Mastery in Endocrine Surgery.

The IAES is critical for surgeons who wish to have a high-impact career, that is, a career affecting the health of strangers. The IAES is a platform designed for exposure to the multiplicity of approaches to patients with endocrine surgical problems. Our international membership shares its knowledge and experience freely, educating one another about our varied contexts of care, and range of solutions. Our membership model supports and encourages participation from a diverse assortment of sites. The IAES is the intersection of the various national and continental echo-chambers of our groups organized inside of their prevailing paradigms where most participants practice along similar principles and care frameworks. This professional association is our chance to understand what works in other systems, so that we have that information available to us to apply in our home system. The IAES experience is indispensable in creating mastery in endocrine surgery.

[EFFICACY OF WELDING TECHNOLOGY AS A PRINCIPAL METHOD OF DISSECTION AND HEMOSTASIS IN ENDOCRINAL SURGERY].

Today in the clinic all surgical interventions on endocrinal organs are conducted, using welding technology. Comparative analysis of the operative interventions efficacy, performed applying a standard method (control group) and using welding technology (the main group), was conducted. Performance of operations, using electric welding technologies have permitted to reduce the operative intervention duration by 20 - 30%, the blood loss volume--by 30 - 50%, a postoperative pain syndrome severity and the analgetics expense--by 20%, a postoperative stationary treatment duration--by 1-2 days.

Frecuencia de Patologías Tiroideas con Tratamiento Quirúrgico / Frequency of Thyroid Diseases with Surgical Treatment

Introducción: La cirugía desempeña un papel fundamental en el tratamiento de las afecciones de la glándula tiroides. Tener noción de la frecuencia real de sus diferentes patologías en la población a la que se le brinda atención en salud es de gran importancia para el buen manejo médico-quirúrgico. Objetivo: Determinar la frecuencia de patologías tiroideas con tratamiento quirúrgico en el Servicio de Cirugía General del Hospital Central "Dr. Emilio Cubas" del Instituto de Previsión Social, de enero de 2008 a diciembre de 2013. Metodología: Estudio retrospectivo, observacional descriptivo de corte transversal, basado en datos secundarios colectados de las historias clínicas, fechas operatorias e informes de anatomía patológica. Resultados: El 2,1% correspondió a patología tiroidea, promedio de 104,5 casos/año, estadía hospitalaria de 3,4 días, predominio del sexo femenino 15:1 y un rango mayor de presentación a los 41-50 años. El 67,3% procedió de las Regiones Sanitarias: Central y Distrito capital. El motivo de consulta más frecuente (77,2%) fue por el aumento de la glándula tiroides. La distribución por agrupación histopatológica fue: Bocio (60,0%), Cáncer (22,8%), Autoinmunes (9,4%) y Adenoma (7,8%). La Tiroidectomía Total (41,8%) fue la técnica quirúrgica más empleada. Conclusión: Las patologías tiroideas con tratamiento quirúrgico fueron más frecuentes en mujeres. La mayor parte procedió del Departamento Central del Paraguay. El Bocio Coloide Multinodular es la patogenia más frecuente entre las Patologías Benignas y el Cáncer Papilar en las Patologías Malignas. Existe un aumento progresivo de casos quirúrgicos tiroideos por año. La Tiroidectomía Total es la técnica más utilizada como tratamiento quirúrgico. La estancia hospitalaria es elevada. Palabras clave: Epidemiología - Glándula Tiroides -Patología Quirúrgica - Tiroidectomía - Paraguay

Introduction: Surgery plays a fundamental role in the treatment of the thyroid glands diseases. Knowing the actual frequency of its different diseases in the population receiving health care service is of great importance in order to offer a proper medical and surgical treatment. Objective: Determine the frequency of thyroid diseases with surgical treatment in the Department of General Surgery, at the Central Hospital "Dr. Emilio Cubas" of the Institute of Social Security, from January 2008 to December 2013. Methodology: A retrospective, observational, descriptive, cross-sectional study of secondary data collected from medical records, surgery records and pathological anatomy reports. Results: Thyroid disease represented 2,1% of the surgeries, averaging 104,5 cases/year, 3,4 days of hospitalization, 15:1 female predominance and a higher incidence at ages 41-50. 67,3% of cases were from the Central and Capital District Health Regions. In 77,2% of cases, the reason for consultation was the enlargement of the thyroid gland. The distribution by histopathological groups was: Goiter (60,0%), Cancer (22,8%), Autoimmune Disease (9,4%) and Adenoma (7,8%). Total Thyroidectomy was the preferred surgical technique (41,8%). Conclusion: Thyroid diseases with surgical treatment are more common in women. Most patients come from the Central Department of Paraguay. Multinodular colloid goiter is the most common pathogenesis among the benign diseases, and papillary cancer among the malignant ones. There is a steady increase in thyroid surgical cases per year. The total thyroidectomy is the most frequently used surgical treatment. The hospitalization period is elevated. Keywords: Epidemiology - Thyroid Gland ­Surgical Pathology- Thyroidectomy - Paraguay

Controladores del tiempo y el envejecimiento: núcleo supraquiasmático y glándula pineal / Aging process entrainment: suprachiasmatic nucleus and pineal gland

El núcleo supraquiasmático (NSQ) es el principal reloj biológico de los mamíferos y sincroniza la actividad de la glándula pineal al ciclo luz-oscuridad a través de una vía polisináptica. El efecto de asa de retroalimentación neuroendocrina se lleva a cabo por la melatonina. El presente trabajo pretende demostrar que la glándula pineal modula la sensibilidad a la luz en el NSQ. Se utilizaron ratas Wistar, y se asignaron a 3 grupos: grupo A (falsa pinealectomía -sham-, sin luz), grupo B (falsa pinealectomía -sham- + luz) y grupo C al cual se le realizó la pinealectomía + luz, después de la manipulación se sacrifican para realizar inmunohistoquímica para c-Fos y al final conteo celular por técnica de estereología. Se obtuvo una reducción del 46,8% del promedio de células inmunorreactivas a c-Fos en el grupo C en comparación del grupo B. Este trabajo muestra que la sensibilidad a la luz está modulada por la actividad de la glándula pineal.

The suprachiasmatic nucleus (SCN) is the main and major biological clock in mammals and is responsible for the synchronization of the pineal gland to the light/darkness cycle through a polysynaptic pathway. The neuroendocrine feedback loop effect is carried out by melatonin. This study was carried out to demonstrate that the pineal gland adjusts the sensibility to light in the suprachiasmatic nucleus. Wistar rats were allocated in 3 groups: Group A (sham pinalectomy, without light), group B (sham pinealectomy + light) and group C which underwent real pinalectomy + light. After the intervention the animals were slain to perform immunohistochemistry for c-Fos and cell counting by stereology technique. A 46.8% average reduction in c-Fos immunoreactive cells was achieved in-group C as compared with group B. The present work shows that sensibility to the light is modulate by the activity of the pineal gland.

Effects of androgenic gland ablation on growth and reproductive parameters of Cherax quadricarinatus males (Parastacidae, Decapoda).

This work investigates the effects of androgenic gland (AG) ablation on the structure of the reproductive system, development of secondary sexual characters and somatic growth in Cherax quadricarinatus males. The AG ablation, which was performed at an early developmental stage (initial weight: 1.85±0.03 g), had no effect on the somatic growth parameters (specific growth rate and growth increment), but it prevented the re-formation of male gonopores and appendices masculinae. However, the red patch differentiation and chelae size were similar to those in control males. All the ablated animals developed a male reproductive system. Testis structure was macroscopically and histologically normal. The distal portion of the vas deferens (DVD) was enlarged in some animals, with histological alterations of the epithelium and the structure of the spermatophore. Results suggest that the higher growth in males than in females may be due to an indirect effect of the AG on energy investment in reproduction rather than to a direct effect of an androgen. This is the first report of a potential action of the AG on the secretory activity of the distal VD and the structural organization of the spermatophore. Although the AG may play a role in the development of male copulatory organs, its association with the red patch development deserves further research. The results obtained in the present study support and complement those from intersexes of the same species.

Insights into eyestalk ablation mechanism to induce ovarian maturation in the black tiger shrimp.

Eyestalk ablation is commonly practiced in crustacean to induce ovarian maturation in captivity. The molecular mechanism of the ablation has not been well understood, preventing a search for alternative measures to induce ovarian maturation in aquaculture. This is the first study to employ cDNA microarray to examine effects of eyestalk ablation at the transcriptomic level and pathway mapping analysis to identify potentially affected biological pathways in the black tiger shrimp (Penaeus monodon). Microarray analysis comparing between gene expression levels of ovaries from eyestalk-intact and eyestalk-ablated brooders revealed 682 differentially expressed transcripts. Based on Hierarchical clustering of gene expression patterns, Gene Ontology annotation, and relevant functions of these differentially expressed genes, several gene groups were further examined by pathway mapping analysis. Reverse-transcriptase quantitative PCR analysis for some representative transcripts confirmed microarray data. Known reproductive genes involved in vitellogenesis were dramatically increased during the ablation. Besides these transcripts expected to be induced by the ablation, transcripts whose functions involved in electron transfer mechanism, immune responses and calcium signal transduction were significantly altered following the ablation. Pathway mapping analysis revealed that the activation of gonadotropin-releasing hormone signaling, calcium signaling, and progesterone-mediated oocyte maturation pathways were putatively crucial to ovarian maturation induced by the ablation. These findings shed light on several possible molecular mechanisms of the eyestalk ablation effect and allow more focused investigation for an ultimate goal of finding alternative methods to replace the undesirable practice of the eyestalk ablation in the future.

[Current operative techniques and strategies in endocrine surgery]. / Aktuelle operative Techniken und Strategien in der endokrinen Chirurgie.

Technical advances and focusing on subsets modified endocrine surgery in the last ten years tremendously. There is on one side a clear trend towards minimal invasive approaches, first of all in the surgery of the adrenal glands, where the transperitoneal or retroperitoneal laparoscopic adrenalectomy has become the gold standard for tumors up to a size of 10 cm in diameter. But also in pancreatic endocrine surgery for small tumors localized in the pancreas tail and up to a certain extend in thyroid and parathyroid surgery, laparoscopic or video assisted techniques are used. On the other side more precise techniques allow a more complete and radical removal of endocrine tissue, especially in thyroid surgery. This article presents a summary of current operative techniques and strategies in endocrine surgery.

Trehalase-2 protein contributes to trehalase activity enhanced by diapause hormone in developing ovaries of the silkworm, Bombyx mori.

Diapause hormone (DH) targets developing ovaries in female pupae to induce embryonic diapause immediately after completion of mesoderm segregation of the silkworm, Bombyx mori. At the same time, DH enhances trehalase activity on the oolemma, which leads to higher concentrations of glycogen in oocytes through the stimulated incorporation of hemolymph trehalose. In B. mori, the treh-1 and -2 genes encoding soluble trehalase (68 kDa) and integral-membrane trehalase (74kDa) have been isolated. DH stimulates mRNA expression of both of these genes. In this study, we aimed to clarify whether ovarian trehalase originates from Treh-1 or Treh-2. Western blotting of the developing ovaries showed positive bands in the membrane-bound fraction, containing trehalase activity, only with antibodies against Treh-1&2 and Treh-2, but not Treh-1, irrespective of nondiapause or diapause egg-producers. The intensities of the positively stained 74 kDa bands were increased approximately 4-fold in ovaries from pupae with intact subesophageal ganglion (SG, a unique DH-biosynthesizing organ), and from pupae that were injected with DH at the middle pupal stage after their SGs were removed on the day of pupation. Furthermore, quantitative real-time PCR data showed that in developing ovaries, copy number of treh-2 mRNA per one copy of rp49 mRNA was approximately 1000-fold higher than that of treh-1 mRNA. These results demonstrate that trehalase activities enhanced by DH originate mainly from treh-2 protein regulated at the transcriptional level.

Resident/fellow assistance in the operating room for endocrine surgery in the era of fellowships.

BACKGROUND: Historically, a high percentage of endocrine surgical procedures are performed by general surgeons in nonteaching environments. With the institution of accredited fellowships, we sought to determine whether that dynamic is changing. MATERIALS AND METHODS: The American College of Surgeons-National Surgeons Quality Improvement Program was queried for all thyroid, parathyroid, and adrenal operations performed during 2005-2008. Resident assistance was classified as none, junior (postgraduate years 1-3), senior (postgraduate years 4 and 5) or fellow (≥ postgraduate year 6). Data were also examined for associations between resident/fellow assistance and surgical outcomes. RESULTS: In all, 24.7% of endocrine operations (7,140/29,161) were performed by an attending surgeon operating alone (17.1% adrenals, 27.4% thyroids, and 20.6% parathyroids). Fellows assisted in 6.6% of operations (18.3% adrenals, 4.7% thyroids, and 8.2% parathyroids; 2006: 586 operations, 2007: 629 operations, and 2008: 720 operations). Comparing attending surgeons operating alone with those assisted by residents/fellows, they had shorter operative times (P < .001), longer surgical duration of stay (parathyroid: 1.73 days, thyroid: 1.80 days, P < .001), and a higher prevalence of obese, diabetic, or octogenarian patients. However, no significant difference was found in the rates of wound infections, medical complications, return to the operating room, or overall morbidity. CONCLUSION: Even with the increase in endocrine surgery fellowships, almost one fourth of all endocrine operations are still performed by attending surgeons operating alone. Although operations assisted by residents/fellows took longer and patients had a greater duration of stay, there were no significant differences in measured outcomes.

Endocrine surgery: where are we today? A national survey of young endocrine surgeons.

BACKGROUND: In recent years, there has been a growing interest in endocrine surgery. Educational objectives have been published by the American Association of Endocrine Surgeons (AAES), but data have not been collected describing the recruitment pool, fellowship, or postfellowship experiences. METHODS: A survey was distributed to endocrine surgeons in practice <7 years and endocrine surgery fellows. Demographic, training, and practice data were collected. RESULTS: The survey response rate was 69% (46/67); 85% were practicing endocrine surgeons and 15% were fellows. In all, 72% of respondents completed an endocrine surgery fellowship, 17% completed surgical oncology, and the remaining individuals completed no fellowship. The mean age was 38 (32-49) years; 39% were women, 67% were white, 26% were Asian, 11% were Hispanic, and 2% were black. A total of 89% completed residency at academic centers. Endocrine surgery fellows performed significantly more endocrine surgery cases in residency than the average graduating chief resident. Mentorship was a critical factor in fellows' decisions to pursue endocrine surgery. Fellows graduated with a median (range) of 150 (50-300) thyroid, 80 (35-200) parathyroid, 10 (2-50) neck dissection, 13 (0-60) laparoscopic adrenal, and 3 (0-35) endocrine-pancreas. Fellows felt the least prepared in neck dissection and pancreas. Of the respondents, 76% of endocrine surgeons in practice are at academic centers, and 75% have practices where most cases are endocrine based. CONCLUSION: Exposure to endocrine surgery and mentorship are powerful factors that influence residents to pursue careers in endocrine surgery. Significant variation is found in the case distribution of fellowships with a relative paucity in neck dissection, pancreas procedures, and research. Recruitment to endocrine surgery should begin in residency, and the standardization of training should be a goal.

Stanniectomy attenuates the renin-angiotensin response to hypovolemic hypotension in freshwater eels (Anguilla rostrata) but not blood pressure recovery.

Plasma Angiotensin II (ANG II) concentrations were measured in SHM (sham-operated 2 weeks) and CSX (corpuscles of Stannius removed 2 weeks) eels before and after the induction of hypovolemic hypotension (HH) by the rapid withdrawal of 8 ml kg bw(-1) of caudal venous blood. Baseline (before exsanguination) plasma ANG II concentrations were similar in SHM and CSX eels (81.3 +/- 18.8 fmol ml(-1) cf. 106 +/- 31.6 fmol ml(-1), respectively) but the elevation in plasma ANG II following HH (1,732 +/- 82 fmol ml(-1)) was attenuated by CSX (368 +/- 127 fmol ml(-1)) showing that the CS are linked to plasma ANG II concentrations. Plasma ANG II in both groups returned to baseline levels within 48 h. Dorsal aortic blood pressures (DABP) were measured in both experimental groups before, and during the 60 min after, blood withdrawal. A 44% decrease in mean DABP was observed in both SHM and CSX eels within 2 min and followed by similar rapid patterns of recovery of systolic, diastolic, and pulse pressures in both groups during the next 60 min showing that short-term recovery of DABP is not CS-dependent. Stanniectomy increased plasma Ca and K(+) and decreased plasma Mg, Na(+), Cl(-) and osmolality which confirms some earlier observations in eels and other freshwater teleosts.

[Visceral surgery]. / Chirurgie.

Visceral surgery has benefited from several significant therapeutical improvements in 2005. They involve more specifically endocrine surgery, obesity, ovarian cancer, rectocele and cystic pancreatic neoplasia. Minimal invasive surgery is increasingly used, for example in endocrine conditions and obesity treatment. New techniques also emerge, such as electrical gastric stimulation for obesity or Stapled Trans Anal Rectal Resection (STARR) for anterior rectocele. Accurate diagnosis criteria allow better management of cystic pancreatic neoplasia, especially to choose the best treatment of this condition.

Influencia de la superespecialización en cirugía endocrina en los resultados de la tiroidectomía en un servicio de cirugía general / Influence of superspecialization in endocrine surgery on outcomes of thyroidectomy in a general surgery department

Introducción. El objetivo de este trabajo fue estudiar la influencia de la superespecialización en los diferentes estándares de la cirugía tiroidea, antes y después de la creación de una unidad de cirugía endocrina. Pacientes y métodos. Estudio retrospectivo comparativo de 2 períodos de 7 años: antes de la creación de la unidad se intervinieron 340 tiroidectomías (G1) y después 583 (G2). Se valoran edad, sexo, riesgo anestésico, cirujano, función tiroidea, datos anatomopatológicos, extensión intratorácica, tipo de tiroidectomía, utilización de drenajes, complicaciones y estancia postoperatoria. Resultados. La edad fue superior en el G2 (G1: 44,7 ± 15 años, G2: 48,09 ± 16,3 años; p < 0,001). No hubo diferencia (p = NS) en el sexo, riesgo ASA, función tiroidea ni enfermedad benigna o no, pero se remitió a más pacientes con bocio nodular en el segundo pe-ríodo (p = 0,009) y hubo más bocios intratorácicos (p = 0,0004). Los MIR realizaron más tiroidectomías con el G2 (p < 0,001). Se realizaron más tiroidectomías bilaterales (G1: 155, G2: 315; p = 0,016) y, dentro de éstas, más tiroidectomías totales (p < 0,001). La tasa de drenajes cervicales (G1: 75,29%; G2: 12,18%) mostró diferencia estadística (p < 0,001). No hubo diferencias en el global de complicaciones postoperatorias. Pese a procederes más agresivos en el G2 la hipocalcemia asintomática fue similar (p = NS), al igual que la sintomática (p = NS) o hipocalcemia permanente (G1: 1,17%; G2: 0,68%; p = NS). La tasa de paresia recurrencial fue similar referida a pacientes (p = NS) o nervios (p = NS). La tasa de parálisis permanente no fue distinta referida a pacientes (p = 0,083) pero sí referida a nervios (G1: 1,44%; G2: 0,33%; p = 0,04). Falleció un paciente del G2 (p = NS). Hubo diferencias significativas en la estancia hospitalaria (p < 0,001) a favor del G2, al igual que pacientes con estancia de 1 día o menos (p < 0,001) e intervenidos en régimen de cirugía mayor ambulatoria (0 frente a 71; p < 0,001). Conclusiones. Una unidad de cirugía endocrina permite una gestión más eficiente de la tiroidectomía. La tasa de tiroidectomías totales es mayor, las complicaciones definitivas son menores, y permite una mejor docencia a los MIR, un menor consumo de recursos y el desarrollo de programas de cirugía mayor ambulatoria para la tiroidectomía (AU)

Introduction. The aim of this study was to analyze the influence of superspecialization in endocrine surgery on the standard of thyroidectomy, both before and after the creation of an endocrine surgery unit. Patients and methods. We performed a retrospective, comparative study of two 7-year periods. Three hundred forty thyroidectomies (G1) were performed before the instauration of the unit, and 583 were carried out afterwards (G2). The variables of age, gender, anesthesia risk, surgeon expertise (staff vs. resident), thyroid function, pathological features, intrathoracic growth, extent of the procedure (unilateral or bilateral), neck drainage, morbidity and mortality and length of hospital stay were compared. Results. Age was older in G2 (G1: 44.7 ± 15 years old, G2: 48.09 ± 16.3 years old; p < 0.001). There were no differences (p NS) between the two groups in gender, anesthesia risk, thyroid function or rate of benign/malignant disease, but there was a greater frequency of nodular (p = 0.009) and intrathoracic goiters (p = 0.0004) in the second period. Residents operated on more patients in G2 (p < 0.001). Bilateral thyroidectomy was more frequent in G2 (G1: 155, G2: 315; p = 0.016) as was the rate of total thyroidectomy vs. subtotal or near total thyroidectomy (p < 0.001). Neck drainage also showed statistically significant differences (G1: 75.29%, G2: 12.18%; p < 0.001). No differences were found in overall postoperative complications. Although the procedures used were more aggressive in G2, similar rates of transient asymptomatic hypocalcemia (p NS) and transient symptomatic (p NS) and permanent hypocalcemia were found (G1: 1.17%, G2: 0.68%, p NS). The rate of transitory recurrent laryngeal nerve paralysis was similar with regard to patients (p NS) or nerves at risk (p NS). Permanent inferior laryngeal nerve paralysis was no different regarding patients (p = 0.083) but statistically significant differences were found with regard to nerves at risk (G1: 1.44%, G2: 0.33%; p = 0.04). One patient in G2 died (p NS). Length of hospital stay was shorter in G2 (p < 0.001) and more patients in this group stayed in hospital for only one day (p < 0.001) or were operated on in the outpatient setting (0 versus 71; p < 0.001). Conclusions. An endocrine surgical unit allows more efficient management of thyroidectomy. It increases the rate of total thyroidectomy, reduces definitive complications and improves training of resident surgeons. In addition, it reduces resource use and allows the development of programs of outpatient thyroid surgery (AU)

Utilidad de la especialización en cirugía endocrina de una unidad del servicio de cirugía general: análisis tras 500 tiroidectomías consecutivas / Utility of specialization in endocrine surgery in a general surgery department: analysis of 500 consecutive thyroidectomies

Introducción. Actualmente está admitido que la subespecialización dentro de la cirugía general mejora la profundización en los diferentes campos de investigación. Los autores se plantean si vale la pena crear unidades de cirugía endocrina en los hospitales de máximo nivel, no sólo desde el punto de vista investigador, sino desde el punto de vista asistencial y de gestión. Material y métodos. Se hace una valoración retrospectiva de 500 tiroidectomías consecutivas, comparando las realizadas por facultativos especialistas de la Unidad de Cirugía Endocrina con las llevadas a cabo por otros facultativos del servicio. También se compararon las 100 primeras con las 100 últimas de entre las realizadas por facultativos de la unidad. Los parámetros valorados, entre otros, fueron los tipos de intervenciones, las complicaciones y las estancias. Resultados. La tasa de complicaciones fue significativamente mayor en el grupo de pacientes operados por facultativos no pertenecientes a la unidad, con complicaciones transitorias en el 22,2 por ciento de los pacientes y definitivas en el 10,7 por ciento. En el grupo de pacientes operados por facultativos de la unidad las complicaciones definitivas fueron prácticamente nulas; las transitorias representaron el 12,9 por ciento y las definitivas, el 0,2 por ciento. Al comparar las primeras 100 realizadas con las 100 últimas dentro de la unidad, no se apreciaron cambios en las complicaciones, sin embargo, las estancias variaron significativamente desde 4,27 a 0,96 días de estancia total. Conclusiones. La creación de unidades de cirugía endocrina en los servicios de cirugía de los hospitales de máximo nivel no sólo mejora el nivel de conocimientos, sino que mejora significativamente los resultados asistenciales y la eficiencia del servicio en los pacientes sometidos a tiroidectomía. (AU)