Endocrine Surgery Center Research Articles

URGENT OPERATIONS IN PATIONS WITH DISEASES OF THYROID GLAND COMPLICATED BY COMPRESSION OF NECK AND MEDIASTINUM

Reports of immediately and urgent interventions on the thyroid gland are rare. The aim of the study was to develop and put into practice the optimal tactics of treating patients with nodular tumors of the thyroid gland, which caused compression of the organs of the neck and mediastinum. From 1974 to 2015, 97 patients with thyroid disease were operated in the Endocrine Surgery Center, they was 0.57% of 29325 patients. All patients had symptoms of compression syndrome. All patients were divided into 2 groups. I group consist of 52 (31.1%) patient who underwent immediately surgical interventions. The second group included 115 (68.9%) patients operated for urgent indications. The mean age of patients operated for immediately reasons was 73.0 ± 1.39 year.The mean age of patients operated for urgent indications was 63.8 ± 1.51 year. Among the reasons that caused the compression syndrome, the differentiated cancer of the thyroid gland was observed in 79 (47.3%) cases. Benign thyroid diseases caused urgent surgical interventions in 88 (52.7%) patients. In our work, we first used the definition of the degree of tracheal constriction with spirography in 135 (80.84%) patients to identify the timing of surgery. In the course of emergency surgical interventions, radical operations were performed on 8 (22.9%) patients with differentiatedcancer of the thyroid gland, in cases of urgent interventions, this figure is 2 times more - 23 (52.3%) patients. The performance of urgent operations increases the possibility of radical surgical interventions, reducing the frequency of postoperative complications.

Receiver Operating Characteristic Analysis of Intraoperative Parathyroid Hormone Monitoring to Determine Optimum Sensitivity and Specificity: Analysis of 896 Cases

Objective: While intraoperative parathyroid hormone (IOPTH) monitoring with a ≥50% drop commonly guides the extent of exploration for primary hyperparathyroidism (pHPT), receiver operating characteristic (ROC) analysis has not been performed to determine whether other criteria yield better sensitivity and specificity. The aim of this study was to identify the optimum percent change of IOPTH following removal of the abnormal parathyroid pathology, in order to predict biochemical cure. Secondary aims were to identify patient subgroups with increased area under the ROC curve (AUC) and the need for moderated criteria. Methods: A retrospective review was performed on patients undergoing primary parathyroid surgery for sporadic pHPT between 1999 and 2010 at a tertiary center for endocrine surgery. Eight hundred and ninety-six patients with primary hyperparathyroidism were included. Multigland disease (MGD) was defined as the intraoperative detection of more than 1 enlarged hypercellular gland or persistent disease after single gland excision. ROC analysis was used to determine the value with the best performance at predicting MGD, following bilateral exploration. Results: MGD was diagnosed in 174 patients (19.4%). ROC analysis demonstrated an AUC of 0.69. An IOPTH drop of 72% was the point of optimal discrimination with a sensitivity of 55% and specificity of 76% for predicting MGD. Subgroup analysis by preoperative calcium, preoperative PTH, localization studies, or pre- and post-excision IOPTH, did not identify any factors associated with an improved AUC. Conclusion: To our knowledge, this is the first study to use ROC analysis in a large patient cohort. An IOPTH drop of 72% was found to have optimal discriminating ability. We failed to identify a subset of patients for whom there was substantial improvement in the AUC, sensitivity, or specificity. Abbreviations: AUC = area under the ROC curve; BE = bilateral neck exploration; FE = focal parathyroid exploration; IOPTH = intraoperative parathyroid hormone; MGD = multigland disease; MIBI = Tc99m-sestamibi I-123 subtraction single-photon emission computed tomography/computed tomography; pHPT = primary hyperparathyroidism; ROC = receiver operating characteristic; SGD = single gland disease; US = surgeon-performed neck ultrasound.

Restoration of clinical and instrumental parameters of the cardiovascular system in patients with diffuse toxic goiter after resolution of thyrotoxicosis

Rationale:Evaluation of the cardiovascular system in patients with common thyroid disorders could be of interest from the perspective to identify new risk factors for cardiovascular events. Whether cardiovascular abnormalities associated with thyrotoxicosis would be reversible after its treatment, needs elucidation.Aim: To assess the degree of restoration and prerequisites for reversion of the signs and symptoms of cardiac injury in the long term after conservative and surgical cure of thyrotoxicosis in patients with diffuse toxic goiter (DTG).Materials and methods: This was an open longitudinal retrospective study performed in the Regional Center for Endocrine Surgery, Chelyabinsk Municipal Clinical Hospital No. 1 in 124 patients with past history of DTG. By the time of examination, all patients were in a stable clinical and laboratory remission after the withdrawal thyrostatic agents or were in controlled post-operative hypothyroidism for 1.5 to 5 years after surgery for DTG. The mean age of the conservatively treated patients (n=62) was 39.9±1.31 years (19 to 55 years). The mean age of the patients that had been treated surgically (n=62; subtotal thyroid resection) was 41.1±1.4 years (21 to 56 years). We compared with patients' complaints, electrocardiographic and echocardiographic parameters by the time of examination with the corresponding data at the time of the primary referral.Results: In the long term after the elimination of thyrotoxicosis, 56.5% (35/62) of the patients who had underwent surgery, were complaining of dyspnea, 54.8% (34/62) of palpitations, and 50% (31/62) of cardialgias (p<0.01), whereas among the conservatively treated patients the corresponding complaints were present in 59.7% (37/62), 64.5% (40/62), and 56.5% (35/62) (p<0.01). Ninety nine (99) percent of the patients, who had arterial hypertension before the treatment, remained hypertensive at the follow-up. In 30% of the surgically treated patients the severity of arterial hypertension was higher than initially. In the surgery group, there was a decrease in the left atrium diameter in 17 patients and in the end-diastolic diameter of the right ventricle in 24 patients; all these patients did not have hypertension at baseline. No restoration of the heart chamber diameters was seen after conservative treatment and after surgery in patients with arterial hypertension. ST segment and T wave abnormalities were not associated with any clinical symptoms both at baseline and in the long term. At the long term follow up all patients had normal thyroid-stimulating hormone (TSH) and thyroxine (T4) levels, with no associations between TSH and T4 levels and clinical and instrumental assessment results. All patients with past history of DTG continued to have tachycardia, arterial hypertension, diastolic dysfunction and increased left ventricular myocardial mass.Conclusion: Cardiovascular abnormalities persisted for a long time after the elimination of DTG. Arterial hypertension that had arisen against the background of DTG had a negative impact on the structural and functional state of the heart in this disease, irrespective of the treatment method used. In the patients with past history of DTG, we identified such predictors of heart failure as tachycardia, arterial hypertension, diastolic dysfunction, increased left ventricular myocardial mass.

Safety of intraoperative neuromonitoring

The identification of laryngeal nerves during thyroidectomy procedures is considered the safest method to prevent variations in the motility of the vocal cords. However, the only visualization of the laryngeal nerves in many situations is not enough to ensure the result. In fact, anatomical wholeness does not always ensure the functional integrity. The number of endocrine surgery centers that use intraoperative neuromonitoring (IONM) is constantly increasing. Neuromonitoring techniques are currently considered safe methods; however, although infrequently, some complications and side effects related to the use of these methods have been reported. Recently, international guidelines on the use of IONM have been drafted and published to improve quality and safety. The aim of this work is to evaluate the safety of IONM by analyzing the complications reported in literature.

Predicting recurrence of papillary thyroid cancer using the eighth edition of the AJCC/UICC staging system.

The AJCC/UICC classification is widely used for predicting survival in papillary thyroid cancer (PTC), but has not been evaluated as a predictor of recurrence. The hypothesis of this study was that the eighth edition of the AJCC system can be used in this novel way. All patients in the study underwent surgery for PTC at a high-volume endocrine surgery centre in France between 1985 and 2015. The seventh and eighth editions of the AJCC/UICC staging system for PTC were employed to predict recurrence and disease-specific survival using the Kaplan-Meier and log rank tests. Among 4124 patients (79·7 per cent female), median age was 50 (i.q.r. 38-60) years; 3906 patients (94·7 per cent) underwent total thyroidectomy, with lymph node dissection in 2495 (60·5 per cent). The eighth edition of the AJCC/UICC staging system placed 91·8, 7·1, 0·4 and 0·7 per cent of patients in stages I-IV respectively. After reclassifying patients from the seventh to the eighth AJCC/UICC edition, the disease was downstaged in 23·8 per cent. Over a median follow-up of 7 years, 260 patients (6·4 per cent) developed recurrent disease, including 5·2 per cent of patients with stage I, 19·6 per cent with stage II, 59 per cent with stage III and 50 per cent with stage IV disease, according to the eighth edition. The eighth edition was a better predictor of recurrence than the seventh edition. The eighth edition of the AJCC/UICC staging system appears to be a novel tool for predicting PTC recurrence, which is a meaningful outcome for this indolent disease. The eighth edition can be used to risk-stratify patients, keeping in mind that other molecular and pathological predictive factors must be integrated into the assessment of recurrence risk.

Вплив етіологічних і соціальних чинників на розвиток і перебіг синдрому діабетичної стопи

Мета дослідження: визначити вплив етіологічних і соціальних чинників на розвиток і перебіг синдрому діабетичної стопи (СДС). Матеріал і методи. У дослідженні взяли участь 2 264 хворих на цукровий діабет 2-го типу (ЦД2) (1 186 чоловіків, 1 078 жінок), які перебували на стаціонарному лікуванні в Українському науково-практичному центрі ендокринної хірургії, трансплантації ендокринних органів і тканин МОЗ України протягом останніх 5 років. Пацієнтів розподілили на 2 групи: І — хворі на ЦД2 із СДС (n=705, 448 чоловіків, 257 жінок), ІІ (контрольна) — хворі на ЦД2 без СДС (n=1 559, 738 чоловіків, 821 жінка). Досліджено вік, соціальний статус, тривалість захворювання, наявність ожиріння, ускладнень ЦД2 і супутньої серцево-судинної патології, структуру оперативних втручань, лікувальну тактику, рівень глікованого гемоглобіну, а також взаємозв’язок між ними. Використано методи статистичної обробки та ретроспективного аналізу. Результати. Середній вік хворих на ЦД2 І групи був більшим за показник хворих ІІ групи, а середній вік жінок в обох групах перевищував такий чоловіків. Більшість пацієнтів в обох групах мала вік 50-69 років. Частка хворих на ЦД2 із числа соціально незахищених верств населення в І групі становила 81,4% проти 70,0% у ІІ групі, а частка жінок із цієї категорії в обох групах була більшою, ніж чоловіків. Середня тривалість ЦД2 була більшою в І групі та в жінок. Більшість хворих І групи мали тривалість ЦД2 6-10 (29,9%) і 11-15 років (23,8%), у ІІ групі — 1-5 (28,4%) і 6-10 років (28,8%). Середній індекс маси тіла (ІМТ) в обох групах відповідав ожирінню 1-го ступеня. Частка хворих з ожирінням у І групі — 45,8%, у ІІ — 54,2%, із морбідним ожирінням — 5,1% і 8,3% відповідно.
 Показники частоти діабетичної ангіопатії нижніх кінцівок, діабетичної ретинопатії, інфаркту міокарда та інсульту становили 39,6%, 65,1%, 18,4%, 12,2% та 24,0%, 56,3%, 8,8%, 7,2% у І і ІІ групах відповідно. Частота СДС у чоловіків (37,8%) в 1,6 раза була вищою, ніж у жінок (23,8%), а діабетичної полінейропатії — навпаки, у чоловіків. У І групі частота атеросклерозу судин нижніх кінцівок становила 47,1% проти 20,2% у ІІ групі, тромбозу вен нижніх кінцівок — 4,6% проти 2,1%, гіпертонічної хвороби — 81,7% проти 77,4%. Частки хворих на монотерапії інсулінами (18,7%), комбінованій терапії препаратами інсуліну та пероральними цукрознижувальними препаратами (ПЦЗП) (34,6%) і загалом на інсулінотерапії (53,3%) були більшими в І групі (у ІІ групі — 11,0%, 26,7% і 37,7% відповідно) за рахунок зменшення частки хворих на монотерапії та загалом на терапії ПЦЗП (у І групі — 45,2% і 79,9%, у ІІ групі — 59,9% і 86,7% відповідно). Середній рівень глікованого гемоглобіну (HbА1с) практично не різнився (у І групі — 8,90Ѓ}1,96%, у ІІ — 9,09Ѓ}2,10%). У жінок обох груп середній рівень HbА1с (у І групі —
 9,23Ѓ}2,02%, у ІІ — 9,30Ѓ}2,05%) і питома вага хворих на ЦД у стадії декомпенсації (у І групі — 69,8%, у ІІ — 69,4%) були більшими, ніж у чоловіків (8,7% і 8,9%, 60,6% і 59,9% відповідно). Наявність серцево-судинних ускладнень ЦД2 і супутньої патології вплинула на структуру перативних втручань на серці і судинах. Частка хворих, яким проведено оперативні втручання на серці і судинах, у І групі була в 5,7 раза більшою, ніж у ІІ (23,3% проти 4,1%). Понад 40% (у І групі — 44,1%, у ІІ — 40,6%) становили діагностичні інтервенційні втручання. Висновки. На розвиток СДС впливають вік, соціальний статус пацієнта, тривалість ЦД2, наявність діабетичної ангіопатії та атеросклерозу судин нижніх кінцівок, а на його перебіг — прогресування діабетичної ангіопатії нижніх кінцівок, атеросклерозу судин і тромбозу вен нижніх кінцівок, наявність гіпертонічної хвороби, інфаркт міокарда та інсульту. На розвиток та перебіг СДС не справляють суттєвого впливу наявність у хворого на ЦД2 ожиріння та дисліпідемії. Частота СДС у чоловіків (37,5%) в 1,6 раза перебільшує показник у жінок (24,0%). Соціальний статус пацієнтів, наявність серцево-судинних ускладнень ЦД2 і супутньої патології негативно позначаються на можливості проведення, адекватності та ефективності лікування ЦД і супутньої патології, а також пацієнтів (збільшення частки хворих на інсулінотерапії з 37,7% до 53,3% за рахунок зменшення частки хворих на терапії ПЦЗП із 86,7% до 79,9%), частоту оперативних втручань на серці і судинах (збільшення частки хворих, яким проведено операції, із 4,1% до 23,3%).

Pediatric endocrinology in Ukraine in 2018

The article provides information and analyzes the statistical indicators for 2018 regarding personnel provision of the pediatric endocrinology in Ukraine, in­patient care for children with endocrine diseases, their disability and oncological morbidity. Data are also provided for registers of children with certain endocrine diseases, namely, diabetes mellitus, including its various forms, pathological dwarfism, disorders of sexual differentiation (DSD). The problem issues of specialized care for children with diseases of the endocrine system are highlighted.It is noted that in 2018 there were 9,105 children with type 1 diabetes mellitus under the age of 18, which is 1.2 per 1,000 children 0—18 y. o. in Ukraine, with type 2 diabetes mellitus — 46 children, and 33 children with neonatal diabetes, with MODY — 32 patients, including 1 case of rare monogenic autoimmune diabetes. The Department of pediatric endocrinology of the Ukrainian Center for Endocrine Surgery, Transplantation of Endocrine organs and tissues of the MOH of Ukraine is conducting a genetic survey of children with rare forms of diabetes and children with DSD. Children undergo a detailed cytogenetic survey in leading genetic laboratories in the world. According to the survey, a database of such patients was created. The database of children with DSD included 95 patients: with chromosomal DSD — 17 children, 46, XY DSD — 46 patients, 46, ХХ — 13 pati­ents. It is reported that in 2018, Ukraine registered 1517 children with dwarfismunder the age of 18 who receive treatment with growth hormone funded from the state budget, including 1060 children with growth hormone deficiency, 312 children with Turner’s syndrome, 78 children with Russell­Silverse syndrome, 50 — with Prader—Willie syndrome, as well as 17 children with nanism due to chronic renal failure.The proposals concerning the improvement of care to children with endocrine system diseases were suggested.

The evolution and progress of the application of intraoperative monitoring in endoscopic thyroid surgery

Intraoperative nerve monitoring (IONM) is a validated and well accepted technology in open thyroid surgery. Intermittent and continuous neuromonitoring are the current technologies that are available. The International Neural Monitoring Group has established standards for the use of nerve monitoring in open surgery. Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is becoming common in high volume endocrine surgery centers. To be widely accepted the safety benchmarks set by open surgery for neuromonitoring have to be met. The evolution of use of IONM in endoscopic thyroid surgery, the current technique of IONM use in TOETVA, equipment used, advantages and disadvantages are discussed in this review.

Opioid Prescribing Practice and Needs in Thyroid and Parathyroid Surgery

In recent years, the medical community's inadvertent contribution to opioid addiction has been recognized. To determine the opioid prescribing practices and opioid needs for patients undergoing thyroid and parathyroid surgery to help reduce postoperative opioid administration. This retrospective cohort study included 1788 opioid-naive patients who underwent thyroid and parathyroid surgery from January 1, 2012, through December 31, 2017, at the high-volume academic endocrine surgery center at Oregon Health and Sciences University. Patients with long-term opioid treatment and those who underwent other head and neck procedures or robotic thyroidectomy were excluded. For analysis, 1765 procedures were available (723 parathyroidectomy, 400 hemithyroidectomy, and 642 total thyroidectomy). The quantity of prescribed opioids was determined in morphine milligram equivalents (MME). Opioid refill data after discharge were also analyzed. Patients were then divided into past (1336 in group 1 [January 1, 2012, to September 30, 2016]) and current (429 in group 2 [October 31, 2016, to December 31, 2017]) prescribing practices. For each procedure, the mean quantity prescribed for each group, difference between the means, 95% CI for the difference, and effect size were calculated. A total of 1702 patients (80.0% female [n = 1361]; mean age, 51.2 years [range, 7-97 years]) undergoing 1765 procedures were included in the analysis. For parathyroidectomy, the mean (SD) opioid quantity prescribed was 176.20 (86.66) MME in group 1 vs 80.08 (74.43) MME in group 2 (effect size, 1.139); for hemithyroidectomy, 204.65 (112.24) MME in group 1 vs 112.24 (102.31) MME in group 2 (effect size, 0.842); and for total thyroidectomy, 214.87 (161.09) MME for group 1 vs 102.29 (87.72) MME for group 2 (effect size, 0.754). In the last quarter of 2017, the numbers of patients discharged without any opioid prescription were 15 of 26 (57.5%) for parathyroidectomy, 12 of 32 (37.5%) for hemithyroidectomy, and 9 of 27 (33.3%) for total thyroidectomy. Patient calls requesting pain medications for group 2 were similar or fewer, depending on the procedure. Those who were prescribed less than 75.0 MME postoperatively did not call for additional opioid prescriptions. Our study suggests that patients undergoing thyroid and parathyroid surgery need little, if any, postoperative opioids.

Coping patterns for nosogenic factors of psychotraumati¬zation among patients with psychoendocrine syndrome

In order to establish patterns and coping strategies in relation to the nosogenic factors of psychotraumatization among the patients with psychoendocrine syndrome on the background of metabolic disorders of the thyroid gland, adrenal cortex and hypogonadism, at the Ukrainian Scientific and Practical Center for Endocrine Surgery, Transplantation of Endocrine Organs and Tissues of the Ministry of Health of Ukraine, 400 patients with the indicated forms of endocrine disorders were examined. The study was conducted with the introduction of the psychodiagnostic method and the Lazarus copying test was used in the study of group comparison. Coping patterns were studied in relation to such factors: the formation of functional and morphological disorders, the presence of a chronic disease, physical activity restrictions, the presence of severely experienced symptoms of the disease, the need for treatment with drugs that have side effects, which adversely affect the state, cancerophobic experience, introspective cognitive and mental disorders, the need for diagnostic procedures and therapeutic measures with high cost, presence of labor restrictions which causes financial difficulties and loss of economically dominant role in the family, limiting the circle of communication, is associated with the presence of the disease or its symptoms, the need to follow a diet, refusal from alcohol and any stimulating substances, and dependence on hormone replacement therapy.

Implementation of ERAS protocol in thyrotoxicosis patients undergoing thyroidectomy

Aim – to evaluate the results of ERAS protocol implementation in a complex of anesthetic management of thyrotoxicosis patients undergoing thyroidectomy in specialized endocrine surgery center. Materials and methods. All patients were divided into 2 groups: a group of "balanced analgesia - propofol" (BA-P) - 44 patients, a group of "control-propofol" (C-P) - 41 patients. All thyrotoxicosis patients underwent thyroidectomy under general anesthesia with mechanical ventilation. In BA-P group the bilateral blockade of superficial cervical plexus (BBSCP) was performed as a component of BA before the propofol general anesthesia. We assessed the pain level by VAS, the usage of narcotic and non-narcotic analgesics, the frequency and severity of postoperative nausea and vomiting (PONV) during the first 24 hours of postoperative (post-op) period. Results and discussion. BA with the BBSCP under propofol general anesthesia provided intraoperative opioid-sparing effect: a significant (p

Williams-Beuren Syndrome With Primary Hyperparathyroidism: A Rare Diagnosis In A Rare Genetic Syndrome

ABSTRACT Objective: This case report is the first to describe functional parathyroid disease in Williams-Beuren Syndrome (WBS). We report a patient with hypercalcemia in infancy and later in adulthood whose unusual complex of elfin facies and multiple medical comorbidities, including hypercalcemia, ultimately led to a diagnosis of WBS by fluorescent in situ hybridization. While hypercalcemia is a common finding in patients with WBS, parathyroid hormone levels are typically suppressed. Methods: This study consists of a case report and literature review conducted in a high-volume university endocrine surgery center. We describe a 58-year-old patient with elfin facies, recurrent hyperparathyroidism, friendly personality, cognitive impairment, recurrent cystitis, hypertension, and stroke who was treated surgically for primary hyperparathyroidism with durable cure of his hypercalcemia. Outcomes are measured with long-term biochemical confirmation of cure after several re-operative surgical interventions. Resul...

Parathyroidectomy for primary hyperparathyroidism in the elderly: experience of a single endocrine surgery center.

Primary hyperparathyroidism is a common endocrine disease, and its incidence increases with age. Our aim was to retrospectively evaluate the impact of age on patient outcomes following parathyroidectomy for primary hyperparathyroidism. Two-hundred fifty-six consecutive patients undergoing parathyroidectomy with preoperative diagnosis of primary hyperparathyroidism were divided into three groups according to patient age: group A, ≤64 years; group B, 65-74 years; and group C, ≥75 years. Thyroid disease was associated with the hyperparathyroidism in 44 patients (28.2%) in group A, 34 (44.7%) in B, and 10 (41.7%) in C (p<0.01). Minimally invasive parathyroidectomy was performed in 104 patients (66.7%) in group A, 35 (46.1%) in B, and 8 (33.3%) in C (p<0.01). Conversion to bilateral exploration was carried out in five cases in group A (4.6%), three in B (8.3%), and two in C (20%). Multiglandular disease was observed in six patients (3.8%) in group A, seven (9.2%) in B, and five (20.8%) in C (p=0.012). Mean postoperative stay was similar between groups; no major complications and no cases of mortality occurred. Multiglandular disease is more common in older patients than younger individuals, and minimally invasive approaches are less used in this patient group. Increased surgical risk and paucity of symptoms in these patients sometimes result in a delay in surgical treatment. Parathyroidectomy is a safe and effective procedure to perform in elderly patients. Multiglandular disease was found to be more prevalent in older patients, but minimally invasive parathyroidectomy can be performed safely. Surgeons should consider parathyroidectomy in patients with primary hyperparathyroidism regardless of age.

Surgical treatment of concomitant thyroid and parathyroid disorders: analysis of 4882 cases.

The thyroid gland disease incidence in hyperparathyroidism (HPT) is higher than the incidence of thyroid disease in general population. Likewise, HPT is more frequent in patients primary admitted due to thyroid disease, than in general population. The aim of this study was to determine the incidence and clinical characteristics of concomitant HPT and thyroid disease, based on a single center experience. From 2009 to 2014, a total of 4882 patients underwent thyroidectomy and/or parathyroidectomy at the Center for Endocrine Surgery, Belgrade. We reviewed the database to find out indications for surgery, clinical characteristics, operative and histopathological findings. Out of 4033 patients, who underwent thyroidectomy, in 114 cases (2.8%) parathyroidectomy was simultaneously performed. Out of these 114 patients, 42 patients (37%) had normocalcemic HPT. Among 849 patients primary operated due to HPT, thyroid gland disease that required surgery was found in 224 (26.4%). In patients primary seen for HPT, thyroid cancer was found in 22 (9.8%), Hashimoto's thyroiditis in 41 (18.3%) and micropapillary carcinoma in 36 cases (16.1%). Due to residual or recidivant HPT, 16 patients (15 who primary underwent parathyroidectomy and 1 primary seen for thyroid disease) needed a reoperation. There are a considerable number of patients with concomitant thyroid and parathyroid disease; this justifies the routine analyses of calcemia and PTH level in patients preparing for thyroidectomy, and sets up the ground for the thyroid investigations in HPT.

Endoscopic and robotic parathyroidectomy in patients with primary hyperparathyroidism.

Primary hyperparathyroidism (PHPT) is one of the most common endocrine disorders for which parathyroidectomy is the most effective therapy. Until late 1970s, the standard approach to parathyroidectomy was a four-gland exploration using a large skin incision. However, 80 to 85 percent of cases of PHPT are caused by a single adenoma. As such, the concept of performing a bilateral exploration in order to visualize all four glands has been argued to be excessive since in the majority of cases, there is only one abnormal gland. Focused exploration (one gland) is currently the standard technique for parathyroidectomy worldwide. Despite a rapid acceptance of minimally invasive approaches in most endocrine surgery centers, the use of an endoscope with or without the use of a robotic system to perform parathyroidectomy remains controversial. The goal of this study was to review current available data about surgical approaches using an endoscope with or without the use of a robotic system in the management of patients with PHPT. For conventional endoscopic and video assisted parathyroidectomy, several comparative studies have demonstrated some advantages in terms of reduced postoperative pain, better cosmetic results and higher patient satisfaction compared to open non-endoscopic minimally invasive parathyroidectomy. Robot-assisted transaxillary parathyroidectomy has the advantage of leaving no scar in the neck but its role has not yet been delineated clearly given the limited number of published series. Subjective postoperative cosmetic evaluation is good by concealing the scar in the axilla or infraclavicular area. However, this approach is associated with more extensive dissection than during conventional open or endoscopic neck access surgical procedures. Patients with true ectopic mediastinal parathyroid glands are good candidates for conventional or robot-assisted thoracoscopic approaches because these glands are in remote and narrow anatomical locations.

Association of BRAF V600E Mutation and MicroRNA Expression with Central Lymph Node Metastases in Papillary Thyroid Cancer: A Prospective Study from Four Endocrine Surgery Centers.

Studies have demonstrated an association of the BRAF(V600E) mutation and microRNA (miR) expression with aggressive clinicopathologic features in papillary thyroid cancer (PTC). Analysis of BRAF(V600E) mutations with miR expression data may improve perioperative decision making for patients with PTC, specifically in identifying patients harboring central lymph node metastases (CLNM). Between January 2012 and June 2013, 237 consecutive patients underwent total thyroidectomy and prophylactic central lymph node dissection (CLND) at four endocrine surgery centers. All tumors were tested for the presence of the BRAF(V600E) mutation and miR-21, miR-146b-3p, miR-146b-5p, miR-204, miR-221, miR-222, and miR-375 expression. Bivariate and multivariable analyses were performed to examine associations between molecular markers and aggressive clinicopathologic features of PTC. Multivariable logistic regression analysis of all clinicopathologic features found miR-146b-3p and miR-146b-5p to be independent predictors of CLNM, while the presence of BRAF(V600E) almost reached significance. Multivariable logistic regression analysis limited to only predictors available preoperatively (molecular markers, age, sex, and tumor size) found miR-146b-3p, miR-146b-5p, miR-222, and BRAF(V600E) mutation to predict CLNM independently. While BRAF(V600E) was found to be associated with CLNM (48% mutated in node-positive cases vs. 28% mutated in node-negative cases), its positive and negative predictive values (48% and 72%, respectively) limit its clinical utility as a stand-alone marker. In the subgroup analysis focusing on only classical variant of PTC cases (CVPTC), undergoing prophylactic lymph node dissection, multivariable logistic regression analysis found only miR-146b-5p and miR-222 to be independent predictors of CLNM, while BRAF(V600E) was not significantly associated with CLNM. In the patients undergoing prophylactic CLNDs, miR-146b-3p, miR-146b-5p, and miR-222 were found to be predictive of CLNM preoperatively. However, there was significant overlap in expression of these miRs in the two outcome groups. The BRAF(V600E) mutation, while being a marker of CLNM when considering only preoperative variables among all histological subtypes, is likely not a useful stand-alone marker clinically because the difference between node-positive and node-negative cases was small. Furthermore, it lost significance when examining only CVPTC. Overall, our results speak to the concept and interpretation of statistical significance versus actual applicability of molecular markers, raising questions about their clinical usefulness as individual prognostic markers.

PREDICTORS OF DIFFICULT AIRWAY MANAGEMENT IN THYROID SURGERY: A FIVE-YEAR OBSERVATIONAL SINGLE-CENTER PROSPECTIVE STUDY

Difficult tracheal intubation (DI) is more common in thyroid than in other surgical branches due to thyromegaly. Proper preoperative airway evaluation is necessary in order to reduce the potential numerous complications. The study examined the incidence of DI in thyroid surgery and the influence of tracheal dislocation and other risk factors on DI. A prospective study was conducted on 2379 patients who underwent thyroidectomy at the Center for Endocrine Surgery, Clinical Center of Serbia, from 2007 to 2012. Patients were divided into groups with (n = 162) and without DI (n = 2217). Besides tracheal dislocation, another 13 risk factors contained in 13 screening tests and three additional factors of gender, age and diagnosis were defined. The incidence of DI in our study was 6.81%. The presence of tracheal dislocation was statistically significant, but not an independent predictor of DI. The diagnosis, large circumference and small neck length, previous DI, recessive mandible, tooth characteristics and oral anomalies were the most significant and independent predictors of DI. Neck circumference and small neck length had highest sensitivity. Previous DI had highest specificity. Thyromegaly, if causing tracheal dislocation and/or stenosis, represents a significant DI predictor, not individually, but in combination with other factors.

3-phosphoglycerate dehydrogenase gene polymorphism amongst patients with thyroid gland cancer

Introduction: Thyroid gland cancer is a rare malignancy in the male population, accounting for up to 2% of all cancers, but it is the most common cancer of the endocrine system, making up to 95% of all estimated new endocrine cancer cases each year. Recent studies suggested an important role of both environmental and genetic factors in cancerogenesis. 3-Phosphoglycerate dehydrogenase (3-PHGDH) gene overexpression is associated with pathogenesis of human cancer and contributes to cell proliferation. Aim: To asses the association of PHGDH gene polymorphism in the group of patients with thyroid gland cancer and the control group of healthy men. Materials and methods: The study encompassed 80 men diagnosed with thyroid gland cancer in Center for Endocrine Surgery, Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia and 100 healthy male volunteers. The DNA was isolated from the peripheral blood with solting out method. The genotypes of 3-PHGDH polymorphism were determined by Polimerase Chain Reaction (PCR) and Restriction Fragment Lenght Polymorphism (RFLP). Gel-electrophoresis was used to separate DNA fragments. Results: There was a statistically highly significant difference between frequencies for genotype distribution of rs541503 polymorphism in patients with thyroid gland cancer and healthy volunteers (χ2 = 38.924; p=0.001). We found that in patients with thyroid gland cancer, the most common genotype is TT and in the control group TC. Major Allele Frequency (MAF (C)) in the control group in our study was 0.61. In patients with carcinoma of the thyroid gland MAF (C) was almost twice lower at 0.31. Allele frequencies in a group of patients with thyroid gland carcinoma compared to the control group showed a statistically significant difference (χ2 = 18.1159; p = 0.001). Conclusion: C allele could be a protective factor in the prevention of the thyroid gland cancer. People with TT genotype are six times more likely to develop thyroid cancer compared to those with the CC genotype.

Surgical approach to mediastinal goiter: An update based on a retrospective cohort study

AimSurgery for mediastinal goiters (MG) is indicated for compression symptoms and risk of malignancy. Total thyroidectomy by cervicotomy is universally considered the standard surgical approach to MG. In selected cases sternotomy or a thoracotomy are used. Options of the operative technique and practical surgical problems are analysed. MethodsA retrospective analysis of twenty-eight-years on 1767 cases of MG in a referral centre for endocrine surgery was carried out. All patients underwent standard preoperative study and CT based surgical planning. Surgery was performed by an experienced surgical team with standard technique via cervical approach or in selected case via sternotomy or thoracotomy. Clinical records were examined. ResultsTotal thyroidectomy was performed in all cases. A cervical approach was used in almost 99% of patients. Significant shorter surgical time was observed for surgery via the cervical approach vs sternotomy and thoracotomy. Benign struma was observed in 1503 patients and a carcinoma in 264. We observed postoperative bleeding in 0.5% of cases, permanent monolateral recurrent laryngeal nerve palsy occurred in 1.3%, bilateral palsy in 0.6%, transient and permanent hypoparathyroidism in 14% and 4.1% respectively. ConclusionMG may be approached by a cervicotomic access only with a clear knowledge of potential risk and complications of the surgical manoeuvres. Sternotomy or of a thoracotomy are indicated only in selected cases but their inapplicability may be really dangerous in those MG not otherwise resectable. MG should be referred only to specialized centre.

Mean Platelet Volume as a Biomarker for Thyroid Carcinoma.

Mean platelet volume (MPV) is a useful early indicator of platelet activation. Platelets differ in terms of functional activity and size. Large platelets are relatively new, more reactive and produce more thrombogenic factors. Therefore, in conditions that involve increased platelet activation, an increase in the proportion of young platelets and MPV is expected. This study involved 146 patients who underwent total thyroidectomy because of benign (99 patients) or malignant (47 patients) diseases of the thyroid. Data on age, sex, MPV, white blood cell (WBC) count, hemoglobin level and platelet count were collected retrospectively. MPV was significantly higher in patients with malignant thyroid diseases than in those with benign thyroid diseases. Age, sex, hemoglobin level, WBC count and platelet count did not significantly differ between the two groups. MPV was significantly higher in patients with thyroid malignancies than in patients with benign thyroid diseases. We propose that MPV might be an important predictive factor for thyroid malignancies. Further prospective studies with a larger number of patients in high-volume endocrine surgery centers are required to confirm our findings.