Thyroid Surgery Safe For Older Patients, Study Finds

Thyroid surgery is safe for older patients, say physicians who found only slight differences in rates of complications and hospital readmissions in a multi-year study."We were pleasantly surprised," says Dr. Melanie W. Seybt, endocrine-head and neck surgeon at the Medical College of Georgia and first author of the study, published in the journal Archives of Otolaryngology -- Head and Neck Surgery. "We suspected older patients might be admitted to the hospital more often, have more complications and more cancer."

But their study of 428 thyroidectomy patients at MCGHealth Medical Center and the Charlie Norwood Veterans Affairs Medical Center between November 2003 and December 2007, including 44 patients over age 65 and 86 between ages 21-35, showed few differences in the two groups.

Surgeons found:

* They could do outpatient surgery in both groups at essentially the same rate, 45.5 percent in the elderly and 51.2 percent in younger patients
* Similar complication rates, with 12.5 percent of older patients having transient problems with low calcium versus 11.1 percent of younger patients.
* The thyroid growth was suspected to be malignant in 4.5 percent of elderly patients and 2.3 percent of younger patients. Final pathology revealed cancer in 27.3 percent of elderly patients and 18.6 percent of older patients.
* Elderly patients had a slightly higher hospital readmission rate -- 4.5 percent versus 1.2 percent -- but readmissions were related to the transient problems with calcium levels not age-related complications.
* Neither group had post-operative bleeding or permanent vocal cord paralysis.

She hopes the findings will decrease concerns among patients and practitioners about the safety of thyroidectomies in the growing elderly population, noting that thorough preoperative screening, important at any age, likely helped minimize adverse reactions in their older patients.

Although thyroid disease tends to be most common in young women, the number of older patients diagnosed with the problem is escalating, Dr. Seybt says, noting that the oldest patient in this study group was 84. With a geriatric population that has increased by 90 percent in the last 30 years, according to the U.S. Census Bureau, the numbers are likely to continue upward.

"A lot of our older patients have other problems, such as heart failure, hypertension and restrictive lung disease, so we are very aggressive about getting medical clearance and optimizing control of their other problems," Dr. Seybt says.

She notes that head and neck surgeries generally have less complications and quicker recoveries than procedures in other parts of the body, such as the abdomen or chest. Low calcium levels are a common complication of thyroid surgery because the adjacent parathyroid glands are typically a little stunned by removal of the thyroid gland, she says. To help avoid problems, patients are routinely placed on a three-week tapering dose of calcium but sometimes still have transient problems, most commonly numbness or tingling around the lips and cramping of the hands and feet. Because of the close proximity to the vocal cords, patients also can have transient or permanent hoarseness.

While its exact cause is unknown, thyroid disease tends to run in families and radiation exposure is believed to be a risk factor for thyroid cancer. The increased availability of quality, non-invasive screening such as ultrasound likely means more cases are being identified at every age, Dr. Seybt says.

Laptop-sized ultrasounds are showing up in many physician offices and thyroid nodules also show up when patients have more sophisticated studies of the head and neck, such as an MRI scan, for other reasons. Patients or their doctors often just feel nodules in the neck although they can be oddly asymptomatic until they grow large enough to impact swallowing and/or breathing. While some of these larger growths are very obvious, those that grow downward into the chest or toward the back can be harder to detect. In older patients, many of the growths likely have been there a while, Dr. Seybt says.

Depending on the size of the growth in patients, surgeons at MCG and the VA will use one of three different approaches. These include a standard, several-inch incision at the base of the neck for the largest growth as well as include minimally invasive thyroidectomy, in which surgeons work through an incision about half the size of the norm, and an endoscopic approach, in which video monitoring and a thin, ultrasonic scalpel reduce incision size another half.

Dr. David Terris, chair of the Department of Otolaryngology-Head and Neck Surgery in the MCG School of Medicine and a pioneer of the minimally invasive approaches, showed in the March 2006 issue of Laryngoscope that the newer, minimally invasive approaches, which reduce the incision size and recovery time, could be used safely in most patients. Dr. Terris is corresponding author on the current study.

Dr. Terris and Sunny Khichi, a senior medical student at MCG, are study co-authors.

World’s First Successful ViKY Robot-assisted Surgery For Pancreatic Tumors

This month Fox Chase Cancer Center performed the world's first successful minimally invasive distal pancreatectomy using the ViKY® system's revolutionary robotic, compact laparoscope holder. The technology, developed in France and tested on thousands of patients in Europe, made its debut in a cancer setting in the United States at Fox Chase. "Fox Chase is among only a handful of institutions worldwide using robotics or laparoscopy to treat patients with nearly all types of cancer," says Robert G. Uzzo, MD, FACS, chairman of the department of surgery at Fox Chase. "The use of technology, like the ViKY system, reinforces our Center's commitment to excellence in minimally invasive surgical techniques for the care of patients with both benign and cancerous conditions."

Fox Chase surgeon Andrew A. Gumbs, MD, who specializes in minimally invasive hepato-pancreatic and biliary (HPB) surgery, explains, "This system is so versatile that surgeons like me are able to use it for many different laparoscopic procedures, including those in the gastrointestinal, urologic, thoracic and gynecologic regions."

Typically with minimally invasive procedures, like a laparoscopic distal pancreatectomy, surgeons use both hands to manipulate the surgical tools and need an assistant to manipulate the endoscope—a thin, lighted tube equipped with a camera that allows the surgeon to view the surgical field.

Gumbs performed this first ever ViKY assisted minimally invasive distal pancreatectomy on a 65-year-old man who was diagnosed with two pancreatic cysts, one of which is potentially cancerous. Pathologists are currently evaluating the cyst.

"The new ViKY robotic laparoscope holder acts as an extra hand during surgery, giving me stability and steadiness," adds Gumbs. "The view of the surgical field is critical, so ViKY's pinpoint accuracy helps me perform more complex procedures laparoscopically." Unlike typical laparoscope holders, the ViKY system's holder is lightweight, easy to set up and use, and takes no floor space.

Standard treatment for pancreatic cancer is surgery to remove the head or tail of the pancreas. When patients present with pancreatic cancer localized to the tail of the pancreas (instead of the head), they undergo a distal pancreatectomy, in which the surgeon removes the tail of the pancreas and leaves the head attached. The remaining portion can function normally by producing and releasing digestive enzymes and hormones. Patients with pancreatic cancer are typically treated with surgery followed by radiation therapy and/or chemotherapy to reduce the risk of recurrence.

The ViKY system gave Gumbs precise control of the laparoscope while he performed the distal pancreatectomy. The endoscope moves according to the surgeon's orders, either through voice recognition or footswitch control.

Before the ViKY technology was available patients might have undergone open surgery. Depending on the complexity of the case, the surgeon may have considered open abdominal surgery, requiring a large incision and a lengthy recovery. Minimally invasive surgical techniques, like the surgery Dr. Gumbs performed, benefit patients in many ways, including a shorter hospital stay, faster recovery, quicker return to daily activity, less risk of infection and less scarring and bleeding.

Gumbs was the first American surgeon to complete a minimally invasive HPB fellowship at the Institut Mutualiste Montsouris in Paris, France. This is the hospital where the first published case of a single incision laparoscopic cholecystectomy in the world was done using the ViKY system. Gumbs is responsible for bringing the ViKY system to Fox Chase and will be training fellow surgeons on this technology.

The ViKY system is manufactured by Endocontrol Medical in La Tronche, France. Endocontrol is an innovative company offering robotic solutions for endoscopic surgeries. Endocontrol was created by Clement Vidal and Patrick Henri of Joseph Fourier University, Grenoble, France, a worldwide leader in computer assisted and robotic surgery.