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.

Hemodynamic Instability during Thyroidectomy in Graves' Disease.

BACKGROUND: The aim of this study was to investigate the changes in vital signs and hemodynamic status that occur in patients during the intraoperative course of thyroidectomy in Graves' Disease (GD). METHODS: A total of 71 patients were included in the study. Patients were directed to surgery when they had large goiters with compressive symptoms or suspicious nodules, were pregnant or lactating, were unresponsive or intolerant to antithyroid drugs (ATDs), or expressed a preference to have surgery. All patients scheduled for operations underwent surgery while in the euthyroid state. RESULTS: Hemodynamic instability was observed in 18 patients during thyroidectomy. Disease duration, sample weight, and thyroid-stimulating hormone receptor antibodies (TRAb) levels were found to be effective on hemodynamic instability. Logistic regression analysis revealed an 11-fold increase in the instability risk in patients with a period of disease shorter than 21 months (P = 0.037). A TRAb value >11.5 increased the risk by 235fold (p < 0.001). CONCLUSION: High levels of TRAb values and new onset of disease with shorter periods of ATDs use may be risk factors for hemodynamic instability during thyroidectomy. Patients with larger thyroid glands are at greater risk for instability during surgery. Those risks should be taken into account during surgery, and the surgical and anesthetic management of the patient should be made more carefully in concordance with the anesthesia team.

Association of biochemical and clinical parameters with parathyroid adenoma weight. Turkish-Bulgarian endocrine and breast surgery study group, hyperparathyroidism registry study.

BACKGROUND: Primary hyperparathyroidism (pHPT) caused by a single benign parathyroid adenoma is a common endocrine disorder that is affected by regional differences. Living in different geographical regions reveals differences in the laboratory results and pathological findings, but studies on this subject are not sufficient. The article focuses on biochemical and pathological effects of geographical differences in parathyroid adenoma. In addition, the present study seeks to elaborate on treatment methods and effectiveness of screening in geographical area of Bulgaria and Turkey. METHOD: In this prospective study, 159 patients were included from 16 centres. Demographic characteristics, symptoms, biochemical markers and pathologic characteristics were analysed and compared between 8 different regions. RESULTS: Patients from Turkish Black Sea had the highest median serum calcium (Ca) level, whereas patients from Eastern Turkey had the lowest median serum phosphorus (P) level. On the other hand, there was no significant difference between Ca, parathormone (PTH) and P levels according to regions. Patients from Eastern Turkey had the highest adenoma weight, while patients from Bulgaria had the lowest adenoma weight. The weight of adenoma showed statistically significant differences between regions (p < 0.001). There was a correlation between adenoma weight and serum PTH level (p = 0.05) and Ca level (p = 0.035). CONCLUSION: This study has provided a deeper insight into the effect of the regional differences upon clinicopathological changing and biochemical values of pHTP patients with adenoma. Awareness of regional differences will assist in biochemical screening and treatment of this patient group.

Impact of Photobiomodulation on T3/T4 Ratio and Quality of Life in Hashimoto Thyroiditis.

Objective and background: Hashimoto's thyroiditis (HT) is both a B cell- and T cell-mediated, organ-specific autoimmune disease. No current treatment for underlying pathological mechanisms is available for HT and once diagnosed it requires long-term levothyroxine (LT4) treatment in most patients. The aim of our study was to evaluate the effects of photobiomodulation (PBM) on HT patients regarding thyroid functions, thyroid autoantibody levels, and decrease in hormone replacement needs. Methods: A total of 350 patients, who were diagnosed with Hashimoto`s thyroiditis, were included in our study. Patients were classified into two groups. Group 1 (n = 210) received PBM and dietary supplementation such as vitamin D, iron, and selenium. Group 2 (n = 140) received dietary supplements only. Patients' needs for LT4 replacement levels, triiodothyronine (T3), thyroxine (T4), and TSH levels, T3/T4 ratio, and thyroid autoantibody levels were evaluated. Results: As we compare both groups, the increase in T3 levels and T3/T4 ratio was markedly superior in Group 1 (p = 0.0001). The decrease in thyroid peroxidase antibody (TPO Ab) levels was also significantly different between both groups (p = 0.0001). Hormone replacement needs were also significantly decreased in Group 1 compared with Group 2 (p = 0.03). Low-level laser therapy (LLLT) is 70 times more effective in increasing T3/T4 ratio (p = 0.001) and 15 times more effective in decreasing levothyroxine dosage. Conclusions: Our results are encouraging and PBM seems to be very effective in increasing T3/T4 ratio and decreasing TPO Ab levels and weekly dosages of LT4 replacement therapy. Anti-inflammatory properties of PBM are greatly responsible for these changes and PBM causes major improvements in HT-related symptoms of the patient.

Is intraoperative nerve monitoring useful for surgical training in thyroid surgery?

OBJECTIVES: Parathyroid glands and recurrent laryngeal nerves (RLNs) are at risk during thyroid surgery. However, the identification of the nerves has reduced these risks. Intraoperative nerve monitoring (IONM) during thyroid surgery has gained widespread acceptance as an aid to the gold standard of visually identifying the RLN. The aim of the present study was to evaluate the effect of the identification of the RLN during thyroidectomy by using IONM. MATERIAL AND METHODS: Seven hundred forty-eight patients were included in our prospectively designed study. Of these 748 patients, 1496 nerves at risk were studied. Group 1 consisted of 736 nerves that were identified using IONM, whereas Group 2 consisted of 760 visually identified nerves. RESULTS: In the non-IONM group, the rate of temporary nerve palsy was lower in patients operated by experienced surgeons than in patients operated by residents (p= 0.001). In the IONM group, RLN injury rates were similar between experienced surgeons and residents. CONCLUSION: In spite of the fact that the duration of the operation was lower with IONM, the abbreviated duration may not appear to have clinical significance. The main advantage is for less experienced surgeons. IONM significantly decreases RLN palsy rates of the surgeons with limited experience in thyroid surgery.

Intraoperative nerve monitoring is useful for surgical training in thyroid surgery.

OBJECTIVE: Parathyroid glands and recurrent laryngeal nerves (RLNs) are at risk during thyroid surgery. However, the identification of the nerves reduced these risks. Intraoperative nerve monitoring (IONM) during thyroid surgery has gained widespread acceptance as an aid to the gold standard of visually identifying the RLN. The aim of the present study was to evaluate the effect of the identification of the RLN during thyroidectomy by using IONM. MATERIAL AND METHODS: Seven hundred forty-eight patients were included in our prospectively designed study. Of these 748 patients, 1496 nerves at risk were studied. Group 1 consisted of 736 nerves that were identified using IONM, whereas Group 2 consisted of 760 visually identified nerves. RESULTS: In the non-IONM group, the rate of temporary nerve palsy was lower in patients who were operated by experienced surgeons than in patients who were operated by residents (p=0.001). In the IONM group, RLN injury rates were similar between experienced surgeons and residents. CONCLUSION: In spite of the fact that the duration of the operation was lower with IONM, the abbreviated duration may not appear to have clinical significance. The main advantage is for less experienced surgeons. IONM significantly decreases RLN palsy rates of surgeons with limited experience in thyroid surgery.

Predictive Factors of Operative Hemodynamic Instability for Pheochromocytoma.

Pheochromocytoma is an uncommon catecholamine-secreting tumor in which resection is often associated with hemodynamic instability (HI). In this study, we aim to clarify the factors affecting surgical HI in patients who underwent surgery with the diagnosis of pheochromocytoma. All patients who underwent surgery with the diagnosis of pheochromocytoma between 2008 and 2015 were analyzed retrospectively. Patients with inconsistent diagnosis or missing outcomes and follow-up data were excluded. A total of 37 patients were included in this study. Patient demographics, operative time, tumor size, period of medical treatment until surgery, catecholamine levels in urine, and HI patterns were analyzed. There were 23 (62%) male and 14 (38%) female patients. Hemodynamic instability occurred in 13 (35%) patients. Overall, HI was higher in patients with tumor size <6 cm (P < 0.02); moreover, urine catecholamine levels were detected significantly higher than a cutoff value of 2000 µg/24 hours in hemodynamically instable group. In this study, tumor diameter of <6 cm and urine catecholamine levels >2000 µg/24 hours were associated with HI. Preoperative management is essential for preventing hypertensive crisis and HI before or during surgery.

Clinical Utility of Tc-99m MIBI SPECT/CT for Preoperative Localization of Parathyroid Lesions.

We aimed to demonstrate the role of SPECT/CT in preoperative localization of parathyroid lesions in patients with hyperparathyroidism who had technetium-99m (Tc-99m) methoxyisobutylisonitrile (MIBI) dual-phase parathyroid scintigraphy. We evaluated retrospectively the scintigraphic data of 103 patients who had parathyroidectomy after Tc-99m MIBI dual-phase parathyroid scintigraphy with SPECT/CT. The planar and SPECT/CT images were evaluated separately to determine their efficacy in localizing parathyroid lesions. These results were then compared with surgical data. There were 84 female and 19 male patients whose mean age was 54 ± 12 years. A total of 115 parathyroid lesions in 103 patients were resected during operations. In 87 patients, with both planar and SPECT/CT images, a total of 100 lesions could be detected correctly. In 11 patients, only SPECT/CT images could show 13 subcentimetric lesions. In three patients, three lesions were evaluated as parathyroid lesions both with planar and SPECT/CT images, but according to histopathologic evaluation, they came out to be nonparathyroidal lesions. In two patients, two parathyroid lesions could not be detected preoperatively neither with planar nor with SPECT/CT images. The lesion-based sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 87 %, 99 %, 97.1 %, 95.3 %, and 95.8 % for planar images and 98.3 %, 99 %, 97.4 %, 99.4 %, and 98.8 % for SPECT/CT images, respectively. Tc-99m MIBI parathyroid scintigraphy should be a diagnostic modality of choice in preoperative evaluation of patients with hyperparathyroidism. SPECT/CT has an incremental value both in demonstrating subcentimetric lesions and in accurately localizing lesions anatomically.

Isolated thyroid metastasis from renal cell carcinoma.

Metastatic neoplasms of the thyroid are uncommon when compared to primary tumors of the gland. Renal cell carcinoma (RCC) is a highly aggressive tumor of the urinary system. It can spread all over the body. Isolated solitary metastases of RCC to the thyroid are very rarely observed. A 64-year-old woman with a history of left radical nephrectomy for RCC, was referred to our clinic with palpable thyroid nodule. Ultrasound confirmed the nodule on the left lobe. Histopathological examination of the thyroidectomy specimen revealed that there were two solitary metastasis of RCC. No other distant metastasis were detected. Metastatic tumors of the thyroid gland are very rare. When patients with thyroid nodule are referred to our clinic with the history of other malignancies, we must consider metastasis. Thyroidectomy is recommended in the case of isolated thyroid metastasis of RCC.

Regional Clinical and Biochemical Differences among Patients with Primary Hyperparathyroidism.

BACKGROUND: Environmental habitat may play a role in clinical disparities of primary hyperparathyroidism (pHPT) patients. AIMS: To compare preoperative clinical symptoms and associated conditions and surgical findings in patients with pHPT, living in different geographical regions from the Black Sea, Mediterranean and Anatolia regions. STUDY DESIGN: Retrospective, clinical-based multi-centric study of 694 patients with pHPT. METHODS: Patients from 23 centers and 8 different geographical regions were included. Data related to baseline demographics, clinical, pathologic and treatment characteristics of 8 regions were collected and included age, gender, residential data, symptoms, history of fracture, existence of brown tumor, serum total Ca and p levels, serum parathormone (PTH) levels, serum 25-OH vitamin D levels, bone mineral density, size of the resected abnormal parathyroid gland(s), histology, as well as the presence of ectopia, presence of dual adenoma, and multiple endocrine neoplasia (MEN)- or familial-related disease. RESULTS: The median age was 54. Asymptomatic patient rate was 25%. The median PTH level was 232 pg/mL and serum total Ca was 11.4 mg/dL. Eighty-seven percent of patients had an adenoma and 90% of these had a single adenoma. Hyperplasia was detected in 79 patients and cancer in 9 patients. The median adenoma size was 16 mm. Significant parameters differing between regions were preoperative symptoms, serum Ca and p levels, and adenoma size. All patients from South-East Anatolia were symptomatic, while the lowest p values were reported from East Anatolia and the largest adenoma size, as well as highest Ca levels, were from Bulgaria. CONCLUSION: Habitat conditions vary between geographical regions. This affects the clinicopathological features of patients with pHPT.

Cancer Frequency in Retrosternal Goiter.

Retrosternal goiter prevalence is 5 to 40 per cent according to classifications in goiter series. Goiters with mediastinal extension were reported to be related with higher cancer rates. In our study, we aimed to investigate whether cancer incidence increased in retrosternal goiters compared with the cervical ones. Three hundred and ninety consecutive patients, who had surgery because of retrosternal goiter in Istanbul University Medical Faculty Department of General Surgery between 2005 and 2015 were included in the study (Group 1). Control group included 880 patients who had surgery because of nontoxic multinodular goiter in the same period (Group 2). Preoperative ultrasonography (USG) was performed to each patient. Fine-needle aspiration biopsy was performed in suspicious nodules and results were recorded. Carcinomas in histopathological examination were classified as intrathorasic and extrathorasic. Diagnostic rates of USG results were compared with histopathologic cancer results. Papillary carcinoma was diagnosed in 76 patients with retrosternal goiter (19%) and in 200 patients in the control group (22%). No statistically significant difference was detected between groups regarding the tumor rates (P > 0.05). One hundred and forty-four tumoral foci were detected in 76 patients with papillary carcinoma in retrosternal goiter patients. Three hundred and seventy tumoral foci were detected in 200 patients with papillary carcinoma in the control group. In the retrosternal goiter group, 104 carcinoma lesions of 144 papillary carcinomas were intrathorasic (72%). No statistically significant difference was detected between intrathorasic (2.1 ± 1 cm) and extrathorasic regiones (1.9 ± 0.8 cm) regarding the tumor size P > 0.05. When patients with and without cancer in the retrosternal goiter group were compared regarding familial thyroid cancer history, radiation to the neck, and cervical adenopathy, no statistically significant difference was detected. Cancer incidence of retrosternal goiters was not higher than that of the cervical ones. Yet, cancer foci of retrosternal goiters were commonly located in the intrathorasic area and were not detected with USG. Depending on these findings, we suggest that all retrosternal goiters should be surgically treated.

Magnetic Probe-Guided Excision of Nonpalpable Neck Lesions.

BACKGROUND: Reoperative neck surgery is technically more demanding because of the presence of scar tissue and distorted anatomy. We aimed to investigate the magnetic probe-guided excision of nonpalpable neck lesions in patients with previously operated neck compartments. METHODS: This study included 9 patients with recurrent/persistent thyroid carcinoma, recurrent/persistent hyperparathyroidism with previously operated neck compartments. The pathologic lesions were localized by ultrasonography, and magnetic tracer (0.2 mL, iron oxide) was injected directly into the pathologic lesions. Careful dissection was carried out following the area of maximum magnetic activity until the nonpalpable lesions were identified and excised. RESULT: All neck lesions were removed in 9 patients. The median count from lesion was significantly higher than values from lesion bed (background activity; (9900/5 seconds vs 250/5 seconds, P < .001). During follow-up, all patients had negative ultrasonography. CONCLUSION: Magnetic probe-guided technique could provide access to nonpalpable lesion localization in centers without readily available access to nuclear medicine facilities.

A Rare Disease of the Digestive Tract: Esophageal Melanosis.

Esophageal melanosis which is characterized by melanocytic proliferation in the squamous epithelium of the esophagus and melanin accumulatin of esophageal mucosa (EM) is a rare disease of the digestive system. Although esophageal melanosis is considered to be a benign disease, its etiology is not cleared and has been reported to be the precursor lesion of esophageal primary melanomas. In this report, we aimed to note esophageal melanosis in a 55-year-old female case who applied to our clinic with difficulty in swallowing, burning behind the breastbone in the stomach, heartburn, indigestion, and pain in the upper abdomen after endoscopic and pathologic evaluation. Complaints dropped with anti-acid therapy and case was followed by intermittent endoscopic procedures because of precursor melanocytic lesions.

Metastatic gastric signet-ring cell carcinoma: A rare cause of acute appendicitis.

We report a 32-year-old patient who underwent laparoscopy with classical symptoms and signs of acute appendicitis. An inflamed, edematous and non-perforated appendix, also a large amount gelatinous ascites, omental and peritoneal implants were seen. Appendectomy was performed and multiple biopsies were taken from omentum and peritoneum for definitive diagnosis. Histopathologic diagnosis was a metastatic gastric signet-ring cell carcinoma (GSRCC) involving appendix and other specimens. A flat lesion involving corpus to antrum was diagnosed by gastroscopy and GSRCC was verified histopathologically in a tertiary centre and the case evaluated as stage IV gastric carcinoma. This case with no sign of gastric cancer was presented as an acute appendicitis. Metastatic carcinoma to the appendix, causing acute appendicitis is extremely rare in clinical practice and usually associated with high morbidity and mortality.

Thyroid cancer incidence in simultaneous thyroidectomy with parathyroid surgery.

OBJECTIVE: Primary hyperparathyroidism (PHPT) is often seen in conjunction with an underlying thyroid disorder. Imaging methods that are used to localize the parathyroid adenoma also detect associated thyroid nodules and thyroid cancer. The aim of this study was to detect the rate of thyroid cancer identified while performing parathyroidectomy and thyroidectomy in patients with PHPT. MATERIAL AND METHODS: Files of all patients who were operated for PHPT and who underwent simultaneous thyroidectomy were analyzed. Data regarding parathyroid pathology, surgical procedures, indications of thyroid surgery, and pathology results were retrospectively recorded. The indications for thyroid surgery included presence of suspicious thyroid nodules in ultrasonography, increase in size of thyroid nodules in follow-up ultrasound, or presence of suspicious thyroid fine needle aspiration biopsy (FNAB) findings. Rates of thyroid cancer detection were investigated according to definite pathology reports. RESULTS: Eighty-three patients who underwent parathyroidectomy with a diagnosis of PHPT with concurrent thyroidectomy in Department of General Surgery, Istanbul University Istanbul Faculty of Medicine were included in the study. Eighteen patients were male (22%) and 65 were female (78%). The median age was 53 (18-70) years. The primary indication for parathyroidectomy was primary hyperparathyroidism in all patients. The thyroid procedures applied in addition to parathyroidectomy were lobectomy + isthmusectomy in 29 patients (35%), bilateral subtotal thyroidectomy in 20 patients (24%), bilateral total thyroidectomy in 23 patients (28%), and total thyroidectomy on one side and near total thyroidectomy to the other side in 11 patients (13%). The only indication for thyroidectomy was the presence of thyroid nodules until 2000 (20 patients, 24%). Indications in the remaining 63 patients included the presence of multiple nodules that cannot be followed up by ultrasonography in 25 patients (30%), presence of a suspicious nodule on ultrasonography in 33 patients (40%), growth in nodule size in 2 patients (2%), and detection of suspicious findings on FNAB in 3 patients (4%). Five patients (6%) were diagnosed with papillary thyroid cancer, four of whom were micropapillary cancer. CONCLUSION: Imaging methods performed to localize the pathological parathyroid gland for a diagnosis of PHPT are useful in estimating other accompanying pathologies. Presence of thyroid nodules should be evaluated before all parathyroid procedures, and if the nodule has an indication for surgery, thyroid surgery should be considered at the same operation with parathyroid surgery.

Minimally Invasive Surgical Approach to Complicated Recurrent Pilonidal Sinus.

Pilonidal sinus is considered as a simple and frequently occurring disease localized at the sacrococcygeal area. However, at the intergluteal region, it can often turn into a chronic and complicated disease. In some cases, it can fistulize up to the gluteal region and appear at the secondary orifices. Minimally invasive surgical techniques are becoming widespread in recent years due to the increased experience and development of new instruments. Limited excision of the pilonidal sinus tract can be a better treatment option compared with large excisions in terms of recovery time and patient's comfort. This case study reports the single-phase surgical treatment of complicated and recurrent pilonidal sinus localized at the gluteal area, with minimal tissue loss and inflammation.

Lithium-associated primary hyperparathyroidism complicated by nephrogenic diabetes insipidus.

Lithium-associated hyperparathyroidism is the leading cause of hypercalcemia in lithium-treated patients. Lithium may lead to exacerbation of pre-existing primary hyperparathyroidism or cause an increased set-point of calcium for parathyroid hormone suppression, leading to parathyroid hyperplasia. Lithium may cause renal tubular concentration defects directly by the development of nephrogenic diabetes insipidus or indirectly by the effects of hypercalcemia. In this study, we present a female patient on long-term lithium treatment who was evaluated for hypercalcemia. Preoperative imaging studies indicated parathyroid adenoma and multinodular goiter. Parathyroidectomy and thyroidectomy were planned. During the postoperative course, prolonged intubation was necessary because of agitation and delirium. During this period, polyuria, severe dehydration, and hypernatremia developed, which responded to controlled hypotonic fluid infusions and was unresponsive to parenteral desmopressin. A diagnosis of nephrogenic diabetes insipidus was apparent. A parathyroid adenoma and multifocal papillary thyroid cancer were detected on histopathological examination. It was thought that nephrogenic diabetes insipidus was masked by hypercalcemia preoperatively. A patient on lithium treatment should be carefully followed up during or after surgery to prevent life-threatening complications of previously unrecognized nephrogenic diabetes insipidus, and the possibility of renal concentrating defects on long-term lithium use should be sought, particularly in patients with impaired consciousness.

Safety and feasibility of laparoscopic adrenalectomy: What is the role of tumour size? A single institution experience.

BACKGROUND: Although, there are studies in the literature having shown the feasibility and safety of laparoscopic adrenalectomy, there are still debates for tumour size and the requirement of the minimal invasive approach. Our hypothesis was that the use of laparoscopy facilitates minimally invasive resection of large adrenal tumours regardless of tumour size. MATERIALS AND METHODS: Within 7 years, 149 patients underwent laparoscopic adrenalectomy at one institution. The patients were divided into two study groups according to tumour size. Group 1 included patients with adrenal tumours smaller than 5 cm and group 2 included larger than 5 cm. Patient demographics and clinical parameters, operative time, complications, hospital stay and final pathology were analysed. Statistical analyses of clinical and perioperative parameters were performed using Student's t-test and Chi-square tests. RESULTS: There were 88 patients in group 1 and 70 in group 2. There were no significant differences between study groups regarding patient demographics, operative time, hospital stay, and complications. Estimated blood loss was significantly higher in group 2 (P = 0.002). The conversion to open rate was similar between study groups with 5.6% versus 4.2%, respectively. Pathology was similar between groups. CONCLUSION: Our study shows that the use laparoscopy for adrenal tumours larger than 5 cm is a safe and feasible technique. Laparoscopic adrenalectomy is our preferred minimally invasive surgical approach for removing large adrenal tumours.

A rare cause of chronic dysphagia: eosinophilic esophagitis†.

Eosinophilic esophagitis (EE) is attributable to environmental factors, allergens and several immunological causes. The most typical symptoms include dysphagia and sensation of food impingement in the retrosternal area. Although its clinical features resemble those of gastroesophageal reflux, proton pump inhibitors are not effective for its treatment. The diagnosis of EE is dependent on the pathological detection of eosinophilic infiltration in esophageal mucosa. In this study, we evaluated a patient who applied to our clinic with complaints of long-term difficulty in swallowing, sensation of food sticking while eating and weight loss; the patient was diagnosed with EE, following biochemical, radiological, endoscopic and pathological assessments and was treated with steroids. The results show that EE should be considered in the differential diagnosis of patients with dysphagia and food impingement in the retrosternal area, and the diagnosis should be confirmed through multiple esophageal biopsies.

Increased interleukin 1 and tumor necrosis factor alpha levels after thyroid surgery.

OBJECTIVE: The aim of this study was to consider levels of the proinflammatory cytokines IL-1 and TNFα after thyroid surgery. MATERIAL AND METHODS: A total of 200 patients who underwent total thyroidectomy enrolled in this study. Drain fluid samples were taken. IL-1 and TNFα results and their relationship with other factors were analyzed. RESULTS: There was a positive correlation between IL-1 and hyperthyroidism (rs=0.614, p<0.001), operative time (rs=0.770, p<0.001), and excised thyroid volume (rs=0.829, p<0.001). Moreover, there was a positive correlation between TNFα and hyperthyroidism (rs=0.430, p<0.001), operative time (rs=0.392, p<0.001), and excised thyroid volume (rs=0.398, p<0.001). CONCLUSION: The results of this study showed us that the parameters related to increased proinflammatory cytokine levels after thyroid surgery were hyperthyroidism, operative time, and excised thyroid volume, but this increase did not show us any clinical outcomes related to these parameters.