Effects of glutamine and omega-3 fatty acids on intestinal neomucosa formation on colon serosa in rats.

Background/aim: Intestinal neomucosa formation is a technique defined for the treatment of short bowel syndrome. This study evaluates the effect of glutamine and omega-3 fatty acids on the growth of intestinal neomucosa on the colonic serosal surface has been evaluated. Materials and methods: Thirty-two adult male Sprague-Dawley rats were randomly divided into 4 groups: sham, control, glutamine, and omega-3. Laparotomy was performed on all groups. For rats other than the sham group, a 1-cm full-thickness incision was made 4 cm proximal to the ileocecal valve, and colonic serosal surface was sutured as a serosal patch over these openings. By using the oral gavage technique, the glutamine group was ingested with 200 mg/kg/day of glutamine, and the omega-3 group was ingested with 100 mg/kg/day of omega-3 fatty acids. At the end of 14 days, the rats were euthanized, blood specimens were collected, and intestinal segments, including serosal patches, were excised. Results: Transforming growth factor-beta was significantly lower in the glutamine group compared to the control group. Similarly, fibroblast growth factor-2 was significantly lower in the glutamine group compared to the sham group. Intestinal neomucosa formation was observed in 100% of rats in the glutamine group. In the control and omega-3 groups, intestinal neomucosa formation was observed in 57.1% and 60% of rats, respectively. The inflammatory response, granulation tissue formation, and fibroblastic activity were more severe in the rats of the glutamine and omega-3 groups. Conclusion: The intestinal neomucosa formation is an experimental technique, and both glutamine and omega-3 fatty acids have the potential to positively affect inflammatory response, granulation tissue formation, and fibroblastic activity. Specifically, glutamine has a favorable effect on intestinal neomucosa formation.

Impact of body weight-based dosing of palonosetron and ondansetron on postoperative nausea and vomiting following laparoscopic sleeve gastrectomy: a randomized, double-blind study.

BACKGROUND: Postoperative nausea and vomiting (PONV) is a frequent adverse effect following laparoscopic sleeve gastrectomy. Palonosetron with a standard dosing (75 µg) schedule has been questioned due to its low efficiency in obese patients. This study aimed to investigate the effectiveness and safety of the body weight-based dosing of palonosetron in managing PONV following laparoscopic sleeve gastrectomy. METHODS: A single-center, prospective, double-blinded randomized study was conducted between August 2021 and December 2021. Patients who underwent laparoscopic sleeve gastrectomy were prospectively recruited in the study. One hundred patients were randomly divided into palonosetron (Group P) and ondansetron (Group O). The demographic and clinical variables were recorded. The primary outcome of the study was the incidence of PONV between the two groups during the hospitalization. The secondary outcomes were the number of rescue anti-emetic and analgesic medications and the Functional Living Index-Emesis scores. RESULTS: There were 50 patients in each group (Group P and Group O). There were significant differences in the scores of POVN, nausea, and vomiting favoring Group P. In Group P, the rate of patients using rescue anti-emetics was significantly lower. The incidence of complete response and proportion of patients with higher Functional Living Index-Emesis scores were significantly higher in patients using palonosetron. CONCLUSIONS: The use of palonosetron significantly reduced the incidence of PONV following laparoscopic sleeve gastrectomy. There was a significant improvement in the scores of Functional Living Index-Emesis in patients using palonosetron.

Intraoperative cricothyroid muscle electromyography may contribute to the monitorization of the external branch of the superior laryngeal nerve during thyroidectomy.

Background: In thyroid surgery, both the recurrent laryngeal nerve (RLN) and external branch of the superior laryngeal nerve (EBSLN) should be preserved for maintaining the vocal cord functions. We aimed to evaluate whether EMG of the CTM applied after the superior pole dissection provided additional informative data to the IONM via ETT or not, regarding the EBSLN function. Methods: The prospectively collected data of the patients, who have undergone thyroidectomy with the use of IONM for the exploration of both the RLN and EBSLN between October 2016 and March 2017, were evaluated retrospectively. Patients over 18 years of age with primary thyroid surgery for malignant or benign thyroid disease, and whom were applied CTM EMG with a needle electrode after the completion of thyroidectomy were included in the study. In the study, each neck side was evaluated as a separate entity considering the EBSLN at risk. Results: The data of 41 patients (32 female, 9 male) (mean age, 46.7 + 9.1; range, 22-71) were evaluated. Sixty seven EBSLNs out of 26 bilateral and 15 unilateral interventions were evaluated. With EBSLN stimulation after the superior pole dissection, positive glottic EMG waveforms via ETT were obtained in 45 (67.2%) out of 67, and the mean glottic amplitude value was 261 + 191 µV (min-max: 116-1086 µV). Positive EMG responses via the CTM EMG were achieved from all of the 67 EBSLNs (100%) with stimulation using a monopolar probe at the most cranial portion above the area of divided superior pole vessels. The mean value of CTM amplitudes via CTM EMG obtained with EBSLN stimulation was 5268 + 3916 µV (min-max:1215 -19726 µV). With EBSLN stimulation, the mean CTM EMG amplitude was detected significantly higher than the mean vocal cord amplitude (p<0.0001). The CTM EMG provided more objective quantifiable data regarding the EBSLN function (100% vs 67,2%, p<0.001). Conclusion: In addition to the IONM via ETT, intraoperative post-dissection CTM EMG via needle electrode is a safe, simple and applicable method that may provide significant additional informative data to IONM with ETT by obtaining and recording objective quantitative data related to the EBSLN function.

The Role of 4D-CT for Pre-Operative Localization in Patients with Primary Hyperparathyroidism with Negative Ultrasonography and/or Sestamibi SPECT/CT.

Objectives: The major cause of primary hyperparathyroidism (pHPT) is parathyroid adenoma. Today, minimally invasive parathyroidectomy (MIP) has become the standard treatment for patients in whom the pathological gland can be localized with pre-operative imaging methods. In this study, we aimed to evaluate the role of 4D-CT in pre-operative localization in patients with pHPT who are negative for ultrasonography (USG) and/or sestamibi single-photon emission computed tomography/CT (SPECT/CT) and will undergo primary surgery. Methods: Patients whom were operated between 2018 and 2023 were included to this study. 4D-CT results of patients with one- or two-negative USG and SPECT/CT results were evaluated retrospectively. Results: In this study, 19 patients (5 men and 14 women) with a mean age of 57.1±8.5 years were evaluated. Pathology results were consistent with parathyroid adenoma in 18 patients (94.7%) and parathyroid hyperplasia in 1 patient (5.3%). USG was negative in six patients, SPECT/CT was negative in 14 patients, and both were negative in four patients. In 4D-CT, positive images were detected in 15 patients and these results were finalized as true positive in 14 patients and false positive in 1 patient. The sensitivity of 4D-CT was 82.4% (95% CI: 60.4-95.3%), positive predictive value was 93.3% (95% CI: 73.8-99.6%), accuracy was 78.9%, and localization rate was 73.7%. In 14 (73.7%) patients, the pathological glands were removed by MIP. Conclusion: In approximately 75% of patients with negative USG and/or SPECT/CT, the pathological gland can be localized with 4D-CT and MIP can be applied in these patients.

Persistent and Recurrent Primary Hyperparathyroidism: Intraoperative Supplemental Methods, Basic Principles of Surgery, and Other Treatment Options.

Reoperative parathyroid surgery is challenging even for experienced surgeons. Cure rates are lower than primary surgery. Good anatomical and embryological knowledge is important. Preoperatively, a comprehensive surgical strategy should be planned. Pre-operative imaging modalities should be used extensively to find the overlooked gland to have a possibility to perform focused parathyroid surgery to avoid possible complications. One of the important developments is the new ancillary methods to find overlooked parathyroid glands. Orthotopic and possible ectopic locations should be known well by the surgeon to increase the surgical success rate. Reoperative parathyroid surgery needs a distinctive approach compared to primary parathyroid surgery. Basic principles include the selection of the incision and route for entering the thyroid region, use of ancillary methods, and intraoperative nerve monitoring and also require a meticulous dissection. Obtaining a surgical cure is difficult and high surgical caution is needed. Post-operative complication rates are higher compared to primary parathyroid surgery. Other treatment methods and medical treatment options may be evaluated in a patient who cannot undergo surgery.

Predictive Factors Affecting the Development of Lateral Lymph Node Metastasis in Papillary Thyroid Cancer.

Objectives: Lateral lymph node metastasis (LLNM) in papillary thyroid cancer (PTC) determines the extent of surgery to be performed and the prognosis of the disease. In this study, we aimed to evaluate the clinicopathological risk factors affecting the development of LLNM. Methods: We retrospectively evaluated the demographic and clinicopathological data of 346 cases with PTC who were operated in our clinic between May 2012 and September 2020. The patients were divided into 2 groups as patients with LLNM (Group 1) and without LLNM (Group 2). Results: Thirty-six (10.4%) patients out of 346 patients with PTC had LLNM. A statistically significant difference was found between Group 1 and Group 2 regarding the male gender (M/F: 38.9% vs. 21.6%; p=0.020), tumor size (2.30±1.99 cm vs. 1.31±1.40 cm; p=0.000), lymphovascular invasion (69.4 vs. 20.6%; p=0.000), multicentricity (69.4% vs. 35.5%; p=0.000), multifocality (p=0.000), aggressive variant (22.2% vs. 9.4%; p=0.000), extrathyroidal extension (50% vs. 16.1% p=0.000), central lymph node metastasis (CLNM) rates (75% vs. 6.5%; p=0.000), and ≥3 cm lymph node metastasis (48.5% vs. 0%, p=0.000), distant metastasis (2.1% vs. 0%, p=0.000), respectively. Multivariance analysis determined the presence of CLNM as an independent risk factor for the development of LLNM. Conclusion: The presence of CLNM in patients with PTC was determined as an independent risk factor for the development of LLNM. Although there has been increasing debate about prophylactic central neck dissection (pCND) in LLNM, pCND should still be considered in these patients as the rate of CLNM is high in patients with LLNM. CLNM might be a reference for surgeons to determine the extent of surgery. In addition, the presence of CLNM is important for close follow-up for the early detection of LLNM recurrence.

Management of Thyroid Nodules.

Thyroid nodules are common and the prevalence varies between 4 and 7% by palpation and 19-68% by high-resolution USG. Most thyroid nodules are benign, and the malignancy rate varies between 7 and 15% of patients. Thyroid nodules are detected incidentally during clinical examination or, more often, during imaging studies performed for another reason. All detected thyroid nodules should be evaluated clinically. The main test in evaluating thyroid function is thyroid stimulating hormone (TSH). If the serum TSH level is below the normal reference range, a radionuclide thyroid scan should be performed to determine whether the nodule is hyperfunctioning. If the serum TSH level is normal or high, ultrasonography (US) should be performed to evaluate the nodule. US is the most sensitive imaging method in the evaluation of thyroid nodules. Computed tomography (CT) and magnetic resonance imaging are not routinely used in the initial evaluation of thyroid nodules. There are many risk classification systems according to the USG characteristics of thyroid nodules, and the most widely used in clinical practice are the American Thyroid Association guideline and the American College of Radiology Thyroid Imaging Reporting and Data System. Fine needle aspiration biopsy (FNAB) is the gold standard method in the evaluation of nodules with indication according to USG risk class. In the cytological evaluation of FNAB, the Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) is the most frequently applied cytological classification. TBSRTC is a simplified, 6-category reporting system and was updated in 2023. The application of molecular tests to FNAB specimens, especially those diagnosed with Bethesda III and IV, is increasing to reduce the need for diagnostic surgery. Especially in Bethesda III and IV nodules, different methods are applied in the treatment of nodules according to the malignancy risk of each category, these are follow-up, surgical treatment, radioactive iodine treatment, and non-surgical ablation methods.

An unusual finding after adrenal surgery: a case series of adrenal schwannomas.

Adrenal schwannomas are rare benign tumors with no specific imaging and laboratory findings to diagnose preoperatively. Due to the limited number of cases in the literature, clinical, imaging, and pathological findings are presented in this study. Case 1 is a 61-year-old woman patient who has a 31-mm mass in the right adrenal gland. This mass was nonfunctional; in imaging studies, this mass had a cystic necrotic component, and high 18-fluorodeoxyglucose (FDG) uptake was seen. There was no metaiodobenzylguanidine (MIBG) uptake. Laparoscopic transabdominal right adrenalectomy was performed, and the pathology result was consistent with adrenal schwannomas. Case 2 is a 63-year-old man patient who presented with a 38-mm mass in the left adrenal gland. This mass was nonfunctional and similar to that in Case 1; this mass had a cystic component. Laparoscopic transabdominal left adrenalectomy was performed. The diagnosis of adrenal schwannoma with degeneration was revealed. Case 3 was a 72-year-old woman patient admitted to the hospital for a 125-mm left adrenal mass. Similar to Case 1, this mass also had a cystic necrotic component in imaging studies. High FDG uptake was seen, and the patient underwent conventional adrenalectomy due to the suspicion of malignancy. After pathological evaluation, a diagnosis of adrenal schwannoma was made. A main diagnostic challenge in adrenal schwannomas is the preoperative diagnosis. These masses have no pathognomonic finding or specific hormonal function. Imaging findings of these masses may increase the suspicion of malignancy, which may affect decisions for surgery and the surgical technique.

Persistent and Recurrent Primary Hyperparathyroidism: Etiological Factors and Pre-Operative Evaluation.

Primary hyperparathyroidism (pHPT) is the most common cause of hypercalcemia and currently the only definitive treatment is surgery. Although the success rate of parathyroidectomy is over 95% in experienced centers, surgical failure is the most common complication today. Persistent HPT (perHPT) is defined as persistence of hypercalcemia after parathyroidectomy or recurrence of hypercalcemia within the first 6 months, and recurrence of hypercalcemia after a normocalcemic period of more than 6 months is defined as recurrent HPT (recHPT). In the literature, perHPT is reported to be 2-22%, and the rate of recHPT is 1-15%. perHPT is often associated with misdiagnosed pathology or inadequate resection of hyperfunctioning parathyroid tissue, recHPT is associated with newly developing pathology from potentially pathologically natural tissue left in situ at the initial surgery. In the pre-operative evaluation, the initial diagnosis of pHPT and the diagnosis of perHPT or rec HPT should be confirmed in patients who are evaluated with a pre-diagnosis (suspect) of perHPT and recHPT. Surgery is recommended if it meets any of the recommendations in surgical guidelines, as in patients with pHPT, and there are no surgical contraindications. The first preoperative localization studies, surgical notes, operation drawings, if any, intraoperative PTH results, pathological results, and post-operative biochemical results of these patients should be examined. Localization studies with preoperative imaging methods should be performed in all patients with perHPT and recHPT with a confirmed diagnosis and surgical indication. The first-stage imaging methods are ultrasonography and Tc99m sestamibi single photon tomography Tc99mMIBI SPECT or hybrid imaging method, which is combined with both single-photon emission computed tomography and computed tomography (SPECT/CT). The combination of USG and sestamibi scintigraphy increases the localization of the pathological gland. In the secondary stage, Four-Dimensional computer tomography (4D-CT) or dynamic 4-dimensional Magnetic Resonance Imaging (4D-MRI) can be applied. It is focused on as a secondary stage imaging method, especially when the lesion cannot be detected by conventional methods. Positron Emission Tomography (PET) and PET/CT examinations with 11C-choline or 18F-fluorocholine are promising imaging modalities. Invasive examinations can rarely be performed in patients in whom suspicious, incompatible or pathological lesion cannot be detected in noninvasive imaging methods. Bilateral jugular vein sampling, selective venous sampling, parathyroid arteriography, imaging-guided fine-needle aspiration biopsy, and parathormone washout are invasive methods.

The Relationship of Negative Imaging Result and Surgical Success Rate in Primary Hyperparathyroidism.

Objectives: In present, the effect of pre-operative negative imaging results on surgical outcomes of primary hyperparathyroidism (pHPT) is still controversial. In this study, we aimed to evaluate the effect of pre-operative imaging on surgical outcomes. Methods: The data of pHPT patients who were operated between 2009 and 2018 were evaluated retrospectively. Patients were divided three groups according to scintigraphy and/or ultrasonography results: Group 1; both imaging positive, Group 2; single imaging positive, and Group 3; patients in whom both imaging modalities are negative. Pre-operative biochemical characteristics, parathyroid pathologies, diameter and volume of the pathological gland, surgery rates, persistence, and recurrent disease rates of the groups were compared. Results: Of 311 patients (258F, 53M) with a mean follow-up period of 24.7±18 months and a mean age of 54.1±12.9 years; 161 were in Group 1, 111 were in Group 2, and 39 were in Group 3. The diameter of pathological gland (2.1±0.8, 1.6±0.9, 1.5±0.7 cm; p<0.001; in Group 1,2,3 respectively) and the volume of pathological gland (2±3.2, 1.4±2.9, 1.1±2.2 cm3; p<0.001; in Group 1,2,3, respectively) in Group 1; the rate of multi gland disease (5.7%, 11%, 21%; p=0.024; in Group 1, 2, 3, respectively) in Group 3 were significantly higher. In the 1, 2, 3 group; bilateral exploration rates were 93.2%, 48.6%, and 5.1%, and focused surgery or unilateral exploration rates were 6.8%, 51.4%, and 94.9%, respectively, with a significant difference (p<0.001). After the first surgery, the cure rate was 91.3%, 93.7%, and 89.7%, and the persistent patient rate was 7.5%, 3.6%, and 10.3% in Groups 1,2,3, respectively, and there was no significant difference. At the end of the follow-up period after secondary intervention applied in persistent and recurrent patients, the overall cure rate was 97.4%, 96.4%, and 97.4%, persistent disease rate 1.3%, 1.8%, and 2.6%, recurrent disease rate 1.3%, 1.8%, and 0%, respectively. Conclusion: In imaging-negative patients with pHPT, the possibility of multi gland disease and smaller pathological glands should be considered at the time of surgery. Surgery in imaging-negative patients can be performed with a similar and acceptable cure rate to imaging-positive patients.

Congenital diaphragmatic hernia with gastric perforation in adult: Intrathoracic gastric perforation.

Congenital diaphragmatic hernias are rarely seen and they are usually diagnosed in the neonatal period. Congenital diaphragmatic de-fect, also known as Bochdalek hernia, usually occurs with the persistence of the pleuroperitoneal canal in the left posterolateral region of the diaphragm in the embryological period. Although it is rarely seen in the adults, conditions such as intestinal volvulus, strangulation, or perforation with congenital diaphragm defect progress with high mortality and morbidity. In this study, we reported our case that we operated for intrathoracic gastric perforation with congenital diaphragmatic defect. When the patient admitted to the hospital, he had an atypical abdominal pain, significant back pain, and suspicious respiratory complaints. Radiological imaging showed that the stomach and the spleen were located in the left hemithorax due to diaphragmatic hernia also stomach was very dilated. Tachycardia, hypotension, and low saturation developed on the 2nd day of the patient's hospitalization. In the control imaging of the patient, in the left hemithorax, stomach was collapsed and the surrounding appearance compatible with hydropneumothorax, after that findings emergency laparotomy was decided. During the operation, as demonstrated by the radiological findings, a diaphragm defect was seen in the left posterolateral region of the diaphragm. The stomach and spleen were herniated to the left hemithorax from this defect. The stomach and spleen were reduced into the abdomen. The left hemithorax was lavaged with 2000 cc isotonic, left tube thoracostomy was applied, and the diaphragm was repaired. The anterior stomach was primarily repaired. In post-operative follow-up, there were no complications other than wound infection and thoracic tube of the patient was removed. The patient who tolerated enteral food was discharged from hospital with full recovery.

The Role of Frozen Section Examination in Thyroid Surgery.

In endocrine pathology, frozen section (FS) examination is most commonly used for the intraoperative evaluation of thyroid and parathyroid tumors, as well as cervical lymph nodes. In the past, frozen section was considered a fundamental tool in thyroid surgery. However, with advancements in preoperative ultrasound and fine-needle aspiration biopsy (FNAB), there have been increasing queries about its routine use due to the improved preoperative diagnosis. Nowadays, while the use of FS during thyroidectomy has decreased, it is still used as an additional method for different purposes intraoperatively. FS may not always provide definitive results. If FS will alter the surgical plan or extent, it should be applied. Routine FS is not recommended for evaluating thyroid nodules. But in addition to FNAB, if FS results may change the operation plan or extent, they can be utilized. FS should not be applied for thyroid lesions smaller than 1 cm, and the entire lesion should not be frozen for FS. For the assessment of thyroid nodules, the use of FS is recommended based on the Bethesda categories of FNAB. In Bethesda I category nodules, FS may contribute to distinguishing between malignant and benign lesions and guide surgical treatment. In Bethesda II nodules, where the malignancy rate is low, the performance of FNAB and FS can be compared, but it's not recommended due to the lack of a significant contribution to the surgical strategy. The sensitivity of FS in Bethesda III and IV nodules is low; its contribution to the diagnosis is limited, and it does not provide an apparent benefit to treatment; therefore, it is not recommended. In Bethesda V nodules, FS can effectively confirm the malignancy diagnosis, contribute to the surgical strategy, and reduce the possibility of completion thyroidectomy, and accordingly, it is recommended for use. Nonetheless, in Bethesda V nodules with a benign FS report, the malignancy rate remains high, so it should not be used to rule out malignancy. In Bethesda VI nodules, the performance of FS is lower or comparable to FNAB and does not significantly contribute to the treatment strategy; hence, it is not recommended. Particularly in patients with papillary thyroid cancer, intraoperative FS can be effective in detecting extrathyroidal extension and can assist the surgeon in determining the extent of thyroid surgery and central neck dissection. FS has high sensitivity and specificity in evaluating the lymphatic status of the central region intraoperatively and can be used to determine the extent of central compartment node dissection. During thyroidectomy, FS examination can be used in recognizing parathyroid tissue and distinguishing it from fatty tissue, thymus, thyroid, lymph nodes, especially in differentiating metastatic lymph nodes.

Can Unilateral Therapeutic Central Lymph Node Dissection Be Performed in Papillary Thyroid Cancer with Lateral Neck Metastasis?

Objectives: Unilateral or bilateral prophylactic central neck dissection (CND) in papillary thyroid cancer (PTC) is still controversial. We aimed to evaluate the risk factors for contralateral paratracheal lymph node metastasis and whether CND might be performed unilaterally. Methods: Prospectively collected data of patients who underwent bilateral CND and lateral neck dissection (LND) with thyroidectomy due to PTC with lateral metastases, between January 2012 and November 2019, were evaluated retrospectively. The patients were divided into two groups according to the presence (Group 1) and absence (Group 2) of metastasis in the contralateral paratracheal region.A total of 42 patients (46 ±15.7 years) were operated. In the contralateral paratracheal region, Group 1 (35.7%) had metastases, while Group 2 (64.3%) had no metastases. In groups 1 and 2, metastasis rates were 100% vs 77.8% (p=0.073), 46.7% vs 18.5% (p=0.078), and 80% vs 40.7% (p=0.023) for the ipsilateralparatracheal, prelaryngeal and pretracheal lymph nodes, respectively.The number of metastatic lymph nodes in the central region was significantly higher in Group 1 compared to Group 2 as; 10.7±8.4 vs. 2.6±2.4 (p=0.001) in bilateral central region material; 8.3±7.4 vs. 2.9±2.7 (p=0.001) in lateral metastasis with ipsilateral unilateral central region; 3.8±3.4 vs. 1.9±1.9 (p=0.023) in ipsilateralparatracheal area; and 3.7±4.6 vs. 0.6±0.9 (p=0.001) in pretracheal region, respectively. However, no significant difference was found regarding the prelaryngeal region material (0.9±1.8 vs. 0.2±0.4 (p=0.71)). Results: >2 metastatic central lymph nodes in unilateral CND material (AUC: 0.814, p<0.001, J=0.563) can estimate contralateral paratracheal metastasis with 93% sensitivity, 63% specificity, while >2 pretracheal metastatic lymph nodes (AUC: 0.795, p<0.001, J: 0.563) can estimate contralateral paratracheal metastasis with 60% sensitivity and 96.3% specificity. Conclusion: In patients with lateral metastases, the rate of ipsilateralparatracheal metastasis is 85%, while the rate of contralateral paratracheal metastasis is 35.7%. The number of ipsilateral central region or pretracheal lymph node metastases may be helpful in predicting contralateral paratracheal lymph node metastases. Notably, unilateral CND may be performed in the presence of ≤ 2 metastases in the ipsilateral central region.

The relationship of pre-operative vitamin D and TSH levels with papillary thyroid cancer.

OBJECTIVE: Our goal in this study is to analyze the correlation between papillary thyroid cancer (PTC) with elevated thyroid-stimulating hormone (TSH) levels and deficiency of vitamin D. METHODS: Patients who underwent thyroidectomy, also with available vitamin D test results preoperatively, were included in the study. The patients were separated into two different categories as having papillary thyroid carcinoma (Group 1), benign diseases (Group 2). According to the TSH (mUI/mL) level and vitamin D values, patients were categorized into four quarters. RESULTS: Preoperatively, TSH level (mean±SDmUI/mL) was higher in Group 1 (2.04±1.55) compared to Group 2 (1.82±1.94) significantly (p=0.029). Preoperatively, vitamin D levels (mean±SD) were higher in Group 1 (15.88±10.88) than in Group 2 (12.94±10.26) significantly (p=0.011). There was no significant difference between Group 1 and Group 2 according to the vitamin D deficiency (65.5%, 72.8%; respectively (p=0.472)). When categorized with reference to pre-operative vitamin D levels, the proportion of patients in Group 2 and Category 1 was higher significantly (p=0.031). CONCLUSION: Although the pre-operative TSH level was significantly higher in papillary thyroid carcinoma than benign thyroid diseases, the categorical distributions of the patients according to the TSH value were similar and the TSH values overlapped. Pre-operative mean vitamin D levels were similar in both PTC and benign thyroid disease groups so PTC was not associated with vitamin D deficiency.

Predictive Factors Affecting the Development of Central Lymph Node Metastasis in Papillary Thyroid Cancer.

Objectives: The most common subtype of thyroid cancer is papillary thyroid cancer (PTC); lymph node metastases are common in this disease. Factors affecting the development of central lymph metastasis of PTC determine the treatment modality and prognosis of the disease. In this study, we aimed to evaluate the clinicopathologic features affecting the development of central lymph node metastasis. Methods: The data of a total of 346 PTC patients who were operated between May 2012 and September 2020 in our clinic and whose follow-up could be reached were evaluated retrospectively. Demographic data, surgical treatment modalities, and histopathological data of all patients were evaluated as a result of at least 6 months of follow-up. Patients age, sex, body mass index, pre-operative TSH levels, anti-TPO, and anti-Tg values at the time of diagnosis, whether lymph node dissection is performed, presence of lymph node metastasis, presence of distant metastasis, stage at the time of diagnosis (TNM 8th edition), ATA risk group at the time of diagnosis, multifocal and/or multicentric (bilaterality), largest tumor size, aggressive histological subtype, lymphovascular invasion of the tumor, extrathyroidal invasion, presence of lymphocytic thyroiditis, and surgical margin positivity were evaluated retrospectively. Results: In the development of PTC central metastasis, distant metastasis, tumor size, multifocality, multicentricity, presence of lymphovascular invasion, aggressive tumor subtype, presence of lateral metastasis, nodular goiter, and extrathyroidal spread were found to be effective. Among these factors, T stage, presence of lymphovascular invasion, and multicentricity were identified as independent risk factors for the development of central metastasis. Conclusion: Today, the investigation of predictive factors for the development of nodal metastasis in PTC does not seem to be out of date anytime soon. In our study, T stage, presence of lymphovascular invasion, and multicentricity were identified as independent risk factors for the development of central metastasis from the histopathological features of the tumor in PTC and of these features, T stage and multicentricity can be predicted by pre-operative imaging in many patients and can be used to decide whether to perform prophylactic SLN dissection in patients. However, new studies are still needed on this issue, in the literature.

Does the Risk of Hypocalcemia Increase in Complementary Thyroidectomy Performed in Papillary Thyroid Cancer?

Objectives: Papillary thyroid cancer (PTC) is the most common type of thyroid cancers. In some patients, due to the histopathological features of PTC, complementary thyroidectomy (CT) may be needed to contralateral thyroid lobe after lobectomy. Hypocalcemia is the most common complication after thyroidectomy and its etiology is multifactorial. It is still controversial whether the CT increases the risk of hypocalcemia or not. In this study, we aimed to evaluate whether CT procedure increases the risk of hypocalcemia compared to total thyroidectomy (TT) in PTC patients. Methods: The data of the patients who were operated between 2015 and 2018 and diagnosed with PTC in the pre-operative or post-operative period were evaluated retrospectively, and two patient groups were formed. Group 1 included 19 patients who were diagnosed with PTC in the pathological examination after lobectomy was performed in the first operation, and after that CT was performed to the contralateral lobe. Among the patients who were diagnosed with pre-operative or post-operative PTC in the same period, 53 patients with characteristics similar to the 1st group in terms of age and gender were selected for Group 2. Biochemical parameters related to calcium metabolism in the pre-operative and post-operative periods, parathyroid autotransplantation and unintentional parathyroid gland removal, post-operative hypocalcemia, and treatment rates were compared between the two groups. Results: There were 19 patients (13 F and 6 M) with a mean age of 48.3±12.1 years and 53 patients with a mean age of 46.3±9 (40 F and 13 M) in Groups 1 and 2, respectively, and there was no significant difference between the groups in terms of age and gender. There was no significant difference in terms of pre-operative parathormone (PTH), phosphorus (P), magnesium (Mg), Vitamin D deficiency rate, parathyroid autotransplantation, and presence of parathyroid gland in thyroid specimen. Pre-operative calcium (Ca) value was 9.33±0.46 in Group 1 and lower than Group 2 (9.65±0.41) (p=0.012). There was no significant difference between the groups in terms of post-operative day 0 Ca, P, Mg, and PTH and post-operative day 1 Ca, Mg, and PTH. Post-operative day 1 P level was significantly lower in Group 1 (2.86±0.72) compared to Group 2 (3.6±0.83). Post-operative hypocalcemia rates were 21.1% and 30.2% in Groups 1 and 2, respectively, and the difference was not significant (p=0.558). In both groups, hypocalcemia was transient and permanent hypoparathyroidism was not detected. Parathyroid autotransplantation rates (10.5% vs. 3.8%; p=0.283) and the rate of unintentionally removed parathyroid gland (0 vs. 15.1; p=0.185) were similar in Groups 1 and 2, respectively. Ca and active Vitamin D administration rates in the post-operative period were similar in Group 1 and Group 2 (10.5% vs. 22.6%; respectively), and there was no significant difference between the groups in terms of receiving treatment (p=0.327). Conclusion: CT can be necessary in some patients with post-operative diagnose of PTC. CT can be performed without increased risk of hypocalcemia compared to TT.

The Role of Bilateral Neck Exploration for Primary Hyperparathyroidism in the Minimally Invasive Parathyroidectomy Era.

Objectives: In recent years, together with the contribution of new imaging methods, minimally invasive parathyroidectomy (MIP) has become the standard procedure in selected patients with the primary hyperparathyroidism (pHPT). However, some patients may still need bilateral neck exploration (BNE). In this study, we aimed to evaluate the factors associated with the necessity of BNE. Methods: Data of the patients, operated by same single surgeon in between 2010 and 2019, were evaluated retrospectively. Patients were divided into two groups as MIP group (group 1) and BNE group (group 2). The risk factors associated with necessity of BNE were evaluated. Results: Three hundred and forty-four patients (288 females and 56 males) were included in study. The mean age was 54.1±12.8. Pre-operative parathormone level (288 pg/mL vs. 190 pg/mL, p<0.001; respectively), compatible, inconsistent and negative imaging on scintigraphy (82.5% vs. 28.7%, 9.6% vs. 19.1, 7.9% vs. 52.25%, p<0.001; respectively), compatible, inconsistent and negative imaging in ultrasonography (USG) (72.9% vs. 20%, 7% vs. 19.1%, 20.1% vs 60.9%, p<0.001; respectively) in combination of USG and scintigraphy, two positive, single positive and negative imaging (72.5% vs. 11.3%, 25.8% vs. 55.7%, 1.7 vs. 33%, p<0.001; respectively), single adenoma, double adenoma, hyperplasia rates in pathology (96.1% vs. 79.1%, 3.1% vs. 12.2%, 0.9% vs. 8.7%, p<0.001; respectively), concomitant thyroidectomy (11.4% vs. 38.3%, p<0.001; respectively), diameter of the removed gland (2.03 vs. 1.58 cm, p<0.001; respectively), and volume of the removed gland (2.27 vs. 1.22 cm3, p<0.001; respectively), were significantly different in group 1 compared to group 2. Low pre-operative parathormone, discordant pathological gland localization compared to pathological gland compatible with scintigraphy images (odds ratio [OR]: 3.690; p=0.027), negative scintigraphy images (OR: 9.174, p=0.000), and need for additional thyroidectomy (OR: 5.067); p=0.000) were determined as independent risk factors increasing the need for BNE in the multinomial logistic regression analysis. Long-term cure rates were similar (98.3% vs. 94.8%, p=0.079; respectively). Conclusion: At present, BNE may be necessary in the surgical treatment of a significant proportion of patients with pHPT. According to our results, the possibility of BNE requirement is higher in patients with low PTH level compared to pre-operative high PTH values, in patients with discordant and negative scintigraphy compared to positive and compatible scintigraphy, and in patients who will undergo additional thyroidectomy. We think that BNE is not an alternative to MIP, but an effective option that is complementary to MIP to achieve optimal results in parathyroid surgery.

The Most Common Anatomical Variation of Recurrent Laryngeal Nerve: Extralaryngeal Branching.

OBJECTIVE: Extralaryngeal branching of recurrent laryngeal nerve (RLN) is frequent. In various studies, detection rate of extralaryngeal nerve branching was increased by intraoperative neuromonitorization (IONM). Our aim was evaluation of the relationship between the features of extralaryngeal branching of RLN and other anatomic variations in thyroidectomy patients under the guidance of IONM. METHODS: Patients underwent thyroidectomy using IONM between January 2016 and December 2019 and whose RLNs were fully explored till the nerve's entry point to the larynx, were enrolled to the study. Extralaryngeal branching of RLN was accepted as branching of the nerve at a ≥5 mm distance from its laryngeal entry point and having its all branches entering the larynx. Entrapment of RLN at the region of ligament of Berry (BL) by a vascular structure or posterior BL and relationship between RLN and inferior thyroid artery (ITA) was evaluated. RESULTS: Out of 696 patients meeting the inclusion criteria, 1127 neck sides (536F and 160M) were evaluated. Mean age was 49.1±13.4 (range; 18-89). Nerve branching ratio was 35.3% and was higher in females than males (38.2%vs.25.8%, p<0.0001, respectively). Extralaryngeal branching of RLN was detected in 398 (35.3%) out of 1127 nerves. A total of 368 (92.5%) RLNs had two, 27 (6.8%) nerves had three, and 3 (0.7%) had multiple branches. RLN crossed anterior to and between branches of ITA more frequently in branching nerves than non-branching nerves (47.7 vs. 44.4% and 12.8% vs. 7.6%, respectively) but crossed posterior to ITA less frequently in branching nerves (38.5% vs. 48%, respectively, p=0.001). Entrapment of RLN at the region of BL was higher in branched nerves (25.9% vs. 17.5%, respectively, p=0.001). Entrapment of RLN wasmore frequent at the right side than left side both in branching (31.5% vs.19.4%, respectively, p=0.008) and non-branching nerves (20.6% vs. 14.4%, respectively). CONCLUSION: Extralaryngeal branching of RLN is not rare and mostly divided into two branches. Branching ratio is higher in females than males. In branching nerves, rate of crossing anterior to and between branches of ITA was higher, in non-branching nerves, rate of crossing posterior to ITA was higher. In branching nerves, possibility of entrapment of RLN at the region of BL was higher. Both in branching and non-branching nerves, entrapment of RLN at the region of BL was higher at the right side. Extralaryngeal branching, relationship between RLN and ITA, and entrapment of RLN at the region of BL are frequently seen and variable anatomic variations and cannot be foreseen preoperatively. Most of the extralaryngeal branches and their relationship with other variations can be detected by finding RLN at the level of ITA and following RLN until its entry point to the larynx.

The Relationship of Magnesium Level with the Recovery of Parathyroid Function in Post-thyroidectomy Hypoparathyroidism.

OBJECTIVES: Hypocalcemia is the most common complication and acute parathyroid gland insufficiency is the main cause of it after thyroidectomy. In this study, we aimed to evaluate the relationship between the recovery time of parathyroid gland function and patient characteristics, preoperative and postoperative electrolyte changes, and intraoperative parathyroid findings in patients with postoperative hypoparathyroidism. METHODS: Patients who underwent total thyroidectomy (TT) with or without central neck dissection ± lateral neck dissection with a parathyroid hormone (PTH) value of <15 pg/mL within the postoperative 4th hour were included in this study. Postoperative calcium level of <8mg/dL was defined as biochemical hypocalcemia and a PTH value of <15 pg/mL was defined as hypoparathyroidism. The patients were divided into three groups according to the time of PTH recovery (>15 pg/mL); within the first 24 hours, between one day and 30 days, after 30 days, respectively. RESULTS: One hundred eleven patients (mean age, 49.3±14.4 years) consisted of Groups 1, 2 and 3, including 19 (16F, 3M), 67 (54F, 13M) and 25 (19F, 6M), respectively. Vitamin D deficiency rates for Groups 1, 2, 3 were 41.7%, 53.1% and 88.2%, respectively (p=0.018). Postoperative day 0 PTH values were 11.69±2.79pg/mL, 6.92±3.45 pg/mL, 4.99±2.36 pg/mL, (p<0.001). Biochemical hypocalcemia rates of Groups 1, 2, 3 on postoperative day 1 were 15.8%, 53.7%, 64%, (p=004) respectively, and calcium values were 8.68±0.67 mg/dL, 8.15±0.66 mg/dL, 7.75±1 mg/dL, (p=0.014), respectively. Magnesium values on postoperative day 1 and 7 for Groups 1, 2, 3 were 1.85±0.1 mg/dL, 1.77±0.17 mg/dL, 1.64±0.17 mg/dL, (p=0.005), and 1.86±0.16mg/dL, 1.82±0.21mg/dL, 1.59±0.15mg/dL (p=0.001), respectively. PTH values on postoperative day 1 and 7 in Groups 1, 2, 3 were 20.5±6.4 pg/mL, 7.06±4.35 pg/mL, 4.66±3.26 pg/mL (p<0.001), and 31.04±10.54pg/mL, 18.72±13.84pg/mL, 4.55±4.9pg/mL (p<0.0001), respectively. Parathyroid function improved in 106 patients, and permanent hypoparathyroidism developed in five patients (4.5%). CONCLUSION: Hypoparathyroidism can recover rapidly in the first 24 hours in patients with a PTH value of around 10 pg/mL at postoperative 4th hour. As the number of preserved parathyroids increased, recovery time decreased. In patients with postoperative hypoparathyroidism, postoperative low magnesium levels may be associated with delayed recovery of parathyroid function.