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Medicina (Kaunas, Lithuania) Nov 2019The most common complications after conventional thyroid surgery in adult patients are recurrent laryngeal nerve (RLN) injury and hypocalcemia. Magnification techniques... (Meta-Analysis)
Meta-Analysis
The most common complications after conventional thyroid surgery in adult patients are recurrent laryngeal nerve (RLN) injury and hypocalcemia. Magnification techniques (surgical loupes or surgical microscope) are used for identification of RLN and parathyroid glands to diminish these complications although more evidence is necessary to assess their safety and efficacy in comparison with direct vision. : Electronic databases (Pubmed, Cochrane Library, Scopus) as well as gray literature sources were searched for randomized controlled trials (RCTs) comparing the frequency of transient/permanent RLN injury and hypocalcemia after thyroid surgery by using magnification techniques and direct vision for identification of RLN and parathyroid glands until October 17, 2019. The main outcomes were transient/permanent RLN injury and hypocalcemia. For all outcomes, 95% confidence intervals (95% CI) were used. Statistical analysis was performed with RevMan 5.3. Systematic review and meta-analysis included 3 RCTs with 437 patients overall. Magnification techniques did not significantly affect the risk of occurrence of transient RLN injury (OR = 0.38, 95% CI (0.11-1.35), I = 0%) and transient hypocalcemia (OR = 0.31, 95% CI (0.09-1.09), I = 23%) compared with direct vision. Included RCTs demonstrated only two patients with permanent hypocalcemia and another one with permanent RLN injury, who belonged to the direct vision group. The use of magnification techniques for identification of RLN and parathyroid glands seems to be as safe as direct vision. However, they do not decrease the risk of RLN injury and transient hypocalcemia after thyroid surgery compared with direct vision. Finally, further prospective research should be conducted as the sample among the studies was small.
Topics: Humans; Radiographic Magnification; Surgical Procedures, Operative; Thyroid Gland
PubMed: 31683924
DOI: 10.3390/medicina55110725 -
PloS One 2019We conducted this meta-analysis to assess the effectiveness of parathyroid gland autotransplantation in preserving parathyroid function during thyroid surgery for... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
We conducted this meta-analysis to assess the effectiveness of parathyroid gland autotransplantation in preserving parathyroid function during thyroid surgery for thyroid neoplasms.
METHODS
We conducted a search by using PubMed, Embase, and the Cochrane Library electronic databases for studies that were published up to January 2019. The reference lists of the retrieved articles were also reviewed. Two authors independently assessed the methodological quality and extracted the data. A random-effects model was used to calculate the overall combined risk estimates. Publication bias was evaluated with a funnel plot using Egger's and Begg's tests.
RESULTS
A total of 25 independent studies involving 10,531 participants were included in the meta-analysis. Compared with patients who did not undergo parathyroid gland autotransplantation, the overall pooled relative risks for patients who underwent parathyroid gland autotransplantation were 1.75 (95% CI: 1.51-2.02, p<0.001) for postoperative hypoparathyroidism, 1.72 (95% CI: 1.45-2.05, p<0.001) for protracted hypoparathyroidism, 1.06 (95% CI: 0.44-2.58, p = 0.894) and 0.71 (95% CI: 0.22-2.29, p = 0.561) for biochemical hypoparathyroidism and biochemical hypocalcemia at 6 months postoperatively, respectively, and 1.89 (95% CI: 1.33-2.69, p<0.001) and 0.22 (95% CI: 0.09-0.52, p = 0.001) for biochemical hypoparathyroidism and biochemical hypocalcemia at 12 months postoperatively, respectively. The pooled relative risks for patients who underwent one parathyroid gland autotransplantation and patients who underwent two or more parathyroid gland autotransplantations were 1.71 (95% CI: 1.25-2.35, p = 0.001) and 2.22 (95% CI: 1.43-3.45, p<0.001) for postoperative hypoparathyroidism, 1.09 (95% CI: 0.59-2.01, p = 0.781) and 0.55 (95% CI: 0.16-1.87, p = 0.341) for hypoparathyroidism at 6 months postoperatively compared with those of patients who did not undergo parathyroid gland autotransplantation.
CONCLUSIONS
Parathyroid gland autotransplantation is significantly associated with increased risk of postoperative and protracted hypoparathyroidism, and the number of autoplastic parathyroid glands is positively correlated with the incidence of postoperative hypoparathyroidism.
Topics: Humans; Hypocalcemia; Hypoparathyroidism; Parathyroid Glands; Postoperative Complications; Risk Factors; Thyroid Neoplasms; Transplantation, Autologous
PubMed: 31412080
DOI: 10.1371/journal.pone.0221173 -
Langenbeck's Archives of Surgery Sep 2019The optimal surgical approach of parathyroidectomy for patients with secondary hyperparathyroidism (SHPT) has been controversial. The updated meta-analysis aimed to... (Meta-Analysis)
Meta-Analysis
PURPOSE
The optimal surgical approach of parathyroidectomy for patients with secondary hyperparathyroidism (SHPT) has been controversial. The updated meta-analysis aimed to compare the effectiveness of subtotal parathyroidectomy (SPTX) versus total parathyroidectomy with autotransplantation (TPTX + AT).
METHODS
A thorough systematic search was performed on the databases of PubMed, EMBASE, and Cochrane library to identify eligible studies. Data were extracted and pooled into a meta-analysis. The primary outcomes were the symptomatic improvement, radiological changes, hypocalcemia rate, the requirement for vitamin D analogues, time to recurrence, recurrence, persistence, and reoperation rates of SPTX versus TPTX + AT.
RESULTS
A total of 18 studies with 3656 patients (1864 patients in SPTX and 1792 patients in TPTX + AT group) were included, and 15 studies were included in quantitative synthesis. No significant difference was observed in symptomatic improvement (93.3%, 89.0%; P = 0.99), radiological changes (85.4%, 85.3%; P = 0.91), hypocalcemia rate (16.6%, 18.1%; P = 0.29), persistence rate (6.1%, 2.0%; P = 0.16), time to recurrence (mean difference 1.46; P = 0.87), recurrence rate (9.2%, 7.1%; P = 0.76), and reoperation rate (5.3%, 5.8%; P = 0.66) between SPTX and TPTX + AT groups. Longer operative time (150 vs. 120 min), prolonged in-hospital stay (5.0 vs. 4.1 days), lower 1-month serum calcium level, and higher requirement for vitamin D analogues at 12 months were significantly observed in patients who underwent TPTX + AT compared to SPTX.
CONCLUSIONS
The two surgical approaches were both effective at controlling SHPT in clinical and laboratory terms. However, most of the data shown were not statistically significant. It was acceptable that surgeons chose either SPTX or TPTX + AT for SHPT.
Topics: Humans; Hyperparathyroidism, Secondary; Length of Stay; Operative Time; Parathyroid Glands; Parathyroidectomy; Recurrence; Reoperation; Transplantation, Autologous
PubMed: 31377854
DOI: 10.1007/s00423-019-01809-7 -
JAMA Otolaryngology-- Head & Neck... Aug 2019Identifying parathyroid glands correctly before a surgical procedure is essential to perform minimally invasive surgery. First-line tests with discordant or negative...
IMPORTANCE
Identifying parathyroid glands correctly before a surgical procedure is essential to perform minimally invasive surgery. First-line tests with discordant or negative results underscore the need for more accurate imaging tests, thus decreasing the requirement for bilateral neck exploration or reintervention.
OBJECTIVE
To review the available evidence to determine positive predictive value, negative predictive value, sensitivity, and specificity in clinical cases in which 18F-fluorocholine positron emission tomography-computed tomography (PET/CT) could be useful as a method to locate the lesions, and the benefits and controversial aspects of the method.
EVIDENCE REVIEW
A search was conducted using the PubMed Central and Cochrane Library databases for studies published in English from July 26, 2014, to November 30, 2018, using the search terms 18 choline, 18F choline, 18F-choline, 18 fluorocholine PET CT, hyperparathyroidism, primary hyperparathyroidism, secondary hyperparathyroidism, tertiary hyperparathyroidism, persistent hyperparathyroidism, recurrent hyperparathyroidism, ectopic hyperparathyroidism, and parathyroid adenoma. Other inclusion criteria were reporting at least 1 of the following measurements: negative or positive predictive value, sensitivity, and specificity of 18F-fluorocholine PET/CT in the diagnosis of hyperparathyroidism (HPT). Exclusion criteria were language other than English, use of a tracer other than 18F-fluorocholine, reports of a single case, and studies not related to HPT. The Oxford Centre classifications for levels of evidence were used.
FINDINGS
Sixteen studies fulfilled the inclusion criteria, comprising a total of 619 patients. Selected studies included 10 prospective cohort studies, 5 retrospective cohort studies, and 1 case series. Of the subtypes of HPT diagnosed using 18F-fluorocholine PET/CT, 579 were primary HPT, 22 were secondary HPT, 1 was tertiary HPT, and 7 were associated with multiple endocrine neoplasia type I. Pathologically, the neoplasms comprised 459 adenomas, 59 hyperplasia, and 19 double adenomas.
CONCLUSIONS AND RELEVANCE
18F-fluorcholine PET/CT may be indicated when results of first-line tests are negative or discordant and in challenging clinical situations where locating the source of HPT is difficult.
PubMed: 31145436
DOI: 10.1001/jamaoto.2019.0574 -
The Cochrane Database of Systematic... Jan 2019Injuries to the recurrent inferior laryngeal nerve (RILN) remain one of the major post-operative complications after thyroid and parathyroid surgery. Damage to this... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Injuries to the recurrent inferior laryngeal nerve (RILN) remain one of the major post-operative complications after thyroid and parathyroid surgery. Damage to this nerve can result in a temporary or permanent palsy, which is associated with vocal cord paresis or paralysis. Visual identification of the RILN is a common procedure to prevent nerve injury during thyroid and parathyroid surgery. Recently, intraoperative neuromonitoring (IONM) has been introduced in order to facilitate the localisation of the nerves and to prevent their injury during surgery. IONM permits nerve identification using an electrode, where, in order to measure the nerve response, the electric field is converted to an acoustic signal.
OBJECTIVES
To assess the effects of IONM versus visual nerve identification for the prevention of RILN injury in adults undergoing thyroid surgery.
SEARCH METHODS
We searched CENTRAL, MEDLINE, Embase, ICTRP Search Portal and ClinicalTrials.gov. The date of the last search of all databases was 21 August 2018. We did not apply any language restrictions.
SELECTION CRITERIA
We included randomised controlled trials (RCTs) comparing IONM nerve identification plus visual nerve identification versus visual nerve identification alone for prevention of RILN injury in adults undergoing thyroid surgery DATA COLLECTION AND ANALYSIS: Two review authors independently screened titles and abstracts for relevance. One review author carried out screening for inclusion, data extraction and 'Risk of bias' assessment and a second review author checked them. For dichotomous outcomes, we calculated risk ratios (RRs) with 95% confidence intervals (CIs). For continuous outcomes, we calculated mean differences (MDs) with 95% CIs. We assessed trials for certainty of the evidence using the GRADE instrument.
MAIN RESULTS
Five RCTs with 1558 participants (781 participants were randomly assigned to IONM and 777 to visual nerve identification only) met the inclusion criteria; two trials were performed in Poland and one trial each was performed in China, Korea and Turkey. Inclusion and exclusion criteria differed among trials: previous thyroid or parathyroid surgery was an exclusion criterion in three trials. In contrast, this was a specific inclusion criterion in another trial. Three trials had central neck compartment dissection or lateral neck dissection and Graves' disease as exclusion criteria. The mean duration of follow-up ranged from 6 to 12 months. The mean age of participants ranged between 41.7 years and 51.9 years.There was no firm evidence of an advantage or disadvantage comparing IONM with visual nerve identification only for permanent RILN palsy (RR 0.77, 95% CI 0.33 to 1.77; P = 0.54; 4 trials; 2895 nerves at risk; very low-certainty evidence) or transient RILN palsy (RR 0.62, 95% CI 0.35 to 1.08; P = 0.09; 4 trials; 2895 nerves at risk; very low-certainty evidence). None of the trials reported health-related quality of life. Transient hypoparathyroidism as an adverse event was not substantially different between intervention and comparator groups (RR 1.25; 95% CI 0.45 to 3.47; P = 0.66; 2 trials; 286 participants; very low-certainty evidence). Operative time was comparable between IONM and visual nerve monitoring alone (MD 5.5 minutes, 95% CI -0.7 to 11.8; P = 0.08; 3 trials; 1251 participants; very low-certainty evidence). Three of five included trials provided data on all-cause mortality: no deaths were reported. None of the trials reported socioeconomic effects. The evidence reported in this review was mostly of very low certainty, particularly because of risk of bias, a high degree of imprecision due to wide confidence intervals and substantial between-study heterogeneity.
AUTHORS' CONCLUSIONS
Results from this systematic review and meta-analysis indicate that there is currently no conclusive evidence for the superiority or inferiority of IONM over visual nerve identification only on any of the outcomes measured. Well-designed, executed, analysed and reported RCTs with a larger number of participants and longer follow-up, employing the latest IONM technology and applying new surgical techniques are needed.
Topics: Adult; Humans; Intraoperative Neurophysiological Monitoring; Operative Time; Randomized Controlled Trials as Topic; Recurrent Laryngeal Nerve; Recurrent Laryngeal Nerve Injuries; Thyroid Gland; Thyroidectomy
PubMed: 30659577
DOI: 10.1002/14651858.CD012483.pub2 -
Revista Colombiana de Psiquiatria... 2019The prescribing of Lithium is common in psychiatric clinical practice. The aim of this study was to identify the most common endocrine side effects associated with this...
The prescribing of Lithium is common in psychiatric clinical practice. The aim of this study was to identify the most common endocrine side effects associated with this drug and to clarify the pathophysiological basis. A systematic review was conducted in Psycinfo, Embase, PubMed, and Scopus. A computerised search for information was performed using a PICO (patient, intervention, comparative, outcomes) strategy. The main neuroendocrine alterations were reported in kidneys, thyroid and parathyroid glands, pancreas, and the communication pathways between the pituitary and adrenal glands. The pathophysiological mechanisms are diverse, and include the inhibition of the thyroid adenylate cyclase sensitive to the thyroid stimulant hormone (TSH) sensitive adenylate cyclase, which causes hypothyroidism. It also reduces the expression of aquaporin type 2, which is associated with nephrogenic diabetes insipidus, and the loss of the ionic balance of calcium that induces hyperparathyroidism and hypercalcaemia. Other considerations are related to alterations in the hypothalamic-pituitary-adrenal axis and a decrease in the production of catecholamines. Finally, another side-effect is the glycaemic dysregulation caused by the insulin resistance. Periodical clinical and para-clinical evaluations are necessary. The author proposes an evaluation scheme.
Topics: Endocrine System Diseases; Humans; Hypothalamo-Hypophyseal System; Lithium Compounds; Pituitary-Adrenal System
PubMed: 30651171
DOI: 10.1016/j.rcp.2017.01.003 -
Oral Oncology Dec 2018New optical technologies enhancing localization or assessing viability of parathyroid glands (PG) during endocrine surgery have been reported in clinical studies. These...
New optical technologies enhancing localization or assessing viability of parathyroid glands (PG) during endocrine surgery have been reported in clinical studies. These technologies could become complementary to the surgeon's eyes and may improve surgical outcomes in thyroidectomy and parathyroidectomy. Here, we conducted a systematic review focusing on PG identification and functional assessment using optical methods to enhance surgery. A systematic literature review was performed using MEDLINE and Embase database. Two authors selected studies and extracted data; qualitative analysis was performed to summarize the characteristics of reported optical tools for thyroidectomy or parathyroidectomy. Identification and vascularisation of PG during surgery were evaluated. Clinical and biochemical outcomes were appraised when reported. Studies relating to parathyroidectomy or thyroidectomy combined with autofluorescence, fluorescent methylene blue, 5-aminolevulinic acid, indocyanine green (ICG), optical coherence tomography, laser speckle contrast imaging, dynamic optical contrast imaging and Raman spectroscopy were identified with MEDLINE and Embase. We included a total of 47 relevant articles with a total of 1615 patients enrolled. Each optical technique is described and appreciated related to its surgical purpose. Autofluorescence and ICG imaging of PG are the most widely reported optical technologies for identification and assessment of vascularisation of PG. Results are mainly based on observational studies and argue for the feasibility of both techniques in endocrine surgery but prospective randomized studies have not been performed. In vivo applications are still limited for the other methods and further investigations correlating these techniques with post-operative parathormone measurements are still needed before considering these technologies in clinical practice.
Topics: Coloring Agents; Humans; Hypoparathyroidism; Indocyanine Green; Intraoperative Period; Optical Imaging; Parathyroid Glands; Parathyroidectomy; Postoperative Complications; Thyroidectomy
PubMed: 30527238
DOI: 10.1016/j.oraloncology.2018.11.011 -
Endocrine Reviews Jun 2019The number of patients surviving ≥5 years after initial cancer diagnosis has significantly increased during the last decades due to considerable improvements in the...
The number of patients surviving ≥5 years after initial cancer diagnosis has significantly increased during the last decades due to considerable improvements in the treatment of many cancer entities. A negative consequence of this is that the emergence of long-term sequelae and endocrine disorders account for a high proportion of these. These late effects can occur decades after cancer treatment and affect up to 50% of childhood cancer survivors. Multiple predisposing factors for endocrine late effects have been identified, including radiation, sex, and age at the time of diagnosis. A systematic literature search has been conducted using the PubMed database to offer a detailed overview of the spectrum of late endocrine disorders following oncological treatment. Most data are based on late effects of treatment in former childhood cancer patients for whom specific guidelines and recommendations already exist, whereas current knowledge concerning late effects in adult-onset cancer survivors is much less clear. Endocrine sequelae of cancer therapy include functional alterations in hypothalamic-pituitary, thyroid, parathyroid, adrenal, and gonadal regulation as well as bone and metabolic complications. Surgery, radiotherapy, chemotherapy, and immunotherapy all contribute to these sequelae. Following irradiation, endocrine organs such as the thyroid are also at risk for subsequent malignancies. Although diagnosis and management of functional and neoplastic long-term consequences of cancer therapy are comparable to other causes of endocrine disorders, cancer survivors need individually structured follow-up care in specialized surveillance centers to improve care for this rapidly growing group of patients.
Topics: Antineoplastic Agents; Endocrine Glands; Endocrine System Diseases; Female; Humans; Immunotherapy; Male; Neoplasms; Radiotherapy; Surgical Procedures, Operative
PubMed: 30476004
DOI: 10.1210/er.2018-00092 -
Nuclear Medicine Communications Feb 2019One of the most promising imaging techniques in primary hyperparathyroidism is PET/CT with choline-based tracers. To investigate the current evidence of these tracers in...
One of the most promising imaging techniques in primary hyperparathyroidism is PET/CT with choline-based tracers. To investigate the current evidence of these tracers in localizing parathyroid adenoma, a systematic review was performed. A comprehensive literature search was carried out and eligible studies were analyzed. Data were extracted, the level of evidence was scored, and performance data were pooled to calculate the weighted detection rate. Eleven articles were included in this study. The pooled detection rate was 97 and 94% on per patient-based and per lesion-based analysis, respectively. There was considerable heterogeneity between studies and the level of evidence was determined to be 3a-, following Oxford criteria. Choline PET/CT has shown favorable results in detection of hyperfunctioning parathyroid tissue and may replace conventional technetium-99m-sestamibi scintigraphy in preoperative planning of parathyroid surgery. However, the quality of current evidence is moderate, and additional high-quality studies are needed to confirm these numbers.
Topics: Choline; Humans; Parathyroid Glands; Positron Emission Tomography Computed Tomography; Radioactive Tracers
PubMed: 30444749
DOI: 10.1097/MNM.0000000000000952 -
PloS One 2018Postoperative hypocalcemia is the most common complication of thyroidectomy. Incidental parathyroidectomy (IP) was thought to be associated with postoperative... (Meta-Analysis)
Meta-Analysis
INTRODUCTION
Postoperative hypocalcemia is the most common complication of thyroidectomy. Incidental parathyroidectomy (IP) was thought to be associated with postoperative hypocalcemia. However, according to previous studies, the risk factors and clinical outcomes of IP remain controversial.
METHODS
Eligible studies were searched in databases including PubMed, Web of Science, and EMBASE from January 1990 to September 2017. Articles focusing on the relationship between IP and postoperative hypocalcemia were included. The risk of publication bias was assessed using Begg's test and Egger's regression asymmetry test. Pooled analysis was performed to evaluate the effect of IP on postoperative hypocalcemia and related risk factors. Sensitivity analysis was also conducted to test the stability of our results. The effects of hypocalcemia type, permanent definition, IP incidence, total thyroidectomy, and malignancy operation were also examined using a further subgroup analysis.
RESULTS
Thirty-five studies were finally included in the analysis after an exhaustive literature review. Pathology data demonstrate that incidental parathyroidectomy occurred in various locations: intrathyroidal (2.2-50.0%), intracapsular (16.7-40.0%) and extracapsular (15.7-81.1%) regions. Overall, the analysis found that malignancy (RR = 1.60, 95% CI: 1.27 to 2.02; p< 0.0001), central neck dissection (RR = 2.35, 95% CI: 1.47 to 3.75; p = 0.0004), total thyroidectomy (RR = 1.42, 95% CI: 1.20 to 1.67; p< 0.0001) and reoperation (RR = 1.81, 95% CI: 1.20 to 2.75; p = 0.005) were significant risk factors of IP in thyroid surgery. There was an obvious effect of IP on temporary/permanent (RR = 1.59, 95% CI: 1.37 to 1.84; p< 0.0001) and permanent (RD = 0.0220, 95% CI: 0.0069 to 0.0370; p = 0.0042) postoperative hypocalcemia. Sensitivity analysis showed that these results were robust. The subgroup analysis found that IP played a significant role in both biochemical and clinical hypocalcemia in thyroidectomy (p < 0.0001 and p = 0.0003, separately). The association of IP and permanent hypocalcemia using different definitions (6 months or more than 12 months) was also confirmed by the analysis. IP increased the incidence of temporary/permanent and permanent hypocalcemia for cases undergoing total thyroidectomy (40.4% vs 24.8% and 5.8% vs 1.4%, respectively). Thyroidectomy with IP was associated with more permanent hypocalcemia (RR = 3.10, 95% CI: 2.01 to 4.78; p< 0.0001) in malignant cases but was not associated with temporary/permanent hypocalcemia.
CONCLUSIONS
Malignancy, central neck dissection, total thyroidectomy and reoperation were found to be significant risk factors of IP. IP increases the risk of postoperative hypocalcemia after thyroidectomy. We recommend a more meticulous intraoperative identification of parathyroid gland in thyroidectomy to reduce IP, particularly for total thyroidectomy and malignancy cases.
Topics: Humans; Hypocalcemia; Medical Errors; Parathyroid Glands; Parathyroidectomy; Postoperative Complications; Risk Factors; Thyroidectomy; Treatment Outcome
PubMed: 30412639
DOI: 10.1371/journal.pone.0207088