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Introduction Voice and swallowing symptoms are frequently reported after thyroidectomy even without laryngeal nerve injury. We aimed to evaluate the effect of strap muscle transection on voice and swallowing outcome after thyroidectomy. Methods Group 1 (G1) consisted of 17 patients who had their strap muscles transected during thyroidectomy and group 2 (G2) consisted of 17 patients who had their strap muscles preserved during thyroidectomy. None of the patients had laryngeal nerve injury. Voice impairment scores (VIS) and swallowing impairment scores (SIS) were obtained preoperatively and at 1 week and 1, 3 and 6 months postoperatively. Pre- and postoperative vocal cord examinations were performed for all patients. The external branch of the superior laryngeal nerve (EBSLN) was evaluated by intraoperative cricothyroid muscle electromyography. Results There was no significant difference in VIS and SIS between the two groups. At postoperative week 1, the VIS and SIS for each group were above preoperative values (G1: p = 0.005 and p = 0.035; G2: p = 0.031, p = 0.346, for VIS and SIS respectively). The VIS and SIS scores at 6 months postoperatively were significantly lower than those of the first week postoperatively (G1: p = 0.04 and p = 0.001; G2: p = 0.022 and p = 0.034 respectively) and similar to preoperative values (G1: p = 0.924 and p = 0.086; G2: p = 0.822 and p = 0.187 respectively). Conclusion Although voice and swallowing complaints increased in the early postoperative period even without recurrent laryngeal nerve and EBSLN injuries, these symptoms are not related with the strap muscle transection.

Background: The internet is a widely used source for receiving medical information. Nevertheless, the quality of data on online platforms is still questioned. Our aim was to compare the laparoscopi...

Background: The internet is a broadly preferred source of information both by patients and medical professionals. YouTube™ is a significant information source that may be a useful tool to inform the public, medical students, and residents, and may improve the learning experience if used adequately. In this study, we aimed to estimate the quality and accuracy of videos regarding Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) aired on YouTube, which is the most popular video platform of the online world. Materials and Methods: We evaluated the first 50 videos, returned by the YouTube research engine, in reply to the "TOETVA" keyword. The popularity of the videos was assessed using the video power index (VPI). The educational quality, accuracy, and transparency of the content regarding TOETVA were estimated by using the DISCERN questionnaire score (DISCERNqs), Journal of American Medical Association benchmark criteria (JAMABC), and global quality score (GQSc). The technical quality was ranked through TOETVA Scoring System (TOETVA-SS) by a TOETVA practicioning endocrine surgeon. Results: The content of the videos were about surgical technique with a rate of 68%. According to sources, videos uploaded by physicians had significantly higher DISCERNqs, JAMABC, GQSc, and TOETVA-SS scores. Unlike, videos uploaded by physicians had a lower VPI than videos uploaded by nonmedical sources. The videos of surgical technique had significantly higher DISCERNqs, JAMABC, GQSc, and TOETVA-SS scores. Surgical technique videos also had higher VPI scores than "information about disease or surgery" videos. Also, negative correlations were found between the VPI (popularity index) and educational value (GQSc), transparency (JAMABC), and technical quality (TOETVA-SS) scores. Conclusions: The data acquired from YouTube videos regarding TOETVA is of below expected quality and reliability. Nevertheless, the educative potential of the online video platform, YouTube, cannot be underestimated.

Amaç: Tıpta teknoloji ilerledikçe intraoperatif sinir monitorizasyonu özellikle tiroid ameliyatları için güçlü bir güvenlik aracı haline gelmiştir. Aralıklı veya sürekli intraoperatif sinir monitörizasyonunun (IONM) rekürren laringeal sinir (RLN) felcini azaltmadaki etkinliği, cerrahın deneyim düzeyi ne olursa olsun RLS'nin hasar görmemesini sağlamak için oldukça tartışılan bir konu olmuştur. Bu prospektif çalışmada, tiro- idektomiye bağlı iyatrojenik RLS felcinin önlenmesi için sürekli intraoperatif sinir monitörizasyonunu (C-IONM) aralıklı intraoperatif sinir monitörizasyonu (I-IONM) ile karşılaştırdık. Gereç ve Yöntem: Yaşları 18 ile 75 arasında değişen 109 hasta, sırasıyla -IONM veya C-IONM uygulanan 64 ve 45'er kişilik 2 gruba ayrıldı. Minimal invaziv cerrahi için seçilen hastalarda RLS'lerin tam eksplore edilememesi veya sinirde tümör invazyonu bulunması dışlama kriteri olarak kabul edildi. Bulgular: Grup 2’deki hastaların sinirlerinin %54’ü yüksek risk al- tında olup, bu oran Grup 1’e göre anlamlı derecede yüksek bulundu (p=0.022). Grup 1 ve Grup 2’deki hastalarda kalıcı ve geçici vokal kord paralizlerinin oranları sırasıyla 4,5% - 0,6% ve 2,8% - 0% olarak saptandı. İstatiksel olarak bu oran anlamlı bulunmadı (p>0,05). Yapılan multivaryant analizde ekstra laryngeal sinir dallanmasının varlığının vokal kord paralizi için bağımsız bir risk faktörü olduğu görüldü (p=0.21). Tartışma ve Sonuç: C-IONM, cerrahın önlenebilir RLS hasarını önce- den tespit edip durdurmasını sağladığı için üstün bir tekniktir. RLS felci vakalarının sayısını en aza indirmek ve bilateral RLS paralizisini önlemek için tiroid ameliyatlarında İONM'nin standart bir yaklaşım olarak kullanılması gerektiğine inanıyoruz.

Objectives The anal fistula is a permanent infectious tunnel formed between the anal canal and skin in the perianal region. Fistulas are treated by surgery at any stage. Many surgical methods have been reported to treat anal fistula. One of the promising surgical methods with a high success rate is ligation of the intersphincteric fistula tract, which is performed in anatomical spaces without damage to the internal and external sphincters. We evaluated the success rate of a modified ligation of the intersphincteric fistula tract procedure for complex anal fistulas in which the technical differences were minimized by the surgery being performed by the same surgical team. Methods In this study, Data of the 56 patients were retrospectively collected. Data regarding patient history, visual and digital anal examination, Cleveland Clinic Florida Fecal Incontinence (CCF-FI) score, anal-phase pelvic magnetic resonance imaging (MRI), rectosigmoidoscopy or colonoscopy and anal manometry were recorded. The changes in data recorded during the preoperative and postoperative periods were compared in each other. Results The mean age of the patients was 41±15.5 years. The number of patients for each fistula type compromised in this study was as follows in accordance with frequency: high transsphincteric fistula, high intersphincteric fistula, and horseshoe abscess. The fistula recurred in seven patients during postoperative follow-up and the success rate of modified LIFT was calculated as 87.5%. The change in the mean±SD preoperative and postoperative CCF-FI scores and anal pressure was not statistically significant. Conclusion One promising advantage of the ligation of the intersphincteric fistula tract procedure is that it turns a complex fistula into a simple fistula that can be treated with minimal risk of sphincter damage.

Pheochromocytomas (PCC) and paragangliomas (PGL) are rare neuroendocrine tumors. Pheochromocytomas arise from chromaffin cells in the adrenal medulla, and PGLs arise from chromaffin cells in the ganglia of the autonomic nervous system. Paragangliomas originate from sympathetic or parasympathetic ganglia in the abdomen, thorax, and pelvis. The majority of PCC and sympathetic PGL are endocrine active tumors causing clinical symptoms by secreting excess catecholamines (norepinephrine, epinephrine, dopamine) and their metabolites. The incidence of PCC and PGL ranges between 2 and 8 per million, with a prevalence between 1:2500 and 1:6500. It peaks between the 3rd and 5th decades of life, and approximately 20% of cases are pediatric patients. The prevalence among patients with hypertension in outpatient clinic ranges between 0.1-0.6% in adults and between 2-4.5% in the pediatric age group. 10-49% of these tumors is detected incidentally in imaging techniques performed for other reasons. However, 4-8% of adrenal incidentalomas are PCCs. Of these neuroendocrine tumors, 80-85% are PCCs and 15-20% are PGLs. Up to 40% of patients with PCC and PGL has disease-specific germline mutations and the situation is hereditary. Of 60% of the remaining sporadic patients, at least 1/3 has a somatic mutation in predisposing genes. 8% of the sporadic cases, 20-75% of the hereditary cases, 5% of the bilateral, adrenal cases, and 33% of the extra-adrenal cases at first presentation are metastatic. Although PCCs and PGLs have scoring systems for histological evaluation of the primary tumor, it is not possible to diagnose whether the tumor is malignant since there is no histological system approved for the biological aggressiveness of this tumor group. Metastasis is defined as the presence of chromaffin tissue in non-chromaffin organs, such as lymph nodes, liver, lungs and bone. Although most of the PCC and PGL are benign, the metastatic disease may develop in 15-17%. Metastatic disease is reported between 2-25% in PCCs and 2.4-60% in PGLs. The TNM staging system of the American Joint Committee on Cancer (AJCC) was developed to predict the prognosis, based on the specific anatomical features of the primary tumor and the occurrence of metastasis.

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.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.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 of29 cmThe 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.

Goiter term is generally used for defining the enlargement of thyroid gland. Thyroid nodules are very common and some of these nodules may harbor malignancy. Multinodular goiter (MNG) disease without thyroid dysfunction is defined as non-toxic MNG. There are many factors in etiology for development of MNG. They can be classified as iodine dependent and non-iodine dependent factors basically. Beyond this basic classification, the effect of many environmental and acquired factors is also effective on the development of goiter. Many methods have described for diagnosis and treatment for non-toxic MNG. Biochemical tests, imagining methods, invasive and non-invasive methods have been used for diagnosis for many years. Each method has advantages and disadvantages, separately. Although the best method for diagnosis is still debatable, distinguishing malignant nodules from benign nodules is the first and most important step for MNG. Biochemical tests such as serum thyroid stimulating hormone (TSH) measurement, thyroid hormone measurement; and thyroid ultrasonography are used for diagnosis of MNG, traditionally. Nowadays, there are some new techniques were developed like ultrasound-elastography. Furthermore, thyroid scintigraphy may be used if there is abnormal TSH measurement. Fine-needle aspiration biopsy and some cross-sectional imaging methods (computed tomography, magnetic resonance imaging, and positron emission tomography) could be used, too. After a certain diagnosis is made, treatment options should be evaluated. Many treatment methods have been used for goiter from ancient times upon today. From non-invasive methods such as medical follow-up to invasive methods such as lobectomy or thyroidectomy are options for treatment. Patients with compression symptoms due to an enlarged thyroid gland are usually candidates for surgery. In this study, it is aimed to determine the most appropriate treatment for the patient by discussing the advantages and disadvantages of all these methods. The present review discusses definition of goiter term, etiology, epidemiology, pathogenesis, diagnostic methods, and treatment methods for nontoxic MNG.

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.

In the present study, we investigated the effects of Vitamin D (vit D) deficiency on aggressiveness of papillary thyroid cancer (PTC).Patients with PTC confirmed with pathological examination, whom were operated by a single surgeon between 2012 and 2017, were included in the study. The data of the patients were analyzed retrospectively. Cancers other than PTC, patients with hyperthyroidism and/or using antithyroid drugs were excluded from the study. The patients were classified as four quartiles according to serum Vit D levels; category 1 (7.1 ng/mL), category 2 (7.2-11.8 ng/mL), category 3 (11.9-23.4 ng/mL) and category 4 (23.5 ng/mL).A total of 133 patients (103 female, 30 male) with mean age of 46.4±13.6 (17-82) years were included in the study. There was no significant difference between the categories in terms of preoperative Vit D values according to the evaluated tumor aggressiveness characteristics. It was determined that the presence of tumor with a size above 1 cm and T3/4 tumor were not affected by Vit D level. There was no significant difference between Vit D categories regarding the characteristics of aggressiveness such as multicentricity, lymphovascular invasion, central, and lateral metastases.According to our results, serum Vit D levels are not associated with the aggressive tumor characteristics of PTC.

We observed significant contractions in the cricothyroid muscle (CTM) after recurrent laryngeal nerve (RLN) stimulation in some patients. We aimed to evaluate whether these contractions resulted from the laryngeal-muscle movement due to the contraction of other intrinsic muscles or actual CTM contraction, with objective real-time intraoperative electromyography (EMG) recordings.This study was performed prospectively in 106 consecutive patients who underwent intraoperative neural monitoring-guided primary thyroid surgery due to various thyroid diseases between February-2015 and February-2016. After completion of the thyroidectomy procedure; the RLN, vagus nerve (VN), external branch of the superior laryngeal nerve (EBSLN), plexus pharyngeus (PP), and contralateral EBSLN (CEBSLN) were stimulated and the responses from the CTM and CPM were recorded and evaluated by EMG through needle electrodes.182 CTMs of 106 patients, with the mean age of 45, were evaluated regarding their innervation patterns. Positive EMG waveforms were achieved from 181 CTMs with EBSLN stimulation. A total of 132 (74%) positive EMG responses were recorded after the stimulation of 179 RLNs. The mean amplitude obtained with CTM EMG with RLN stimulation was 5.5% of that with EBSLN stimulation. The CTM amplitude was 39% of the vocal cord amplitude with RLN stimulation. Positive EMG responses of 96 CTMs (55%) with VN stimulation were recorded. The mean amplitude through CTM EMG with VN stimulation was 6% of that with EBSLN stimulation. Positive EMG responses were achieved from 10 (0.6%) CTMs with the stimulation of 170 PPs. The mean amplitude obtained from CTMs with PP stimulation was 4.3% of that with EBSLN stimulation. Positive EMG amplitudes of 35 (67%) CTMs were obtained with stimulation of 52 CEBSLN. Temporary vocal cord paralysis was detected in six patients (5% of patients and 3.3% of the nerves) postoperatively.The RLN contributes significantly to the innervation of the CTM. Despite the findings associated with the contribution of the PP and CEBSLN to the CTM innervation, further studies are needed. We are of the opinion that these are among the significant factors that contribute to the differences in clinical findings between patients with EBSLN injuries.

Surgery is one of the most appropriate treatment options for many patients with substernal goiter (SG). However, SG surgery has some technical difficulties and a higher risk of complications compared to normal cervical thyroid surgery. Due to these technical difficulties and complication risks, which we also mentioned in our study, SG surgery should be performed by experienced and high-volume endocrine surgeons in centers with a large team and technical equipment. Pre-operative clinical and radiological evaluation and definitions in SG were evaluated in detail in our previous study. Detailed pre-operative evaluation, pre-operative risk assessment, surgical anatomy, anesthesia, appropriate surgical planning and estimation of surgical width are extremely important in SG surgery, where surgical technical difficulties and increased complication risks compared to cervical thyroid surgery come to the fore. In this study, we aimed to evaluate these preoperative and peroperative preparations in detail.

Thyroid-stimulating hormones (TSHs) are associated with the risk of differentiated thyroid cancer. The relationship between pre-operative TSH levels and aggressive features is unclear. We aimed to evaluate the relationship between pathological features of papillary thyroid carcinoma (PTC) and high TSH levels.Patients who were operated between 2012 and 2017 and who were found to have PTC in their pathology were included in the study. The relationship between TSH and the features of tumor aggressiveness was evaluated in the patients.Of the 132 patients, TSH level was significantly higher in those with lymphovascular invasion than those without (p=0.048), in those with central metastases than in those without (p=0.014), and in those with extrathyroidal spread than in those without (p=0.003). When patients were categorized into four 25% quartiles according to TSH (mUI/mL) level; the rate of extrathyroidal invasion increased as the TSH level increased, and the level was significantly higher in quartile 1 than the others, with significant difference (p=0.030).Pre-operative increase in TSH level is associated with an increased risk of extrathyroidal spread and central lymph node metastasis. TSH level may be a pre-operative valuable predictive factor for patients' risk of central metastasis.

The most common subtype of thyroid cancer is papillary thyroid cancer (PTC); lymph node metastases are common in this disease. Factors affecting the development of central lymph metastasis of PTC determine the treatment modality and prognosis of the disease. In this study, we aimed to evaluate the clinicopathologic features affecting the development of central lymph node metastasis.The data of a total of 346 PTC patients who were operated between May 2012 and September 2020 in our clinic and whose follow-up could be reached were evaluated retrospectively. Demographic data, surgical treatment modalities, and histopathological data of all patients were evaluated as a result of at least 6 months of follow-up. Patients age, sex, body mass index, pre-operative TSH levels, anti-TPO, and anti-Tg values at the time of diagnosis, whether lymph node dissection is performed, presence of lymph node metastasis, presence of distant metastasis, stage at the time of diagnosis (TNM 8th edition), ATA risk group at the time of diagnosis, multifocal and/or multicentric (bilaterality), largest tumor size, aggressive histological subtype, lymphovascular invasion of the tumor, extrathyroidal invasion, presence of lymphocytic thyroiditis, and surgical margin positivity were evaluated retrospectively.In the development of PTC central metastasis, distant metastasis, tumor size, multifocality, multicentricity, presence of lymphovascular invasion, aggressive tumor subtype, presence of lateral metastasis, nodular goiter, and extrathyroidal spread were found to be effective. Among these factors, T stage, presence of lymphovascular invasion, and multicentricity were identified as independent risk factors for the development of central metastasis.Today, the investigation of predictive factors for the development of nodal metastasis in PTC does not seem to be out of date anytime soon. In our study, T stage, presence of lymphovascular invasion, and multicentricity were identified as independent risk factors for the development of central metastasis from the histopathological features of the tumor in PTC and of these features, T stage and multicentricity can be predicted by pre-operative imaging in many patients and can be used to decide whether to perform prophylactic SLN dissection in patients. However, new studies are still needed on this issue, in the literature.

The enlargement of multinodular goiter into the mediastinum through the thoracic inlet or ectopic thyroid tissues directly in the mediastinum is defined as Substernal Goiter (SG). However, there is no clear consensus in the literature on this definition. There are many definitions for SG in the literature. Most definitions are similar or overlapping. Since the thyroid is located in the neck above the thoracic inlet in its normal anatomical position, the simplest clinical definition should be preferred among the definitions regarding its descent below the thoracic inlet and adjacent to the mediastinal organs. In the American Thyroid Association guideline, SG is defined as clinical or radiological protrusion of the thyroid gland over the sternal notch or clavicle in a patient with a slightly extended neck in the supine position. SGs can be classified as primary or secondary according to their origins. In addition, there are combined SGs resulting from the enlargement of the primary SG, which is the growth of the cervical thyroid gland toward the mediastinum, and the secondary SG, which is defined as an ectopic mediastinal mass, together. We find it appropriate to define such SGs as mixed SGs. In this disease, which has the same etiology and etiopathogenesis as cervical goiter, the descent of the thyroid gland into the mediastinum due to some anatomical factors explains the physiopathology. Compression symptoms of mediastinal major vascular structures, trachea, and esophagus cause the symptoms and findings of SGs due to its localization. In addition, the relationship of SGs with possible malignancy risk and hyperthyroidism affecting the indications and methods of treatment has been discussed for a long time. In this study, we aimed to evaluate the definitions, classification, physiopathology, laboratory and imaging methods used for diagnosis, the relationship of SG with hyperthyroidism and malignancy, and briefly the treatment methods, according to the current studies from literature.

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.

Objective: We aimed to present a case with a previous thyroid surgery, who developed an internal jugular vein thrombus due to papillary thyroid cancer (PTC) in the remnant tissue. Case: A 54-year-old female patient, with a previous subtotal thyroidectomy, presented with a mass on the left side of her neck. Thyroid ultrasound disclosed a heterogeneous nodule of 67x48x32 mm in the left thyroid lobe. An isoechoic tumor thrombus was observed extending intraluminally from the middle thyroid vein to the internal jugular vein. No lymph node or solid organ invasion were detected in the neck. Fine needle aspiration biopsy revealed cytological findings consistent with PTC. Total thyroidectomy, left sided central neck dissection and partial left jugular vein resection was performed. The pathologic examination revealed mid-differentiated unifocal encapsulated follicular variant of PTC. The whole-body scan performed after the postoperative treatment of 150 mCi of radioactive iodine, revealed multiple lung metastases. Conclusion: The presence of a tumor thrombus in the thyroid vein or internal jugular vein is strongly suspicious for malignancy even in the absence of malignant findings on cytology. It is an important finding that is highly suspicious for distant metastasis in the cytologically diagnosed patients.

At present, intraoperative neuromonitorization (IONM) with surface electrode-based endotracheal tube (ETT) is a standard method in thyroidectomy and can be performed either intermittently IONM (I-IONM) or continuously IONM (C-IONM). Despite the valuable contribution of I-IONM to the thyroidectomy, it still has limitations regarding the recording electrodes and stimulation probe. New approaches for overcoming the limitations of I-IONM and developing the method are taking attention. Most of the technical issues of IONM with surface electrode-based ETT are related with inadequate contact of electrodes to the vocal cords. Nowadays, efficiency of various recording electrodes is under investigation. Recording electrodes such as needle electrodes applied to thyroarytenoid or posterior cricoarytenoid muscle (PCA), surface electrodes applied to the PCA, and needle or adhesive electrodes applied to the tracheal cartilage or skin, can make safe recordings similar to the ETT electrodes. Despite their invasiveness, needle electrodes record higher electromyography (EMG) amplitudes than tube electrodes do. Adhesive surface electrodes make safe EMG recordings, although amplitudes of these electrodes are usually lower than those of the tube electrodes. These different types of electrodes are less affected by tracheal manipulations and amplitude changes are lower compared to the tube electrodes. During C-IONM, an additional stimulation probe is applied to the vagus nerve after dissecting the nerve circumferentially. Recently, without applying a probe, a new continuous monitorization method called laryngeal adductor reflex CIONM (LAR-CIONM) using sensorial, central, and motor components of LAR arch which is an automatic, primitive brainstem reflex protecting the tracheoesophageal tree from foreign body aspiration, has been implemented. Afferent track of LAR communicates laryngeal mucosa to the brainstem by internal branch of the superior laryngeal nerve and efferent track reaches larynx through recurrent laryngeal nerve. Total outcome of LAR activation is the closure of laryngeal entry by bilateral vocal cord adduction. In LAR-CIONM, a stimulus is given by an electrode from one side of surface electrode-based ETT and amplitude response of the LAR at the vocal cord is followed on the operation side. Recently, it has been reported that real-time EMG response can be obtained with stimulation probe cables applied to dissectors or energy devices during the dissection through I-IONM.

The use of intraoperative neuromonitoring (IONM) is getting more common in thyroidectomy. The data obtained by the usage of IONM regarding the laryngeal nerves' anatomy and function have provided important contributions for improving the standards of the thyroidectomy. These evidences obtained through IONM increase the rate of detection and visual identification of recurrent laryngeal nerve (RLN) as well as the detection rate of extralaryngeal branches which are the most common anatomic variations of RLN. IONM helps early identification and preservation of the non-recurrent laryngeal nerve. Crucial knowledge has been acquired regarding the complex innervation pattern of the larynx. Extralaryngeal branches of the RLN may contribute to the motor innervation of the cricothyroid muscle (CTM). Anterior branch of the extralaryngeal branching RLN has always motor function and gives motor branches both to the abductor and adductor muscles. In addition, up to 18% of posterior branches may have adductor and/or abductor motor fibers. In 70-80% of cases, external branch of superior laryngeal nerve (EBSLN) provides motor innervation to the anterior 1/3 of the thyroarytenoid muscle which is the main adductor of the vocal cord through the human communicating nerve. Furthermore, approximately 1/3 of the cases, EBSLN may contribute to the innervation of posterior cricoarytenoid muscle which is the main abductor of ipsilateral vocal cord. RLN and/or EBSLN together with pharyngeal plexus usually contribute to the motor innervation of cricopharyngeal muscle that is the main component of upper esophageal sphincter. Traction trauma is the most common reason of RLN injuries and constitutes of 67-93% of cases. More than 50% of EBSLN injuries are caused by nerve transection. A specific point of injury on RLN can be detected in Type 1 (segmental) injury, however, Type 2 (global) injury is the loss of signal (LOS) throughout ipsilateral vagus-RLN axis and there is no electrophysiologically detectable point of injury. Vocal cord paralysis (VCP) develops in 70-80% of cases when LOS persists or incomplete recovery of signal occurs after waiting for 20 min. In case of complete recovery of signal, VCP is not expected. VCP is temporary in patients with incomplete recovery of signal and permanent VCP is not anticipated. Visual changes may be seen in only 15% of RLN injuries, on the other hand, IONM detects 100% of RLN injuries. IONM can prevent bilateral VCP. Continuous IONM (C-IONM) is a method in which functional integrity of vagus-RLN axis is evaluated in real time and C-IONM is superior to intermittent IONM (I-IONM). During upper pole dissection, IONM makes significant contributions to the visual and functional identification of EBSLN. Routine use of IONM may minimalize the risk of nerve injury. Reduction of amplitude more than 50% on CTM is related with poor voice outcome.

Objective: It is still controversial whether performing central neck dissection (CND) in addition to total thyroidectomy (TT) increases the risk of complications. In the present study, we aimed to evaluate the effect of CND on the development of complications in differentiated thyroid cancer (DTC) compared to TT. Material and Methods: The data of 186 patients (136 females and 50 males) with a mean age of 48.73±14.78 (range, 17–82) whom were operated for DTC were evaluated retrospectively. The patients were divided into two groups; TT (Group 1) and CND±TT/Completion thyroidectomy±lateral neck dissection (Group 2). Results: There were 117 (91 F, 26 M) patients in Group 1 and 69 (45 F, 24 M) patients in Group 2. Parathyroid auto transplantation (PA) was significantly higher in Group 2 compared to Group 1 (42% vs. 6%) (p=0.000). Total (58% vs. 21.4%, respectively; p=0.000) and transient hypoparathyroidism (52.2% vs. 20.5%, respectively; p=0.000) were significantly higher in Group 2 than in Group 1, but permanent hypoparathyroidism rates were statistically not significant (5.8% vs. 0.9%, respectively; p=0.064). In the multinomial logistic regression analysis, CND alone was determined as an independent risk factor for increased both total and transient hypoparathyroidism. The relative risk (RR) of CND for total hypoparathyroidism was 5.2 times increased (odds ratio [OR]: 0.192) (p=0.007), while the RR for transient hypoparathyroidism was 3.5 times increased (OR: 0.285) (p=0.036). According to the number of nerves at risk, CND was performed in 119 neck side and only thyroidectomy was performed in 253 neck side. Total vocal cord paralysis (VCP) rate (9 [7.6%] vs. 6 [2.4%], respectively) (p=0.017) and transient VCP rate (7 [6%] vs. 4 [1.6%], respectively) (p=0.021) in patients who underwent CND were significantly higher compared to those who underwent only thyroidectomy. In multinomial logistic regression analysis performing only CND was an independent risk factor for total VCP, and increased the total VCP RR approximately 5.34 times (OR:0.184; p=0.007). Conclusion: Although CND can be applied without increasing the rates of permanent hypoparathyroidism and VCP compared to TT, it increases the risk of total and transient hypoparathyroidism, total, and transient VCP. Patients undergoing CND should be followed carefully in terms of transient hypoparathyroidism.

Vitamin D deficiency is a very common global health problem. Evidence from recent studies focuses on the extraskeletal effects of vitamin D (Vit D) deficiency. Chronic lymphocytic thyroiditis (or Hashimoto's thyroiditis) is an autoimmune disease of the thyroid. Although there are many studies reporting that autoimmune thyroid diseases may be associated with Vitamin D deficiency, this is still a controversial issue that has not yet been proven. In this study, we aimed to appraise whether there is a relationship between lymphocytic thyroiditis diagnosed by histopathological evaluation and Vitamin D deficiency.Data of 256 patients whom were operated by a single surgeon in a single center between 2012 and 2017 and whose preoperative vitamin D tests and thyroid pathologies have been collected, were retrospectively evaluated. Due to the pathological examination, two groups were formed considering the presence of lymphocytic thyroiditis (Group 1), and the absence of lymphocytic thyroiditis (Group 2). Vitamin D deficiency was defined as the level20 ng/mL (50 nmol/L) and Vitamin D insufficiency was defined as the level 21-29 ng/mL (525-725 nmol/L).There were 108 (92F/16M) patients in Group 1, and 148 (116F/32M) patients in Group 2, and the mean age was lower in Group 1 (p=0.053). The mean vitamin D levels (16.6±15.2 vs. 14±10, p=0.409) and vitamin D deficiency rates (67.6% vs. 72.3%, p=0.416) were found similar between the Groups 1 and 2. No positive significant correlation was found between lymphocytic thyroiditis and vitamin D level or vitamin D deficiency rates. There was a positive correlation between lymphocytic thyroiditis and age, preoperative thyroid-stimulating hormone level, preoperative anti-thyroglobulin ,and anti-thyroid peroxidase levels, but no significant relationship was found with Vitamin D level.According to our results, lymphocytic thyroiditis was not associated with either Vitamin D deficiency or Vitamin D level.

Objectives The curative treatment of primary hyperparathyroidism (PHPT) is surgery. Persistent and recurrent disease may develop after surgical treatment. In this study, we aimed to evaluate the surgical cure rate in patients who underwent surgery for PHPT in our clinic. Methods The data of patients who underwent parathyroidectomy for PHPT by two experienced surgeons between 2000 and 2015 in our clinic were retrospectively evaluated. Patients who were followed for at least 6 months after their first parathyroidectomy were included in the study. Surgical cure and persistent and recurrent disease rates were evaluated in patients. Results During this period, 368 interventions were performed in 357 patients (293 F and 64 M) who were operated for PHPT in our clinic, with a mean age of 54.9±13.1 years. In the first surgery, 116 patients (32.5%) had bilateral neck exploration, 251 patients (67.5%) had unilateral neck exploration (UNE) or focused parathyroid surgery (FPS). In the first operation, 343 patients (96.1%) had cure, 14 patients (13 F and 1 M) remained persistent. Secondary surgical intervention was performed in 11 patients. UNE or FPS was performed to 10 patients (90.9%); partial sternotomy was performed to one patient. Ten of the patients had cure. Three of these patients had a solitary parathyroid adenoma that was not removed in the first surgery, and seven patients had a second adenoma. Four patients remained persistent (1.1%). Recurrent disease developed in four patients during follow-up (1.1%). Total cure rate was 97.8%. Conclusion The only definitive treatment for PHPT is surgery. High surgical cure can be achieved by pre-operative evaluation and appropriate surgical planning. However, persistent PHPT may develop, especially due to double adenoma or ectopic location. Patients with persistent PHPT can be evaluated with repeat imaging methods and with appropriate surgical planning, a high cure rate can be obtained in secondary surgery, which can increase the total surgical cure rate. Recurrence rate is rare.

Objectives: Hypocalcemia is the most common complication and acute parathyroid gland insufficiency is the main cause of it after thyroidectomy. In this study, we aimed to evaluate the relationship between the recovery time of parathyroid gland function and patient characteristics, preoperative and postoperative electrolyte changes, and intraoperative parathyroid findings in patients with postoperative hypoparathyroidism. Methods: Patients who underwent total thyroidectomy (TT) with or without central neck dissection ± lateral neck dissection with a parathyroid hormone (PTH) value of 15 pg/mL); within the first 24 hours, between one day and 30 days, after 30 days, respectively. Results: One hundred eleven patients (mean age, 49.3±14.4 years) consisted of Groups 1, 2 and 3, including 19 (16F, 3M), 67 (54F, 13M) and 25 (19F, 6M), respectively. Vitamin D deficiency rates for Groups 1, 2, 3 were 41.7%, 53.1% and 88.2%, respectively (p=0.018). Postoperative day 0 PTH values were 11.69±2.79pg/mL, 6.92±3.45 pg/mL, 4.99±2.36 pg/mL, (p

Background: The recurrent laryngeal nerve (RLN) can be injured during thyroid surgery, which can negatively affect a patient's quality of life. The impact of intraoperative anatomic variations of t...

Objectives: Follicular neoplasm/suspected follicular neoplasm (FN/FNS) Bethesda Category (BC)-4 group cases are known as the gray zone. Nodules diagnosed in cytology are excised. However, very few of these nodules are malignant. Our aim is to investigate the usability of clinical-radiological-pathological parameters to reduce unnecessary surgery. In addition, we questioned the benefit of repeating fine-needle aspiration biopsy (rFNAB) in these nodules, which is not recommended, but performed for clinical or patient-related reasons. Methods: The files of all thyroid FNAB patients conducted in our institution between January 2014 and September 2020 were scanned in the database. In our study, 185 (5.1%) nodules with cytology results of which were classified as FN/FNS were identified among 3624 nodules that were applied FNAB during this period. Twenty-eight patients were excluded from the study group. 157 nodules belonging to 157 patients between the ages of 21 and 82 years who were operated and met the study criteria were identified from patients with these nodules. The files of all patients were scanned and the results of age, gender, ultrasonographic nodule characteristics, FNAB repeat, type of surgery, and postoperative pathology were recorded. All data were analyzed by comparing them with nodule features. SPSS 15.0 for Windows program was used for statistical analysis. Results: A significant correlation was found between the incidence of malignancy and male gender and hypervascularization (p=0.017 and p=0.002, respectively). Malignancy was less in nodules larger than 2 cm (p=0.014). There was no relationship between other clinical and radiological features and malignancy. In 29 nodules with rFNAB, a significant correlation was found between malignancy and advanced age (52.9-years-old), presence of nodules smaller than 2 cm and hypervascularization (p=0.047, p=0.047, and p=0.030, respectively). Conclusion: We recommend careful review of patients with hypervascular, hypoechogenic, and microcalcific BC-4 nodules (male gender and older patients at greater risk). Because of the serious risk of malignancy, patients with these features should be prepared for patient management with total thyroidectomy after examination with frozen section applied to the nodule during the operation.

The 2019 novel coronavirus disease (COVID-19) was initially seen in Wuhan, China, in December 2019. World Health Organization classified COVID-19 as a pandemic after its rapid spread worldwide in a few months. With the pandemic, all elective surgeries and non-emergency procedures have been postponed in our country, as in others. Most of the endocrine operations can be postponed for a certain period. However, it must be kept in mind that these patients also need surgical treatment, and the delay time should not cause a negative effect on the surgical outcome or disease process. It has recently been suggested that elective surgical interventions can be described as medically necessary, time-sensitive (MeNTS) procedures. Some guidelines have been published on proper and safe surgery for both the healthcare providers and the patients after the immediate onset of the COVID-19 pandemic. We should know that these guidelines and recommendations are not meant to constitute a position statement, the standard of care, or evidence-based/best practice. However, these are mostly the opinions of a selected group of surgeons. Generally, only life-threatening emergency operations should be performed in the stage where the epidemic exceeds the capacity of the hospitals (first stage), cancer and transplantation surgery should be initiated when the outbreak begins to be controlled (second stage), and surgery for elective cases should be performed in a controlled manner with suppression of the outbreak (third stage). In this rapidly developing pandemic period, the plans and recommendations to be made on this subject are based on expert opinions by considering factors, such as the course and biology of the disease, rather than being evidence-based. In the recent reports of many endocrine surgery associations and in various reviews, it has been stated that most of the cases can be postponed to the third stage of the epidemic. We aimed to evaluate the risk reduction strategies and recommendations that can help plan the surgery, prepare for surgery, protect both patients and healthcare workers during the operation and care for the patients in the postoperative period in endocrine surgery.

Objective Recognition of extralaryngeal branching of the recurrent laryngeal nerve is crucial because prevention of vocal cord paralysis requires preservation of all branches of the recurrent laryngeal nerve. We assessed the prevalence of extralaryngeal branching of the recurrent laryngeal nerve and the median branching distance from the point of bifurcation to the entry point of the nerve into the larynx. Material and methods Prospective operative data on recurrent laryngeal nerve branching were collected from 94 patients who underwent thyroid or parathyroid surgery between September 2011 and May 2012. Results A total of 161 recurrent laryngeal nerves were examined (82 right, 79 left). Overall, 77 (47.8%) of 161 recurrent laryngeal nerves were bifurcated before entering the larynx. There were 36 (43.9%) branching nerves on the right and 41 (51.9%) branching nerves on the left, and there was no significant difference between the sides in terms of branching (p=0.471). Among 67 patients who underwent bilateral exploration, 28.4% were found to have bilateral branching, 40.3% had unilateral branching, and the remaining 31.3% had no branching. The median branching distance was 15 mm (5-60mm). Conclusion Extralaryngeal division of recurrent laryngeal nerve is a common and asymmetric anatomical variant. These variations can be easily recognized if the recurrent laryngeal nerve is identified at the level of the inferior thyroid artery and then dissected totally to the entry point of the larynx. Inadvertent division of a branch may lead to vocal cord palsy postoperatively, even when the surgeon believes the integrity of the nerve has been preserved.

Objective: Despite the high frequency of bilateral disease in patients with papillary thyroid cancer (PTC), the importance of bilaterality in the prognosis of the disease is still unclear. In this study, we aimed to figure out the effects of bilaterality in the prognosis of the disease. Material and Method: A total of 113 patients with PTC, who were treated in our clinic with total thyroidectomy between 2011 and 2014, were divided into three groups: Group 1, patients with unilateral disease with single focus; Group 2, patients with unilateral disease with multiple foci; Group 3, patients with bilateral disease with multiple foci. Results: There was a statistically significant difference between the presence of bilateral disease, compared to unilateral disease, in terms of lymphovascular invasion (p=0.001), the diameter of the tumor (p=0.028), extra- thyroidal disease (p=0.012), T stage of the disease (p=0.042) and lymph node metastasis (p=0.001). Conclusion: Patients with bilateral papillary thyroid cancer are more likely to have larger tumors, higher extra- thyroidal dissemination rates, advanced T stages, lymph node metastasis and more aggressive tumors when compared to unilateral disease. Due to these considerations, the surveillance of the patients with bilateral papillary thyroid disease should be done more carefully and effectively.

Objectives: this study aimed to analyze the effects of intraoperative neuromonitoring (IONM) on the prevalence of vocal cord palsy (VCP) in thyroid surgery. Methods: data from 493 patients (839 nerves at risk [NAR]) who underwent thyroid surgery between July 2014 and May 2016 were retrospectively evaluated. The patients were divided into 2 groups: Group 1 (G1) consisted of patients who underwent surgery without IONM, whereas group 2 (G2) consisted of patients who underwent surgery with IONM. The surgical techniques were identical, and experienced surgeons performed the procedures in both groups. Intraoperative neuromonitoring was performed in compliance with the International Neural Monitoring Guidelines. Results: in total, 211 patients (170 female, 41 male) with 360 NAR were included in G1, and 282 patients (220 female, 62 male) with 479 NAR were included in G2. The number of VCP per NAR in G1 and G2 was 33 (9.2%) and 27 (5.6%), respectively (P =.005). The number of transient VCP per NAR in G1 and G2 was 27 (7.5%) and 23 (4.8%; P =.230), respectively. The number of permanent VCP per NAR in G1 and G2 was 6 (1.7%) and 4 (0.8%; P =.341), respectively. Bilateral VCP was detected in 4 (2.7%) patients in G1, whereas there was no patient with bilateral VCP in G2 (P =.033). Conclusions: intraoperative neuromonitoring may decrease the incidence of total VCP and prevent the development of bilateral VCP, which has unfavorable results for both patients and health-care professionals., NA

The majority of pheochromocytoma (PCC) and paraganglioma (PGL) are endocrine active tumors, and they cause clinical symptoms by secreting excess one or more catecholamines (epinephrine, norepinephrine, and dopamine) and their inactive metabolites (metanephrine, normetanephrine, 3-metoxythromine). Although signs and symptoms regarding excess catecholamine often develop in PCC and PGL (PPGL), non-functional PPGLs may present with local compression symptoms. Persistent, sometimes worsening hypertension is the most common finding and occurs in 80-90% of the patients. Classically defined symptom triad; headache, sweating and palpitations are seen in only 25% of the patients with PCC. The difference of clinical symptoms may be related to the tumor secretion, epinephrine or norepinephrine. All patients with signs and symptoms suggestive of catecholamine excess should be screened by biochemical tests regardless of whether they have hypertension or not. Not all patients with newly diagnosed hypertension need to be screened, but only patients with additional tips for catecholamine excess should be screened. Approximately 20% of the PPGLs are diagnosed in childhood, and the male/female ratio is 2/1. 60-90% of pediatric patients present with hypertension. PPGL in pregnancy is rare, and the estimated incidence ranges between 1/15000-1/54000. Although early diagnosis is the most important factor in preventing mortality, diagnosis is not as easy as it is a rare condition. Hypertension is a common complication in pregnancy, occurring in 5-10%. Computed tomography should not be used as the imaging method during pregnancy; the first choice is magnetic resonance imaging with gadolinium or without contrast. Plasma free metanephrine or 24-hour urinary fractionated metanephrine level is recommended as a screening test for the diagnosis of PPGL in the Endocrine Society Clinical Practice Guideline. In suspicious situations, tests should be repeated. Since 40% of these patients have germline mutations, genetic tests are recommended for all patients with PPGL regardless of family history and age. Preoperative knowledge of germline mutations affects the surgical approach and the extent of adrenalectomy. After the biochemical diagnosis is made in PPGL, the tumor is localized with imaging methods to make the operation plan. In this review, we aimed to evaluate the clinical findings, diagnostic tests, and imaging studies for tumor localization in PPGL.

Objectives Currently, laparoscopic adrenalectomy is the gold standard technique for suitable patients with adrenal masses. In this study, we aimed to assess the postoperative results of patients who underwent laparoscopic adrenalectomy. Methods Between January 2014 and October 2019, 76 cases were operated and retrospectively evaluated. Laparoscopic transabdominal adrenalectomy was applied to the patients. Demographic profiles, preoperative indications, intraoperative and postoperative complications, mortality and length of hospital stay were evaluated. Results Seventy-six patients (30 male, 46 female) with a mean age of 47.2±11.7 (range 22-71) years underwent laparoscopic adrenalectomy. Thirty-nine of the patients had right; 33 of the patients had left adrenal masses. Three patients had bilateral adrenal cortical hyperplasia. One patient was operated for paraganglioma. Conversion to open adrenalectomy was observed in four patients (5.26%). Nine patients (11.8%) experienced intraoperative and postoperative complications. Intraoperative and postoperative complications were bleeding from spleen (2 cases) and upper pole of kidney (1 case), renal artery injury (1 case), bleeding from liver parenchyma (2 cases), ischemia of spleen and pancreas (1 case), small intestinal injury (1 case) and incisional hernia (1 case). The complication rate is acceptable and comparable with other studies in the literature. Conclusion Laparoscopic adrenalectomy can be safely applied in suitable patients with acceptable complications and low conversion rates.

Pheochromocytomas (PCC) and paragangliomas (PGL) are rare neuroendocrine tumors arising from chromaffin cells in the adrenal medulla, sympathetic or parasympathetic ganglia. Currently, the only curative treatment option of pheochromocytomas/paraganglioma (PPGL) is surgical resection. Surgery aims to eliminate both risks of hypersecretion and tumor growth. The consequences of hypersecretion should be carefully controlled with medical therapy before and during the surgery. Postoperative major complications are hypotension and rebound hypoglycemia, and patients should be followed closely for 24-48 hours. The choice of surgical approach is determined based on multiple factors, including germline genetic test results, the size of the tumor, body mass index, surgeon's experience, and the likelihood of malignancy. Primary tumor resection does not completely eliminate the risk of tumor persistence and recurrence. Therefore, all patients with PPGL who are surgically treated should be followed for at least 10 years for recurrent disease and new tumor formation. Although surgical resection is the only curative treatment for PPGLs, surgical treatment is palliative except for resectable locoregional metastases in metastatic disease or for isolated distant metastases. The purpose of palliative treatment is to reduce hormone secretion and prevent metastasis-related complications in a critical anatomical location Combined and alfa;- and beta- adrenergic blockade is usually applied in patients with PPGL preoperatively. Some patients may present with pheochromocytoma multisystem crisis, which is a life-threatening condition that can involve cardiovascular, pulmonary, neurological, gastrointestinal, renal, hepatic and metabolic systems. Pheochromocytoma crisis may be spontaneous or may present with the tumor manipulation, trauma, corticosteroids, beta-blockers, anesthetic drugs, and the stimulation of non-adrenal surgical stress. These patients should be considered as medical emergencies rather than surgical emergencies. In this review, it was aimed to evaluate the pre-, per and post-operative management, curative and palliative surgical management, and postoperative outcomes and follow-up of the patients with PPGLs.

The 2019 novel coronavirus disease (COVID-19) was initially seen in Wuhan, China, in December 2019. World Health Organization classified COVID-19 as a pandemic after its rapid spread worldwide in a few months. With the pandemic, all elective surgeries and non-emergency procedures have been postponed in our country, as in others. Most of the endocrine operations can be postponed for a certain period. However, it must be kept in mind that these patients also need surgical treatment, and the delay time should not cause a negative effect on the surgical outcome or disease process. It has recently been suggested that elective surgical interventions can be described as medically necessary, time-sensitive (MeNTS) procedures. Some guidelines have been published on proper and safe surgery for both the healthcare providers and the patients after the immediate onset of the COVID-19 pandemic. We should know that these guidelines and recommendations are not meant to constitute a position statement, the standard of care, or evidence-based/best practice. However, these are mostly the opinions of a selected group of surgeons. Generally, only life-threatening emergency operations should be performed in the stage where the epidemic exceeds the capacity of the hospitals (first stage), cancer and transplantation surgery should be initiated when the outbreak begins to be controlled (second stage), and surgery for elective cases should be performed in a controlled manner with suppression of the outbreak (third stage). In this rapidly developing pandemic period, the plans and recommendations to be made on this subject are based on expert opinions by considering factors, such as the course and biology of the disease, rather than being evidence-based. In the recent reports of many endocrine surgery associations and in various reviews, it has been stated that most of the cases can be postponed to the third stage of the epidemic. We aimed to evaluate the risk reduction strategies and recommendations that can help plan the surgery, prepare for surgery, protect both patients and healthcare workers during the operation and care for the patients in the postoperative period in endocrine surgery.

Indications for adrenalectomy are malignancy suspicion or malignant tumors, non-functional tumors with the risk of malignancy and functional adrenal tumors. Regardless of the size of functional tumors, they have surgical indications. The hormone-secreting adrenal tumors in which adrenalectomy is indicated are as follows: Cushing's syndrome, arises from hypersecretion of glucocorticoids produced in fasciculata adrenal cortex, Conn's syndrome, arises from an hypersecretion of aldosterone produced by glomerulosa adrenal cortex, and Pheochromocytomas that arise from adrenal medulla and produce catecholamines. Sometimes, bilateral adrenalectomy may be required in Cushing's disease due to pituitary or ectopic ACTH secretion. Adenomas arise from the reticularis layer of the adrenal cortex, which rarely releases too much adrenal androgen and estrogen, may also develop and have an indication for adrenalectomy. Adrenal surgery can be performed by laparoscopic or open technique. Today, laparoscopic adrenalectomy is the gold standard treatment in selected patients. Laparoscopic adrenalectomy can be performed transperitoneally or retroperitoneoscopically. Both approaches have their advantages and disadvantages. In the selection of the surgery type, the experience and habits of the surgeon are also important, along with the patient's characteristics. The most common type of surgery performed in the world is laparoscopic transabdominal lateral adrenalectomy, which most surgeons are more familiar with. The laparoscopic anterior transperitoneal approach is the least preferred laparoscopic method in adrenalectomy. Retroperitoneal laparoscopic adrenalectomy can be performed with a posterior or lateral approach. In addition to conventional laparoscopy, laparoscopic surgery is robot-assisted, which can be administered by transperitoneal or retroperitoneal approach. In addition, conventional or robot-assisted laparoscopic adrenalectomy can be performed transabdominally or retroperitoneally using the single-port method. Today, partial adrenalectomy can be performed using laparoscopic techniques in bilateral adrenal masses, hereditary diseases with the risk of developing multiple adrenal tumors, and solitary masses of the adrenal gland. Open surgery is indicated in the case of malignancy or suspected malignancy and large tumors when laparoscopic surgery is contraindicated. The risk of conversion to open surgery is low (approximately 5%). The open transperitoneal anterior approach is the most common open intervention, especially in large tumors with malignancy or suspected malignancy. This procedure can be performed using a midline incision, bilateral or unilateral subcostal incision, Makuuchi or modified Makuuchi incision. Thoracoabdominal incision may be required, especially in the removal of large malignant lesions as a block. The open retroperitoneal approach can be applied posteriorly or laterally.

COVID-19 was first seen in China at the end of December 2019. COVID-19 is a novel type of coronavirus that is defined as SARS-CoV-2, which can be mild or severe in the lungs, causing acute respiratory infection. The disease was first presented in the literature as Coronavirus Disease 2019 (COVID-19) in February 2020. The disease spread rapidly and was declared as a pandemic by the World Health Organization (WHO) on March 11, 2020. There have been approximately 7734185 reported cases, and 412369 reported deaths to date (09/June/2020). As COVID-19 spread in the world and our country, hospitals struggling with this disease have also become risky areas for transmitting the disease. Health workers also have a high risk of viral contamination from direct contact of droplets and surfaces. Personal protective equipment (PPE), such as masks, coveralls, gloves, face shields and/or goggles, are mandatory. The aim is to spread the flow of cases requiring hospitalization over time, thereby preventing possible accumulation in hospitals. All non-urgent procedures, such as elective surgeries and diagnostic interventions, were significantly affected. The hospitalization procedures were mostly allocated to patients with COVID-19 infection, and surgical operations were postponed. Only urgent surgical cases and oncological surgeries that cannot be postponed were performed during this pandemic process. Patients followed by oncology are immunosuppressed both because of the disease itself and the side effects of chemotherapy and/or radiotherapy taken. This makes patients more susceptible to infections, and the prognosis of infections in these patients is worse and more destructive. Cancer patients are almost twice as likely to catch COVID-19 compared to the general population. The choice of surgical procedures and perioperative management of the patients with malignancy has become even more important in the COVID-19 pandemic. In this study, we analyzed the treatment processes of our patients with malignancy that underwent a surgical oncological procedure during this pandemic.

Objectives: In a thyroidectomy, the external branch of the superior laryngeal nerve (EBSLN) is a potential risk during the superior pole dissection due to its close anatomical relationship with the superior thyroid artery and its highly variable anatomy. In this study, we aimed to evaluate the relationship of EBSLN with the superior pole considering Cernea classification and the factors affecting this relationship. Methods: The data of thyroidectomized 126 patients (95 female, 31 male) with 200 neck sides (mean age of 45.6±12.1 years) using intraoperative neuromonitoring (IONM) for the EBSLN exploration were evaluated retrospectively. During the superior pole dissection, the EBSLN course was classified according to Cernea classification after being confirmed with IONM. It was defined as a large goiter in the case of the thyroid lobe volume being >50 cc. The factors influencing the presence of type 2b, which has the highest risk of injury, were evaluated using logistic regression analysis. Results: Of the 200 EBSLNs evaluated, 52 (26%) were type 1, 134 (68%) were type 2a, and 14 (7%) were type 2b. The mean volumes of the resected thyroid lobes were 22±25 cc (min-max: 2-136), 23±20 cc (3-163), and 39±24 cc (3-65) in type 1, 2a and 2b, respectively, which was significantly higher in type 2b (p=0.035). Presence of large goiter rates were 5.8% (n=3), 8.2% (n=11), 64.3% (n=9) in type 1, 2a, and 2b, respectively, and was significantly higher in type 2b (p=0.0001). There was no significant difference between EBSLN Cernea types concerning age, sex, nerve side, presence of cancer and hyperthyroidism. In logistic regression analysis, large goiter was the only independent factor associated with Cernea type 2b. In case of a lobe volume greater than 50 cc, the probability of type 2b presence was approximately 25 times higher (p

Primary hyperparathyroidism (pHPT) is characterized by an increase in the levels of PTH and Ca, or one of these (Ca, PTH) as a result of a dysregulation of calcium (Ca) metabolism due to inappropriate excess parathyroid hormone (PTH) autonomously produced from one or more than one parathyroid glands. Ninety to 95% of pHPT is a sporadic type, which is not associated with the familial history and other endocrine organ tumors, and 5-10% of it is hereditary. While 80-85% of pHPT arises from a single parathyroid adenoma, 4-5% is caused by a double adenoma, 10-15% by multigland hyperplasia and less than 1% by parathyroid cancer. The diagnosis of pHPT is reached biochemically. The only curative treatment of pHPT is surgery. The choice of surgery in pHPT may vary depending on whether the patient has hereditary HPT or thyroid disease requiring surgical treatment, preoperative localization studies and the findings in these studies, the possibilities of using intraoperative PTH and the preference of the surgeon. The preoperatively determined surgical strategy can be revised according to intraoperative findings in case of need to achieve excellent results. The two main approaches in the surgical treatment of pHPT are BNE (bilateral neck exploration) and MIP (minimal invasive parathyroidectomy). Although BNE is a consistently valid option that has excellent results in the surgical treatment of pHPT and is considered the gold standard, MIP is the ideal approach in selected patients with clinically and radiologically considered a single-gland disease. Negative imaging is not a contraindication for parathyroid surgery and is not a criterion for the presence or absence of surgical indication. Although both methods are safe and effective in the surgical treatment of sporadic pHPT, there is still controversy regarding the effectiveness of both methods. Surgical intervention should establish the risk-benefit balance well, minimize the risk of persistent and recurrent disease and provide the highest cure rate without increasing the risk of complications. Complication rates are higher in the secondary surgery, thus in secondary procedures, selective surgery should be performed under guidance of an imaging modality. The surgical strategy should be determined to achieve maximum cure with minimum dissection and minimal morbidity. In this study, we aimed to determine the type of surgical treatment and pHPT patients suitable for the surgical treatment.

Classical understanding of the function of the pharyngeal plexus in humans is that it relies on both motor branches for innervation of the majority of pharyngeal muscles and sensory branches for the pharyngeal wall sensation. To date there has been no reported data on the role of the pharyngeal plexus in vocal cord innervation. The aim of this study is to evaluate whether or not the plexus pharyngeus contributes to the innervation of the vocal cords. One hundred twenty-five sides from 79 patients (59 female, 20 male) undergoing thyroid surgery with intraoperative neuromonitoring were prospectively evaluated. While vocal cord function was evaluated with endotracheal tube surface electrodes, cricothyroid and cricopharyngeal muscle electromyographic recordings were obtained with a pair of needle electrodes. The ipsilateral pharyngeal plexus, external branch of the superior laryngeal nerve, and recurrent laryngeal nerve were stimulated with a monopolar probe at 1 mA. With stimulation of the plexus pharyngeus on 125 operated sides, positive electromyographic waveforms were detected from five ipsilateral vocal cords (accounting for 3.2% of all vocal cords monitored and 6.3% of patients). The mean EMG amplitude of the vocal cords with stimulation of the plexus pharyngeus was 147 ± 35.5 μV (range 110-203). In one case, the long latency time of 19.8 ms correlated with innervation by the glottic closure reflex pathway. The short latencies seen in the other four cases [3.9 ± 1.1 ms (range 3.2-5.5)] correlated with direct innervation. In some cases, the plexus pharyngeus may contribute to vocal cord innervation by reflex or direct innervation patterns in humans.

Primary hyperparathyroidism (pHPT) is the third most common endocrine disease and the most common cause of outpatient hypercalcemia. Historically, most patients presented with overt symptoms and signs of pHPT. With the advent and widespread use of automated blood analyzers, currently the majority of patients are diagnosed through routine biochemical laboratory testing done for other aims. The majority of patients are minimally symptomatic or asymptomatic. The clinical presentation of pHPT varies from asymptomatic disease to classic symptomatic disease in which renal and/or skeletal complications are observed. The term “mild pHPT” has been interpreted in many different ways over the past 30 years. Mild pHPT was clearly defined as a disease in asymptomatic patients who do not meet surgical criteria set out by the updated International Guidelines. Normocalcemic pHPT was first defined formally at the time of the ‘’Third International Workshop on the Management of Asymptomatic pHPT’’ in 2008. Normocalcemic pHPT, a variant of the traditional hypercalcemic presentation of pHPT, is characterized by consistently elevated PTH concentrations with normal total and ionized serum calcium (Ca) concentration in the absence of secondary causes for elevated PTH concentrations. Primary hyperparathyroidism may present as classic pHPT (in which both Ca and PTH are high), nonclassic (normohormonal or nonsuprese) pHPT (in which Ca is high and PTH is normal), normocalcemic pHPT (in which Ca is normal and PTH is high) biochemically. The only curative therapy for pHPT is parathyroidectomy. Parathyroidectomy is clearly indicated in all symptomatic patients. ‘’Fourth International Workshop on the Management of Asymptomatic pHPT’’ had been performed in 2013. Surgical indications for pHPT are determined according to the age, Ca level, skeletal and renal findings. In some patients with asymptomatic disease, surgery is not mandatory. On the other hand, even in these patients who don’t meet any criteria for parathyroidectomy, surgery is always an option because it is the only exact treatment for pHPT. The optimal treatment strategy for patients with normocalcemic pHPT has not yet been proved. Experts advise that patients be referred for parathyroidectomy if they have or progress complications of pHPT such as osteoporosis, fragility fractures or kidney stones, even if normocalcemia continues. Patients without complications at the time of diagnosis could be monitored for disease progression.