Endoscopic approaches in head and neck endocrine surgery introduction of TOETVA (TransOral Endoscopic Thyroidectomy by Vestibular Approach) into clinical use at the Department of Surgery of the University Hospital in Brno.

Transoral endoscopic surgery of the thyroid and parathyroid glands is a modification of neck surgery using natural orifices. The classic approach in neck surgery is the gold standard, which we modified in 2007 by introducing Minimally Invasive Video-Assisted Thyroidectomy/Parathyroid-ectomy (MIVAT/P). We have been using TransOral Endoscopic Thyroidectomy/Parathyroidectomy by Vestibular Approach (TOETVA/TOEPVA) since the end of the last year and have operated on four patients. This method is more attractive for patients because it does not leave a visible scar on the neck, which is common in MIVAT/P. TOETVA is a promising procedure with many advantages, such as healing without visible scars, less pain, minimally invasive dissection and a clear operating field to both thyroid lobes and parathyroid glands. Presentation of the first case. Patients indicated for TOETVA must meet certain criteria - nodule(s) up to 3.5 cm, gland volume up to 30 ml, benign FNAB, papillary, follicular carcinoma not advanced, well differentiated, up to the nodule size of 10 mm with 1 lymph node up to 10 mm. The contraindications include a large goiter, previous neck surgery, history of thyroiditis, lymphadenopathy of the neck, advanced thyroid cancer. Relative contraindications include previous radiotherapy to the throat, Grave´s disease, and obese patients with a short neck. Intraoperative findings may result in a modification of the procedure. TOETVA is an excellent choice for selected patients who want to avoid a neck incision. This method provides the benefit of using standard endoscopic instruments and techniques. It is a safe and effective procedure that provides a good cosmetic result and considerable comfort in terms of clarity of the operating field by zooming in with an endoscopic camera. Longer operating times become shorter due to the learning curve effect.

IgG4 Sclerosing Cholangitis - an Inflammation Imitating Tumour of the Pancreas and Biliary Tract.

BACKGROUND: Immunoglobulin (Ig) G4 associated sclerosing cholangitis is a rare inflammatory disease of the biliary tract. Although it is a very progressive condition, it responds to steroid therapy. IgG4 associated sclerosing cholangitis can mimic pancreatic carcinoma, cholangiocarcinoma, and primary sclerosing cholangitis; therefore, it is very important to obtain a differential diagnosis. IgG4 sclerosing cholangitis is a biliary form of IgG4 related systemic disease, in which afflictions of more organs is afflictions of more organs are common, typically biliary form together with pancreatic one. Nonspecific symptoms are obstructive icterus, fatigue, and weight loss. Atypical imaging of the biliary tree and pancreas can be used to distinguish it from other diseases. Laboratory data show elevation of bilirubin, liver enzymes, IgG4 and total IgG concentrations. Sometimes IgE is also elevated with the eosinophilia, oncomarker CA 19-9 and autoimmune antibody is sometimes detected. CASE: This article presents a case of IgG4 sclerosing cholangitis and its related findings. The patient was intially referred for suspected pancreatic tumour, the presumed diagnosis was later changed to cholangiocarcinoma type 4 with concurrent autoimmune pancreatitis. Atypical imaging in cholangiography made us suspect IgG4 inflammation and the diagnostic process began. CONCLUSION: The diagnosis of this disease uses so called HISORt criteria. It is a very complex process in which the success of steroid therapy as a final step can be conclusive, as it was in our case. It is essential to exclude a malign neoplastic growth. The authors declare they have no potential confl icts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers. Submitted: 5. 12. 2018 Accepted: 10. 1. 2019.