A prospective evaluation of recurrent laryngeal nerve paralysis during thyroidectomy.
We should continue to strive to make surgery better for our patients. New approaches that result in fewer complications, less pain, better cosmesis, shorter convalescence, and longer survival should be sought. In this paper, Dr. Chung (10.1007/s00268-007-9117-0) and colleagues have examined the bilateral axillo-breast (BAB) approach for thyroidectomy in a cohort of patients with papillary microcarcinoma. This new minimally-invasive approach to thyroidectomy has the advantage of leaving no visible cervical scar. The authors wished to examine the completeness of resection, complications, outcomes and usefulness of this new technique. There is much interest in the thyroid surgery community in providing excellent cosmetic results. Some groups have minimized the size of the standard Kocher incision; others have attempted to avoid any visible scar on the neck by approaching the thyroid endoscopically through the axilla and/or chest. In this report, the investigators study a technique that may be cosmetically more desirable for certain patients, but has not yet been proven to result in equivalent resection for malignancy when compared to the conventional approach. The reader must critically examine the data to determine if the BAB technique is not only cosmetically superior to the conventional operation, but at least equivalent in terms of complication rate and completeness of resection for malignant disease. To determine if the BAB approach is as safe and effective as conventional thyroidectomy Dr. Chung and colleagues performed a retrospective comparison of 103 BAB patients with 198 conventional thyroidectomy patients. The study population included only patients with papillary microcarcinoma. All patients underwent postoperative laryngoscopy two weeks after the operation to evaluate for recurrent laryngeal nerve injury. Completeness of resection was assessed in those patients who underwent total thyroidectomy by measurement of unstimulated thyroglobulin levels three months after the operation. In a small subset of patients, stimulated thyroglobulin levels were measured. Other complications examined included bleeding, infection, and temporary or permanent hypocalcemia. In most surgical series the risk of hemorrhage, infection, permanent recurrent laryngeal nerve injury, and permanent hypoparathyroidism for first-time conventional ‘‘open’’ thyroid operations is low, occurring in less than 2% of cases in series from high volume thyroid centers [1–5]. The complication rates observed for BAB in this study are comparable to those of other studies of conventional thyroidectomy from high volume centers. The authors should also be commended for the routine use of postoperative laryngoscopy to detect vocal cord dysfunction with high sensitivity. Measurement of serum thyroglobulin was the only method used to quantitate residual thyroid tissue in this study. Formal anatomic and functional imaging studies such as ultrasound, MRI, and radioiodine scanning were not performed. Quantifying residual thyroid tissue by these modalities may be superior to serum thyroglobulin measurements for several reasons. The measurement of serum thyroglobulin is unreliable in the presence of anti-thyroglobulin antibodies. Furthermore, the serum thyroglobulin level is not linearly correlated with the volume of thyroid tissue, but is a product of the TSH level and the volume of normal thyroid tissue and/or thyroid cancer and metastases. Because of this, it is problematic to compare the C. Sturgeon (&) Section of Endocrine Surgery, Northwestern University Department of Surgery, 201 E. Huron St., Galter 10-105, Chicago, IL 60611, USA e-mail: firstname.lastname@example.org