Despite severe cardiac disease, total thyroidectomy can be performed successfully under general anaesthesia. Surgery should be considered early in the treatment plan. Surgery is particularly appropriate where it is considered necessary to continue amiodarone, when there are complications from the medications used to treat thyrotoxicosis and to facilitate fitness for or defer the need for cardiac transplantation.
It is unlikely that a trial of sufficient power to demonstrate or refute the beneficial effects of presymptomatic investigation of thyroid nodules will take place. We propose a pragmatic approach based on current evidence that balances the benefit of early diagnosis and treatment with the cost to the patient and the healthcare system associated with unnecessary investigations and surgery.
Where ultrasound localization is performed by experienced endocrine surgeons, minimally invasive parathyroidectomy is a feasible and safe approach in the pregnant patient with primary hyperparathyroidism.
A prospective study was conducted to assess the value of surgeon-performed ultrasound (SUS) in primary hyperparathyroidism. A total of 204 consecutive patients were studied prospectively with surgeon performed neck ultrasound. The results were compared with sestamibi nuclear scintigraphy (SNS) and radiologist-performed ultrasound (RUS) and correlated with the operative findings. SUS was true positive in 173 of 204 (85%), false positive in two (1%), false negative in 23 (11%), and true negative in six (2.5%) in patients, where the gland was inaccessible by US (sensitivity 88%, PPV 98%). SNS was true positive in 126 of 188 (67%), false positive in 3%, and false negative in 30% (sensitivity 69%, PPV 95%). RUS was true positive in 57 of 139 (40%), false positive in 5%, false negative in 52% and true negative in 3% (sensitivity 43%, PPV 89%). Comparing correct localization with incorrect localization by the Fisher's exact test, SUS was superior to SNS (p < 0.0001) and to RUS (p < 0.0001). 116 patients had bilateral neck exploration and 88 had open focused minimally invasive surgery. Five percent had multigland disease and 97% were cured after one operation. SUS was the only imaging modality in 16 patients and was sufficiently convincing to allow minimally invasive parathyroidectomy in eight. Surgeons treating hyperparathyroidism should find SUS a valuable tool. In our experience, SUS was more accurate than RUS whose costeffectiveness is questionable.
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