The Year in Surgical Thyroidology: Recent Technological Developments and Future Challenges.

Background: The field of surgical and interventional thyroidology is rapidly evolving. In the past few years, we have seen the introduction and establishment of many novel surgical adjuncts, techniques, and disruptive ablative technologies that have impacted the field. Methods: We identified the most influential articles on technological developments in surgical and interventional thyroidology that were published from September 1, 2020, to August 1, 2021. We searched three electronic databases and consulted experts. Results: Major findings are summarized. Continuous intraoperative nerve monitoring (cIONM) lowered the risk of early postoperative vocal cord palsy 1.8-fold and permanent palsy 29 · 4-fold compared with intermittent intraoperative nerve monitoring. Parathyroid autofluorescence yielded a diagnostic odds ratio (OR) of 228.9 for detection of parathyroid glands over visualization, with 96% sensitivity and 92% specificity. There was no significant difference in the incidence of major complications between the transoral endoscopic thyroidectomy vestibular approach (TOETVA) and transcervical thyroidectomy (1.5% vs. 2.1%, p = 0.75), and a higher body mass index did not lead to a significant increase in the odds of cumulative complication with TOETVA for the overweight (OR = 0.52 [95% confidence interval {CI} 0.17-1.58]) and obese groups (OR = 1.69 [CI 0.74-3.88]). Radiofrequency ablation (RFA) for benign thyroid nodules typically resulted in a 50-85% volume reduction with faster recovery times, less pain levels, and higher social and psychological well-being compared with conventional thyroidectomy at 15 months post-treatment, although physical well-being levels were higher in the conventional thyroidectomy group at this time. RFA for papillary thyroid microcarcinoma showed no significant difference in local tumor progression (1.8% vs. 3.3%, p = 0.209), lymph node metastasis (0.6% vs. 0.6%, p = 1.000), recurrence (1.2% vs. 2.4%, p = 0.244), and 4-year recurrence-free survival rates (98.2% vs. 97.0%, p = 0.223) when compared with transcervical lobectomy. Conclusions: cIONM, parathyroid autofluorescence, transoral vestibular approach thyroid surgery, and RFA for benign and malignant thyroid nodules are some of the latest additions to the surgeon's and interventionalist's armamentarium to manage thyroid disease. These technological advancements demonstrate promise to improve outcomes, decrease complications, and enhance a patient's quality of life, but further rigorous studies are needed to define their utility and value.

The 2021 European Group on Graves' orbitopathy (EUGOGO) clinical practice guidelines for the medical management of Graves' orbitopathy.

Graves' orbitopathy (GO) is the main extrathyroidal manifestation of Graves' disease (GD). Choice of treatment should be based on the assessment of clinical activity and severity of GO. Early referral to specialized centers is fundamental for most patients with GO. Risk factors include smoking, thyroid dysfunction, high serum level of thyrotropin receptor antibodies, radioactive iodine (RAI) treatment, and hypercholesterolemia. In mild and active GO, control of risk factors, local treatments, and selenium (selenium-deficient areas) are usually sufficient; if RAI treatment is selected to manage GD, low-dose oral prednisone prophylaxis is needed, especially if risk factors coexist. For both active moderate-to-severe and sight-threatening GO, antithyroid drugs are preferred when managing Graves' hyperthyroidism. In moderate-to-severe and active GO i.v. glucocorticoids are more effective and better tolerated than oral glucocorticoids. Based on current evidence and efficacy/safety profile, costs and reimbursement, drug availability, long-term effectiveness, and patient choice after extensive counseling, a combination of i.v. methylprednisolone and mycophenolate sodium is recommended as first-line treatment. A cumulative dose of 4.5 g of i.v. methylprednisolone in 12 weekly infusions is the optimal regimen. Alternatively, higher cumulative doses not exceeding 8 g can be used as monotherapy in most severe cases and constant/inconstant diplopia. Second-line treatments for moderate-to-severe and active GO include (a) the second course of i.v. methylprednisolone (7.5 g) subsequent to careful ophthalmic and biochemical evaluation, (b) oral prednisone/prednisolone combined with either cyclosporine or azathioprine; (c) orbital radiotherapy combined with oral or i.v. glucocorticoids, (d) teprotumumab; (e) rituximab and (f) tocilizumab. Sight-threatening GO is treated with several high single doses of i.v. methylprednisolone per week and, if unresponsive, with urgent orbital decompression. Rehabilitative surgery (orbital decompression, squint, and eyelid surgery) is indicated for inactive residual GO manifestations.

Continuous Laryngeal Adductor Reflex Versus Intermittent Nerve Monitoring in Neck Endocrine Surgery.

OBJECTIVE: Intraoperative neuromonitoring (IONM) techniques aim to identify and potentially prevent nerve injury during surgeries. Prior studies into the efficacy of recurrent laryngeal nerve (RLN) IONM convey mixed results, with some claiming equivalence between IONM and no monitoring at all. The goal of the current study was to compare continuous RLN monitoring using the laryngeal adductor reflex (LAR) to intermittent RLN monitoring (intermittent IONM) to determine whether continuous monitoring reduces the incidence of intraoperative RLN injury during neck endocrine surgeries. METHODS: In this observational, historical case-control study, a historical cohort of patients monitored with intermittent-IONM (group 1, n = 130) were compared to prospectively collected data from consecutive nerves-at-risk monitored continuously with the LAR (LAR-CIONM, group 2, n = 205), at a single center by a single surgeon. The test benefit ratio and relative risk reduction (RRR) for LAR-CIONM over intermittent IONM were calculated. RESULTS: For group 1, nine nerves at risk exhibited intraoperative LOS with transient postoperative vocal fold (VF) hypomobility (n = 2) or immobility (VFI, n = 7). For group 2, two nerves at risk (0.98%) had sudden intraoperative LAR LOS following bipolar cautery, resulting in postoperative transient VFI (P = .004). In each group, there was one case of permanent postoperative VFI. The test benefit rate ratio for LAR-CIONM demonstrated a dramatic effect at 5.23, with an RRR of 81.0%. CONCLUSION: LAR-CIONM significantly decreased rates of postoperative transient VF paralysis and paresis over intermittent IONM alone (P = .004). Surgeons should be aware of the benefits and limitations of intermittent IONM versus CIONM. Intermittent IONM, although useful in nerve mapping and intraoperative decision making, has minimal benefit for the prevention of nerve injury, whereas CIONM can potentially reduce nerve injury rates and improve patient outcomes. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:230-236, 2021.

Prevención de morbilidades post-tiroidectomía total y subtotal: una revisión bibliográfica / Prevention of total and subtotal post-thyroidectomy morbidities: a bibliographic review

Las enfermedades tiroideas han presentado un auge en los últimos tiempos, aumentando consigo mismo el reporte de las intervenciones quirúrgicas. La tiroidectomía es una de las cirugías más practicadas en endocrinología y tras su realización se han descrito complicaciones, siendo éstas vinculadas a ciertos factores de riesgos que potencian su aparición. Se realizó búsqueda bibliográfica en el período comprendido entre febrero de 2018 a diciembre de 2019, en bases de datos internacionales (PubMed, Cochrane, SCIELO, LILACS y Redalyc) y búsqueda manual en Google Scholar, utilizando los términos complicaciones de tiroidectomías, complicaciones post-quirúrgicas, cirugía de tiroides y tiroidectomías. Se identificaron tres agrupaciones generales de factores de riesgo postquirúrgico: Factores intrínsecos de la enfermedad, comorbilidades del paciente y asociados al procedimiento quirúrgico. Es indispensable identificar y corregir comorbilidades para la prevención de complicaciones postquirúrgicas, puesto que las complicaciones continúan siendo una causa de considerable preocupación.

Resultado del tratamiento quirúrgico del cáncer de tiroides Hospital Universitario Comandante "Faustino Pérez Hernández" Matanzas / Outcome of thyroid cancer surgical treatment. University Hospital ¨Comandante Faustino Pérez Hernández. Matanzas

RESUMEN Introducción: el cáncer de tiroides representa un 1% del total de todos los tipos de cáncer. Su incidencia parece aumentar un 4% cada año, y en la actualidad es el octavo cáncer más frecuente en mujeres. Objetivo: evaluar el resultado del tratamiento quirúrgico en el cáncer de tiroides. Materiales y métodos: se realizó un estudio observacional, descriptivo y retrospectivo que incluye todos los pacientes operados de cáncer tiroides en el servicio de Cirugía General del Hospital Universitario "Comandante Faustino Pérez Hernández", en el período desde enero de 1993 a diciembre del 2018. Se empleó un modelo recolector de datos con las variables de interés para el estudio y los resultados se presentaron en tablas de frecuencia, números y porciento. Resultados: el cáncer de tiroides fue más frecuente en el grupo etario de 31 a 50 años, predomino el sexo femenino, la variedad histológica papilar fue la más frecuente, la técnica quirúrgica más empleada fue la tiroidectomía total. El hipotiroidismo fue la complicación más encontrada. Conclusiones: el cáncer de tiroides es más frecuente en pacientes relativamente jóvenes y del sexo femenino, la variedad papilar, la tiroidectomía total y el hipotiroidismo como complicación posquirúrgica son los de más incidencia (AU).

SUMMARY Introduction: thyroid cancer represents 1% of the total of all kinds of cancer. Its incidence seems to increase 4% every year, and at the present time it is the eighth more frequent cancer in women. Objective: to evaluate the results of the thyroid cancer surgical treatment. Materials and methods: a retrospective, descriptive, observational study was carried out including all patients who underwent a surgery of thyroid cancer in the service of General Surgery of the University Hospital ¨Comandante Faustino Perez Hernandez¨ in the period from January 1993 to December 2018. A data collector model was used with the variables of interest for the study and the results were presented by charts of frequency, numbers and percent. Results: the thyroid cancer was more frequent in the age group of 31 to 50 years; the female sex prevailed; the most frequent variety was the histological papillary one; the most used surgical technique was total thyroidectomy. Hypothyroidism was the most commonly found complication. Conclusions: thyroid cancer is more frequent in relatively young, female patients; the papillary variety, total thyroidectomy and hypothyroidism as surgical complication are the ones with higher incidence (AU).

Sleep disturbance and delirium in patients with acromegaly in the early postoperative period after transsphenoidal pituitary surgery.

Sleep disturbance is a common comorbidity among patients with acromegaly [patients with growth hormone (GH)-secreting tumor] due to somatotropic axis change and sleep apnea. However, no previous studies exist concerning sleep disturbance and delirium in the early postoperative period in patients with acromegaly undergoing transsphenoidal tumor surgery. Herein, we aimed to compare the incidence of postoperative sleep disturbance and delirium in the early postoperative period between patients with GH-secreting and nonfunctioning pituitary tumors.We retrospectively reviewed the medical records of 1286 patients (969 with nonfunctioning and 317 with GH-secreting tumors) without history of psychological disease and sedative or antipsychotic use. We examined the use of antipsychotics/sedatives and findings of psychology consultation within the first postoperative week. Only patients with sleep disturbance noted in medical records were considered to have postoperative sleep disturbance. Patients with an Intensive Care Delirium Screening Checklist score of 4 or more were considered to have postoperative delirium.The incidence of postoperative sleep disturbance was higher in the GH-secreting group than in the nonfunctioning tumor group (2/969 [0.2%] vs 6/317 [1.9%]; P = .004; odds ratio = 9.328 [95% confidence interval, 1.873-46.452]). Univariable regression analysis showed that only diagnosis (GH-secreting tumor or nonfunctioning tumor) was a risk factor for sleep disturbance, and not sex, age, body mass index, American Society of Anesthesiologists physical status score, surgery duration, anesthesia duration, anesthesia type, tumor size, cavernous sinus invasion, or bleeding. The incidence of postoperative delirium was comparable between the 2 groups (6/969 [0.6%] vs 0/317 [0%]; P = .346).Patients with acromegaly showed increased incidence of sleep disturbance than those with nonfunctioning tumors in the early postoperative period after transsphenoidal tumor surgery. A prospective study evaluating sleep quality in patients with GH-secreting tumors in the early postoperative period could be conducted based on our findings.

Adrenal-sparing surgery for a hormonally active tumour - a single-centre experience.

INTRODUCTION: Surgeries that spare the adrenal cortex during adrenalectomy have profound justification. Indications for this type of surgery are fairly strict, and more than 30 years of observations continuously verify the results of the procedure. MATERIAL AND METHODS: Of a total of 650 adrenalectomies, 22 (3.4%) were adrenal cortex-sparing surgeries. There were 16 women and six men in this group. In 10 cases, surgery was performed for pheochromocytoma, eight cases involved Conn's syndrome, and in four cases - paragangliomas located in the para-adrenal region. Secretory activity was identified in all cases. RESULTS: Laparoscopic partial adrenalectomy was performed in 20 patients. Conversion to open laparotomy was necessary in two cases. In patients after bilateral resection of pheochromocytoma surgery, glucocorticoids were supplemented for six weeks. No significant surgical complications were observed in this group. CONCLUSIONS: Partial adrenalectomy for minor lesions should be a much more commonly utilised treatment method (of choice). Where bilateral adrenalectomy is necessary, a sparing procedure on one side protects patients from the need for hormonal substitution. The remaining part of the adrenal gland undertakes satisfactory secretory function after six weeks at the latest.

Can the Use of Video-Based Interventions Increase Public Knowledge About Endocrine Surgeons?

BACKGROUND: Endocrine surgery (ES) is a relatively young subspecialty of general surgery, and prior research has shown low public awareness of these specialists' roles. We hypothesized that a video-based intervention could increase public knowledge of the specialty in an effective and efficient manner. METHODS: Participants were recruited at three public locations (a farmer's market, a public park, and a university hospital) and were given a three-question survey to assess baseline knowledge of ES. They then watched one of two video-based educational interventions and completed an identical postintervention survey. Two surveyors recruited 80 individuals per site, with 40 participants in each intervention group. Participants' sex and age and whether or not they were on clinical staff at the University of Alabama at Birmingham were recorded. RESULTS: A total of 240 participants were recruited; 61.3% female with median age 40 y. Preintervention, only 42.1% of participants could correctly define ES. ES were confused with endocrinologists by 44.6%, which was not different between sites (P = 0.09). Significantly, more participants at all sites could correctly define ES postintervention (67.9% versus 42.1%; P < 0.001). Clinical staff did not perform better than the lay public at any location (P = 0.32). The long video had a significantly greater increase in correct responses compared with the short video overall (32.5% versus 19.1%; P < 0.001) and at each location. CONCLUSIONS: This study confirms the public's general lack of knowledge about ES and their scope of practice. A video-based intervention was successful in improving knowledge of the practice of ES, with a longer, explanatory video being most effective.

The revised clinical practice guidelines on the management of thyroid tumors by the Japan Associations of Endocrine Surgeons: Core questions and recommendations for treatments of thyroid cancer.

The Japan Associations of Endocrine Surgeons has developed the revised version of the Clinical Practice Guidelines for Thyroid Tumors. This article describes the guidelines translated into English for the 35 clinical questions relevant to the therapeutic management of thyroid cancers. The objective of the guidelines is to improve health-related outcomes in patients with thyroid tumors by enabling users to make their practice evidence-based and by minimizing any variations in clinical practice due to gaps in evidential knowledge among physicians. The guidelines give representative flow-charts on the management of papillary, follicular, medullary, and anaplastic thyroid carcinoma, along with recommendations for clinical questions by presenting evidence on the relevant outcomes including benefits, risks, and health conditions from patients' perspective. Therapeutic actions were recommended or not recommended either strongly (◎◎◎ or XXX) based on good evidence (😊)/good expert consensus (+++), or weakly (◎, ◎◎ or X, XX) based on poor evidence (😣)/poor expert consensus (+ or ++). Only 10 of the 51 recommendations given in the guidelines were supported by good evidence, whereas 35 were supported by good expert consensus. While implementing the current guidelines would be of help to achieve the objective, we need further clinical research to make our shared decision making to be more evidence-based.

Transoral endocrine surgery: Considerations for adopting a new technique.

Transoral endocrine surgery encompasses a group of operations whereby the thyroid or parathyroid gland is removed through the oral vestibule. This operation has the advantage of leaving no cutaneous scar and a risk profile similar to open surgery. Adoption of this technique has increased dramatically over the last several years. It is of paramount importance for surgeons to undergo adequate training before adopting this technique.

Metastatic pheochromocytoma and paraganglioma: Management of endocrine manifestations, surgery and ablative procedures, and systemic therapies.

Metastatic pheochromocytomas and paragangliomas (MPPGs) are rare neuroendocrine tumors. Most patients present with advanced disease that is associated with manifestations of catecholamine release. Surgical resection of the primary tumor and ablative therapies of metastases-whenever possible-may improve clinical outcomes and, perhaps, lengthen the patient's overall survival. Significant steps in understanding the genetic alterations linked to MPPGs and scientific progress made on cancers that share a similar pathogenesis are leading to the recognition of potential systemic therapeutic options. Data derived from clinical trials evaluating targeted therapies such as tyrosine kinase inhibitors, radiopharmaceuticals, immunotherapy, and combinations of these will likely improve the outcomes of patients with advanced and progressive MPPGs. Exemplary of this success is the recent approval in the United States of the high-specific-activity iodine131 meta-iodine-benzylguanidine (MIBG) for patients with unresectable and progressive MPPGs that express the noradrenaline transporter. This review will discuss the therapeutic approaches for patients with MPPGs.

Training in endocrine surgery.

BACKGROUND/PURPOSE: In Europe, the Division of Endocrine Surgery (DES) determines the number of operations (thyroid, neck dissection, parathyroids, adrenals, neuroendocrine tumors of the gastro-entero-pancreatic tract (GEP-NETs)) to be required for the European Board of Surgery Qualification in (neck) endocrine surgery. However, it is the national surgical boards that determine how surgical training is delivered in their respective countries. There is a lack of knowledge on the current situation concerning the training of surgical residents and fellows with regard to (neck) endocrine surgery in Europe. METHODS: A survey was sent out to all 28 current national delegates of the DES. One questionnaire was addressing the training of surgical residents while the other was addressing the training of fellows in endocrine surgery. Particular focus was put on the numbers of operations considered appropriate. RESULTS: For most of the operations, the overall number as defined by national surgical boards matched quite well the views of the national delegates even though differences exist between countries. In addition, the current numbers required for the EBSQ exam are well within this range for thyroid and parathyroid procedures but below for neck dissections as well as operations on the adrenals and GEP-NETs. CONCLUSIONS: Training in endocrine surgery should be performed in units that perform a minimum of 100 thyroid, 50 parathyroid, 15 adrenal, and/or 10 GEP-NET operations yearly. Fellows should be expected to have been the performing surgeon of a minimum of 50 thyroid operations, 10 (central or lateral) lymph node dissections, 15 parathyroid, 5 adrenal, and 5 GEP-NET operations.

Parathyroid surgery: an evidence-based volume-outcomes analysis : European Society of Endocrine Surgeons (ESES) positional statement.

BACKGROUND: The interest in correlation between hospital and surgeon practice volume and postoperative outcomes has grown considerably over the last decades; it has been suggested that surgery is likely to be associated with higher cure rates, lower morbidity and more favourable results in cost-effectiveness when performed in a high-volume setting. The aim of this paper is to undertake an evidence-based literature review of the relationship between surgical volume and clinical outcomes in parathyroidectomy for primary hyperparathyroidism. We used accepted quality markers to identify the relationship between volume and outcome with a view to defining a reproducible minimal surgical volume-related standard of care in parathyroid surgery. METHODS: A peer review literature analysis of volume and outcomes in parathyroid surgery was carried out and assessed from an evidence-based perspective. Results were discussed at the 2019 Conference of the European Society of Endocrine Surgeons devoted to "Volumes, Outcomes and Quality Standards in Endocrine Surgery". RESULTS: Literature reports no prospective randomised studies; thus, a low level of evidence may be achieved. CONCLUSIONS: Parathyroid surgery is at increased risk of failures, morbidity and need for reoperations and cost when performed in low-volume settings; thus, it should be concentrated in dedicated settings, with adequate annual volume and expertise. Acceptable results may be achieved moving parathyroid surgery cases away from low-volume settings (< 15 parathyroidectomies/year). Challenging procedures (primary hyperparathyroidism without unequivocal preoperative localization, hereditary variants, paediatric patients, reoperations) should be confined to high-volume settings (> 40 parathyroidectomies/year).

Surgical approaches and results of treatment for hereditary paragangliomas.

Paragangliomas (PGL) are rare neuroendocrine tumours; parasympathetic PGL are predominantly non-secreting and located at the skull base and neck, while sympathetic PGL are typically catecholamine-secreting and located at abdomino-pelvic level. Approximately 40% of PGL may be caused by germline mutations; hereditary variants should be suspected especially in case of positive family history, early onset, multifocal, or recurrent PGL. Significant genotype-phenotype correlation has been recognized, including syndromic presentation, location, multifocality and risk of malignancy. Surgical resection remains the only curative strategy, but the outcomes may be unsatisfactory because of surgical morbidity and recurrence rate. However, due to the rarity of the disease, most data derive from case-report or limited series. This paper was aimed to review the available literature on the epidemiology, diagnosis, clinical features, treatment of PGL in order to discuss the surgical approach and the results of treatment in hereditary PGL.

The Importance of Family History in the Management of Endocrine Disease.

Family history is an essential component of the workup of endocrine surgery patients. The family history can change the diagnosis, management, and follow-up of endocrine patients. Here we discuss the importance of family history, review familial endocrine disorders, and develop a list of pertinent questions to ask when taking a family history of patients with endocrine disorders.

Proper handling of the pyramidal lobe in minimal access thyroid procedures.

The thyroid gland is a butterfly-shaped gland located in the lower part of the anterior surface of the neck between the fifth cervical and the first thoracic vertebra. Usually, it consists of two lateral, almost symmetrical lobes, the connective isthmus and the pyramidal lobe. The pyramidal lobe is a conical or cylindrical projection of the gland's parenchyma that extends superiorly to the thyroid cartilage or the hyoid bone. Most often, it originates from the isthmus and it is located to the left of the middle line. It can be absent in up to 50% of the cases. From the time of Theodor Kocher who performed the first classic thyroidectomies, we are now entering the era of minimal access thyroid surgery where new techniques are devised in order to provide a better cosmetic result. The presence of the pyramidal lobe is a classic example of an anatomic variation of the thyroid gland that plays an important role in the completeness of a total thyroidectomy, especially when the procedure is carried out for an autoimmune or malignant disease. The pyramidal lobe can also increase the complexity of minimal access procedures that are nowadays applied for the removal of the thyroid gland. The purpose of this article is to outline the importance of the pyramidal lobe in minimal access thyroid surgery.

Surgical therapy of adrenal tumors: guidelines from the German Association of Endocrine Surgeons (CAEK).

BACKGROUND AND AIMS: Previous guidelines addressing surgery of adrenal tumors required actualization in adaption of developments in the area. The present guideline aims to provide practical and qualified recommendations on an evidence-based level reviewing the prevalent literature for the surgical therapy of adrenal tumors referring to patients of all age groups in operative medicine who require adrenal surgery. It primarily addresses general and visceral surgeons but offers information for all medical doctors related to conservative, ambulatory or inpatient care, rehabilitation, and general practice as well as pediatrics. It extends to interested patients to improve the knowledge and participation in the decision-making process regarding indications and methods of management of adrenal tumors. Furthermore, it provides effective medical options for the surgical treatment of adrenal lesions and balances positive and negative effects. Specific clinical questions addressed refer to indication, diagnostic procedures, effective therapeutic alternatives to surgery, type and extent of surgery, and postoperative management and follow-up regime. METHODS: A PubMed research using specific key words identified literature to be considered and was evaluated for evidence previous to a formal Delphi decision process that finalized consented recommendations in a multidisciplinary setting. RESULTS: Overall, 12 general and 52 specific recommendations regarding surgery for adrenal tumors were generated and complementary comments provided. CONCLUSION: Effective and balanced medical options for the surgical treatment of adrenal tumors are provided on evidence-base. Specific clinical questions regarding indication, diagnostic procedures, alternatives to and type as well as extent of surgery for adrenal tumors including postoperative management are addressed.

Somatosensory evoked potential: Preventing brachial plexus injury in transaxillary robotic surgery.

OBJECTIVES/HYPOTHESIS: The potential for brachial plexopathy due to arm positioning is a major concern regarding the robotic transaxillary approach. Intraoperative nerve monitoring via somatosensory evoked potential (SSEP) has been suggested to prevent such injury. In this study, we examined the use of SSEP in detecting imminent brachial plexus traction during robotic transaxillary thyroid and parathyroid surgery. STUDY DESIGN: Retrospective case series. METHODS: A analysis was performed for all patients undergoing robotic transaxillary surgery with continuous intraoperative SSEP monitoring at a North American institution between 2015 and 2017. A significant intraoperative SSEP change was defined as a decrease in signal amplitude of >50% or an increase in latency of >10% from baseline established during preoperative positioning. RESULTS: One hundred thirty-seven robotic transaxillary surgeries using SSEP monitoring were performed on 123 patients. Seven patients (5.1%) developed significant changes, with an average SSEP amplitude reduction of 73% ± 12% recorded at the signals' nadir. Immediate arm repositioning resulted in recovery of signals and complete return to baseline parameters in 14.3 ± 9.2 minutes. There was no difference in age (40.4 ± 9.4 years vs. 44.5 ± 13.4 years; P = .31) or body mass index (27.3 ± 3.7 kg/m2 vs. 26.9 ± 6.1 kg/m2 ; P = .79) between cases with and without SSEP change. Operative time was shorter for patients with significant SSEP change (131.6 ± 14.7 minutes vs. 146.5 ± 46.7 minutes; P = .048). There were no postoperative positional brachial plexus injuries. CONCLUSIONS: SSEP is a novel, safe, and reliable tool in detection of position-related brachial plexus neuropathy. Intraoperative monitoring using SSEP can play a vital role in early recognition and prevention of injury during robotic transaxillary thyroid and parathyroid surgery. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:2663-2668, 2019.

Financial implications of telemedicine visits in an academic endocrine surgery program.

BACKGROUND: Telemedicine is an emerging medium for the delivery of ambulatory care, but the reimbursement profile of telemedicine visits in the surgical setting has not been well studied. METHODS: A retrospective assessment of telemedicine encounters for thyroid and parathyroid conditions occurring from April 2015 to April 2017 was performed. Financial reimbursement from commercial payers for new and established patient visits were compared between telemedicine visits and in-person visits. Patient "savings" in terms of travel distance and drive time were calculated. RESULTS: A total of 290 telemedicine encounters were conducted; 7% were initial consultations, 47% were postoperative visits, and 45% were follow-up visits. The median patient age was 57 years. The median round-trip travel distance saved was 123.6 miles with estimated drive time of 2.4 hours per encounter. In 2% of cases, a second in-person visit within the 90-day global period occurred after a postoperative telemedicine encounter. Charges were filed for 67 encounters. The initial unpaid claims rate was 6%, which was consistent with the unpaid claims rate for in-person visits. The charge-to-collection ratio was comparable to that of in-person visits. There was a higher ratio of level 2 visits in the telemedicine encounters. Over the study period, 70 clinic hours were liberated via the use of telemedicine. CONCLUSION: Endocrine surgery telemedicine visits have the same level for level reimbursement profile as in-person visits. Down-coding and elimination of components of in-office physical examinations may lead to modest decreases in overall reimbursement. Other advantages include reallocation of clinic resources and decreased travel burden for patients.