Comparison of transoral endoscopic thyroidectomy vestibular approach and open conventional thyroidectomy regardıng inflammatory responses, pain, and patient satisfaction: a prospective study

IntroductionThe application of transoral endoscopic thyroidectomy vestibular approach (TOETVA) is becoming widespread throughout the world. We primarily aimed to evaluate the severity of surgical trauma in TOETVA and conventional open thyroidectomy (COT) regarding the inflammatory response including the comparison of surgical stress markers [interleukin-6 (IL-6), C-reactive protein (CRP), white blood cell (WBC)].Material and methodThis non-randomized prospective study enrolled two groups with 20 patients each: COT group and TOETVA group. Patients aged 18–65 years with benign thyroid disease; with fine needle aspiration biopsy results of Bethesda III, IV or Bethesda V, VI (<1 cm nodule); thyroid volume <50 cm3; nodule diameter <4 cm; female gender without a previous neck, chin, and/or oral surgery; without vocal cord paralysis preoperatively; and patients in euthyroid state were enrolled to the study. Preoperative, postoperative second hour, first day, and second day CRP, WBC, and IL-6 levels were evaluated. Pain intensity was evaluated with the visual analog scale (VAS) score on the 2nd and 12th hour, 1st and 2nd days postoperatively.ResultsAll the patients were female and mean age was significantly higher in the COT group. The operative time was significantly longer in the TOETVA group. No significant difference was found between the two groups regarding IL-6 levels. In the TOETVA group, postoperative second hour WBC value (p = 0.044) and first (p = 0.002) and second day (p = 0.005) CRP values were significantly higher. In the TOETVA group, the lower lip and lower chin VAS scores were significantly higher at 2nd and 12th hour, on the first and second days. The anterior neck VAS score was significantly higher in the TOETVA group at the second hour (p = 0.025). General and cosmetic satisfactions were similar at the 15th and 30th days in both groups.ConclusionThe longer operative time and higher postoperative CRP level and VAS score in the chin and lower lip in the TOETVA group suggested that the method is not a minimally invasive technique compared to COT. However, the presence of similar total complication rates and early postoperative general and esthetic satisfaction that improves over time in both groups suggests that the clinical effect of increased magnitude of systemic inflammatory response in TOETVA might be temporary and acceptable

An unusual finding after adrenal surgery: a case series of adrenal schwannomas

Adrenal schwannomas are rare benign tumors with no specific imaging and laboratory findings to diagnose preoperatively. Due to the limited number of cases in the literature, clinical, imaging, and pathological findings are presented in this study. Case 1 is a 61-year-old woman patient who has a 31-mm mass in the right adrenal gland. This mass was nonfunctional; in imaging studies, this mass had a cystic necrotic component, and high 18-fluorodeoxyglucose (FDG) uptake was seen. There was no metaiodobenzylguanidine (MIBG) uptake. Laparoscopic transabdominal right adrenalectomy was performed, and the pathology result was consistent with adrenal schwannomas. Case 2 is a 63-year-old man patient who presented with a 38-mm mass in the left adrenal gland. This mass was nonfunctional and similar to that in Case 1; this mass had a cystic component. Laparoscopic transabdominal left adrenalectomy was performed. The diagnosis of adrenal schwannoma with degeneration was revealed. Case 3 was a 72-year-old woman patient admitted to the hospital for a 125-mm left adrenal mass. Similar to Case 1, this mass also had a cystic necrotic component in imaging studies. High FDG uptake was seen, and the patient underwent conventional adrenalectomy due to the suspicion of malignancy. After pathological evaluation, a diagnosis of adrenal schwannoma was made. A main diagnostic challenge in adrenal schwannomas is the preoperative diagnosis. These masses have no pathognomonic finding or specific hormonal function. Imaging findings of these masses may increase the suspicion of malignancy, which may affect decisions for surgery and the surgical technique

Laparoscopic adrenalectomy in a patient with situs inversus totalis

Situs inversus totalis(SIT) is a relatively rare condition involving transposition of both the abdominal and thoracic viscera. SIT typically presents as left to right reversal of the viscera combined with dextrocardia, while the individual organs function is normal. Although there are no obvious abnormalities in the function of transposed organs, anatomical irregularity causes important technical difficulties in the surgical treatment of these patients. In this study, we aim to report surgical challenges in laparoscopic adrenalectomy in a patient with SIT

Intraoperative Posterior Cricoarytenoid Muscle Electromyography May Predict Vocal Cord Function Prognosis after Loss of Signal during Thyroidectomy

Purpose Intraoperative posterior cricoarytenoid muscle (PCAM) electromyography (EMG) may be useful for predicting postoperative vocal cord function (VCF) and prognosis of vocal cord palsy (VCP) in patients with intraoperative loss of signal (LOS). Materials and Methods Thirty out of 395 patients having LOS detected by intraoperative neural monitoring (IONM), were applied intraoperative PCAM EMG. Results VCP was present in all Type 1 injury RLNs (16) (100%) and in 8 (57%) of 14 RLNs with Type 2 injury (p = 0.005). 14 out of 30 LOS patients (47%) had positive PCAM EMG amplitudes. The sensitivity, specificity, positive and negative predictive values and accuracy rates for predicting postoperative VCP via PCAM EMG, were calculated as 66.7%, 100%,100%, 42.86% and 73.33%. The negative PCAM EMG was related to VCP in both Type 1 and Type 2 LOS. VCP recovery time of Type 1 LOS patients was significantly longer than that of Type 2 LOS patients (p = 0.009). In Type 2 LOS, VCP recovery time was significantly longer in negative PCAM EMG patients compared to positive PCAM EMG patients (p = 0.046). Conclusion Negative PCAM EMG is associated with the postoperative VCP. Type 1 injury results in VCP regardless of PCAM EMG results, and VCF recovers after a longer period compared to Type 2 LOS. In Type 2 LOS, positive PCAM EMG may result in VCP by 40%. However, the presence of negative PCAM EMG is related to the postoperative VCP in all patients and the recovery time is longer compared to positive PCAM EMG patients

Is craniocaudal dissection of recurrent laryngeal nerve safer than lateral approach: a prospective randomized study comparing both techniques by using continuous intraoperative nerve monitoring.

PURPOSE: This study was performed to compare the real-time electromyographic (EMG) changes and the rate of recurrent laryngeal nerve (RLN) injury in craniocaudal and lateral approaches for RLN during thyroidectomy. METHODS: One hundred twelve and 86 patients were prospectively randomized to receive lateral (group 1) or craniocaudal (group 2) approach to RLN, respectively, under continuous intraoperative nerve monitoring. RESULTS: Loss of signal (LOS) occurred in 7 (2.0%) of 356 nerves at risk (NAR). LOS was significantly associated with repeated adverse EMG changes and presence of RLN entrapment at the ligament of Berry (LOB), which was accompanied by other clinicopathological or anatomical features, such as tubercle of Zuckerkandl (TZ), extralaryngeal branching, hyperthyroidism, autoimmune thyroid disease (ATD), or thyroid lobe volume of >29 cm(3) (P = 0.001 and P = 0.030, respectively). The rate of repeated adverse EMG changes and LOS in the NARs with LOB entrapment accompanied by other clinicopathological and anatomical features was higher in group 1 vs. group 2 (11.1% vs. 2.2%, respectively and 9.7% vs. 0%, respectively; P = 0.070). The total rate of vocal cord palsy (VCP) was significantly higher in group 1 than in group 2 (P = 0.005). The rate of permanent VCP showed no significant difference between the 2 groups. CONCLUSION: The craniocaudal approach to the RLN is safer than the lateral approach in the RLNs with entrapment at the LOB accompanied by other features, such as TZ, extralaryngeal branching, hyperthyroidism, ATD, or high thyroid lobe volume

Transient asystole related to carbon dioxide embolism during transoral endoscopic parathyroidectomy vestibular approach

Background Rarely, during the endoscopic thyroidectomy, carbon dioxide (CO2) embolism may occur. Methods Case 1: A 65-year-old female who was seen with prolonged fatigue and generalized bone pain was diagnosed primary hyperparathyroidism (PHPT) based on her preoperative biochemical profile. Transoral endoscopic parathyroidectomy vestibular approach (TOEPVA) was planned. Case 2: A 52-year-old male patient was seen with weakness and hepatosteatosis and was diagnosed PHPT based on the laboratory workup. TOEPVA was planned. Results After subplatysmal dissection with vascular tunnel probe, both of the patients developed severe bradycardia and hypotension leading to asystole during the CO2 insufflation. The possibility of CO2 embolism was considered and insufflation was terminated. After a successful cardiac massage, sinus rhythm returned. Conclusion TOEPVA may develop CO2 embolism leading to asystole during the CO2 insufflation

Transoral endoscopic parathyroidectomy vestibular approach (TOEPVA) for primary hyperparathyroidism: Turkey's experience

Turk, Yigit/0000-0001-9755-8163WOS:000625027200001PubMed: 33660120Aim Parathyroid surgery has witnessed a significant evolution with the introduction of more efficacious preoperative localization imaging techniques and the use of rapid intraoperative parathormone assays. Parathyroid surgery can now be performed with the minimum of invasion. Through the adaptation of the transoral endoscopic thyroidectomy vestibular approach (TOETVA), the technique has now been adopted for parathyroid surgery, known as the transoral endoscopic parathyroidectomy vestibular approach (TOEPVA). We present here the initial experiences of 11 centers carrying out TOEPVA surgery in Turkey. Materials and methods Participating in the study were 11 centers, all of which were tertiary care institutions carrying out endocrine surgery. A retrospective review was made of 35 primary hyperparathyroidism patients who underwent the TOEPVA procedure between July 2017 and January 2020. Results of the total 35 patients, 32 patients underwent the TOEPVA procedure successfully. All patients but one were female, and the mean age was 47.2 (20-73) years. According to localization studies, 18 of the lesions were lower left, 12 were lower right, 3 were upper right and 2 were upper left. The mean operative time was 116 (30-225) min, and three cases were converted to an open procedure. Simultaneous thyroidectomy was performed in seven cases. The average PTH level dropped to normal within 20 min. after the resection in all cases. The complication rate was 19% (ecchymosis, subcutaneous emphysema, nasal bleeding, surgical site infection and seroma). There were neither recurrent nerve palsies, nor mental nerve root or branch injuries. The average hospital stay was 1 day. No persistence was documented on follow up. Conclusion TOEPVA is a "hidden scar" parathyroidectomy procedure that can be safely performed on parathyroid adenomas, in cases that have scar-related concerns. Having its own procedure-related complications, the procedure provides satisfactory objective results, particularly in centers experienced in endoscopic and endocrine surgery

A Rare Presentation of Autonomously Functioning Papillary Thyroid Cancer: Malignancy in Marine-Lenhart Syndrome Nodule

Objective. Marine-Lenhart Syndrome (MLS) is defined as concomitant occurrence of autonomously functioning thyroid nodule (AFTN) with Graves’ disease (GD). Malignancy in a functional nodule is rare. We aimed to present an extremely rare case of papillary thyroid cancer in a MLS nodule with lateral lymph node metastases. Case. A 43-year-old male presented with hyperthyroidism and Graves’ ophthalmopathy. On Tc99m pertechnetate scintigraphy, a hyperactive nodule in the left upper thyroid pole was detected and the remaining tissue showed a mildly increased uptake. The ultrasonography demonstrated 15.5 × 13.5 × 12 mm sized hypoechoic nodule in the left upper pole of the thyroid and round lymph nodes on the left side of the neck. Fine needle aspiration biopsy (FNAB) of the nodule and lymph node revealed cytological findings consistent with papillary cancer. Total thyroidectomy with central and left modified radical neck dissection was performed. On pathologic examination, two foci of micropapillary cancer were detected. The skip metastases were present in three lymph nodes on the neck. Conclusion. AFTN can be seen rarely in association with GD. It is not possible to exclude malignancy due to the clinical and imaging findings. In the presence of suspicious clinical and sonographic features, FNAB should be performed