Applicability of transoral endoscopic parathyroidectomy through vestibular route for primary sporadic hyperparathyroidism: A South Indian experience.

Introduction: Primary hyperparathyroidism is one of the most common endocrine disorders requiring surgical parathyroidectomy for its definitive treatment. Surgical exploration is traditionally performed through conventional open neck approach. A wide range of minimal access and minimally invasive endoscopic techniques (gas less and with gas) have been attempted in the past two decades. In this context, we evaluated the feasibility and safety of an innovative transoral endoscopic parathyroidectomy (EP) technique, which represents a paradigm shift in transluminal endocrine surgery. Materials and Methods: This is a prospective study conducted at a tertiary care Endocrine Surgery Department in South India between May 2016 and August 2017. We employed a novel transoral, lower vestibular route for EP. All the clinical, investigative, operative, pathological and post-operative data were collected from our prospectively filled database. Statistical analysis was performed with SPSS 20.0 version. Operative Technique: Under inhalational general anaesthesia, access to the neck was obtained with 3 ports (central frenulotomy and two lateral port sites), dissected in subplatysmal plane and insufflated with 6 mm Hg CO2 for working space. Rest of surgical steps is similar to conventional open parathyroidectomy. Results: Out of the 38 hyperparathyroidism cases operated during the study, 12 (32%) were operated by this technique. Mean operative time was 112 ± 15 min (95-160). The post-operative course was uneventful with no major morbidity, hypocalcemia or recurrent laryngeal nerve palsy. Cure and diagnosis were confirmed by >50% fall in intraoperative parathyroid hormone levels and histopathology (all were benign solitary adenomas). Conclusions: Through this study, we opine that this novel transoral vestibular route parathyroidectomy is a feasibly applicable approach for primary sporadic hyperparathyroidism, especially with solitary benign adenomas.

Hyperemesis Gravidarum is a Syndrome of Metabolic and Endocrine Disturbances: A Case Description.

Hyperemesis gravidarum is a clinical syndrome characterized by excess vomiting, dehydration and weight loss associated high human chorionic gonadotropin levels, usually occurring in the first trimester of gestation. It often presents with severe electrolyte imbalance, mental confusion and may be associated with thyroid dysfunction. We are describing the management of one such case riddled with multiple metabolic events.

SILACIG: A novel technique of single-incision laparoscopic appendicectomy based on institutional experience of 29 cases.

INTRODUCTION: More reports of single-incision laparoscopic appendectomy are appearing in literature as it is an improvement over multiport laparoscopy in further reducing the trauma to abdomen. But, most of techniques require expensive gadgets like commercial ports and manoeuverable instruments, which are not available at many centres. In this context, a feasibility study of our own operative technique of single-incision laparoscopic appendectomy with less expensive conventional instrumentation was conducted at a single centre. MATERIALS AND METHODS: This prospective study was carried out in tertiary care teaching institute of a semi-urban area in South India over a period of 1 year from March 2011 to February 2012. Twenty-nine patients of appendicitis were included in this study. Based on the principles of single-incision laparoscopy, we developed a glove port utilizing readily available operation theatre equipment. RESULTS: Mean operative time was 56±12 minutes. Mean age of subjects was 34±15 years. M: F ratio was 2:1. There was no significant perioperative morbidity or mortality. Mean follow-up period was 8 months. CONCLUSION: Our initial experience with this technique of single-incision laparoscopic appendectomy demonstrates its feasibility, safety at a very low cost.

Utility of Virtual Platform for Conducting Practical Examination for Medical Students During Covid Times: A Prospective Study from Gynaecology Department.

BACKGROUND: As the novel coronavirus 2019 (COVID-19) continues its pandemic surge globally along with its social distancing norms, the physical conduction of practical examinations for medical graduates and postgraduates has become difficult. Software-based systems and social media platforms could provide alternatives for ensuring regular medical education and exam-oriented assessments. In this context, we evaluated our own experience with virtual conduction of semester practical exams for medical graduates. MATERIAL AND METHODS: This prospective study was conducted in Gynaecology and Obstetrics department. We employed live streaming educational video conferencing software for virtual consultation between medical students, patients (case presentations), internal and external examiners. The outcomes were evaluated in terms of conduction of various components of practical examination-Viva, case presentations, instruments, slides, specimen examination. Statistical analysis was performed by descriptive statistics through Microsoft Excel sheet. RESULTS: Virtual conduction examination/evaluation was performed on 150 medical students by examiners from a distant location. No problems occurred except few short duration (less than 5 min) interruptions due to internet connectivity issues. 125/150 (83.5%) of medical students and all examiners (2 internal and 2 external) expressed satisfaction with virtual medical evaluation. CONCLUSIONS: 83.5% of medical students and all examiners expressed satisfaction with virtual medical evaluation during this COVID pandemic. Our findings suggest that virtual conduction of practical annual medical exams through virtual video conferencing platform appears to be an optimal alternative during COVID pandemic.

Indian endocrine surgery websites are they comparable?

INTRODUCTION: In modern day surgical practice, patients and their relatives garner more knowledge through websites rather than direct interaction with the consultant physician. We aimed to assess whether Indian endocrine surgery websites matched with their counterparts abroad. MATERIALS & METHODS: We identified 60 endocrine surgery websites worldwide and 12 endocrine surgery websites maintained by trained endocrine surgeons from India. The website parameters, demographic data of the websites, rank, and other parameters were assessed using a professional website (www.Alexa.com). An endocrine surgeon along with a technical website advisor rated the content, presentation, and likes from a scale of 1-5 (1 minimum score and 5 maximum score). RESULTS: A total of 72 individual endocrine surgery websites, out of which 60 were from abroad and 12 were from India, were analyzed. A majority of foreign websites were ranked (43/60), whereas 2/12 Indian websites were ranked (P < 0.0001). Foreign websites had a better landscape profile. Except for pancreatic facts, which were significantly different (P = 0.006) between Indian and foreign websites, there was no significant difference in thyroid facts, parathyroid facts, adrenal facts, photographs, videos, postop advice, contact information, publications, and complications. CONCLUSION: Most parameters were comparable in both groups. Postoperative advice and complications were present in only a few websites. A well-designed endocrine surgery website can aid both the patient and the treating physician.

Persistent Elevation of Parathormone Levels after Surgery for Primary Hyperparathyroidism.

BACKGROUND: Persistent elevation of serum parathyroid hormone (PTH) despite normocalcemia have been documented in 8- 40% of patients after parathyroidectomy. We hereby report our experience from different centers across India to determine clinical significance of postoperatively elevated PTH levels and review relevant literature. METHODS: We conducted a retrospective case series study and reviewed all the patients who underwent surgery for primary hyperparathyroidism (PHPT) from April 2010 to January 2020. RESULTS: Total of 201 patients was diagnosed as PHPT. Out of available follow-up data of 180 patients, a total of 54 patients (30%) had persistently elevated PTH (PePTH) at 1 month. Patients with PePTH were older with higher preoperative serum calcium, iPTH, alkaline phosphatase and lower serum phosphate and 25-hydroxy vitamin D3 levels. Creatinine clearance was found to be significantly lower in patients with PePTH. Multiple linear regression analysis revealed that preoperative 25-OH D3 concentration, creatinine clearance and iPTH are the factors influencing persistent elevation of PTH levels. Significantly lower serum calcium and higher alkaline phosphatase levels were observed in PePTH patients with preoperative 25-OH D3 levels <20 ng/mL. Thirty patients at 6 months, 24 patients at 1 year, 18 patients at 2 years and 9 patients at 3 years had eucalcemic PTH elevation. Nine out of 126 (7%) patients with normal initial postoperative calcium and iPTH levels developed PePTH, with none culminating into recurrent hyperparathyroidism. CONCLUSION: Though the pathogenesis of such a phenomenon still remains to be elucidated, a multifactorial mechanism appears to play a role.

Regression of Ophthalmopathic Exophthalmos in Graves' Disease After Total Thyroidectomy: a Prospective Study of a Surgical Series.

Autoimmune ophthalmopathy is one of the salient clinical features associated with Graves' disease. Exophthalmos is one of the commonest manifestations of Graves' associated ophthalmopathy. It is reported to regress after thyroidectomy favourably compared to radioiodine or antithyroid drug therapy. In this context, we present our experience based on a surgical series of Graves' disease. This is a prospective study of 15 patients of Graves' disease associated with ophthalmopathic exophthalmos. Preoperative and monthly postoperative evaluation of exophthalmos was done with Hertel's exophthalmometer, apart from documenting lid, extra-ocular muscle and orbital involvement. The minimum follow-up of the cohort was 12 months. The female to male ratio was 12:3 and the mean age of the subjects was 33.4 years (18-55). Exophthalmos was bilateral in 13 and unilateral in 2 patients. All the 15 patients underwent total thyroidectomy without any major morbidity. Exophthalmos regressed in 12 patients at a mean follow-up of 15.6 ± 6.4 months (14-38) and was static in 3. None of the cases had worsened ophthalmopathy at the final follow-up. Mean regression of exophthalmos was 2.1 mm (1-5). The regression was statistically significant at P value = 0.035. Surgery has a positive impact on the regression of ophthalmopathic exophthalmos associated with Graves' disease.

A Technique of Single-Incision Laparoscopic Appendectomy Using Conventional Multiport Laparoscopic Instruments (SILACI): Preliminary Experience of 32 Cases.

Single-incision laparoscopic appendectomy seeks to further reduce the trauma of parietal access to abdomen. The challenge of this surgery lies in the compromised ergonomics of instrument movement and triangulation. In this context, a feasibility study of an operative technique of single-incision laparoscopic appendectomy with technical modifications was conducted. This prospective study was carried out in tertiary care teaching institute of a semi-urban area in South India over a period of 1 year from June 2010 to May 2011. Thirty-two patients of acute appendicitis were included in this study. Mean operative time was 56.7 min (40-85 min). Mean age of subjects was 41 ± 15 years. M/F ratio was 2:1. There was no significant peri-operative morbidity or mortality. Mean follow-up period was 8 months. We propose that this technique of single-incision laparoscopic appendectomy using conventional multiport laparoscopic instruments (SILACI) is feasible, safe, and cost-effective.

Resection of Unresectable Stage IVB Thyroid Cancer Encasing the Carotid Artery.

Stage IVB thyroid cancer includes carotid encasement or infiltration of the prevertebral fascia and mediastinal vessels. Stage IVB disease is considered unresectable due to grave consequences of attempting resection. We report a rare case of carotid artery engulfment being resected uneventfully without carotid resection.

Salient anatomical landmarks of thyroid and their practical significance in thyroid surgery: a pictorial review of thyroid surgical anatomy (revisited).

Thyroid surgery is a prototype of operations requiring thorough knowledge of surgical anatomy. There are many vital and delicate anatomical structures such as recurrent laryngeal nerve, superior laryngeal nerve, parathyroid glands, and distinct fascial planes surrounding the thyroid gland. A protean range of pathologies such as goiter, nodules, thyroiditis, and malignancy distort or alter the location and course of these structures and planes. The distinct vascular supply and high vascularity of thyroid region challenges the surgeon's expertise. Several pathologies like malignancy, multinodularity, toxicity, and retrosternal extension further compounds this vascular aspect of surgery. Several structures of embryological importance such as pyramidal lobe, tubercle of Zuckerkandl, and ligament of Berry have decisive clinical implications in the surgical management of thyroid disorders. Surgeons attempting thyroidectomy need to have thorough knowledge of embryology and surgical anatomy of the thyroid gland. In this context, we highlight through a pictorial assay the embryological and anatomical aspects of the thyroid gland emphasizing on their clinical and surgical importance.

Criteria for Laparoscopic Advanced Surgery in Semi-Equipped Setup (CLASS): Feasibility Study Based on Institutional Experience.

Laparoscopic and Minimally invasive techniques have become a routine practice for various surgical disorders in present times. Though, advanced laparoscopic procedures are feasible they are largely restricted to fewer centers due to lack of advanced instrumentation, finances and expertise at most of them. In this context, we conducted a feasibility study to evolve definite criteria for performing advanced laparoscopic surgeries in resource restricted set-ups. We present our experience with 25 cases of advanced laparoscopic procedures using conventional laparoscopic instruments. We evaluated the clinico-investigative profile and operative details of all the patients. We classified the surgical expertise, laparoscopic instrumentation, surgical set ups and patient factors systematically to evolve the criteria for feasibility of advanced laparoscopicsurgery. Out of the 22 eligible patients for the study, various laparoscopic surgeries performed were - Fundoplication (4), Cystogastrostomy (3), Endoscopic thyroidectomy (7), Thoracoscopic Thyroidectomy (2), Adrenalectomy (5) and Retroperitoneal paraganglioma excision (1). There was no mortality and two morbidities in the form of hypercarbia and a tracheo-cutaneous fistula in 2 cases of endoscopic thyroidectomy. According to the criteria, we propose our surgical set up falls in to Grade 3, for which this criteria fits in. This study demonstrates the feasibility of advanced laparoscopic procedures in semi-equipped set-up, preferably by employing institute specific criteria of CLASS.

Operative technique of endoscopic thyroidectomy: a narration of general principles.

Endoscopic thyroidectomy is fast becoming a reality with increasing experience in endocrine surgery. Many techniques of minimally invasive video-assisted thyroidectomy through cervical and extra-cervical routes such as chest wall, transaxillary, trans-oral, post-auricular, trans-luminal approach have been attempted. At present anterior chest wall or trans-axillary routes are favourite extra-cervical routes. In this context, we describe our operative technique of endoscopic thyroidectomy through chest wall to highlight the surgical steps of practical importance.

Large cystic renal cell carcinoma leading to diagnostic dilemma: a case report.

Large cystic renal tumours can be confused with hepatic lesions even on crosssectional imaging. Careful clinical, sonographic and imaging analysis is needed for establishing correct diagnosis. We report a case of papillary cystic renal carcinoma in a 60 year old man, which was confused with amoebic liver abcess and was initially drained. Subsequent recurrence of symptoms prompted us to re-evaluate the case and repeat sonography confirmed the extrahepatic origin of mass based on simple observation that the liver and mass were moving separately on inspiration. Later guided aspiration from solid component of the mass confirmed the diagnosis as renal cell carcinoma. He was successfully treated with radical nephrectomy with uneventful post-operative recovery.

A Unusual Case of Complicated Zenker's Diverticulum.

We report the surgical management of a case of Zenker's diverticulum in a 64 year old man, complicated by metallic nail penetration and surgical scarring due to previous surgery for cervical vertebral trauma.

Surgical Indications for Goiter with Background Hashimoto's Thyroiditis: Institutional Experience.

Hashimoto's thyroiditis (HT) is usually treated conservatively with thyroxine. Its incidence is higher in Iodine sufficient areas and may require surgery for associated nodularity or complications. A retrospective study on surgically treated HT cases was conducted in a teritiary care teaching hospital in an Iodine sufficient area of Southern India. 34 cases of goiter with associated HT, who underwent thyroidectomy between 2007 and 2010 were analysed for indications of surgery. Minimum follow-up period was 6 months. F:M ratio was 31:3 with mean age of 41.3 years. Goiter was diffuse in 41% and nodular in 59%. 16 (47%) of patients were hypothyroid. Autoimmune association was found in 35%. Commonest surgery done was hemithyroidectomy in 12 (35%) followed by subtotal thyroidectomy in 10 cases. Most frequent indication for surgery was nodular goiter in 12 (35%) followed by associated malignancy, persistent goiter, pressure symptoms and painful thyroiditis. Histopathology showed diffuse HT alone in 12 (35%) and rest of the cases had HT as a component synchronous with other pathologies. Associated pathologies were benign multinodular goiter (6), colloid nodule (6), papillary cancer (5), follicular adenoma (4), cyst (1). Surgery for HT is primarily indicated for associated pathologies like dominant nodule, suspicious or proven malignancy, persistent goiter, painful thyroiditis, pressure symptoms and rarely for HT perse. Rate of surgery for HT associated goiter appears to be higher in Iodine sufficient areas, the cause of which needs to be studied further.

Pipestem carotids as a marker of vascular insult in graves' disease.

We present a case of Graves' disease with a image of plain radiograph of neck showing bilateral carotid calcifications and briefly discuss the pathophysiology of vascular calcification in Graves' disease.

Combined Cervical and Video-assisted Thoracoscopic Thyroidectomy (CAVATT): A Simplified and Innovative Approach for Goiter with Posterior Mediastinal Extension.

We report a case of benign multinodular goiter with right sided posterior mediastinal extension managed by a simplified anaesthetic and surgical protocol. Single lumen endotracheal tube was used for intubation. Access to mediastinum was obtained by 2 working ports in 2nd and 4th intercostal spaces. Mediastinal extension is dissected thoracoscopically and delivered cervically. Post operative course was uneventful with no pulmonary and surgical morbidity.

Phyllodes tumour of the breast: clinicopathological analysis of recurrent vs. non-recurrent cases.

BACKGROUND: The aim of this study was to present our experience of dealing with patients with phyllodes tumours (PT) and to correlate the risk of local recurrence with different clinicopathological factors. MATERIALS AND METHODS: This was a retrospective study of 25 women with PT, who were managed at our centre between 1991 and 2005. All the available clinical, operative and histological details were retrieved. The median follow-up period was 4 years (range, 1-9 years). Various clinicopathological features were compared between patients who suffered from recurrent tumours to those not experiencing any recurrence. RESULTS: The mean age of the patients was 45 +/- 7 years and the mean duration of symptoms was 30 +/- 10 months. The mean tumour diameter was 10.5 +/- 5 cm. Preoperative diagnosis with fine needle aspiration cytology could be made in 72% of cases. Overall, 39 surgical procedures were performed (14 of which were performed for recurrences). The histology report was benign, borderline and malignant PT in 28%, 20% and 52% of cases respectively. Recurrent tumours were observed in 36% of patients and 16% experienced more than one recurrence. Two patients with malignant PT developed metastases in the follow-up period, and one of them died. Except for the extent of primary surgery, there were no significant differences in other clinicopathological factors between the recurrent and non-recurrent groups. Patients who had wide local excision (WLE) and procedures of greater magnitudes as primary procedures did not experience recurrence (p = 0.008). However, when WLE was performed for recurrent tumours, 50% of patients suffered from recurrence. CONCLUSION: WLE seems to be the initial procedure of choice for all PTs, and mastectomy for recurrent tumours. Further studies are needed to define the role of adjuvant therapies.