Efficacy of simvastatin in reducing postoperative adhesions after thyroidectomy: an experimental study.

BACKGROUND: We aimed to investigate whether simvastatin had any impact on the prevention of adhesion formation after thyroidectomy in a rat model. METHODS: This study was performed in 66 Wistar albino rats randomized into three experimental groups. A right hemithyroidectomy was carried out in all the rats. Simvastatin was administered locally at a dose of 0.5 mg/kg and 0.8 mg/kg. Control rats received a saline solution only. Changes during the 1st week, 1st month and 3rd month were evaluated. Efficacy of the treatment was assessed by using a scoring system. RESULTS: The severity of adhesions in low-dose simvastatin group was significantly less than the control and high-dose groups during the 1st and 3rd month (p < .05). In addition, adhesions were less in the high dose group during the 3rd month, when compared to the control group (p < .05). Moreover, fibrosis and fibroblast scores, which represent adhesions, were significantly lower in low-dose and high-dose groups at 3rd month, compared to controls (p < .05). CONCLUSIONS: We investigated the influence of simvastatin application on post-thyroidectomy adhesion formation in rats. Whether adhesions, causing technical difficulties during neck redo surgery, can be reduced by the use of simvastatin in human, needs to be studied.

How informed are endocrine surgery patients about the risks of surgery after approving an informed consent?

OBJECTIVE: The aim is to evaluate if patients reach the level of competence that enables them to make the best decision for themselves with oral and written informed consent process that is legally valid. MATERIAL AND METHODS: This study included 62 patients who applied to Ege University Hospital Department of General Surgery Endocrine Surgery Clinics and in whom oral and written informed consent was obtained by a surgeon. Patients who were willing to participate in the study were asked to fill in a questionnaire containing questions regarding the concept of consent. RESULTS: Seventy-one percent of patients were female and 29% were male, with a mean age of 50.4±17.9 years. Six percent of patients were illiterate, 51.6% had primary education and 16.1% were college graduates. One in every two patients stated that they have never heard of informed consent concept before, 16% stated that they signed the consent without reading it. Among these patients, 88% reported that they trusted the physician and did not bother reading because they have already been verbally informed. Verbal briefing by the doctor was detected as 92%. Similarly, 91% of the patients reported that the time allocated to read and fill-in the form was enough. CONCLUSION: Informing is not composed simply of conveying information, but also to elevate patients to a proficiency level where they could decide with their best interest. It is thought that the results obtained in this study might guide studies to improve the quality of information in patients undergoing surgery.

Thyroid cartilage needle vs. endotracheal tube electrodes in EBSLN monitoring during thyroidectomy.

During thyroidectomy, both needle electrodes (NE) and endotracheal tube electrodes (ETE) can be used. Incomplete contact of the endotracheal tube electrode with the vocal cords, endotracheal tube electrode may hinder an optimal outcome and even result in an inability to obtain an electromyography wave while neuromonitoring the external branch of the superior laryngeal nerve (EBSLN). There is no study that compares NE and ETE for EBSLN monitoring. Therefore, this study compares NE and ETE recordings during EBSLN monitoring. Twenty-six consecutive patients undergoing total thyroidectomy were included in this study. Intraoperative neuromonitoring was performed simultaneously with both NEs and ETEs. Pre-resection (V1, R1, and S1) and post-resection (V2, R2, and S2) amplitudes and latencies were recorded for both types of electrodes. The Mann-Whitney U test was used for statistical analysis. Twenty-one women and five men were included, and 52 nerves at risk were evaluated. The mean amplitudes for right S1 (314 vs. 168 µV, p = 0.009) and right S2 (428 vs. 161 µV, p: 0.001) and for left S1 (346 vs. 229 µV, p: 0.017) and left S2 (413 vs. 229 µV, p: 0.009) were statistically higher for the NE group. All amplitudes obtained using NEs, except on the left for V1, R1, V2, and R2, were statistically higher than those obtained using ETEs. There was no loss of signal or vocal cord palsy in the patients. There were no needle-related complications. EBSLN monitoring using NE is a safe alternative to ETE. With NE, higher amplitudes were obtained. Level of evidence: Level 3.

What should be done in thyroid nodules less than two centimeters, ultrasonographically suspicious and cytologically benign?

OBJECTIVE: Although fine needle aspiration biopsy has a high sensitivity in thyroid nodule assessment, ultrasonography findings should not be underestimated. With this study, we aimed to evaluate cytologically benign nodules smaller than two centimeters, where ultrasonography findings were suspicious. MATERIAL AND METHODS: Thirty-one patients undergoing thyroidectomy between January 2009 and January 2013 were included in this retrospectively designed study. Thyroid ultrasonography and thyroid fine needle aspiration biopsy (FNAB) results were evaluated. Ultrasonographically, all patients had multinodular tissue formation and nodules had at least one of the suspicious features (nodules with hypoechogenicity, irregular margins, absence of halo, taller-than-wide, increased vascularity and microcalcifications). Maximum size of the nodules was 2 cm. Thyroidectomy was performed in this ultrasonographically suspicious, but cytologically benign group due to clinical suspicion, cosmetic reasons or patient preference. RESULTS: All patients underwent a total thyroidectomy. The group consisted of 27 female and 4 male patients, with a mean age of 49.5 years. According to the final pathology reports, there were 13 (41.9%) multinodular goiters, 2 (6.4%) follicular adenomas, 1 (3.2%) Hashimoto's thyroiditis and 15 (48.3%) thyroid cancers. Patients with cancer had at least two suspicious ultrasound findings. Except five patients with papillary microcarcinoma, cancer was diagnosed in ultrasonographically suspicious nodules in all patients. The percentage of patients with benign FNAB results, but with at least two suspicious ultrasound findings of malignancy in the biopsied nodules, was 32.2%. CONCLUSION: FNAB remains to be the gold standard in the management of ultrasonographically suspicious nodules smaller than 2 centimeters. Nevertheless, due to its high sensitivity, in case of presence of suspicious features on ultrasonography, we believe that thyroidectomy should be a treatment option if there is a clinical suspicion and the patient carries at least two suspicious ultrasonography findings.

The importance of staging systems for the determination of prognosis of well-differentiated thyroid cancer.

OBJECTIVE: In this study, we aimed to determine the significance of the staging systems (EORTC, De Groot, MACIS, and TNM) on the prognosis of well-differentiated thyroid cancer patients who underwent surgery in our clinics. MATERIAL AND METHODS: This retrospective study included 181 patients who were operated between December 1995-December 2007, with a diagnosis of thyroid cancer. In order to obtain data related to cancer staging, a computer program for PDA was developed to facilitate parameter recording. Survival analysis was performed. The findings were compared to the predicted rates by the staging systems. RESULTS: According to the De Groot staging system, stage 1 and stage 2 patients' results were compatible, but stage 3 and 4 patients' results were different (stage 3; 87% versus 66.6%, stage 4; 35% versus 100%, p=0.04). In the MACIS staging system, 20-year survival rates are determined and comparison should not be made due to insufficient follow-up period in this study. When compared to the EORTC staging system, stage 3 and stage 4 patients' results were determined different (stage 3; 51% versus 100%, stage 4; 33% versus 50%, p=0.02). The most consistent results in terms of prognosis was determined in comparison with the TNM staging system (stage 1; 100% versus 97.8%, stage 4; 45.3% versus 50%). CONCLUSION: Many classification systems are proposed for well-differentiated thyroid cancer, to predict the behavior of the tumor. In this study, we concluded that for determination of prognosis in well-differentiated thyroid cancer, the TNM staging system could best predict prognosis consistent with clinical findings.

Evaluation of public's perception of scar cosmesis after thyroidectomy: results of a survey of Turkish versus South Korean individuals.

Purpose: Visible scars on the neck caused by thyroid surgery give rise to significant aesthetic, functional, and psychosocial problems. The objective of this study is to comparatively investigate the public perception of neck scar cosmesis in Turkish and South Korean populations. Methods: This survey was prepared to collect participants' demographic and socioeconomic data and determine their perception of scar cosmesis on the neck and consisted of 15 questions. One thousand thirty-nine individuals who did not undergo thyroid surgery completed the survey. The P-values of <0.05 were deemed to indicate statistical significance. Results: There were 1,039 respondents, of whom 525 (50.5%) were Turkish and 514 (49.5%) were South Korean. South Korean respondents stated that they would be significantly more uncomfortable with the thought of having a scar due to thyroid surgery, compared to the Turkish respondents (P < 0.001). The South Korean respondents stated that they would be significantly more concerned about the scar's length, thickness, and darkening color, compared to the Turkish respondents (P < 0.001 for all cases). Conclusion: Patients' expectations, which are affected by various sociodemographic factors and cultural characteristics, are as important as the medical condition when deciding on the type of thyroid surgery. The study findings clearly indicated that the South Korean population would be significantly more uncomfortable with having a scar on the neck, compared to the Turkish population. Therefore, in selected cases, a scarless thyroidectomy approach, such as transoral endoscopic thyroidectomy, vestibular approach may be preferable for societies like South Korea.

Intraoperative freehand SPECT as an alternative imaging technique for use in radioguided parathyroidectomy.

Freehand single photon emission computed tomography (fhSPECT) is a technique that is used to monitor body's radioactivity intraoperatively. Accordingly, in this study, the feasibility of using fhSPECT for intraoperative 3D mapping in radioguided parathyroidectomy has been assessed. Patients, who were diagnosed with primary hyperparathyroidism consecutively, were scanned intraoperatively using fhSPECT to locate parathyroid adenomas before surgical procedure. The fhSPECT images were acquired intraoperatively using a declipse®SPECT device (SurgicEyeTM). The fhSPECT protocol could not be completed due to the technical problems in one patient. Parathyroid adenoma was located in the first patient with no lateral deviation. Nevertheless, a deviation of 8 mm was detected in the depth of the parathyroid adenoma, which is the distance of parathyroid adenoma from the skin. A 20 mm lateral deviation and a 10 mm deviation in depth were detected in the second patient. In the third patient, as was the case in the first patient, parathyroid adenoma was located with no lateral deviation. However, there was a 15 mm deviation in the depth of the parathyroid adenoma. A 5 mm lateral deviation was detected in the fourth patient yet with no deviation in the depth of parathyroid adenoma. Finally, neither lateral nor vertical deviation was detected in fifth patient. Based on the findings of this study, it was concluded that the fhSPECT technology can be helpful to a certain degree in locating the parathyroid adenoma. However, further studies are needed to support the findings of this preliminary study.

Life-threatening abdominal injury during a soccer game: a rare clinical case.

Soccer (football) is a popular sport worldwide and can result in severe abdominal injuries. Nevertheless, the necessity of surgical intervention for abdominal organ injuries has been reported rarely. We report a case who was injured during a soccer game who underwent abdominal surgery. Distal subtotal pancreatectomy, splenectomy, cholecystectomy, and choledochotomy + T-tube drainage were performed. He was discharged on the postoperative seventh day without any complication.

The use of thyroid cartilage needle electrodes in intraoperative neuromonitoring during thyroidectomy: Case-control study.

BACKGROUND: The most commonly used recording-side method in intraoperative neural monitoring (IONM) detects the stimulus with the endotracheal tube surface (ETS) electrodes placed in the endotracheal tube during thyroidectomy. The thyroid cartilage needle (TCN) electrode method is an alternative recording-side system in IONM. This study compared two recording-side techniques in IONM. METHODS: Data were retrospectively analyzed from 885 patients who underwent thyroidectomy between January 2012 and December 2020, with 110 ETS and 775 TCN electrodes. Patients' demographics, diagnosis, surgery type, and amplitudes of all stimulation steps were compared. Costs per patient were calculated. RESULTS: No significant differences were found in the demographic data between the two groups. All amplitudes were higher in the IONM system where TCN electrodes were used than that with ETS electrodes (all stimulation steps p < 0.001, except left-V2 p = 0.007). Further, TCN electrodes were 20 times cheaper than the ETS electrodes. CONCLUSION: TCN electrodes are an inexpensive and efficient alternative to ETS electrodes in IONM.

Patient Eligibility for Transoral Endoscopic Thyroidectomy Vestibular Approach in an Endemic Region.

OBJECTIVE: Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a scarless method that enables thyroidectomyusing natural orifice of the body. The opinion which is even common among TOETVA performing surgeons is that this surgery involves a small percentage of thyroidectomy applied patients. In this study, based on the currently accepted exclusion criteria, we aimed to determine what percentage of patients, who underwent thyroidectomy in an endemic area are actually suitable for TOETVA. METHODS: Between January 2017 and December 2019, 1197 consecutive patients who underwent surgery for thyroid pathology in our clinic were analyzed retrospectively. Pre-operative evaluations were made according to the current exclusion criteria and as a result, patients with no previous neck surgery, no history of radiotherapy, no retrosternal thyroid extension, and none lymph node dissection operation been made and whose thyroid gland diameter is <10 cm and gland volume is not more than 45 ml, malignant nodule diameter is <2 cm, and benign nodule diameter is <4 cm are involved to this study by being considered appropriate for TOETVA procedure. RESULTS: According to the criteria, 513 patients (42.8%) were found suitable for TOETVA. A total of 421 (82%) of these patients were female and 92 (18%) were male. The mean age was 46.2±13.2. A total of 192 (37%) of these patients were operated due to the benign reasons, and 321 (63%) of these patients operated due to the malignancy or suspicion of malignancy. Average nodule size was 1.9 cm, and the average thyroid volume was 23.8 ml among benign patients. Whereas among malignant patients, the average nodule size was 1.7 cm and the average thyroid volume was 21.8 ml. A total of 462 (90.1%) of the patients were applied to the total thyroidectomy and 51 (9.9%) of the patients were applied to the hemithyroidectomy. In the same period, 29 patients operated through TOETVA and 4 patients operated through bilateral axillary breast approach thyroidectomy. When the final pathology, results of the patients were examined, papillary thyroid carcinoma was seen in 301 (58.7%) patients, benign pathologies were seen in 192 (37.4%) patients, and 20 (3.9%) patients were diagnosed with other pathologies (follicular thyroid carcinoma, poorly differentiated carcinoma and Hürthle cell neoplasia, etc.). CONCLUSION: Although "patient willingness" factor could not be included in the study, TOETVA eligible patient repository is wider contrary to popular belief. In our humble opinion, TOETVA method is going to pursue its spread and become a part of the routine surgical training session due to its effectiveness in terms of credibility in today's world where cosmetic concerns gradually gain prominence.

Comparison of Monopolar and Bipolar Stimulator Probes for Intraoperative Nerve Mapping During Thyroidectomy: A Prospective Study.

OBJECTIVES/HYPOTHESIS: During intraoperative neuromonitoring in thyroid surgery, two different kinds of stimulator probes, monopolar and bipolar, are commonly used to stimulate the laryngeal nerves. We explore the unique characteristics of both of these probes as they relate to intraoperative laryngeal nerve mapping. METHODS: Twenty-one patients undergoing neuromonitored thyroidectomy by a single surgeon were enrolled. Electromyography (EMG) amplitude and latency measurements were prospectively recorded concurrently from 1 mA stimulation of vagus nerve (VN) and inferior/superior recurrent laryngeal nerve before (with and without fascia) and after thyroid resection using bipolar and monopolar stimulator probes. RESULTS: Significantly higher amplitudes were obtained with monopolar stimulator probes as compared to bipolar probes, in several stimulation scenarios such as at right VN pre-resection (carotid sheath intact), right VN pre-resection (carotid sheath dissected), right VN post-resection and left VN (carotid sheath dissected). No significant differences were found between amplitudes and latency values in all other stimulation scenarios. CONCLUSIONS: According to this study, both probes are reliable and safe for neural mapping. The kind of probe used during neural monitoring is based on surgical situations and surgeon preference. LEVEL OF EVIDENCE: 3 (According to Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence) Laryngoscope, 131:E2718-E2726, 2021.

Influence of rocuronium on achieving optimal vagal stimulation during intraoperative nerve monitoring in thyroid surgery.

BACKGROUND: In the present study we determine the feasibility of intraoperative neuromonitoring following the administration of a nondepolarizing neuromuscular blocking agent during thyroid operations, as well as the influence of rocuronium on the achievement of optimal vagal stimulation during intraoperative neuromonitoring in thyroid surgery. We further investigate whether accelerometry is a reliable approach to obtaining an ipsilateral vagus signal prior to recurrent laryngeal nerve dissection. METHODS: Included in the study were 61 thyroidectomized patients whose demographic data, indications, type of surgery, vagus, and recurrent nerve values before and after resection were obtained. We created five groups of patients based on the twitch values recorded during ipsilateral vagus stimulation prior to the recurrent laryngeal nerve dissection: (1) <10%, (2) 11-25%, (3) 26-50%, (4) 51-75% and (5) >75%. RESULTS: The average electromyography amplitudes of the vagus nerve prior to the determination of the recurrent laryngeal nerve for each group were 552 µV, 463 µV, 543 µV, 513 µV and 551 µV, respectively. No difference between the groups was observed in this regard (p > 0.05). CONCLUSION: It can be expected that as soon as the effects of neuromuscular blockers on the peripheral muscles begin to abate, it will be possible to obtain the ipsilateral vagus signal prior to recurrent laryngeal nerve dissection at the desired levels. It can be concluded from this study that accelerometry using the pollicis muscle is an unreliable tool for the interpretation of the proper electromyography signals of the vagus nerve prior to the determination of the recurrent laryngeal nerve.

Objective analysis of swallowing and functional voice outcomes after thyroidectomy: A prospective cohort study.

BACKGROUND: Impairment in voice and swallowing functions are common after thyroidectomy. We aimed to evaluate the objective functional voice and swallowing outcomes in a series of patients undergoing thyroidectomy. METHODS: A total of 43 consenting patients who underwent thyroidectomy were prospectively recruited. Subjective evaluation of swallowing was assessed with 'Swallowing Impairment Score' and 'MD Anderson Dysphagia Inventory'. Fiberoptic endoscopic evaluation of swallowing (FEES) was applied for objective evaluation. Also, functional oral intake scale (FOIS) and functional outcome swallowing scale (FOSS) were used for swallowing assessment. Voice evaluation was assessed with videostrobolaryngoscopy (VSL) and 'The Multi-Dimensional Voice Program (MDVP)' was used for capturing and analyzing the voice samples. All evaluations were performed preoperatively and on 1st day, 2nd week and 6th months postoperatively. This study is registered with ClinicalTrials.gov, number NCT03436186. RESULTS: According to the objective analyses there was no difference between pre- and post-operative scores for the intake of fluid and thickened liquid food. There was a significant difference regarding light and moderate residual accumulation in solid food intake (p = 0.013). FOSS showed no difference, but FOIS revealed specific functional limitation (p = 0.034). Subjective data showed no correlation with objective findings (p > 0.05). Regarding voice evaluation, a significant increase was observed in standard deviation of average fundamental frequency and degree of subharmonics (p < 0.01). CONCLUSION: Even in the absence of recurrent laryngeal nerve injury, subjective and objective swallowing and voice alterations do occur after thyroidectomy.

Clinical behavior and outcome of papillary T1 thyroid cancers: South Korea vs. Turkey vs. Colombia in a cohort study analyzing oncological outcomes.

BACKGROUND/PURPOSE: There has not been an international multicentric study to examine the relationship between thyroid cancer clinical outcomes and geographic location for South Korea, Colombia, and Turkey, whereas thyroid cancer is amongst the highest three cancer types seen in South Korea and Turkey. The aim of the study was to assess regional differences of T1 papillary thyroid cancer outcomes in Korea, Turkey and Colombia. METHODS: This is an observational non-randomized study. A total of 2720 patients who have been operated for T1 papillary thyroid cancer between 2011 and 2014 and are on routine follow-up have been recruited. The mean follow-up was 46.4 ± 10.7 months. Data were collected in a commonly used database and analyses were conducted. RESULTS: Patients participated in South Korea (88.2%), Turkey (9.1%) and Colombia (2.6%). Eighty percent were female. Female dominance tended to be higher in Colombia (p = 0.01). Mean age at diagnosis was 45.2 years. There was no mortality. Recurrence tended to be higher in Colombia (p < 0.001). Moreover, statistical analysis revealed differences among patients regarding symptoms (p < 0.001), family history (p < 0.001), euthyroidism (p < 0.001), anti-Tg and/or anti-TPO positivity (p < 0.001), FNAB results (p < 0.001), type of resection (p < 0.001), prophylactic central node dissection (p < 0.001), tumor size (p < 0.001), multifocality (p < 0.001), bilaterality (p < 0.001), tumor subtype (p < 0.001) and radioactive iodine treatment (p < 0.01). CONCLUSION: Thyroid cancer is becoming more commonly diagnosed worldwide. This international multicentric study has identified differences in disease presentation, treatment approaches and outcome, which need to be investigated, especially by increasing the number of participating countries. Future comparisons will facilitate developments in treatment for the benefit of patient outcomes.

The interaction of oxidative stress response with cytokines in the thyrotoxic rat: is there a link?

Oxidative stress is regarded as a pathogenic factor in hyperthyroidism. Our purpose was to determine the relationship between the oxidative stress and the inflammatory cytokines and to investigate how melatonin affects oxidative damage and cytokine response in thyrotoxic rats. Twenty-one rats were divided into three groups. Group A served as negative controls. Group B had untreated thyrotoxicosis, and Group C received melatonin. Serum malondialdehyde (MDA), glutathione (GSH), glutathione reductase (GR), glutathione peroxidase (GPx), and nitric oxide derivates (NO*x), and plasma IL-6, IL-10, and TNF-alpha were measured. MDA, GSH, NO*x, IL-10, and TNF-alpha levels increased after L-thyroxine induction. An inhibition of triiodothyronine and thyroxine was detected, as a result of melatonin administration. MDA, GSH, and NO*x levels were also affected by melatonin. Lowest TNF-alpha levels were observed in Group C. This study demonstrates that oxidative stress is related to cytokine response in the thyrotoxic rat. Melatonin treatment suppresses the hyperthyroidism-induced oxidative damage as well as TNF-alpha response.

Traumatic diaphragmatic rupture: look to see.

OBJECTIVE: Traumatic diaphragmatic rupture (TDR) is a rare but potentially life threatening clinical entity with a high incidence of associated injuries. In this article, our experience with this challenging diagnosis is presented. METHODS: In this study, a total of 68 patients with TDR, were operated in our center between July 1994 and September 2005. Study group was analyzed retrospectively. The etiological factors, management and outcomes were discussed. RESULTS: The mean age was 32.9 years with a female to male ratio of 9/59. TDR was right-sided in 16.2% (n=11) and left-sided in 83.8% (n=57). The cause of the rupture was penetrating trauma in 51 (75%), and blunt trauma in 17 (25%). Only three patients (4.4%) had late diagnosis. Associated injuries were seen in 91% (n=62) of the patients. The most common used incision was a laparotomy incision (89.6%). Morbidity and mortality were encountered in 13.1% (n=9) and 16.2% (n=11) patients, respectively. CONCLUSIONS: Although rare, diaphragmatic rupture must be suspected in any patient with thoracoabdominal injury. Early diagnosis of TDR is sometimes difficult and depends on a high index of suspicion. Surgical repair is necessary even for small tears. The most common approach is the transabdominal approach, which allows a complete exploration of the abdominal organs for associated injuries. The transthoracic approach might be used in most cases with latent diaphragmatic rupture.

The recurrent laryngeal nerve and the inferior thyroid artery--anatomical variations during surgery.

BACKGROUND AND AIMS: Recognition of variations of the inferior laryngeal nerve is essential. We aimed to investigate the relationship of the inferior laryngeal nerve with the inferior thyroid artery. MATERIALS AND METHODS: A study was undertaken between August 2005 and August 2006. A total of 253 adult patients undergoing thyroid surgery were included in this prospective, non-randomized study. Both sides of the thyroid gland were considered separately. RESULTS: Sixteen variations of the nerve were clarified. In the most observed variation, the nerve was deep to the artery. Two and three nervous branches were seen in 22.5% and 1.6% of the patients, respectively. Bifurcation of the nerve was mostly observed on the left side. No non-recurrent laryngeal nerve was found. CONCLUSION: To avoid the risk of nerve damage during thyroid surgery, a good knowledge of the variations of the inferior laryngeal nerve is essential. This is important to achieve an undisturbed quality of life for the thyroid patient.

Primary squamous cell carcinoma of the thyroid: report of three cases.

We report three cases of squamous cell carcinoma of the thyroid, which is an unusual malignant tumor that needs to be distinguished from other thyroid pathologies due to its aggressive behaviour. Three men, with an average of 63 years old, presented with progressive enlargement in the neck, hoarse voice or weight loss. Physical and radiological examinations revealed clues where malignancy was suspected and surgical resections were performed. Histopathological examination of the specimens was diagnosed as squamous cell carcinoma. Proper workup excluded the possibility of any primary site of SCC other than the thyroid. All patients died within 5 months. Adjuvant therapy evaluation is still inconclusive. Complete surgical resection still remains the primary choice for cure. We believe that radical resection with clear surgical margins followed by adjuvant chemo-radiation therapy is a curative strategy for achieving any chance of long-term survival.

Surgeon's view on the limitations of left-handedness during endoscopic surgery.

BACKGROUND: The influence of endoscopic surgery on left-handedness is unclear. The aim of this study was to investigate the role of left-handedness during endoscopic surgery. MATERIALS AND METHODS: A survey distributed during the 15th Congress of the Turkish Society of Surgery, held in 2006, was conducted to 194 participants. The survey was focused on hand preference and endoscopic surgery. Besides demographic data and use of endoscopy, lateral predominance, questions related to surgical performance (open and endoscopic), training support during residency, and operating room experiences during endoscopic surgery were assessed. RESULTS: The laterality preference in performing surgery was left in 9.3% (n = 18). Almost 50% of the left-handed surgeons believed that endoscopic surgery needs to be modified for the left-handed endoscopic surgeon, although 66% reported they had no difficulty while using endoscopic instruments and did not need any modification during surgical endoscopy. Over 86% of all surgeons reported that laterality had no importance for them if they were a patient undergoing endoscopic surgery, while 14% of surgeons refused to be operated on by a left-handed surgeon. CONCLUSION: Endoscopic surgery has impact on laterality-related comfort, and technical modifications are warranted for left-handed surgeons. Further research is needed to address questions related to hand dominance in surgical endoscopic skill performance that allows more comprehensive conclusions.

Perioperative management of Sneddon syndrome during thyroidectomy.

The perioperative management of an adult woman with Sneddon syndrome is presented. This syndrome is characterized by vasculopathy, hypercoagulable state, ischemic cerebral events, livedo reticularis, heart valve disease, and renal insufficiency. During surgery in these patients, the balance between bleeding and thrombosis requires rapid diagnostic information for therapeutic decisions. Thrombelastographic analysis may be a valuable tool to use in monitoring these patients.