Double Parathyroid Adenoma Presenting as One Mass: A Case Report.

Background and Objectives: Primary hyperparathyroidism is a common endocrinological condition, which is usually caused by solitary parathyroid adenoma. The aim of this article is to present a case of double adenoma presenting as one and literature review on this topic. Case presentation: 56 years old female suffering from generalized fatigue, bone pain, unstable body weight and palpitations was diagnosed with primary hyperparathyroidism. Further investigation revealed elevated parathyroid hormone (PTH), ionized and total calcium levels. Imaging showed two adenomas merging into one. Parathyroidectomy was performed and final intraoperative PTH (IOPTH) decreased by 71.6%. Parathyroid adenoma measuring 40 mm x 15 mm x 11 mm and weighing 1 g 483 mg was excised. 7 weeks after surgery patient was feeling well but her PTH level was elevated again. Conclusions: As far as we know, the double parathyroid adenoma presented in this case report is the largest reported in the Northern Europe and the first one that presents as one mass within the region. Double adenoma increases the risk of recurrent primary hyperparathyroidism (PHPT) and requires more careful and longer follow up after surgery than solitary adenomas. Final IOPTH must decrease by at least 50% within 10 minutes. This case shows that despite final IOPTH drop by more than 50%, after few weeks normocalcemic elevated parathyroid hormone (NCePTH) phenomenon was noticed. This phenomenon does not indicate surgical failure.

The stress for surgeons: exploring stress entities with the robotic senhance surgical system.

Robotic surgery is on its way to revolutionizing traditional surgical procedures, offering precise and minimally invasive techniques hypothesized to shorten recovery times and improve patient outcomes. While there have been multiple publications on robotic systems' medical and procedural achievements, more emphasis should be put on the surgeon's experience, especially in comparison with laparoscopic surgery. The present report aims to systematically examine the stress impact on surgeons by comparing the robotic Senhance Surgical System (Asensus Surgical, Durham, North Carolina, U.S.A) to laparoscopic surgery. The well-established "SURG-TLX" survey is used to measure distinct stress entities. The "SURG-TLX" survey is a modified version of the NASA-TLX, validated for surgery by M. Willson. Based on a comprehensive database from six centers encompassing various disciplines and surgical procedures, our analysis indicates significantly reduced "overall stress" levels for robotic (cockpit) compared to laparoscopic surgeons. Exploring the "SURG-TLX" stress dimensions further between methods (robotic vs. laparoscopic) and surgeon position (laparoscopic, (robotic) bedside, or (robotic) cockpit) resulted in significantly more Mental (p.value < 0.015), less Physical Demands (p.value < 0.001) and less Distraction (p.value < 0.009) for robotic surgery, especially regarding the robotic cockpit surgeons. This finding suggests that robotic surgery with the Senhance Surgical System contributes to a favorable stress profile for surgeons, potentially enhancing their overall well-being and performance.

Effect of the COVID-19 pandemic on surgery for indeterminate thyroid nodules (THYCOVID): a retrospective, international, multicentre, cross-sectional study.

BACKGROUND: Since its outbreak in early 2020, the COVID-19 pandemic has diverted resources from non-urgent and elective procedures, leading to diagnosis and treatment delays, with an increased number of neoplasms at advanced stages worldwide. The aims of this study were to quantify the reduction in surgical activity for indeterminate thyroid nodules during the COVID-19 pandemic; and to evaluate whether delays in surgery led to an increased occurrence of aggressive tumours. METHODS: In this retrospective, international, cross-sectional study, centres were invited to participate in June 22, 2022; each centre joining the study was asked to provide data from medical records on all surgical thyroidectomies consecutively performed from Jan 1, 2019, to Dec 31, 2021. Patients with indeterminate thyroid nodules were divided into three groups according to when they underwent surgery: from Jan 1, 2019, to Feb 29, 2020 (global prepandemic phase), from March 1, 2020, to May 31, 2021 (pandemic escalation phase), and from June 1 to Dec 31, 2021 (pandemic decrease phase). The main outcomes were, for each phase, the number of surgeries for indeterminate thyroid nodules, and in patients with a postoperative diagnosis of thyroid cancers, the occurrence of tumours larger than 10 mm, extrathyroidal extension, lymph node metastases, vascular invasion, distant metastases, and tumours at high risk of structural disease recurrence. Univariate analysis was used to compare the probability of aggressive thyroid features between the first and third study phases. The study was registered on ClinicalTrials.gov, NCT05178186. FINDINGS: Data from 157 centres (n=49 countries) on 87 467 patients who underwent surgery for benign and malignant thyroid disease were collected, of whom 22 974 patients (18 052 [78·6%] female patients and 4922 [21·4%] male patients) received surgery for indeterminate thyroid nodules. We observed a significant reduction in surgery for indeterminate thyroid nodules during the pandemic escalation phase (median monthly surgeries per centre, 1·4 [IQR 0·6-3·4]) compared with the prepandemic phase (2·0 [0·9-3·7]; p<0·0001) and pandemic decrease phase (2·3 [1·0-5·0]; p<0·0001). Compared with the prepandemic phase, in the pandemic decrease phase we observed an increased occurrence of thyroid tumours larger than 10 mm (2554 [69·0%] of 3704 vs 1515 [71·5%] of 2119; OR 1·1 [95% CI 1·0-1·3]; p=0·042), lymph node metastases (343 [9·3%] vs 264 [12·5%]; OR 1·4 [1·2-1·7]; p=0·0001), and tumours at high risk of structural disease recurrence (203 [5·7%] of 3584 vs 155 [7·7%] of 2006; OR 1·4 [1·1-1·7]; p=0·0039). INTERPRETATION: Our study suggests that the reduction in surgical activity for indeterminate thyroid nodules during the COVID-19 pandemic period could have led to an increased occurrence of aggressive thyroid tumours. However, other compelling hypotheses, including increased selection of patients with aggressive malignancies during this period, should be considered. We suggest that surgery for indeterminate thyroid nodules should no longer be postponed even in future instances of pandemic escalation. FUNDING: None.

Robotic cholecystectomy using Senhance robotic platform versus laparoscopic conventional cholecystectomy: a propensity score analysis.

INTRODUCTION: Our study objective was to evaluate differences in intraoperative and postoperative outcomes of robotic cholecystectomy (RC) using Senhance robotic platform vs laparoscopic cholecystectomy (LC). MATERIAL AND METHODS: A retrospective case - matched analysis was performed for all patients who underwent cholecystectomy from November 2018 to November 2019. RC cases were matched to LC. RC was performed using Senhance robotic platform. Propensity score matching analysis with a ratio of 1:1 (RC: LC) was performed. The groups were matched according to age, sex, body mass index (BMI). All procedures were performed by two same experienced robotic surgeons at Klaipeda University Hospital (O.D. and V.E.). Age, BMI, operative time, blood loss and length of hospital stay were collected and analysed between those patient groups. RESULTS: A total of 40 patients underwent RC or LC. There were no statistical differences between groups in concern of length of hospital stay, blood loss or complications. There were no bile duct injuries in either group, no intraoperative complications, no conversions either RC to LC or LC to open surgery. One patient in robotic group was reoperated on postoperative day 5 regarding sub-hepatic haematoma. The only statistical significance was in operative time (p < .05) which was longer in RC group. Median docking time was 12 min (range 5-23). CONCLUSIONS: Robotic cholecystectomy using Senhance robotic platform appears to be safe in comparison with laparoscopic cholecystectomy. Laparoscopic cholecystectomy might be feasible in gaining robotic surgery skills.

Predictors of postoperative hypocalcemia occurring after a total thyroidectomy: results of prospective multicenter study.

BACKGROUND: Thyroid surgeries are among the most common operations performed in the world. Hypocalcemia following total thyroidectomy is a common complication that is sometimes difficult to correct. The aim of this study is to determine the risk factors for hypocalcemia following total thyroidectomy and their clinical value. METHODS: From January 2015 through to April 2017, 400 patients were included in this prospective multicenter study. All patients underwent total thyroidectomy due to various thyroid diseases. The following risk factors were analyzed: pre-operative and post-operative biochemical blood parameters, clinical effects and factors related to surgery, the patient, and the disease. RESULTS: Post-operative hypocalcemia developed in 257 patients (64.2%). Of them, 197 patients (76.7%) were diagnosed with asymptomatic hypocalcemia. Clinical symptoms were present in 60 of the 257 patients with hypocalcemia (23.3%). The statistically significant predictors of hypocalcemia were decreased calcium and ionized calcium pre-operatively (p < 0.001), parathyroid hormone on day one following surgery (p < 0.001), thyrotoxicosis <10 years before surgery (odds ratio 1.65, 95% CI 1.01-2.70, p = 0.046), the number of parathyroid glands found during surgery (odds ratio 0.52, 95% CI 0.38-0.70, p < 0.001), ligation of the trunk of the left inferior thyroid artery (odds ratio 2.04, 95% CI 1.27-3.29, p = 0.003), ligation of the trunk of the right inferior thyroid artery (odds ratio 2.37, 95% CI 1.47-3.81, p < 0.001), and the number of transplanted parathyroid glands (odds ratio 1.87, 95% CI 1.12-2.97, p = 0.015). In the multivariate analysis, age (odds ratio 1.05, 95% CI 1.01-1.09, p = 0.029) and gender (odds ratio 5.94, 95% CI 1.13-31.26, p = 0.035) were statistically significant predictors. CONCLUSIONS: This study demonstrates that there is a number of different patient (gender, age, and duration of thyrotoxicosis <10 years before surgery) and surgical (number of parathyroid glands found during surgery, decreased calcium and ionized calcium before surgery, parathyroid hormone on day one following surgery, and ligation of the trunk of the left and right inferior thyroid artery) risk factors predictive of hypocalcemia following total thyroidectomy. Optimization of the surgical technique could possibly prevent the occurrence of hypocalcemia after total thyroidectomy in some cases; in other cases, identification of known risk factors post-operatively could permit early detection and effective treatment of these patients.

Video-assisted loboisthmectomy by the subclavicular approach. A case report.

The main advantage of minimally invasive thyroidectomy is a good cosmetic effect. Minimally invasive video-assisted thyroidectomy (MIVAT) is performed without gas insufflation in contrast to endoscopic thyroidectomy. In general, MIVAT is carried out through an incision in the middle part of the neck, not covered with clothes. The MIVAT thyroid lobectomy can also be done through the subclavicular approach. We describe a case of a 19-year-old female patient with a tumour of the left side of the neck. Thyroid ultrasound scan (UST) with thyroid fine-needle aspiration and cytological examination (FNAC) were performed. Thyroid-stimulating hormone (TSH), free triiodothyronine (FT3) and anti-tyreoperoxidase (ATPO) were checked. Video-assisted hemithyroidectomy was performed through an incision below the left clavicle. Intraoperative pathology examination of the specimen was carried out. The UST showed a solitary 13 mm × 23 mm nodule in the left lobe of the thyroid, the FNAC showed benign pathology. Thyroid function tests were normal (TSH 0.90 mIU/l; FT3 4.70 pmol/l). Video-assisted hemithyroidectomy was done through the incision below the left clavicle. Histopathological examination proved thyroid hyperplasia nodosum. There were no intra- or postoperative complications. The patient was discharged on the second day. Clinical and cosmetic outcomes 2 months after surgery were good. Minimally invasive video-assisted thyroid lobectomy performed via the subclavicular area is feasible and provides good cosmetic outcomes.