Endocrine Surgeons Research Articles

ODP098 Hyperparathyroidism Caused by Two Large Water Clear Cell Adenomas

Abstract Background In ambulatory settings, primary hyperparathyroidism is the most prevalent cause of hypercalcemia. Approximately 85% of primary hyperparathyroidism cases are caused by a solitary parathyroid adenoma; other causes include diffuse parathyroid hyperplasia, multiple parathyroid adenomas, and parathyroid cancer. Chief cell adenomas are the most prevalent; adenomas can also consist of oxyphil cell adenomas, lipoadenomas, or mixed cell adenomas. Water clear cell adenoma (WCCA) is a rare tumor formed of large clear cells with foamy pink cytoplasm. Fewer than 30 cases have been recorded in the literature. Case A 52-year-old male with polyuria and polydipsia, diagnosed with hypercalcemia was referred to an endocrinologist. His calcium was 10.9 mg/dl, corresponding parathyroid hormone (PTH) 74 pg/ml, 24-hour urine calcium 818 mg/24hr, vitamin D 25–hydroxy 24.2 ng/ml. He was referred to an endocrine surgeon. A 4-dimensional CT scan revealed soft tissue masses posterior to the thyroid and in the tracheoesophageal groove, consistent with potential parathyroid masses. In the operating room, baseline intraoperative PTH (ioPTH) was 371 pg/ml. A large left superior gland was removed from its normal position, and the ioPTH dropped to 104 pg/ml at 10 minutes post-resection, followed by a rise to 525 pg/ml. A large descended (ectopic) right superior gland was then identified and resected, and the ioPTH decreased to 72, 44, and 57 pg/ml at 10, 15 and 20 minutes post-resection. The remaining parathyroid glands were not identified due to adipose tissue in the neck and likely gland suppression in the setting of high PTH. The pathology report of the two excised glands (left superior 3.2×1.7×0.5cm and 3.703g, right superior 3.4×1.3×0.4cm and 1.86g) demonstrated water clear cell tissue. Post-operatively, patient's polyuria and polydipsia resolved. Labs collected 3 months after surgery demonstrated normalization of the calcium and PTH. The patient was advised to continue follow up every six months. Conclusion Water clear cell parathyroid adenomas are extremely rare. Water clear-cell lesions are considered indolent because excised adenomas are markedly larger than conventional adenomas and grow to a considerable size before becoming biochemically active and diagnosed. Clinical presentation of water clear cell parathyroid lesion is like other causes of primary hyperparathyroidism. The only way to diagnose is via histopathological examination. In rare cases, clear cell renal carcinoma can metastasize to the parathyroid gland causing a similar presentation. Additionally, the rate of hypercalcemia recurrence is higher in WCCA as compared to chief cell adenoma. Therefore, closer follow up of these patients is recommended. Reporting additional cases will aid in our understanding of this uncommon entity, elucidating possible causes/associations, natural history, typical appearances, and post-treatment prognosis. Presentation: No date and time listed

Speech Therapy for Post Thyroidectomy Patients: A Clinical Audit

Objective: We aim to audit the provision of speech counselling to those patients who underwent thyroidectomy for their respective diseases who presented to surgery department in 2021 Methodology: This clinical audit was conducted in surgical D unit department of Surgery, Khyber Teaching Hospital, Peshawar from January 2021 to November 2022. A total of 50 patients each for the audit group and the re-audit group were selected through non-probability consecutive sampling for both genders. A predesigned proforma According to clinical practice guidelines and British association of endocrine and thyroid surgeon’s guidelines (BAETS) was used. Data was entered into Microsoft excel, analyzed through SPSS version 23 and results were presented in the form of descriptive writing and tables. Results: The mean age of the study population was 42.64 +/- 11.51 with relatively more female patients. None of the patients in the audit group were properly given speech counselling irrespective of their disease or surgery status. In the re-audit group, 100% of the patients were given proper post-operative speech therapy which resulted in 84% percent of the patients attaining their usual voice, seven patients having some roughness in their tone and only one patient having occasional problems with breathing. Conclusion: Despite their rarity, voice changes after a straightforward thyroidectomy can be quantified. For ethical and legal reasons, this is significant in the preoperative and postoperative counselling of patients before thyroidectomy.

A multicenter evaluation of near-infrared autofluorescence imaging of parathyroid glands in thyroid and parathyroid surgery

BackgroundThe usefulness of incorporating near-infrared autofluorescence into the surgical workflow of endocrine surgeons is unclear. Our aim was to develop a prospective registry and gather expert opinion on appropriate use of this technology. MethodsThis was a prospective multicenter collaborative study of patients undergoing thyroidectomy and parathyroidectomy at 7 academic centers. A questionnaire was disseminated among 24 participating surgeons. ResultsOverall, 827 thyroidectomy and parathyroidectomy procedures were entered into registry: 42% of surgeons found near-infrared autofluorescence useful in identifying parathyroid glands before they became apparent; 67% correlated near-infrared autofluorescence pattern to normal and abnormal glands; 38% of surgeons used near-infrared autofluorescence, rather than frozen section, to confirm parathyroid tissue; and 87% and 78% of surgeons reported near-infrared autofluorescence did not improve the success rate after parathyroidectomy or the ability to find ectopic glands, respectively. During thyroidectomy, 66% of surgeons routinely used near-infrared autofluorescence to rule out inadvertent parathyroidectomy. However, only 36% and 45% felt near-infrared autofluorescence decreased inadvertent parathyroidectomy rates and improved ability to preserve parathyroid glands during central neck dissections, respectively. ConclusionThis survey study identified areas of greatest potential use for near-infrared autofluorescence, which can form the basis of future objective trials to document the usefulness of this technology.

A historical look at Cleveland: Its health care institutions and contributions to endocrine surgery

It is a great honor to be able to give the Stuart D. Wilson, MD Historical Lecture. I wanted to thank Dr Fahey for giving me this opportunity for which I am deeply grateful. I first became a member of the American Association of Endocrine Surgeons (AAES) in 1992 and on my wall in my office is my membership certificate signed by the president of the AAES, who was Stuart D. Wilson, MD.

A Canadian centre's experience with prone retroperitoneoscopic adrenalectomy.

Minimally invasive adrenalectomy is the standard of care for the surgical management of benign adrenal disease. The transperitoneal laparoscopic approach (TLA) is the most common approach used worldwide; however, many centres have adopted a posterior retroperitoneoscopic approach (PRA), as it is reported to offer several advantages. We describe our experience with PRA. We performed a retrospective review of the charts of patients who underwent minimally invasive adrenalectomy via PRA or TLA performed by a single endocrine surgeon between September 2010 and December 2019 at a tertiary academic centre in British Columbia, Canada. Patient and tumour characteristics, operative times and postoperative outcomes were compared between the 2 groups. During the study period, 58 patients underwent adrenalectomy via PRA, and 41 underwent adrenalectomy via TLA. The median American Society of Anesthesiologists score was higher in the TLA group than the PRA group (3.0 v. 2.6, p = 0.02). Adrenal glands were heavier in the TLA group than the PRA group (mean 63.4 g v. 19.2 g, p < 0.001). The mean anesthesia preparation time was shorter with PRA than with TLA (51.5 min v. 63.7 min, p < 0.001), as was mean operative time (77.9 min v. 118.4 min, p < 0.001) and mean hospital length of stay (2 d v. 4 d, p < 0.001). There was no difference in the complication rate between the 2 groups. Our study shows that PRA offers shorter operative time and length of stay for appropriately selected patients. Thus, it has become the preferred approach at our centre for minimally invasive adrenalectomy.

Down the Rabbit Hole: Evaluation of Internet Information Quality in Parathyroid and Thyroid Surgery

IntroductionPatients often discuss information obtained from Internet sources during clinic visits, which can be of variable quality and depth. We sought to review and assess information on the Internet regarding common operations within endocrine surgery. MethodsUsing Google's search engine, the top 100 websites from the search phrase “parathyroid surgery,” and the top 100 websites from the phrase “thyroid surgery” were identified. Each website was evaluated for accessibility, accuracy, and completeness of information about gland hormone function, associated disease processes, and surgery itself. Results were stratified based on the website type, and bivariate analysis was performed to determine accuracy by category. Presence of author credentials, last webpage update, and presence of advertisements were also assessed. Inter-rater reliability was calculated for each variable. ResultsFor parathyroid surgery, at least two-thirds of all websites included information about surgery, hormone function, and disease processes. For thyroid surgery, 71% of websites included procedure information, but only 52% included information about hormone function and 56% about disease processes. Less than 30% of all websites included advertisements and less than 25% listed author credentials or provided references. Academic or research-affiliated sources were most likely to have zero inaccuracies, but 44% of all websites had at least one potential inaccuracy. Inter-rater reliability achieved at least moderate agreement (>0.41) for 56% of variables. ConclusionsThere is a wide array of information available to patients online, and accuracy varies based on multiple factors including the type of website. Endocrine surgeons and related practitioners must be cognizant of this fact when discussing treatment plans with patients.

Indocyanine green fluorescence and near-infrared autofluorescence may improve post-thyroidectomy parathyroid function

BackgroundNear-infrared autofluorescence and indocyanine green fluorescence are 2 recent tools introduced to improve postoperative parathyroid function during thyroid surgery. MethodsWe conducted a randomized prospective study. Patients undergoing total thyroidectomy were randomly assigned either to the fluorescence group, in which near-infrared autofluorescence and indocyanine green fluorescence were used, or to the control group. The primary outcomes of the study were the rate of postoperative transient and symptomatic hypocalcemia. ResultsA significantly higher number of parathyroid glands were identified in the fluorescence group (3.83 vs 3.64, P = .028). The rate of postoperative symptomatic hypocalcemia was significantly lower in the fluorescence group (6% vs 17%, P = .015), as was the dosage (1.53 vs 1.91 g, P = .007) and the duration of calcium therapy (32.30 vs 45.66 days, P = .003). Having at least 2 well-vascularized parathyroid glands correlates to lower rates of transient hypocalcemia (7.4% vs 21.9%, P = .037) as well as to higher serum calcium (8.70 vs 8.42 mg/dL, P = .027) and parathyroid hormone levels (19.15 vs 11.4 pg/mL, P = .0002) on postoperative day 1. ConclusionNear-infrared autofluorescence and indocyanine green fluorescence are novel tools that may support the endocrine surgeon in preserving and predicting post-thyroidectomy parathyroid gland function.

A Pilot Study of Augmented Intelligence Risk-Based Stratification for Endocrine Surgical Waiting List Prioritisation.

Introduction The New Deal for Surgery report encouraged using new technology in healthcare to address the 377,689 patients in England awaiting National Health Service (NHS) hospital treatment in July 2022. During the pandemic's second wave, this pilot study investigated the utility of COMPASS Surgical List Triage (COMPASS SLT; C2-Ai, Cambridge, England), an augmented intelligence-based system, in assisting surgical decision-making on patient prioritisation. Data generated from COMPASS SLT was compared to data from the British Association of Endocrine and Thyroid Surgeons' (BAETS) and Federation of Surgical Specialties Associations' (FSSA) prioritisation guidance. Methods A cohort of thyroidectomy and parathyroidectomy patients on the surgical waiting list at Imperial College Healthcare NHS Trust, London, United Kingdom, was used. COMPASS SLT calculated individuals' mortality and significant morbidity risk (risk >2.5%).Significant morbidity risk was set at 2.5% or above following internal model validation, thus reducing the risk of model overfitting occurring with COMPASS SLT. The additional increase in mortality and morbidity due to treatment delay was calculated. Actual treatment time was aligned to the treatment delay (in weeks) experienced by each patient. Results Twenty-nine patients, with a median age of 43 years and a waiting time of 18 weeksat the onset of the second wave, were enrolled. Non-statistically significant differences (p=0.937) between the FSSA and BAETS classifications were identified. However, cohort size could promote a type II error. An increase in median mortality and morbidity risk (p<0.001) arising from treatment delay and decisions based on the FSSA and BAETS classifications were identified. Conclusion COMPASS SLT can supplement clinical decision-making. An augmented intelligence tool can provide clinicians objectivity and flexibility in prioritising patients, with information on individual morbidity and mortality.

Approach to the Patient: Management and the Long-term Consequences of Graves' Disease in Children

In children, Graves' disease (GD) is the most common cause of hyperthyroidism. Most pediatric patients with GD will not go into lasting remission, even following many years of antidrug therapy. Thus, most pediatric patients will require radioactive iodine (RAI) or surgery. When antithyroid drugs are used, methimazole is the drug of choice. When methimazole is used in children, up to 20% will have minor adverse reactions and serious adverse events occur in up to 1%. RAI is an effective form of therapy when the thyroid size is less than 80 g. Because of concerns of whole-body radiation exposure, it is recommended that RAI be avoided in children under 5 years of age, and dosages less than 10 mCi be used between 5 and 10 years of age. Surgery is an effective treatment in children if performed by a high-volume thyroid surgeon. Because of the scarcity of high-volume pediatric thyroid surgeons, a multidisciplinary approach using pediatric surgeons and endocrine surgeons can be considered. Whereas there is a trend toward long-term antithyroid drug therapy in adults, for several reasons, this approach may not be practical for children. Determining the optimal treatment for the pediatric patient with GD, requires consideration of the risks and benefits relating to age and likelihood of remission.

Multidisciplinary training in managing post-thyroidectomy haematoma and front of neck access

Background: After local review of two cases of post-thyroidectomy haematoma, we implemented a care pathway to include the recent consensus guidelines of the Difficulty Airway Society, British Association of Otorhinolaryngology, Head and Neck Surgery, and British Association of Endocrine and Thyroid Surgeons. We created thyroid emergency boxes which follow the path of the patient from theatre to recovery to the ward and organised two multidisciplinary teaching sessions, providing training in the new guidelines and hands-on practice.

Collaborative approach to the emergency management of post-thyroidectomy haematoma

Background: The risk of haemorrhage after thyroid surgery is 1–5%. Our local incidence at Royal Surrey Hospital over the past 2 yr is 2%. As haematoma develops, pressure in the neck increases leading to impaired venous return from the head, causing progressive laryngeal oedema. Opening the neck wound allows immediate release of pressure, which should prevent worsening of the oedema and help optimise intubation conditions. Difficult Airway Society (DAS), British Association of Endocrine and Thyroid Surgeons (BAETS), and Ear, Nose and Throat UK (ENT UK) developed consensus guidelines for early recognition and management of haematoma after thyroid surgery, along with a series of recommendations that would ‘improve patient safety by identifying key areas in clinical management, training and institutional preparedness’.1 Methods: Initially we wanted to assess our local policies and awareness of the guidelines, and any specific issues related to post-thyroidectomy haematoma management in our hospital. We surveyed the multidisciplinary team (MDT) including PACU nurses, anaesthetists, and ENT (ear, nose, throat) surgeons, to assess their knowledge of the clinical signs of impending airway compromise secondary to haematoma development and the key steps in its management. We also reviewed the postoperative areas for the presence of appropriate equipment to manage a post thyroidectomy haematoma. Results: Our hospital does not currently have a specific ‘post-thyroidectomy haematoma management’ box in any of the postoperative areas or wards, nor does any equipment accompany the patient out of theatre for this eventuality. Most members of the MDT involved with these patients had not received any formal training in post-thyroidectomy haematoma recognition or management and were not aware of any guidelines covering this scenario. The PACU nurses knew the most important symptoms of impending airway compromise, but not all were aware of the more subtle signs (e.g. anxiety). More ENT surgeons (85%) were aware of the guidelines than anaesthetists (33%). Of the anaesthetists, 75% were aware that part of the management includes releasing the sutures/clips; however, only 25% knew where to find the appropriate equipment to carry this out. All ENT surgeons were aware of the appropriate management; however, they highlighted the importance of formal teaching given that often only the skin was opened and not the deeper tissues, which would not necessarily treat the problem. Conclusions: Going forward, we plan to introduce printed guidelines (DESATS [Difficulty swallowing; Early warning score; Swelling; Anxiety; Tachypnoea; Stridor] for monitoring plus management of suspected haematoma) to accompany the patient from theatre to PACU and the ward. We will also bring in an emergency box with the SCOOP (skin exposure, cut sutures, open skin, open muscles, pack wound) guideline included in the postoperative areas. Finally, we are arranging appropriate MDT education/training sessions on the guidelines and the role of the emergency box. We aim to then re-survey the MDT to ascertain their confidence managing these cases, and to identify any problems with the use of the guidelines or the box. 1.Iliff HA, El-Bogdadhly K, Ahmad I, et al. Anaesthesia 2022: 77; 82–95

Outpatient endocrine surgery practice patterns are highly variable among US endocrine surgery fellowship programs

BackgroundCurrent studies and guidelines have reported that outpatient endocrine surgery is safe. However, none recommend specific postoperative protocols. MethodsAn internet-based survey, developed using expert input, was distributed to current (2021–2022) endocrine surgery fellows in American Association of Endocrine Surgeons–accredited programs (n = 23). Programs with ≤2% same-day discharge rate were compared with those with ≥2% same-day discharge rate. ResultsThe survey response rate was 91% (21/23), representing 20 United States institutions performing >15,000 cervical endocrine operations annually. The same-day discharge rate after total thyroidectomy was not normally distributed across institutions (P < .0001) but appeared bimodal, highlighting dogmatic differences in the pursuit of same-day discharge. Nine programs had ≤2% same-day discharge rate, whereas seven had ≥90% same-day discharge rate. Fourteen (70%) reported minimum observation periods before discharge, without consistency across procedures or institutions. Total thyroidectomy patients were observed longer. Fourteen (70%) reported no geographic restrictions for same-day discharge. In programs with >2% same-day discharge (n = 11), clinical and operative factors inconsistently influenced same-day discharge after thyroidectomy. Living alone precluded same-day discharge in 3 programs. Lateral neck dissection and chronic anticoagulation each greatly reduced same-day discharge in one program and precluded same-day discharge in another. Central neck dissection, Graves’ disease, substernal goiter, continuous positive airway pressure use, difficult/bloody operation, and signal on nerve stimulation had no or minimal effect on same-day discharge. Postoperative medication recommendations varied among programs. Although anticoagulation/antiplatelet agents were similarly held preoperatively across programs, resumption varied. Narcotics were routinely prescribed in 35%. ConclusionSame-day discharge is not uniform across endocrine surgery training programs and is likely primarily driven by surgeon preference. Factors influencing same-day discharge vary significantly among programs.

Cervical ultrasound for the evaluation of the vocal cords: A pilot study in an endocrine surgery unit

IntroductionCervical ultrasound (CE) has emerged as a promising tool in recent years for vocal cord (VC) assessment in patients undergoing thyroid surgery. Our aim is to assess the reliability of CE once implemented in an endocrine surgery unit and performed by the surgeons themselves. Material and method86 participants with no history of laryngeal pathology or cervical surgery underwent CE by three independent endocrine surgeons. Laryngeal structures and specifically the VCs were analysed. To consider the examination as diagnostic, the VCs had to be visualised statically and during phonation. The time taken to perform the technique and the interobserver variability were also analysed. ResultsOf the 86 participants, 51.2% were male with a mean age of 43 years. The range of diagnostic examinations between surgeons was 60–68%, with substantial agreement between the 3 explorers (Fleiss’s K-value = .714). Male sex and advanced age were factors associated with non-assessability of the technique. The mean procedure time was 72 s. ConclusionsCE is a fast, non-invasive, feasible bedside tool useful for the assessment of VCs prior to thyroid surgery, mainly in young women.

Malign Tiroid Nodülleri için Biyolojik Belirteçlerin Prediktif Değeri. Tek Merkez Deneyimi

Background: Thyroid nodules are mostly benign. Although it varies by region, 5.4% of nodules in men and 6.5% of nodules in women may be malignant. In rural regions where a radiologist, an endocrine surgeon, a cytologist, and an endocrinologist are not present, difficulties may be experienced in the management of thyroid nodules. &#x0D; Objectives: This present study aims to determine if it is possible to comment on whether the nodule is malignant by evaluating the biological markers in patients with thyroid nodules.&#x0D; Methods: We reviewed retrospectively the data of patients between January 2019 and September 2020 who underwent total thyroidectomy in terms of thyroid ultrasonography results, thyroid fine-needle aspiration biopsy results, neutrophil, platelet, lymphocyte, red blood cell, and mean erythrocyte volume (MCV) values, histopathological examination results of thyroid specimens. Subsequently, we calculated Mentzer index, Systemic immune-inflammatory index, and neutrophil-lymphocyte ratio for each patient.&#x0D; Results: 140 patients were included in the study. 110 (78.6%) of the patients were female and 30 (21.4%) were male. The mean age of the patients was 48 ± 12.5 (20-76). There was no statistically significant difference in Mentzer index, Systemic inflammatory index, and neutrophil-lymphocyte ratios between patients with malignant and benign thyroid nodules.&#x0D; Conclusion: Biological markers have limited predictive power in the management of thyroid nodules. Therefore, the use of biomarkers that we have studied in the treatment of thyroid nodules does not seem possible at present.

Limited disease progression in endocrine surgery patients with treatment delays due to COVID-19

BackgroundThe COVID-19 pandemic profoundly impacted the delivery of care and timing of elective surgical procedures. Most endocrine-related operations were considered elective and safe to postpone, providing a unique opportunity to assess clinical outcomes under protracted treatment plans.MethodsAmerican Association of Endocrine Surgeon members were surveyed for participation. A REDCap survey was developed and distributed to 27 institutions to assess the impact of COVID-19-related delays. Information collected included patient demographics, primary diagnosis, resumption of care, and assessment of disease progression by the surgeon.ResultsTwelve out of 27 institutions completed the survey (44.4%). Of 850 patients, 74.8% (636) were female; median age was 56 (IQR 44-66) years. 4.0% (34) of patients, had not been seen since their original surgical appointment was delayed. 86.2% (733) of patients had a delay in care with women more likely to have a delay (87.6% vs. 82.2% of men, =3.84, p=0.05). Median length of delay was 70 (IQR 42-118) days. Among patients with a delay in care, primary disease site included thyroid (54.2%), parathyroid (37.2%), adrenal (6.5%), and pancreatic/GI neuroendocrine tumors (1.3%). 4.0% (26) of patients experienced disease progression and 4.1% (24) had a change from the initial operative plan. Length of delay was not associated with disease progression (p=0.96) or a change in operative plan (p=0.66).ConclusionWhile some patients experienced disease progression during COVID-19 delays to endocrine disease-related care, most patients with follow-up did not. Our analysis indicates that temporary delay may be an acceptable course of action in extreme circumstances for most endocrine-related surgical disease.

Endocrine surgeons are performing more thyroid lobectomies for low-risk differentiated thyroid cancer since the 2015 ATA guidelines

BackgroundThe 2015 American Thyroid Association guidelines recommended either total thyroidectomy or lobectomy for surgical treatment of low-risk differentiated thyroid cancer and de-escalated recommendations for central neck dissections. The study aim was to investigate how practice patterns among endocrine surgeons have changed over time. MethodsAll adult patients with low-risk differentiated thyroid cancers (T1–T2, N0/Nx, M0/Mx) in the Collaborative Endocrine Surgery Quality Improvement Program (2014-2021) were identified. The outcomes between patients undergoing lobectomy versus total thyroidectomy were compared using multivariable logistic regression. The annual percent change in the proportion of lobectomies and central neck dissections performed was estimated using joinpoint regression. ResultsIn total, 5,567 patients with low-risk differentiated thyroid cancers were identified. Of these, 2,261 (40.6%) were very low-risk tumors ≤1 cm, and 2,983 (53.6%) were low-risk tumors >1 and <4 cm. Most patients (67.9%) underwent total thyroidectomy. Compared to total thyroidectomy, lobectomy was associated with outpatient surgery (adjusted odds ratio 5.19, P < .001), a decreased risk of postoperative emergency department visits (adjusted odds ratio 0.63, P = .03), and decreased risk of hypoparathyroidism events (adjusted odds ratio 0.03, P < .001). Compared to before (2014–2015), patients undergoing surgery after publication of the revised guidelines (2016–2021) had higher odds of lobectomy and lower odds of central neck dissection for tumors ≤1 cm (lobectomy adjusted odds ratio 2.70, P < .001; central neck dissections adjusted odds ratio 0.64, P = .03) and tumors between 1 and 4 cm (lobectomy adjusted odds ratio 2.27, P < .001; central neck dissection adjusted odds ratio 0.62, P < .001). ConclusionAfter publication of the 2015 American Thyroid Association guidelines, there has been an increase in thyroid lobectomies as a proportion of all thyroid operations performed by endocrine surgeons for low-risk differentiated thyroid cancer. This has implications for reduced health care use and costs, with potential population-level benefits.

Arterial blood supply of the internal neck organs: anatomy, topography, clinical significance in endocrine surgery

BACKGROUND. Current trends of «fast track surgery» give rise to development of new safe techniques of the thyroid and parathyroid surgery, the purpose of which is to minimize the level of postoperative complications, such as vocal cord palsy, hypoparathyroidism, bleeding. In this regard, it is important for the endocrine surgeon to save «dry operating field», which contributes to the clear visualization of such «thin» structures as the recurrent laryngeal nerve, the external branch of the superior laryngeal nerve and the parathyroid glands. Therefore, the key issue of this surgery is to understand the anatomical and topographic features of the blood supply to the internal neck organs (a complex of neck organs consisting of the thyroid and parathyroid glands, larynx, trachea, esophagus).AIM. To determine the main sources of arterial blood supply of the internal neck organs and their anatomical, topographic features.MATERIALS AND METHODS. The computed tomography protocols of cervical branches of brachiocephalic arteries were analysed in the study. The thickness of the reconstructed sections in the axial, frontal and sagittal planes was 0.35±0.05 mm. The fact of blood supply was confirmed by the anatomical close of the arterial structure to the internal organ and the presence of intramural arterial branches.RESULTS. The course of all cervical branches of the subclavian and common carotid artery was traced among 42 patients. It is noted, that only the inferior, superior thyroid arteries and thyroid ima artery supply internal neck organs with the blood. At the same time, the superior thyroid artery was visualized in all angiograms. However, the inferior thyroid artery was absent in 2.4% of cases. The thyroid ima artery was rarely detected (in 4.8% of patients). In 73.2% of cases, the inferior thyroid artery was detected high at the upper third level of the thyroid lobe and then had a descending course. In 23.2% of cases, the artery was formed at the middle third level of the thyroid lobe and was directed horizontally to the gland. Only in 3.6% of cases, the ascending course was determined in the vessel. The inferior thyroid artery was located on the posterior surface of the thyroid lobe, where it formed glandular branches. On the contrary, the branches of the superior thyroid artery were located mainly along the anterolateral surface of the thyroid gland. The average thickness of the inferior thyroid artery was 2.1±0.5 mm, and the superior thyroid artery was 1.6± 0.7 mm.CONCLUSION. According to the study, arterial blood supply to the internal neck organs is provided mainly by the inferior and superior thyroid arteries. At the same time, the trunk of the inferior thyroid artery is larger than the superior thyroid artery (p=0.032). The inferior thyroid artery forms branches along the posterior surface of the thyroid lobe and from a topographic point of view it is the main source of blood supply to the parathyroid glands. In most cases, the inferior thyroid artery has a descending course, is directed along the posterior surface of the thyroid gland and forms an X-shaped intersection with the recurrent laryngeal nerve.

American Association of Endocrine Surgeons Guidelines for Adrenalectomy

Adrenalectomy is the definitive treatment for multiple adrenal abnormalities. Advances in technology and genomics and an improved understanding of adrenal pathophysiology have altered operative techniques and indications. To develop evidence-based recommendations to enhance the appropriate, safe, and effective approaches to adrenalectomy. A multidisciplinary panel identified and investigated 7 categories of relevant clinical concern to practicing surgeons. Questions were structured in the framework Population, Intervention/Exposure, Comparison, and Outcome, and a guided review of medical literature from PubMed and/or Embase from 1980 to 2021 was performed. Recommendations were developed using Grading of Recommendations, Assessment, Development and Evaluation methodology and were discussed until consensus, and patient advocacy representation was included. Patients with an adrenal incidentaloma 1 cm or larger should undergo biochemical testing and further imaging characterization. Adrenal protocol computed tomography (CT) should be used to stratify malignancy risk and concern for pheochromocytoma. Routine scheduled follow-up of a nonfunctional adrenal nodule with benign imaging characteristics and unenhanced CT with Hounsfield units less than 10 is not suggested. When unilateral disease is present, laparoscopic adrenalectomy is recommended for patients with primary aldosteronism or autonomous cortisol secretion. Patients with clinical and radiographic findings consistent with adrenocortical carcinoma should be treated at high-volume multidisciplinary centers to optimize outcomes, including, when possible, a complete R0 resection without tumor disruption, which may require en bloc radical resection. Selective or nonselective α blockade can be used to safely prepare patients for surgical resection of paraganglioma/pheochromocytoma. Empirical perioperative glucocorticoid replacement therapy is indicated for patients with overt Cushing syndrome, but for patients with mild autonomous cortisol secretion, postoperative day 1 morning cortisol or cosyntropin stimulation testing can be used to determine the need for glucocorticoid replacement therapy. When patient and tumor variables are appropriate, we recommend minimally invasive adrenalectomy over open adrenalectomy because of improved perioperative morbidity. Minimally invasive adrenalectomy can be achieved either via a retroperitoneal or transperitoneal approach depending on surgeon expertise, as well as tumor and patient characteristics. Twenty-six clinically relevant and evidence-based recommendations are provided to assist surgeons with perioperative adrenal care.

TH8.8 Retrospective study on the safety of thyroid surgery with confirmed benign histology in a UK district general hospital

Abstract Aim With increasingly aging population, more thyroidectomies are being performed in the elderly. These surgeries may be suspected to be unsafe as majority of the geriatric population suffer from comorbidities. Our local study explored the safety of thyroid surgery with confirmed benign histology in the elderly, with the post-operative complication rates being the primary outcome measures. Methods The study group included patients over 75 years who had thyroid surgeries with confirmed benign histology in a UK district general hospital from January 2010 to January 2022. We then analysed the rates of complications including temporary hypocalcemia, permanent hypocalcemia, vocal cord palsy and haematoma. Results 41 elderly patients underwent thyroid surgery with confirmed benign histology in our facility within the period. 78% of them had thyroid lobectomy and the commonest indication for surgery was benign multinodular goitre. There were no haematomas, no permanent vocal cord palsies and no cases of permanent hypocalcemia. Only 3(7.3%) patients had transient hypocalcemia, and 2(4.9%) had vocal cord palsy which all resolved before 6 months. Conclusions Our study has demonstrated that it is generally safe to perform thyroidectomy in the elderly population with low hypocalcemia and vocal cord palsy rates as compared to the British Association of Endocrine and Thyroid Surgeons’ report of 10.2% and 7.8% for hypocalcemia and early cord palsy rates respectively in all age-groups. Nevertheless, we would advocate appropriate patient selection in terms of ASA classification. For example, 50% of those who had post-operative vocal cord palsy in our study had an ASA of 3.

The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Secondary and Tertiary Renal Hyperparathyroidism.

To develop evidence-based recommendations for safe, effective, and appropriate treatment of secondary (SHPT) and tertiary (THPT) renal hyperparathyroidism. Hyperparathyroidism is common among patients with chronic kidney disease, end-stage kidney disease, and kidney transplant. The surgical management of SHPT and THPT is nuanced and requires a multidisciplinary approach. There are currently no clinical practice guidelines that address the surgical treatment of SHPT and THPT. Medical literature was reviewed from January 1, 1985 to present January 1, 2021 by a panel of 10 experts in SHPT and THPT. Recommendations using the best available evidence was constructed. The American College of Physicians grading system was used to determine levels of evidence. Recommendations were discussed to consensus. The American Association of Endocrine Surgeons membership reviewed and commented on preliminary drafts of the content. These clinical guidelines present the epidemiology and pathophysiology of SHPT and THPT and provide recommendations for work-up and management of SHPT and THPT for all involved clinicians. It outlines the preoperative, intraoperative, and postoperative management of SHPT and THPT, as well as related definitions, operative techniques, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Preoperative and Perioperative Care, Surgical Planning and Parathyroidectomy, Adjuncts and Approaches, Outcomes, and Reoperation. Evidence-based guidelines were created to assist clinicians in the optimal management of secondary and tertiary renal hyperparathyroidism.