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Objective. Thyroid fine-needle aspiration (FNA) and cytology is a reliable diagnostic method used in the assessment of malignancy when evaluating thyroid nodules, in conjunction with clinical and ultrasonographic findings. The aim of this study is to compare clinical, ultrasonographic, cytological and histopathological findings in children who underwent thyroid FNA. Methods. Subjects comprised 80 patients (52 female) aged 13.7±2.8 years at the time of FNA who where evaluated for thyroid nodules. Clinical, ultrasonographic and cytological findings of patients were evaluated retrospectively. Results. Autoimmune thyroiditis was present in 30% and history of radiotherapy to the head or neck in 10%. The cytological diagnosis of patients included: inadequate or hemorrhagic sample in 10%; benign in 42.5%; atypia or follicular lesion of undetermined significance (AUS/FLUS) in 15%; suspicion of follicular neoplasia (SFN) in 7.5%; suspicion of malignancy (SM) in 8.8%; and malignant in 16.3%. Thirty-seven patients underwent thyroidectomy. Malignancy rates for histopathologic follow-up were 75%, 85.7% and 100% for SFN, SM and malignant categories, respectively. Only one benign and two AUS/FLUS FNAs were found to be malignant on histopathological examination. Among patients who had received radioiodinetherapy, 87.5% had malignancy. In this study, the sensitivity of FNA was 96%, specificity 50%, positive predictive value 90.9%, negative predictive value 75%, and diagnostic value of FNA was 89.2%. Conclusion. Thyroid FNA results were highly compatible with histopathological examination. Sensitivity, positive predictive value and diagnostic value of FNA were high. [ABSTRACT FROM AUTHOR]

Purpose: The objective of this study was to characterize the electrophysiological characteristics of nonrecurrent inferior laryngeal nerves (NRILNs) that were dissected via intraoperative neuromonitoring (IONM) and concomitant vascular anomalies in patients with NRILNs., Methods: A retrospective analysis was conducted on 7865 patients who underwent thyroidectomy with IONM at three tertiary referral centers. The study included 42 patients in whom an NRILN was detected. IONM data and postoperative vocal cord (VC) examinations were recorded for all patients. The absence of an initial vagal EMG response and/or a short (<3.5 ms) latency period during the initial vagal stimulation or the inability to identify the RLN within the Beahrs triangle was considered highly suspicious for the presence of an NRILN. Postoperative cross-sectional imaging was performed in 36 out of 42 patients to assess any concurrent vascular anomalies., Results: The prevalence of NRILN was 0.53%. An NRILN was suspected due to EMG findings in 32 (76%) patients and the inability to identify the RLN within the Beahrs triangle in the remaining 10 (24%) patients. The mean right VN latency period was 3.05 ± 0.15 ms. The V1 latency period of the right VN was shorter than 3.5 ms in 39 (93%) and longer than 3.5 ms in 3 (7%) patients. One of these three patients with latency>3.5ms had a large mediastinal goiter. Transient VC paralysis occurred in one (2.4%) patient. Of the 36 patients with postoperative imaging data, 33 (91.4%) had vascular anomalies. All 33 patients had aberrant right subclavian arteries, and 13 (39.4%) also had accompanying additional vascular anomalies., Conclusion: The NRILN is an anatomical variation that increases the risk of nerve injury. Observation of an absent EMG response and/or a short latency period during the initial vagal stimulation facilitates the detection of an NRILN at an early stage of thyroidectomy in the majority of patients., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision., (Copyright © 2024 Sormaz, Iscan, Tunca, Kostek, Aygun, Matlim Ozel, Soytas, Poyanli, Sari, Uludag and Giles Senyurek.)

Background: Adrenal gland injury (AGI) associated with trauma is an uncommon and often overlooked condition. This study aimed to evaluate the frequency of AGI in individuals with severe trauma injuries and investigate the outcomes of patients with AGI., Methods: All patients admitted to a tertiary trauma referral center under the trauma protocol who had a computed tomography (CT) scan between January 2012 and January 2023 were analyzed retrospectively. Patients who were dead on arrival and patients with incomplete data were excluded. They were classified into two main groups, adult and pediatric, and further subcategorized by the presence or absence of radiologically evident AGI. Demographic data, mechanism of injury, injury severity scores (ISS), presence of concurrent abdominal injury, and 30-day mortality rates were compared. A separate analysis was performed for factors affecting mortality rates., Results: A total of 1,253 patients were included: 950 adults and 303 pediatric patients. In the adult group, AGI was detected in 45 (4.7%) patients and was more commonly associated with the following mechanisms of injury: motor vehicle accidents (26.7% vs. 14.3%) and pedestrian accidents (37.8% vs. 15.5%). Injury to the right side was more common (55.6%). Patients with AGI had higher rates of concurrent liver (17.8% vs. 3.9%), spleen (11.1% vs. 3.6%), and kidney injuries (15.6% vs. 1.3%). In the pediatric population, AGI was detected in 30 patients (14.8%), a significantly higher rate compared to the adult group. Similar to the adult group, AGI was more commonly associated with concurrent abdominal injuries and had a right-sided dominance (60%), but the rate of concurrent abdominal injuries was higher in the pediatric group (80% vs. 46%). The 30-day mortality was significantly higher in both adult and pediatric AGI groups compared to patients without AGI (adult: 15.6% vs. 2.9%, pediatric: 10% vs. 1.8%). In patients with AGI, major head and neck injuries and chest injuries were associated with mortality., Conclusion: Adrenal gland injuries due to trauma are not uncommon. They are usually associated with blunt trauma and other concurrent abdominal organ injuries. The major contributors to mortality in patients with AGI were major head and neck injuries and chest injuries.

Background: Intraoperative neural monitoring (IONM) has been utilized for a variety of thyroid pathologies, including papillary thyroid carcinoma (PTC). Remnant thyroid tissue following total thyroidectomy (TT) in patients with PTC is associated with increased recurrence. The aim of this study is to investigate whether the use of IONM in PTC surgery has an impact on the completeness of thyroidectomy., Methods: Retrospectively, patients with preoperative diagnosis of PTC, who underwent TT in a tertiary center were reviewed. They were grouped based on the IONM usage, and 1:1 propensity-score match was performed. Primary outcome was the completeness of thyroidectomy, determined by measuring postoperative stimulated thyroglobulin levels (sTg)., Results: Among 274 clinically node-negative PTC patients who underwent TT and ipsilateral prophylactic central lymph-node dissection, a total of 170 patients (85:85) were matched. Postoperative sTg levels were significantly lower in the IONM group (1 ng/dL vs. 0.4 ng/dL; p  < 0.01) with higher percentage of the patients with sTg levels <1 ng/ml (50.6% vs. 69.4%; p  = 0.01). More patients in the no-IONM group received RAI ablation with significantly higher doses (mean mci: 120 vs. 102; p  = 0.02)., Conclusion: The use of IONM during thyroidectomy provides improvement in the completeness of thyroidectomy and reduction in postoperative sTg levels which can be used as a guide by clinicians to avoid RAI ablation in selected PTC patients and to adjust low ablative doses in patients who are scheduled for remnant ablation.

Background: The primary surgical approach for removing adrenal masses is minimally invasive adrenalectomy. Recognition of anatomical landmarks during surgery is critical for minimizing complications. Artificial intelligence-based tools can be utilized to create real-time navigation systems during laparoscopic and robotic right adrenalectomy. In this study, we aimed to develop deep learning models that can identify critical anatomical structures during minimally invasive right adrenalectomy., Methods: In this experimental feasibility study, intraoperative videos of 20 patients who underwent minimally invasive right adrenalectomy in a tertiary care center between 2011 and 2023 were analyzed and used to develop an artificial intelligence-based anatomical landmark recognition system. Semantic segmentation of the liver, the inferior vena cava (IVC), and the right adrenal gland were performed. Fifty random images per patient during the dissection phase were extracted from videos. The experiments on the annotated images were performed on two state-of-the-art segmentation models named SwinUNETR and MedNeXt, which are transformer and convolutional neural network (CNN)-based segmentation architectures, respectively. Two loss function combinations, Dice-Cross Entropy and Dice-Focal Loss were experimented with for both of the models. The dataset was split into training and validation subsets with an 80:20 distribution on a patient basis in a 5-fold cross-validation approach. To introduce a sample variability to the dataset, strong-augmentation techniques were performed using intensity modifications and perspective transformations to represent different surgery environment scenarios. The models were evaluated by Dice Similarity Coefficient (DSC) and Intersection over Union (IoU) which are widely used segmentation metrics. For pixelwise classification performance, accuracy, sensitivity and specificity metrics were calculated on the validation subset., Results: Out of 20 videos, 1000 images were extracted, and the anatomical landmarks (liver, IVC, and right adrenal gland) were annotated. Randomly distributed 800 images and 200 images were selected for the training and validation subsets, respectively. Our benchmark results show that the utilization of Dice-Cross Entropy Loss with the transformer-based SwinUNETR model achieved 78.37%, whereas the CNN-based MedNeXt model reached a 77.09% mDSC score. Conversely, MedNeXt reaches a higher mIoU score of 63.71% than SwinUNETR by 62.10% on a three-region prediction task., Conclusion: Artificial intelligence-based systems can predict anatomical landmarks with high performance in minimally invasive right adrenalectomy. Such tools can later be used to create real-time navigation systems during surgery in the near future.

Background: Minimally invasive adrenalectomy is the main surgical treatment option for the resection of adrenal masses. Recognition and ligation of adrenal veins are critical parts of adrenal surgery. The utilization of artificial intelligence and deep learning algorithms to identify anatomic structures during laparoscopic and robot-assisted surgery can be used to provide real-time guidance., Methods: In this experimental feasibility study, intraoperative videos of patients who underwent minimally invasive transabdominal left adrenalectomy procedures between 2011 and 2022 in a tertiary endocrine referral center were retrospectively analyzed and used to develop an artificial intelligence model. Semantic segmentation of the left adrenal vein with deep learning was performed. To train a model, 50 random images per patient were captured during the identification and dissection of the left adrenal vein. A randomly selected 70% of data was used to train models while 15% for testing and 15% for validation with 3 efficient stage-wise feature pyramid networks (ESFPNet). Dice similarity coefficient (DSC) and intersection over union scores were used to evaluate segmentation accuracy., Results: A total of 40 videos were analyzed. Annotation of the left adrenal vein was performed in 2000 images. The segmentation network training on 1400 images was used to identify the left adrenal vein in 300 test images. The mean DSC and sensitivity for the highest scoring efficient stage-wise feature pyramid network B-2 network were 0.77 (±0.16 SD) and 0.82 (±0.15 SD), respectively, while the maximum DSC was 0.93, suggesting a successful prediction of anatomy., Conclusions: Deep learning algorithms can predict the left adrenal vein anatomy with high performance and can potentially be utilized to identify critical anatomy during adrenal surgery and provide real-time guidance in the near future., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Adrenal schwannomas are rare benign tumors with no specific imaging and laboratory findings to diagnose preoperatively. Due to the limited number of cases in the literature, clinical, imaging, and pathological findings are presented in this study. Case 1 is a 61-year-old woman patient who has a 31-mm mass in the right adrenal gland. This mass was nonfunctional; in imaging studies, this mass had a cystic necrotic component, and high 18-fluorodeoxyglucose (FDG) uptake was seen. There was no metaiodobenzylguanidine (MIBG) uptake. Laparoscopic transabdominal right adrenalectomy was performed, and the pathology result was consistent with adrenal schwannomas. Case 2 is a 63-year-old man patient who presented with a 38-mm mass in the left adrenal gland. This mass was nonfunctional and similar to that in Case 1; this mass had a cystic component. Laparoscopic transabdominal left adrenalectomy was performed. The diagnosis of adrenal schwannoma with degeneration was revealed. Case 3 was a 72-year-old woman patient admitted to the hospital for a 125-mm left adrenal mass. Similar to Case 1, this mass also had a cystic necrotic component in imaging studies. High FDG uptake was seen, and the patient underwent conventional adrenalectomy due to the suspicion of malignancy. After pathological evaluation, a diagnosis of adrenal schwannoma was made. A main diagnostic challenge in adrenal schwannomas is the preoperative diagnosis. These masses have no pathognomonic finding or specific hormonal function. Imaging findings of these masses may increase the suspicion of malignancy, which may affect decisions for surgery and the surgical technique., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Kostek, Unlu, Caliskan, Aygun, Iscan, Dural, Sormaz, Tunca, Giles Senyurek and Uludag.)

Some pediatric papillary thyroid carcinoma (PPTC) cohorts have suggested a preliminary correlation with respect to DICER1 mutation status and histomorphology in both benign and malignant follicular cell-derived nodules; however, the data regarding correlates of DICER1-related sporadic PPTCs subtyped based on the 2022 WHO classification criteria are largely unavailable. The current study investigated the status of hotspot DICER1 mutations with clinical, histological and outcome features in a series of 56 patients with PPTCs with no clinical or family history of DICER1-related syndromic manifestation. Fifteen (27%) PPTCs harbored BRAF p.V600E. Eight (14%) cases of PPTCs harbored DICER1 mutations with no associated BRAF p.V600E. DICER1 mutations were identified in exons 26 and 27. A novel D1810del (c.5428&#95;5430delGAT) mutation was also detected. We also confirmed the absence of hotspot DICER1 mutations in the matched non-tumor tissue DNA in all 8 DICER1-related PPTCs. The mean age of DICER1-harboring PPTCs was 15.1 (range: 9-18) years whereas the rest of this cohort had a mean age of 14.8 (range 6-18) years. With the exception of one PPTC, all DICER1-related PPTCs were seen in females (female-to-male ratio: 7). The female to male ratio was 3.8 in 48 DICER1-wild type PPTCs. In terms of histological correlates, 5 of 8 (63%) DICER1-mutant PPTCs were invasive encapsulated follicular variant papillary thyroid carcinomas (FVPTCs) including 4 minimally invasive FVPTCs and 1 encapsulated angioinvasive FVPTC, whereas the remaining 3 PPTCs were infiltrative classic papillary thyroid carcinomas (p < 0.05). The incidence of DICER1 mutations was 19.5% in BRAF p.V600E-wild type PPTCs. Sixty-three percent of DICER1 hotspot mutations occurred in invasive encapsulated FVPTCs, and this figure represents 38% of invasive encapsulated FVPTCs. Only one (12%) patient with DICER1-related disease showed a single lymph node with micro-metastasis. Unlike DICER1-wild type patients, no distant metastasis is identified in patients with DICER1-related PPTCs. The current series expands on the surgical epidemiology of somatic DICER1-related PPTCs by correlating the mutation status with the clinicopathological variables. Our findings underscore that female gender predilection and enrichment in low-risk follicular-patterned PTCs are characteristics of DICER1-related PPTCs., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Purpose: This study was performed to compare the real-time electromyographic (EMG) changes and the rate of recurrent laryngeal nerve (RLN) injury in craniocaudal and lateral approaches for RLN during thyroidectomy., Methods: One hundred twelve and 86 patients were prospectively randomized to receive lateral (group 1) or craniocaudal (group 2) approach to RLN, respectively, under continuous intraoperative nerve monitoring., Results: Loss of signal (LOS) occurred in 7 (2.0%) of 356 nerves at risk (NAR). LOS was significantly associated with repeated adverse EMG changes and presence of RLN entrapment at the ligament of Berry (LOB), which was accompanied by other clinicopathological or anatomical features, such as tubercle of Zuckerkandl (TZ), extralaryngeal branching, hyperthyroidism, autoimmune thyroid disease (ATD), or thyroid lobe volume of >29 cm 3 (P = 0.001 and P = 0.030, respectively). The rate of repeated adverse EMG changes and LOS in the NARs with LOB entrapment accompanied by other clinicopathological and anatomical features was higher in group 1 vs. group 2 (11.1% vs. 2.2%, respectively and 9.7% vs. 0%, respectively; P = 0.070). The total rate of vocal cord palsy (VCP) was significantly higher in group 1 than in group 2 (P = 0.005). The rate of permanent VCP showed no significant difference between the 2 groups., Conclusion: The craniocaudal approach to the RLN is safer than the lateral approach in the RLNs with entrapment at the LOB accompanied by other features, such as TZ, extralaryngeal branching, hyperthyroidism, ATD, or high thyroid lobe volume., Competing Interests: Conflict of Interest: No potential conflict of interest relevant to this article was reported., (Copyright © 2022, the Korean Surgical Society.)

Metastasis is the second most common type of adrenal gland mass. In patients undergoing follow-up for nonadrenal malignancy, adrenalectomy is performed when metastasis to adrenal gland is suspected on the basis of positron emission tomography-computed tomography (PET-CT) imaging. This study investigated the efficacy of PET-CT in the discrimination of metastatic lesions from nonmetastatic lesions in the adrenal glands. In this multicentric study, data was collected from enrolled centers. Forty-one patients who underwent surgery for suspected adrenal metastases were evaluated retrospectively. The following data types were collected: demographic, primary tumor, maximum standardized uptake value of adrenal mass (a-SUVx) and detectability in computed tomography and/or magnetic resonance imaging, and specimen size and histopathology. Six patients were excluded due to unavailability of PET-CT reports and 4 for being primary adrenal malignancy. The rest were divided into 2 groups (metastatic: n = 17, 55% and nonmetastatic: n = 14, 45%) according to histopathology reports. There was no statistical difference between the analyzed values, except the a-SUVx (P < .05). The a-SUVx cutoff value was defined as 5.50 by receiver operating characteristic curves and compared with literature. There was no statistical difference when each group was divided as low and high (P > .05). It was found that PET-CT was able to discriminate metastatic lesions from primary benign lesions (P = .022). PET-CT can discriminate primary benign lesions and metastatic lesions by cutoff 5.5 value for a-SUVx., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: This study aimed to evaluate the role of risk stratification by the American Thyroid Association (ATA) pediatric thyroid cancer risk levels and BRAF V600E mutation to predict the response to treatment in papillary thyroid cancer (PTC) patients ≤18 years old., Methods: Clinical outcomes during a median period of 6 (2-21.8) years were assessed in 70 patients, according to ATA pediatric risk stratification, BRAF V600E mutation status, and dynamic risk stratification (DRS) at final follow-up., Results: Of 70 patients, 44 (63%), 14 (20%), and 12 (17%) were classified initially as low-, intermediate-, and high-risk, respectively. BRAF V600E mutation analysis data was available in 55 (78.6%) patients, of whom 18 (32.7%) had the BRAF V600E mutation. According to the final DRS, 61 (87%), two (3%), six (9%), and one (1%) patients were classified as an excellent, incomplete biochemical, incomplete structural, and indeterminate response, respectively. All ATA low-risk patients showed excellent response to treatment, whereas the rate of excellent response was 65.4% in intermediate- and high-risk levels (p<0.001). The rates of excellent response in BRAF V600E positive and negative patients were 83% and 92%, respectively (p=0.339). The rate of locoregional recurrence was significantly higher in BRAF V600E positive vs negative patients (33.3% vs 2.7% respectively, p=0.001)., Conclusion: ATA pediatric risk stratification is effective in predicting response to treatment in PTC patients ≤18 years old. The presence of BRAF V600E mutation was highly predictive for recurrence but had no significant impact on the rate of excellent response to treatment at final follow-up.

Purpose: The COVID-19 pandemic brought unprecedented conditions for overall health care systems by restricting resources for non-COVID-19 patients. As the burden of the disease escalates, routine elective surgeries are being cancelled. The aim of this paper was to provide a guideline for management of endocrine surgical disorders during a pandemic., Methods: We used Delphi method with a nine-scale Likert scale on two rounds of voting involving 64 experienced eminent surgeons and endocrinologists who had the necessary experience to provide insight on endocrine disorder management. All voting was done by email using a standard questionnaire., Results: Overall, 37 recommendations were voted on. In two rounds, all recommendations reached an agreement and were either endorsed or rejected. Endorsed statements include dietary change in primary hyperparathyroidism, Cinacalcet treatment in secondary hyperparathyroidism, alpha-blocker administration for pheochromocytoma, methimazole ± β-blocker combination for Graves' disease, and follow-up for fine-needle aspiration results of thyroid nodules indicated as Bethesda 3-4 cytological results and papillary microcarcinoma., Conclusion: This survey summarizes expert opinion for the management of endocrine surgical conditions during unprecedented times when access to surgical treatment is severely disrupted. The statements are not applicable in circumstances in which surgical treatment is possible., (© 2021. Italian Society of Surgery (SIC).)

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: 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 the RLN on nerve injury remains unclear. Objectives of this study were to (1) better understand the detailed surgical anatomic variability of the RLN with a worldwide perspective; (2) establish potential correlates between intraoperative RLN anatomy and electrophysiologic responses; and (3) use the information to minimize complications and assure accurate and safe intraoperative neuromonitoring (IONM). Methods: A large international registry database study with prospectively collected data was conducted through the International Neural Monitoring Study Group (INMSG) evaluating 1000 RLNs at risk during thyroid surgery using a specially designed online data repository. Monitored thyroid surgeries following standardized IONM guidelines were included. Cases with bulky lymphadenopathy, IONM failure, and failed RLN visualization were excluded. Systematic evaluation of the surgical anatomy of the RLN was performed using the International RLN Anatomic Classification System. In cases of loss of signal (LOS), the mechanism of neural injury was identified, and functional evaluation of the vocal cord was performed. Results: A total of 1000 nerves at risk (NARs) were evaluated from 574 patients undergoing thyroid surgery at 17 centers from 12 countries and 5 continents. A higher than expected percentage of nerves followed an abnormal intraoperative trajectory (23%). LOS was identified in 3.5% of NARs, with 34% of LOS nerves following an abnormal intraoperative trajectory. LOS was more likely in cases of abnormal nerve trajectory, fixed splayed or entrapped nerves (including at the ligament of Berry), extensive neural dissection, cases of cancer invasion, or when lateral lymph node dissection was needed. Traction injury was found to be the most common form of RLN injury and to be less recoverable than previous reports. Conclusions: Multicenter international studies enrolling diverse patient populations can help reshape our understanding of surgical anatomy during thyroid surgery. There can be significant variability in the anatomic and intraoperative characteristics of the RLN, which can impact the risk of neural injury.

Objective: The purpose of the study was to evaluate the impact of the coronavirus disease (COVID-19) pandemic on endocrine surgical volumes., Methods: There were periodic surgical restriction sin our country in 2020 due to the pandemic. Endocrine surgery volumes at the Division of Endocrine Surgery, Istanbul Medical Faculty were compared between 2019 and 2020., Results: The surgical volume reduction in 2020 compared to 2019 was 20%, 54.5%, and 40% for thyroid, parathyroid, and adrenal surgery, respectively. Surgical volume for thyroidectomy for benign nodular goiter and parathyroidectomy significantly decreased, whereas adrenal surgery showed no significant difference in 2020 compared to 2019. No significant difference was found in the rates of thyroid cancer and adrenocortical cancer surgery in 2020compared to 2019., Conclusion: The COVID-19 outbreak led to a significant reduction in the annual rates of parathyroidectomy and thyroidectomy for benign goiter, whereas the volume of thyroid cancer and adrenal surgeries were similar to the previous year., Competing Interests: Conflict of Interest: None declared., (Copyright: © 2021 by The Medical Bulletin of Sisli Etfal Hospital.)

Purpose: Novel thyroidectomy techniques have been described to minimize the visible scar. Hereby, we aim to present our experience with transoral robotic thyroidectomy (TORT) without axillary access., Material and Methods: Between August 2018 and March 2019, six eligible patients were enrolled to undergo TORT. Procedures were performed by using the Da Vinci Xi platform under intermittent intraoperative nerve monitoring., Results: All patients were female, and the mean age was 40.0 ± 14.4 years. Three patients underwent total thyroidectomy, and lobectomy was performed for the remaining three patients. In one patient, the procedure was converted to conventional open thyroidectomy due to bleeding. The mean docking time, console time and total operative time were 22.8 ± 5.2 min, 118.5 ± 48.7 min and 218.29 ± 50.6 min for total thyroidectomy and 21.8 ± 4.1 min, 68.6 ± 6.1 min and 177.6 ± 15.1 min for lobectomy, respectively. All patients were discharged uneventfully., Conclusions: Pure TORT is a safe procedure, when performed in carefully selected patients by experienced surgeons, but further prospective studies with larger number of patients are required., (© 2020 John Wiley & Sons Ltd.)

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., Competing Interests: Conflict of Interest: None declared., (Copyright: © 2020 by The Medical Bulletin of Sisli Etfal Hospital.)

We examined SCC development of 24 FA patients, who received HSCT from HLA-matched relatives. In our BMT center, we applied low-dose CY + LFI + ATG (n:13) as conditioning regimen for FA patients between 1992 and 1999, and CY + BU + ATG (n:11) between 1999 and 2002. The aim of this study was to investigate SCC development after HSCT and examine features of the follow-up patients. The 10-year overall survival (OS) of the group with LFI + regimen was 43%, whereas the group without LFI regimen was 60%. There was a statistically significant relationship between infections (viral/bacterial) and overall survival (Fisher's Exact test P < .001). Five out of 13 long-term (>1 year) surviving patients developed SCC in the HNSCC (n:4) and esophagus (n:2) region (a patient with oral SCC developed a second primary esophageal SCC). The SCC rate in our FA patients was 38%, four of the SCC patients were transplanted with irradiation used conditioning regimens, three of them had acuteGvHD (Grade II-III), only one developed chronic GvHD. The interval between HSCT and SCC diagnosis was median 13 (range 6-18) years, the age for the development of cancer was median 21 (range 15-32) years. Survival after SCC was low, median 6 months (range 6-12), due to delayed SCC diagnosis, tumor progression under therapy and treatment-related toxicities of the usually reduced RT and/or CT., (© 2020 Wiley Periodicals LLC.)

Objective: Although multicentricity is a common feature of thyroid papillary microcancer, it might be difficult to predict this histopathological feature preoperatively., Methods: The records of 306 papillary microcancer patients who underwent thyroidectomy were evaluated. Papillary microcancer was diagnosed as an incidental histopathological finding in 242 (group 1), and by preoperative fine-needle aspiration biopsy in 64 (group 2). Demographic data and histopathological features were compared between the two groups., Results: Age (44 ± 11.4 vs. 43 ± 14 years) and male/female ratio (44/193 vs. 12/52) showed no significant difference between groups 1 and 2 (p > 0.05). Mean tumor size was significantly larger in group 2 (5.2 ± 2.8 mm) compared to group 1 (3.7 ± 2.4 mm) ( p = 0.004). The frequency of thyroid capsule invasion (44 vs. 19%, p = 0.0001), microscopic extrathyroidal invasion (25 vs. 10%, p = 0.004) and multicentricity (44 vs. 29%, p = 0.04), and bilateral lobar involvement (22 vs. 10%, p = 0.0001) was significantly higher in group 2 compared to group 1., Conclusion: Multicentricity with bilateral lobar involvement and aggressive histopathological features are more frequent in papillary microcancer patients diagnosed with preoperative fine-needle aspiration biopsy compared to papillary microcancer diagnosed as postoperative incidental histopathological finding., Competing Interests: The authors have no conflicts of interest to declare., (Copyright © 2019 by S. Karger AG, Basel.)

Objective: Thyroid fine-needle aspiration (FNA) and cytology is a reliable diagnostic method used in the assessment of malignancy when evaluating thyroid nodules, in conjunction with clinical and ultrasonographic findings. The aim of this study is to compare clinical, ultrasonographic, cytological and histopathological findings in children who underwent thyroid FNA., Methods: Subjects comprised 80 patients (52 female) aged 13.7±2.8 years at the time of FNA who where evaluated for thyroid nodules. Clinical, ultrasonographic and cytological findings of patients were evaluated retrospectively., Results: Autoimmune thyroiditis was present in 30% and history of radiotherapy to the head or neck in 10%. The cytological diagnosis of patients included: inadequate or hemorrhagic sample in 10%; benign in 42.5%; atypia or follicular lesion of undetermined significance (AUS/FLUS) in 15%; suspicion of follicular neoplasia (SFN) in 7.5%; suspicion of malignancy (SM) in 8.8%; and malignant in 16.3%. Thirty-seven patients underwent thyroidectomy. Malignancy rates for histopathologic follow-up were 75%, 85.7% and 100% for SFN, SM and malignant categories, respectively. Only one benign and two AUS/FLUS FNAs were found to be malignant on histopathological examination. Among patients who had received radioiodinetherapy, 87.5% had malignancy. In this study, the sensitivity of FNA was 96%, specificity 50%, positive predictive value 90.9%, negative predictive value 75%, and diagnostic value of FNA was 89.2%., Conclusion: Thyroid FNA results were highly compatible with histopathological examination. Sensitivity, positive predictive value and diagnostic value of FNA were high., Competing Interests: No potential conflict of interest relevant to this article was reported., (©by Acta Endocrinologica Foundation.)

Despite the notable increasing incidence of papillary thyroid microcarcinoma (PTMC), the optimal treatment of the patients with PTMC remains controversial. Because of no consensus about its treatment, the suggested treatment varies from active surveillance alone to total thyroidectomy. Although the 2015 revised American Thyroid Association guideline recommends hemithyroidectomy as the first-line treatment, active surveillance has also been discussed and accepted as another approach for the patients with PTMC. However, the same guideline does not recommend fine needle aspiration biopsy for nodules sized <1 cm, even it is suspicious. In such situation, neither active surveillance nor hemithyroidectomy could be discussed, with a lack of objective cytologic data about the nodules sized <1 cm. In this situation, the decision to perform FNAB to the nodules <1 cm in size depends on the performer of the thyroid ultrasonography. In this invited review, we have discussed the diagnosis and prognostic factors for PTMCs. We have also discussed surgical strategies as the accepted the first-line treatment in patients with PTMC., Competing Interests: Conflict of Interest: None declared., (Copyright: © 2018 by The Medical Bulletin of Sisli Etfal Hospital.)

Purpose: To evaluate the bilateral patterns and motor function of the extralaryngeal branches (ELB) of the recurrent laryngeal nerve(RLN)., Methods: This study included 500 consecutive patients who underwent total thyroidectomy. Intraoperative nerve monitoring (IONM) was used in 230 patients. Demographic data, indications for surgery, the bilateral patterns of ELB of the RLN, electromyographic activity of the ELB, distance between the branching point to the entrance into the larynx, and the rate of postoperative morbidity were analyzed., Results: The overall rate of ELB was 27.6% (276/1000). A single trunk of the RLN on both sides was found in 269 (54%) patients, whereas ELB on both sides was observed in 45 (9%) patients. The rates of ELB on the left and right sides were 26.6 and 28.6%, respectively. Of the 89 branched nerves which were dissected using IONM, an evoked motor response was present in 100% of the anterior branches and 5.6% of the posterior branches. The mean branching distance of the RLN was significantly greater in female patients than in male patients on the left side (p = 0.031). The patterns of ELB showed no significant difference in male and female patients. The rates of postoperative transient and permanent hypoparathyroidism and unilateral RLN palsy were 21.6 and 2.8%, and 3.2 and 0.8%, respectively. The rate of RLN palsy was higher in branched nerves compared to those with a single trunk (0.75 vs 0.3%; p = 0.2)., Conclusion: Unilateral ELB of the RLN might be observed in approximately 1/4 of the patients, while bilateral branching is rare. A few number of posterior branches of the RLN can have motor function. The RLN's with ELB might have a higher risk of injury compared to those with a single trunk.

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.

Background/aim: This study aimed to investigate the role of the mitochondrial apoptotic pathway in benign thyroid nodules., Materials and Methods: Paired samples of nodular and normal tissues were collected from 26 patients with nodular goiters undergoing thyroidectomy. Variable expression of Bcl-2, Bax and Bad genes were evaluated by quantitative PCR., Results: Expression level of Bad gene in nodules was found to be significantly decreased compared to normal tissues (p=0.049). A positive correlation was observed between nodule size and Bad expression levels (correlation coefficient=0.563, p=0.004); and this correlation was stronger in hot nodules (n=18, correlation coefficient=0.689, p=0.003). No significant difference was observed between nodular and normal tissue expressions of Bax and Bcl-2., Conclusion: These results suggest that Bad expression correlates with the size of benign thyroid nodules and also its relatively lower expression in nodules, warrant further investigation., (Copyright© 2018, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background: Transcatheter arterial embolization (TAE) is an effective minimally invasive adjunct to surgery for the management and/or palliation of adrenal tumors., Methods: In this case study, we reported three patients who underwent preoperative TAE before adrenalectomy for large hypervascular adrenal tumors. All patients underwent preoperative embolization 24 h before the operation and were then followed up at the intensive care unit surgery., Results: The largest diameter of the adrenal lesions ranged between 8 and 17 cm. Hypertensive attack occurred in one patient with pheochromocytoma during embolization. No other complications associated with the procedure was noted. The adrenal tumors were totally excised in all patients. The major intraoperative findings associated with preoperative embolization were marked reduction in hypervascularity and the decrease in the size of collateral vessels. No major hemorrhage necessitating blood transfusion were noted during surgery., Conclusions: Preoperative embolization of large hypervascular adrenal masses could reduce perioperative blood loss by reducing tumor vascularity.

Background: A thyroidectomy can be performed via a cervical incision in most patients with retrosternal goiter., Aims: To investigate the correlation between the volume of the mediastinal portion of the thyroid gland and the need for an extra-cervical approach for retrosternal goiter., Study Design: Diagnostic accuracy study., Methods: The measurement of craniocaudal length and the volume of the mediastinal component of the thyroid gland on computerised tomography images was performed in 47 patients with retrosternal goiter. Of these 47 patients, 8 (17%) required an extra-cervical approach and were classified as group 1, and 39 (83%) patients that required a cervical incision were classified as group 2. Receiver operating characteristic analysis was performed to determine the cut-off value for the craniocaudal length and the volume of the mediastinal thyroid mass, which significantly correlated with an extra-cervical approach for retrosternal goiter., Results: Reoperative surgery was significantly more frequent in group 1 than in group 2 (50% vs 13%; p=0.03). The craniocaudal length of the mediastinal thyroid gland was significantly longer in group 1 than in group 2 (77±11 mm vs 31±21 mm, respectively; p=0.0001). The volume of the mediastinal component was significantly larger in group 1 compared to group 2 (264±106 cm3 vs 40±41 cm3, respectively; p=0.0001). The receiver operating characteristic curve of craniocaudal length and the volume of the mediastinal component identified ≥66 mm and ≥162 cm3 as the cut-off values with the maximum accuracy, respectively. The craniocaudal length of the thyroid mass below the thoracic inlet ≥66 mm or a volume of the mediastinal portion ≥162 cm3 were significantly associated with an extra-cervical approach (p=0.0001). For predicting an extra-cervical approach, the sensitivity, positive predictive value and negative predictive value of the cut-off value for craniocaudal length was 87.5%, 64% and 97%, respectively. For predicting an extra-cervical approach, the sensitivity, positive predictive value and negative predictive value of the cut-off values for the mediastinal volume were 100%, 89% and 100%, respectively., Conclusion: A thyroid volume of ≥162 cm3 extending below the thoracic inlet was a significant determining factor for an extra-cervical approach, with a negative predictive value for the extra-cervical approach of 100% for retrosternal goiter with smaller volumes. Further studies with an increased number of patients are needed to determine the value of volumetric analysis of retrosternal goiter to predict the need for an extra-cervical approach in retrosternal goiter.

Hepatocellular carcinoma (HCC) is the most common primary malignancy of the liver, and extrahepatic metastases are typically found during disease progression. The incidence of adrenal metastasis (AM) from HCC in autopsy series ranges from 4.6 to 12.5%, and it is the second most common site of metastasis after the lungs. To date, there have been few reports of patients who underwent adrenalectomy for isolated AM from HCC after liver transplantation (LT). A woman aged 55 years was referred to our clinic for the evaluation of a right adrenal mass that was detected by abdominal ultrasonography at another center. She had undergone liver transplantation secondary to HCC and acute liver failure due to cryptogenic liver cirrhosis 138 months previously. She had been followed up for 5 years following LT after which she declined to continue with further follow-up. After radiologic and biochemical evaluation, she underwent adrenalectomy and the histopathologic examination revealed a 10 × 8 × 7-cm adrenal mass, which was considered to be an isolated AM from HCC. To our knowledge, this is the first case of isolated AM from HCC in the literature that was diagnosed 138 months after liver transplantation. Isolated AM from HCC after LT is rare and might be detected a long time after LT. Curative surgical resection of isolated metachronous AM from HCC in the absence of disseminated disease might provide for an acceptable disease-free period after adrenalectomy.

Background: The impact of single and combined interpretations of ultrasonography and sestamibi scintigraphy to select the appropriate surgical approach in patients with primary hyperparathyroidism were evaluated retrospectively., Methods: A total of 183 patients with primary hyperparathyroidism who were evaluated preoperatively using both ultrasonography and sestamibi scintigraphy were included in the study. The results of preoperative localization studies were correlated with intraoperative findings and postoperative histopathological results. The localization rates of individual and combined interpretations of ultrasonography and sestamibi scintigraphy were evaluated., Results: The overall sensitivity and the positive predictive value of ultrasonography and sestamibi scintigraphy were 76% and 90%, and 81% and 91%, respectively. Both imaging studies were concordant for the same localization(s) in 121 (66%) of 183 patients. The prevalence rates of single-gland and multiglandular disease were 90% (N.=109) and 10% (N.=12), respectively, in patients with concordant results (P=0.0001). The overall rate of localization was 91% (N.=110) in these patients. In these patients with concordant results, the sensitivity and the positive predictive value of imaging were 91% and 100%, respectively. The localization rates were 96% and 42% for single-gland and multiglandular disease, respectively (P=0.0001). Of the remaining 62 patients, 50 had negative imaging with either ultrasonography (N.=29) or MIBI (N.=21). Of the 29 patients with negative ultrasonography results, sestamibi scintigraphy was positive in 23. Of the 21 patients with negative sestamibi scintigraphy imaging, ultrasonography was positive in 15. Thus, 38 patients had a single positive imaging result. The majority (95%) of these 38 patients had single-gland disease, and the rate of multiglandular disease was 5% (P=0.0001). The rate of localization was 95% (36/38) in patients with a single positive imaging study. Eighteen patients had discordant imaging results., Conclusions: The overall rate of localization in primary hyperparathyroidism is greater than 90% if ultrasonography and sestamibi scintigraphy are concordantly positive for the same localization, and the prevalence of multiglandular disease is low in patients with concordant imaging. An image-guided surgical approach and selective parathyroidectomy exhibit high cure rates in the setting of concordantly positive sestamibi and ultrasonography results, even if intraoperative parathormone monitoring is not used.

Background: The aim of the study was to evaluate the results of ultrasonography (US)-guided percutaneous radiofrequency ablation (RFA) in hyperparathyroid patients who refused surgery or had high surgical risks., Patients and Methods: Five patients with hyperparathyroidism (HPT) underwent US-guided RFA for a single hyperfunctioning parathyroid lesion. Post-ablation serum calcium and parathormone (PTH) assays were performed. All patients underwent imaging studies 6 months after the ablation to visualize the post-ablation change in the size of the treated parathyroid lesions., Results: All patients were normocalcemic on the post-ablation 1st day and 6th month. The post-ablation PTH levels were normal in three patients but remained elevated in two patients. The size of the parathyroid lesion was ≥30 mm in the two patients with elevated PTH, whereas the lesion was smaller than 30 mm in those with normal post-ablation PTH values., Conclusion: Although this is a limited case series, it demonstrates the potential feasibility of RFA for HPT. Benefits were achieved particularly in patients with small parathyroid lesions.

This is a case report of a 40-year-old man with an adrenal mass that was found incidentally on routine check-up examination. MRI showed a 30 × 51 × 57 mm cystic-semisolid heterogeneous mass; hormonal functions were within normal limits. Operative removal was planned because of the large size of the mass. Histopathological and immunohistochemical findings were consistent with adenomatoid tumour. The patient was disease-free at 1 year follow-up. We present this case with its radiological and histological characteristics under the review of the literature., (2015 BMJ Publishing Group Ltd.)

Background: To investigate the rate of operative success in excision of nonpalpable lymph nodes with metastatic disease achieved with radioguided occult lesion localization (ROLL) and intraoperative ultrasonography (IOUS) in patients with papillary thyroid cancer (PTC)., Methods: Twenty consecutive PTC patients with nonpalpable lymph nodes with metastatic disease localized in previously operated fields were randomized to receive ROLL (n = 11) or IOUS (n = 9). Nodes were excised along with adjacent soft tissue to accomplish a compartment-oriented dissection. The duration of operation, rate of postoperative complications, pre- and postoperative serum thyroglobulin (Tg) levels, and the findings of postoperative neck ultrasonography and postablation scan were recorded in all patients. Measures of operative success included a postoperative Tg level <50% of preoperative Tg level and no abnormal lesions on postoperative imaging., Results: Histopathologic examination confirmed the excision of all preoperatively identified metastatic nodes. Additional nodes also were excised (2.3 ± 3.3 per specimen in the ROLL group and 1.6 ± 1.8 per specimen in the IOUS group), 23% of which were metastatic. No postoperative complications occurred in either group. The duration of operation was similar in the 2 groups (P = .4). Postoperative imaging confirmed the clearance of suspicious nodes in all patients. The rate of operative success in ROLL and IOUS group were 100% and 89%, respectively., Conclusion: In patients with recurrent PTC, a high rate of operative success in excision of nonpalpable metastatic lymph nodes was achieved by both ROLL and IOUS. We recommend compartment-oriented dissection; this approach may maximize the removal of metastatic nodes not identified by preoperative imaging., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Purpose: Concomitant use of chemotherapy and a radiation dose schedule that is more efficient compared to conventional radiotherapy may provide better outcomes in patients with esophageal cancer. This study aimed to assess the efficacy and tolerability of neoadjuvant cisplatin-based chemotherapy and hyperfractionated accelerated radiotherapy regimen in this group of patients., Methods and Materials: A total of 20 newly diagnosed treatment-naïve esophageal cancer patients were included in the study. Neoadjuvant cisplatin and 5-FU were given with 28-day intervals in a total of three courses. Along with the third course of chemotherapy, hyperfractionated accelerated radiotherapy (HART) was given with the following dose schedule: 5760 cGy/36 fr/16 day., Results: All patients could receive the planned RT dose of 5760 cGy. Odynophagia was the most frequent grade III acute toxicity (50%). None of the acute toxicity reactions required treatment discontinuation. Grade III or higher subacute/late toxicity occurred in 10 patients (75%) including 5 deaths, mostly esophageal. Radiologically, 8 patients (40%) had complete response, 8 (40%) had partial response, and 3 (15%) had stable disease, with only 1 patient (5%) having progressive disease. Seven patients underwent surgery. Overall, 8 patients (40%) had local control. The 5 years overall survival rate was 38.1%., Conclusions: Neoadjuvant hyperfractionated accelerated radiotherapy plus chemotherapy may help to target local disease control and increase survival in patients with esophageal cancer. Further studies to improve neoadjuvant and radical chemoradiotherapy dose schedules are warranted for maximum tumor control rates with minimal toxicity.

Minimally invasive surgery has gained a rapid development and popularity in the recent years. With these developments in minimally invasive surgery, video-thoracoscopic approaches has become more frequently preferred interventions for benign esophageal lesions. Herein, we report a case of a giant esophageal leiomyoma which was successfully enucleated by video-thoracoscopic approach without any peroperative or postoperative complications.

Gastrointestinal complications such as gastrointestinal bleeding and perforation due to immunosuppressant use are seen more frequently after solid organ transplantation. A 52-year-old male was admitted on the 7th day of a living donor renal transplantation with serous drainage at the incision site. He had no abdominal complaints. He was on triple immunosuppressant therapy. Abdominal plain X-ray and ultrasonography were normal, but diffuse extraluminal air was detected on the computed tomography scan. There were no pathological laboratory findings regarding the function of the renal allograft. We began the operation laparoscopically and then converted to laparotomy. Sigmoid colonic perforation was detected on the antimesenteric side. Neither diverticulitis nor ischemia was observed, and no evidence of iatrogenic injury was seen. There was no transrectal instrumentation history. Omentoplasty and sigmoid loop colostomy were performed. He was discharged on the 9th day following the operation. His colostomy was closed one year after the operation. Gastrointestinal complications can be fatal, but do not seem to influence the long-term survival or renal allograft function. Most of them are seen after using high doses of immunosuppressants to manage the early postoperative period or episodes of acute rejection. Early diagnosis and aggressive treatment play an important role in survival.

Introduction: Different mechanisms for the expression of pendrin which is an apical iodide transporter have been reported in nodular thyroid tissues compared to normal thyroid. The aim of the present study was to determine the alterations of pendrin expression in nodular and surrounding non-nodular thyroid tissues and clarify the role of pendrin in the functional behaviour of nodular lesions., Material and Methods: Twenty-six nodular and paired non-nodular normal thyroid tissues were collected at the same centre. Patients were divided into two groups based on the function of the dominant thyroid nodule; hot nodules (n = 18) and cold nodules (n = 8). mRNA levels of pendrin were evaluated by quantitative RT-PCR. Pendrin protein expression was determined by immunohistochemical analysis. Results of dominant nodules were compared to non-nodular thyroid tissue of the same patient., Results: No statistically significant difference was found with respect to qualitative and quantitative measurements of pendrin expression between hot and cold nodules. However, percent immunohistochemical staining of pendrin was significantly higher in both hot and cold nodules compared to non-nodular thyroid tissue of the same patients. RT-PCR revealed comparable mRNA levels of pendrin gene between hot nodules and corresponding normal thyroid tissues. However, in cold nodules, significantly decreased mRNA levels of pendrin were observed compared to normal thyroid tissue. mRNA levels of pendrin showed significant positive correlation with TSH in corresponding non-nodular thyroid tissues., Conclusions: The present study demonstrates that expression of pendrin could not be influenced by TSH in thyroid nodules and expression level of pendrin seems not to have an effect on nodule function.

Background: The aim of this study was to compare outcome measures between conventional transabdominal laparoscopic adrenalectomy and single-incision laparoscopic adrenalectomy (SILA)., Methods: Between January 2006 and April 2010, a total of 96 patients underwent laparoscopic adrenalectomy. Of these, 74 (77.1%) underwent conventional transabdominal laparoscopic adrenalectomy (group 1) and 22 (32.9%) underwent SILA (group 2). Age, sex ratio, tumor size, operating time, blood loss, postoperative visual analog pain scale (VAS) scores, and duration of hospitalization were compared between the two groups., Results: The mean ages of the patients in groups 1 and 2 were 43.4 ± 12.3 and 43.3 ± 10 years, respectively (P = 0.7). The female:male ratios in groups 1 and 2 were 1.6:1 and 4.5:1, respectively (P < 0.0001). The mean tumor size was significantly larger in group 1 than in group 2 (4.7 ± 1.5 vs. 3.34 ± 1.06 cm, respectively; P = 0.093). No significant difference was found between group 1 and group 2 with respect to the mean operating time (68.4 ± 20.8 vs. 63.9 ± 16.9 min, respectively; P = 0.36) or the level of intraoperative blood loss (38 ± 26.5 vs. 48.4 ± 62.4 ml, respectively; P = 0.26). The postoperative VAS score was significantly lower in group 2 than in group 1 (2.05 ± 0.57 and 3.28 ± 0.63, respectively; P < 0.0001). The length of hospital stay was significantly higher in group 1 than in group 2 (3.04 ± 1.2 and 2.45 ± 0.96 days, respectively; P = 0.04)., Conclusion: The findings of the present study suggest that SILA is as safe as conventional transabdominal laparoscopic adrenalectomy. Furthermore, SILA is associated with less pain and better cosmesis than the conventional laparoscopic procedure.

Background: The purpose of this study was to investigate the efficiency of a radioguided occult lesion localization technique in reoperative thyroid and parathyroid procedures in patients who had undergone previous neck exploration for thyroid or parathyroid disease., Methods: Twenty-one consecutive patients who were scheduled for reoperative thyroid or parathyroid surgery were studied. The indication for reoperation was recurrent papillary thyroid cancer (PTC) in eight patients, completion thyroidectomy for PTC in eight patients who had previously undergone a bilateral subtotal thyroidectomy, recurrent goiter in two patients, primary hyperparathyroidism in two patients, and recurrent parathyroid cancer in one patient. Ninety minutes before surgery, 0.1 mL of Technetium-99m (0.2 mCi)-labeled macroaggregated albumin was injected directly into the lesion under ultrasonographic guidance. During surgery, a handheld gamma probe was used to localize and excise the lesions. The background and postexcisional site radioactivities were compared to confirm the completeness of each procedure. The radiation dose in the operating room environment, duration of surgery, and postoperative complication rates were evaluated in all patients. In patients with PTC, the change in serum thyroglobulin (Tg) following surgery was noted., Results: Thirty lesions were marked and excised. The postexcisional bed gamma counts (610 ± 141) were markedly decreased compared with the pre-excisional site counts (21,415.8 ± 4993.4; p = 0.0001). The ratio of the postexcisional and background counts (4.6 ± 4.3) was significantly lower than the ratio of the pre-excisional and background counts (173.7 ± 156.4; p = 0.0001). The mean operation duration was 53.3 ± 7.5 minutes. The dose absorbed by the hands of the surgeon was estimated as 0.07 ± 0.02 and 0.15 ± 0.05 millisievert/h when one or three lesions were marked, respectively. One patient developed postoperative transient hypoparathyroidism. After surgery, serum Tg levels dropped to <2 ng/mL in 86% (6/7) of the patients with PTC whose preoperative serum Tg was elevated., Conclusions: The radioguided occult lesion localization technique was efficient in the perioperative identification of thyroid and parathyroid tumors in patients who were undergoing reoperation for PTC and hyperparathyroidism.

Background: We investigated central compartment recurrence (CCR) and mortality rate in patients with papillary thyroid carcinoma (PTC) who had no central lymph node dissection (CLND) at the time of primary operation., Methods: The medical records of 343 patients who underwent operations for PTC between January 1988 and December 2002 with a mean postoperative follow-up period of 9 +/- 4 years, were reviewed., Results: Twenty-two patients (6%) had locoregional recurrence. The lateral, central, or both compartments were involved in 16, 2, and 4 of 22 patients, respectively. The rate of CCR was 2% (6/343). Five (2%) patients died from PTC due to locoregional invasion (tracheal and esophageal invasion) in 3 patients and distant metastasis in 2 patients. Older age (>or=60), initial metastatic lateral cervical lymph nodes, size of primary tumor size >or=3 cm, microscopic extrathyroidial extension, and aggressive histologic subtypes (diffuse sclerosing, tall-cell, poorly differentiated) of PTC were risk factors for CCR and mortality (P = .0001)., Conclusion: Initial CLND might be of value to prevent CCR and mortality in PTC patients with initial metastatic cervical lateral lymph nodes, older age (age >or=60), primary tumor size >or=3 cm, and agressive histopathologic features of PTC.

Objective: This study aimed to compare the impact of total versus subtotal thyroidectomy on calcium metabolism and bone mineral density in euthyroid, premenopausal women., Subjects: The study included 24 premenopausal women who had undergone total (n = 10) or subtotal (n = 14) thyroidectomy and who were receiving nonsuppressive doses of thyroxine. The median post-operative period was four years. We determined, in all patients, the following parameters associated with calcium metabolism: total serum calcium, inorganic phosphate, intact parathormone, calcitonin and alkaline phosphatase. The bone mineral density of the spine and hip were measured using a Hologic QDR 4500C bone densitometer and were compared with controls matched for age and peak bone mineral density (using the t-test)., Results: The measured calcium metabolism parameters were normal in all patients, and none had osteoporosis. There was no significant difference in the bone mineral density measurements for the spine and hip, comparing patients who had undergone total versus subtotal thyroidectomy (using the t-test)., Conclusion: The impact of total thyroidectomy on bone mineral metabolism is not significantly different from that of subtotal thyroidectomy, in premenopausal women with normal thyroid-stimulating hormone values.