Total thyroidectomy.
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History, 19th Century↗
Biomedical subjects
T S Reeve
Publications and source records attributed to T S Reeve.
Total thyroidectomy: its role in the management of thyroid disease.
Of 7812 patients treated for thyroid disease in the Endocrine Surgical Unit at the Royal North Shore Hospital, 825 underwent total thyroidectomy as an initial procedure. One third of these patients (269) were operated on for malignancy and the remaining 556 were treated for benign conditions such as multinodular goitre (405), Graves' Disease (79) and thyroiditis (45). The rate of recurrent laryngeal nerve palsy was 0.5% while permanent hypoparathyroidism occurred in 0.6% of cases, the low complication rate being due to the technique of capsular dissection employed in the Unit. The number of total thyroidectomies performed as a percentage of all thyroid operations has risen from 4% in 1970 to more than 40% in 1990. The majority of this increase has been due to surgery for multinodular goitre where the proportion of patients treated by total thyroidectomy now exceeds 80%. A similar but smaller increase has been seen in an analysis of the New South Wales figures for all other public and private hospitals. It is concluded that the complication rate from total thyroidectomy can no longer be used to argue against its use as the definitive operation for malignant disease of the thyroid. Furthermore, in view of the risks of re-operative surgery, total thyroidectomy should be considered the operation of choice for most benign disease affecting the whole thyroid gland such as multinodular goitre, thyroiditis, and in a significant number of goitres affected by thyrotoxicosis.
Adolescent↗
Total thyroidectomy: the technique of capsular dissection.
This paper describes the technique of total thyroidectomy using capsular dissection. Total thyroidectomy is a safe straightforward anatomical procedure in which meticulous dissection can provide protection to the parathyroid glands and to the recurrent laryngeal nerve. This protection is achieved by using capsular dissection, hugging the gland and dividing the tertiary branches (i.e. the third order of division) of the vessels while dissecting the parathyroid glands with their vascular pedicles free from the thyroid surface, with minimal exposure of the recurrent laryngeal nerve and disturbance of its blood supply. Total thyroidectomy removes all visible thyroid tissue although it is permissible to leave a very small remnant of tissue (less than a fraction of a gram) in the region of the ligament of Berry in order to protect the recurrent laryngeal nerve and the blood supply to the parathyroid glands. This technique ensures that the incidence of complications, including permanent hypoparathyroidism and recurrent laryngeal nerve palsy, is reduced to a minimum.
History, 20th Century↗
Does Graves' disease or thyrotoxicosis affect the prognosis of thyroid cancer.
Twenty-one patients who underwent surgical treatment for thyrotoxicosis and who were found at operation to have thyroid cancer are presented. Sixteen had Graves' disease and 5 had toxic nodular goiter. The group with Graves' is compared with 110 euthyroid patients with thyroid cancer who underwent their initial surgery in the same time period and who were of the same age (+/- 1 yr) and sex as the patients with Graves' disease. None of the thyrotoxic patients died during follow-up of 2-24 yr or developed subsequent metastases. The 1 patient with a local lymph node metastasis has not shown evidence of recurrence. Hypoparathyroidism appeared as a complication in only 1 patient. The size of tumors in the patients with Graves' disease was significantly smaller than in the euthyroid group. The course of the disease in both the patients with Graves' disease and the thyrotoxic group as a whole was relatively benign. This series does not support the recent suggestions that thyroid cancer in patients with Graves' disease is more aggressive than in either patients with toxic nodular goiter or euthyroid subjects. Patients with Graves' disease and thyroid cancer should be treated identically to other patients with thyroid cancer. Therapy should consist of total thyroidectomy followed by a postoperative 131I scan. Residual tissue or metastases found on the scan should be ablated with 6 GBq 131I. The patient should receive a suppressive dose of T4.
Adult↗
RACS Lecture. The collegiate role in the development of professionalism in the modern community.
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Clinical Competence↗
What rate of infusion of intravenous nutrition solution is required to stimulate uptake of amino acids by peripheral tissues in depleted patients?
We examined the effect of varying the quantities (0, 0.1, 0.2, 0.3, and 0.4 gN.kg-1.[day]-1) of nitrogen input on N balance, 3-methylhistidine (3MH) excretion, plasma amino acid concentration and the net flux of amino acids across the leg in depleted patients requiring parenteral nutrition. The calorie-to-nitrogen ratio was 140 to 1 (kcal:1 gN) and consequently the patients received varying amounts of calories (8, 14, 28, 42, and 56 kcal.kg-1.[day]-10. There was negative nitrogen balance and net loss of amino acids from the limb during fasting. An infusion of 0.2 gN.kg-1.[day]-1 of IVN reversed the net catabolic process and resulted in equilibrium of peripheral total amino acid flux and of tyrosine flux without a decrease in 3MH excretion. Net uptake of total amino acids and tyrosine in peripheral tissues was achieved with 0.4 gN.kg-1.[day]-1 and 56 kcal.kg-1.[day]-1. This was associated with a fivefold increase in 3MH excretion (p less than 0.01), indicating that net anabolism occurred with increased protein turnover. Fifty per cent of the amino acids taken up by peripheral tissues during infusions of 0.4 gN.kg-1.[day]-1 was due to the uptake of glutamate (Glu) and 20% was due to the uptake of branched chain amino acids (BCAA). Plasma Glu concentration, [Glu], did not increase with increasing IVN infusion, but BCAA concentrations did. Although the mean plasma [Glu] did not change with IVN infusion, there was an independent effect of plasma [Glu] (p less than 0.0001) and of N input (p less than 0.0001) on Glu flux, indicating that even at high infusion rates the maximal capacity of peripheral tissues to take up Glu had not been reached.
Amino Acids↗
Fine needle biopsy of thyroid nodules: the importance of technique.
Fine needle biopsy (FNB) is the most accurate method available for the investigation of single thyroid nodules. The exact technique employed, however, varies considerably among clinicians: in our institution the incidence of 'inadequate' specimens produced ranges from only 13 to 62%, depending on the individual performing the biopsy. In a prospective in vivo study, a variety of biopsy techniques employing different gauge needles and differing numbers of passes with and without aspiration were assessed with respect to the quality of cytological specimen produced. Criteria assessed included the number of cells or sheets of cells, cell clumping, blood contamination, amount of colloid, and overall slide quality. Samples obtained with a 21 gauge needle without aspiration consistently gave best individual cell morphology. On the other hand, samples obtained with a 23 gauge needle with five aspirated passes through the nodule gave the highest yield of cells with an acceptable minimal increase in the degree of blood contamination and cell clumping. In order to achieve consistent yields from FNB of thyroid nodules, a combination of these two techniques is recommended.
Adult↗
Radical treatment of mal perforans in diabetic patients with arterial insufficiency.
Forty patients with diabetes mellitus and severe mal perforans underwent dorsal excision of the involved metatarsal head with primary closure of the plantar ulcer. Patients were screened before operation with noninvasive studies documenting pulse examination, ankle pressure index, and toe blood pressures. Fifteen of 40 patients (38%) had no palpable pedal pulses. Three patients had vascular reconstruction before metatarsal head resection. Mean toe pressure of the entire group was 135 +/- 35 mm Hg (range, 60 to 190), with six patients having a pressure less than 100 mm Hg. All patients had primary healing of the plantar wound and secondary healing of the dorsal incision with no amputations or readmissions for forefoot sepsis in the mean follow-up of 38.5 months (range, 2 to 54 months). In seven patients with recurrent ulcers, no relationship was found between measured indexes of forefoot perfusion and recurrence. However, all patients with recurrence were noncompliant in returning for follow-up orthotic care. This technique provides a means to ensure rapid healing of severe mal perforans while decreasing hospitalization, wound care, and periods of immobilization and is applicable in diabetic patients with arterial insufficiency and toe pressure of at least 60 mm Hg.
Blood Pressure↗
Increase in crosslinking of nonenzymatically glycosylated collagen induced by products of lipid peroxidation.
The increase in crosslinking in normal and nonenzymatically glycosylated rat tail tendon collagen after treatment with decomposing lipid hydroperoxides was assessed by measuring the breaking time of tendons immersed in 7 M urea under a 3 g weight at 40 degrees C (thermal rupture time). The incubation of tendons in 200 mM glucose for 43 h at 40 degrees C increased thermal rupture times from 5.15 to 26.38 min, (P less than 0.001) with no significant corresponding increase in tendons incubated in buffer alone. After incubation of the glycosylated tendons in the presence of peroxidized linoleic/arachidonic acid vesicles for about 20 h, their thermal rupture time increased to 3360 min (P less than 0.001). The rupture time for normal tendons after the same treatment was 206 min. These apparent crosslinking increases cannot be fully accounted for by reactions involving malondialdehyde, as incubation of both glycosylated and normal tendons in enzymatically produced malondialdehyde resulted in a modest two- to threefold increase in thermal rupture time.
Animals↗
Trainee surgery in teaching hospitals: is there a cost?
The morbidity rate for 2858 patients undergoing thyroidectomy over the 10 year period January 1977-December 1986 was examined and related to the involvement of a surgical trainee in the operative procedure. There was no overall difference in specific complication rates related to the surgical procedure, being 13.8% when the procedure was undertaken by a consultant, and 13.1% when a surgical trainee was involved in the procedure. There was a significant increase (P = 0.0025) in operative time increasing from 127 min for the consultant to 146 min when the trainee was involved (a 15% increase). There was no significant difference in bed stay for any of the groups. Surgical trainees can be safely taught operative skills under supervision without risk of increased complications. There is a cost, however, to the hospital system in terms of increased demands on time and operative facilities.
Costs and Cost Analysis↗
Neuromuscular symptoms in elderly patients with hyperparathyroidism: improvement with parathyroid surgery.
In a consecutive series of 100 neck explorations for primary hyperparathyroidism, 42 patients were 60 years of age or older; in this group of elderly patients the surgical cure rate was 100%. These patients were reviewed retrospectively by means of a structure interview. Twenty-one patients had had preoperative neuromuscular symptoms that ranged from coma to subjective muscular weakness. These patients had significantly-higher preoperative serum calcium and parathyroid hormone levels than did 21 patients without neuromuscular symptoms (P = 0.003 and P = 0.046, respectively). Most of the neuromuscular symptoms improved in the postoperative period. In particular, 15 of 17 patients with muscle weakness reported a significant improvement, while 14 of 15 patients who suffered from fatigue and lethargy reported an improvement. An improvement also occurred in the level of day-to-day function in eight patients. While surgery for primary hyperparathyroidism generally is undertaken for a specific indication, such as severe hypercalcaemia or renal stones, it appears from this study that neuromuscular symptoms also may improve, particularly in elderly patients.
Adolescent↗
Catalysis of lipid peroxidation by glucose and glycosylated collagen.
Peroxidation of membranes of linoleic/arachadonic acid vesicles at 40 degrees C was catalysed by glucose or glycosylated collagen. Kinetics of hydroperoxide production were similar in both cases. There was a kinetic lag, the duration of which was inversely proportional to the amount of glucose or glycosylated collagen used to initiate the peroxidation. This was followed by a rapid increase in the rate of oxidation. The final rate was independent of the amount of catalyst added. Vesicle lysis accompanied the increases in peroxidation. Addition of desferrioxamine, an iron chelator, only partially inhibited the oxidative process.
Animals↗
Surgical treatment for thyrotoxicosis.
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Humans↗
Secondary thyroidectomy: a twenty-year experience.
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Adolescent↗
Influence of the menstrual cycle on the concentrations of estrogen and progesterone receptors in primary breast cancer biopsies.
There is controversy in the literature regarding the effects of endogenous hormones on estrogen receptors (ER) and progesterone receptors (PR) in young women with breast cancer. We studied 117 young women with primary breast cancer and assessed their breast biopsies for ER and PR. The women had a record of their last menstrual period prior to breast biopsy. The menstrual cycle was divided into four phases--early proliferative (days 1-7), late proliferative (days 8-15), early secretory (days 16-22), and late secretory (days 23-30). There were lower levels of both ER and PR in biopsies excised during the early secretory phase than in other phases of the cycle; early proliferative phase receptor positive medians of ER = 77 fmol/mg protein and PR = 467 fmol/mg protein fell to ER = 28 fmol/mg and PR = 128 fmol/mg protein in the early secretory phase.
Adult↗
An enzyme immunoassay compared with a ligand-binding assay for measuring progesterone receptors in cytosols from breast cancers.
To assay progesterone receptor (PR), we compared Abbott's enzyme immunoassay (PR-EIA) with a ligand-binding assay involving dextran-coated charcoal (PR-DCC), using cytosols prepared from 109 breast-cancer biopsies. Results by the two PR methods agreed well. Least-squares analysis produced a line of best fit having a slope of 0.88, an intercept on the PR-EIA axis of 16 fmol per milligram of protein, and a correlation coefficient (r2) of 0.87. To evaluate whether accurate PR-EIA measurements could be obtained on stored cytosols, we compared PR-EIA values for fresh cytosols with values for cytosols stored for various lengths of time up to 13 weeks. Agreement was excellent, especially when the samples showing very high binding (greater than 600 fmol per milligram of protein) were excluded. The lines of best fit after least-squares analyses of the remaining values had slopes between 1.0 and 1.1, intercepts less than 3 fmol/mg, and r2 all greater than 0.91.
Adult↗
Total thyroidectomy. The preferred option for multinodular goiter.
Total thyroidectomy is an operation that has generally been reserved for the management of differentiated thyroid carcinoma. Over the last decade total thyroidectomy has become used increasingly and is now the preferred option in the authors' unit for the management of multinodular goiter affecting the entire gland. Over the period from 1975 to 1985, 853 thyroidectomies have been performed for multinodular goiter; of these, 115 have been total thyroidectomies. During that time, the incidence of total thyroidectomy for multinodular goiter has increased in percentage terms from 9% in 1975 to 50% in 1985. There have been two cases of permanent hypoparathyroidism and one case of permanent recurrent laryngeal nerve injury, and these occurred in patients who had less than total thyroidectomy. Total thyroidectomy is an appropriate operation for the management of diffuse multinodular goiter where the entire gland is involved because it precludes patients from requiring further surgery for recurrent disease, with its high associated risks. It must be emphasized, however, that protection of the recurrent laryngeal nerve and parathyroid glands must still be paramount in dealing with benign thyroid disease.
Goiter, Nodular↗