Intraoperative Adjuncts in Thyroid Surgery.

Thyroidectomy is relatively safe and often can be done as a minimally invasive procedure. Although they may be associated with a learning curve, thoughtful use of intraoperative adjuncts such as energy devices, recurrent laryngeal nerve monitoring, and parathyroid autofluorescence have the potential to make incremental improvements in the safety and efficiency of thyroid surgery. Perhaps many of these adjuncts may be of greatest benefit when used routinely by less experienced surgeons or selectively in higher-risk operations, although their adoption in practice continues to increase overall.

ACR Appropriateness Criteria® Parathyroid Adenoma.

Hyperparathyroidism is defined as excessive parathyroid hormone production. The diagnosis is made through biochemical testing, in which imaging has no role. However, imaging is appropriate for preoperative parathyroid gland localization with the intent of surgical cure.

Lobectomy for treatment of differentiated thyroid cancer: can patients avoid postoperative thyroid hormone supplementation and be compliant with the American Thyroid Association guidelines?

Background: The American Thyroid Association recommended thyroid lobectomy as an alternative for low-risk differentiated thyroid cancer. One hypothetical benefit includes avoiding lifelong thyroid hormone supplementation; however, guidelines recommend maintaining the thyroid-stimulating hormone <2 mIU/L postoperatively in low-risk patients. Our hypothesis is that most patients will require hormone supplementation to maintain thyroid-stimulating hormone <2 mIU/L, minimizing this advantage of lobectomy.

Impact of vocal cord ultrasonography on endocrine surgery practices.

Background: It is common practice to perform flexible laryngoscopy (FL) to ensure true vocal cord (TVC) mobility in patients with previous neck operations or patients with suspected VC dysfunction. Vocal cord ultrasonography (VCUS) is accurate in identifying TVC paralysis. The goal of this study is to evaluate the impact of VCUS as the initial study to confirm TVC mobility in patients requiring preoperative FL.

Feasibility of surgeon-performed transcutaneous vocal cord ultrasonography in identifying vocal cord mobility: A multi-institutional experience.

Background: Transcutaneous vocal cord ultrasonography (TVCUS) is a noninvasive study used to identify true vocal cord (TVC) mobility. Its sensitivity in predicting TVC paralysis when compared with indirect flexible laryngoscopy (IFL) ranges from 62 to 93%. This study aimed to evaluate the feasibility of surgeon-performed TVCUS in assessing TVC mobility in the outpatient setting.

Minimizing cost and maximizing success in the preoperative localization strategy for primary hyperparathyroidism.

Ultrasonography of the thyroid, parathyroid, and soft tissues of the neck should always be performed before parathyroidectomy. The most cost-effective localization strategies seem to be ultrasonography followed by four-dimensional computed tomography (4DCT) or ultrasonography followed by sestamibi ± 4DCT. These localization strategies are highly dependent on the quality of imaging.

Comparison between preconsultation ultrasonography and office surgeon-performed ultrasound in patients with thyroid cancer.

Background: Cervical ultrasonography (US) is mandatory before surgery for thyroid cancer and recommended for thyroid nodule evaluation. Therefore, most patients undergo thyroid ultrasound before surgical evaluation. Several US findings are critical for adequate surgical planning but they are often not mentioned on preconsultation US.

American Thyroid Association statement on outpatient thyroidectomy.

Background: The primary goals of this interdisciplinary consensus statement are to define the eligibility criteria for outpatient thyroidectomy and to explore preoperative, intraoperative, and postoperative factors that should be considered in order to optimize the safe and efficient performance of ambulatory surgery.

Summary: A series of criteria was developed that may represent relative contraindications to outpatient thyroidectomy, and these fell into the following broad categories: clinical, social, and procedural issues. Intraoperative factors that bear consideration are enumerated, and include choice of anesthesia, use of nerve monitoring, hemostasis, management of the parathyroid glands, wound closure, and extubation.

Ultrasound elastography in the evaluation of thyroid nodules for thyroid cancer.

Purpose Of Review: High-resolution ultrasonography has become mandatory while evaluating patients with thyroid nodules. Although B-mode and Doppler ultrasonography are highly sensitive for diagnosis of thyroid lesions, they lack specificity in differentiating benign from malignant nodules. Ultrasound elastography has proven valuable in discriminating these lesions.

Case series of targeted parathyroidectomy with surgeon-performed ultrasonography as the only preoperative imaging study.

Background: Targeted parathyroidectomy for treatment of sporadic primary hyperparathyroidism (SPHPT) has become the preferred approach in many centers. Therefore, preoperative localization studies are increasingly important. Although surgeon-performed ultrasonography (SUS) is equivalent to sestamibi scanning (MIBI), many surgeons still obtain either a MIBI or both studies before cervical exploration.

A summary of the new phenomenon of normocalcemic hyperparathyroidism and appropriate management.

Purpose Of Review: The phenomenon of normocalcemic hyperparathyroidism (NCHPT) remains largely unknown and not well understood. Recently, with more investigators reporting on the subject, NCHPT has been proposed to be a precursor of the classic hypercalcemic primary hyperparathyroidism (HPT).

Recent Findings: This manuscript will discuss the most recent findings regarding the diagnosis, natural history, treatment and follow-up of NCHPT.

Contemporary and practical uses of intraoperative parathyroid hormone monitoring.

Objective: To describe the evolution and current applications of intraoperative parathyroid hormone (PTH) monitoring along with a detailed description of intraoperative protocol and assay methodology.

Methods: Review of the literature regarding the role of intraoperative PTH monitoring in parathyroidectomy, controversies associated with its use in the treatment of hyperparathyroidism, and outcomes using this operative approach. The technologies currently available for "quick" PTH measurement are summarized.

Effectiveness of "office"-based, ultrasound-guided differential jugular venous sampling (DJVS) of parathormone in patients with primary hyperparathyroidism.

Background: Pre-operative localization is the first step for focused parathyroidectomy. Surgeon-performed ultrasonography (SUS) is used often as a single method of localization; however, when equivocal, sestamibi (MIBI) scan is still indicated. Intra-operative differential jugular venous sampling (DJVS) is positive in 71-80% of patients.

Recent findings in the use of intraoperative parathyroid hormone monitoring in parathyroid disease.

Purpose Of Review: To discuss recent findings and controversies regarding intraoperative parathyroid hormone monitoring (IPM) in guiding parathyroidectomy.

Recent Findings: IPM is being frequently used in guiding surgeons to complete excision of abnormal glands during parathyroidectomy for sporadic primary hyperparathyroidism (SPHPT). This adjunct is now being used in many centers around the world and has become a standard of care in the treatment of SPHPT.

Long-term outcome of patients with intraoperative parathyroid level remaining above the normal range during parathyroidectomy.

Background: Criterion requiring intraoperative parathyroid hormone (IOPTH) drops >50% from the highest, preincision or preexcision level, 10 minutes after the abnormal gland's excision predicts operative success with 98% accuracy. The purpose of this study is to correlate IOPTH dynamics with recurrent hyperparathyroidism (RecHPT) and eucalcemia with high PTH (HPTH).

Methods: We followed 383 consecutive patients with parathyroidectomy guided by IOPTH monitoring using the above criterion for >6 months.

Role of intraoperative parathormone monitoring during parathyroidectomy in patients with discordant localization studies.

Background: Many patients with sporadic primary hyperparathyroidism (SPHPT) have discordant preoperative Tc-99m-sestamibi (MIBI) and ultrasonography studies prior to focused parathyroidectomy (PTX). This study examines the usefulness of intraoperative parathormone monitoring (IPM) during PTX in patients with discordant preoperative localization studies.

Methods: A retrospective series of 225 consecutive SPHPT patients with MIBI scans and surgeon performed ultrasonography (SUS) prior to focused parathyroidectomy were studied.

Long-term outcome of patients with elevated parathyroid hormone levels after successful parathyroidectomy for sporadic primary hyperparathyroidism.

Hypothesis: Untreated long-term elevated parathyroid hormone (PTH) levels after successful parathyroidectomy may predict recurrent hyperparathyroidism (HPT). Although elevated PTH levels have been reported in eucalcemic patients after parathyroidectomy for sporadic primary HPT, the long-term clinical significance of this finding remains unclear.

Design: Retrospective case series.

Does histopathology predict parathyroid hypersecretion and influence correctly the extent of parathyroidectomy in patients with sporadic primary hyperparathyroidism?

Background: Parathyroid histopathology has been used to predict single or multiglandular disease (MGD). "Hyperplasia" implies MGD, whereas "adenoma" suggests single gland involvement. Intraoperative parathyroid hormone (PTH) monitoring (IPM) guides parathyroidectomy based on function.

Consequences of parathyroidectomy in patients with "mild" sporadic primary hyperparathyroidism.

Background: The use of a targeted, less-invasive approach is changing the operative indications in sporadic primary hyperparathyroidism (SPHPT). Now, patients with "mild" HPT are offered parathyroidectomy. However, the operative findings and outcome of these patients are unknown.

Intra-operative parathyroid hormone monitoring in patients with parathyroid cancer.

Background: Intra-operative parathyroid hormone (PTH) monitoring (IPM) is 97% accurate in predicting postoperative eucalcemia in sporadic primary hyperparathyroidism (SPHPT). However, its usefulness in parathyroid cancer has not been demonstrated. This study reports IPM accuracy during surgical resections for parathyroid cancer.

Consequences of targeted parathyroidectomy guided by localization studies without intraoperative parathyroid hormone monitoring.

Background: After excision of an abnormal gland, the dynamics of intraoperative parathyroid hormone (PTH) levels signal whether or not more hypersecreting tissue is present. This quantitative assurance of operative success has led to targeted exploration of the hyperfunctioning gland(s). Some have questioned the need for intraoperative PTH monitoring (IPM) in the presence of positive nuclear scanning.

Surgeon-performed ultrasonography as the initial and only localizing study in sporadic primary hyperparathyroidism.

Background: With a secure diagnosis of hyperparathyroidism, preoperative localization of abnormal glands is the initial step toward limited parathyroidectomy. Nuclear scanning and ultrasonography done by third parties are costly. We investigated whether ultrasonography performed by the operating surgeon (SUS) could be the initial and only preoperative localization study in patients with sporadic primary hyperparathyroidism.