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Thyroid and Parathyroid Surgery: Achieving Optimal Outcomes
Allan Siperstein, M.D.Chair Surgery InstituteDirector, Endocrine Surgery CenterCleveland Clinic
May 2009
ThyroidThyroid
Greek word Greek word thyreosthyreos-- shield shapedshield shaped
Histology of normal thyroidHistology of normal thyroid
Characteristics of Malignant Characteristics of Malignant
Thyroid NodulesThyroid Nodules
•• solitary nodulesolitary nodule
•• hard, fixedhard, fixed
•• rapidly enlargingrapidly enlarging
•• ipsilateral adenopathyipsilateral adenopathy
•• hoarseness with vocal chord paralysishoarseness with vocal chord paralysis
•• development of nodule at age less than development of nodule at age less than 14 or greater than 65 years14 or greater than 65 years
•• history of low dose ionizing radiationhistory of low dose ionizing radiation
Evaluation of Solitary or Dominant Evaluation of Solitary or Dominant
Thyroid NodulesThyroid Nodules
Hx X-ray Therapy
FNA
Observe
Total Thyroidectomy
yesno
ColloidNodule
“Benign”
FollicularNeoplasm
“Suspicious”
PapillaryCancer
“Cancer”
InadequateSpecimen
LobectomyTotal
Thyroidectomy
Radioiodine scansRadioiodine scans
Thyroid sono in 35yo manThyroid sono in 35yo man
ThyroidLeft jugular
noncompressed
Left jugular
compressed
Sono guided needle placementSono guided needle placement
Equipment for FNAEquipment for FNA
3cm incision marked3cm incision marked
Specimen and incisionSpecimen and incision
Location of parathyroidsLocation of parathyroids
DeDe--Evolution of disease severity in Evolution of disease severity in
HyperparathyroidismHyperparathyroidism
•• Classically patients presented with CaClassically patients presented with Ca++++ >12 >12 and significant symptomsand significant symptoms
•• Routine Routine chemchem panels detected panels detected ““asymptomaticasymptomatic”” patients with mildly patients with mildly elevated elevated calciumscalciums
•• Use of CaUse of Ca++++ and PTH screening in patients and PTH screening in patients with osteoporosis and kidney stones is with osteoporosis and kidney stones is detecting disease with high normal or detecting disease with high normal or minimally elevated minimally elevated calciumscalciums
Nice big parathyroid adenomaNice big parathyroid adenoma
Parathyroid disease in 2009Parathyroid disease in 2009
Difficulties in diagnosis of mild Difficulties in diagnosis of mild
hyperparathyroidismhyperparathyroidism
•• 11°° HP HP vsvs 2 2 °° HP HP vsvs normalnormal
•• Use of ionized Ca, albumin, Use of ionized Ca, albumin, VitVit D levelsD levels
•• 24h urinary Ca to exclude BFHH24h urinary Ca to exclude BFHH
•• Pts on Pts on bisphosphonatesbisphosphonates
•• May need serial studies to establish May need serial studies to establish diagnosisdiagnosis
2002 NIH Criteria for Surgery2002 NIH Criteria for Surgery
•• Blood calcium level more than 1.0 mg/Blood calcium level more than 1.0 mg/dLdLabove normalabove normal
•• 2424--hour urinary calcium excretion greater hour urinary calcium excretion greater than 400 mg/daythan 400 mg/day
•• Kidney function reduced by 30% below Kidney function reduced by 30% below normalnormal
•• Bone mineral density reduced by 2.5 Bone mineral density reduced by 2.5 standard deviations below young, healthy standard deviations below young, healthy controlscontrols
•• Age less than 50Age less than 50
VanderWalde, L. H. et al. Arch Surg 2006;141:885-891.
Fracture-free survival of 1569 patients with primary hyperparathyroidism
Minimally Invasive Parathyroid Surgery = Minimally Invasive Parathyroid Surgery =
MIPSMIPS
•• This is a marketing term used to make This is a marketing term used to make patients think one approach to parathyroid patients think one approach to parathyroid surgery has significantly better outcomes than surgery has significantly better outcomes than anotheranother
•• Surgeons should define their operations in Surgeons should define their operations in technical terms:technical terms:
•• Single gland exploration through 2cm incisionSingle gland exploration through 2cm incision
•• 4 gland exploration through a 2.5cm incision4 gland exploration through a 2.5cm incision
•• Single gland exploration using videoscopic Single gland exploration using videoscopic instrumentationinstrumentation
Extent of Parathyroid ExplorationExtent of Parathyroid Exploration
•• Bilateral explorationBilateral exploration-- look for all 4 look for all 4 glandsglands
•• Unilateral explorationUnilateral exploration-- look for 2 glands look for 2 glands on one sideon one side
•• Focal explorationFocal exploration-- look for single look for single abnormal glandabnormal gland
•• Select cases based on localizing studiesSelect cases based on localizing studies
•• End procedure based on rapid intraop PTHEnd procedure based on rapid intraop PTH
Key to the success of focal exploration:Key to the success of focal exploration:
•• What is the incidence of multiple gland What is the incidence of multiple gland diseasedisease
•• How good are localizing studies in How good are localizing studies in predicting single gland diseasepredicting single gland disease
•• How good is intraop PTH measurement in How good is intraop PTH measurement in determining that all pathology has been determining that all pathology has been removedremoved
•• How good is the long term followHow good is the long term follow--upup
•• What is an acceptable failure rate balanced What is an acceptable failure rate balanced by the proposed benefitsby the proposed benefits
Incidence of multiple gland diseaseIncidence of multiple gland disease
•• Retrospective review at 2 endocrine Retrospective review at 2 endocrine
surgery centers: Emory and CCFsurgery centers: Emory and CCF
•• 828 patients with 1828 patients with 1o o hyperparathyroidismhyperparathyroidism
•• Bilateral neck explorationBilateral neck exploration
•• Disease patterns:Disease patterns:
single adenomas single adenomas 7171%%
double adenomas double adenomas 15%15%
hyperplasia hyperplasia 1313%%
0
10
20
30
40
50
% D
A P
ati
en
ts
1 2 3 4 5 6
Distribution of Double AdenomasDistribution of Double Adenomas
Both
Superior
Both
Inferior
Right
Superior
Left
Inferior
Left
Superior
Right
Inferior
Both
Left
Both
Right
*P<.001*
Sestamibi Iodine subtraction scan Sestamibi Iodine subtraction scan
with SPECT imagingwith SPECT imaging
Tc sestamibi I 123 Subtraction
Surgeon PreformedSurgeon Preformed
Parathyroid UltrasoundParathyroid Ultrasound
•• 7.5 MHz or higher 7.5 MHz or higher transducertransducer
•• Curved or small Curved or small footprint linearfootprint linear
•• Patient positioned Patient positioned supine with neck supine with neck hyperextendedhyperextended
Experience and Outcomes Experience and Outcomes
•• Importance of experience is intuitiveImportance of experience is intuitive
•• Many published reports confirm thisMany published reports confirm this
•• Clinician volumeClinician volume
•• Hospital volumeHospital volume
•• What about thyroid/parathyroid surgery?What about thyroid/parathyroid surgery?
•• Sosa Sosa et al, et al, Annals of Surgery 1998Annals of Surgery 1998
•• StavrakisStavrakis et al, et al, Surgery 2007Surgery 2007
•• PieracciPieracci et al, et al, World J. of Surgery 2008World J. of Surgery 2008
ReRe--operative Surgeryoperative Surgery
•• Significant percentage of our practiceSignificant percentage of our practice
•• Some unavoidableSome unavoidable
•• Many felt to be avoidableMany felt to be avoidable
•• Can reCan re--operations be reliably classified as operations be reliably classified as
avoidable or unavoidable?avoidable or unavoidable?
AimsAims
1. Create a set of criteria for classifying re1. Create a set of criteria for classifying re--
operations as avoidable or unavoidableoperations as avoidable or unavoidable
2. Determine the incidence of avoidable re2. Determine the incidence of avoidable re--
operations in thyroid and parathyroid operations in thyroid and parathyroid
surgerysurgery
3. Determine whether clinical volume 3. Determine whether clinical volume
affects the incidence of avoidable reaffects the incidence of avoidable re--
operationsoperations
MethodsMethods
•• All patients undergoing reAll patients undergoing re--operative thyroid operative thyroid and parathyroid surgery 1999and parathyroid surgery 1999--20072007
Pre-op imaging
Intra-op findings
Histopathology
Objective criteria
+
Avoidable or Unavoidable?
MethodsMethods
•• Hospital volume obtained using inpatient & Hospital volume obtained using inpatient &
outpatient dataoutpatient data
•• < 20 cases/year = low< 20 cases/year = low--volume centervolume center
•• ≥≥ 20 cases/year = high20 cases/year = high--volume centervolume center
•• Each reEach re--operation treated as separate case operation treated as separate case
Criteria for Avoidable Criteria for Avoidable vsvs
Unavoidable OperationsUnavoidable Operations
•• Example for Thyroid CasesExample for Thyroid Cases
•• UnavoidableUnavoidable �� Completion thyroidectomy after Completion thyroidectomy after
lobectomylobectomy for follicular neoplasm on FNAfor follicular neoplasm on FNA
•• AvoidableAvoidable �� Selective LN excision (Selective LN excision (““berry berry
pickingpicking””) with recurrence in same compartment) with recurrence in same compartment
•• Example for Parathyroid CasesExample for Parathyroid Cases
•• UnavoidableUnavoidable �� Persistent 1Persistent 1ºº HPT due to ectopic gland HPT due to ectopic gland
inaccessible through standard incisioninaccessible through standard incision
•• AvoidableAvoidable �� Persistent 1Persistent 1ºº HPT due to missed gland in normal HPT due to missed gland in normal
anatomic locationanatomic location
Study GroupStudy Group
280 patients underwent re-operative surgery
227 single re-operations
53 multiple re-operations
395 total re-operations
335 cases with initial hospital data
available
Number of % of TotalCases
Type of Re-operationThyroid 189 56%
Parathyroid 146 44%
Hospital Volume
High-Volume Center 167 50%Low Volume Center 168 50%
Re-operation ClassificationAvoidable 134 40%Unavoidable 201 60%
Case DistributionCase Distribution
Incidence of Avoidable ReIncidence of Avoidable Re--operations:operations:
Thyroid Thyroid vs.vs. Parathyroid SurgeryParathyroid Surgery
70%Unavoidable
Avoidable30%
47%Unavoidable
Avoidable53%
Thyroid Re-operations
189 cases
Parathyroid Re-operations
146 cases
Thyroid Cases: Thyroid Cases:
Low Low vs.vs. HighHigh--Volume CentersVolume Centers
High-Volume Centers
103 cases
Low-Volume Centers
86 cases
54% 46%
CCF
Avoidable Thyroid ReAvoidable Thyroid Re--operationsoperations
High-Volume Centers
103 cases
Low-Volume Centers
86 cases
UnavoidableAvoidable
57%*
85%
15%*
43%
* p < 0.001
Avoidable
Unavoidable
Thyroid Cancer CasesThyroid Cancer Cases
High-Volume Centers
72 cases
Low-Volume Centers
62 cases
55%*
88%
12%*
45%Unavoidable
Avoidable
* p < 0.001
Unavoidable
Avoidable
Benign Thyroid CasesBenign Thyroid Cases
High-Volume Centers
31 cases
Low-Volume Centers
24 cases
* p = NS
33%*
81%
19%*
67%Unavoidable
Avoidable
Unavoidable
Avoidable
Hospital Volume and Incidence ofAvoidable Thyroid Re-operations
< 5 5-20 20-50 50-100 > 1000
20
40
60
80
100%
Avo
idab
le R
efe
rrals
Annual Number of Thyroid Cases
High-Volume Centers
Low-Volume Centers
56%
Parathyroid Cases: Parathyroid Cases:
Low Low vs.vs. HighHigh--Volume CentersVolume Centers
High-Volume Centers
64 cases
Low-Volume Centers
82 cases
44%56%
CCF
Avoidable Parathyroid ReAvoidable Parathyroid Re--operationsoperations
High-Volume Centers
64 cases
Low-Volume Centers
82 cases
78%*
78%
22%*22%
* p < 0.001
Unavoidable
Avoidable
Avoidable
Unavoidable
Persistent 1Persistent 1ºº HPTHPT CasesCases
High-Volume Centers
62 cases
Low-Volume Centers
34 cases
* p < 0.001
95%*
59%
41%*
5%
Avoidable
Unavoidable
Avoidable
Unavoidable
Persistent 1Persistent 1ºº HPTHPT Cases: Cases:
Impact of Initial Sestamibi ScanImpact of Initial Sestamibi Scan
0
20
40
60
80
100
70
%
100%*
* p < 0.001
% Correct
Imaging% Avoidable
36%
17%
*% Correct
Imaging% Avoidable
Low-Volume Center
High-Volume Center
Hospital Volume and Incidence of
Avoidable Parathyroid Re-operations
< 5 5-20 20-50 50-100 > 1000
20
40
60
80%
Avo
idab
le R
efe
rrals
Annual Number of Parathyroid Cases
High-Volume Center
Low-Volume Center
Complications
0
3
6
9
High-Volume
Center
Low-Volume
Center
% R
LN
In
jury
p < 0.05
3%
9%
Initial Operations Re-operations
p < 0.001
% C
om
pli
cati
on
s
RLN Injury after Initial Operation: High vs. Low-Volume Center
Complication Rates in Our Practice: Initial vs. Re-operative Surgery
0
3
6
9
1%
4%
ConclusionsConclusions
•• ReRe--operative thyroid & parathyroid surgery can be operative thyroid & parathyroid surgery can be
reliably classified as avoidable or unavoidablereliably classified as avoidable or unavoidable
•• A significant number of reA significant number of re--operative thyroid and operative thyroid and
parathyroid surgeries are avoidableparathyroid surgeries are avoidable
•• Most avoidable reMost avoidable re--operations originate from lowoperations originate from low--
volume centers volume centers �� Persistent 1Persistent 1ºº HPT, Thyroid CancerHPT, Thyroid Cancer
•• Provides further evidence for concentrating the Provides further evidence for concentrating the
treatment of thyroid & parathyroid disease to hightreatment of thyroid & parathyroid disease to high--
volume centers volume centers
Keys to successful high volume Keys to successful high volume
Endocrine Surgery programEndocrine Surgery program
•• 4 surgeons4 surgeons-- group practice modelgroup practice model
•• Dedicated RNs & NPDedicated RNs & NP
•• ““One stop shoppingOne stop shopping””
•• Pre visit record reviewPre visit record review
•• Lab studiesLab studies
•• ConsultConsult
•• UltrasoundUltrasound
•• Needle biopsyNeedle biopsy
Challenging Parathyroid LocalizationChallenging Parathyroid Localization