND from September 2018 to March 2020 were reviewed retrospectively, including 12 who underwent robotic surgery and 28 who underwent open surgery. All operations were performed by a single endocrine surgeon. Results: Operation time was significantly longer in the robotic than in the open group (277.08

Impact of Surgeon-Performed Ultrasound on Treatment of Thyroid Cancer Patients

Background The 2015 American Thyroid Association Management Guidelines for patients with thyroid nodules recommended a comprehensive sonographic evaluation of thyroid nodules’ characteristics and the presence of any suspicious cervical lymph nodes (LNs) in the central and lateral compartments. This detailed sonographic assessment is still not routinely performed. We hypothesized that an endocrine surgeon-performed ultrasound (SUS) significantly enhances the management of thyroid cancer patients when compared with referral ultrasound (RUS). Methods We conducted a retrospective review of 267 consecutive thyroid surgery patients who were diagnosed with thyroid cancer on final pathology. All patients had undergone a SUS, but only 130 cohorts with both RUS and SUS were included. Features of thyroid nodules and LN and changes in the management plan were recorded. Results Based on SUS assessment, 26 patients (20%) were noted to have suspicious thyroid nodules which warranted a fine-needle aspiration (FNA) and were missed in RUS. On FNA, there were 12 patients with Bethesda categories III/IV and 14 patients with Bethesda V/VI. Those 26 patients were found to have a malignancy in the final pathology assessment. Thirty-eight patients (29.2%) were noted to have suspicious central/lateral neck findings on SUS but were not reported in RUS. Additionally, 8 patients (6.1%) were found to have a parathyroid adenoma by SUS and required concurrent parathyroidectomy. Discussion A comprehensive neck ultrasound in thyroid cancer patients, performed by their endocrine surgeon, could enhance management planning and outcomes. This finding highlights the critical need for education and improvement of routine neck ultrasonographic examination performed in the community.

Epidemiology and results of surgical treatment of euthyroid and toxic goiter depending on the peculiarities of clinical course, tracheal compression and comorbidity

BACKGROUND: At the time of seeking medical help, some patients have nodular/multinodular goiter of large and gigantic sizes, which leads to compression of the neck organs. In the structure of benign diseases, neck compression is diagnosed in 10% of cases, and tracheal narrowing is found in 84% of patients in this group. It was experimentally established that narrowing of the trachea leads to the development of hypertension in the pulmonary circulation. Patients with nodular/multinodular goiter with compression of the neck organs belong to the age group of 50 years and older, the peculiarity of which is comorbidity of varying severity. Cardiopulmonary syndromes may mask compression of the organs of the neck by the thyroid gland. As a rule, patients come and/or go to a cardiologist, pulmonologist, gastroenterologist and other specialists, as a result of which the timelines for timely surgical treatment are missed. Often, patients are delivered to the endocrine surgeon urgently due to the development of asphyxiation. The symptoms of impaired external respiration and the initial manifestations of pulmonary hypertension, as a result of compression syndrome, preceding this condition are evaluated only retrospectively. AIMS: To study the frequency of tracheal compression and symptoms of chronic hypoxia in the structure of benign thyroid diseases requiring surgical treatment, as well as an assessment of the nature of comorbid pathology and the results of surgical treatment. METHODS: A retrospective analysis of the results of surgical treatment of benign thyroid diseases for the period from March to August 2019 was carried out (100 observations). RESULTS: Toxic goiter prevailed in the structure of benign thyroid diseases (74%). Tracheal compression was observed in 69% of cases. When trachea was compressed, arterial hypertension statistically significantly prevailed (2, p0.01). The appearance of wheezing on inhalation/exhalation and an increase in its frequency were detected when the trachea narrowed to the thyroid gland to 10 mm or less in 10 cases (10%) with a statistically significant prevalence of pulmonary hypertension (2, p0.01). Thyroidectomy prevailed in the structure of operations (80%). There was no statistically significant increase in surgical complications depending on the severity of tracheal compression, age, and concomitant pathology. There were no fatal outcomes. CONCLUSIONS: Surgical treatment of patients with benign thyroid diseases complicated by compression of the neck organs is also shown safely regardless of age and associated pathology.