[Show abstract][Hide abstract] ABSTRACT: The patient was referred for management of a left adrenal incidentaloma. Preoperative CT scan and MRI showed focal calcification. Here we are presenting this video demonstrating robotic-assisted laparoscopic adrenalectomy for left adrenal mass.
[Show abstract][Hide abstract] ABSTRACT: Recurrent laryngeal nerve (RLN) injury is one of the most common complications of thyroid surgery. RLN injury can cause vocal cord paralysis, affecting the patient's voice and the quality of life. Injury of the external branch of the superior laryngeal nerve (EBSLN) can cause cricothyroid muscle denervation affecting high vocal tones. Thus, securing the laryngeal nerves in these surgeries is of utmost importance. Visual identification of the nerves has long been the standard method for this precaution. Intraoperative neuromonitoring (IONM) has been introduced as a novel technology to improve the protection of the laryngeal nerves and reduce the rate of RLN injury. The aim of this article is to provide a brief description of the technique and review the literature to illustrate the value of IONM. IONM can provide early identification of anatomical variations and unusual nerve routes, which carry a higher risk of injury if not detected. IONM helps in prognosticating postoperative nerve function. Moreover, by detecting nerve injury intraoperatively, it aids in staging bilateral surgeries to avoid bilateral vocal cord paralysis and tracheostomy. The article will discuss the value of continuous IONM (C-IOMN) that may prevent nerve injury by detecting EMG waveform changes indicating impending nerve injury. Herein, we are also discussing anatomy of laryngeal nerves and aspects of its injury.
[Show abstract][Hide abstract] ABSTRACT: Current advancement in robotic surgery has provided a safe, precise, 3-dimensional (3D) magnified dissection for parathyroid surgery without the need for CO2 insufflation, and with a better cosmetic outcome due to an invisible scar in the axillary or retroauricular region. Preoperative imaging studies that assist in the localization of lesions have been key elements in patients' selection for targeted parathyroid surgery.
[Show abstract][Hide abstract] ABSTRACT: Objectives/HypothesisSurgeon experience has been recognized in several clinical fields as a significant element of superior management outcomes. In this study, we seek to assess the association between surgeon volume and patients' community health status with the outcomes of thyroid and parathyroid surgery indicated for primary malignancies.Study DesignA cross-sectional study utilizing the State Inpatient Databases, 2010–2011, for Florida, New York, and Washington was merged with the County Health Rankings database.Methods
International Classification of Diseases, Ninth Revision codes were used to identify adult (≥18 years) patients who underwent thyroidectomy or parathyroidectomy indicated for primary malignancies.ResultsA total of 6,347 records were included. Compared to high-volume surgeons, patients treated by low-volume surgeons were more likely to develop postoperative complications in the 1-month period after the operation (odds ratio: 4.34, 95% confidence interval: 3.31-5.70, P < .001). Furthermore, both low- and intermediate-volume surgeons were associated with a longer hospital stay (>2 days) and a higher risk of admission to the intensive care unit (P < .01 each). Cost of health services was significantly in the highest quartile (>$10,254.66) for patients treated by low-volume surgeons (P < .001). Patients who lived in communities of poor health measures had a higher risk of postoperative complications (16.3% vs. 11.8%, P = .030) independent of the clinical presentation and management type. Patients living in high health-risk communities and those of black and Hispanic backgrounds were more likely to be treated by low-volume surgeons (P < .001 each).Conclusions
The surgeon's volume and the patient's living conditions are crucial and independent factors in multiple aspects of endocrine cancer management.Level of Evidence4 Laryngoscope, 2015
The Laryngoscope 09/2015; DOI:10.1002/lary.25606 · 2.14 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Secondary thyroid cancer is believed to lead to a more aggressive clinical course than primary thyroid cancer. We aim to examine the difference between primary and secondary thyroid cancer in terms of patient characteristics and perioperative outcomes at the national level.
A cross-sectional study utilizing the Nationwide Inpatient Sample database for 2003-2010 was merged with County Health Rankings Data. International Classification of Diseases, Ninth Revision (ICD-9) codes were used to identify adult patients with thyroid cancer.
A total of 21,581 discharge records were included. Overall, 16,625 (77.0 %) patients had primary cancer, while the rest (23.0 %) had secondary cancer. Younger (<45 years) and older (>65 years) patients, males, and those of White or Hispanic background were more likely to have secondary cancers (p < 0.05 each). The prevalence of secondary cancer was higher in communities of low health risk (24.0 % vs. 21.1 %; p < 0.024). Secondary cancer was more likely to be managed by total thyroidectomy (odds ratio [OR] 2.40, 95 % CI 2.12-2.73) and to require additional radical neck dissection (OR 12.51, 95 % CI 10.98-14.25). Patients with secondary thyroid cancers were at higher risk of postoperative complications (p < 0.01 each). The cost of secondary cancer management was significantly higher than primary cancer (US$12,449.00 ± 302.07 vs. US$7848.12 ± 149.05; p < 0.001). However, compared with intermediate-volume surgeons, the complication risk was lower for high-volume (OR 0.47, 95 % CI 0.24-0.92; p = 0.026).
Secondary thyroid cancer is associated with a higher risk of perioperative complications and higher cost and distinct demographic profile. Patients managed by higher-volume surgeons were less likely to experience disadvantageous outcomes.
Annals of Surgical Oncology 08/2015; DOI:10.1245/s10434-015-4800-0 · 3.93 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The pre-operative diagnosis of thyroid tumors is determined by gold standard fine needle aspiration (FNA) biopsy. This has been widely accepted and offers the most cost-effective approach for evaluation of thyroid nodules. However, its diagnostic accuracy can pose a challenging scenario to surgeons. These diagnostic difficulties may subject patients to unnecessary thyroidectomies for benign thyroid nodules. Thus, additional molecular tests are needed to improve the sensitivity and specificity of FNA. The role of molecular markers is being proposed to predict the type and risk of malignancy to abate the need for diagnostic thyroidectomies. This review discusses their utility and validity in pre-operative diagnosis of thyroid nodules and how these markers can enhance the accuracy of FNA cytology.
[Show abstract][Hide abstract] ABSTRACT: Comprehensive neck ultrasound (US) examination has become an essential component of preoperative workup for patients with thyroid cancer. Regional cervical lymph nodes may be involved in cases of Hashimoto's thyroiditis (HT). This study seeks to examine the sonographic pattern of lymph nodes in patients with HT.
This is a retrospective study looking at patients with confirmed diagnoses of HT on final surgical pathology who underwent preoperative comprehensive neck US. We compared preoperative ultrasound for patients with HT to euthyroid patients with goiter. Data collected included number, size and ultrasonographic features of cervical lymph nodes.
We included a total of 417 patients: 202 patients with HT in the study group, and 215 patients with goiter and euthyroid status in the control group. Patients with HT had a higher number of total cervical lymph nodes than the control group (2.00±2.35 vs. 0.76±1.36 mm; P<0.0001), most notably in cervical levels III and IV (P<0.05 for both).
HT seems to be associated with an ultrasonographic pattern of increased number of enlarged cervical lymph nodes, particularly in levels III, and IV.
[Show abstract][Hide abstract] ABSTRACT: Recurrent laryngeal nerve (RLN) injury is one of the most common complications of thyroid surgery. Injury
to the external branch of the superior laryngeal nerve is less obvious and affects the voice variably; however,
it can be of great significance to professional voice users. Recent literature has led to an increase in theuse of neuromonitoring as an adjunct to visual nerve identification during thyroid surgery. In our review of
the literature, we discuss the application, efficacy and safety of neuromonitoring in thyroid surgery. Although
intraoperative neuromonitoring (IONM) contributes to the prevention of laryngeal nerves injury, there was no
significant difference in the incidence of RLN injury in thyroid surgery when IONM was used compared with
visual identification alone. IONM use is recommended in high risk patients; however, there are no clear
identification criteria for what constitutes “high risk”. There is no clear evidence that IONM decreases the risk
of laryngeal nerve injury in thyroid surgery. However, continuous IONM provides a promising tool that can
prevent imminent nerve traction injury by detecting decreased amplitude combined with increased latency.
[Show abstract][Hide abstract] ABSTRACT: The objective of this study was to describe national trends in robotic thyroid surgery from 2009 through 2013.
The University HealthSystem Consortium (UHC) database was searched for patients undergoing robotic thyroidectomy (RT) from 2009 through 2013. Another US institution's RT data, not included in the UHC database, were also evaluated. Patient demographics, institutional volume, comorbid conditions, complications, and cost information were analyzed.
Sixty-one institutions performed 484 RT during the study period. From 2009 through 2011, US annual RT volume increased from 39 cases to 140. Annual volume dropped to 69 cases in 2012 and 93 cases in 2013. Higher volume centers reported lower complication rates (P<0.02). Hematoma formation (3.7%) was the most common complication, and there was one death. Over ten percent of patients were obese. Brachial plexus injury and axillary skin flap perforations were reported in less than one percent of cases. Mean cost for a total RT was $13,287 ($5,125 - $42,444).
From 2009 through early 2011, there was a steady increase in RT volume, especially among high volume institutions. In mid to late 2011, there was a noticeable drop in RT volume, which significantly altered the projected trajectory of the procedure in this country. Despite higher complication rates, lower volume centers perform the majority of RT and are also responsible for recent increases in RT utilization patterns in the US.
Thyroid: official journal of the American Thyroid Association 05/2015; DOI:10.1089/thy.2015.0066 · 4.49 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Reoperation for recurrent papillary thyroid cancer (PTC) can be associated with a high rate of complications and failure to provide lasting remission. Percutaneous ethanol injection (PEI) may be an effective nonsurgical management option for locally recurrent PTC.
This systematic analysis of the current literature compares the efficacy and complications related to PEI vs reoperative surgical intervention for treatment of locally recurrent PTC.
Original studies were identified using the keywords "thyroid/ethanol" and "recurrent thyroid cancer/repeat surgery."
Studies evaluating reoperation or PEI for lymph node metastases in patients with primary surgery of total thyroidectomy with appropriate lymph node dissection where indicated were included in the analysis for both reoperation and PEI. Animal studies, single case reports, and studies with fewer than 10 lesions were excluded.
Outcomes included interval to detection of recurrence, success and failure rates, recurrence rates, complication rates, and follow-up duration. Between-group outcome differences were calculated using random-effects models, and pooled data cross-tabulation and logistic regression analysis were used.
In all, 945 publications were identified, and 27 studies met the inclusion criteria. There were no studies that directly compared the 2 treatment techniques. A total of 1617 patients were included in this analysis; 168 (11.4%) were treated with PEI, and 1449 (88.6%) were treated with reoperation. Reoperation was successful in 94.8% of cases compared with an 87.5% success rate for PEI (odds ratio [OR], 2.58; 95% CI, 1.55-4.31; P < .001). The recurrence rates for PEI and reoperation at the site of the treated lesion or elsewhere in the neck were also similar (OR, 1.07; 95% CI, 0.65-1.77; P = .78). Reoperation was associated with a 3.5% pooled risk of complications, while PEI incurred a pooled risk of 1.2% (OR, 2.9; 95% CI, 0.72-12.3; P = .08). However, most studies did not report routine preoperative and postoperative laryngoscopies, an evaluation needed for accurate neural complication analysis associated with each procedure.
High-quality, well-designed studies are needed to evaluate the feasibility of incorporating PEI into the treatment protocol of PTC. Although presently inferior to reoperation, PEI has the potential to be a widely accepted and effective nonsurgical treatment option for limited recurrent PTC in poor surgical candidates or patients seeking to avoid multiple reoperations.
Archives of Otolaryngology - Head and Neck Surgery 04/2015; 141(6). DOI:10.1001/jamaoto.2015.0596 · 2.33 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Robot assisted thyroid surgery has been the latest advance in the evolution of thyroid surgery
after endoscopy assisted procedures. The advantage of a superior field vision and technical advancements
of robotic technology have permitted novel remote access (trans-axillary and retro-auricular) surgical
approaches. Interestingly, several remote access surgical ports using robot surgical system and endoscopic
technique have been customized to avoid the social stigma of a visible scar. Current literature has displayed
their various advantages in terms of post-operative outcomes; however, the associated financial burden
and also additional training and expertise necessary hinder its widespread adoption into endocrine surgery
practices. These approaches offer excellent cosmesis, with a shorter learning curve and reduce discomfort to surgeons operating ergonomically through a robotic console. This review aims to provide details of various remote access techniques that are being offered for thyroid resection. Though these have been reported to be safe and feasible approaches for thyroid surgery, further evaluation for their efficacy still remains.
[Show abstract][Hide abstract] ABSTRACT: The aim of this study is to compare the safety and efficacy of conventional laparotomy with those of robotic and laparoscopic approaches to hepatectomy.
Independent reviewers conducted a systematic review of publications in PubMed and Embase, with searches limited to comparative articles of laparoscopic hepatectomy with either conventional or robotic liver approaches. Outcomes included total operative time, estimated blood loss, length of hospitalization, resection margins, postoperative complications, perioperative mortality rates, and cost measures. Outcome comparisons were calculated using random-effects models to pool estimates of mean net differences or of the relative risk between group outcomes. Forty-nine articles, representing 3702 patients, comprise this analysis: 1901 (51.35%) underwent a laparoscopic approach, 1741 (47.03%) underwent an open approach, and 60 (1.62%) underwent a robotic approach. There was no difference in total operative times, surgical margins, or perioperative mortality rates among groups. Across all outcome measures, laparoscopic and robotic approaches showed no difference. As compared with the minimally invasive groups, patients undergoing laparotomy had a greater estimated blood loss (pooled mean net change, 152.0 mL; 95% confidence interval, 103.3-200.8 mL), a longer length of hospital stay (pooled mean difference, 2.22 days; 95% confidence interval, 1.78-2.66 days), and a higher total complication rate (odds ratio, 0.5; 95% confidence interval, 0.42-0.57).
Minimally invasive approaches to liver resection are as safe as conventional laparotomy, affording less estimated blood loss, shorter lengths of hospitalization, lower perioperative complication rates, and equitable oncologic integrity and postoperative mortality rates. There was no proven advantage of robotic approaches compared with laparoscopic approaches.
[Show abstract][Hide abstract] ABSTRACT: Introduction: Fine needle aspiration cytology (FNA) of thyroid nodules can lead to changes that extensively replace cytologically confirmed thyroid lesions. These replaced thyroid lesions are called vanishing tumors, and can be challenging to pathologists, endocrinologists and surgeons, rendering the final pathological diagnosis difficult to interpret. We performed a retrospective analysis focusing on the issues that tend to compromise management plans for these vanishing tumors.
Study Design: Retrospective review
Methods: Data of 609 patients referred to our institution for thyroid surgery were reviewed. Patients with suspicious lesions on neck ultrasound underwent FNA biopsy. We compared FNA cytological and surgical pathological findings to identify patients with vanishing tumors. FNA-induced reactive changes such as cystic degeneration, hemorrhage, calcification, cholesterol crystals, fibrosis and granulation tissue were identified.
Results: Seventeen patients (2.7%) were identified with vanishing tumors in specimen pathology. Preoperative FNA cytology was indeterminate in seven (41.1%) and benign in ten (58.8%) patients. The mean size of vanishing tumors was 2.4±1.5 cm in greatest dimension. On surgical pathology, all nodules showed regressive changes partially or entirely replacing the tumor. There were seven nodules (41.1%) that were entirely replaced while remaining ten nodules showed partial replacement of tumors by regressive changes. Three (23%) nodules presented with focal areas of optically clear nuclei suspicious of PTC; one showed an additional focus of follicular neoplasm of uncertain malignant potential.
Conclusions: FNA-induced secondary changes can lead to obliteration of nodules, leading to surgical pathology diagnosis with no evidence of benign or malignant lesions. Pathologists and surgeons should be aware of this challenging scenario. In the presence of expert opinions, FNA cytology can provide a definitive diagnosis for these vanishing tumors.
Society of Surgical Oncology, Houston, Texas; 03/2015