Adrenalectomy for incidental and symptomatic phaeochromocytoma: retrospective multicentre study based on the Eurocrine® database.

BACKGROUND: Phaeochromocytoma is sometimes not diagnosed before surgery and may present as an adrenal incidentaloma. The aim of this study was to investigate differences in clinical presentation and perioperative outcome in patients with subclinical and symptomatic phaeochromocytoma, and in patients operated with and without preoperative α-blockade. METHODS: This was a retrospective observational study of patients with a histopathological diagnosis of phaeochromocytoma registered in Eurocrine®, the European registry for endocrine tumours, between 1 January 2015 and 31 March 2020. Patient characteristics, clinical presentation, tumour detection, and perioperative variables were analysed. RESULTS: Some 551 patients were included. Of these, 486 patients (88.2 per cent) had a preoperative diagnosis of phaeochromocytoma. Tumours were detected as incidentalomas in 239 patients (43.4 per cent) and 265 (48.1 per cent) had a preoperative diagnosis of hypertension. Preoperative α-blockade was more frequently used in patients with a known phaeochromocytoma (350, 90.9 per cent) than in patients with other indications for adrenalectomy (16, 31 per cent). Complications did not differ between patients who had surgery because of catecholamine excess compared with those who had other indications for surgery (19 (3.9 per cent) versus 2 (3 per cent); P = 0.785), nor did the conversion rate from minimally invasive to open surgery differ between the groups. There were no obvious differences in complications, according to the Clavien-Dindo classification, based on preoperative α-blockade or not. CONCLUSION: Subclinical phaeochromocytoma detected incidentally is common. A significant proportion of patients with phaeochromocytoma did not have α-blockade before surgery, without an apparent effect on complications.

Phaeochromocytoma is an unusual adrenal tumour with hormonal overproduction of catecholamines leading to a severe condition, including extreme hypertension in some situations. It is treated with surgery. Medical treatment before surgery is used to minimize surgical complications related to high blood pressure. A large proportion of phaeochromocytomas are detected incidentally, without symptoms, on radiological examination for other reasons. The aim of this study was to investigate differences in patient characteristics and surgical results in patients operated with or without symptoms of phaeochromocytoma. Patients registered in the large, European database, Eurocrine®, between 2015 and 2020 were included in the study. The study showed that phaeochromocytoma without symptoms is common. Medical treatment before surgery does not seem to affect complications.

Complications after medullary thyroid carcinoma surgery: multicentre study of the SQRTPA and EUROCRINE® databases.

BACKGROUND: Surgery is the curative therapy for patients with medullary thyroid carcinoma (MTC). In determining the extent of surgery, the risk of complications should be considered. The aim of this study was to assess procedure-specific outcomes and risk factors for complications after surgery for MTC. METHODS: Patients who underwent thyroid surgery for MTC were identified in two European prospective quality databases. Hypoparathyroidism was defined by treatment with calcium/active vitamin D. Recurrent laryngeal nerve (RLN) palsy was diagnosed on laryngoscopy. Complications were considered at least transient if present at last follow-up. Risk factors for at-least transient hypoparathyroidism and RLN palsy were identified by logistic regression analysis. RESULTS: A total of 650 patients underwent surgery in 69 centres at a median age of 56 years. Hypoparathyroidism, RLN palsy and bleeding requiring reoperation occurred in 170 (26·2 per cent), 62 (13·7 per cent) and 17 (2·6 per cent) respectively. Factors associated with hypoparathyroidism were central lymph node dissection (CLND) (odds ratio (OR) 2·20, 95 per cent c.i. 1·04 to 4·67), CLND plus unilateral lateral lymph node dissection (LLND) (OR 2·78, 1·20 to 6·43), CLND plus bilateral LLND (OR 2·83, 1·13 to 7·05) and four or more parathyroid glands observed (OR 4·18, 1·46 to 12·00). RLN palsy was associated with CLND plus LLND (OR 4·04, 1·12 to 14·58) and T4 tumours (OR 12·16, 4·46 to 33·18). After compartment-oriented lymph node dissection, N0 status was achieved in 248 of 537 patients (46·2 per cent). CONCLUSION: Complications after surgery for MTC are procedure-specific and may relate to the unavoidable consequences of radical dissection needed in some patients.

European multicentre study on outcome of surgery for sporadic primary hyperparathyroidism.

BACKGROUND: International multicentre outcome studies of surgery for primary hyperparathyroidism (pHPT), especially for rate of conversion to bilateral neck surgery and persistent hypercalcaemia, are scarce. METHODS: Eurocrine® is a European database for endocrine surgery. Data are entered according to predefined data fields. Outcomes for patients who underwent first surgery for sporadic pHPT were analysed. Multivariable analysis was performed to identify risk factors for adverse outcome using Cox regression with constant follow-up. RESULTS: A total of 5861 patients were registered between 2015 and 2018. Preoperative localization procedures were used in most patients, with moderate sensitivity. Intraoperative parathyroid hormone (ioPTH) measurement was used in three-quarters of patients. Bilateral surgery was performed in 1574 patients (26·9 per cent). Among 4683 patients (79·7 per cent) for whom unilateral or focused operation was planned, the procedure was converted to bilateral surgery in 396 (8·5 per cent). The risk of conversion decreased with the use of ioPTH monitoring (relative risk (RR) 0·77). Persistent hypercalcaemia was registered in 253 patients (4·3 per cent), and was less likely with the use of two (RR 0·55) or three (RR 0·44) localization procedures. In patients with a concordant localized single lesion, the rate of persistent hypercalcaemia was 2·5 per cent. The risk of persistent hypercalcaemia decreased with the use of ioPTH measurement, but was increased in patients with negative localization procedures and conversion to bilateral surgery. CONCLUSION: The use of ioPTH measurement decreased the risk of conversion and persistent hypercalcaemia. The use of two or three localization procedures decreased the risk of persistent hypercalcaemia; in patients with a concordant single lesion, the risk of persistent hypercalcaemia was low.

Central lymph node dissection and permanent hypoparathyroidism after total thyroidectomy for papillary thyroid cancer: population-based study.

BACKGROUND: Papillary thyroid cancer is treated with total/near-total thyroidectomy (TT) with or without central lymph node dissection (CLND), depending on risk factors and tumour size. Balancing the risk of disease recurrence and surgical morbidity remains a challenge. A population-based nationwide study was undertaken to evaluate the risk of permanent hypoparathyroidism associated with CLND. METHOD: Data on patients with stage pT1-3 papillary thyroid cancer, who underwent TT with or without CLND between 1 July 2004 and 30 June 2014 were retrieved from the Scandinavian Quality Register for Thyroid, Parathyroid and Adrenal Surgery. Drug use was ascertained by cross-linking with the Swedish Prescribed Drug Register. Permanent hypoparathyroidism was defined as treatment with active D vitamin or oral calcium drugs for more than 6 months after surgery. Data were analysed separately for all patients and those who underwent TT + CLND. Univariable and multivariable logistic regression analyses were done, yielding odds ratios (ORs) with 95 per cent confidence intervals. RESULTS: A total of 722 patients were included in the study. Permanent hypoparathyroidism was more common in the TT + CLND group than the TT group: 30 of 265 patients (6·6 per cent) versus six of 457 (2·3 per cent) (P = 0·011). In multivariable logistic regression analysis, CLND was a risk factor for permanent hypoparathyroidism (OR 3·74, 95 per cent c.i. 1·46 to 9·59, based on use of combined therapy 6 months after surgery). In patients who had TT + CLND, node negativity was associated with a risk of permanent hypoparathyroidism (OR 3·08, 1·31 to 7·25). CONCLUSION: CLND is an independent risk factor for permanent hypoparathyroidism. Node negativity is associated with a higher risk of permanent hypoparathyroidism.

Mortality after surgery for primary hyperparathyroidism: results from a nationwide cohort.

BACKGROUND: Contemporary patients with primary hyperparathyroidism are often diagnosed with mildly raised serum calcium levels. Previous studies have reported increased mortality in patients with primary hyperparathyroidism. This retrospective cohort study aimed to examine whether contemporary patients operated for primary hyperparathyroidism have higher mortality than the general population, and whether mortality in these patients is associated with serum calcium concentration, adenoma weight or multiglandular disease. METHODS: Patients from a Swedish national cohort consisting of patients registered in the Scandinavian Quality Register for Thyroid, Parathyroid, and Adrenal Surgery 2003-2013, were matched with population controls. The National Patient Register, the Swedish Cause of Death Register, and socioeconomic data were cross-linked. End of follow-up was 10 years after surgery, 31 December 2015, or emigration. Mortality was analysed by standardized mortality ratio, Kaplan-Meier survival estimates, and univariable and multivariable Cox regression. Multiple imputation by chained equations was performed on missing data. RESULTS: After exclusions, there were 5009 patients with primary hyperparathyroidism and 14 983 controls. Multivariable Cox regression analysis adjusted for age, sex, Charlson Co-morbidity Index, marital status, level of education, disposable income, and period of surgery showed lower mortality in patients than controls (hazard ratio (HR) 0.83, 95 per cent c.i. 0.75 to 0.92). In univariable Cox regression of mortality in patients, serum calcium concentration (mmoles per litre) was associated with mortality (HR 2.20, 1.53 to 3.16). This association remained in multivariable Cox regression after multiple imputation (HR 1.79, 1.19 to 2.70). CONCLUSION: Mortality was not increased in patients operated for primary hyperparathyroidism compared with controls in a contemporary setting. Preoperative serum calcium concentration might, however, influence survival.

[EUROCRINE®: adrenal surgery 2015-2019- surprising initial results]. / EUROCRINE®: Nebennierenoperationen 2015 bis 2019 ­ überraschende erste Ergebnisse.

BACKGROUND: Since 2015 operations performed in the field of endocrine surgery have been entered into the European registry EUROCRINE®. The aim of this analysis was a description of the current healthcare situation for adrenal surgery in a homogeneous healthcare environment corresponding to the German-speaking countries-or to the presence of the working group on surgical endocrinology (CAEK) of the German society for general and visceral surgery (DGAV)-and to assess the adherence to current international treatment guidelines. METHODS: An analysis of the preoperative diagnostics, the applied operative techniques and the underlying histological entities was carried out for all operations on adrenal glands in Germany, Switzerland and Austria, which were registered in EUROCRINE® from 2015 to 2019. RESULTS: In the total of 21 participating hospitals from the German-speaking EUROCRINE® countries, 658 operations on adrenal glands were performed. In 90% of cases unilateral adrenalectomy was performed, in 3% bilateral adrenalectomy and in 7% other resection procedures. In 41% the main histological diagnosis was an adrenocortical adenoma. In 15% malignant entities were detected on final histology, including 6% adrenocortical carcinoma (ACC) and 8% metastases to the adrenal glands. 23% of the operations were performed for pheochromocytoma. This entity was primarily resected using minimally invasive approaches (82%), whereas minimally invasive techniques were applied in 28% for ACC and in 66% for metastases to the adrenal glands. CONCLUSION: Surprisingly, following adrenocortical adenoma and pheochromocytoma, the third most common histological entity was metastasis of different extra-adrenal primary tumors to the adrenal gland. Of the operations for ACC 28% were scheduled for minimally invasive techniques, but conversion to open surgery was necessary in 20%. The analysis revealed discrepancies between treatment reality and international guideline recommendations that raise questions, which will be addressed by an updated version of the EUROCRINE® module for the documentation of adrenal surgery.

Effect of intraoperative nerve monitoring on postoperative vocal cord palsy rates after thyroidectomy: European multicentre registry-based study.

BACKGROUND: Intraoperative nerve monitoring (IONM) of the recurrent laryngeal nerve (RLN) predicts the risk of vocal cord palsy (VCP). IONM can be used to adapt the surgical strategy in order to prevent bilateral VCP and associated morbidity. Controversial results have been reported in the literature for the effect of IONM on rates of VCP, and large multicentre studies are required for elucidation. METHODS: Patients undergoing first-time thyroidectomy for benign thyroid disease between May 2015 and January 2019, documented prospectively in the European registry EUROCRINE®, were included in a cohort study. The influence of IONM and other factors on the development of postoperative VCP was analysed using multivariable regression analysis. RESULTS: Of 4598 operations from 82 hospitals, 3542 (77·0 per cent) were performed in female patients. IONM was used in 4182 (91·0 per cent) of 4598 operations, independent of hospital volume. Postoperative VCP was diagnosed in 50 (1·1 per cent) of the 4598 patients. The use of IONM was associated with a lower risk of postoperative VCP in multivariable analysis (odds ratio (OR) 0·34, 95 per cent c.i. 0·16 to 0·73). Damage to the RLN noted during surgery (OR 24·77, 12·91 to 48·07) and thyroiditis (OR 2·03, 1·10 to 3·76) were associated with an increased risk of VCP. Higher hospital volume correlated with a lower rate of VCP (OR 0·05, 0·01 to 0·13). CONCLUSION: Use of IONM was associated with a low rate of postoperative VCP.

ANTECEDENTES: La monitorización nerviosa intraoperatoria (intraoperative nerve monitoring, IONM) del nervio laríngeo recurrente (recurrent laryngeal nerve, RLN) predice el riesgo de parálisis de la cuerda vocal (vocal cord palsy, VCP). La IONM se puede utilizar para adaptar la estrategia quirúrgica con el objetivo de prevenir la VCP bilateral y la morbilidad asociada. La literatura describe resultados controvertidos de la influencia de la IONM sobre las tasas de VCP, por lo que se requieren grandes estudios multicéntricos para aclararlo. MÉTODOS: De mayo de 2015 a enero de 2019, las tiroidectomías efectuadas como primera intervención quirúrgica por patología tiroidea benigna - documentadas prospectivamente en el registro europeo EUROCRINE© - se incluyeron en un estudio de cohortes. La influencia de la IONM y otros factores sobre el desarrollo de VCP postoperatoria fueron analizados utilizando un análisis de regresión multivariable. RESULTADOS: De 4.598 operaciones efectuadas en 82 hospitales e incluidas en el estudio, 3.542 (77,0%) fueron realizadas en mujeres. La IONM se utilizó en 4.182 de 4.598 (91,0%) operaciones independientemente del volumen del hospital. La VCP postoperatoria se diagnosticó en 50 de 4.598 (1,1%) pacientes. La utilización de IONM se asoció con un menor riesgo de VCP postoperatoria en el análisis multivariable (razón de oportunidades, odds ratio, OR 0,34 (i.c. del 95% 0,16-0,73)). La detección de lesión del RLN durante la cirugía (OR 24,77 (12,91 a 48,07)) y la tiroiditis (OR 2,03 (1,10 a 3,76)) se asociaron con un riesgo aumentado de VCP. Un elevado volumen de casos se correlacionó con menor frecuencia de VCP (OR 0,05 (0,01 a 0,13)). CONCLUSIÓN: La utilización de la IONM se asoció con una baja tasa de VCP postoperatoria.

Evaluating risk factors for re-exploration due to postoperative neck hematoma after thyroid surgery: a nested case-control study.

PURPOSE: Postoperative bleeding after thyroid surgery remains a potentially lethal complication. Outpatient thyroidectomy is an increasing trend in the high volume centers. There is a need to identify risk factors for postoperative bleeding in order to select proper patients for outpatient thyroidectomy. This study aimed to investigate this issue using a national population-based register. MATERIAL AND METHOD: A nested case-control study on patients registered in the Swedish national register for endocrine surgery (SQRTPA) was performed. Patients with postoperative bleeding were matched 1:1 by age and gender to controls. Additional information on cases and controls was obtained from attending surgeons using a questionnaire. Risk factors for postoperative bleeding were evaluated with logistic regression and are presented as odds ratios (ORs) with 95% confidence intervals (CIs). The time of bleeding in relation to surgery was also investigated. RESULTS: There were 9494 operations, and 174 (1.8%) of them involved postoperative bleeding. In the whole cohort, patients with postoperative bleeding were older, 58 (46-69) vs. 49 (37-62) years, than patients without, p < 0.01. Male patients had a higher risk of bleeding, OR 2.18 (95% CI 1.58-2.99). In the case-control cohort, drain was an independent risk factor for bleeding, OR 1.64 (1.05-2.57). Two-thirds of patients bled within 6 h after surgery. The incidence of bleeding after 24 h was 10%. CONCLUSION: High age, male gender, and drain are independent risk factors for bleeding after thyroid surgery. Even with careful patient selection, prolonged observation might be necessary in thyroid surgery.

Mortality in patients with permanent hypoparathyroidism after total thyroidectomy.

BACKGROUND: Permanent hypoparathyroidism remains the most common adverse outcome after total thyroidectomy, but long-term effects of hypoparathyroidism are unknown. The aim was to investigate mortality in patients with permanent hypoparathyroidism after total thyroidectomy. METHODS: Data from the Scandinavian Quality Register for Thyroid, Parathyroid and Adrenal Surgery were linked with the Swedish National Prescription Register for Pharmaceuticals and the Swedish National Inpatient Register. Patients who underwent total thyroidectomy between 1 July 2005 and 30 June 2014 for benign thyroid disease, and who used active vitamin D for at least 6 months after surgery, were classified as having permanent hypoparathyroidism and included in the study cohort. Risk of death was assessed using Cox regression analysis, adjusting for age, sex, thyrotoxicosis and co-morbidity. RESULTS: There were 4899 patients, with a mean(s.d.) age of 46·3(15·8) years; 83·1 per cent were women, and 2932 patients (59·8 per cent) had thyrotoxicosis. In all, 246 patients (5·2 per cent) were classified as having permanent hypoparathyroidism. Mean(s.d.) follow-up was 4·4(2·4) years, and 109 patients (2·2 per cent) died during follow-up. Compared with patients without permanent hypoparathyroidism, the risk of death was significantly higher among patients with permanent hypoparathyroidism after total thyroidectomy (adjusted hazard ratio 2·09, 95 per cent c.i. 1·04 to 4·20). CONCLUSION: Permanent hypoparathyroidism after total thyroidectomy for benign disease is common and associated with an increased risk of death.

A Nested Case-Control Study on the Risk of Surgical Site Infection After Thyroid Surgery.

INTRODUCTION: It is unclear if antibiotic prophylaxis reduces the risk of surgical site infection (SSI) in thyroid surgery. This study assessed risk factors for SSI and antibiotic prophylaxis in subgroups of patients. METHOD AND DESIGN: A nested case-control study on patients registered in the Swedish National Register for Endocrine Surgery was performed. Patients with SSI were matched 1:1 by age and gender to controls. Additional information on patients with SSI and controls was queried from attending surgeons using a questionnaire. Risk factors for SSI were evaluated by logistic regression analysis and presented as odds ratio (OR) with 95% confidence interval (CI). RESULTS: There were 9494 operations; 109 (1.2%) patients had SSI. Patients with SSI were older (median 53 vs. 49 years) than patients without SSI p = 0.01 and more often had a cancer diagnosis 23 (21.1%) versus 1137 (12.1%) p = 0.01. In the analysis of patients with SSI versus controls, patients with SSI more often had post-operative drainage 68 (62.4%) versus 46 (42.2%) p = 0.01 and lymph node surgery 40 (36.7%) versus 14 (13.0%) p < 0.01, and both were independent risk factors for SSI, drain OR 1.82 (CI 1.04-3.18) and lymph node dissection, OR 3.22 (95% CI 1.32-7.82). A higher number of 26(62%) patients with independent risk factors for SSI and diagnosed with SSI did not receive antibiotic prophylaxis. Data were missing for 8 (31%) patients. CONCLUSION: Lymph node dissection and drain are independent risk factors for SSI after thyroidectomy. Antibiotic prophylaxis might be considered in patients with these risk factors.

Risk of recurrent laryngeal nerve palsy in patients undergoing thyroidectomy with and without intraoperative nerve monitoring.

BACKGROUND: Vocal cord palsy occurs in 3-5 per cent of patients after thyroidectomy. To reduce this complication, intraoperative nerve monitoring (IONM) has been introduced, although its use remains controversial. This study investigated the risk of postoperative vocal cord palsy with and without the use of intermittent IONM. METHODS: Patients registered in the Scandinavian Quality Register for Thyroid, Parathyroid and Adrenal Surgery, 2009-2013, were included. Early palsy of the recurrent laryngeal nerve was diagnosed within 6 weeks after surgery. Permanent palsy was defined as that persisting after 6 months. Univariable and multivariable logistic regression analyses were used to examine risk factors for vocal cord palsy. RESULTS: The cohort consisted of 5252 patients undergoing thyroidectomy. IONM was used in 3277 operations (62·4 per cent); postoperative laryngoscopy was performed in 1757 patients (33·5 per cent). Early vocal cord palsy occurred in 217 patients (4·1 per cent), of which three were bilateral, all in the group without IONM. Permanent vocal cord palsy occurred in 62 patients (1·2 per cent). In the multivariable analysis of 1757 patients who had postoperative laryngoscopy, the use of IONM was not associated with a decreased risk of early vocal cord palsy (odds ratio (OR) 0·67, 95 per cent c.i. 0·44 to 1·01), but decreased the risk of permanent vocal cord palsy (OR 0·43, 0·19 to 0·93). [Correction added on 11 November 2016 after first publication: the word 'routine' has been removed from this section.] CONCLUSION: IONM reduced the risk of permanent vocal cord palsy. No bilateral recurrent laryngeal nerve injury occurred following IONM.

Prediction of permanent hypoparathyroidism after total thyroidectomy.

BACKGROUND: Hypoparathyroidism is a common complication with thyroid surgery. The ability to predict a high risk of permanent hypoparathyroidism is important for individual prognosis and follow-up. METHODS: Permanent hypoparathyroidism, defined as continuing need for vitamin D medication at 1-year post-operatively, was investigated in patients after total thyroidectomy. Blood levels of calcium and parathyroid hormone (PTH) were measured intra-operatively, the day after surgery and at 1 month post-operatively. Logistic regression analysis was performed to investigate the risk of vitamin D treatment at last follow-up, calculated as odds ratios (ORs) with 95 % confidence intervals (CIs). Patients were followed until cessation of vitamin D and/or calcium medication, until death, loss to follow-up, or end of follow-up, whichever came first. RESULTS: A total of 519 patients were included. The median (range) follow-up in patients unable to cease vitamin D was 2.7 (1.2-10.3) years. The rate of permanent hypoparathyroidism was 10/519, 1.9 %. Parathyroid auto-transplantation was performed in 90/519 (17.3 %) patients. None of these developed permanent hypoparathyroidism, nor did any patient with normal PTH day 1 (>1.6 pmol/l or 15 pg/ml). The adjusted risk (OR, 95 % CI) for permanent hypoparathyroidism for log PTH on day 1 was 0.25 (0.13-0.50). In patients not auto-transplanted and with unmeasurable PTH day 1 (<0.7 pmol/l or 6.6 pg/ml), 8/42 (19.2 %) developed permanent hypoparathyroidism. CONCLUSIONS: Auto-transplantation protects against permanent hypoparathyroidism, whereas low PTH day 1 is associated with high risk.

Hypocalcaemia after total thyroidectomy for Graves' disease and for benign atoxic multinodular goitre.

PURPOSE: Postoperative hypocalcaemia has been reported to be more common after total thyroidectomy (TT) for Graves' disease than after TT for benign atoxic multinodular goitre (MNG). The reasons for this potential association are not clear. In the present study, the frequency and risk factors of hypocalcaemia after TT for Graves' vs MNG were compared. METHODS: Between January 1999 and October 2009, patients with first-time surgery for Graves' disease or MNG treated with a TT were included in the study. Postoperative hypocalcaemia was defined by symptoms, calcium levels and treatment with calcium and/or vitamin D analogues during postoperative hospital stay, at discharge, and at the 6-week and 6-month follow-ups. Outcomes were compared with Mann-Whitney, chi(2) and Fishers' exact test where appropriate and by multivariable logistic regression analysis. RESULTS: There were 128 patients with Graves' disease and 81 patients with MNG. Patients with Graves' disease were younger than patients with MNG (median age, 35 vs 51 years, p < 0.001). Symptoms of hypocalcaemia were more common in patients with Graves' disease (p < 0.001; OR, 95 % CI 3.26, 1.48-7.14), but the frequency of biochemical hypocalcaemia, postoperative levels of parathyroid hormone (PTH) and treatment with calcium and vitamin D did not differ between groups of patients. CONCLUSION: Apart from more frequent symptoms of hypocalcaemia in patients with Graves' disease, there was no difference in the overall frequency of biochemical hypocalcaemia, low levels of PTH and/or treatment with calcium and vitamin D.

Risk factors for medically treated hypocalcemia after surgery for Graves' disease: a Swedish multicenter study of 1,157 patients.

BACKGROUND: For reasons that remain unclear, surgery for Graves' disease is associated with a higher risk of hypocalcemia than surgery for benign atoxic goiter. In the present study, we evaluated risk factors for postoperative hypocalcemia in patients undergoing operation for Graves' disease. METHODS: Data from 1,157 patients who underwent operation for Graves' disease between 2004 and 2008 were extracted from the Scandinavian database for Thyroid and Parathyroid Surgery. Risk factors for postoperative hypocalcemia (in-hospital i. v. calcium; treatment with vitamin D analog at discharge, at 6 weeks, and at 6 months postoperatively) were evaluated by logistic regression analysis. RESULTS: Risk factors for i. v. calcium were low hospital volume of thyroid surgery (odds ratio [OR]: 95 % confidence interval [95 % CI], 0.99: 0.99-1.00), age (0.95: 0.91-1.00), operative time (1.02: 1.01-1.02), university hospital (12.91: 2.68-62.30), and reoperation for bleeding (10.32: 1.51-70.69). The risk for treatment with vitamin D at discharge increased with operative time (1.01: 1.00-1.02), excised gland weight (1.01: 1.00-1.01), parathyroid autotransplantation (5.19: 2.28-11.84), and reoperation for bleeding (12.00: 2.43-59.28). At 6 weeks, vitamin D medication was associated with gland weight (1.00: 1.00-1.01), and preoperative medication with ß-blockers (4.20: 1.67-10.55). At 6 months, vitamin D medication was associated with gland weight (1.00: 1.00-1.01) and reoperation for bleeding (10.59: 1.58-71.22). CONCLUSIONS: Risk factors for medically treated hypocalcemia varied at different times of follow-up. Young age, operative time, type of hospital, and parathyroid autotransplantation were associated with early postoperatively hypocalcemia. Preoperative ß-blocker treatment was a risk factor at the first follow-up. At early and late follow-up, gland weight and reoperation for bleeding were associated with medically treated hypocalcemia.

Biochemical diagnosis of primary hyperparathyroidism: Analysis of the sensitivity of total and ionized calcium in combination with PTH.

OBJECTIVES: To investigate the accuracy of the biochemical diagnosis of primary hyperparathyroidism (pHPT) in a consecutive series of patients with operatively verified disease. DESIGN AND SUBJECTS: Four hundred thirty-six patients with pHPT, 340 women and 96 men, were reviewed. Biochemical variables, including total calcium (Ca), ionized calcium (Cai) and PTH were analyzed and registered in a prospective database. RESULTS: In the subgroup of patients with more mild hypercalcemia (Ca below 2.70mmol/L) the correlation between Ca and Cai was poor. 19 respectively 18 patients had preoperatively a Ca respectively Cai level within the reference range. Further 35 patients had preoperatively a normal level of PTH. The diagnostic sensitivities, in detecting pHPT, for Ca, Cai and the combination of Ca and Cai were 96%, 96% and 99%. CONCLUSION: If calcium and ionized calcium are not used in the diagnostic workup of pHPT some 4% of the patients will be overlooked. We recommend analyzing both Ca and Cai in the diagnostic workup of pHPT.

A prospective study of 100 roboticallyassisted laparoscopic adrenalectomies.

We evaluated robotically assisted laparoscopic adrenalectomy (RLA) in a prospective study of 100 consecutive patients (60 women and 40 men) undergoing unilateral adrenalectomy at the University Hospital. The median age was 59 (24-82) years and BMI 27.6 (17.1-40.9) kg/m(2). Preoperative diagnoses were Conn's syndrome 30%, pheochromocytoma 23%, Cushing syndrome 27% and non-functional tumor 20%. The median tumor size was 53 (10-106) mm. The majority of the 7% of the patients who were converted to open surgery were in the early phase after the introduction of the technique. The BMI of the patients who were converted to open surgery was significantly higher, 31.5 (range 25.3-37.8) compared to, 27.5 (range 17.1-40.9) in patients without conversion (P = 0.047). The median weight of the tumor was 51 g for patients with conversion (range 18-97 g) and 30 g (range 8-128 g) for patients without conversion (P = 0.066). The median console operation time for the whole series was 88 min (range 39-397 min). The console operation time decreased significantly with the numbers of patients operated (r = 0.372; P = 0.0003). There was an association between the weight of the specimen and operation time (r = 0.42; P = 0.0001). RLA is a safe and a feasible surgical alternative for treating all kind of adrenal disorders, particularly large tumors and more complex circumstances. The present study clearly shows that a learning curve is present for the console surgeon and assistants.

Randomized clinical trial comparing open with video-assisted minimally invasive parathyroid surgery for primary hyperparathyroidism.

BACKGROUND: : Previous studies of video-assisted techniques for parathyroidectomy in patients with primary hyperparathyroidism have found similar or better results compared with bilateral neck exploration. The aim of the present study was to compare open minimally invasive parathyroidectomy with the video-assisted technique for primary hyperparathyroidism in a multicentre randomized trial. METHODS: : Some 143 patients were randomized to open (n = 75) or video-assisted (n = 68) parathyroidectomy after positive sestamibi scintigraphy. There were no differences in preoperative data. The open operation was performed through a 15-mm incision. The video-assisted techniques used were minimally invasive video-assisted parathyroidectomy (MIVAP) or video-assisted parathyroidectomy using the lateral approach (VAPLA). Data were collected prospectively including postoperative pain scoring. RESULTS: : The procedure was significantly quicker for the open compared to the video assisted operations: mean(s.d.) 60(35) versus 84(47) min (P = 0.001). Both groups of patients had similar conversion rates and the same outcome, with comparable incision lengths, low scores for postoperative neck discomfort, high cosmetic satisfaction and low complication rates. CONCLUSION: : Open minimally invasive parathyroidectomy for primary hyperparathyroidism was quicker than either video-assisted technique. REGISTRATION NUMBER: NCT00877981 (http://www.clinicaltrials.gov)