Clinico-pathologic profile and outcomes of pediatric endocrine patients managed by endocrine surgeons: Experience over three decades in a tertiary center in India

BACKGROUND

Pediatric endocrine disorders requiring surgical intervention are rare and so are experienced surgeons dealing with these. The aim of the current study was to investigate disease profile and perioperative outcome of pediatric patients with surgical endocrine disorders in an endocrine surgery unit.

METHODS

This retrospective study (Sep 1989-Aug 2019) consisted of pediatric endocrine surgery patients (<18 years) who were managed by a team of pediatric endocrinologists and endocrine surgeons at our center. Patients were divided into three cohorts consisting of a decade each. Clinico-pathologic variables, perioperative events operative and follow-up details were recorded.

RESULTS

A total of 332 children were included and their mean age was 14.6 ± 3.9 years (M:F = 1:1.6). Thyroid disorders were most prevalent (59.8%), followed by adrenal (28.2%), parathyroid (10.4%), and pancreas (1.5%). Incidence of benign, malignant, and congenital/developmental disorders were 65.4, 28.1 and 8.3, respectively. Familial association was observed in 8.9% children, which is highest among pheochromocytoma patients. Overall, 201 thyroidectomies + associated procedures, 35 parathyroidectomies, 96 adrenal and paraganglioma resections, and 5 pancreatic procedures were performed. Median hospital stay was 5.6 ± 4.1 days. The number of cases increased significantly over 3 decades. Clinical profile and outcome did not vary except for significant decrease in incidence of malignant pathology (p = 0.04) and increase in VHL cases (p = 0.04) in the last decade though overall increase in familial cases was nonsignificant (p = 0.11). No perioperative mortality was observed except for 3% after adrenalectomy.

CONCLUSION

A team of dedicated endocrine surgeons and pediatric endocrinologists is effective in management of pediatric endocrine surgery.

Association of Medicaid expansion of the Affordable Care Act with operations for benign endocrine surgical disease

•Background: The Affordable Care Act's Medicaid expansion increased insurance coverage and access to care for endocrine cancers, though impact on benign endocrine disease is unknown. •Methods: Patients undergoing operations for benign thyroid, parathyroid, and adrenal disease were collected from the Vizient® Clinical Data Base from 2009 to 2016 and grouped by state Medicaid expansion status in January 2014. Insurance coverage was analyzed by difference-in-differences analysis, and logistic regression evaluated odds of operation by insurance status. •Results: 134,242 patients were included. Medicaid coverage in expansion states increased for all operations (Adj-DD 5.78%, p < 0.001) with decreases in uninsured and private insurance. Medicaid patients had increased odds of undergoing thyroid operations (OR 1.56, p < 0.001) and decreased odds of parathyroid (OR 0.68, p < 0.001) or adrenal operations (OR 0.70, p < 0.001) versus private insurance. •Conclusion: Medicaid expansion increased insurance coverage for benign endocrine disease, however, barriers remain for Medicaid patients with parathyroid and adrenal disease.

Narcotic Free Cervical Endocrine Surgery: A Shift in Paradigm

BACKGROUND AND OBJECTIVE

The opioid epidemic has stimulated initiatives to reduce the number of unnecessary narcotic prescriptions. We adopted an opt-in prescription system for patients undergoing ambulatory cervical endocrine surgery (CES). We hypothesized that empowering patients to decide whether or not to receive narcotics for pain control would result in fewer unnecessary opioid prescriptions.

METHODS

We enrolled all patients scheduled for outpatient CES between July 2017 and June 2018 in a narcotic opt-in program. Patient demographics, procedure characteristics, and postoperative pain scores were collected prospectively. Statistical analyses were performed to correlate clinical predictors with narcotic request. Results were compared against a historical control group. The study was approved by the University IRB.

RESULTS

A total of 216 consecutive patients underwent outpatient CES following implementation of the program. Only nine (4%) requested prescription narcotic medication at discharge, and no patient called after discharge to request analgesic medications. Compared with our prior treatment paradigm, we achieved a 96.6% reduction in the number of narcotic tablets prescribed, and a 98% reduction in unconsumed tablets. Univariate analysis suggested history of substance abuse (P < 0.001), anxiety (P = 0.01), depression (P < 0.001), baseline narcotic use (P = 0.004), highest pain postoperatively (P = 0.004), and incision length (P = 0.007) as predictive for narcotic request. Multivariate analysis retained significance with incision length and history of substance abuse.

CONCLUSION

By empowering patients undergoing ambulatory CES to accept or decline a prescription, we reduced the number of prescribed narcotic tablets by 96.6%. Although longer incisions and prior substance abuse predict higher likelihood of requesting pain medication on discharge, 207 of 216 patients were treated with acetaminophen alone.

MANAGEMENT OF ENDOCRINE DISEASE: Papillary thyroid microcarcinoma: toward an active surveillance strategy

In the last decades, the incidence of thyroid cancer (TC) has more than doubled, but the disease-specific mortality rate was stable. To date, 30-40% of all TC is represented by papillary microcarcinomas (mPTC), an indolent tumor, that probably remained undiagnosed before routine ultrasound use. In 1993, Miyauchi was the first who hypothesized a conservative approach for low-risk mPTC and introduced the concept of active surveillance (AS) in its clinical management. The progression rate of mPTC during AS was low and delaying surgery did not impact the efficacy of treatment or outcome. Since then, several authors from all over the world have reported their experience of AS in mPTCs. As suggested by current guidelines, AS can be considered as an alternative to immediate surgery to avoid overtreatment in low-risk mPTC and may be the strategy to avoid complications from unnecessary surgery. In the last years, AS inclusion criteria have been extended to both bigger tumors and to younger/healthier patients. The adoption of AS should take into consideration not only tumor characteristics but also patient psychological profiles and medical team expertise. Its safety and efficacy have been demonstrated in long-term outcome studies and in other types of tumors; however, skepticism in patients, families and physicians should be overcome by strong recommendations coming from scientific guidelines. This review analyses the several and different experiences of AS and the potential obstacles in implementing it as a routine approach in mPTC patients.

MANAGEMENT OF ENDOCRINE DISEASE: The role of surgical adrenalectomy in primary aldosteronism

Primary aldosteronism is common and contributes to adverse cardiovascular, kidney, and metabolic outcomes. When instituted early and effectively, targeted therapies can mitigate these adverse outcomes. Surgical adrenalectomy is among the most effective treatments because it has the potential to cure, or attenuate the severity of, pathologic aldosterone excess, resulting in a host of biochemical and clinical changes that improve health outcomes. Herein, we review the role of surgical adrenalectomy in primary aldosteronism while emphasizing the physiologic ramifications of surgical intervention, and compare these to other targeted medical therapies for primary aldosteronism. We specifically review the role of curative adrenalectomy for unilateral primary aldosteronism, the role of non-curative adrenalectomy for bilateral primary aldosteronism, and how these interventions influence biochemical and clinical outcomes in relation to medical therapies for primary aldosteronism.

Endocrine surgery during COVID-19 pandemic: do we need an update of indications in Italy?

The ongoing spread of the coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) poses a significant threat to global health. As the coronavirus outbreak began spreading, hospitals were forced to relocate resources to treat the growing number of COVID-19 patients. As a consequence, doctors across the country canceled tens of thousands of nonurgent surgeries. However, recognizing that the COVID-19 situation may be highly variable and fluid in different communities across the country, elective surgery could be still allowed in some centers for patients included in the high-priority class. The majority of endocrine disorders requiring surgical treatment in patients identifiable as first-priority class, or needing hospitalization within 30 days, are generally represented by malignant thyroid tumors, hyperthyroidism, hyperparathyroidism, and some adrenal disorders. The need for urgent intervention is evaluated on a case-by-case basis according to the severity of the symptoms, the likelihood of progression, and global clinical judgment. On the basis of the above indications, during the last 4 weeks, we performed 18 planned surgical treatments in patients with thyroid cancer (total thyroidectomies, plus lymph node dissection if needed) or multinodular toxic goiter. In no case, postoperative ventilatory support was needed, and the average hospital stay was 3 days. The negative COVID-19 status for all the treated patients was appropriately evaluated beforehand. Nobody knows how long the current COVID-19 pandemic will be lasting. Certainly, we will be requested in the next future to incrementally offer surgical services for endocrine disorders that have been deferred for the COVID-19 pandemic.

A rare enzymatic defect, true isolated 17,20-lyase deficiency leading to endocrine disorders and infertility: case report

The cytochrome P450 17A1 catalyzes the formation of 17-hydroxysteroids and 17-ketosteroid. Most defects in CYP17A1 impair both enzymatic activities and cause a combined 17α-hydroxylase/17,20-lyase deficiency, which impairs hormone production (cortisol and sex steroids), sexual development, and puberty. Isolated 17,20-lyase deficiency is usually defined by evidently normal activity of 17α-hydroxylase with a dramatic decline of 17,20-lyase activity or complete inactivity. The changes in enzyme activity lead to a lack in the production of sex steroids with normal levels of glucocorticoid and mineralocorticoid hormones. A 24-years-old married woman, as a product of a consanguineous marriage, presented with infertility and a background marked by primary amenorrhea. Laboratory data showed low normal serum cortisol levels and low levels of 17-hydroxyprogesterone. Also, her adrenal androgens were low but estradiol was normal. The chromosomal investigation uncovered a male karyotype of 46, XY. These clinical and laboratory evidence confirm the determination of an isolated 17,20-lyase deficiency in a genotypic male.

[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.

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.

[High-tech medical care in surgical endocrinology]

The number of patients with endocrine system diseases increases annually. Widespread introduction of screening programs and improvement of laboratory and instrumental diagnostic is one of the most important causes for this. Treatment of patients with endocrine system diseases within the high-tech medical care leads to perform the unique surgical interventions. It increases survival and patients' life quality.

Pineal cysts in children: case-based update

PURPOSE

Pineal cysts (PC) are found in children as often asymptomatic and without change in their size over the time. However, there are some debatable issues about their evolution and management in the pediatric population. The aim of the present paper is to update the information regarding pathogenesis, clinical presentation, and management of these lesions.

METHODS

All the pertinent literature was reviewed, and a meta-analysis of operated on cases was carried out. An illustrative case regarding the clinical evolution of a 13-year-old girl is also presented.

RESULTS AND CONCLUSIONS

PC are often asymptomatic and do not evolve over the time. However, since there is a certain risk of clinical and/or radiological progression, or even sudden and severe clinical onset (apoplexy), both a clinical and radiological follow-up is recommended in the pediatric age. The surgical excision is usually limited to symptomatic patients or to cases with clear radiological evolution.

Endocrine outcomes in endoscopic pituitary surgery: a literature review

BACKGROUND

Since the introduction of fully endoscopic surgery this new technique has been adopted with enthusiasm by many but not all pituitary surgeons. Whilst some advantages of minimal access have been recognised, the information on endocrine outcomes has been slow to accumulate.

METHOD

This literature review examined all the endoscopic papers for endocrine results and complication rates. Where adequate detail was provided these results were broken down by subtype and the pooled cure rates calculated.

FINDINGS

The review revealed that the fully endoscopic method is the equal of the microscopic technique for endocrine remission in functioning pituitary tumours. Furthermore the endoscopic results in functioning macroadenomas are substantially better than the microscopic results with similar complication rates.

CONCLUSIONS

Endoscopic pituitary surgery offers significant advantages over the microscopic technique and should become the standard method of pituitary adenoma surgery.

Surgical prophylaxis for inheritable malignant diseases: breast cancer and endocrine disease

Despite advances in modern medicine, cancer remains all too common and deadly. At its core, cancer is a disease of our DNA. As such, many cancers are passed from parents to children, making cancer one of the most commonly inherited diseases. Presently, we have no meaningful methods of "preventing" the malignant transformation that occurs as a result of an inherited gene, but investigators have identified several genetic mutations and subsequently developed risk-reduction strategies that sometimes involve surgery.

A "defined baseline" in PTH monitoring increases surgical success in patients with multiple gland disease

BACKGROUND

Parathyroid hormone (PTH) monitoring with a quick intact PTH (QIPTH) assay is used in minimally invasive exploration for primary hyperparathyroidism (PHPT) in order not to miss multiple gland disease (MGD). Controversy exists on which criterion is most reliable to predict cure.

METHODS

QIPTH values of 310 consecutive patients (single gland disease [SGD]: n = 289; MGD: n = 21) with sporadic PHPT were analyzed using 3 different criteria: "Vienna Criterion": >/=50% decay from a defined "baseline" level (right after induction of anesthesia before skin incision) 10 min after excision. "Miami Criterion": >/=50% decay from highest (preincision or preexcision) value 10 min after excision; "Halle Criterion": decay of the PTH- level to less than or equal to 35 pg/mL within 15 min after excision.

RESULTS

The "Vienna" and "Halle Criteria" correctly detected MGD in 19 (91%) and the "Miami Criterion" in 12 (57%) of 21 patients. Incorrect prediction of incomplete excision occurred in 22 patients (8%) with SGD, using the "Vienna Criterion" ("Miami Criterion": 2%, "Halle Criterion": 29%). All of these were recognized intraoperatively from unintended intraoperative manipulation (n = 18), technical failure (n = 2), or borderline increased PTH values (n = 2), and they did not lead to bilateral exploration. Analyzing patients with SGD and MGD, accuracy and specificity were 92% and 89% for the "Vienna Criterion," 93% and 54% applying the "Miami Criterion," and 72% and 89% using the "Halle Criterion."

CONCLUSION

Strict definition of a PTH "baseline level" ("Vienna Criterion") improves intraoperative diagnosis of MGD, thus reducing reoperations and increasing long-term cure.

[Stem cell biology and therapeutic hopes: forbidden game?]

Stem cell biology is one of the most exciting subjects in life science nowadays. The major point in stem cell biology is the extraordinary capacity of these cells to self-renew and to give rise to different cell types. Nevertheless, major issues remain to be cleared and very few diseases can actually be cured based on stem cell therapy. Adult stem cells remain difficult to locate, isolate and amplify in a homogeneous fashion and, thus, limit their therapeutic application in clinical trial. Embryonic stem cells could represent a new hope in stem cell therapy but in addition to the scientific difficulties, over ethical and judiciary issues should be addressed. In order to cure routinely patients, controlled conditions for stem cell isolation, amplification, differentiation, and administration must be defined and effective tissue integration have to be established. In this review we will discuss these different aspects of stem cell biology.

Successful bone marrow transplantation for IPEX syndrome after reduced-intensity conditioning

Immune dysregulation, polyendocrinopathy, enteropathy, X-linked (IPEX) syndrome is a rare, fatal autoimmune disorder caused by mutations in the FOXP3 gene leading to the disruption of signaling pathways involved in regulatory T-lymphocyte function. Lifelong multiagent immunosuppression is necessary to control debilitating autoimmune manifestations such as colitis and food allergies. Allogeneic hematopoietic stem cell transplantation (HSCT) can restore T-cell regulatory function but has been previously associated with poor outcome. We describe successful HSCT in 4 patients with IPEX syndrome using a novel reduced-intensity conditioning regimen that resulted in stable donor engraftment, reconstitution of FOXP3+ T regulatory CD4+ cells, and amelioration of gastrointestinal symptoms.

Relapsing acute adult epiglottitis following hypophysectomy

Adult epiglottitis is an uncommon disease that may become fatal because of sudden airway obstruction. Recurrent adult epiglottitis has been reported rarely in the literature. We present a case of relapsing epiglottitis in a patient with corticosteroid insufficiency secondary to pituitary surgery. It is the first case to highlight this infection occurring in a relapsing manner in a patient with pituitary-adrenocortical insufficiency on long-term steroid replacement therapy.

Gastrointestinal manifestations of endocrine disease

The hormonal interactions among the systems throughout the body are not fully understood; many vague clinical symptoms may in fact be manifestations of underlying endocrine diseases. The aim of the following review is to discuss gastrointestinal manifestations of surgically correctable endocrine diseases, focusing on abnormalities of thyroid function, cancer and finally autoimmune diseases. We also review manifestations of pancreatic endocrine tumors, and multiple endocrine neoplasia.

[Successful subtotal parathyroidectomy for giant tumor calcinosis with secondary hyperparathyroidism]

A 54-year-old woman was referred to our hospital for the treatment of secondary hyperparathyroidism due to chronic renal failure. She was on hemodialysis for 7 years and suffered from giant tumor calcinosis of the major joints associated with severe hypercalcemia and hyperphosphatemia. The largest one of the left hip joint caused gait disturbance. Medical therapy was unsuccessful and she underwent subtotal parathyroidectomy. After the operation, although the levels of serum calcium and phosphate were not normalized, the level of parathyroid hormone was lowered to the normal range. The volume of the tumor calcinosis gradually reduced and she became able to walk for a short distance 10 months after the operation.

[Surgical management in patients with endocrine disease]

The surgical diagnosis and treatment of endocrine tumors is individually described in each session of this journal. I will described the recent topics of endocrine surgery. In thyroid, ultrasonography has developed rapidly, and increases the diagnostic ability of thyroid and parathyroid tumors enable minimally invasive thyroidectomy and parathyroidectomy. Unfortunately, recombinant human TSH and 131I high dose therapy are not widely used in Japan. In hyperparathyroidism, whole PTHH assay is currently available. Intraoperative quick whole PTH assay is essential for direct mini-incision parathyroidectomy. Although MIBI scintigraphy is useful to detect parathyroid tumors, but this use is not approved by the government. Somatoscintigraphy is promising method to detect neuroendocrine tumors. Differential diagnosis of Cushing syndrome and Preclinical Cushing syndrome have been clearly. Adrenal venous sampling by fine catheter is useful to detect micro mass of primary aldosteronism.

Intraoperative ultrasound

Intraoperative ultrasound (IOUS) can provide various diagnostic information that is otherwise not available, and can guide or assist various surgical procedures in real time. With refinement of equipment, IOUS is currently used in a wide variety of surgical operations,such as hepatobiliary, pancreatic, endocrine, cardiovascular,and neurologic surgery. Our overview of IOUS, including instrumentation,techniques, indications, advantages, disadvantages,and future perspective, is described in this article. Being safe, quick, accurate, and versatile intraoperatively, IOUS is a valuable technique that surgeons are recommended to master to improve intraoperative decision making and surgical procedures.

Neurosurgical aspects of critical care neurology

The management of the pediatric neurosurgical patient requires a detailed understanding of the diagnosis and management of disorders of ICP. Frequently the care of these patients will require collaboration between several different teams of physicians. Most important, frequent and clear communication between the ICU physician and the neurosurgeon will facilitate the delivery of the best-quality care to these children. This chapter will identify and discuss issues relevant to neurosurgeons and intensive care physicians taking care of children with complex problems related increased intracranial pressure.

Who performs endocrine operations in the United States?

BACKGROUND

Endocrine surgery is a discipline that is dedicated to high-quality care of patients with endocrine surgical disease. The relationship between its "identity" as a separate field and clinical practice patterns is not known.

METHODS

The National Inpatient Sample was searched by the International Classification of Diseases-9th revision-Clinical Modification codes for parathyroidectomy, thyroidectomy, and adrenalectomy for the years 1988 through 2000. The surgeons who performed these operations were profiled by 2 methods: Method A, by the percentage of the total primary International Classification of Diseases-9th revision-Clinical Modification procedure codes that were the selected endocrine procedures; method B, by absolute number of index endocrine procedures performed per year. Only patients with complete coding data for the surgeons were included.

RESULTS

In this sample, surgeons whose practice was comprised of 25% or less of these endocrine procedures performed 11,071 parathyroidectomies (78% of total), 46,210 thyroidectomies (82% of total), and 4209 adrenalectomies (94% of total). In contrast, surgeons whose practice was comprised of more than 75% of these endocrine procedures performed 769 parathyroidectomies (5% of total), 1560 thyroidectomies (3% of total), and 128 adrenalectomies (3% of total).

CONCLUSION

If these data can be extrapolated to indicate generalized practice patterns, the majority of common operations for endocrine disease are performed by surgeons whose practice is not focused on endocrine surgery. However, much of this effect is due to the fact that non-endocrine surgeons far outnumber endocrine surgeons. This understanding of clinical practice patterns will be important to consider during future studies that seek to determine the relationship between surgeon volume and patient outcomes.

Craniopharyngioma: presentation and endocrine sequelae in 36 children

We studied the clinical presentation by age of 36 children with craniopharyngioma, and outcome by height and body mass index (BMI). Presenting symptoms included headache (51.4%), vomiting (31%), visual disturbances (22.9%), polyuria and/or polydipsia (17.1%), delayed puberty (19.4%), short stature (13.8%), and precocious puberty (2.7%). Growth deceleration was overlooked, as was diabetes insipidus (actual rate, 52% for both). Delayed puberty was observed in all patients of appropriate age. Mean height standard deviation score (SDS) at admission was significantly lower than mean target height SDS (p = 0.004), while mean final height SDS was similar (p = 0.14). BMI SDS at last follow-up was similar to mean parental BMI SDS. We conclude that although endocrinopathies are present in most patients with craniopharyngioma, they are rarely the reason for referral. While affected prepubertal children have non-endocrine complaints, most adolescents are referred because of delayed puberty. Diabetes insipidus may be more prevalent in craniopharyngioma than previously reported. When patients with hypothalamic obesity are excluded, mean BMI SDS remains within normal range and is influenced mostly by parental BMI SDS.

[Minimally invasive endocrine surgery: aspects of diagnostic imaging]

Since 1997 minimally invasive surgical techniques are used for the treatment of diseases of the adrenals, thyroid, parathyroid and the endocrine pancreas. In contrast to open surgical procedures special radiological examinations are the basis for minimally invasive techniques after biochemical testing. The basis of excellent results are a careful evaluation and preparation of the patient in a centre with experience in the open techniques and a frequency of at least 20 endoscopic adrenalectomies a year. Adrenal tumours can be removed endoscopically through a transperitoneal or an extraperitoneal route. The endoscopic exploration of the parathyroids in patients with biochemically proven primary hyperparathyroidism was modified to video-assisted exploration because of the long operating times. An alternative to the video-assisted procedure is the minimally invasive open exploration. With this technique reoperations can be performed and ipsilateral thyroid nodules (found in more than 50% in middle Europe) can be removed. Small solitary thyroid nodules are the indication for an endoscopic or video-assisted exploration of the thyroid. A laparoscopic exploration of the pancreas was performed in 68 patients with neuroendocrine pancreatic tumours. The experience of the surgical team improves the postoperative long term results, thus minimally invasive endocrine surgery should be performed in centres with great experience in the treatment of endocrine tumours and with the possibility of close contact to other specialists interested in this topic.

[Diagnosis and therapy of diseases of the endocrine system: new trends in nuclear medicine]

Diagnosis and therapy of endocrine disorders in nuclear medicine has been improved through the implementation of new techniques especially with positron emission tomography (PET). In modern concepts of parathyroid gland surgery an exact anatomic localisation of adenomas is necessary, which may be achieved with MIBI-Scintigraphy being the most sensitive method in primary hyperparathyroidism. The optimal access to localise adenomas is the investigation with combined SPECT/X-CT systems. The use of such systems for diagnosing neuroendocrine tumors of the gastrointestinal system may also be helpful. For neoplasms of the adrenal gland PET systems could be used to differentiate between benign and malignant entities or to detect primary tumours. In case of incidentalomas J131-Norcholesterol and MIGB-scintigraphy has been proven helpful. Indications for nuclear medicine studies to detect abnormalities of the hypothalamic-hypophyseal system are established rarely.

Pterional surgery of meningiomas of the tuberculum sellae and planum sphenoidale: surgical results with special consideration of ophthalmological and endocrinological outcomes

OBJECT

The authors reviewed 47 cases of suprasellar meningiomas with special attention to ophthalmological and endocrinological outcomes.

METHODS

All patients underwent surgery performed via a unilateral pterional approach between January 1983 and January 1998. Ophthalmological and endocrinological examinations were performed before the operation as well as 1 week and 3 months postoperatively. A special scoring system was adopted to quantify the extent of ophthalmological disturbances. Complete tumor resection was possible in all but one patient. There were no fatalities and the rate of visual improvement was 80%. The best prognoses were found in patients younger than 50 years and in patients in whom the duration of symptoms was less than 1 year. Before surgery, tumor-related endocrine disturbances were present in only three women who suffered from secondary hypogonadism; two of these patients recovered after surgery. Postoperatively, no patient needed replacement therapy for pituitary dysfunction. The overall tumor recurrence rate was 2.1% (one of 47 cases). For patients in whom long-term (> 5 years) follow-up data were available, the recurrence rate was 4.2% (one of 24 cases).

CONCLUSIONS

In this series, complete resection of suprasellar meningiomas was possible through a unilateral pterional craniotomy and was associated with a low morbidity rate and no deaths.

[Assessment of the adequacy of health services in day hospital care: experience of an endocrine surgery day care unit at a university polyclinic]

The aim of the study was to assess the appropriateness of the provision of surgical treatment in the day hospital setting and at the same time to evaluate the efficacy of the service provided. The study was conducted on admissions to a day care unit operating in conjunction with the surgery division of a university hospital. The evaluation of appropriateness was carried out using explicit criteria, based on regional regulations and on guidelines drawn up by the Agency for Regional Health Services. The criteria related to the hospital bed equivalent Rotation Index and to the types of DRGs treated and services provided. Efficacy was assessed using the following para-meters: number of US-guided fine needle aspiration biopsies; techniques used; age, sex and nodule size; patient distribution by results of diagnostic examination; cytological classification; percentage of patients with complications. We also evaluated the possibility of transferring short-term (2-3 days) surgical admissions from ordinary regimens to the day care setting. The results of this study yield useful synthetic indicators for assessing the appropriateness both of the day care function as a whole and of individual operating units, providing both administrative and medical staff with a useful frame of reference for the planning of health-care management.

Complications of laparoscopic adrenalectomy: results of 169 consecutive procedures

Laparoscopic adrenalectomy (LA) has become the gold standard for adrenalectomy. Review of the literature indicates that the rate of intra- and postoperative complications is not negligible. The aim of this study was to evaluate the complications observed in a series of 169 consecutive LAs performed at a same center for a variety of endocrine disorders. Between June 1994 and December 1998 a series of 169 LAs were performed in 159 patients: 149 unilateral LAs and 10 bilateral LAs. There were 98 women and 61 men with a mean age of 49. 7 years (range 22-76 years). There were patients with 61 Conn syndrome, 41 with Cushing syndrome, 1 androgen-producing tumor, 29 pheochromocytomas, and 37 nonfunctioning tumors. Mean tumor size was 32 mm (range 7-110 mm). LA was performed by a transperitoneal flank approach in the lateral decubitus position. Mean operating time was 129 minutes (range 48-300 minutes) for unilateral LA and 228 minutes (range 175-275 minutes) for bilateral LA. There was no mortality. Twelve patients had a significant complication (7.5%): three peritoneal hematomas requiring (in two cases) laparotomy and (in one case) transfusion; one parietal hematoma; three intraoperative bleeding episodes without need for transfusion; one partial infarction of the spleen; one pneumothorax; one capsular effraction of the tumor; and two deep venous thromboses. Eight tumors were malignant at final histology (4.7%), of which four were completely removed laparoscopically. Conversion to open surgery was required in eight cases (5%): for malignancy in four cases, difficulty of dissection in three cases, and pneumothorax in one case. With a mean follow-up of 26.58 months (range 6-60 months) all patients are disease-free. We conclude that LA is a safe procedure. With increasing experience the morbidity becomes minor. To avoid complications LA should be converted to open surgery if local invasion is suspected or if there is difficulty with the dissection.