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Quality of life and clinical outcome Source J Pediatr Surg SO 2015 Mar 13 [PMIDX25805004]

Quality of life and clinical outcome Source J Pediatr Surg SO 2015 Mar 13 [PMIDX25805004]
Quality of life and clinical outcome Source J Pediatr Surg SO 2015 Mar 13 [PMIDX25805004]

Quality of life and clinical outcome after thyroid surgery in children:A 13years single center experience

Eva Stokhuijzen a ,Alida F.W.van der Steeg b ,c ,Els J.Nieveen van Dijkum d ,Hanneke M.van Santen e ,1,A.S.Paul van Trotsenburg a ,?,1

a

Department of Pediatric Endocrinology,Emma Children's Hospital,Academic Medical Center,University of Amsterdam,Meibergdreef 9,Amsterdam,The Netherlands

b

Pediatric Surgical Center of Amsterdam,Emma Children's Hospital Academic Medical Center and VU University Medical Center,Meibergdreef 9,Amsterdam,The Netherlands c

Center of Research on Psychology in Somatic Diseases (CoRPS),Tilburg University,Waranda 2,Tilburg,The Netherlands d

Department of Endocrine Surgery,Academic Medical Center,University of Amsterdam,Meibergdreef 9,Amsterdam,The Netherlands e

Department of Pediatric Endocrinology,University Hospital for Children and Youth 'Het Wilhelmina Kinderziekenhuis'University Medical Centre Utrecht,Utrecht,the Netherlands

a b s t r a c t

a r t i c l e i n f o Article history:

Received 2December 2014

Received in revised form 17February 2015Accepted 23February 2015Available online xxxx Key words:

Thyroid surgery Children Adolescents Quality of life Clinical outcome

Background:Given the low mortality of pediatric patients diagnosed with thyroid disease,quality of life (QoL)after thyroid surgery is very important.To organize the best possible patient care we analyzed our experience with respect to QoL and clinical outcome.

Methods:This is a single center,retrospective cohort study.Data of patients who underwent thyroid surgery b 19years between January 2000and December 2012were collected.QoL was measured using the child health questionnaire child form (CHQ-CF87,b 18years)and the World Health Organization quality of life assessment (WHOQOL-100,≥18years).

Results:Forty patients were included (mean age 13.7years;29females (72.5%)).Twenty-six patients underwent total thyroidectomy (including 7repeat surgeries),14underwent hemithyroidectomy.QoL assessment in 26patients revealed lower physical QoL in patients with a current age b 18years (n =11)(p b .001),but higher overall and physical QoL in patients ≥18years (n =15)compared with controls (p =.01and p =.036respectively).Patients ≥18years,who underwent total thyroidectomy experienced lower overall and physical QoL compared with those who underwent hemithyroidectomy (p =.035and p =.005respectively).

Conclusions:Surgery for thyroid disease during childhood signi ?cantly affects QoL.However,QoL seems to improve with increasing age,and hemi-thyroidectomy has less negative effects on QoL than total thyroidectomy.

?2015Elsevier Inc.All rights reserved.

Given the very low mortality in children diagnosed with thyroid disease requiring thyroid surgery [1,2],efforts should be made to prevent or at least minimize morbidity owing to surgical treatment,and to monitor patient related outcomes like quality of life (QoL).

Thyroid surgery in children is performed for both benign and malignant disease.Although it is considered to be a safe procedure,postoperative complications may occur [3,4].The most common complications are bleeding,hypoparathyroidism and recurrent laryngeal nerve (RLN)injury.Postoperative hypocalcemia owing to

hypoparathyroidism (transient or permanent)can result in severe cramps,tetany and convulsions and often requires strict monitoring of postoperative serum calcium levels with oral or intravenous calcium supplementation therapy.If a child develops permanent hypoparathy-roidism,lifelong medication is needed.The reported incidence of permanent hypoparathyroidism after thyroid surgery in children ranges from 0%to 32%[5–13].RLN paralysis can either be transient or permanent and can result in signi ?cant morbidity,including hoarseness and/or dysphagia.Generally,the occurrence of permanent RLN paralysis in children is less than 2%(range from 0%to 38%)[5–13].

Previously,it has been shown that thyroid disease can signi ?cantly affect QoL of both adolescents and adults [14–17].However,probably owing to the low annual numbers of thyroid surgery in children,studies assessing the effects of thyroid surgery in children,on their QoL are lack-ing.The aim of this study was to obtain insight in the QoL and clinical outcome of children and young adults who underwent thyroid surgery before the age of 19years in our center between 2000and 2012,in relation to their thyroid disease,the type of surgery they underwent

Journal of Pediatric Surgery xxx (2015)xxx –xxx

?Corresponding author at:Department of Pediatric Endocrinology,H7-240,Emma Children's Hospital,Academic Medical Center,Meibergdreef 9,1105AZ Amsterdam,The Netherlands.Tel.:+31205668844;fax:+31205669683.

E-mail addresses:e.stokhuijzen@amc.uva.nl (E.Stokhuijzen),a.vandersteeg@vumc.nl (A.F.W.van der Steeg),e.j.nieveenvandijkum@amc.uva.nl (E.J.Nieveen van Dijkum),h.m.vansanten@umcutrecht.nl (H.M.van Santen),a.s.vantrotsenburg@amc.uva.nl (A.S.P.van Trotsenburg).1

Contributed equally to this publication and are both members of the European Society for Paediatric Endocrinology

(ESPE).

https://www.sodocs.net/doc/fe13203834.html,/10.1016/j.jpedsurg.2015.02.0670022-3468/?2015Elsevier Inc.All rights

reserved.

Contents lists available at ScienceDirect

Journal of Pediatric Surgery

j o u rn a l h o m e p a g e :w w w.e l s e v i e r.c o m/l o c a t e /j p e d s u r g

and development of permanent complications.Concerning QoL,we hypothesized that patients who underwent thyroid surgery during child-hood experienced lower QoL compared with the healthy population. 1.Materials and methods

1.1.Patients and data collection

Children who underwent thyroid surgery before the age of19years in the period from January2000to December2012were invited to visit the outpatient clinic in the period from April to June2013to undergo clinical outcome investigations and QoL assessment.Permission from the Medical Ethical Committee was https://www.sodocs.net/doc/fe13203834.html,rmed consent was acquired from all patients and/or parents who visited the outpatient clinic or completed QoL questionnaires.Patients who visited the outpa-tient clinic underwent a physical examination(with special attention to the thyroid region)and QoL assessment.In addition,a blood sample was drawn to assess thyroid hormone state(TSH,free T4).Those who were not able to visit the outpatient clinic but agreed to participate in the QoL study were sent a QoL questionnaire(no physical examination or assessment of thyroid hormone state was performed).In addition, data of all patients were collected from medical charts and surgery and pathology reports.Data included patient demographics, preoperative diagnosis(based on a combination of physical examination?ndings,thyroid hormone state,thyroid ultrasound, thyroid scintigraphy or?ne-needle aspiration cytology(FNAC)), postoperative diagnosis(based on?nal pathology results),type of surgical procedure,and intraoperative and postoperative complications. For deceased patients and patients who were not willing to participate in the follow-up study,the last available data from the medical charts and laboratory results were used.

1.2.De?nitions of surgical procedure and intraoperative and postoperative complications

Thyroid surgery was de?ned as hemithyroidectomy,subtotal or total thyroidectomy(with or without lymph node picking,or central or modi?ed lymph node dissection).All surgeons(resident,fellow, (pediatric)surgeon or endocrine surgeon)who participated in the surgical procedures were recorded from the surgery reports.Intraoper-ative complications were de?ned as bleeding,unilateral or bilateral RLN injury,or unintentional parathyroid gland removal/devascularization. Postoperative complications were de?ned as bleeding,wound infection, transient or permanent hypoparathyroidism and transient or permanent RLN paralysis.Hypoparathyroidism was de?ned as a plasma total calcium level b2.15mmol/L(reference range2.15–2.75mmol/L) and the need of treatment with calcium and/or vitamin D(selectively decided by the treating physician/pediatric endocrinologist).Hypopara-thyroidism was considered to be transient if all treatment for hypocalcemia was stopped within6months and permanent if a patient required medication at the last moment of follow-up(at least ≥6months postsurgery).RLN paralysis was de?ned by the description of clinical symptoms in the medical charts,including hoarseness and/or dysphagia.Postoperative laryngoscopy was not routinely performed. RLN paralysis was considered to be transient if problems resolved within6months and permanent if problems had persisted until the last moment of follow-up(at least≥6months postsurgery).

1.3.Quality of life

Patients who agreed to participate in the QoL study were asked to complete two questionnaires(at the outpatient clinic or at home).One questionnaire assessed QoL and one was a demographic questionnaire.

In patients with a current age b18years,QoL was assessed using the child health questionnaire child form(CHQ-CF87)which is a generic QoL assessment tool that has good reliability and validity[18].The questionnaire covers the physical,emotional and social well being of children.Items are scored using a four to six point Likert scale and converted to a0–100point continuum,with higher scores indicating a better QoL.Norm values of the Dutch population are available and allow for comparison with‘healthy’children[19].In patients ≤10years of age,one or both parents/care-takers were allowed to assist the patient in completing the questionnaires.In patients≥18years,QoL was assessed using the World Health Organization quality of life assessment instrument(WHOQOL-100),the Dutch version[20].The WHOQOL contains100items together assessing QoL in24facets covering6domains(physical health,psychological health,level of independence,social relationships,environment,spirituality/personal beliefs)and a general evaluative facet(overall QoL and general health). The response scale is a?ve point Likert scale.Scores on each facet and domain can range from4to20,with higher scores indicating a better QoL.Norm values of the Dutch population are available and allow for comparison with‘healthy’adults[21].

1.4.Statistical analysis

Variables are expressed as frequencies,means±standard deviation (SD)or medians(total range).In QoL analyses,intergroup differences were calculated in both CHQ-CF87and WHOQOL-100groups for type of thyroid disease(benign vs.malignant,based on?nal pathological result), type of surgery(hemithyroidectomy vs.total thyroidectomy)and the oc-currence of permanent complications(yes vs.no).The CHQ-CF87scores were compared with a sample of Dutch school children(n=281), representing a healthy control group.The WHOQOL-100scores were compared with a sample obtained from Dutch controls(n=411)from a normative sample of4802subjects.One sample T-test was used to cal-culate intergroup differences.All tests were two-sided.For all analyses, statistical signi?cance was set at a p-value of b.05.Statistical analyses were carried out using SPSS version20(SPSS,Chicago,IL,USA).

2.Results

2.1.Patient characteristics,thyroid diseases and surgical procedures

Forty patients were included with a mean age of13.7years(range 1.6–18.9years)at time of initial thyroid surgery(Table1).Twenty-?ve patients visited the hospital for follow-up investigations. Concerning QoL assessment,6patients were not able to visit the hospi-tal(owing to far distance or lack of time),and were only sent question-naires.During follow-up2patients had deceased owing to non-thyroidal causes(1owing to the consequences of metastatic adenocar-cinoma and1owing to a metabolic disease).Four patients did not want to participate(no reasons given)and3patients were lost to follow-up.

In total,47surgical procedures were performed(Table1).Overall, 12residents,2fellows,5pediatric surgeons,1surgeon and1endocrine surgeon participated in the surgical interventions.

The indications for initial thyroid surgery were mainly thyroid nodule(s)(n=15,37.5%),followed by multinodular goiter(n=10, 25%)and prophylactic thyroidectomy for multiple endocrine neoplasm type2a(MEN2a)syndrome(n=7,17.5%),

Histological examination revealed differentiated thyroid carcinoma in 12patients(11PTC and1follicular thyroid carcinoma(FTC))and medul-lary thyroid carcinoma in2patients.One child with multinodular goiter (and indeterminate FNAC result)was diagnosed with disseminated PTC 29months after initial surgery(pathological diagnosis was based on tis-sue biopsied from the lung).Mean follow-up time from initial operation to last moment of follow-up was4.6years(range28days–13.2years).

2.2.Perioperative and postoperative complications

Table2shows the acute perioperative and postoperative complica-tions after thyroid surgery.There were no bleeding complications

2 E.Stokhuijzen et al./Journal of Pediatric Surgery xxx(2015)xxx–xxx

during surgery.Postoperatively,2patients developed a wound infection and both required repeat surgery to remove the accumulated ?uid collection.Thirteen patients required postoperative calcium and/or vitamin D treatment,re ?ecting hypoparathyroidism.Symptoms of hypo-calcemia were reported in only 2patients (paresthesia).In 4of 5patients with permanent hypoparathyroidism parathyroid gland tissue was found in the surgical specimen.In 1case the surgery report revealed a dif ?cult procedure,as in ?ammation,adhesions and ?brosis were present in the patient with Hashimoto thyroiditis.No speci ?c annotations were men-tioned in the surgical reports of the remaining 4cases.2.3.Follow-up

Of 12patients diagnosed with differentiated thyroid cancer,10received radioactive iodine ablation treatment post-surgery.Because of small tumor size 2patients did not receive additional treatment.At the last moment of follow-up,malignant thyroid disease was persistent in 2patients despite repeated treatment with radioactive iodine.In 1

patient with medullary thyroid carcinoma,calcitonin was detectable at last moment of follow-up (5years postsurgery),yet no additional foci of malignant disease were found and therefore no repeat surgical intervention was planned.All patients treated for Graves'disease achieved complete remission.The patient who underwent total thyroidectomy for extremely painful Hashimoto thyroiditis was free of pain after surgery.2.4.Quality of life

Thirty-one patients returned the QoL questionnaires,of which 26could be analyzed (5were incomplete).

Eleven of 26patients were b 18years and completed the CHQ-CF87(mean age 13.6years,range 9.1–17.8years).In this group 2patients underwent a hemithyroidectomy and 9a total thyroidectomy.Five patients were diagnosed with malignant thyroid disease (all after total thyroidectomy)and 1patient developed permanent hypoparathyroid-ism.At time of QoL assessment,10of 11patients were treated with

Table 1

Patient characteristics.Study number Age at

surgery (y)Gender FNAC result Preoperative diagnosis

Type of surgery

Postoperative diagnosis a

Number of surgeries Duration of follow-up (y)1.14.9M Benign Nodule Hemi T x Nodule 113.12.18.8F Benign Nodule Hemi T x Nodule 111.23.15.4F Benign Nodule Hemi T x Nodule 1 6.84.16.5F Benign Nodule Hemi T x Nodule

10.25.14.8F Benign Nodule Hemi T x Nodule/Hashimoto 1 5.16. 5.8F Benign Nodule Hemi T x PTC 2 4.97.9.0F Benign Nodule Hemi T x Nodule 138.b 17.8F Benign Nodule Total T x PTC 10.69.8.4F Indet.Nodule Hemi T x FTC 211.510.c 17.5F Indet.Nodule Hemi T x PTC 2 2.411.12.4F Indet.Nodule Hemi T x Nodule 1 3.312.17.7M Indet.Nodule Total T x PTC 1313.14.7M Indet.Nodule Hemi T x PTC 2 2.914.d 5.2M Indet.Nodule Hemi T x PTC 2 2.915.e 13.4F Indet.Nodule Hemi T x PTC 2 2.316.17.9F Benign MNG Hemi T x MNG 1217.f 16.2F Benign MNG Hemi T x MNG 1 5.718.17.9F Benign MNG Hemi T x MNG 10.119.14.5F Benign MNG Hemi T x MNG 1420.c 16.4F Benign MNG Total T x MNG 1 3.421.16.3F Benign MNG Hemi T x MNG 1 1.722.g 15.5F Indet.MNG Hemi T x MNG 112.823.h 15.6M -MNG Subtotal T x MNG 2 4.824.15.3F -MNG Hemi T x MNG 1 3.625.16.2M -MNG Total T x

MNG

1 2.126.13.5M -MEN 2a Total T x +Ln x (modi ?ed)No malignancy 11127.8.7F -MEN 2a Total T x +Ln x (central)MTC 1 5.128.13.3F -MEN 2a Total T x MTC

1 5.129.8.9M -MEN 2a Total T x No malignancy 1 3.130. 1.6F -MEN 2a Total T x No malignancy 1 1.131. 1.9F -MEN 2a Total T x No malignancy 1232.7.7F -MEN 2a

Total T x No malignancy 1 1.933.16.2M -Graves'disease Total T x Graves'thyroiditis 1 4.634.18.1F -Graves'disease Total T x Graves'thyroiditis 1 3.835.18.9F -Graves'disease Total T x Graves'thyroiditis 1 2.936.i 15.3M -Graves'disease Total T x PTC

1 2.137.13.7M -Graves'disease Total T x

Graves'thyroiditis

1 1.938.18.9F -PTC Total T x +Ln x (modi ?ed)PTC +cervical Ln metastasis (1)113.239.8.7F -PTC

Total T x +Ln x (node picking)PTC +cervical Ln metastases (2)19.140.

13.8

F

-Hashimoto thyroiditis

Total T x

Hashimoto thyroiditis

1

3.7

FNAC,?ne-needle aspiration cytology;Indet.,indeterminate;MNG,multinodular goiter;MEN 2a,multiple endocrine neoplasia type 2a;PTC,papillary thyroid carcinoma;FTC,follicular thyroid carcinoma;MTC,medullary thyroid carcinoma;T x ,thyroidectomy;Ln,lymph node;Ln x ,lymph node dissection (central/modi ?ed/node picking).a

Based on ?nal pathological result.b

Patient treated with 131I-MIBG therapy for neuroblastoma (1999).c

Patient with Cowden syndrome.d

Patient treated with 131I-MIBG therapy for neuroblastoma (2004).e

Patient treated with 131I-MIBG therapy for neuroblastoma (1998),removal of parathyroid adenoma during this surgical procedure.f

Patient with McCune –Albright syndrome.g

Patient treated with external beam radiation therapy for retinoblastoma (1985).h

Patient diagnosed with disseminated papillary thyroid carcinoma 29months after initial surgery.i

Patient with Down syndrome.

3

E.Stokhuijzen et al./Journal of Pediatric Surgery xxx (2015)xxx –xxx

thyroxine.Thyroid hormone state was assessed in10of11patients, resulting in7patients with a normal thyroid hormone state,1(uninten-tionally)mildly overtreated and1(unintentionally)mildly undertreated patient.For diagnostic purpose,1patient was withdrawn from thyroxine, and in the remaining case thyroid hormone state was not tested for logis-tical reasons.Of the CHQ-CF87questionnaire,the following domains were statistically analyzed:general health perception,physical functioning, emotional functioning,and self-esteem.Patients b18years scored signi?cantly lower on the physical domain of QoL compared with the norm(p b.001)(Table3).No intergroup difference for type of thyroid disease(6benign vs.5malignant diagnoses),type of thyroid surgery(2 hemi vs.9total thyroidectomies)or the occurrence of permanent complications(1yes vs.10no)was found(data not shown).

Fifteen patients aged≥18years completed the WHOQOL-100 (mean age21.1years,range18.2–32.3years).In this group9patients underwent a hemithyroidectomy,6a total thyroidectomy.Three pa-tients were diagnosed with a malignant thyroid disease(all after total thyroidectomy)and1patient developed permanent hypoparathyroid-ism.At time of QoL assessment,7of15patients were treated with thy-roxine.Thyroid hormone state was assessed in11of15patients, resulting in8patients with a normal thyroid hormone state,2mildly (unintentionally)undertreated patients and1patient(not treated with thyroxine)with mild hypothyroidism.In the remaining4cases, thyroid hormone state was not tested for logistical reasons.

Patients≥18years scored signi?cantly higher on the overall QoL and the physical domain of QoL compared with the norm(p=.01and p=.036respectively)(Table4).A signi?cant intergroup difference was found for type of surgery.After hemithyroidectomy,overall and physical domain QoL scores were higher compared with the norm (p b.001and p b.005respectively),whereas patients who underwent total thyroidectomy had similar QoL scores as the norm.No intergroup difference for type of thyroid disease(12benign vs.3malignant diagno-ses)or the occurrence of permanent complications(1yes vs.14no)was found(data not shown).3.Discussion

This study provides the results of QoL assessment of26of40patients treated with thyroid surgery during childhood.Patients b18years (n=11)experienced lower physical QoL compared with the norm (using the CHQ-CF87questionnaire).On the contrary,young adults (≥18years,n=15)who underwent thyroid surgery during childhood showed better overall and physical QoL compared with the norm(using the WHOQOL-100questionnaire).Young adults who underwent a total thyroidectomy during childhood(n=6)experienced lower overall and physical QoL compared with those who underwent a hemithyroidectomy.

Given the very low mortality of children with thyroid disease, examination of patient reported outcomes is becoming more important and for this reason QoL was assessed.When it comes to QoL studies in patients with thyroid disease,data from pediatric cohorts are scarce and the majority of published studies assessed QoL in disease speci?c patient groups[14–17].We chose to use the CHQ-CF87and WHOQOL-100questionnaires because we were particularly interested in patients' satisfaction with their functioning in daily life.To our knowledge,this is the?rst study to analyze QoL in a heterogeneous group of patients who underwent thyroid surgery during childhood.

Although we were only able to score QoL in26of40patients,our hy-pothesis,that patients who underwent thyroid surgery during childhood experienced inferior QoL in comparison with healthy controls,was con-?rmed by analysis of the physical domain of QoL in our patient group b18years.In attempt to explain this?nding,we veri?ed whether type of disease(benign vs.malignant),type of surgery(hemithyroidectomy vs.total thyroidectomy),or the occurrence of permanent hypothyroidism could signi?cantly in?uence the outcome.Multivariate analysis showed no intergroup differences,which is supposedly the result of a small num-ber of included patients(for example,only1patient b18years with per-manent hypoparathyroidism was included in QoL assessment). Interestingly,a“response shift”between this group and young adult

Table2

Perioperative and postoperative complications after thyroid surgery.

Intraoperative complications (n=15,37.5%)a RLN paralysis

(n=4,10%)

Hypoparathyroidism

(n=13,32.5%)

Transient

(n=4)

Permanent

(n=0)

Transient

(n=8)

Permanent

(n=5)

Hemi T x(n=20)3(15%)11c

Subtotal T x(n=1)

Total T x(n=15)7b(46.7%)164

Total T x+Ln x(n=4)4b(100%)111 Completion T x after hemi T x(n=6)and subtotal T x(n=1)1(14%)1

RLN,recurrent laryngeal nerve;T x,thyroidectomy;Ln,lymph node;Ln x,lymph node dissection(central/modi?ed/node picking).The percentages in the second column denote the per-centage of intraoperative complications of the corresponding surgical procedure.

a Unintended parathyroid gland tissue removal in all15cases.

b In1patient,parathyroid gland was autotransplanted into the sternocleidomastoid muscle.

c Patient with intende

d removal of parathyroid adenoma during this surgical procedure.

Table3

Results of the quality of life analysis using the child health questionnaire child form(CHQ-CF87).

Thyroid surgery(n=11),mean±SD Controls(n=281),mean±SD a One sample T-test

Diff CI(95%)P value

CHQ-CF87(n=11)

GH75±31.677±14?3.00?25.62to19.62.770 RP66.7±16.297±9?30.30?41.25to?19.42b.001 RE88.9±17.294±15?5.10?16.67to6.45.348 SE74.4±19.577±12?2.65?15.78to10.48.660

GH,general health perception;RP,role:physical functioning;RE,role:emotional functioning;SE,self esteem;SD,standard deviation;Diff,difference;CI,con?dence interval.

a Controls are norm values of the Dutch population[19].

4 E.Stokhuijzen et al./Journal of Pediatric Surgery xxx(2015)xxx–xxx

patients was found.Most likely,the achievement of better coping strategies may account for the higher scores in adulthood.To illustrate this statement,one can imagine that it is easier for adults to anticipate to the new,postsurgical situation(as they can adjust their daily activities to their physical condition),whereas children aiming to come along with their peer group possess less scope to make decisions on such an individual level.In addition,the difference in number of total thyroidecto-mies(9of11patients b18years(81%)vs.6of15patients≥18years (40%),respectively)may have contributed to this outcome.Also,it seems conceivable that patients'current thyroid function might in?uence the QoL scores.In our cohort,7of11(63.6%)patients b18years and8of 15(53.3%)patients≥18years had normal thyroid function tests,thereby (at least)not fully explaining the difference in QoL scores that we found. As this QoL study was performed in a relatively small patient group and only at one point in time(with inter-individual variance in the post-surgery time period),results should be interpreted with caution. Nevertheless,this outcome may suggest that thyroid surgery affects QoL in pediatric patients in a negative way.To be able to draw de?nite conclusions and to verify the effects over time,QoL studies at multiple points in time are needed.If results from a prospective QoL study in a cohort of children treated with surgery and followed for several years after they have reached the age of18con?rm our hypothesis,implemen-tation of appropriate counseling for possible side effects of the surgical treatment(including the effects on the physical domain of QoL)may be useful to achieve better coping.

The?nding that patients≥18years who underwent total thyroidecto-my(n=6)experience lower QoL compared with those who underwent hemithyroidectomy(n=9),may be explained by a negative effect of lifelong dependence on levothyroxine treatment after total thyroidecto-my(only1patient who underwent hemithyroidectomy used levothyroxine at time of QoL assessment).Another possible explanation is the effect of the underlying disease on QoL.Although no signi?cant intergroup difference for the type of thyroid disease(benign vs. malignant)was found(most likely owing to the small number of included patients in the QoL assessment)it is still conceivable that an unequal distribution of diseases across both groups affects QoL outcomes.In this cohort3of6patients with total thyroidectomy were diagnosed with thyroid cancer,versus0of9patients with hemithyroidectomy and this unequal distribution may potentially contribute to the difference in QoL between both groups(with lower scores in patients treated for malignan-cy[22,23]).In conclusion,these results suggest that the type of thyroid surgery affects the patients'QoL.To further explore this association,QoL should be assessed in a larger cohort of patients.

A noteworthy?nding in this patient cohort is that2of8patients (25%)with a benign FNAC result were found to have thyroid cancer.Reasons for surgery despite the benign FNAC were fear of a false negative FNAC with a suspect nodule on ultrasound,fear of malignancy (expressed by the patient),fear of repeated biopsies and dysphagia owing to the size of the nodule.Although the sensitivity of FNAC in de-tecting thyroid cancer seems low,other studies also mention a low ac-curacy especially of FNAC with a benign result[24,25].A reason may be sample errors.The number of false negatives might be decreased by explicitly combining FNAC and ultrasound results[26],or using FNAC in combination with mutation analysis(evaluating rearrange-ments and point mutations that are known to be associated with thy-roid cancer)[27].Compared to similar studies,we found a rather high percentage of patients with permanent hypoparathyroidism after total thyroidectomy[5,6].Of the5patients with permanent hypoparathy-roidism,2were diagnosed with MEN2a,1with Hashimoto thyroiditis, 1with Graves'disease and1with a malignant nodule(all con?rmed on?nal pathological results).Surgery reports described a dif?cult pro-cedure only in the patient with Hashimoto thyroiditis,as in?ammation, adhesions and?brosis were present.In an attempt to diminish this high percentage,our center recently introduced a collaborative approach by a high volume endocrine surgeon(80–100thyroid surgeries per year) and a pediatric surgeon.Studies evaluating the effects of such a collabo-rative approach show promising results with regard to the occurrence of permanent complications[5,10,28,29].

This study possesses the inherent limitations of retrospective re-views,as data are subject to the limitations of observations.Since QoL was only measured at one point in time,results should be interpreted with caution.Although it seems likely to presume that the occurrence of permanent complications would signi?cantly affect patients'QoL (as hypoparathyroidism is a bothersome condition,treated with strict, lifelong medication),we were unable to demonstrate this,probably owing to low numbers of patients participating in the QoL assessment. To draw de?nitive conclusions,QoL studies should be undertaken in a larger group of patients and preferably prospectively at several points in time(at least pre-and postsurgery).

4.Conclusion

In conclusion,these data suggest that thyroid surgery in childhood may signi?cantly affect patients'QoL.However,QoL seems to improve with increasing age.In addition,hemithyroidectomy has less profound negative effects on QoL than total https://www.sodocs.net/doc/fe13203834.html,rge scale QoL stud-ies,measuring QoL at multiple points in time,should be undertaken in pediatric patients to further de?ne the effects on the short and long term of thyroid surgery during childhood.

Table4

Results of the quality of life analysis using World Health Organization quality of life questionnaire(WHOQOL-100).

Thyroid surgery

(n=15),mean±SD Hemi T x(n=9),

mean±SD

Total T x(n=6),

mean±SD

Control(n=411),

mean±SD a

One sample

T-test,P value

A B C D

WHOQOL-100(n=15)

Overall QoL15.7±3.117.0±1.713.7±3.813.3±0.8A vs D.01

B vs D b.001

C vs D.8

B vs C.035 Domain of QoL Physical14.7±2.616.1±2.312.6±1.313.1±0.9A vs D.036

B vs D.005

C vs D.356

B vs C.005 Psychological14.4±2.714.9±2.713.7±2.913.8±0.4A vs D.417

B vs D.264

C vs D.914 T x,thyroidectomy;SD,standard deviation;QoL,quality of life;vs,versus.

a Controls are norm values of the Dutch population[21].5

E.Stokhuijzen et al./Journal of Pediatric Surgery xxx(2015)xxx–xxx

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6 E.Stokhuijzen et al./Journal of Pediatric Surgery xxx(2015)xxx–xxx

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每当人们不尊重我们时,我们总被深深激怒。然而在内心深处,没有一个人十分尊重自己。———马克·吐温 忍辱偷生的人,绝不会受人尊重。———高乃依 敬人者,人恒敬之。———《孟子》 人必自敬,然后人敬之;人必自侮,然后人侮之。———扬雄 不知自爱反是自害。———郑善夫 仁者必敬人。———《荀子》 君子贵人而贱己,先人而后己。———《礼记》 尊严是人类灵魂中不可糟蹋的东西。———古斯曼 对一个人的尊重要达到他所希望的程度,那是困难的。———沃夫格纳 经典素材 1元和200元 (尊重劳动成果) 香港大富豪李嘉诚在下车时不慎将一元钱掉入车下,随即屈身去拾,旁边一服务生看到了,上前帮他拾起了一元钱。李嘉诚收起一元钱后,给了服务生200元酬金。 这里面其实包含了钱以外的价值观念。李嘉诚虽然巨富,但生活俭朴,从不挥霍浪费。他深知亿万资产,都是一元一元挣来的。钱币在他眼中已抽象为一种劳动,而劳动已成为他最重要的生存方式,他的所有财富,都是靠每天20小时以上的劳动堆积起来的。200元酬金,实际上是对劳动的尊重和报答,是不能用金钱衡量的。 富兰克林借书解怨 (尊重别人赢得朋友)

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draft 草稿drag 拖拉扯 dry out 使浸水之物完全变干dry up 干涸 favour 喜爱恩惠fit in 相适合相融合 govern 统治hear from 接到……的信 help(…)out 帮之某人摆脱困境或危难 in all 一共in many ways 在很多方面 in need 在困境中in other words换句话说 junior 较年幼的资历较浅的地位较低的 keep it up 保持成绩优秀继续干下去 leave … alone不管别惹让……一个人呆着和……单独在一起make fun of 取消meet with 遇到会晤经历 neat 好的整齐的匀称的never mind 不必担心obey 服从occupy 占用占领占据 otherwise 否则不然用别的方法 out of breath 上气不接下气 out of the question 不可能的不值得讨论 participate 参加参与pause 暂停终止recommend 推荐建议reflect 思考 relevant 有关的resign 辞去 ring up 给…..打电话scare 恐吓使恐吓 (be)scare to death 吓死了 settle in (迁入新居,更换工作后)安顿下来

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