The Year in Surgical Thyroidology: Recent Technological Developments and Future Challenges

Background: The field of surgical and interventional thyroidology is rapidly evolving. In the past few years, we have seen the introduction and establishment of many novel surgical adjuncts, techniques, and disruptive ablative technologies that have impacted the field. Methods: We identified the most influential articles on technological developments in surgical and interventional thyroidology that were published from September 1, 2020, to August 1, 2021. We searched three electronic databases and consulted experts. Results: Major findings are summarized. Continuous intraoperative nerve monitoring (cIONM) lowered the risk of early postoperative vocal cord palsy 1.8-fold and permanent palsy 29 · 4-fold compared with intermittent intraoperative nerve monitoring. Parathyroid autofluorescence yielded a diagnostic odds ratio (OR) of 228.9 for detection of parathyroid glands over visualization, with 96% sensitivity and 92% specificity. There was no significant difference in the incidence of major complications between the transoral endoscopic thyroidectomy vestibular approach (TOETVA) and transcervical thyroidectomy (1.5% vs. 2.1%, p = 0.75), and a higher body mass index did not lead to a significant increase in the odds of cumulative complication with TOETVA for the overweight (OR = 0.52 [95% confidence interval {CI} 0.17-1.58]) and obese groups (OR = 1.69 [CI 0.74-3.88]). Radiofrequency ablation (RFA) for benign thyroid nodules typically resulted in a 50-85% volume reduction with faster recovery times, less pain levels, and higher social and psychological well-being compared with conventional thyroidectomy at 15 months post-treatment, although physical well-being levels were higher in the conventional thyroidectomy group at this time. RFA for papillary thyroid microcarcinoma showed no significant difference in local tumor progression (1.8% vs. 3.3%, p = 0.209), lymph node metastasis (0.6% vs. 0.6%, p = 1.000), recurrence (1.2% vs. 2.4%, p = 0.244), and 4-year recurrence-free survival rates (98.2% vs. 97.0%, p = 0.223) when compared with transcervical lobectomy. Conclusions: cIONM, parathyroid autofluorescence, transoral vestibular approach thyroid surgery, and RFA for benign and malignant thyroid nodules are some of the latest additions to the surgeon's and interventionalist's armamentarium to manage thyroid disease. These technological advancements demonstrate promise to improve outcomes, decrease complications, and enhance a patient's quality of life, but further rigorous studies are needed to define their utility and value.

The 2021 European Group on Graves' orbitopathy (EUGOGO) clinical practice guidelines for the medical management of Graves' orbitopathy

Graves' orbitopathy (GO) is the main extrathyroidal manifestation of Graves' disease (GD). Choice of treatment should be based on the assessment of clinical activity and severity of GO. Early referral to specialized centers is fundamental for most patients with GO. Risk factors include smoking, thyroid dysfunction, high serum level of thyrotropin receptor antibodies, radioactive iodine (RAI) treatment, and hypercholesterolemia. In mild and active GO, control of risk factors, local treatments, and selenium (selenium-deficient areas) are usually sufficient; if RAI treatment is selected to manage GD, low-dose oral prednisone prophylaxis is needed, especially if risk factors coexist. For both active moderate-to-severe and sight-threatening GO, antithyroid drugs are preferred when managing Graves' hyperthyroidism. In moderate-to-severe and active GO i.v. glucocorticoids are more effective and better tolerated than oral glucocorticoids. Based on current evidence and efficacy/safety profile, costs and reimbursement, drug availability, long-term effectiveness, and patient choice after extensive counseling, a combination of i.v. methylprednisolone and mycophenolate sodium is recommended as first-line treatment. A cumulative dose of 4.5 g of i.v. methylprednisolone in 12 weekly infusions is the optimal regimen. Alternatively, higher cumulative doses not exceeding 8 g can be used as monotherapy in most severe cases and constant/inconstant diplopia. Second-line treatments for moderate-to-severe and active GO include (a) the second course of i.v. methylprednisolone (7.5 g) subsequent to careful ophthalmic and biochemical evaluation, (b) oral prednisone/prednisolone combined with either cyclosporine or azathioprine; (c) orbital radiotherapy combined with oral or i.v. glucocorticoids, (d) teprotumumab; (e) rituximab and (f) tocilizumab. Sight-threatening GO is treated with several high single doses of i.v. methylprednisolone per week and, if unresponsive, with urgent orbital decompression. Rehabilitative surgery (orbital decompression, squint, and eyelid surgery) is indicated for inactive residual GO manifestations.

Sleep disturbance and delirium in patients with acromegaly in the early postoperative period after transsphenoidal pituitary surgery

Sleep disturbance is a common comorbidity among patients with acromegaly [patients with growth hormone (GH)-secreting tumor] due to somatotropic axis change and sleep apnea. However, no previous studies exist concerning sleep disturbance and delirium in the early postoperative period in patients with acromegaly undergoing transsphenoidal tumor surgery. Herein, we aimed to compare the incidence of postoperative sleep disturbance and delirium in the early postoperative period between patients with GH-secreting and nonfunctioning pituitary tumors.We retrospectively reviewed the medical records of 1286 patients (969 with nonfunctioning and 317 with GH-secreting tumors) without history of psychological disease and sedative or antipsychotic use. We examined the use of antipsychotics/sedatives and findings of psychology consultation within the first postoperative week. Only patients with sleep disturbance noted in medical records were considered to have postoperative sleep disturbance. Patients with an Intensive Care Delirium Screening Checklist score of 4 or more were considered to have postoperative delirium.The incidence of postoperative sleep disturbance was higher in the GH-secreting group than in the nonfunctioning tumor group (2/969 [0.2%] vs 6/317 [1.9%]; P = .004; odds ratio = 9.328 [95% confidence interval, 1.873-46.452]). Univariable regression analysis showed that only diagnosis (GH-secreting tumor or nonfunctioning tumor) was a risk factor for sleep disturbance, and not sex, age, body mass index, American Society of Anesthesiologists physical status score, surgery duration, anesthesia duration, anesthesia type, tumor size, cavernous sinus invasion, or bleeding. The incidence of postoperative delirium was comparable between the 2 groups (6/969 [0.6%] vs 0/317 [0%]; P = .346).Patients with acromegaly showed increased incidence of sleep disturbance than those with nonfunctioning tumors in the early postoperative period after transsphenoidal tumor surgery. A prospective study evaluating sleep quality in patients with GH-secreting tumors in the early postoperative period could be conducted based on our findings.

The revised clinical practice guidelines on the management of thyroid tumors by the Japan Associations of Endocrine Surgeons: Core questions and recommendations for treatments of thyroid cancer

The Japan Associations of Endocrine Surgeons has developed the revised version of the Clinical Practice Guidelines for Thyroid Tumors. This article describes the guidelines translated into English for the 35 clinical questions relevant to the therapeutic management of thyroid cancers. The objective of the guidelines is to improve health-related outcomes in patients with thyroid tumors by enabling users to make their practice evidence-based and by minimizing any variations in clinical practice due to gaps in evidential knowledge among physicians. The guidelines give representative flow-charts on the management of papillary, follicular, medullary, and anaplastic thyroid carcinoma, along with recommendations for clinical questions by presenting evidence on the relevant outcomes including benefits, risks, and health conditions from patients' perspective. Therapeutic actions were recommended or not recommended either strongly (◎◎◎ or XXX) based on good evidence (😊)/good expert consensus (+++), or weakly (◎, ◎◎ or X, XX) based on poor evidence (😣)/poor expert consensus (+ or ++). Only 10 of the 51 recommendations given in the guidelines were supported by good evidence, whereas 35 were supported by good expert consensus. While implementing the current guidelines would be of help to achieve the objective, we need further clinical research to make our shared decision making to be more evidence-based.

Metastatic pheochromocytoma and paraganglioma: Management of endocrine manifestations, surgery and ablative procedures, and systemic therapies

Metastatic pheochromocytomas and paragangliomas (MPPGs) are rare neuroendocrine tumors. Most patients present with advanced disease that is associated with manifestations of catecholamine release. Surgical resection of the primary tumor and ablative therapies of metastases-whenever possible-may improve clinical outcomes and, perhaps, lengthen the patient's overall survival. Significant steps in understanding the genetic alterations linked to MPPGs and scientific progress made on cancers that share a similar pathogenesis are leading to the recognition of potential systemic therapeutic options. Data derived from clinical trials evaluating targeted therapies such as tyrosine kinase inhibitors, radiopharmaceuticals, immunotherapy, and combinations of these will likely improve the outcomes of patients with advanced and progressive MPPGs. Exemplary of this success is the recent approval in the United States of the high-specific-activity iodine¹³¹ meta-iodine-benzylguanidine (MIBG) for patients with unresectable and progressive MPPGs that express the noradrenaline transporter. This review will discuss the therapeutic approaches for patients with MPPGs.

Training in endocrine surgery

BACKGROUND/PURPOSE

In Europe, the Division of Endocrine Surgery (DES) determines the number of operations (thyroid, neck dissection, parathyroids, adrenals, neuroendocrine tumors of the gastro-entero-pancreatic tract (GEP-NETs)) to be required for the European Board of Surgery Qualification in (neck) endocrine surgery. However, it is the national surgical boards that determine how surgical training is delivered in their respective countries. There is a lack of knowledge on the current situation concerning the training of surgical residents and fellows with regard to (neck) endocrine surgery in Europe.

METHODS

A survey was sent out to all 28 current national delegates of the DES. One questionnaire was addressing the training of surgical residents while the other was addressing the training of fellows in endocrine surgery. Particular focus was put on the numbers of operations considered appropriate.

RESULTS

For most of the operations, the overall number as defined by national surgical boards matched quite well the views of the national delegates even though differences exist between countries. In addition, the current numbers required for the EBSQ exam are well within this range for thyroid and parathyroid procedures but below for neck dissections as well as operations on the adrenals and GEP-NETs.

CONCLUSIONS

Training in endocrine surgery should be performed in units that perform a minimum of 100 thyroid, 50 parathyroid, 15 adrenal, and/or 10 GEP-NET operations yearly. Fellows should be expected to have been the performing surgeon of a minimum of 50 thyroid operations, 10 (central or lateral) lymph node dissections, 15 parathyroid, 5 adrenal, and 5 GEP-NET operations.

Surgical approaches and results of treatment for hereditary paragangliomas

Paragangliomas (PGL) are rare neuroendocrine tumours; parasympathetic PGL are predominantly non-secreting and located at the skull base and neck, while sympathetic PGL are typically catecholamine-secreting and located at abdomino-pelvic level. Approximately 40% of PGL may be caused by germline mutations; hereditary variants should be suspected especially in case of positive family history, early onset, multifocal, or recurrent PGL. Significant genotype-phenotype correlation has been recognized, including syndromic presentation, location, multifocality and risk of malignancy. Surgical resection remains the only curative strategy, but the outcomes may be unsatisfactory because of surgical morbidity and recurrence rate. However, due to the rarity of the disease, most data derive from case-report or limited series. This paper was aimed to review the available literature on the epidemiology, diagnosis, clinical features, treatment of PGL in order to discuss the surgical approach and the results of treatment in hereditary PGL.

Proper handling of the pyramidal lobe in minimal access thyroid procedures

The thyroid gland is a butterfly-shaped gland located in the lower part of the anterior surface of the neck between the fifth cervical and the first thoracic vertebra. Usually, it consists of two lateral, almost symmetrical lobes, the connective isthmus and the pyramidal lobe. The pyramidal lobe is a conical or cylindrical projection of the gland's parenchyma that extends superiorly to the thyroid cartilage or the hyoid bone. Most often, it originates from the isthmus and it is located to the left of the middle line. It can be absent in up to 50% of the cases. From the time of Theodor Kocher who performed the first classic thyroidectomies, we are now entering the era of minimal access thyroid surgery where new techniques are devised in order to provide a better cosmetic result. The presence of the pyramidal lobe is a classic example of an anatomic variation of the thyroid gland that plays an important role in the completeness of a total thyroidectomy, especially when the procedure is carried out for an autoimmune or malignant disease. The pyramidal lobe can also increase the complexity of minimal access procedures that are nowadays applied for the removal of the thyroid gland. The purpose of this article is to outline the importance of the pyramidal lobe in minimal access thyroid surgery.

Is it time to reconsider lobectomy in low-risk paediatric thyroid cancer?

OBJECTIVE

Current guidelines recommend total thyroidectomy for nearly all children with well-differentiated thyroid cancer (WDTC). These guidelines, however, derive from older data accrued prior to current high-resolution imaging. We speculate that there is a subpopulation of children who may be adequately treated with lobectomy.

DESIGN

Retrospective analysis of prospectively maintained database.

PATIENTS

Seventy-three children with WDTC treated between 2004 and 2015.

MEASUREMENTS

We applied two different risk-stratification criteria to this population. First, we determined the number of patients meeting American Thyroid Association (ATA) 'low-risk' criteria, defined as disease grossly confined to the thyroid with either N0/Nx or incidental microscopic N1a disease. Second, we defined a set of 'very-low-risk' histopathological criteria, comprising unifocal tumours ≤4 cm without predefined high-risk factors, and determined the proportion of patients that met these criteria.

RESULTS

Twenty-seven (37%) males and 46 (63%) females were included in this study, with a mean age of 13·4 years. Ipsilateral- and contralateral multifocality were identified in 27 (37·0%) and 19 (26·0%) of specimens. Thirty-seven (51%) patients had lymph node metastasis (N1a = 18/N1b = 19). Pre-operative ultrasound identified all cases with clinically significant nodal disease. Of the 73 patients, 39 (53·4%) met ATA low-risk criteria and 16 (21·9%) met 'very-low-risk' criteria. All 'very-low-risk' patients demonstrated excellent response to initial therapy without persistence/recurrence after a mean follow-up of 36·4 months.

CONCLUSIONS

Ultrasound and histopathology identify a substantial population that may be candidates for lobectomy, avoiding the risks and potential medical and psychosocial morbidity associated with total thyroidectomy. We propose a clinical framework to stimulate discussion of lobectomy as an option for low-risk patients.

Quality indicators in pituitary surgery: a need for reliable and valid assessments. What should be measured?

Engagement with improving the quality of clinical care is a key component of medical professionalism. Central to Quality Improvement (QI) agenda are the development of valid, reliable and accurate quality metrics. We cannot improve what we do not measure. Pituitary surgery, which in the 21st century usually means trans-sphenoidal surgery (TSS), is unusual; it is a neurosurgical procedure in which complex outcomes can be measured precisely. We have clear guidelines for establishing remission/cure in functional endocrine disease and precise diagnostic tools with which to investigate our patients. Visual recovery can be equally precisely measured with standardised equipment. Moreover, TSS is one of the commonest major surgical procedures carried out in the 34 UK individual neurosurgical units. Most will carry out about 30-40 procedures each year, with four or five units notably higher with numbers in excess of one hundred cases. There are, potentially, plenty of data out there. Given this background, how best should we measure quality in this important area of clinical practice?

Health-related quality of life in patients treated for nonfunctioning pituitary adenomas during the years 2000-2010

OBJECTIVE

The published data on health-related quality of life (HRQoL) after treatment of nonfunctioning pituitary adenomas (NFPAs) are conflicting. We evaluated HRQoL in a recent series of patients who had surgery for an NFPA.

DESIGN

Cross-sectional study including a large control population.

PATIENTS AND MEASUREMENTS

A HRQoL questionnaire (15D) was sent to all patients (n = 161) having undergone transsphenoidal surgery for NFPA in the years 2000-2010 at the Helsinki University Hospital. The 15D score and dimension scores of the study population (n = 137) were compared with those of a large (n = 4967) gender- and age-standardized control population. Possible independent predictors of HRQoL in the patients were estimated with multivariate regression analysis.

RESULTS

Postoperatively, 57% of the patients had normal visual function. After a mean follow-up of 7·4 ± 3·2 years (mean ± SD), 62% suffered from hypopituitarism. Overall, HRQoL was near-normal in patients compared to controls (15D scores 0·885 ± 0·114 vs 0·903 ± 0·093, respectively, P = 0·07). On single dimensions, patients had impaired vision and sexual activity (both P < 0·0005), more depression and distress (both P < 0·005) and less discomfort and symptoms (P < 0·05). Age, body mass index, diabetes, depression and reoperation were independent predictors of impaired HRQoL (all P < 0·05). Thyroxine substitution was associated with impaired and hydrocortisone and testosterone substitution (males only) with better HRQoL (all P < 0·05).

CONCLUSIONS

This recent series of NFPA patients demonstrates that overall HRQoL is near-normal after medium term follow-up; the most impaired dimensions were in vision and sexual activity. Comorbidities are strong predictors of impaired HRQoL.

[SURGICAL TREATMENT OF METASTATIC NON—FUNCTIONING NEUROENDOCRINE TUMORS OF THE PANCREAS]

Experience of surgical treatment of 6 patients for synchronous and 9 — metachronous metastases of non—functioning neuroendocrine pancreas tumors (NEPT) in the liver was presented. In 14 (93.3%) patients made R0 resection. In 5 patients due synchronous metastases the combination intervention on pancreas and liver was performed, in one — limited to the removal of the primary tumor. Regarding synchronous metastasis in 8 patients resection of the liver, in 1 — multivisceral resection was performed. NEPT G2 stage diagnosed in 13 (86.7%) patients, neuroendocrine carcinoma G3 — in 2 (13.3%). Indications for surgical treatment of metastatic NEPT is resectable forms of the disease and the appearance of metastases is not earlier than 6 months after the first operation.

LIMITATIONS OF CURRENT APPROACHES FOR THE TREATMENT OF ACROMEGALY

OBJECTIVE

Acromegaly is a rare disease characterized by hypersecretion of growth hormone (GH), typically from a benign pituitary somatotroph adenoma, that leads to subsequent hypersecretion of insulin-like growth factor 1 (IGF-1). Patients with acromegaly have an increased risk of mortality and progressive worsening of comorbidities. Surgery, medical therapy, and radiotherapy are currently available treatment approaches for patients with acromegaly, with overall therapeutic goals of lowering GH levels and achieving normal IGF-1 levels, reducing tumor size, improving comorbidities, and minimizing mortality risk. Although surgery can lead to biochemical remission in some patients with acromegaly, many patients will continue to have uncontrolled disease and require additional treatment.

METHODS

We reviewed recently published reports and present a summary of the safety and efficacy of current treatment modalities for patients with acromegaly.

RESULTS

A substantial proportion of patients who receive medical therapy or radiotherapy will have persistently elevated GH and/or IGF-1. Because of the serious health consequences of continued elevation of GH and IGF-1, there is a need to improve therapeutic approaches to optimize biochemical control, particularly in high-need patient populations for whom current treatment options provide limited benefit.

CONCLUSION

This review discusses current treatment options for patients with acromegaly, limitations associated with each treatment approach, and areas within the current treatment algorithm, as well as patient populations for which improved therapeutic options are needed. Novel agents in development were also highlighted, which have the potential to improve management of patients with uncontrolled or persistent acromegaly.

[EFFICACY OF WELDING TECHNOLOGY AS A PRINCIPAL METHOD OF DISSECTION AND HEMOSTASIS IN ENDOCRINAL SURGERY]

Today in the clinic all surgical interventions on endocrinal organs are conducted, using welding technology. Comparative analysis of the operative interventions efficacy, performed applying a standard method (control group) and using welding technology (the main group), was conducted. Performance of operations, using electric welding technologies have permitted to reduce the operative intervention duration by 20 - 30%, the blood loss volume--by 30 - 50%, a postoperative pain syndrome severity and the analgetics expense--by 20%, a postoperative stationary treatment duration--by 1-2 days.

Endonasal endoscopic transsphenoidal pituitary surgery: early experience and outcome in paediatric Cushing's disease

BACKGROUND

Selective adenomectomy remains the first-line treatment for Cushing's disease (CD), until recently by microscopic transsphenoidal pituitary surgery. Endonasal transsphenoidal endoscopic surgery (ETES) is emerging as a novel, less invasive treatment for pituitary adenomas and has become the optimal surgical approach.

OBJECTIVE

There are no published series for the treatment of paediatric CD by ETES, and we report our centre's preliminary results.

DESIGN

Retrospective analysis.

PATIENTS

Six paediatric patients (median age 15·8 years; range 11·7-17·0 years) fulfilled standard diagnostic criteria for CD. Preoperatively, no abnormality was identified on pituitary MR scanning in 3 (50%) patients, one had a macroadenoma. Bilateral petrosal sinus sampling demonstrated central ACTH secretion (IPS/P ACTH ratio ≥3·0, post-CRH) in 3/6 (50%) patients. The same neurosurgeon and endoscopic nasal surgeon undertook all the operations.

OUTCOME MEASURES

Therapeutic outcome and rate of complications.

RESULTS

Clinical recovery and biochemical 'cure' were achieved in 5 (83%) patients, and a corticotroph adenoma was confirmed histologically in all cured cases. One case developed post-operative CSF leak requiring lumbar drain insertion and patching. At a mean interval of 4·7 years (0·1-10·8 years) post-operatively, cured patients have shown no recurrence. One patient, with a large diffuse adenoma requiring more extensive surgery, has panhypopituitarism, and another patient has GH and gonadotrophin deficiencies.

CONCLUSIONS

Our experience shows that ETES for removing corticotroph adenomas in children, in most cases not visualized on MRI, is minimally invasive and gave excellent post-operative recovery/results. In skilled hands, this technique provides an alternative to conventional transsphenoidal microscopic surgery in managing paediatric CD.

Pediatric endocrine surgery: a 20-year experience at the Mayo Clinic

CONTEXT

Surgically managed endocrinopathies are rare in children. Most surgeons have limited experience in this field. Herein we report our operative experience with pediatric patients, performed over two decades by high-volume endocrine surgeons.

SETTING

The study was conducted at the Mayo Clinic (a tertiary referral center).

PATIENTS

Patients were <19 years old and underwent an endocrine operation (1993-2012).

MAIN OUTCOME MEASURES

Demographics, surgical procedure, diagnoses, morbidity, and mortality were retrospectively reviewed.

RESULTS

A total of 241 primary cases included 177 thyroid procedures, 13 neck dissections, 24 parathyroidectomies, 14 adrenalectomies, 7 paragangliomas, and 6 pancreatic procedures. Average age of patients was 14.2 years. There were 133 total thyroidectomies and 40 hemithyroidectomies. Fifty-three cases underwent a central or lateral neck dissection. Six-month follow-up was available for 98 total thyroidectomy patients. There were four cases of permanent hypoparathyroidism (4%) and no permanent recurrent laryngeal nerve (RLN) paralyses. Sequelae of neck dissections included temporary RLN neurapraxia and Horner's syndrome. Parathyroidectomy was performed on 24 patients: 20 with primary hyperparathyroidism (HPT), three with tertiary HPT, and one with familial hypocalciuric hypocalcemia. Three patients (16%) had recurrent HPT, all with multiglandular disease. One patient had temporary RLN neurapraxia. We performed seven bilateral and seven unilateral adrenalectomies; eight were laparoscopic. Indications included pheochromocytoma, Cushing's syndrome, adrenocortical carcinoma, congenital adrenal hyperplasia, and ganglioneuroma. One death was due to adrenocortical carcinoma. Five paraganglioma patients had succinate dehydrogenase subunit B mutations, and one recurred. Six patients with insulinoma underwent enucleation (n = 5) or distal pancreatectomy (n = 1). A single postoperative abscess was managed nonoperatively.

CONCLUSION

Pediatric endocrine procedures are uncommon but can be safely performed with complication rates comparable to those of the adult population. It is imperative that these operations be performed by high-volume surgeons.

[News in endocrinology in 2013]

Transsphenoidal surgery is the treatment of choice for acromegaly due to pituitary adenoma but it is not always possible to reduce or control tumor growth, inhibit GH hypersecretion and normalize IGF-I. The first-line drug treatment in 2013 remains the somatostatin analogues. In 2012 and 2013 have been published several publications presenting the prognosis of well-differentiated thyroid cancers of intermediate risk. Indeed, the dose of radioactive iodine administered to patients with "favorable" histology in this risk category should be reduced without change in prognosis. Elastograhy could, in combination with conventional ultrasound features, allow a better selection of thyroid nodules that need a cytology, with, however, still limitations in the detection of follicular carcinomas.

[Experience of high frequency electric welding in endocrine surgery]

The comparative analsis of the effectiveness of surgical interventions performed by the standard method and using electric welding technology in endocrine surgery was hold. Compared duration of surgery, amount of intraoperatve blood loss, frequency of intra- and early postoperative complications. Found that the use of weding technology ensures shorter duration of surgery, on average by 30%, amount of blood loss--by 20-50%, the frequency of intra- and early postoperative complications.

Cushing's disease -- assessing the efficacy of transsphenoidal surgery

Cushing's disease (CD) is caused by a pituitary adenoma secreting corticotrophin (ACTH) that leads to cortisol excess. Despite a characteristic clinical picture, it is often difficult to make a proper diagnosis, as it requires complex and long-lasting diagnostic procedures. Selective transsphenoidal surgery (TSS) remains the treatment of choice for CD. Untreated or improperly treated Cushing's disease leads to the development of serious complications, which lower patients' quality of life. Mortality in this group is high, reaching 50% within a 5-year follow-up period. In this study, we present our own experience and discuss the importance of preoperative hormone measurements, magnetic resonance imaging (MRI) of the pituitary, results of histopathological examination (immunohistochemical and ultrastructural in electron microscopy) and postoperative early and late hormonal assessment in the aspect of TSS efficacy. The performed analysis is based on the current criteria for remission of Cushing's disease. Our study emphasises the need for long-term postoperative endocrinological follow-up, which facilitates early detection of recurrent hypercortisolemia.

The dynamics of post-operative plasma ACTH values following transsphenoidal surgery for Cushing's disease

Rapid assessment of adrenal function is critical following transsphenoidal surgery (TSS) for Cushing's disease (CD) in order to determine surgical efficacy. We hypothesize that there may be a role for ACTH measurement as a rapid indicator of adrenal function. Following surgery for CD, glucocorticoids were withheld and paired plasma ACTH and serum cortisol levels were measured every 6 h. Post-operative hypocortisolemia was defined as serum cortisol <2 mcg/dl or a serum cortisol <5 mcg/dl with the onset of symptoms of adrenal insufficiency within 72 h. We studied 12 subjects, all female, mean age 44.6 years (range 25-55), including 13 surgeries: nine subjects attained hypocortisolemia. Plasma ACTH levels decreased more in subjects with hypocortisolemia (0.9 pg/ml/hr, P = 0.0028) versus those with persistent disease (0 0.2 pg/ml/hr, P = 0.26) within the first 48 h after surgery. In contrast to subjects with persistent disease, all subjects with hypocortisolemia achieved a plasma ACTH <20 pg/ml by 19 h (range 1-19 h). Four of the nine subjects with hypocortisolemia achieved plasma ACTH <20 pg/ml by 13 h and the remaining five subjects by 19 h. Hypocortisolemia occurred between 3-36 h following achievement of a plasma ACTH <20 pg/ml. In CD, a reduction in postoperative plasma ACTH levels differentiates subjects with surgical remission versus subjects with persistent disease. The utility of plasma ACTH measurements in the postoperative management of CD remains to be determined.

Acromegaly with negative pituitary MRI and no evidence of ectopic source: the role of transphenoidal pituitary exploration?

Growth hormone (GH) producing adenomas of the pituitary gland are usually macroadenomas (>10 mm in size). Often these adenomas are locally invasive by the time of diagnosis. Acromegaly secondary to a very small pituitary microadenoma not visualized on pituitary magnetic resonance (MR) imaging is rare. We report a patient with acromegaly and an unremarkable pituitary MR imaging who had negative work up for ectopic growth hormone-releasing hormone (GHRH) or GH secreting tumors. Transsphenoidal pituitary exploration revealed a pituitary adenoma located on the left side of the sella against the medial wall of the cavernous sinus extending posteriorly along the floor of the sella all the way to the right side. The acromegaly was treated with resection of the pituitary adenoma and normalization of serum insulin-like growth factor 1 (IGF-1) and GH levels. In a patient with acromegaly and unremarkable pituitary MR imaging, with no evidence of ectopic GH and GHRH production, transsphenoidal pituitary exploration is a reasonable approach and may result in clinical improvement and biochemical cure in the hand of experienced surgeon. This approach may avoid long term medical treatment with its associated cost.

Short-duration, single-agent antibiotic prophylaxis for meningitis in trans-sphenoidal surgery

Perioperative bacterial meningitis after trans-sphenoidal surgery for pituitary and parasellar lesions is an uncommon but serious complication. Little evidence guides the choice of chemoprophylaxis in this setting. To begin to address this deficiency, we investigated the incidence of perioperative meningitis in 442 patients who underwent trans-sphenoidal surgery and received a short chemoprophylaxis regimen with a single agent and did not require lumbar drainage. In 2005 we instituted a standardized antibiotic prophylaxis protocol for trans-sphenoidal surgery that utilized intravenous cefuroxime, a second-generation cephalosporin with broad coverage and excellent spinal fluid penetration, administered 30 min before surgery and 8 h later. The primary endpoint was the incidence of perioperative (within 30 days of surgery) bacterial meningitis. Data from The Barrow Pituitary Outcomes Project, a prospectively maintained patient research database, were supplemented with review of medical records and hospital discharge codes. There were no cases of perioperative meningitis. Three patients developed delayed meningitis associated with persistent or recurrent spinal fluid leakage 2-8 months after surgery. Perioperatively, seven patients received additional antibiotics for urinary tract infections. A single-agent, short-duration chemoprophylaxis regimen for trans-sphenoidal surgery is effective at preventing perioperative meningitis in patients who do not require lumbar drainage after surgery. The results of this regimen compare favorably to historical rates achieved with longer regimens that use two antibiotics. Future studies will investigate the role prophylactic antibiotics play in nasal mucosa healing and sinusitis.

Cushing's disease: results of treatment and factors affecting outcome

OBJECTIVE

To analyze the therapeutic results of intervention and the factors affecting the outcome of patients with Cushing's disease (CD) cared for at the All Indian Institute of Medical Science (AIIMS), New Delhi.

DESIGN

Patients with Cushing's disease treated at a teritiary care centre from January 2000 to December 2009 were prospectively studied.

RESULTS

Ninety-seven patients received treatment for CD during this period. Mean duration of follow-up was 3.4 ± 2.2 (mean ± SD) years. Eighty-one patients (83.5%) underwent transsphenoidal surgery (TSS) as the primary treatment modality. Fifty-four patients (66.7%) went into remission after initial TSS; ten (18.5%) of them relapsed after a mean follow-up period of 2.9 ± 2.1 (mean ± SD) years. Histopathologic examination of resected tissue showed corticotroph adenoma in 48 of the 54 (88.9%) who went into remission and 17 of the 27 (63.0%) who did not go into remission after the initial TSS. Sixteen patients with severe hypercortisolism underwent bilateral adrenalectomy (BA) as a life-saving measure which was followed by pituitary surgery 6 to 12 months later. Five patients including one with a large macroadenoma required three or more procedures to achieve eucortisolism.

CONCLUSION

Fifty-four out of 81 (66.7%) of our patients with CD had remission following initial TSS, ten of whom relapsed later on. Sixteen patients unerwent BA as a life-saving procedure. Factors affecting outcome were, age, gender, low dose dexamethasone suppression test cortisol value and histologic confirmation of corticotroph adenoma.

[A case of giant hemorrhagic adrenal pseudocystectomy with a flank incision]

The patient was a 43-year-old woman who underwent detailed examinations for a retroperitoneal cystic lesion that was incidentally found during orthopedic treatment. Although the tumor was a non-functioning tumor, and diagnostic imaging was negative for malignancy, the tumor was surgically resected with a flank incision. The histopathological diagnosis was adrenal pseudocyst.

Prophylactic antibiotic trends in transsphenoidal surgery for pituitary lesions

Pituitary surgery involves operating in the nasal cavity, which is considered a clean-contaminated wound. In the absence of evidence-based guidelines for preventing surgical site infections in trans-sphenoidal surgery, a survey of current opinion on prophylactic antibiotics might help elucidate the current acceptable practices and identify opportunities for prospective clinical trials that could lead to the development of practice guidelines. An on-line, 10-question, multiple-choice survey was distributed by e-mail link to the membership of the International Society of Pituitary Surgeons. Sixty-nine members responded to the survey. Ninety-one percent indicated that there was no strong evidence supporting antibiotic use, but 81% used them to be safe. Ninety percent of respondents used intravenous prophylactic antibiotics, while only 16% used intranasal antibiotics. The most commonly used antibiotics were cephalosporins (72%) and penicillins (21%). Seventy-six percent used antibiotics for 24 h or less after surgery. The most commonly reported indications for prophylactic antibiotics were prevention of meningitis and sinusitis. The results of the survey describe current acceptable practices for chemoprophylaxis in patients undergoing transsphenoidal pituitary surgery.

Surgery for gastroenteropancreatic neuroendocrine tumors (GEPNETS)

The only therapy with the potential for complete cure of patients with gastroenteropancreatic neuroendocrine tumors is complete surgical excision. Surgical options per se are often dictated by the tumor's site of origin, degree of tumor burden, and overall health or debility of the individual patient. This article considers different options based on the type of tumor and site of origin.

The role of outcomes data for assessing the expertise of a pituitary surgeon

PURPOSE OF REVIEW

Over the past four decades, advances in surgical technique, instrumentation, and anatomical knowledge have fueled the evolution and sophistication of transsphenoidal pituitary surgery. Paralleling these advances have been major improvements in endocrinological and overall clinical outcomes in patients with pituitary adenomas and other parasellar lesions such as Rathke's cleft cysts and craniopharyngiomas. In this review, we assess the impact of neurosurgeon expertise as a determinant of outcome in pituitary surgery.

RECENT FINDINGS

Published data since the 1980s indicate that remission rates, overall clinical outcomes and surgical complication rates in pituitary and parasellar surgery are related to neurosurgeon practice volume and cumulative clinical experience. More recently, pituitary surgery has been increasingly performed using an endonasal endoscopic approach. Reports over the last decade suggest when an experienced pituitary neurosurgeon performs a fully endoscopic or endoscope-assisted tumor removal; outcomes are similar if not better than when performed by a traditional microscopic transsphenoidal approach.

SUMMARY

A focused clinical practice and large transsphenoidal surgical volume appear to be important outcome determinants for patients with pituitary and parasellar tumors. Strategies that may further improve patient outcomes include establishing guidelines for pituitary tumor centers of excellence and more focused residency and fellowship training in endonasal endoscopic transsphenoidal surgery. Encouraging regionalization of care to higher volume pituitary tumor centers of excellence and promoting patient education on the importance of surgical expertise may further enhance pituitary patient outcomes.

Perioperative considerations in diabetic patients

Diabetes mellitus is an increasingly common disease that affects people of all ages, resulting in significant morbidity and mortality. Diabetic patients require more frequent hospitalization, have greater lengths of stay, and cost more to manage than non-diabetics. The major risk factors for diabetics undergoing surgery are the end-organ diseases associated with diabetes: cardiovascular disease, autonomic neuropathy and immune deficiency. Physicians should pay extra attention to preoperative and preprocedure evaluation and treatment of these diseases to ensure optimal perioperative management. Furthermore, these patients unexpectedly develop hemodynamic instability in response to vasopressor or vasodilator administration during anesthesia, this being of particular importance in patients with concurrent ischemic heart disease in whom it may have a direct effect on mortality. Recent studies have shown that tight glycemic control in diabetic patients undergoing major surgery has been shown to improve perioperative morbidity and mortality.

Mineralocorticoid antagonists treatment versus surgery in primary aldosteronism

Recent evidence indicates a greater frequency of primary aldosteronism (PA) among patients with hypertension than the previously accepted prevalence. PA was once considered a relatively benign form of hypertension associated with low incidence of organ complications. Recent views, however, suggest that long-term exposure to increased aldosterone levels might result in cardiovascular, renal, and metabolic sequelae that occur independently of the blood pressure level. Cross-sectional comparisons with patients with essential hypertension have demonstrated that patients with PA are at higher risk of cardiovascular events, have more frequent left ventricular hypertrophy and diastolic dysfunction, have greater urinary albumin losses as a marker of a hemodynamic intrarenal adaptation, and are insulin resistant. Some of these findings have been corroborated by the results of short-term, follow-up studies where it was shown that unilateral adrenalectomy or treatment with mineralocorticoid receptor (MR) antagonists are effective in correcting hypertension and hypokalemia. Normalization of blood pressure and correction of hypokalemia, however, are not the only goals in managing PA and effective prevention of organ complications is mandatory in these patients. The relative efficacy of adrenalectomy and MR antagonists, in the long-term, on the cardiovascular, renal, and metabolic outcomes still needs evaluation, being the aldosterone-induced tissue damage the main factor that could justify the cost of increasing efforts in screening of disease and differentiation of subtypes. In this narrative review, we summarize the results obtained with either surgical or medical treatment of PA and outline the findings of long-term, prospective studies on the effects of treatment on cardiovascular and renal outcomes and on insulin sensitivity.

The long-term survival in adrenocortical carcinoma with active surgical management and use of monitored mitotane

Adrenocortical carcinoma (ACC) is a rare tumour disease with sinister prognosis also after attempts to radical surgery; better prognosis is seen for low-stage tumours. Adjuvant treatment with the adrenolytic drug mitotane has been attempted, but not proven to prevent from recurrence. The drug may offer survival advantage in case of recurrence. The aim of this single-centre study (1979-2007) of 43 consecutive patients was to evaluate the long-term survival after active surgical treatment combined with monitored mitotane (to reduce side effects of the drug). The series is unique, since all patients were offered a period of mitotane as adjuvant or palliative treatment; six patients refused mitotane. Despite a high proportion of high-stage tumours (67%), the complete resection rate was high (77%). The disease-specific 5-year survival was high (64.1%); very high for patients with low-stage tumours without evident relation to mitotane levels. Patients with high-stage tumours had a clear survival advantage with mitotane levels above a threshold of 14 mg/l in serum. The hazard ratio for patients with high mitotane levels versus all patients indicates a significant effect of the drug. The results indicate that adjuvant mitotane may be the standard of care for patients with high-stage ACC after complete resection.

Rationale for treatment and therapeutic options in Cushing's disease

Cushing's disease results from prolonged overexposure of tissues to endogenous glucocorticoids, secondary to adrenocorticotrophin excess from the pituitary. Common clinical signs and symptoms include weight gain, hypertension, and osteoporosis. Effective treatment of Cushing's disease can normalize biochemical levels, reverse comorbidities, and improve overall survival and quality of life. Treatment options include pituitary or adrenal surgery, radiotherapy, and various medical therapies, but each has important limitations. Medical therapies that effectively target the pituitary tumour are urgently needed.

Surgical treatment of pituitary tumours

The surgical treatment of pituitary tumours underwent considerable evolution during the past centennial. Since Schloffer's first description, excellent surgeons refined the surgical techniques, utilised hormonal measurements and imaging investigations at different times to define surgical success or failure. To date, transsphenoidal surgery is the approach of choice for over 90% of pituitary tumours, but still transcranial operations are needed even in experienced hands when asymmetrical and large pituitary tumours with minor intrasellar components present. When the indication for surgery stands, the complication rate to date is relatively low, particularly if the surgeon and his or her centre have sufficient experience in the field. In microadenomas, the success rate reported from expert authors approaches 90%. Generally speaking, patients with non-functioning pituitary adenomas, acromegaly, thyrotropinomas and Cushing's disease are excellent candidates for primary surgical treatment. Re-operations are generally associated with less favourable outcomes. In prolactinomas, the primary therapy is medical; however, when dopamine agonists are not well tolerated or inefficient, an operative treatment should be considered. Although alternative medical treatments exist in acromegaly and thyrotropinomas, surgical treatment is relatively cheap. The implementation of endoscope-assisted, entirely endoscopic, image-guided surgery and intra-operative magnetic resonance (MR) imaging, particularly in combination with utilisation of the established microsurgical techniques, extends the surgical spectrum. Lesions become surgically accessible, which one did not dare to touch even a century ago. Moreover, it seems that the patient's safety has increased and more patients have their tumours completely resected, which is equivalent to a higher remission rate in hormonally active tumours.

Surgical treatment and follow up on undescended testis

With skill and ability to control a variety of operative techniques, undescended testes can be placed in the scrotum with 90% success rate in palpable testes and 85% in abdominal testes. Long term results are related also to the variability of the disease. A hypothesis that in cryptorchid testes a common etiologic antenatal factor is associated with infertility and/or testicular malignancy is supported by the finding of the influence of maternal lifestyle factors on fertility, a relative cancer risk of OR: 2.0 in contralateral descended testis of unilateral cryptorchidism, impaired germ cell number at birth in some cryptorchid testes and Intratubular Germ Cell Neoplasia seen in early childhood. The hypothesis that the abnormal location of the testis exposes the testis to infertility and malignant transformation is supported by the findings of early treatment lowering the risk of both infertility and testicular cancer. Disrupted endocrine regulation may be combined with both hypotheses.

The impact of laparoscopy in the management of non-palpable testes

Undescended testis is one of the most common congenital abnormalities of the genitourinary system. In 10-20% of these boys, a testis is located completely inside the abdominal cavity. Multiple operative techniques have been described and are associated with a variable success rate. In this review we evaluate the use of laparoscopy in the management of the non-palpable testis to determine what advantages it might offer over the open technique. On the basis of current evidence it seems that laparoscopy is the only diagnostic and therapeutic procedure that is accurate enough to elucidate the diagnosis of non-palpable testis and also allows surgical treatment to be carried out in the same setting.

A randomised controlled trial of routine suction drainage after elective thyroid and parathyroid surgery with ultrasound evaluation of fluid collection

OBJECTIVE

To determine the need for suction drainage after elective thyroid and parathyroid surgery.

DESIGN

Randomised controlled trial.

SETTING

University teaching hospital.

PARTICIPANTS

Patients requiring elective thyroid or parathyroid surgery were recruited and informed consent was obtained (n = 100). Before wound closure, patients were randomised into either group A (to remain without suction drainage) or group B (to receive suction drainage). Excluded patients were those requiring associated neck dissection and those with bleeding diatheses, all of whom would necessarily require drainage in our unit.

MAIN OUTCOME MEASURES

Primary - ultrasound evaluation of any collection in the thyroid bed, performed 1-day postoperatively. Secondary - postoperative complications; length of in-patient stay.

RESULTS

One hundred patients completed the study, and groups A and B comprised 50 patients each. Patients in each group exhibited a mean age of 49 years, and a male to female ratio of 1 : 9. Both groups were also well-matched regarding type of operation, size of tumour and histopathological diagnosis. Modal and median postoperative neck collection volume on ultrasound examination was 0 and 0 cm(3) respectively (range 0-16 cm(3)) in group A and was 0 and 0 cm(3) (range 0-70 cm(3)) in group B. This difference was not statistically significant, but three patients with a haematoma were all in the suction drainage group. Difference in complication rates between groups was also not statistically significant. Modal and median length of in-patient stay was 2 and 2 days respectively (range 2-3 days) in group A and 3 and 3 days (range 2-4 days) in group B, and this difference was statistically significant (P = 0.0006).

CONCLUSION

Routine suction drainage after uncomplicated elective thyroid and parathyroid surgery appears unnecessary, and prolongs in-patient stay.

[Insulinoma]

Insulinoma is considered the most common endocrine tumour of the pancreas with an annual prevalence of 4 cases per million people. Contrary to the other endocrine tumours of this organ, over 90% of the insulinomas are benign in nature. The clinical presentation of this neoplasm depends on excessive production of insulin and pro-insulin and is characterised by the symptoms of neuroglycopenia and catecholamine response. Effective management requires directed biochemical testing, careful choice of preoperative imaging tests, and complete pancreatic exploration by an experienced endocrine surgeon utilising intraoperative ultrasound. The only curative treatment for insulinoma is complete resection of the tumour. The aim of this paper is to critically discuss contemporary diagnosis and treatment of this neoplasm on the basis of progress made in recent years.

Seminars: Local and regional anesthesia for thyroid surgery

BACKGROUND

Thyroid surgery is performed by a large number of surgeons with varying experience in thyroidectomy. The standard technique involves the use of general anesthesia, which provides patient comfort and virtually unlimited time to conduct the operation. Historically, thyroid surgery was conducted under local anesthesia by surgeons with significant expertise in the treatment of thyroid diseases. Over the past decade, there has been a renewed interest in the art of performing thyroidectomy under local/regional anesthesia in some specialized high volume endocrine surgery centers.

METHODS

Here we review the indications and contraindications and technical considerations for performing thyroidectomy under local or regional anesthesia.

RESULTS AND CONCLUSION

Local and regional anesthesia is safe and well tolerated for the majority of thyroid surgery.