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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_901_Библиотеки_им_академика_М_И_Перельмана
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342
Intraoperative decision making about recurrent laryngeal nerve
Case scenario Management
Perform immediate primary repair ➔restores tone to the involved vocal
cord but not full function
Transected unilateral RLN nerve
Aborting procedure is not benecial ➔ if total thyroidectomy is indicated
➔ continue operation while the surgeon is aware of the risk of bilateral
nerve injury
H. Hashmi and K. Patel
Transected nerve in which tension
free repair is not possible
Anatomically intact nerve + loss of
signal
Research
Reference Findings
Barczyński M, Konturek A, Pragacz K,
Papier A, Stopa M, Nowak
W.Intraoperative nerve monitoring
can reduce prevalence of recurrent
laryngeal nerve injury in thyroid
reoperations: results of a retrospective
cohort study. World J Surg.
2014;38(3):599–606
Sun H, Tian W, Jiang K, etal. Clinical
guidelines on intraoperative monitoring
during thyroid and parathyroid
surgery. Ann Transl Med.
2015;3(15):213
Attempt a nerve graft or ansa cervicalis hitch
Usually a reversible injury (nerves regenerate at 1mm/day)
Abort surgery after performing essential procedure on the ipsilateral side
and plan for return to operating room in future
The use of IONM adds both operative time and cost by an average of
5–7% to routine thyroid surgery with no observed increase in value.
IONM appears to have a role in repeat operations on the thyroid gland.
The prevalence of recurrent laryngeal nerve injury is higher in repeat
thyroid surgery, approaching 12.5% for temporary and 3.8% for
permanent events. In a retrospective cohort study of patients undergoing
thyroid reoperation, IONM resulted in an observed reduction in both
temporary and permanent paresis of the recurrent laryngeal nerve
compared with patients who had nerve visualization only
Testing the vagus nerve rst prior to any dissection near the recurrent
nerve is a good positive control to verify that the endotracheal tube
(ETT) is in the proper place and that the nerve monitor is working well
If a blind sweep is done and might have injured the nerve down in the
chest where it cannot be seen➔ verify intact signal on the vagus nerve
11 Endocrine
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Complications of Thyroidectomy andTheir Management
Complications of thyroidectomy and their management
Complication Characteristics Management
343
Injury to recurrent laryngeal
nerve
Superior laryngeal nerve
injury
Neck hematoma Any patient with neck swelling, difculty
Unilateral injury➔ dysphonia
Bilateral injury➔ bilateral cord paresis,
air way obstruction, and severe aspiration
All patients with suspected RLN injury
should undergo at least a bedside swallow
evaluation
Injury results in loss of voice projection,
a deepening of the voice, and voice
fatigability
breathing or swallowing, increased pain,
or voice hoarseness in the recovery room
needs immediate evaluation for neck
hematoma
Hypoparathyroidism because of transient
or permanent damage to or removal of
the parathyroid glands
PTH levels may take up to 1year after
surgery to fully recover
2–3% of patients have permanent
hypoparathyroidism
Chin tuck and turning of the head
toward the side of injury can
facilitate swallowing
Speech therapy
If respiratory distress➔ evacuate
hematoma at bedside
Do not sedate or intubate patient
with hematoma unless you are ready
to do an emergency surgical airway
(because hematoma can lead to
laryngospasm)
Evacuate hematoma before inducing
anesthesia
Supplemental calcium (rst in oral
form and only in intravenous form if
the patient is severely symptomatic
with painful muscle cramping or
tetany)
Magnesium is required for adequate
calcium absorption➔ supplement
magnesium if low
Checking PTH level 4h after surgery
Hypoparathyroidism
If the PTH is >20pg/mL ➔ low risk of
postoperative hypocalcemia
If the PTH is undetectable ➔ high risk
for postoperative hypocalcemia ➔
prophylactic vitamin D and calcium
supplements
If the PTH<20pg/mL➔ intermediate
risk➔prophylactic treatment should be
considered
Oral activated vitamin D to maintain
normal calcium levels if the PTH
level remains low
344
Complications of thyroidectomy and their management
Complication Characteristics Management
H. Hashmi and K. Patel
Hypothyroidism The smaller the size of the residual
functioning thyroid tissue the higher the
risk of developing postoperative
hypothyroidism
Risk factors: Hashimoto disease (degree
of lymphocytic inltration into the
remaining thyroid tissue has a negative
effect on thyroid function
Most postoperative hypothyroidism
(90%) develop within the rst year after
lobectomy
Research
Reference Findings
Levothyroxine is the standard
therapy
Older adult patients (age>65years)
or those with known coronary arterial
disease should be started at a lower
dose
Evaluate for H. pylori associated
gastritis/atrophic gastritis/celiac
disease if a patient requires a higher
dose of levothyroxine than
anticipated
Patients with a history of gastric
bypass also may require higher doses
Drugs that impair the absorption of
levothyroxine: cholestyramine,
calcium, sucralfate, sevelamer,
phenobarbital, carbamazepine,
phenytoin, rifampicin, and estrogen
Verloop H, Louwerens M, Schoones JW,
Kievit J, Smit JWA, Dekkers OM.Risk of
hypothyroidism following
hemithyroidectomy: systematic review and
meta-analysis of prognostic studies. J Clin
Endocrinol Metab. 2012;97(7):2243–2255
Park I, Her N, Choe J-H, Kim JS, Kim
J-H.Management of chyle leakage after
thyroidectomy, cervical lymph node
dissection, in patients with thyroid cancer.
Head Neck. 2018;40(1):7–15
This meta-analysis evaluating hypothyroidism postoperatively
demonstrated the overall risk as 22% in patients who underwent
hemithyroidectomy
This retrospective review of all patients who underwent
thyroidectomy and/or lymph node dissection for thyroid cancer over
a 11-year period. The incidence of chyle leak was 0.9% and was
greater in lateral neck dissections (3.9%) compared to central neck
dissection (0.6%). Most of chyle leaks from central and/or right
lateral neck dissection were managed conservatively (92%). For
those in the conservative management group who had decreased
output to less than half the original volume in 2days of treatment, all
but one resolved with conservative management alone (99%)
d
Recurrent laryngeal nerve
Th
11 Endocrine
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Hyperparathyroidism
Anatomy
Embryology
The superior parathyroid glands are derived
from the fourth branchial pouch
The inferior parathyroid glands are derived the
third branchial pouch
Superior parathyroid glands
Superior parathyroid glands ➔ located
posterolateral to the RLN at the level of the
cricoid cartilage
Ectopic glands may be identied in a
paraesophageal position or within the carotid
sheath or they may be intrathyroidal
yroid
345
Superior
parathyroid
gland
Inferior
parathyroi
gland
Inferior parathyroid glands
Inferior parathyroid glands ➔located
anteromedial to the RLN
Inferior parathyroid glands ➔ more likely to be
ectopic due to a longer path of descent
➔ectopic glands may be identied within the
thymus or carotid sheath, or intrathyroidal
Superior and inferior parathyroid glands receive
their blood supply from the inferior thyroid
artery
346
H. Hashmi and K. Patel
Physiology
PTH increases serum calcium by:
1. Increased bone resorption through indirect stimulation of osteoclasts
2. Increased production of calcitriol in the kidney ➔ stimulates calcium absorption in the small intestine
3. Decreased urinary calcium excretion due to stimulation of calcium reabsorption in the distal convoluted tubule
and collecting duct
4. PTH inhibits phosphate reabsorption at the proximal convoluted tubule. Phosphate form water-insoluble
salts with calcium➔ decrease in plasma calcium levels
Primary hyperparathyroidism types
Types Characteristics Management
Primary
hyperparathyroidism
Secondary
hyperparathyroidism
Occurs when one or more parathyroid
glands overproduce parathyroid hormone
Most common cause is parathyroid
adenoma (85%)
Patients commonly experience kidney
stones, bone pain, changes in neurologic
status, and gastrointestinal problems, and
polyuria
Caused by overproduction of parathyroid
hormone due to an external stimulus
(low serum calcium and elevated
phosphate)
Most commonly due to vitamin D
deciency or chronic renal failure
Signs and symptoms include bone pain,
osteodystrophy, osteoporosis, pruritus,
hypertension, cardiomyopathy, and
calciphylaxis
Single-gland disease ➔ resection with focused
parathyroid exploration (preoperative
localization)
Multi-gland disease ➔bilateral parathyroid
exploration
Four-gland hyperplasia ➔subtotal
parathyroidectomy (all but a small portion of
one enlarged gland is removed or total
parathyroidectomy with autotransplantation
into the forearm
Lithium-induced HPT ➔ four-gland exploration
(lithium has a tendency to cause four-gland
hyperplasia)
Primary treatment is pharmacologic (correct
vitamin D deciency, hypocalcemia, and
hyperphosphatemia
Indications for parathyroidectomy: Refractory
hyperparathyroidism (PTH >800pg/mL with
hypercalcemia or hyperphosphatemia) or severe
symptoms (refractory pruritus, progressive
extra- skeletal calcication or calciphylaxis,
unexplained myopathy)
Tertiary
hyperparathyroidism
Occurs in postrenal transplant patients
after long-standing parathyroid
stimulation from hypocalcemia ➔
autonomous secretion of PTH regardless
of calcium level
Parathyroidectomy is the only treatment for
patients who meet criteria
11 Endocrine
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Hypercalcemia
Differential diagnosis of
hypercalcemia
347
Most common cause of hypercalcemia in the outpatient setting ➔ primary
hyperparathyroidism
Most common cause of hypercalcemia in the inpatient setting➔hypercalcemia
of malignancy
Aggressive uid resuscitation of uids at 200mL/h ➔ rst line of treatment
Management of acute
hypercalcemia
Phosphate supplementation (to correct compensatory hypophosphatemia
associated with hypercalcemia)
Treatment options for acute hypercalcemia
Treatment option Characteristics
Loop diuretics Not preferred anymore for treatment of hypercalcemia because it worsen electrolyte
derangements and volume depletion
Bisphosphonates
Calcitonin Renal absorption of calcium is blocked. Rapid onset of action (within 6h)
Glucocorticoids Benecial for lymphomas secreting calcitriol
Calcimimetic agents
(Cinacalcet)
Dialysis Benecial for hypercalcemia with renal failure and volume overload
Denosumab (Prolia) Monoclonal antibody, which prevents the development of osteoclasts
Differential diagnosis of hyperparathyroidism
Inhibit osteoclastic bone resorption➔ IV form should be given asap, but they reach
maximum effectiveness in 2–4days
Should be used with caution because they have a long half-life ➔ may lead to
hypocalcemia
Decrease the production of PTH ➔ useful for parathyroid cancer and ectopic production
of PTH
Primary
hyperparathyroidism
Normocalcemic
hyperparathyroidism
(a variant of primary
hyperparathyroidism)
Familial
hypocalciuric
hypocalcemia
Calcium
PTH
(10–65
pg/ml)
Elevated Elevated Low >0.02 Normal Surgery
Elevated Normal Normal Controversial
Mildly
elevated
(8.5–
10.5mg/
dL) Phosphate
Mildly
elevated
Normal/low Low (<100
24-h
urine
calcium
excretion
mg/24hr)
Calciumcreatinine
clearance
Low (<0.01) Normal Medical
Vitamin
D levels Management
management
Surgery
contraindicated
348
Differential diagnosis of hyperparathyroidism
H. Hashmi and K. Patel
Calcium
Secondary
hyperparathyroidism
Tertiary
hyperparathyroidism
PTH
(10–65
pg/ml)
Elevated Normal/low Normal/high Low Medical
Elevated Elevated High Normal/
(8.5–
10.5mg/
dL) Phosphate
Research
Reference Findings
Wilhelm SM, Wang TS, Ruan DT, etal.
The American Association of Endocrine
Surgeons guidelines for denitive
management of primary
hyperparathyroidism. JAMA Surg.
2016;151(10):959–968
Indications for parathyroidectomy
24-h
urine
calcium
excretion
The American Association of Endocrine Surgeons and an international
group of experts have developed guidelines for evaluating a patient
with suspected primary hyperparathyroidism. Biochemical evaluation
should include total calcium, parathyroid hormone levels, creatinine,
and 25-hydroxyvitamin D levels. Patients should also undergo 24-hour
urine testing for creatinine and calcium. A recent addition to the
guidelines was the recommendation that patients with asymptomatic
primary hyperparathyroidism should undergo abdominal imaging to
detect nephrocalcinosis or nephrolithiasis
Calciumcreatinine
clearance
Vitamin
D levels Management
management
Surgery
low
All patients with symptomatic disease (nephrolithiasis, fragility fractures, bone pain, osteoporosis)
Markedly elevated serum calcium (1mg/dL above normal)
Bone density at the hip, lumbar spine, or distal radius T-score<−2.5
Previous asymptomatic vertebral fracture
Presence of nephrolithiasis or nephrocalcinosis on radiograph, ultrasound, or CT
Creatinine clearance <60mL/min
24-hour urinary calcium >400mg/d (>10mmol/dayE)
Age younger than 50years
Neurocognitive or neuropsychiatric symptoms (recently added by American Association of Endocrine Surgery)
Parathyroid Cancer
Parathyroid cancer
Associated
syndromes
Hyperparathyroidism jaw tumor syndrome ➔ increased risk of developing parathyroid carcinoma
(mediated by HRPT2 mutations)
11 Endocrine
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Parathyroid cancer
Neck mass (70%), paralyzed recurrent laryngeal nerve (advanced and invasive disease), dysphagia
or dyspnea (mass effect of the tumor on the trachea or esophagus or to direct invasion of these
Presentation
structures), profound lethargy, weakness, anorexia, pancreatitis, nephrolithiasis, and renal failure
Parathyroxicosis (hypercalcemia crisis): Is a life-threatening condition caused by very high
calcium levels (ca>16mg/dL) characterized by azotemia, oliguria, weakness, and coma
Presents with serum ca>14mg/dL
349
Diagnosis
Imaging
Management
Follow-up
Elevated alkaline phosphatase and beta-human chorionic gonadotropin
EKG changes: Shortened QT segments
FNA should be avoided
Neck ultrasound: First imaging study (high-risk features: Lobulated, hypoechoic, ill-dened
borders, calcication, thick capsule, local inltration)
4-D CT scan
En bloc resection of the parathyroid gland + ipsilateral thyroid lobe + any contiguous structures
with grossly negative margins
Avoid rupturing capsule
If lymph node involvement ➔ipsilateral lymph node dissection
Locally recurrent parathyroid carcinoma ➔ re-exploration and resection
Follow-up with calcium and PTH levels
Monitor calcium postoperative because of risk of hungry bone syndrome (hypocalcemia and
hypophosphatemia)
If calcium levels do not drop ➔ suspect incomplete resection
Neck ultrasound or CT to localize recurrence➔ FNA for suspected recurrence or re-exploration if
local recurrence
Most common site for recurrence is in the surgical bed
Most common site for metastatic disease: lung, liver and bone ➔ resect metastasis if causing
hypercalcemia
Prognosis Long-term prognosis is poor
Survival depends on operative resection
Mortality from hypercalcemia
350
H. Hashmi and K. Patel
Parathyroidectomy
Modalities for preoperative localization
Modality Advantages Disadvantages
Sestamibi scintigraphy Sensitivity ranges from 65% to 85%
Good for larger singular lesions
SPECT (Sestamibi single
photon emission computed
tomography)
Cervical ultrasound Detect thyroid pathology Operator dependent
4-D CT scan Precise anatomic details
Provides three-dimensional data and
results in improved sensitivity and
specicity when compared with a
traditional sestamibi scan
Useful for reoperative cases
Difculty detecting multiple lesions
Misleading in the setting of concomitant
thyroid disease
Increased cost
Research
Reference Findings
Adler JT, Chen H, Schaefer S, Sippel RS.Does routine
use of ultrasound result in additional thyroid
procedures in patients with primary
hyperparathyroidism? J Am Coll Surg.
2010;211(4):536–539
Most experienced surgeons use a 2-imaging test
algorithm (as opposed to single imaging test), and if
concordant and conrmatory of solitary adenoma,
focused exploration may be appropriate
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Parathyroidectomy
351
Make a transverse incision two ngerbreadths above the sternal notch
Key Steps
Conrming parathyroid
adenoma resection
Raise the subplatysmal aps from the thyroid cartilage superiorly to the sternal
notch inferiorly
Retract the strap muscles laterally
Start exploration with a suspected abnormal gland ➔proceed to the ipsilateral
gland ➔proceed to contralateral glands
Retract the thyroid lobe medially to search the area around the thyroid gland and
the tracheoesophageal groove
Division of the middle thyroid vein helps with exposure
When an abnormal gland is found ➔dissect along the lateral aspect of the gland
until the vascular pedicle is isolated
Isolate and preserve the recurrent laryngeal nerve prior to ligation of the pedicle
Normal-appearing glands should not be resected
Frozen section ➔ to conrm that resected tissue was parathyroid gland
Intraoperative PTH levels should be assessed➔ to conrm complete removal of
hyperfunctioning glands
Level should be checked pre- incision, pre-excision, and at 10min after excision
PTH levels should decrease to <50% of the highest of either the pre-incision or
pre-excision PTH levels within 10min
If PTH levels remain >50% of pre-incision ➔ continue looking for abnormal
glands (including ectopic or supernumerary glands)
Intraoperative decision making
Intraoperative case Management
Preoperative images localize a single
adenoma
PTH levels did not drop after single
adenoma resection
Preoperative imaging did not localize
adenoma
Missing superior parathyroid gland during
4 gland exploration
Missing inferior thyroid gland during 4
gland exploration
Focused parathyroidectomy + intraoperative PTH levels monitoring
Comprehensive 4 gland exploration
Comprehensive 4 gland exploration
Focus on the paraesophageal and retroesophageal spaces (divide
middle thyroid vein for better exposure)
Focus on the thymus and resect it➔ if still missing ➔ divide
middle thyroid vein to provide exposure to tracheoesophageal
groove and the carotid sheath➔ if still missing ➔ ipsilateral thyroid
lobectomy
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