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Minimally invasive nonendoscopic thyroidectomy
Otolaryngology–Head and Neck Surgery (2007) 137, 362-363
LETTERS TO THE EDITOR Minimally invasive nonendoscopic thyroidectomy
REFERENCES
1
I applaud Cavicchi et al for sharing their experience and contributing to the understanding and development of the minimally invasive nonendoscopic thyroidectomy (MIT). I would like to make several points, however, as we move forward with the cautious and logical application of minimal access thyroid surgery techniques. The authors report a modest 15.6% incidence of MIT in their center, which is similar to the low 10.6% reported by Miccoli et al.2 However, both of these clinical series are from relatively iodine-deficient Italy, which therefore results in a higher volume of endemic nontoxic multinodular goiter than in the United States. The proportion of US patients eligible for endoscopic thyroidectomy has been reported to be 28.8%.3 Many of the remaining patients are candidates for less than maximal surgery, with incision lengths varying from three to six cm. In fact, as minimal access surgery matures, it is becoming evident that one size does not fit all. I recommend a graded approach in accessing the thyroid compartment, which is customized to the patient and his or her disease, rather than a binary approach of MIT versus conventional thyroid surgery. The authors suggest that the standard neck incision length for thyroidectomy is six cm. There are numerous references and an abundance of experience to confirm that most standard incisions are at least eight to 10 cm and in many cases as large as 12 to 14 cm. An important advantage conferred by the use of endoscopes (in addition to the superior visualization offered) is the ability to safely reach the superior pole from a low incision that is inconspicuous. Although Cavicchi et al1 describe the ease of managing the superior pole vasculature from a higher incision, one of the benefits of MIT (namely, cosmesis) is defeated. Finally, there is very little justification in their data for observing patients in the hospital for a minimum of 48 hours after surgery. As minimal access surgery continues to be embraced, we should be ready to exploit some of the advantages of the reduced dissection and minimal bleeding involved by sending patients home shortly after surgery.4 David J. Terris, MD, FACS Department of Otolaryngology–Head and Neck Surgery Medical College of Georgia Augusta, Georgia E-mail, [email protected]
FINANCIAL DISCLOSURE Ethicon Endo-Surgery-Thyroid Course Director; Medtronic Xomed: Consultant for instrument development.
1. Cavicchi O, Piccin O, Ceroni AR, et al. Minimally invasive nonendoscopic thyroidectomy. Otolaryngol Head Neck Surg 2006;135:744 –7. 2. Miccoli P, Berti P, Materazzi G, et al. Minimally invasive videoassisted thyroidectomy: five years of experience. J Am Coll Surg 2004; 199:243– 8. 3. Terris DJ, Chin E. Clinical implementation of endoscopic thyroidectomy in selected patients. Laryngoscope 2006;116:1745– 8. 4. Terris DJ, Moister B, Seybt MW, et al. Outpatient thyroid surgery is desirable and safe. Otolaryngol Head Neck Surg 2007;136(4)556-9. PMID17418250 [PubMed in process].
doi:10.1016/j.otohns.2007.02.025 Impact of snoring on anthropometric measures of OSA We wish to respond to the article by Galer et al,1 because it appears to disagree strongly with the thesis of our paper, “Snoring significance in patients undergoing home sleep studies.” Our study2 concluded that snoring is a significant and under-recognized factor in obstructive sleep apnea syndrome. It showed that “in 3 multiple-regression analyses, the percent of time snoring, average loudness, and peak loudness are all significantly predicted by the apnea hypopnea index (all P ⬍ 0.003), body mass index (all P ⬍ 0.001), and age (P ⫽ 0.014). Daytime sleepiness was strongly predicted by percent time snoring (P ⫽ 0.014).” Other studies have come to similar conclusions.3 However, Galer et al conclude that “snoring did not correlate with the anthropometric variables such as body mass index” (BMI) and respiratory disturbance index (RDI). In attempting to understand the reasons for such opposing conclusions in these two papers we have difficulty comparing the data. The criterion for classifying snoring is not fully defined by Galer et al. Although definition of snoring has not been agreed on, for the purpose of our study, we defined snoring as sound loudness, after cancellation of ambient noise, greater than 50 dB. Possible reasons for the conflicting results are Galer et al’s small sample, less than the strongest analysis methods, and the use of the SNAP system for polysomnography recording. It is important to recognize that their report only shows that the snoring parameters, as defined by the proprietary and not fully described methods of the SNAP system, fail to show statistical relevance to anthropometric data. Other methods of measuring snoring do show a “correlation to anthropologic variables.” This further strengthens our argument that a definition of snoring must be developed. We suggest that the Galer article’s conclusion might have been that their study failed to find an association between snoring and OSA rather than that there is no association. The purpose of this communication is to encourage
0194-5998/$32.00 © 2007 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.
LETTERS TO THE EDITOR Minimally invasive nonendoscopic thyroidectomy
REFERENCES
1
I applaud Cavicchi et al for sharing their experience and contributing to the understanding and development of the minimally invasive nonendoscopic thyroidectomy (MIT). I would like to make several points, however, as we move forward with the cautious and logical application of minimal access thyroid surgery techniques. The authors report a modest 15.6% incidence of MIT in their center, which is similar to the low 10.6% reported by Miccoli et al.2 However, both of these clinical series are from relatively iodine-deficient Italy, which therefore results in a higher volume of endemic nontoxic multinodular goiter than in the United States. The proportion of US patients eligible for endoscopic thyroidectomy has been reported to be 28.8%.3 Many of the remaining patients are candidates for less than maximal surgery, with incision lengths varying from three to six cm. In fact, as minimal access surgery matures, it is becoming evident that one size does not fit all. I recommend a graded approach in accessing the thyroid compartment, which is customized to the patient and his or her disease, rather than a binary approach of MIT versus conventional thyroid surgery. The authors suggest that the standard neck incision length for thyroidectomy is six cm. There are numerous references and an abundance of experience to confirm that most standard incisions are at least eight to 10 cm and in many cases as large as 12 to 14 cm. An important advantage conferred by the use of endoscopes (in addition to the superior visualization offered) is the ability to safely reach the superior pole from a low incision that is inconspicuous. Although Cavicchi et al1 describe the ease of managing the superior pole vasculature from a higher incision, one of the benefits of MIT (namely, cosmesis) is defeated. Finally, there is very little justification in their data for observing patients in the hospital for a minimum of 48 hours after surgery. As minimal access surgery continues to be embraced, we should be ready to exploit some of the advantages of the reduced dissection and minimal bleeding involved by sending patients home shortly after surgery.4 David J. Terris, MD, FACS Department of Otolaryngology–Head and Neck Surgery Medical College of Georgia Augusta, Georgia E-mail, [email protected]
FINANCIAL DISCLOSURE Ethicon Endo-Surgery-Thyroid Course Director; Medtronic Xomed: Consultant for instrument development.
1. Cavicchi O, Piccin O, Ceroni AR, et al. Minimally invasive nonendoscopic thyroidectomy. Otolaryngol Head Neck Surg 2006;135:744 –7. 2. Miccoli P, Berti P, Materazzi G, et al. Minimally invasive videoassisted thyroidectomy: five years of experience. J Am Coll Surg 2004; 199:243– 8. 3. Terris DJ, Chin E. Clinical implementation of endoscopic thyroidectomy in selected patients. Laryngoscope 2006;116:1745– 8. 4. Terris DJ, Moister B, Seybt MW, et al. Outpatient thyroid surgery is desirable and safe. Otolaryngol Head Neck Surg 2007;136(4)556-9. PMID17418250 [PubMed in process].
doi:10.1016/j.otohns.2007.02.025 Impact of snoring on anthropometric measures of OSA We wish to respond to the article by Galer et al,1 because it appears to disagree strongly with the thesis of our paper, “Snoring significance in patients undergoing home sleep studies.” Our study2 concluded that snoring is a significant and under-recognized factor in obstructive sleep apnea syndrome. It showed that “in 3 multiple-regression analyses, the percent of time snoring, average loudness, and peak loudness are all significantly predicted by the apnea hypopnea index (all P ⬍ 0.003), body mass index (all P ⬍ 0.001), and age (P ⫽ 0.014). Daytime sleepiness was strongly predicted by percent time snoring (P ⫽ 0.014).” Other studies have come to similar conclusions.3 However, Galer et al conclude that “snoring did not correlate with the anthropometric variables such as body mass index” (BMI) and respiratory disturbance index (RDI). In attempting to understand the reasons for such opposing conclusions in these two papers we have difficulty comparing the data. The criterion for classifying snoring is not fully defined by Galer et al. Although definition of snoring has not been agreed on, for the purpose of our study, we defined snoring as sound loudness, after cancellation of ambient noise, greater than 50 dB. Possible reasons for the conflicting results are Galer et al’s small sample, less than the strongest analysis methods, and the use of the SNAP system for polysomnography recording. It is important to recognize that their report only shows that the snoring parameters, as defined by the proprietary and not fully described methods of the SNAP system, fail to show statistical relevance to anthropometric data. Other methods of measuring snoring do show a “correlation to anthropologic variables.” This further strengthens our argument that a definition of snoring must be developed. We suggest that the Galer article’s conclusion might have been that their study failed to find an association between snoring and OSA rather than that there is no association. The purpose of this communication is to encourage
0194-5998/$32.00 © 2007 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.