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Background: Phaeochromocytoma is sometimes not diagnosed before surgery and may present as an adrenal incidentaloma. The aim of this study was to investigate differences in clinical presentation and perioperative outcome in patients with subclinical and symptomatic phaeochromocytoma, and in patients operated with and without preoperative a-blockade. Methods: This was a retrospective observational study of patients with a histopathological diagnosis of phaeochromocytoma registered in EurocrineVR, the European registry for endocrine tumours, between 1 January 2015 and 31 March 2020. Patient characteristics, clinical presentation, tumour detection, and perioperative variables were analysed. Results: Some 551 patients were included. Of these, 486 patients (88.2 per cent) had a preoperative diagnosis of phaeochromocytoma. Tumours were detected as incidentalomas in 239 patients (43.4 per cent) and 265 (48.1 per cent) had a preoperative diagnosis of hypertension. Preoperative a-blockade was more frequently used in patients with a known phaeochromocytoma (350, 90.9 per cent) than in patients with other indications for adrenalectomy (16, 31 per cent). Complications did not differ between patients who had surgery because of catecholamine excess compared with those who had other indications for surgery (19 (3.9 per cent) versus 2 (3 per cent); P=0.785), nor did the conversion rate from minimally invasive to open surgery differ between the groups. There were no obvious differences in complications, according to the Clavien-Dindo classification, based on preoperative a-blockade or not. Conclusion: Subclinical phaeochromocytoma detected incidentally is common. A significant proportion of patients with phaeochromocytoma did not have a-blockade before surgery, without an apparent effect on complications. [ABSTRACT FROM AUTHOR]

Background: Surgery is the curative therapy for patients with medullary thyroid carcinoma (MTC). In determining the extent of surgery, the risk of complications should be considered. The aim of this study was to assess procedure-specific outcomes and risk factors for complications after surgery for MTC. Methods: Patients who underwent thyroid surgery for MTC were identified in two European prospective quality databases. Hypoparathyroidism was defined by treatment with calcium/active vitamin D. Recurrent laryngeal nerve (RLN) palsy was diagnosed on laryngoscopy. Complications were considered at least transient if present at last follow-up. Risk factors for at-least transient hypoparathyroidism and RLN palsy were identified by logistic regression analysis. Results: A total of 650 patients underwent surgery in 69 centres at a median age of 56 years. Hypoparathyroidism, RLN palsy and bleeding requiring reoperation occurred in 170 (26·2 per cent), 62 (13·7 per cent) and 17 (2·6 per cent) respectively. Factors associated with hypoparathyroidism were central lymph node dissection (CLND) (odds ratio (OR) 2·20, 95 per cent c.i. 1·04 to 4·67), CLND plus unilateral lateral lymph node dissection (LLND) (OR 2·78, 1·20 to 6·43), CLND plus bilateral LLND (OR 2·83, 1·13 to 7·05) and four or more parathyroid glands observed (OR 4·18, 1·46 to 12·00). RLN palsy was associated with CLND plus LLND (OR 4·04, 1·12 to 14·58) and T4 tumours (OR 12·16, 4·46 to 33·18). After compartment-oriented lymph node dissection, N0 status was achieved in 248 of 537 patients (46·2 per cent). Conclusion: Complications after surgery for MTC are procedure-specific and may relate to the unavoidable consequences of radical dissection needed in some patients. [ABSTRACT FROM AUTHOR]

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

Purpose: The management of indeterminate thyroid nodules remains a topic of ongoing debate, particularly regarding the differentiation of malignancy. Somatic mutation analysis offers crucial insights into tumor characteristics. This study aimed to assist the clinical management of indeterminate nodules with somatic mutation analysis., Methods: Aspiration samples from 20 indeterminate thyroid nodules were included in the study. A next-generation sequencing panel containing 67 genes was used for molecular profiling. The results were compared with pathology data from surgical material, which is considered the gold standard. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated., Results: Variants in six genes (NRAS, BRAF, TP53, TERT, PTEN, PIK3CA) were detected in 10 out of 20 samples. We identified nine Tier 1 or 2 variants in 10 (67 %) out of 15 malignant nodules (NRAS, BRAF, TP53, TERT, PTEN, PIK3CA) and one Tier 2 (PIK3CA) variant in one out of five benign nodules. The study demonstrated an NPV of 40 %, a PPV of 90 %, a specificity of 80 %, and a sensitivity of 60 %., Conclusion: Based on the detected molecular markers, at least nine patients (45 %) could be managed correctly without needing a repeat FNAB attempt. This study underscores the clinical practicality of molecular tests in managing nodules with indeterminate cytology. Additionally, this study emphasizes the importance of considering the patient's age when determining the DNA- or RNA-based genetic testing method. Finally, we discussed the significance of the somatic mutation profile and its impact on the current pathological classification., Competing Interests: Declaration of Competing Interest The authors declare that the research was conducted without any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Elsevier GmbH. All rights reserved.)

Background: The aim of this study is to describe the management and associated follow-up strategies adopted by thyroid surgeons with different surgical volumes when loss of signal (LOS) occurred on the first side of planned bilateral thyroid surgery, and to further define the consensus on intraoperative neuromonitoring (IONM) applications., Methods: The International Neural Monitoring Study Group (INMSG) web-based survey was sent to 950 thyroid surgeons worldwide. The survey included information on the participants, IONM team/equipment/procedure, intraoperative/postoperative management of LOS, and management of LOS on the first side of thyroidectomy for benign and malignant disease., Results: Out of 950, 318 (33.5%) respondents completed the survey. Subgroup analyses were performed based on thyroid surgery volume: <50 cases/year (n = 108, 34%); 50 to 100 cases/year (n = 69, 22%); and >100 cases/year (n = 141, 44.3%). High-volume surgeons were significantly ( P  < .05) more likely to perform the standard procedures (L1-V1-R1-S1-S2-R2-V2-L2), to differentiate true/false LOS, and to verify the LOS lesion/injury type. When LOS occurs, most surgeons arrange otolaryngologists or speech consultation. When first-side LOS occurs, not all respondents decided to perform stage contralateral surgery, especially for malignant patients with severe disease (eg, extrathyroid invasion and poorly differentiated thyroid cancer)., Conclusions: Respondents felt that IONM was optimized when conducted under a collaborative team-based approach, and completed IONM standard procedures and management algorithm for LOS, especially those with high volume. In cases of first-site LOS, surgeons can determine the optimal management of disease-related, patient-related, and surgical factors. Surgeons need additional education on LOS management standards and guidelines to master their decision-making process involving the application of IONM., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

We aimed to investigate the effects of video game habits, duration of experience, and training in different surgical clinics on the success of robotic surgery simulators. In this prospective, observational, comparative, and multi-clinical study, all participants played Temple Run and Piano Tiles 2 ™ mobile games for 1 month, after answering a questionnaire including their sociodemographic characteristics, surgical experience, and past and current video game experience. At the end of the period, participants experienced four different robotic surgery simulator tasks (Camera Targeting 1, Energy Switching 1, Ring and Rail 2, Vertical Defect Suturing) in da Vinci ® Skills Simulator ™ . Additionally, sociodemographic data were statistically analyzed with mobile game scores and 13 different performance scores obtained from the simulator. All robotic surgery simulator skill applications were carried out at Ege University Hospital in Izmir. All surgical residents in the general surgery, urology, and pediatric surgery clinics were included in the study. Sixty of the sixty-four participants in total completed all the processes. Four participants were excluded from the study. When clinical performances were compared, it was seen that the general surgery clinic performed better than other clinics in two parameters (overall score, time to complete) of the 'Camera Targeting' task (p = 0.01 and p = 0.006). Participants with mobile phone games experience were successful in the 'Energy Switching' task with less misapplied energy time (p = 0.039). Participants with high scores in Piano Tiles 2 ™ were more successful in the 'Energy Switching' task and completed the 'Ring Rail' task with fewer movements (p < 0.05). Participants with more surgical and laparoscopic surgery experience scored higher in the 'Camera Targeting' and 'Energy Switching' tasks and completed the assignments with less movement. Again, these participants completed the 'Vertical Defect Suturing' task faster and the 'Ring Rail' task with less movement. In addition, participants with more laparoscopy experience scored higher in the 'Ring Rail' task (p < 0.05). In this study, we showed the effect of recent gaming experience on robotic surgery abilities along with previous video game experience. For surgeons and surgeon candidates in robotic surgery training, the importance of video game-based learning techniques will increase when combined with rapidly developing simulation technologies.ClinicalTrials.gov Identifier: NCT05510960., (© 2023. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Purpose: This study aims to compare posterior retroperitoneal laparoscopic adrenalectomy (PRLA) and laparoscopic transperitoneal adrenalectomy (LTA) in adults using pan-European data as conflicting results have been published regarding length of hospital stay, institutional volume, and morbidity., Methods: This retrospective cohort study analyzed data from the surgical registry EUROCRINE®. All patients undergoing PRLA and TLA for adrenal tumours and registered between 2015 and 2020 were included and compared for morbidity, length of hospital stay, and conversion to open surgery., Results: A total of 2660 patients from 11 different countries and 69 different hospitals were analyzed and 1696 LTA were compared to 964 PRLA. Length of hospital stay was shorter after RPLA, with less patients (N = 434, 45.5%, vs N = 1094, 65.0%, p < 0.001) staying more than 2 days. In total, 96 patients (3.6%) developed a complication Clavien-Dindo grade 2 or higher. No statistical difference was found between both study groups. After propensity score matching, length of hospital stay was shorter after PRLA (> 2 days 45.2% vs 63.0%, p < 0.001). After multivariable logistic regression, factors associated with morbidity were age (OR 1.03), male sex (OR 1.52), and conversion to open surgery (OR 5.73)., Conclusion: This study presents the largest retrospective observational analysis comparing LTA and PRLA. Our findings confirm the shorter length of hospital stay after PRLA. Both techniques are safe leading to comparable morbidity and conversion rates., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Freehand single photon emission computed tomography (fhSPECT) is a technique that is used to monitor body's radioactivity intraoperatively. Accordingly, in this study, the feasibility of using fhSPECT for intraoperative 3D mapping in radioguided parathyroidectomy has been assessed. Patients, who were diagnosed with primary hyperparathyroidism consecutively, were scanned intraoperatively using fhSPECT to locate parathyroid adenomas before surgical procedure. The fhSPECT images were acquired intraoperatively using a declipse ® SPECT device (SurgicEye TM ). The fhSPECT protocol could not be completed due to the technical problems in one patient. Parathyroid adenoma was located in the first patient with no lateral deviation. Nevertheless, a deviation of 8 mm was detected in the depth of the parathyroid adenoma, which is the distance of parathyroid adenoma from the skin. A 20 mm lateral deviation and a 10 mm deviation in depth were detected in the second patient. In the third patient, as was the case in the first patient, parathyroid adenoma was located with no lateral deviation. However, there was a 15 mm deviation in the depth of the parathyroid adenoma. A 5 mm lateral deviation was detected in the fourth patient yet with no deviation in the depth of parathyroid adenoma. Finally, neither lateral nor vertical deviation was detected in fifth patient. Based on the findings of this study, it was concluded that the fhSPECT technology can be helpful to a certain degree in locating the parathyroid adenoma. However, further studies are needed to support the findings of this preliminary study., (© 2022. Italian Society of Surgery (SIC).)

Background: Adrenalectomy is routinely performed via the minimally invasive approach. Safety of adrenalectomy using the robot-assisted technique has been widely demonstrated by several series, but the literature is scarce regarding the comparison of conventional laparoscopic versus robot-assisted approach. We decided to carry out a multicenter study to compare clinical and surgical outcomes between laparoscopic and robotic adrenalectomy., Methods: This is a retrospective case-control study, including data from centers affiliated to the Surgical Registry EUROCRINE. Patients undergoing laparoscopic surgery for adrenal tumors and registered between 2015 and 2018 were included. Robot-assisted versus laparoscopic adrenalectomy was compared. All comparisons were carried out in terms of complication rate, conversion rate and duration of stay., Results: A total of 1,005 patients from 46 clinics underwent robotic or conventional laparoscopic adrenalectomy. Median age was 55 (interquartile range: 45-65) years. Robotic adrenalectomy was performed in 189 (18.8%) patients. According to Clavien-Dindo classification, complication rate was lower in the robotic surgery group (1.6% vs 16.5%, P < .001). Laparoscopic surgery and active hormonal status were significantly correlated with complications, both in univariate and multivariate analysis. There was no significant difference between laparoscopic and robotic surgery groups, in terms of conversion rate (2.1% vs 0.5%, respectively, P = .147). Duration of stay was shorter in the robotic adrenalectomy group (82.1% vs 28.8%, P < .001)., Conclusion: Analysis of the EUROCRINE database supports that robotic adrenalectomy resulted in a lower complication rate and shorter duration of stay, compared with laparoscopic adrenalectomy. Granular data to support this is warranted., (Copyright © 2021. Published by Elsevier Inc.)

Aim: 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., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC part of Springer Nature.)

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., Competing Interests: Declaration of competing interest The authors declare that they have no conflict of interests. Availability of data and material (data transparency):, (Copyright © 2021. Published by Elsevier Taiwan LLC.)

Background: The most commonly used recording-side method in intraoperative neural monitoring (IONM) detects the stimulus with the endotracheal tube surface (ETS) electrodes placed in the endotracheal tube during thyroidectomy. The thyroid cartilage needle (TCN) electrode method is an alternative recording-side system in IONM. This study compared two recording-side techniques in IONM., Methods: Data were retrospectively analyzed from 885 patients who underwent thyroidectomy between January 2012 and December 2020, with 110 ETS and 775 TCN electrodes. Patients' demographics, diagnosis, surgery type, and amplitudes of all stimulation steps were compared. Costs per patient were calculated., Results: No significant differences were found in the demographic data between the two groups. All amplitudes were higher in the IONM system where TCN electrodes were used than that with ETS electrodes (all stimulation steps p < 0.001, except left-V2 p = 0.007). Further, TCN electrodes were 20 times cheaper than the ETS electrodes., Conclusion: TCN electrodes are an inexpensive and efficient alternative to ETS electrodes in IONM., (© 2021 Wiley Periodicals LLC.)

Background: Phaeochromocytoma is sometimes not diagnosed before surgery and may present as an adrenal incidentaloma. The aim of this study was to investigate differences in clinical presentation and perioperative outcome in patients with subclinical and symptomatic phaeochromocytoma, and in patients operated with and without preoperative α-blockade., Methods: This was a retrospective observational study of patients with a histopathological diagnosis of phaeochromocytoma registered in Eurocrine®, the European registry for endocrine tumours, between 1 January 2015 and 31 March 2020. Patient characteristics, clinical presentation, tumour detection, and perioperative variables were analysed., Results: Some 551 patients were included. Of these, 486 patients (88.2 per cent) had a preoperative diagnosis of phaeochromocytoma. Tumours were detected as incidentalomas in 239 patients (43.4 per cent) and 265 (48.1 per cent) had a preoperative diagnosis of hypertension. Preoperative α-blockade was more frequently used in patients with a known phaeochromocytoma (350, 90.9 per cent) than in patients with other indications for adrenalectomy (16, 31 per cent). Complications did not differ between patients who had surgery because of catecholamine excess compared with those who had other indications for surgery (19 (3.9 per cent) versus 2 (3 per cent); P = 0.785), nor did the conversion rate from minimally invasive to open surgery differ between the groups. There were no obvious differences in complications, according to the Clavien-Dindo classification, based on preoperative α-blockade or not., Conclusion: Subclinical phaeochromocytoma detected incidentally is common. A significant proportion of patients with phaeochromocytoma did not have α-blockade before surgery, without an apparent effect on complications., (© The Author(s) 2021. Published by Oxford University Press on behalf of BJS Society Ltd.)

Background: In the present study we determine the feasibility of intraoperative neuromonitoring following the administration of a nondepolarizing neuromuscular blocking agent during thyroid operations, as well as the influence of rocuronium on the achievement of optimal vagal stimulation during intraoperative neuromonitoring in thyroid surgery. We further investigate whether accelerometry is a reliable approach to obtaining an ipsilateral vagus signal prior to recurrent laryngeal nerve dissection., Methods: Included in the study were 61 thyroidectomized patients whose demographic data, indications, type of surgery, vagus, and recurrent nerve values before and after resection were obtained. We created five groups of patients based on the twitch values recorded during ipsilateral vagus stimulation prior to the recurrent laryngeal nerve dissection: (1) <10%, (2) 11-25%, (3) 26-50%, (4) 51-75% and (5) >75%., Results: The average electromyography amplitudes of the vagus nerve prior to the determination of the recurrent laryngeal nerve for each group were 552 μV, 463 μV, 543 μV, 513 μV and 551 μV, respectively. No difference between the groups was observed in this regard (p > 0.05)., Conclusion: It can be expected that as soon as the effects of neuromuscular blockers on the peripheral muscles begin to abate, it will be possible to obtain the ipsilateral vagus signal prior to recurrent laryngeal nerve dissection at the desired levels. It can be concluded from this study that accelerometry using the pollicis muscle is an unreliable tool for the interpretation of the proper electromyography signals of the vagus nerve prior to the determination of the recurrent laryngeal nerve., Competing Interests: Declaration of competing interest The authors report no potential financial and non-financial conflicts of interest., (Copyright © 2020. Published by Elsevier Taiwan LLC.)

Edward Delos Churchill, one of the most notorious American surgeons of the 20th century, influenced countless surgeons and set medical practices that were used for decades. His scope of interests included surgery of the lungs, heart, thyroid, parathyroid glands, and military surgery among others. Churchill was one of the first to expand the field of the newly found parathyroid bodies by performing several experimental excisions of the glands and publishing numerous guidelines based on his innovative work. Additionally, he aspired to address many of the literature gaps that led him to conclusions that would benefit both the surgeons and patients throughout the country. Most importantly, his deep interest in endocrinology and his aggregate approach of medicine led him to discoveries that paved the way to the modern endocrine surgery practices.

Background: Transoral endoscopic thyroidectomy using the vestibular approach (TOETVA) is a novel technique for thyroid cancer surgery. We aimed to review our initial experiences with TOETVA for the management of thyroid carcinoma, using retrospective analyses of a larger single-center case series., Methods: From September 2016 to April 2018, 132 patients with thyroid cancer underwent TOETVA. A three-port technique through the oral vestibule was used to perform endoscopic thyroidectomy with ipsilateral central compartment dissection using conventional laparoscopic instruments, and an endoscopic retractor that we developed., Results: All patients had papillary thyroid carcinoma. Less-than total or total thyroidectomy with ipsilateral central compartment node dissection was performed (124 vs. 8). The mean operation time was 87.6 min (range 56-213 min). The average number of lymph nodes resected was 2.6 (range 1-12). Six patients experienced transient hoarseness, which was resolved within 3 months. Most of the patients were discharged within 3 days after surgery., Conclusions: In this large series from a single center, we found that TOETVA with the endoscopic retractor can be performed safely and radically in selected patients with thyroid cancer.

Transoral endoscopic thyroidectomy by vestibular approach (TOETVA) is now being performed in increasing frequency and getting more and more attention. TOETVA is carried out through three incisions in the oral vestibular area. Thyroidectomy is performed endoscopically using conventional laparoscopic instruments, an energy based device and neuromonitoring instruments. Intraoperative neuromonitoring is one of the tools of utmost importance, used for navigation and confirmation of the functional integrity of the recurrent nerve during TOETVA. The aim of this study is to give information about the standards and technique of intraoperative neuromonitoring of the recurrent laryngeal nerves during TOETVA procedures. TOETVA is a safe technique with no visible scarring and hence resulting in an excellent cosmetic effect. We believe that neuromonitoring of the recurrent laryngeal nerves also minimizes the risk of nerve damage and is an essential safety component in this technique., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare., (2020 Gland Surgery. All rights reserved.)

The transoral thyroidectomy (TT) is a feasible novel surgical procedure that does not need visible incisions, a truly cutaneous scar-free surgery. Inclusion criteria are (a) patients who have a ultrasonographically (US) estimated thyroid diameter not larger than 10 cm, (b) US estimated gland volume ≤45 mL, (c) nodule size ≤50 mm, (d) a benign tumor, such as a thyroid cyst, single-nodular goiter, or multinodular goiter, (e) follicular neoplasm, and (f) papillary microcarcinoma without evidence of metastasis. The procedure is carried out through a three-port technique placed at the oral vestibule; one 10-mm port for a 30° endoscope and two additional 5-mm ports for dissecting and coagulating instruments. CO 2 insufflation pressure is set at 6 mmHg. An anterior cervical subplatysmal space is created from the oral vestibule down to the sternal notch, laterally to the sternocleidomastoid muscle medial edges. TT is done fully endoscopically using conventional endoscopic instruments., Competing Interests: Conflict of Interest: The authors have no conflicts of interest to declare.

Intraoperative neuromonitoring (IONM) in thyroid gland surgery provides real-time feedback to the endocrine surgeon regarding the electrophysiological consequences of surgical manipulation of the laryngeal nerves. The goal of monitoring modalities is to detect surgical or physiological insults to the recurrent laryngeal nerve (RLN) while they are still reversible or, in cases where prevention is not an option, to minimize the damage done to these structures during thyroidectomy. In recent decades, monitoring of the RLN has become a fundamental part of endocrine surgery. IONM is a feasible procedure in both open and endoscopic, robotic thyroidectomy. Experts in IONM have organized a working group of general, endocrine, head and neck ENT surgeons and endocrinologists (International Neural Monitoring Study Group; INMSG) to develop standards for practicing this technique in endoscopic and robotic thyroidectomy. This paper presents recent clinical and research experience with intraoperative neural monitoring for thyroid gland surgery.

Objectives/hypothesis: This multicenter study aimed to 1) evaluate early postoperative vocal fold function in relation to intraoperative amplitude recovery, and 2) determine optimal absolute and relative thresholds of intraoperative amplitude recovery heralding normal early postoperative vocal fold function, both after segmental type 1 and after global type 2 loss of signal (LOS)., Study Design: Prospective outcome study., Methods: This study, encompassing nine surgical centers from four countries, correlated intraoperative amplitude recovery with early postoperative vocal fold function using receiver operating characteristic analysis., Results: Included in this study were 68 patients, 48 women and 20 men, who sustained transient recurrent laryngeal nerve injury during thyroid surgery under continuous intraoperative nerve monitoring. Early transient vocal fold palsy was seen in 18 (64%) of 28 patients with ipsilateral segmental LOS type 1, and in 10 (25%) of 40 patients with ipsilateral global LOS type 2. On receiver operating characteristic analysis, relative amplitude thresholds were superior to absolute amplitude thresholds in predicting vocal fold function after LOS type 2 (area under the curve [AUC]: 0.83 vs. 0.65; P = .01 vs. P = .15; Youden index 44% and 253 µV) and LOS type 1 (AUC: 0.96 vs. 0.97; P < .001 each; Youden index 49% and 455 µV). Amplitude recovery ≥50% of baseline after LOS always indicated intact vocal fold function., Conclusions: When the nerve amplitude recovers ≥50% of baseline after segmental LOS type 1 or global LOS type 2, it is appropriate to extend completion thyroidectomy to the other side during the same session., Level of Evidence: 2b Laryngoscope, 129:525-531, 2019., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Pancreatic neuroendocrine tumors (PanNETs) are rare in von Hippel-Lindau disease (VHL) but cause serious morbidity and mortality. Management guidelines for VHL-PanNETs continue to be based on limited evidence, and survival data to guide surgical management are lacking. We established the European-American-Asian-VHL-PanNET-Registry to assess data for risks for metastases, survival and long-term outcomes to provide best management recommendations. Of 2330 VHL patients, 273 had a total of 484 PanNETs. Median age at diagnosis of PanNET was 35 years (range 10-75). Fifty-five (20%) patients had metastatic PanNETs. Metastatic PanNETs were significantly larger (median size 5 vs 2 cm; P  < 0.001) and tumor volume doubling time (TVDT) was faster (22 vs 126 months; P  = 0.001). All metastatic tumors were ≥2.8 cm. Codons 161 and 167 were hotspots for VHL germline mutations with enhanced risk for metastatic PanNETs. Multivariate prediction modeling disclosed maximum tumor diameter and TVDT as significant predictors for metastatic disease (positive and negative predictive values of 51% and 100% for diameter cut-off ≥2.8 cm, 44% and 91% for TVDT cut-off of ≤24 months). In 117 of 273 patients, PanNETs >1.5 cm in diameter were operated. Ten-year survival was significantly longer in operated vs non-operated patients, in particular for PanNETs <2.8 cm vs ≥2.8 cm (94% vs 85% by 10 years; P  = 0.020; 80% vs 50% at 10 years; P  = 0.030). This study demonstrates that patients with PanNET approaching the cut-off diameter of 2.8 cm should be operated. Mutations in exon 3, especially of codons 161/167 are at enhanced risk for metastatic PanNETs. Survival is significantly longer in operated non-metastatic VHL-PanNETs., (© 2018 Society for Endocrinology.)

Although the authors of the present review have contributed to genetic discoveries in the field of pheochromocytoma research, we can legitimately ask whether these advances have led to improvements in the diagnosis and management of patients with pheochromocytoma. The answer to this question is an emphatic Yes ! In the field of molecular genetics, the well-established axiom that familial (genetic) pheochromocytoma represents 10% of all cases has been overturned, with >35% of cases now attributable to germline disease-causing mutations. Furthermore, genetic pheochromocytoma can now be grouped into five different clinical presentation types in the context of the ten known susceptibility genes for pheochromocytoma-associated syndromes. We now have the tools to diagnose patients with genetic pheochromocytoma, identify germline mutation carriers and to offer gene-informed medical management including enhanced surveillance and prevention. Clinically, we now treat an entire family of tumors of the paraganglia, with the exact phenotype varying by specific gene. In terms of detection and classification, simultaneous advances in biochemical detection and imaging localization have taken place, and the histopathology of the paraganglioma tumor family has been revised by immunohistochemical-genetic classification by gene-specific antibody immunohistochemistry. Treatment options have also been substantially enriched by the application of minimally invasive and adrenal-sparing surgery. Finally and most importantly, it is now widely recognized that patients with genetic pheochromocytoma/paraganglioma syndromes should be treated in specialized centers dedicated to the diagnosis, treatment and surveillance of this rare neoplasm., (© 2018 Society for Endocrinology.)

Objectives: The incidence of papillary microcarcinomas, which are defined as thyroid cancers of <10mm in size, has been increasing in the last decade. Herein, we present internet-based questionnaire results performed by the Turkish Association of Endocrine Surgery with the aim to evaluate the perspective of the management of papillary microcarcinomas in Turkey., Material and Methods: The user-friendly questionnaire consisted of 13 questions in total. These questions mainly addressed the surgical management of nodules and cancer of <1 cm in size. Patient management before, during, and after surgical intervention was also included; additionally, the "active surveillance approach" was questioned., Results: There were 420 responders in total who were of multidisciplinary origin (endocrinologists, surgeons, nuclear medicine specialists, pathologists, and oncologists). Total thyroidectomy was the predominant treatment approach (65%) for the classical type of microcarcinoma limited in one lobe, whereas in cases of microcarcinomas incidentally diagnosed during hemithyroidectomy, complementary surgery approach was advised by 40% of the responders. The responders found capsule invasion (86%) and patient based management (94%) of high importance. The percentage of the responders who recommended radioactive iodine ablation in incidental cancers having no aggressive criteria was 51%. The survey participants that were against routine central dissection in these cases accounted for 73% of the responders. The recommendation of active surveillance (follow-up without any interventional therapy) was limited with 9% responders., Conclusion: The results of the questionnaire demonstrated that there have been various choices in Turkey for the surgical treatment of the papillary microcarcinomas., Competing Interests: Conflict of Interest: The authors has no conflicts of interest to declare.

Ectopic parathyroid glands can be located at any anatomical location from the base of the tongue to the mediastinum. One-third of these glands migrate deep into the mediastinum, which are not accessible with a low cervical incision. In this article, we described the robotic approach to an ectopic mediastinal parathyroid gland. This management method of mediastinal adenomas has significant advantages when compared to conventional surgery.

Benign goiter is the most common endocrine disease that requires surgery, especially in endemic areas suffering from iodine-deficiency. Recent European and American guidelines recommended total thyroidectomy for the surgical treatment of multinodular goiter. Total thyroidectomy has now become the technique of choice and is widely considered the most reliable approach in preventing recurrence. Nevertheless, total thyroidectomy carries a substantial risk in terms of hypoparathyroidism and the morbidity associated with injury to the inferior laryngeal nerve. In this context, partial/less-than-total thyroidectomy is being considered once again as a viable alternative. This review will discuss the extent of thyroid surgery for benign disease and the impact of the surgical protocol on the patient- and surgeon-specific risk factors for specific complication rates., Competing Interests: Conflicts of Interest: The author has no conflicts of interest to declare

Importance: Effective cancer prevention is based on accurate molecular diagnosis and results of genetic family screening, genotype-informed risk assessment, and tailored strategies for early diagnosis. The expanding etiology for hereditary pheochromocytomas and paragangliomas has recently included SDHA, TMEM127, MAX, and SDHAF2 as susceptibility genes. Clinical management guidelines for patients with germline mutations in these 4 newly included genes are lacking., Objective: To study the clinical spectra and age-related penetrance of individuals with mutations in the SDHA, TMEM127, MAX, and SDHAF2 genes., Design, Setting, and Patients: This study analyzed the prospective, longitudinally followed up European-American-Asian Pheochromocytoma-Paraganglioma Registry for prevalence of SDHA, TMEM127, MAX, and SDHAF2 germline mutation carriers from 1993 to 2016. Genetic predictive testing and clinical investigation by imaging from neck to pelvis was offered to mutation-positive registrants and their relatives to clinically characterize the pheochromocytoma/paraganglioma diseases associated with mutations of the 4 new genes., Main Outcomes and Measures: Prevalence and spectra of germline mutations in the SDHA, TMEM127, MAX, and SDHAF2 genes were assessed. The clinical features of SDHA, TMEM127, MAX, and SDHAF2 disease were characterized., Results: Of 972 unrelated registrants without mutations in the classic pheochromocytoma- and paraganglioma-associated genes (632 female [65.0%] and 340 male [35.0%]; age range, 8-80; mean [SD] age, 41.0 [13.3] years), 58 (6.0%) carried germline mutations of interest, including 29 SDHA, 20 TMEM127, 8 MAX, and 1 SDHAF2. Fifty-three of 58 patients (91%) had familial, multiple, extra-adrenal, and/or malignant tumors and/or were younger than 40 years. Newly uncovered are 7 of 63 (11%) malignant pheochromocytomas and paragangliomas in SDHA and TMEM127 disease. SDHA disease occurred as early as 8 years of age. Extra-adrenal tumors occurred in 28 mutation carriers (48%) and in 23 of 29 SDHA mutation carriers (79%), particularly with head and neck paraganglioma. MAX disease occurred almost exclusively in the adrenal glands with frequently bilateral tumors. Penetrance in the largest subset, SDHA carriers, was 39% at 40 years of age and is statistically different in index patients (45%) vs mutation-carrying relatives (13%; P < .001)., Conclusions and Relevance: The SDHA, TMEM127, MAX, and SDHAF2 genes may contribute to hereditary pheochromocytoma and paraganglioma. Genetic testing is recommended in patients at clinically high risk if the classic genes are mutation negative. Gene-specific prevention and/or early detection requires regular, systematic whole-body investigation.

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., Competing Interests: Conflict of Interest: No conflict of interest was declared by the authors.

Oncocytic neoplasms of the adrenal gland are extremely rare tumors. These tumors differ from their nononcocytic counterparts in some respects. The aim of this study was to review and discuss the clinical, histological, and immunohistochemical features of as well as the prognosis for these rare tumors. In total, 16 cases diagnosed as adrenocortical oncocytic neoplasms between January 2011 and December 2016 were included in the study. The demographic data, gross characteristics, histological data, and immunohistochemical data (Chromogranin-A, Synaptophysin, α-Inhibin, Melan-A, Ki67, PHH3) were reevaluated. The follow-up data for these patients were added in January 2017. Of the 16 cases, 12 were adrenocortical adenoma, 1 was borderline adrenocortical tumor, and 3 were adrenocortical carcinoma. The tumors equally affected both genders. The tumors were not generally large. Tumor cells had pleomorphic nuclei in ten cases, but it was more obvious in one case. The mitotic figure count was low in most tumors. Atypical mitosis and necrosis were observed in three and four tumors, respectively. None of cases included sinusoidal invasion, vascular invasion, or capsular invasion. We detected the expression of at least one specific marker (e.g., Melan-A, Inhibin-α) of the adrenal cortex in all tumors. None of the tumors were immunoreactive for Chromogranin-A. Ki-67 proliferation index was lower than 5% in all cases except three oncocytic carcinomas. In two cases, PHH3 positivity was not seen, while it was lower than 3 of 10 high-powered fields in ten cases and higher in 4 cases. All patients were alive and disease free except for two patients with adrenocortical carcinoma. In conclusion, determining the clinical, histological, and immunohistochemical characteristics of these extremely rare tumors can provide important information for early diagnosis, treatment, and follow-up of these cases.

Objective: In recent years, major progress has been made in the field of endocrine surgery in Turkey, similar to that in the rest of the world. Parallel to these developments, there has been a significant increase in the number of publications in the related field. Our study aimed to evaluate Turkey's publications related to endocrine surgery in the international arena., Material and Methods: Members of the general surgery departments from academic centers in Turkey were determined. Using these member names, a PubMed search was performed for English papers related to "endocrine surgery." For searching papers from non-academic centers, the same engine was used. To reach manuscripts possibly missed by the PubMed search, 3 national calls were made through the website of the Turkish Society of Endocrine Surgery. The obtained papers were divided into "thyroid," "parathyroid," "adrenal," and "neuroendocrine tumors" and were listed according to the publication year. In addition, all manuscripts were listed according to the publishing journal and the 2012 impact factor of that journal. This study did not require ethical approval, because it did not involve evaluation of experimental or patient data., Results: A search of Turkish general surgery clinics revealed 497 international publications, between 1976 and 2012. When listed according to the year of publication, most publications were found to be in the year 2009. Papers appeared mostly in "Surgery Today." The mean impact factor of the journals where the papers have been published was 1.9 (0.1-13.8). The rates of thyroid, parathyroid, adrenal tissue and neuroendocrine tumors related publications were 69%, 10%, 15% and 6%, respectively. Since this study is not an experimental study or a study related to patient data, we did not apply for ethical approval., Conclusion: The contribution of Turkish general surgeons' to world science is apparent when evaluated in terms of publications related to endocrine surgery until recently. Particularly, since 2002, with the increase in the number of publications in the field of endocrine surgery, there has been an increase in Turkey's importance on the international platform.

Objective: The aim is to evaluate if patients reach the level of competence that enables them to make the best decision for themselves with oral and written informed consent process that is legally valid., Material and Methods: This study included 62 patients who applied to Ege University Hospital Department of General Surgery Endocrine Surgery Clinics and in whom oral and written informed consent was obtained by a surgeon. Patients who were willing to participate in the study were asked to fill in a questionnaire containing questions regarding the concept of consent., Results: Seventy-one percent of patients were female and 29% were male, with a mean age of 50.4±17.9 years. Six percent of patients were illiterate, 51.6% had primary education and 16.1% were college graduates. One in every two patients stated that they have never heard of informed consent concept before, 16% stated that they signed the consent without reading it. Among these patients, 88% reported that they trusted the physician and did not bother reading because they have already been verbally informed. Verbal briefing by the doctor was detected as 92%. Similarly, 91% of the patients reported that the time allocated to read and fill-in the form was enough., Conclusion: Informing is not composed simply of conveying information, but also to elevate patients to a proficiency level where they could decide with their best interest. It is thought that the results obtained in this study might guide studies to improve the quality of information in patients undergoing surgery.

Objective: Although fine needle aspiration biopsy has a high sensitivity in thyroid nodule assessment, ultrasonography findings should not be underestimated. With this study, we aimed to evaluate cytologically benign nodules smaller than two centimeters, where ultrasonography findings were suspicious., Material and Methods: Thirty-one patients undergoing thyroidectomy between January 2009 and January 2013 were included in this retrospectively designed study. Thyroid ultrasonography and thyroid fine needle aspiration biopsy (FNAB) results were evaluated. Ultrasonographically, all patients had multinodular tissue formation and nodules had at least one of the suspicious features (nodules with hypoechogenicity, irregular margins, absence of halo, taller-than-wide, increased vascularity and microcalcifications). Maximum size of the nodules was 2 cm. Thyroidectomy was performed in this ultrasonographically suspicious, but cytologically benign group due to clinical suspicion, cosmetic reasons or patient preference., Results: All patients underwent a total thyroidectomy. The group consisted of 27 female and 4 male patients, with a mean age of 49.5 years. According to the final pathology reports, there were 13 (41.9%) multinodular goiters, 2 (6.4%) follicular adenomas, 1 (3.2%) Hashimoto's thyroiditis and 15 (48.3%) thyroid cancers. Patients with cancer had at least two suspicious ultrasound findings. Except five patients with papillary microcarcinoma, cancer was diagnosed in ultrasonographically suspicious nodules in all patients. The percentage of patients with benign FNAB results, but with at least two suspicious ultrasound findings of malignancy in the biopsied nodules, was 32.2%., Conclusion: FNAB remains to be the gold standard in the management of ultrasonographically suspicious nodules smaller than 2 centimeters. Nevertheless, due to its high sensitivity, in case of presence of suspicious features on ultrasonography, we believe that thyroidectomy should be a treatment option if there is a clinical suspicion and the patient carries at least two suspicious ultrasonography findings.

Objective: In this study, we aimed to determine the significance of the staging systems (EORTC, De Groot, MACIS, and TNM) on the prognosis of well-differentiated thyroid cancer patients who underwent surgery in our clinics., Material and Methods: This retrospective study included 181 patients who were operated between December 1995-December 2007, with a diagnosis of thyroid cancer. In order to obtain data related to cancer staging, a computer program for PDA was developed to facilitate parameter recording. Survival analysis was performed. The findings were compared to the predicted rates by the staging systems., Results: According to the De Groot staging system, stage 1 and stage 2 patients' results were compatible, but stage 3 and 4 patients' results were different (stage 3; 87% versus 66.6%, stage 4; 35% versus 100%, p=0.04). In the MACIS staging system, 20-year survival rates are determined and comparison should not be made due to insufficient follow-up period in this study. When compared to the EORTC staging system, stage 3 and stage 4 patients' results were determined different (stage 3; 51% versus 100%, stage 4; 33% versus 50%, p=0.02). The most consistent results in terms of prognosis was determined in comparison with the TNM staging system (stage 1; 100% versus 97.8%, stage 4; 45.3% versus 50%)., Conclusion: Many classification systems are proposed for well-differentiated thyroid cancer, to predict the behavior of the tumor. In this study, we concluded that for determination of prognosis in well-differentiated thyroid cancer, the TNM staging system could best predict prognosis consistent with clinical findings.