Management of endocrine surgical disorders during COVID-19 pandemic: expert opinion for non-surgical options.

PURPOSE: The COVID-19 pandemic brought unprecedented conditions for overall health care systems by restricting resources for non-COVID-19 patients. As the burden of the disease escalates, routine elective surgeries are being cancelled. The aim of this paper was to provide a guideline for management of endocrine surgical disorders during a pandemic. METHODS: We used Delphi method with a nine-scale Likert scale on two rounds of voting involving 64 experienced eminent surgeons and endocrinologists who had the necessary experience to provide insight on endocrine disorder management. All voting was done by email using a standard questionnaire. RESULTS: Overall, 37 recommendations were voted on. In two rounds, all recommendations reached an agreement and were either endorsed or rejected. Endorsed statements include dietary change in primary hyperparathyroidism, Cinacalcet treatment in secondary hyperparathyroidism, alpha-blocker administration for pheochromocytoma, methimazole ± ß-blocker combination for Graves' disease, and follow-up for fine-needle aspiration results of thyroid nodules indicated as Bethesda 3-4 cytological results and papillary microcarcinoma. CONCLUSION: This survey summarizes expert opinion for the management of endocrine surgical conditions during unprecedented times when access to surgical treatment is severely disrupted. The statements are not applicable in circumstances in which surgical treatment is possible.

Performance of F-18 Fluorocholine PET/CT for Detection of Hyperfunctioning Parathyroid Tissue in Patients with Elevated Parathyroid Hormone Levels and Negative or Discrepant Results in conventional Imaging.

OBJECTIVE: Our aim was to assess the diagnostic performance of F-18 fluorocholine (FCH) positron emission tomography/computed tomography (PET/CT) in detecting hyperfunctioning parathyroid tissue (HPT) in patients with elevated parathyroid hormone levels with negative or inconclusive conventional imaging results and to compare the findings with those obtained using technetium-99m sestamibi (MIBI) scintigraphy and neck ultrasonography (US). MATERIALS AND METHODS: Images of 105 patients with hyperparathyroidism who underwent FCH PET/CT, dual-phase MIBI parathyroid scintigraphy (median interval: 42 days), and neck US were retrospectively analyzed. The gold standard was histopathological findings for 81 patients who underwent parathyroidectomy and clinical follow-up findings in the remaining 24 patients. Sensitivities, positive predictive values (PPVs), and accuracies were calculated for all imaging modalities. RESULTS: Among the 81 patients who underwent parathyroidectomy, either parathyroid adenoma (n = 64), hyperplasia (n = 9), neoplasia (n = 4), or both parathyroid adenoma and hyperplasia (n = 1) were detected, except 3 patients who did not show HPT. Of the 24 (23%) patients who were followed-up without operation, 22 (92%) showed persistent hyperparathyroidism. FCH PET/CT showed significantly higher sensitivity than MIBI scintigraphy and US in detection of HPT (p < 0.01). Sensitivity, PPV, and accuracy of FCH PET/CT were 94.1% (95/101), 97.9% (95/97), and 92.4% (97/105), respectively. The corresponding values for MIBI scintigraphy and US were 45.1% (46/102), 97.9% (46/47), and 45.7% (48/105) and 44.1% (45/102), 93.8% (45/48), and 42.9% (45/105), respectively. Among the 35 patients showing negative MIBI scintigraphy and neck US findings, 30 (86%) showed positive results on FCH PET/CT. FCH PET/CT could demonstrate ectopic locations of HPT in 11 patients whereas MIBI and US showed positive findings in only 6 and 3 patients, respectively. CONCLUSION: FCH PET/CT is an effective imaging modality for detection of HPT with the highest sensitivity among the available imaging techniques. Therefore, FCH PET/CT can be recommended especially for patients who show negative or inconclusive results on conventional imaging.

Experience of an endocrine surgeon in laparoscopic transperitoneal adrenalectomy.

BACKGROUND: Laparoscopic adrenalectomy (LA) is currently recognized as the gold standard for the treatment of most adrenal lesions, with a high safety and feasibility profile. This study aimed to present the extensive experience of a specialized endocrine surgeon in LA in a relatively large series of patients. METHODS: A total of 116 LAs performed from June 2009 to 2018 were evaluated in terms of adrenal pathologies, perioperative management, complications, conversions, tumor size, operative time, and learning curve. The learning curve was assessed using the cumulative sum (CUSUMOT) technique. RESULTS: Of 116 LAs, 107 (92.2%) were completed successfully, 77 (72%) of which were for Cushing's syndrome (n = 43, 55.8%), pheochromocytoma (n = 26, 33.8%), and Conn's syndrome (n = 8, 10.4%). Conversion was required in 9 cases (7.8%), the most common cause being limited space complicating dissection (n = 3). The mean operative time for successful LAs (unilateral 85, bilateral 22) was 74.7 min (range 40-210 min) and the mean hospital stay was 1.7 days (range 1-5 days). Gender, tumor size and body mass index were found to have no significant relationship with the operative time (p > 0.05). Postoperative normalization in hormone profiles was obtained in all patients but one. Aside from grade-I port-site infections in four patients (3.7%), no postoperative major complications and 30-day mortality were observed. On the CUSUMOT graph, the learning period covered the first 34 operations. CONCLUSIONS: Laparoscopic adrenalectomy is safe and advantageous, but requires a dedicated team involving experienced endocrine surgeons who have achieved competency after completion of the learning curve.

Missed thyroid gland after total thyroidectomy.

Missed gland is an extremely rare condition. It is a mediastinal thyroid mass found after total thyroidectomy. We report a case of missed gland. The patient underwent total thyroidectomy due to multinodular goiter and thyroid stimulating hormone levels did not increase after surgery. Pathological tests revealed a micropapillary carcinoma. Thyroid ultrasonography and scintigraphy scan revealed mediastinal thyroid mass. The patient underwent redo surgery without sternotomy and there was no morbidity after the second surgical procedure. Most missed thyroid gland cases are due to incomplete removal of plunging thyroid goiter during total thyroidectomy. They also can be attributed to a concomitant, unrecognized mediastinal goiter, which is not connected to the thyroid gland with vessels or a thin fibrous band. It should be noted that absence of signs like mediastinal mass or tracheal deviation in preoperative chest X-ray does not exclude substernal goiter. The presence of a missed thyroid gland should be kept in mind when postoperative thyroid stimulating hormone levels remain unchanged.

Adrenal angiosarcoma.

Adrenal angiosarcoma is an uncommon neoplasm that derives from the vascular endothelium; due to its biological behavior, it should be distinguished from other adrenal tumors. We herein report a case of a 57-year-old woman with diagnosis of an adrenal tumor that was suspected to be malignant. The specimen was histopathologically proved to be an angiosarcoma. The patient was suffering from right upper quadrant pain; after laboratory and radiological workup, a non-functioning right adrenal mass, 14 cm in size, was recognized. A right subcostal incision was made, and adrenalectomy was performed successfully with tumor-free surgical margins. Two months after the operation, a positron emission tomography-computed tomography scan was ordered for follow-up. No tumor tissue or any other metastatic foci remained. The patient had been referred to our medical oncology department and underwent retroperitoneal radiotherapy. However, unfortunately, the patient died due to cardiac insufficiency during the follow-up period.

Silk suture reaction in thyroid surgery.

Silk suture reaction (i.e., a benign granulomatous inflammatory foreign body reaction) is a rare complication of thyroid surgery. Here, two cases of post-thyroidectomy suture reaction are presented. Both of the patients were female, one is 48 and the other is 34 years old. The patients were presented with neck swelling and leakage of serous fluid from the Kocher's incision. Both patients had normal free T4, free T3, and TSH values. The 48-year-old female patient had a right subtotal and left near-total thyroidectomy 6 years ago and the other had bilateral total thyroidectomy 6 years ago. In the physical examination a mobile, painless, red, swelling was palpated in front of neck. In the ultrasound of both patients, a heterogeneous nodule with hypoechoic rim was seen, however, in scintigraphy no radiopharmaceutical involvement was observed in thyroid region. Due to suspicion of thyroid malignancy, a fine needle aspiration biopsy was performed and foreign body reaction was revealed cytologically. A suture reaction can vary from an erythematous swelling to chronic granulomatous reaction. The time interval between the operation and formation of suture reaction was 6 years in both of the cases thus these patients were considered as chronic patients. Foreign body reaction diagnosis was confirmed with fine needle aspiration biopsy. It is important to diagnose these chronic inflammation cases since these cases can mimic recurrence in thyroid malignancies. A post-thyroidectomy suture reaction is diagnosed cytologically with fine needle aspiration biopsy and by surgical removal of suture, this chronic inflammatory reaction can be cured.

Skin metastasis on the neck: an unusual presentation of recurrence of papillary thyroid carcinoma.

Skin metastasis of papillary thyroid carcinoma (PTC) is rare. Here, two cases of skin metastases of PTC are presented. Both of the patients were females, one is 83 and the other is 65 years old. The patients were admitted to the hospital with a movable skin lesion on anterior neck region. Free T3 and T4 levels were in normal levels and TSH levels were low in both patients. The 83-year-old patient underwent total thyroidectomy due to papillary thyroid cancer and received 131I ablation therapy and then thyroid suppression therapy. After the surgery, the patient lived without evidence of disease for 3 years and then skin metastasis occurred. The 65-year-old patient had a total thyroidectomy 5 years ago due to PTC then neck dissection due to metastasis 3 years later and then received 131I ablation therapy. Thyroid ultrasonography of both patients showed hypoechoic nodules with central vascularization. In the histological examination of both patients, cystic lesions filled with papillary structures were seen. Fine needle aspiration biopsy (FNAB) taken from both patients were papillary carcinoma with solid trabecular pattern. PTC tends to metastasize to regional lymph nodes but distant metastasis is rare. When distant metastasis develops, prognosis of the disease is poor. Therefore, skin metastasis of papillary thyroid cancer is a poor prognostic factor. If the patient does not have a thyroid malignancy history, diagnosis of PTC metastatic to the skin may be difficult since primary skin tumors such as apocrine tumors have similar histopathological features. However, in the presented cases since there was a PTC history, the diagnosis was easier with the help of histopathological examination. Skin metastasis of PTC should be kept in mind when differential diagnosis of atypical skin lesions are made especially in the patients with thyroid malignancy history.

Single port thoracoscopic treatment of thoracic duct injury after thyroidectomy with neck dissection.

Chylous leakage is a complication of thyroidectomy accompanied by bilateral neck dissection with incidence of 0.5-6.2%. A 51-year-old female patient underwent total thyroidectomy, bilateral and central neck dissection for papillary thyroid carcinoma. In post-operative 4th day, left sided chylous leakage was observed as 1,500 cc/day through neck drain. Leakage did not cease after 1-month conservative treatment so single port thoracoscopic intervention was performed. Under general anesthesia, patient was placed in left lateral decubitus position. An Alexis® retractor was placed through sixth intercostal space. Thoracic cavity was visualized with 30º scope. Posteroinferior edge of lower lobe was retracted superior posteriorly with a Foerster clamp to display inferior pulmonary ligament, which was then divided with electrocautery. Posterior mediastinal pleura between azygous vein and chest wall was incised to mobilize the vein. After that, mediastinal pleura between azygous vein and esophagus was cut longitudinally and esophagus was retracted anteriorly to dissect towards aorta. By dissection, thoracic duct was revealed as a thin tubular structure with occasional peristalsis. After isolation of the duct, it was clipped using Hem-o-lok®. Finally, fibrin sealant was applied to decrease risk of recurrence. One chest tube was placed to ensure adequate drainage of thoracic cavity and complete re-expansion of lung. Neck drain and chest tube was extracted in postoperative second and fourth day respectively and patient was discharged at 8th day. Single port thoracoscopy is a safe choice for treatment of chylous leakages due to cervical ductus thoracicus injury with faster recovery.

Bupivacaine application reduces post thyroidectomy pain: Cerrahpasa experience.

BACKGROUND: We aimed to evaluate the impact of bupivacaine administration into the surgical field after total thyroidectomy on post-operative pain and analgesic requirement with a double-blind, prospective, clinical and randomized study. METHODS: The study was performed between 2010 and 2011. Pain assessment was performed with the visual analog score (VAS). Patients were pre-operatively, randomly divided into two groups to receive either bupivacaine or saline. One group received a 10-mL of bupivacaine solution while the other group was treated with the same volume of 0.9% NaCl through the drain after completion of total thyroidectomy procedure. All patients were anesthetized and operated with the same anesthesia and surgical team. RESULTS: Ninety-one patients (20 males) were included in the study. No patient dropped out of the study during the procedures. No mortality was seen. The VAS scores were significantly lower in the bupivacaine administered group at post-operative minute 30 (3.7±3.2 vs. 5±2.9; P=0.03), hour one (3.04±2.4 vs. 4.2±2.8; P=0.04), and hour eight (1.8±2.04 vs. 3.2±2.1; P=0.005). Thirteen patients required analgesia during their hospital stay in the bupivacaine group while this number was twenty-two in the saline group (P=0.005). CONCLUSIONS: Local bupivacaine administration into the surgical field after total thyroidectomy reduces pain and analgesic requirement during the hospital stay.

Is Nerve Monitoring Required in Total Thyroidectomy? Cerrahpasa Experience.

Thyroidectomy is an elective operation performed in an anatomically complex region in which certain structures are responsible for vital functions and special senses. This study aims to compare the effects of two different technical approaches-nerve dissection combined with intraoperative nerve monitoring (IONM) and no nerve identification-on recurrent laryngeal nerve (RLN) damage in total thyroidectomy. One hundred and sixty-one consecutive cases that underwent total thyroidectomy and 322 RLN under risk were evaluated. In group 1 (n = 162), nerve dissection combined with IONM was performed, whereas no RLN identification was performed in group 2 (n = 160). While the duration of operation in group 1 (34.23 ± 12.21 min) was statistically shorter than that in group 2 (36.98 ± 16.79 min, p = 0.017), there was no significant difference between groups related to RLN palsy (group 1 n = 10, group 2 n = 7). Use of IONM was found only to shorten the duration of operation. According to our presented experience, there is no benefit of IONM-combined routine dissection of RLN during total thyroidectomy on the prevention of RLN palsy.

Short-stay Sutureless Thyroidectomy is Safe and Effective: Cerrahpasa Experience.

Hospitalizing patients up to 72 hours after thyroidectomy is a classical approach. However, the length of hospitalization has decreased following surgical procedures with new technological devices. Seven hundred one consecutive patients who underwent sutureless total thyroidectomy (STT) between October 2011 and 2013 were included in this study. Six hundred seventy-two (95.9%) were discharged before 24 hours following surgery (short-stay = SS), and 29 were discharged later (delayed-discharge = DD). This study aims to assess short-stay STT with early postoperative complications and readmission to hospital. One hundred forty-three SS patients were male and 529 were female. Mean age was 48 ± 13 years, BMI was 28.7 ± 8.3 kg/m2. Mean hospital stay for SS was 18.13 ± 1.97 (17-23) hours. Histopathology was benign in 443 (65.92%) and malignant in 229 (34.08%) in the SS group. In three (0.4%) of the SS group drainage was required because of hematoma, and in seven (1%) wound infection was observed. One hundred seven (7.9%) [permanent = 7 (0.52%)] of 1344 recurrent laryngeal nerves (RLNs) in SS were seen paralyzed in postoperative vocal cord examination. Hypocalcemia (all transient) was observed in 52 (7.74%) of the SS group. Eight of those 52 readmitted to hospital with symptomatic hypocalcemia and were treated as outpatients. There was no mortality. Of the DD group, two stayed in the intensive care unit, two had dysphonia, two had hematoma with anti-coagulant use, one had fever, four did not tolerate diet, five refused discharge, and 13 had symptomatic hypocalcemia. Sutureless total thyroidectomy can be performed safely and effectively as short-stay surgery.

Evidence-based Analysis on The Clinical Impact of Intraoperative Neuromonitoring in Thyroid Surgery: State of the Art and Future Perspectives.

Laryngeal nerve injuries are one the most critical complications during thyroid and parathyroid surgery. Iatrogenic damages to the recurrent laryngeal nerve (RLN) are relevant in terms of clinical implications, economic costs, and for malpractice litigation. In order to minimize potential neural damages, a standardized surgical technique is mandatory. Intraoperatory neuromonitoring (IONM) of the RLN is an important adjunct to the traditional approach and is a reliable tool for neural mapping and in dissection and prognostication of postoperative neural function 4. Because of this, most of the iatrogenic damages are not related to direct transection, but they are visually undetectable. Notwithstanding the increasing use of IONM at this stage, there is still the need for prospective, randomized, well-powered, and well-designed trials in order to further validate (via evidence-based data) the role of IONM in thyroid surgery. The aim of this review is to provide a critical analysis of the scientific evidences on the clinical impact of IONM in thyroid surgery showing the unsolved problems and the future challenges.

Sutureless thyroidectomy with energy-based devices: Cerrahpasa experience.

Total thyroidectomy makes up the majority of all thyroidectomy cases. Energy-based advanced vessel-sealing devices which were developed in recent years for the control of vascular pedicles allowed significant progress in thyroid surgery. This study is designed to compare the efficiency and safety of the two energy-based vessel-sealing devices (Ligasure™ LF1212 and Harmonic FOCUS(®)) in sutureless thyroidectomy. Two hundred and forty-five consecutive patients underwent sutureless total thyroidectomy. Patients were randomized for the Ligasure™ LF1212 (n = 126) or Harmonic FOCUS(®) (n = 119). The parameters of demographics, surgical indications, morbidity, incision length, duration of operation, weight of specimen, amount of drainage, postoperative pain, hospital stay, and histopathology of specimen were recorded. Mean duration of operation was 37.98 ± 14.98 min (16-92 min) and was significantly shorter for Harmonic FOCUS(®) (p < 0.001). Mean hospital stay was 1.09 ± 0.3 (1-3) days. Morbidity rate was 9.8 % in total, whereas no mortality was observed. In terms of morbidity rates, no significant difference was determined between the two groups (p = 0.476). In both groups, there was no need for extra analgesic application other than the routine given after surgery. According to our experience, sutureless thyroidectomy can be performed with low morbidity rates in secure and efficient way.

Minimal invasive parathyroidectomy with local anesthesia for well-localized primary hyperparathyroidism: "Cerrahpasa experience".

Imaging guided well-localized single gland excision via smaller incision without intraoperative parathormone (ioPTH) can be performed in ambulatory settings. Forty-six consecutive patients with solitary parathyroid adenoma causing primary hyperparathyroidism (PHPT), who underwent laterally approached minimal invasive parathyroidectomy (MIP) through 2-3 cm incision between January 2011 and April 2012, were included in the study. All data were collected prospectively; analyzed retrospectively. Intervention with local anesthesia was applied to 46 patients. Parathyroidectomy with local anesthesia and IV sedation was successfully completed in 42 of those. Forty-two patients had biochemically confirmed PHPT; single gland disease was supported by imaging methods. Localization was decided in 15 patients just with USG, in 11 patients just with scintigraphy, and in 16 patients with both. Preoperative mean serum total calcium value was 11.13 ± 1.02 mg/dl. Immediate postoperative and postoperative 2nd week's serum calcium levels were 10.62 ± 1.43 mg/dl (p = 0.006), 9.24 ± 0.79 mg/dl (p < 0.001), respectively. Preoperative mean serum PTH value was 434.17 ± 550.22 pg/ml. Immediate postoperative and postoperative 2nd week's PTH values were 34.69 ± 28.50 pg/ml (p < 0.001), 91.21 ± 81.86 pg/ml (p < 0.001), respectively. In all interventions, no ioPTH assay or frozen section was performed. Forty-one patients (97.62 %) had reduction of serum PTH levels equal or more than 50 %. Cure rate for short-term follow-up was also 97.62 %. One patient had persistent hypercalcemia. Mean operation time was 15:09 ± 6:38 min (range 5:30-35:00). For all excised parathyroid adenomas, average weight was 2,278 ± 1,653.01 mg (range 100-8,000). For patients with well-localized single gland disease, MIP with local anesthesia and IV sedation have high cure rates and less morbidity at experienced centers without general anesthesia and hospital stay.