Endoscopic approaches in head and neck endocrine surgery introduction of TOETVA (TransOral Endoscopic Thyroidectomy by Vestibular Approach) into clinical use at the Department of Surgery of the University Hospital in Brno.

Transoral endoscopic surgery of the thyroid and parathyroid glands is a modification of neck surgery using natural orifices. The classic approach in neck surgery is the gold standard, which we modified in 2007 by introducing Minimally Invasive Video-Assisted Thyroidectomy/Parathyroid-ectomy (MIVAT/P). We have been using TransOral Endoscopic Thyroidectomy/Parathyroidectomy by Vestibular Approach (TOETVA/TOEPVA) since the end of the last year and have operated on four patients. This method is more attractive for patients because it does not leave a visible scar on the neck, which is common in MIVAT/P. TOETVA is a promising procedure with many advantages, such as healing without visible scars, less pain, minimally invasive dissection and a clear operating field to both thyroid lobes and parathyroid glands. Presentation of the first case. Patients indicated for TOETVA must meet certain criteria - nodule(s) up to 3.5 cm, gland volume up to 30 ml, benign FNAB, papillary, follicular carcinoma not advanced, well differentiated, up to the nodule size of 10 mm with 1 lymph node up to 10 mm. The contraindications include a large goiter, previous neck surgery, history of thyroiditis, lymphadenopathy of the neck, advanced thyroid cancer. Relative contraindications include previous radiotherapy to the throat, Grave´s disease, and obese patients with a short neck. Intraoperative findings may result in a modification of the procedure. TOETVA is an excellent choice for selected patients who want to avoid a neck incision. This method provides the benefit of using standard endoscopic instruments and techniques. It is a safe and effective procedure that provides a good cosmetic result and considerable comfort in terms of clarity of the operating field by zooming in with an endoscopic camera. Longer operating times become shorter due to the learning curve effect.

[Rare case of a giant parathyroid adenoma]. / Raritní prípad obrovského adenomu prístítného telíska.

Currently, primary hyperparathyroidism is the third most common endocrine disorder worldwide. In the last years, though, the numbers of patients with this diagnosis have been clearly increasing. Females are affected more often, and the age of patients is usually over 50 years. The diagnosis is guided by clinical symptoms of the patient and by biochemical and imaging methods results. [1] When parathyroid adenoma is identified as the source of primary hyperparathyroidism, the necessary extent of resection is performed. The present case involved a rapid diagnostic process necessary to stabilize the patient, together with localization of the adenoma for the indicated surgery. Ultrasound-guided exploration found a surprisingly large tumour of the parathyroid gland causing the acute clinical condition with symptoms suggestive of primary hyperparathyroidism with discrete mechanical compression of the upper mediastinum.Key words: critical diagnosis of hyperparathyroidism acute-active parathyroid adenoma extirpation of a huge parathyroid tumour - normalization of the clinical condition.

[The value of intraoperative ultrasonography in parathyroid surgery]. / Výteznost peroperacní ultrasonografi v chirurgii prístítných telísek.

INTRODUCTION: Ultrasound of the neck is a sovereign complementary imaging method suitable for determining morphological changes in thyroidology which uses the so-called B-mode two-dimensional images for the neck area that are complemented by duplex Doppler imaging. Diagnostic verification is performed by sonographists from among radiologists and endocrinologists providing regular outpatient care; the surgeon uses ultrasound for navigation to attain the focus to be operated on. Sonography will provide information on the structure of the thyroid, of the parathyroids, their relationship to the surrounding organs (location, size, relationship to breathing and swallowing pathways). We search for the presence of any pathological abnormalities such as the affection of other organs, tumour invasion into surrounding tissue; it is also important to assess the size and nature of the cervical lymph nodes pretracheally, prelaryngeally, paratracheally, along the vascular plexus and supraclavicularly, where thyroid tumours may form metastases. USG assessment of the regional lymph nodes should not be forgotten before surgical management of thyroid nodules or the parathyroids. Thanks to the introduction of ultrasound as an additional screening method in parathyroid surgery we have gained the opportunity of more precise and successful localisation of pathological parathyroid lesions, which is beneficial for patients with hyperparathyroidism. MATERIAL AND METHODS: We worked with a group of patients from 2002 to 2010 when we selected 370 prospectively followed patients operated on for endocrine disease of the thyroid and parathyroid glands. The group consisted of 77 men and 293 women. This group was further selected according to the required criteria specified in the text. Since we are focusing on peroperative ultrasound and on the detection and specification of the position of the parathyroid glands for the surgeon, we are concentrating chiefly on pathological parathyroid glands. These are imaged as circumscribed hypoechoic lesions with hyperechoic margin. Ultrasonography is considered both a sovereign standard diagnostic method and a very valuable navigational method used to localise pathological glands. We use a linear as well as a special "hockey stick" probe which has a higher resolution. RESULTS: For comparison, both detection methods - gamma navigation and ultrasound - are dealt with. We are fully aware of the small number of patients in the selected groups. The results of the statistical analysis show that the use of ultrasound and gamma navigation shortens the overall operation time. More interesting, however, is the indicator of the range of variation, i.e. the difference between the maximum and minimum length of operation. When using one or the other detection method, the variation range is significantly lower and it is apparent that using the gamma-ray or ultrasound navigation system, the detection of the parathyroid gland, particularly when unusually located, is much simpler and thus faster. This finding is also supported by an additional parameter, variance, which expresses the variability of the distribution of values - around the average length of operation. CONCLUSION: Preoperative and intraoperative detection of hyperactive parathyroid glands is useful for minimizing the extent of surgical intervention, reducing operation time and decreasing the risk of perioperative complications. It is not necessary to use a radionuclide and therefore the method can be used even where there is no nuclear medicine station. It is also possible to detect glands which do not accumulate radionuclides and thus cannot be imaged with MIBI scintigraphy/SPECT CT. Still, an experienced surgeon remains irreplaceable. We dare say that if such a surgeon can make use of the above mentioned auxiliary methods in addition, the rate of success in this field of surgery increases substantially.

[Personal experience with infrared spectrometry analysis of urinary calculi]. / Nase zkusenosti s infracervenou spektrometrickou analýzou mocových konkrementu.

Analysis of urinary concrements has a very important place in clinical biochemistry departments, as it is one of the basic prerequisites for effective causal therapy and prophylaxis of nephrolithiasis. Qualitative chemical reactions, used most frequently, have shortcomings as regards the identification of components of calculi and do not provide a real idea on the composition of calculi (9). An accurate identification can be made only by physical methods, which, however, call for very expensive equipment. Clinical departments in Prague, Brno and Ostrava collaborate therefore with research institutes which possess the necessary equipment and where the analyses of calculi are made. Because the majority of clinical biochemical departments have limited access to modern infrared computer controlled spectrometers, this form of collaboration was used also in the authors' department.

[Drug-induced urolithiasis caused by N4-acetylsulfamethoxazole (Biseptol) and oxolinic acid (Desurol)]. / Léková urolitiáza z N4-acetylsulfamethoxazolu (Biseptol) a kyseliny oxolínové (Desurol).

The authors describe rare types of drug-induced urolithiasis in two female patients (N4-acetylsulfamethoxazole--a Biseptol metabolite and oxolinic acid--Desurol). To improve the diagnosis of drug induced urolithiasis the authors recommend a combination of microscopic methods and infrared spectroscopy. They findings are documented by photographs and infrared absorption spectra.