Morbidity and long-term outcome of surgery for renal hyperparathyroidism: results from a prospective cohort.

PURPOSES: Surgery remains an important treatment option for renal hyperparathyroidism (rHPT). The number of long-term outcome studies of parathyroidectomy is limited. METHODS: All consecutive patients with a parathyroidectomy for rHPT between 09/2009 and 04/2021 in a Belgian tertiary referral hospital were prospectively enrolled. The main outcomes were (long-term) cured proportion and postoperative morbidity (hypocalcemia, recurrent laryngeal nerve (RLN) palsy, re-intervention for bleeding, and wound morbidity). RESULTS: Sixty patients with a median age of 57 years were analyzed, including 23 patients before kidney transplantation, 23 patients without kidney transplantation, and 14 patients after kidney transplantation. Median time to transplant was 15 (6-24) months after parathyroidectomy. Morbidity was low with only two non-urgent returns to theatre (wound infection and non-compressive hematoma), two temporary RLN paralyses, and no 30-day mortality. Length of hospital stay was longer in patients with parathyroidectomy before kidney transplant, due to a more severe and prolonged need for calcium supplementation. After a median follow-up of 63 months, 37 patients (62%) were still alive, and 11 patients (18%) developed a recurrence. CONCLUSIONS: This single-surgeon, single-center cohort with long-term follow-up confirms the safety and excellent 'cure' proportions of surgery for rHPT but stretches the importance of long-term follow-up.

European multicentre study on outcome of surgery for sporadic primary hyperparathyroidism.

BACKGROUND: International multicentre outcome studies of surgery for primary hyperparathyroidism (pHPT), especially for rate of conversion to bilateral neck surgery and persistent hypercalcaemia, are scarce. METHODS: Eurocrine® is a European database for endocrine surgery. Data are entered according to predefined data fields. Outcomes for patients who underwent first surgery for sporadic pHPT were analysed. Multivariable analysis was performed to identify risk factors for adverse outcome using Cox regression with constant follow-up. RESULTS: A total of 5861 patients were registered between 2015 and 2018. Preoperative localization procedures were used in most patients, with moderate sensitivity. Intraoperative parathyroid hormone (ioPTH) measurement was used in three-quarters of patients. Bilateral surgery was performed in 1574 patients (26·9 per cent). Among 4683 patients (79·7 per cent) for whom unilateral or focused operation was planned, the procedure was converted to bilateral surgery in 396 (8·5 per cent). The risk of conversion decreased with the use of ioPTH monitoring (relative risk (RR) 0·77). Persistent hypercalcaemia was registered in 253 patients (4·3 per cent), and was less likely with the use of two (RR 0·55) or three (RR 0·44) localization procedures. In patients with a concordant localized single lesion, the rate of persistent hypercalcaemia was 2·5 per cent. The risk of persistent hypercalcaemia decreased with the use of ioPTH measurement, but was increased in patients with negative localization procedures and conversion to bilateral surgery. CONCLUSION: The use of ioPTH measurement decreased the risk of conversion and persistent hypercalcaemia. The use of two or three localization procedures decreased the risk of persistent hypercalcaemia; in patients with a concordant single lesion, the risk of persistent hypercalcaemia was low.

Combined cervicosternotomy and cervicotomy for true retrosternal goiters: a surgical cohort study.

OBJECTIVE: Intrathoracic goiters are a heterogeneous group characterized by limited or extensive substernal extension. Whereas the former can be treated through cervicotomy, the latter sometimes requires a cervicosternotomy. Whether cervicosternotomy leads to more morbidity remains unclear. This study aimed to compare intra- and postoperative morbidity in patients treated by cervicotomy or cervicosternotomy for intrathoracic goiters and standard thyroidectomy. METHODS: In a prospectively gathered cohort undergoing thyroid surgery (2010-2019) intra- and postoperative morbidity of cervicotomy (N = 80) and cervicosternotomy (N = 15) for intrathoracic goiters was compared to each other and to a 'standard' thyroidectomy (N = 1500). RESULTS: An intrathoracic extension prior to surgery was found in 95 (6%) of all thyroidectomies. Eighty patients (84%) were operated by cervicotomy and 15 (16%) by cervicosternotomy. The risk of temporary recurrent laryngeal nerve palsy was much higher in the cervicosternotomy group (21%) compared to cervicotomy (4%) and standard thyroidectomy (3%). The risk of temporary hypocalcemia after cervicotomy (28%) was comparable to a standard thyroidectomy (32%) but higher after cervicosternotomy (20%). No cases of permanent hypocalcemia or laryngeal nerve palsy were observed in both groups with substernal extension. The need for surgical reintervention was significantly higher in the cervicotomy group (6%) compared to cervicosternotomy (0%) and standard thyroidectomy (3%). CONCLUSION: In patients undergoing thyroid surgery for an intrathoracic goiter, cervicosternotomy was associated with more temporary laryngeal nerve palsy, but none of the interventions resulted in higher risks of permanent nerve damage, permanent hypocalcemia, or reintervention for bleeding. Reintervention was even more common after cervicotomy compared to cervicosternotomy. LEVEL OF EVIDENCE: IV.

Intra-operative vagal neuromonitoring predicts non-recurrent laryngeal nerves: technical notes and review of the recent literature.

BACKGROUND: During thyroid surgery, extreme caution must be taken not to harm the recurrent laryngeal nerve to avoid vocal cord palsy. A non-recurrent laryngeal nerve (NRLN) is a rare anatomical variation that is extremely vulnerable during thyroid surgery. METHODS: Description of two NRLN during thyroid surgery discovered early by using continuous intra-operative vagal nerve neuromonitoring and review of the literature. RESULTS: During thyroid surgery, we use continuous intra-operative vagal nerve neuromonitoring starting with checking vagal nerve signals. It is essential to start stimulation in the most proximal portion of the carotid sheath. An absent pre-dissection signal on the right vagal nerve with a positive signal on the left vagal nerve indicates a non-recurrent course of the right laryngeal nerve. Post-operatively computed tomography scan (CT-scan) was performed and showed an associated extra-anatomical course of the subclavian artery also known as an arteria lusoria. CONCLUSION: The NRLN is an important surgical challenge because unilateral palsy can lead to permanent hoarseness. This anomaly emphasizes the importance of a thorough surgical dissection and the use of intra-operative vagal nerve neuromonitoring. Our method of continuous intra-operative vagal nerve monitoring makes it possible to predict a non-recurrent laryngeal nerve in an early stage during surgery.

Robotic-assisted parathyroidectomy through lateral cervical approach: first results in Belgium.

OBJECTIVE: A parathyroidectomy has been the treatment of choice for primary hyperparathyroidism. Especially the improved imaging techniques have led to minimally invasive techniques. Aim of this study was to evaluate our experience with robot-assisted parathyroidectomy through lateral cervical approach. STUDY DESIGN: Prospective clinical cohort. METHODS: All consecutive patients who underwent a robotic-assisted parathyroidectomy for primary hyperparathyroidism since 2011 were enrolled in this study. Demographic data, biometrics, imaging data and surgery data were collected. Main outcomes were postoperative hypocalcemia, recurrent laryngeal nerve paralysis and other postoperative complications. RESULTS: Twenty-two patients were enrolled. When patients with conversion were excluded (39%) mean operating time was 69 min. In all patients a normal value of serum PTH-levels was achieved 4 h postoperatively. Mean value of serum calcium was 2.92mmol/L preoperative and 2.33mmol/L postoperative. There was no persistent hypocalcemia in any of our patients. 87% was discharged on the first postoperative day. Esthetic results were excellent. CONCLUSIONS: Robotic-assisted parathyroidectomy through lateral cervical approach is a safe and feasible procedure in patients with posteriorly localized parathyroid adenomas. Preoperative imaging techniques are crucial to detect the exact location.

Preliminary results after Single-Incision Laparoscopic Colorectal Surgery.

OBJECTIVE: Single-incision laparoscopic surgery (SILS) represents the recent advance in laparoscopic surgery claiming to be less invasive than conventional laparoscopic surgery. This study investigates the feasibility and safety of the procedure in colorectal surgery and reports the experiences in our center. METHODS: We retrospectively evaluated 41 consecutive patients surgically treated in our institution (February 2011-April 2013). The patient characteristics were evaluated for: gender, age, body mass index and ASA-score. Data included: indication, procedure, intraoperative complications, operation time, number of lymph nodes, postoperative complications, length of stay (LOS), morbidity and cosmesis. RESULTS: SILS was performed in 41 patients including 9 patients with colorectal cancer resection. We performed 3 ileocaecal resections, 11 right hemicolectomies, 7 sigmoidectomies and 20 rectosigmoidectomies. The operation time ranged from 45-210 min (median 123 min). Number of lymph nodes identified, ranged from 1-37 (median n=8). Six post-operative complications (14%) occurred: 1 gastroparesis, 1 subobstruction, 1 anastomotic leak and 3 patients needed a blood transfusion postoperatively. Median LOS was 6 days (range 4-21 days). One delayed complication (2,4%) occurred (eventration). None of the patients died. All patients had satisfactory cosmetic results. CONCLUSIONS: With the proviso that the study population was limited in size, SILS is feasible and is a save procedure in colorectal surgery and the procedure has an obvious cosmetic benefit. The results are comparable to other international reports. Still the procedure should be restricted to selected patients and performed by experienced surgeons. Additional prospective studies are essential to define the further benefit.

Harlequin syndrome after thyroidectomy for compressive retrosternal goiter. Case report and review of the literature.

A 74-year-old woman with known euthyroid multinodular retrosternal goiter necessitated an urgent intubation at home, due to acute respiratory distress evoked by tracheal compression. Extubation after a few days failed, and she underwent an urgent total thyroidectomy. During postoperative extubation the patient developed suddenly unilateral facial flushing and sweating at the left side, without ptosis of the left levator palpebrae superioris. These symptoms persisted during the next 24 hours. The skin at the right side of the face remained uninvolved. In the early postoperative period this appearance recurred at moments of emotions, exercise or heat. Beside this, the patient had a normal recovery. Six weeks later this reaction couldn't be provoked anymore. 'Harlequin' syndrome (unilateral facial flushing and sweating) is caused by a lesion of the controlateral sympathetic chain at the levels T2 and T3. It is unknown if the sweating and vasodilation at the "healthy" side is normal or if it is a reaction of hyperactivity.

The Chilaiditi Syndrome : Another Greek Tragedy ? Case report and short review of literature.

The Chilaiditi syndrome is a rare disorder, characterized by a broad spectrum of (gastro-intestinal) symptoms due to an interposition of a segment of bowel between the liver and the diaphragm. This anatomical variation is diagnosed through abdominal x-ray and is known as the Chilaiditi sign. Since the syndrome can lead to severe complications, such as perforation, intestinal obstruction or bowel ischemia, awareness of this syndrome is essential for every general surgeon. Knowledge of predisposing factors is necessary to treat possible complications accordingly. Conservative -management often is sufficient. Surgical intervention is reserved for those who do not respond to conservative line of management or those with severe complications.

Appendicitis-like clinical image elicited by Enterobius vermicularis: case report and review of the literature.

A 17-year-old female patient presented with the clinical features of an acute appendicitis. During laparoscopic exploration a macroscopically normal appendix was found. Since there were no intra-abdominal abnormalities found, the appendix was resected. Anatomopathology demonstrated Enterobius vermicularis, a pinworm infecting only humans, and mostly living in the caecum. This parasite is responsible for possibly the most common helminthic infection in the developed world. Its role in the pathogenesis of acute appendicitis is controversial, but more recent studies indicate a stronger association between enterobiasis and appendicitis. Often, enterobius mimics appendicitis by obstructing the lumen of the appendix, thereby causing appendiceal colic. This case report stresses the importance of microscopic examination of all appendectomy resection specimens. In case of enterobius infestation, systemic therapy of patient and family is necessary.

Corticomedullary mixed tumor of the adrenal gland-a clinical and pathological chameleon: case report and review of literature.

Adrenal tumors mostly present with specific and unique clinical features, regarding their endocrine metabolism. A 53-year-old man came to our Department for a left adrenal mass discovered incidentally. Biochemical and imaging findings were suspicious for a pheochromocytoma. The patient underwent a laparoscopic left adrenalectomy. A well-circumscribed 5.5-cm mass was removed. It was composed of adrenal cells intimately admixed with pheochromocytes. Immunohistochemical studies were positive both for cortical cells (inibin-α, synaptophysine and melan-A) and medullary cells (S-100 and chromogranine A). Final pathology was of corticomedullary mixed tumor (CMT). CMT is a rare tumor with 14 cases previously reported in literature, with wide variable biochemical behavior, such as his radiological and pathological features. Prevalence and actual malignant potential are yet unknown to our knowledge.

Phototoxic reaction after parathyroid surgery: case report and review of the literature.

BACKGROUND: A woman of 41 years old underwent surgery for primary hyperparathyroidism. She developed a long-lasting sharply demarcated erythematous skin reaction, appearing one hour after parathyroid surgery. This erythematous reaction felt like sunburn and was limited to the light exposed skin of the operation field, leading to the diagnosis of a phototoxic reaction. Since this phototoxic reaction occurred just after changing the operation lamp from a halogen type to a Light-Emitting Diode (LED) type, we suspected that the type of operation lamp could be a part of the cause of this phototoxic reaction. This is because our department has never before diagnosed phototoxic reactions (with a halogen type of operation lamp) during methylene blue (MB) assisted parathyroid surgery. METHODS: To investigate the cause of this phototoxic reaction, we performed an analysis of the adverse effects of all administered peroperative drugs and an evaluation of altered operation conditions. RESULTS: MB, used as a peroperative surgical marker of the parathyroid glands, was the most likely causal agent of this phototoxic reaction. Emission spectrum analysis of the operation light shows that the new LED operation lamp gives a high intensity of blue light. This may have resulted in activation of MB leading to a phototoxic reaction. CONCLUSIONS: To our knowledge, this is the first described phototoxic reaction in adults due to MB used as peroperative marker. Although rare, this potential side effect should be considered when using high doses of MB in combination with high intensity of blue light.