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Background: The diagnosis of thyroid nodular diseases requires an integrated approach that has been widely established over the past years. This strategy includes: ultrasonography (US) with; implemented Color-Power-Doppler, conventional scintigraphy also with positive indicators, specific pathological studies targeted by immunohistochemically-assays, and the fine needle; aspiration biopsy (FNAB), which, usually, in case of "Follicular Lesions" (10-20%) findings is; unable to distinguish carcinoma from follicular adenoma, then indicating the necessity of surgery to; obtain a correct diagnosis. The aim of this study was to evaluate the role of the scintigraphy with; positive indicators, both preoperatively in diagnostic approach of the thyroid nodules and; intraoperatively as a guide to the extension of the surgical excision., Methods: On 4482 Thyroidectomy performed, we selected 360 cases of follicular neoplasms (192; females and 168 males). In the preoperative phase, these patients underwent 99 m Tc-sestaMIBI; scintigraphy with both early (10 min) and late (2 h) image acquisition, which were later; compared to the ones obtained by image subtraction of means 99 m Tc-pertechnetate. Following the; sestamibi administration before intervention, we selected the most up-taking nodularity with the; assistance of a specific surgical probe (Neoprobe), quantifying uptake with relation to the surgical pathology, for an amount of 324 total thyroidectomies and 36 hemi thyroidectomies., Results: In all cases of multinodular goiter the benign nodules showed an intraoperative low sestamibi uptake whereas follicular carcinomas showed both a high preoperative uptake and, as a; percentage, the highest values of intraoperative uptake; on the other hand, follicular adenomas had; both pre-and intraoperative mean values of uptake. On the contrary, papillary carcinomas only; showed a mild uptake., Conclusions: Preoperative sestamibi scintigraphy confirmed its importance in improving the information obtained through different diagnostic investigations. Also intraoperatively, it pointed; out high-risk nodules more accurately. Therefore, radio (Sestamibi) guided surgery could have an; interesting rule in the thyroid follicular lesion treatment., (Copyright © 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Introduction: Hemostasis during thyroidectomy is essential; however the most efficient and cost-effective way to achieve this is unclear. The aim of this study was to evaluate the outcome of total thyroidectomy (TT) performed with the combination of harmonic scalpel (HS) and an advanced hemostatic pad (Hemopatch)., Methods: Patient undergone TT were divided into two groups: HS + hemopatch and HS + traditional hemostasis groups. The primary endpoint was 24-h drain output and blood-loss requiring reintervention. Secondary endpoints included surgery duration, postsurgical complications and hypocalcemia rates., Results: Between September 2014 and March 2015, 60 patients were enrolled (30 to Hs + Hemopatch, 30 to Hs and standard hemostasis); 71.4% female; mean age 48.5 years. The 24-h drain output was lower in the HS + hemopatch group compared with standard TT. HS and hemopatch also had a shorter mean surgery time (p < 0.0001) vs standard TT., Conclusion: combination of hemopatch plus HS is effective and safe for TT with a complementary hemostatic approach., (Copyright © 2015. Published by Elsevier Ltd.)

Background: Hemostasis during thyroidectomy is essential; however, the safest, most efficient, and most cost-effective way to achieve this is unclear. This randomized, multicenter, single-blind, prospective study evaluated the efficacy and safety of using different hemostatic approaches in patients undergoing total thyroidectomy., Methods: Patients aged ≥18 to 70 years were randomized to Floseal + a harmonic scalpel (HS), Floseal alone, HS alone, or standard total thyroidectomy. Primary endpoint was 24-hour drain output. Secondary endpoints included surgery duration and complications., Results: Two hundred and six patients were randomized to Floseal + HS (n = 52), Floseal alone (n = 54), HS alone (n = 50), and standard total thyroidectomy (n = 50). The 24-hour drain output was lower in the Floseal + HS group compared with standard thyroidectomy. Floseal + HS also had a shorter surgery time (P < .0001) versus the other 3 treatments., Conclusion: Floseal + HS can be effective at reducing postsurgical drain output and provides a complementary hemostatic approach in patients undergoing total thyroidectomy., (© The Author(s) 2015.)

Background: Intra Operative Nerve Monitoring (IONM) has been used in head and neck surgery since the 1970s. Its utilization for monitoring and protecting the recurrent laryngeal nerve, however, is a controversial subject. This paper details the use, value, and cost of this technology within a single institution., Methods: We conducted a retrospective chart review, analysis of surgery time with and without IONM, analysis of postoperative vocal cord function, and review of the literature, Results: IONM did not reduce the operative time during total thyroidectomies in our experience. Use of IONM increased the cost of each surgery by € 450. IONM did not decrease the number of injured nerves (postoperative paresis)., Conclusions: IONM has proven to be highly useful in certain circumstances but has not been definitively proven to protect the nerve any more effectively than the gold standard of nerve visualization. In our study, the use of IONM did not reduce the time of thyroid surgery and did increase the cost. While IONM may, in special clinical circumstances such as revision and malignant thyroid surgery, increase the value of the operation, its use for every thyroid surgery does not appear to be cost effective or valuable to the patient.

Introduction: Hemostasis during thyroidectomy is essential; however, the safest, most efficient and cost-effective way to achieve this is unclear. The aim of this study was to evaluate the outcome of total thyroidectomy (TT) performed with combination of harmonic scalpel (HS) and Floseal., Methods: Patients undergone TT were divided into two groups: HS + Floseal and traditional hemostasis groups. The primary endpoint was 24-h drain output and blood-loss requiring reintervention. Secondary endpoints included surgery duration, postsurgical complications and hypocalcemia rates., Results: Between September 2012 and January 2014, 165 patients were enrolled (100 to HS + Floseal, 65 to standard hemostasis); 80.5% female; mean age 42.3 years. The 24-h drain output was lower in the HS + Floseal group compared with standard TT. HS + Floseal also had a shorter mean surgery time (p < 0.0001) vs standard TT. No differences in post-surgical complications and in hypocalcemiarates between groups., Conclusion: combination of Floseal plus the HS is effective and safe for TT and it provides a complementary hemostatic approach., (Copyright © 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: Hypocalcemia caused by transient or definitive hypoparathyroidism is the most frequent complication after total thyroidectomy (TT). We aimed to compare the impact of age and the clinical usefulness of oral calcium and vitamin D supplements on postoperative hypocalcemia after TT, and to determine which risk factors are important for hypocalcemia incidence., Methods: Two hundred consecutive patients treated by TT were included prospectively in the present study. All patients supplemented oral calcium and vitamin D in the post-operative time. The data concerning symptomatic and laboratoristichypocalcemia were collected., Results: Symptomatic hypocalcemia developed only in 19 patients (9.5%), whereas laboratory hypocalcemia developed in 36 patients (18%). The risk for postoperative hypocalcemia was increate 20-fold for patients older than 50 years., Conclusions: Age is significantly associated with postoperative hypocalcemia. Implementing oral calcium and vitamin D after total thyroidectomy can reduce the incidence of hypocalcemia related to surgery.

Introduction: Injury to cranial nerve represents 5% of negligence litigation against general surgeons and of all malpractice jury verdicts in endocrine surgery 60% accounts for recurrent nerve injuries and 15% for anoxic brain injuries from RLN injuries, unrecognized post-operatively. During Total Thyroidectomy is reported an incidence of failure to find the nerve in 5- 18% of cases and if we think that routine identification of the RLN during thyroid surgery has reduced the injury rate from 10% to less than 4% and that the incidence of nerve paralysis was 3 to 4 times greater in cases where the nerve was not exposed than in cases where was routinely exposed, then we understand the importance of a clear identification during every thyroid dissection, Materials and Methods: 880 Total Thyroidectomies during the last 4 years, since Jannuary 2007 until December 2010, (610 F, 270 M; mean age 44,5 years old, range 14-83). All patients were examined pre and postoperatively (1-6 months after) by direct laryngoscopy or laryngofibroscopy to check vocal cord mobility (medium follow up 25.5 months range 3-50 months). The Authors reviewed charts from two randomized groups, selected by a double blind, statistically designed study and again compared in a multivariate analysis (Stat 2004 ltd): 1) 480 total sutureless thyroidectomies, performed during the previous year with continuous intra-operative nerve monitoring using dedicated endotracheal tube with a last generation Nerve Integrity Monitor Pulse II (N.I.M. pulse II®) 2) 400 total sutureless thyroidectomies: performed with continuous intra-operative nerve monitoring using dedicated Laryngeal Electrode, a self-adhesive device designed to fit onto standard reinforced endotracheal tubes (Neurosign® 1040 - 4 Channel EMG) RESULTS: There were no statistically significative difference between the two groups for distribution of age, sex, epidemiological characteristics, type of pathology etc. The incidence of major complications in thyroid surgery in the first two groups (total Thyroidectomy performed by NIM and by Neurosign), as well as compared with the data of the literature are absolutely overimposable; only significative difference is a reduction of the costs in the second group (Neurosign). The 1st group (NIM) specificity is 90.2% (433/480). There were 6 cases of temporary RLN paralysis (temporary paralysis rate: 1.25 % of patients), 3 true positive and 3 false negative. Finally there were 3 cases of permanent RLN paralysis (0.75%), 2 truepositive and 1 false-negative developed after 10 days (demyelination by thermal injury). The 2nd group (Neurosign) specificity of 89 % (356/400). There were 6 cases of temporary RLN paralysis (rate: 1.5 %, p > 0.5), 2 true positive, 1 false positive and 4 false negative. Finally 2 cases of permanent RLN paralysis (0.5% p > 0.5), 2 true-positive., Discussion and Conclusion: Our data confirm a useful application of NIM and Neurosign in thyroid dissection nerve prevention. We don't believe that those procedures can be useful for learning thyroid gland surgery, because can't preserve from an accurate dissection and nerve identification technique, but can only support in nerve-at-risk thyroidectomy or during dissection can support expert surgeon's decision, having a clear pre-operative (post-anesthesiologist) and post-operative predictive value. Those procedures are anyway expensive and time consuming (25000-30000 € for the E.M.G. system and almost 200-250 € for each dedicated endotracheal tube in NIM group). So Neurosign group has over-imposable results in terms of complications specificity and accurancy (no statistically significative differences), but it's a much cheaper procedure!

Background: We conducted an observational multicentric clinical study on a cohort of patients undergoing thyroidectomy for thyroid carcinoma. The aim of this study was to evaluate the benefits of the use of ultrasonic dissector (UAS) vs. the use of a conventional technique (vessel clamp and tie) in patients undergoing thyroid surgery for cancer., Methods: From June 2009 to May 2010 we evaluated 321 consecutive patients electively admitted to undergo total thyroidectomy for thyroid carcinoma. The first 201 patients (89 males, 112 females) presenting to our Department underwent thyroidectomy with the use of UAS while the following 120 patients (54 males, 66 females) underwent thyroidectomy performed with a conventional technique (CT): vessel clamp and tie., Results: The operative time (mean: 75 min in UAS vs. 113 min in CT, range: 54 to 120 min in UAS vs. 68 to 173 min in CT) was much shorter in the group of thyroidectomies performed with UAS. The incidence of transient laryngeal nerve palsy (UAS 3/201 patients (1.49%); CT 1/120 patients (0.83%)) was higher in the group of UAS; the incidence of permanent laryngeal nerve palsy was similar in the two groups (UAS 2/201 patients (0.99%) vs. CT 2/120 patients (1.66%)). The incidence of transient hypocalcaemia (UAS 17/201 patients (8.4%) vs. CT 9/120 patients (7.5%)) was higher in the UAS group; no relevant differences were reported in the incidence of permanent hypocalcaemia in the two groups (UAS 5/201 patients (2.48%) vs. 2/120 patients (1.66%)). Also the average postoperative length of stay was similar in two groups (2 days)., Conclusion: The only significant advantage proved by this study is represented by the cost-effectiveness (reduction of the usage of operating room) for patients treated with UAS, secondary to the significant reduction of the operative time. The analysis failed to show any advantages in terms of postoperative transient complications in the group of patients treated with ultrasonic dissector: transient laryngeal nerve palsy (1.49% in UAS vs. 0.83% in CT) and transient hypocalcaemia (8.4% in UAS vs. 7.5%in CT). No significant differences in the incidence of permanent laryngeal nerve palsy (0.8% in UAS vs. 1.04% in CT) and permanent hypocalcaemia (2.6% in UAS vs. 2.04% in CT) were demonstrated. The level of surgeons' expertise is a central factor, which can influence the complications rate; the use of UAS can only help surgical action but cannot replace the experience of the operator.

Aim: In the present study the authors assess the advantages of new technologies in thyroid surgery: to prevent nerve injury by using an intra-operative continuous nerve-monitoring techniques and to compare the real advantages of advanced coagulation devices., Materials and Methods: Among a series of 440 thyroidectomies (jan 2004-feb 2006) the Authors reviewed charts from two groups: (1) 240 total thyroidectomies performed using the traditional monopolar electrocautery, non-absorbable stitches for the principal vascular pedicles. (2) 140 total thyroidectomies performed using dedicated small bipolar electro thermal coagulator (ligasure-precise). (3) Since 2006 in a double blind group selection of 70, we've performed sutureless thyroidectomy with continuous intraoperative nerve monitoring using dedicated endotracheal tube. Mean operative time, post-operative bleeding, post-operative stay, incidence of transient or definitive laryngeal nerve lesions, incidence of permanent or transient hypocalcaemia, costs of the procedures were analyzed., Results: Major complications in the first two groups compared with the data of the literature are absolutely over-imposable, except a reduction of incidence of transient hypocalcaemia in the Precise group, but if we compare data of the 3rd group (NIM), we find a significative reduction of transient and permanent laryngeal nerve palsy incidence., Discussion and Conclusion: This new technology offers several advantages: (1) atraumatic; (2) easy to use; (3) continuous monitoring and audio feedback to the surgeon (4) works outside the operation field (5) high sensitiveness. Cost-analysis confirm that NIM + ligasure have same or less cost and time and probably less complications than traditional Total Thyroidectomy.

Background: In recent years it has seen an increase of incidental thyroid carcinomas (ICs), most of the ICs are any microcarcinoma (MC). The term refers to a CT, predominantly papillary, and smaller than or equal to 1 cm. The MC is characterized by a papillary heterogeneous clinical behavior ranging from small outbreak discovered accidentally after surgery than the cancer that manifests clinically with lymph node metastases in the neck or rarely systemic., Methods: From January 2007 to June 2009, 1507 patients for benign disease were subjected to surgery., Results: Histological examination confirmed the diagnosis of benignity in 1339 cases. In 168, however, we detected unexpected, incidental carcinoma (CI). In patients with CI receiving total surgery (TT), the next iteration we agree with the endocrinologist. In cases of lobectomia, was run TT and was heading endocrinology. Of the 168 patients with incidental CT, 147 had papillary carcinomas, 12 follicular carcinomas, 5 follicular variant papillary carcinomas, 2 oncocytic carcinomas, 1 uncertain malignancy., Conclusion: In our study has highlighted the lack of data (medical history, ultrasound, scintigraphic), they may portend the presence of a tumor in the specimen CI. In all patients with CI, the surgical indication was given for symptomatic disease, for impairment of thyroid function, for failure to respond to medical therapy or unable to continue. The IC is almost always a microcarcinoma, predominantly papillary, and smaller than or equal to 1 cm, has little biological aggressiveness and is susceptible to metabolic radioiodine therapy. On the basis of these data we feel reasonably acceptable to a close follow-up endocrine surgery, particularly in patients with multinodular disease and stress the need for a multi-specialized team.

Aim: Iatrogenic damage to the recurrent laringeal nerve is the most feared complication in thyroid surgery and the main cause for vocal cord palsy. Prevention of such a lesion is based upon the thorough search for the nerve along its anatomic pathway. In the present study the Authors discuss an important anatomic variation: non-recurrent inferior laryngeal nerve, emphasizing the aspects of surgical anatomy, on the basis of their own experience in neck surgery., Materials and Methods: The study takes into conideration 301 surgical interventions on the thyroid gland, in 268 women and 33 men; consisting in 256 total thyroidectomies and 45 loboisthmectomies, as follows: 186 for nodular goiter, 48 for follicular nodule, 34 for papillifer carcinoma, 33 for toxic goiter. The identification and exposure of inferior laryngeal nerve was performed according to the principles and technique by Lahey., Results: The overall prevalence of non recurrent inferior laryngeal nerve was equal to 0.33% (1/301 operations). The anomaly is prevailing on the right side, being due by an anomalous reabsorption of the IV ventral arch. This is the cause of the formation of a subclavian artery that is responsible for dysphagia lusoria., Conclusions: The rationale for the preservation of recurrent nerve is its systematic identification and exposure along all its course from its laryngeal entry. Diagnosis of non recurrent inferior laryngeal nerve is exclusively intra-operative. The anomaly is clinically asymptomatic and its suspicion can be posed in case of vascular anomalies or dysphagia. In such a circumstance the golden diagnostic tool is the angio Tc-RMN, while both the EGDS and baritate esophagous can be of some diagnostic help.

Introduction: We carried out a retrospective analysis of our experience in the management of Differentiated Thyroid Carcinoma (DTC), in order to better define prognostic factors (age, gender, histological type, stage) and outline a standard procedure, where it's possible, for surgical treatment., Patients and Methods: Patient population consisted of 432 cases, operated from 1978 to 2003. We carried out 285 operations of total thyroidectomy of which 39 associated to some kind of lymphadenectomy, 66 totalization (21 pts had been operated in other institutes), 60 subtotal thyroidectomies and 21 lobo-isthmectomies. Survival and mortality curves for age, sex, histological type, grading and staging have been calculated. Kaplan-Meyer statistical elaboration for disease-free interval and Mann-Whitney test for the comparison of different clinical and pathological data have been employed., Results: The statistical analysis puts in evidence that on 432 cases examined, with a follow-up from 1 to 25 ys (median = 6.33 ys) and with a drop-out of 60 cases (13.8 %), total mortality for cancer has been of 24 cases (6,4%), with a median interval free by disease of 4.2 ys (range 5 months to 25 ys), and a probability to stay free by disease at 12 and 24 months respectively of 95.1% and 91.6%. The median survival is resulted of 5.8 ys (range 1 to 25 ys) with a probability of survival at 24 and 48 months respectively of 97.5% and 94.3%. The multivariate analysis evidences the most important variables, i.e. age > 45 ys, tumor of intermediate malignancy, with size 1.5 cm, operative M+, significantly condition the prognosis, noticeably getting worse it, independently by the kind of carried out operation., Conclusion: Our present therapeutic choices are: 1. total thyroidectomy in the treatment of the apparently benign pathology when bilaterally with spread; the checking at the final histological exam of a cancer makes however think adequate the carried out operation; 2. lobo-isthmectomy in the treatment of unilateral benign pathology or with suspect FNAB for follicular neoplasm; the histological checking of a cancer makes think the operation adequate only in presence of favourable prognostic parameters, but in presence even of just one unfavourable variable, we consider necessary the totalization; 3. total thyroidectomy in presence of a certain or strongly suspected preoperative diagnosis of cancer.

A retrospective study was carried out to assessed reliability of the prognostic factors (histology, age, sex, and stage), and standard procedures for the surgical treatment of differentiated thyroid cancers (DTC). From the 144 DTC cases reviewed with follow-up ranging from 1 to 25 years (m = 6.33 years), total mortality for cancer was found to be 55% (8 patients), with a predictive positive value for recurrence of 95.4% and 91.8% at 12 and 24 months, respectively. Median survival was 8.8 years (range 1 to 25 years). The multivariate analysis showed that factors such as age > 45 years, histology of intermediate malignancy, size up to 1.5 cm, and presence of metastases, significantly worsened the prognosis, regardless of the intervention that was carried out. We suggest total thyroidectomy for the treatment of benign pathologies and confirmed or suspected cases of cancer. We reserve loboisthmectomy for the treatment of benign pathologies confined to one lobe or those with FNAB suggesting a follicular neoplasm.

Hypocalcemia is one of the most frequent complications after total extracapsular thyroidectomy (TET). In most of cases it is a transient phenomenon. The aim of this study is to evaluate if and how the oral administration of calcium or calcium combined with D-vitamin could effectively prevent post-thyroidectomy hypocalcemia. A randomized prospective study was performed, recruiting 120 patients who underwent total thyroidectomy. The patients in our series were randomly assigned to one of two groups: group A--patients who received calcium lactogluconate/calcium carbonate (mg 300 per day); group B--patients who received calcium carbonate/cholecalciferol therapy (calcium carbonate: 1500 mg per day; cholecalciferol 400 UI per day). The groups were well matched for age, sex and pathologies. Patients of both A and B groups were divided in two subgroups: those operated on for benign thyroid diseases (A1 and B1) and those operated on for malignancy (A2, B2). Serum calcium assays, performed 24, 48 and 72 hours after surgery, showed mean values of calcemia higher in patients of the B1 and B2 group. Statistical analysis was performed using a Student's t test. Mean serum calcium concentrations on post-operative day one, two and three were higher in patients of the group B (p<<0.01). Early and combined oral administration of both calcium and vitamin D seemed to prove major efficacy in preventing and treating post-operative hypocalcemia, showing mean serum calcium levels higher than those of patients who received only oral calcium administration. Nevertheless, further studies are necessary to validate these data.

In the present study the Authors tried and assess the advantages of the standard sutureless thyroidectomy performed by the Ligasure Vessel Sealing System, thanks to the use of the dedicated Precise handle. The Authors compared the efficacy of haemostasis and the economical impact of the device, in terms of drug administration and costs. The Authors comparatively analyzed 120 total extracapsular thyroidectomies (TET) performed by the standard operative technique (Group A, control) and 70 TET achieved by the "sutureless technique" (Group B, case). There was a statistically significant decrease of transient postoperative hypocalcemia (5.71% vs 7.5%) and also of mean operative time (about 20 minutes) in patients of the group B. Non significant decrease of other kind of complications (postoperative hemorrhage, transient and permanent inferior laryngeal palsy, stupor of the superior laryngeal nerve, seromas) were also observed. The use of the Ligasure Precise resulted easy, safe and efficient in the Authors' experience. It allowed the decrease of postoperative haemorrhages and mean operative time.

Background: The study evaluates the incidence of both early and protracted post-thyroidectomy hypocalcemia over a 6-year period (1995-2000) in a series of 330 consecutive thryoid operations. The aim was to identify the profile of patients with the greatest risk of permanent parathyroid functional insufficiency and a suitable treatment protocol., Methods: Having performed a statistical ana-lysis of all the variables, we divided the entire population of 330 patients into 4 groups based on the extent of demolition, the method of organotherapeutic replacement with L-Thyroxine and the (eco-radioguided) procedure used to identify the parathyroids: 59 patients undergoing subtotal thyroidectomy; 155 patients undergoing total thyroidectomy who commenced replacement organotherapy from postoperative day 15-30; 94 patients undergoing total thyroidectomy who commenced replacement organotherapy from postoperative day 1; 22 patients undergoing total thyroidectomy who underwent routine intraoperative parathyroid assay., Results: The results show that the impact of more radical surgery in determining hypocalcemia, in particular protracted hypocalcemia, represents the most striking characteristic of patients with the greatest probability of permanent parathyroid insufficiency. We emphasise that early correction of postoperative hypothyroidism can drastically reduce the incidence of both early and protracted hypocalcemia., Conclusions: In conclusion, hypoparathyroidism is an exceptional event, whereas hypocalcemia is relatively common after total thyroidectomy. The effects of the early correction of postoperative hypothyroidism are undoubtedly beneficial, as is the use of eco- and radioguided methods for the intraoperative identification of the parathyroid glands, although they are not free from limits and criticism.