RESUMO
BACKGROUND: Intraoperative parathyroid hormones have been used to establish operative success in patients with primary hyperparathyroidism. This study's aim was to assess the impact of estimated glomerular filtration rate and serum creatinine levels on the fulfillment of >50% drop and normalization of intraoperative parathyroid hormone levels. METHODS: Patients successfully treated for primary hyperparathyroidism were analyzed. The samples for parathyroid hormone were collected at baseline, 5-, 10-, and 30-minutes postexcision. The patients were classified as follows: (1) estimated glomerular filtration rate >60 mL/min, (2) estimated glomerular filtration rate <60 mL/min and serum creatinine levels <1.2 mg/dL, and (3) estimated glomerular filtration rate <60 mL/min and serum creatinine levels >1.2 mg/dL. Comparative analysis of patients achieving the >50% parathyroid hormone drop criterion and normalization of intraoperative parathyroid hormone was performed. RESULTS: One hundred-fourteen patients were distributed as follows: 88 patients (77.2%), 14 (12.3%), and 12 (10.5%) for groups 1, 2 and 3, respectively. No difference between groups in the proportion of patients fulfilling the >50% parathyroid hormone drop criterion was found. An abnormally elevated intraoperative parathyroid hormone level at 30-minute postexcision was observed in 0, 14.3, and 16.6% in groups 1, 2, and 3, respectively (P ≤ .0001). CONCLUSION: In the study, >50% parathyroid hormone drop criterion was equally achieved despite normal or reduced estimated glomerular filtration rate. When serum creatinine levels increased >1.2 mg/dL and estimated glomerular filtration rate declined <60 mL/min, the likelihood of reaching normal intraoperative parathyroid hormone levels postexcision was significantly lower.
Assuntos
Hiperparatireoidismo Primário , Insuficiência Renal , Humanos , Hiperparatireoidismo Primário/cirurgia , Creatinina , Monitorização Intraoperatória , Estudos Retrospectivos , Paratireoidectomia , Hormônio Paratireóideo , Rim/fisiologiaRESUMO
Background: The incidence of micropapillary thyroid carcinoma (mPTC) has increased in the last decade. Active surveillance (AS) has been proposed as an alternative management for low-risk mPTC based on preoperative Kuma criteria. Controversy still exists on how to appropriately manage this group of patients, as some low-risk mPTC may harbor some postoperative features associated with disease recurrence as described in the 2015 American Thyroid Association (ATA) guidelines. Methods: We retrospectively reviewed 108 patients with histopathologic diagnosis of mPTC after surgery at a third level hospital in Mexico City from 2000 to 2018. Demographic and clinicopathologic data were analyzed as predictors for disease recurrence and/or metastatic disease (lymph node or distant). Comparison between group stratification based on preoperative Kuma criteria and postoperative 2015 ATA guidelines risk criteria for disease recurrence was performed. Measures of diagnostic accuracy were obtained for preoperative risk features according to the Kuma criteria. Results: Of 108 patients, 79 (73%) were classified as preoperative high-risk mPTC and 29 (27%) as low risk based on the Kuma criteria. Of these 79 high-risk patients, 38 (48%) were reclassified as low risk for disease recurrence, 12 (15%) as intermediate risk, and 29 (37%) remained as high risk based on the 2015 ATA risk criteria. Of the 29 preoperative low-risk patients, 19 (65.5%) remained as postoperative low risk for disease recurrence, 2 (7%) as intermediate risk, and 8 (27.5%) as high risk. Higher accuracy of preoperative risk features was obtained for lymph node and distant metastases, 84.2% and 97.2%, respectively. After multivariate analysis, age <40 years and microscopic extrathyroidal extension (ETE) were associated with higher risk for metastatic disease (lymph node or distant) in our cohort. Conclusions: Patients with mPTC under 40 years old and microscopic ETE are more prone to develop metastatic disease (lymph node or distant). One-third of our patients stratified as low-risk mPTC according to the Kuma criteria for AS had histopathologic features associated with a more aggressive clinical behavior or structural recurrence. In addition, lymph node and distant metastases are the preoperative risk features with the highest diagnostic accuracy for preoperative risk stratification.
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Câncer Papilífero da Tireoide/cirurgia , Glândula Tireoide/cirurgia , Neoplasias da Glândula Tireoide/cirurgia , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Metástase Linfática/patologia , Masculino , Pessoa de Meia-Idade , Período Pós-Operatório , Guias de Prática Clínica como Assunto , Estudos Retrospectivos , Medição de Risco , Câncer Papilífero da Tireoide/patologia , Glândula Tireoide/patologia , Neoplasias da Glândula Tireoide/patologia , Adulto JovemRESUMO
Introduction: Transoral endoscopic thyroidectomy by vestibular approach (TOETVA) is a relatively new technique for the surgical treatment of thyroid diseases. We present the initial experience of a reference hospital of Mexico with TOETVA. Materials and Methods: This is a comparative retrospective study of cases (TOETVA) and controls (open thyroidectomy) treated by the endocrine surgeons between July 2017 and April 2019. Cases were patients of any gender, older than 18 years of age, with malignant thyroid nodules <2 cm or undetermined <5 cm without extrathyroidal extension and no lymph node or distant metastasis. Demographic, operative, and postoperative data were obtained and analyzed. Results: Twenty patients were surgically treated by TOETVA during the study period. Controls were paired based on type of surgery and dominant thyroid nodule. Ninety percent of the patients had a definitive diagnosis of malignancy. No statistically significant differences were found in age, BMI, length of stay, thyroid lobes size, and complication rates. Operative time was longer in TOETVA (216.7 ± 62.5 vs. 153.9 ± 49.25 minutes; t test P < .0001) and intraoperative blood loss was lesser for the TOETVA group (38.25 ± 38.9 vs. 101.8 ± 126.6 mL; t test P < .04). Conclusions: TOETVA is a feasible and relatively safe surgical technique for patients with benign and malignant thyroid diseases. Complication rates seem to be comparable with conventional open technique with lesser intraoperative bleeding; nevertheless, it requires longer operative times.