Pre-Operative Selective vs Non-Selective α-Blockade in Pheochromocytoma-Paraganglioma Patients Undergoing Surgery: A Meta-Analysis.

The main objective of this systematic review and meta-analysis was to review, assess and report on the studies that have evaluated selective alpha blockade (SAB) vs. non-selective alpha blockade (NSAB) therapy in patients undergoing surgery for pheochromocytomas and paragangliomas (PPGL). We performed a systematic search of electronic databases. A meta-analysis was conducted to examine the effectiveness of the two blockades. RevMan 5.3 was used for the meta-analysis. Of the eight articles that met the inclusion criteria, there was only one randomized control trial. Meta-analysis showed that there was no significant difference between the groups SAB and NSAB with regard to intra-operative systolic blood pressure (SBP) >160 mm Hg (relative risk (RR) 0.95 [95% CI 0.57, 1.56] P = 0·83) and intra-operative vasopressor requirement (RR 1.10 [95% CI 0.96, 1.26] P = 0·16). Meta-analysis revealed that there was a significant difference between the groups (SAB vs NSAB) with respect to post-operative vasopressor requirement (RR 1.66 [95% CI 1.0, 2.74] P = 0·05). There was no significant difference between the groups with respect to post-operative complications (RR 0.84 [95% CI 0.58, 1.22] P = 0·36). In conclusion, as patients blocked selectively may have a higher incidence of vasodilator requirement intra-operatively, NSAB offers some haemodynamic advantage over SAB. However, NSAB's real clinical benefit cannot be ascertained with the current studies as this difference did not result in any significant advantage over SAB with regard to morbidity or mortality.

Does Tumor Marking Before Neoadjuvant Chemotherapy Helps Achieve Better Outcomes in Patients Undergoing Breast Conservative Surgery? A Systematic Review.

Patients with breast cancer are increasingly being offered breast conserving surgery (BCS) following neoadjuvant chemotherapy (NACT). We aimed to conduct a systematic review to assess the advantage of tumor marking in patients undergoing BCS after NACT. After registering the protocol for a systematic review with PROSPERO, a systematic search was conducted through September 30, 2020, for all studies involving patients undergoing BCS post NACT after tumor marking. Margin status on final histology was the primary outcome. Oxford Centre for Evidence Based Medicine (OCEBM) levels were used to assess internal validity. A total of 636 records from Medline/PubMed, 1381 from Embase, and 1422 from Cochrane library were extracted. After screening, 15 articles (1520 patients) were included for data synthesis. For marking, 6 studies used metallic markers and 5 used 125I-radioactive seeds (RSL) followed by skin tattoo and radio-guided occult lesion localization using 99mTc (ROLL) in one study each. Most studies used a single marker at the center except for two (143 patients), who practiced the bracketing technique. Incidence of unsatisfactory margins (positive/close) ranged from 5 to 23.5%. After excluding patients with complete pathological response, the "adjusted unsatisfactory margin" rate was found to be 19.3% (10.4-33%). Overall 20.6 recurrences (locoregional/distant) were reported per 1000 patient-years follow-up. Overall survival (OS) was only reported by one study as 96.6% and 84.7% in patients with and without marker placement (p = .01). Re-excision and secondary mastectomy rates (reported by nine studies) were 7.3% and 5.7% respectively. There is limited evidence that tumor marking before neoadjuvant chemotherapy improves the rate of unsatisfactory margins or survival outcomes in a patient undergoing BCS after NACT.

Changing paradigms in endoscopic thyroid surgery: A comparison between scarless-in-the-neck axillo-breast approach and totally scarless transoral approach.

BACKGROUND: To avoid cervical scar in thyroid surgery, various approaches have been proposed. The commonly used approach is combined axillo-breast approach (ABA). However, trans-orovestibular approach (TOVA) is getting popular. The aim of this study is to compare surgical outcomes of patients who underwent endoscopic hemithyroidectomy (EHT) by either ABA or TOVA. PATIENTS AND METHODS: This was a retrospective analysis of clinical data of patients who underwent EHT from January 2013 to December 2018. Patients were divided into two groups: Group A - through ABA and Group B - through TOVA. RESULTS: A total of eighty patients underwent EHT in Group A and 25 in Group B. In both groups, most patients were female (male: female = 1:4.7 in Group A and 1:7.33 in Group B, P = 0.515). In both groups, there was no difference in age (the mean age was 33.44 ± 10.44 years in Group A and 33.04 ± 14.01 years in Group B, P = 0.391) and in size of the nodule (Group A - 3.91 ± 1.17 cm and Group B - 3.6 ± 1.39 cm, P = 0.228). The operating time was significantly less in Group B (Group A - 152.25 ± 30.19 mins and Group B - 126.80 ± 22.94 mins, P ≤ 0.01). The post-operative hospital stay was significantly less in Group B (mean 3.17 ± 0.97 days in Group A and 2.24 ± 0.60 days in Group B, P ≤ 0.01). CONCLUSION: TOVA is associated with shorter operating time and hospital stay with comparable outcomes. Cosmetic outcome is excellent in TOVA, however requires further subjective evaluation.

Natural Orifice Endoscopic Thyroidectomy via Transoral Vestibular Approach (TOVA): Single Surgeon Experience from North India.

The transoral vestibular approach (TOVA) is the shortest route for endoscopic thyroidectomy (ET) to approach the thyroid and is a totally scar free procedure, hence it has a clear cosmetic advantage not only over conventional open thyroid surgery but also over other remote access approaches for ET like axilla, breast and chest wall approaches. The aim of this study was to evaluate the feasibility, safety and our initial outcomes of TOVA and highlight the advantages of 3D endoscopic equipment in remote access thyroid surgery. We reviewed our prospectively maintained database who underwent ET. 42 patients who fulfilled the stringent inclusion criteria were offered TOVA. We have used novel Trans-vestibular approach with 3D technology for endoscopic thyroid surgery in all cases. Clinico-demographic profile, investigations, operative details, histopathology and postoperative complications and follow-up data were analyzed by using statistical analysis with SPSS19.00 version. Out of 203 ET operated during study period, 42 (20.69%) patients were operated through TOVA. Hemithyroidectomy were performed in all the patients. There were 3 men and 39 women (M:F = 1:13). Mean tumor size was 3.54 ± 1.17 cm. All patients were euthyroid. All patient had cytological diagnosis of Bethesda category II-IV and all underwent hemithyroidectomy. Mean operation time was 107.71 ± 17.60 min and post-operative length of hospital stay was 2.90 ± 1.28 days. Besides magnification, 3D endoscopy provided excellent depth perception which helped in precise dissection in the restricted space and aided in identification and preservation of the two most vital structures i.e. recurrent laryngeal nerve and parathyroid glands. As most of our patients present with larger goitres, not many patients desirous of ET can be offered TOVA. This novel TOVA has fairly stringent inclusion criteria, however it is the only approach which offers completely scarless endoscopic thyroidectomy and should be offered to eligible patients desirous of ET.

Robotic thyroid surgery using bilateral axillo-breast approach: From a trainees' point of view.

BACKGROUND: Across surgical disciplines, the demand for cosmetically superior procedures is stronger than ever and patient-centered health care has become the standard of care. Endoscopic thyroidectomy has revolutionized the field of minimal access endocrine surgery and akin to other surgical disciplines, there has been a natural progression towards robot-assisted thyroidectomy. Amongst the many described approaches, bilateral axillo-breast approach (BABA) and transaxillary are most widely practiced. AIMS AND OBJECTIVES: Our aim was to describe the technique of robot-assisted thyroid surgery (RATS) using BABA. METHODS: This is based on the corresponding authors' training and experience of over 50 cases of RATS using BABA, at the Seoul National University, Republic of Korea. RESULTS: Post-operative outcomes were excellent with lesser pain, better cosmesis and similar oncological outcomes in carefully selected thyroid cancers in comparison to conventional thyroidectomy. CONCLUSION: RATS using BABA is easy to master for endoscopic thyroid surgeons and offers excellent postoperative outcomes, ergonomics, vision and dexterity.

Endoscopic versus Conventional Thyroid Surgery: A Comparison of Quality of Life, Cosmetic Outcomes and Overall Patient Satisfaction with Treatment.

BACKGROUND: Our aim was to investigate whether the surgical approach, i.e. endoscopic (ET) versus conventional/open thyroidectomy (ConT), contributes towards the improvement in quality of life (QoL), cosmetic outcomes and overall patient satisfaction with treatment. METHODS: We conducted a prospective study (October 2016-August 2018) consisting of patients undergoing hemithyroidectomy for euthyroid, non-malignant solitary thyroid nodules (STNs). Patients were divided into two groups: Group I (ET)-41 patients and Group II (ConT)-52 patients. ET was performed via bilateral-axillo breast approach (BABA). A thyroid disease-specific questionnaire "ThyPRO-39hin" was used to evaluate pre- and post-operative QoL. Visual analogue scale (VAS) was used for post-operative pain. Cosmetic satisfaction, paraesthesia and overall satisfaction with treatment were evaluated using Likert-type verbal response scales. Pre- and post-operative scores (>6 months) were compared, and p value < 0.05 was considered significant. RESULTS: Mean age (p = 0.26), gender distribution (p = 0.07), mean tumour size (p = 0.74) and preoperative scores of QoL were comparable between the two groups. Post-operatively scores of symptom domain (p = 0.03), tiredness (p = 0.03), impaired social life (p = 0.03), cosmetic complaints (p = < 0.001) and overall QoL (p = < 0.001) were significantly better in Group I. Also, post-operative pain perception at first follow-up visit (p = 0.001) was lower in patients undergoing ET/Group I, with higher scar satisfaction scores (p = < 0.001) and overall satisfaction with treatment (p = < 0.001). Post-operative paraesthesia perception was comparable (p = 0.06) amongst the two groups. CONCLUSION: In this cohort study, patients undergoing endoscopic thyroid surgery reported superior post-operative QoL, cosmetic and overall satisfaction with treatment as compared to conventional/open thyroidectomy.

Primary hyperparathyroidism in developing world: a systematic review on the changing clinical profile of the disease.

While the developed world is focusing on laying guidelines for selecting out cases of Asymptomatic primary hyperparathyroidism (PHPT) for surgical intervention and promoting minimal access surgery, the developing world is observing a change in disease spectrum from advanced symptomatic to lesser degree of symptomatic disease and not many with associated Vitamin D deficiency. Few studies from the developing countries of the world have focused on the changing clinical spectrum of PHPT. Objective of this study is to review the changing profile of PHPT in developing world. A systematic literature search was done in December 2017 focussing on publications from the developing world. All studies pertaining to the epidemiology of PHPT published after 1st January 2000 and published in English language were included for analysis. Most of the studies published from developing countries report a predominance of symptomatic disease (79.6% of all included patients) with musculoskeletal disease present in the majority of patients (52.9%). The combined mean serum total calcium (11.9 ± 1.4 mg/dL), serum PTH (668.6 ± 539 pg/mL), serum alkaline phoshpatase (619 ± 826.9 IU/L) and weight of excised parathyroid glands (4.4 ± 3.8 grams) are much higher than those reported from the western studies. Despite this, we found that there is a distinct trend towards a milder form of disease presentation and biochemical profile noticeable in more recent times. Although there is a striking difference in all aspects of PHPT disease epidemiology, clinical presentation and biochemical profile of developing and developed countries, there is a distinct trend towards a milder form of disease presentation and biochemical profile in more recent times.

Primary hyperparathyroidism in developing world: a systematic review on the changing clinical profile of the disease

ABSTRACT While the developed world is focusing on laying guidelines for selecting out cases of Asymptomatic primary hyperparathyroidism (PHPT) for surgical intervention and promoting minimal access surgery, the developing world is observing a change in disease spectrum from advanced symptomatic to lesser degree of symptomatic disease and not many with associated Vitamin D deficiency. Few studies from the developing countries of the world have focused on the changing clinical spectrum of PHPT. Objective of this study is to review the changing profile of PHPT in developing world. A systematic literature search was done in December 2017 focussing on publications from the developing world. All studies pertaining to the epidemiology of PHPT published after 1st January 2000 and published in English language were included for analysis. Most of the studies published from developing countries report a predominance of symptomatic disease (79.6% of all included patients) with musculoskeletal disease present in the majority of patients (52.9%). The combined mean serum total calcium (11.9 ± 1.4 mg/dL), serum PTH (668.6 ± 539 pg/mL), serum alkaline phoshpatase (619 ± 826.9 IU/L) and weight of excised parathyroid glands (4.4 ± 3.8 grams) are much higher than those reported from the western studies. Despite this, we found that there is a distinct trend towards a milder form of disease presentation and biochemical profile noticeable in more recent times. Although there is a striking difference in all aspects of PHPT disease epidemiology, clinical presentation and biochemical profile of developing and developed countries, there is a distinct trend towards a milder form of disease presentation and biochemical profile in more recent times.

Extracervical endoscopic thyroid surgery via Bilateral Axillo-Breast approach (BABA).

Extracervical, scarless in-the-neck endoscopic thyroidectomy (SET) is a relatively new offshoot of minimal access neck surgery which is gaining popularity rapidly. Among all the approaches described, hybrid approaches such as axillary-breast and bilateral axillo-breast (BABA) are most practiced world over. We have performed more than 130 cases of SET using various approaches (ABA, BABA and transoral vestibular approach). We find BABA most suitable for patients who present with larger goitres (≥6cm), toxic glands or low-grade thyroid cancers and are desirous of SET. Here, we describe the surgical technique of BABA, its pros and pitfalls based on our experience.

Feasibility of Endoscopic Thyroidectomy via Axilla and Breast Approaches for Larger Goiters: Widening the Horizons.

Scarless (in the neck) endoscopic thyroidectomy (SET) has evolved into a cosmetically preferred alternative to conventional thyroidectomy (ConT). Recently many of our patients are demanding SET; however their goitres are larger than the recommended size of 4-6 cm. Our aim was to compare the outcomes of ET for small (<6 cm) vs large (≥6 cm) goitres and determine its feasibility in such cases. This is a retrospective analysis of prospectively maintained database of patients undergoing ET. Patients were divided into 2 groups: I, small (<6 cm) and II, large goitres (≥6 cm). Their demographic and clinicopathological profiles, operation time, conversion and complication rates, and hospital stay were compared. 99 patients (101 procedures) were included: group I, 60 patients (61 procedures), and group II, 39 patients (40 procedures). Mean tumor size (± SD) was 4.4 ± 0.9 cm and 6.7 ± 1.1 cm in groups I and II, respectively. The groups were comparable with respect to demographic and clinical profile except for mean duration of goiter [30.1 ± 32.6 months (group I) vs 60.5 ± 102.4 months (group I), p = 0.03] and gland weight [21.5 ± 15.3 grams (group I) vs 62.3 ± 51.3 grams (group II), p = 0.001]. Although there was no significant difference between mean operating times, long term perioperative outcomes, and conversion rates, temporary hypocalcaemia and length of stay were longer in group II. One patient had permanent vocal cord palsy (~1%, 1/101); none had permanent hypoparathyroidism. Our results indicate that ET can be offered to a subset of patients with larger goitres desirous of SET with no significant difference in mean operation time, conversions, and long term postoperative complications in experienced hands.

Endoscopic Thyroid Surgery Through Trans-oral Vestibular Approach (TOVA): A Case Series and Review of Literature.

Endoscopic surgery is now standard of care for different Endocrine Disorders; the endoscopic thyroid surgery is becoming more popular and different approaches has been practice by many thyroid surgeon worldwide. Trans-orovestibular approach, based on the principle of natural orifice transluminal surgery is truly scar free thyroid surgery and has minimal dissection. We are presenting here three cases of benign solitary thyroid nodule operated endoscopically through trans-oro-vestibular approach in one male and two female patients. Described about the approach, challenges during surgery and outcome. These surgeries documented very few in literatures in live human patients. Transoral endoscopic thyroid surgery through vestibular approach is shortest and direct remote access approach. The need of limited dissection in this approach provides less complication and excellent cosmetic outcome in strictly selected patients.

Congenital right bochdalek hernia presenting as emergency in old age: a case report.

Congenital diaphragmatic hernias (CDHs) are known to present even after the neonatal period. Posterolateral Bochdalek hernias account for the majority of cases. About 85 % tend to occur on the left side, while the right side accounts for roughly 13 % of the cases. We present a case of a right-sided Bochdalek hernia in an elderly man who was asymptomatic for 60 years of life. The patient presented with vague right upper abdominal discomfort, and ultrasound abdomen revealed herniation of the small bowel into right hemithorax, showing sluggish peristalsis, raising a suspicion of impaired vascularity. He subsequently underwent contrast CT, which confirmed herniation of small bowel loops into right thorax with normal vascularity but dilatation of bowel loops and a possibility of closed-loop obstruction. He was taken up for emergency surgery. The patient had uneventful recovery.