Impact of fellowship training for specialists on thyroidectomy outcomes of patients with thyroid cancer.

We aimed to evaluate the impact of fellowship training (FT) for thyroid specialists on the outcomes of patients with thyroid cancer. We reviewed surgeries performed for thyroid cancer before (non-FT group) and after (FT group) fellowship training and compared several variables, including length of stay of patients, tumor diameter, surgical method, lymph node dissection, parathyroid implantation, surgical duration, intraoperative blood loss, and postoperative complications. Compared with the non-FT group, the FT group had a shorter hospital stay, more adequate fine needle aspiration biopsy of the thyroid, less intraoperative blood loss, higher rate of parathyroid implantation, higher lymph node dissection rate, and lower nerve injury and hypoparathyroidism rates. When the surgical duration was < 200 min and/or only central lymph node dissection was performed, the FT group had a lower incidence of postoperative complications than the non-FT group. When, the incidence of postoperative complications, including postoperative nerve injury and hypoparathyroidism. In conclusion, FT for thyroid specialists is beneficial for patients with thyroid cancer and may allow a shorter hospital stay and reduced incidence of postoperative complication. Accordingly, FT may facilitate a more appropriate surgical approach with a preoperative pathological diagnosis.

Parathyroid Allotransplantation: Report of Outcomes in 3 Patients.

BACKGROUND: Hypoparathyroidism is a relatively rare endocrine disorder defined as inadequate parathyroid hormone (PTH) secretion leading to a clinical syndrome characterized by hyperphosphatemia and hypocalcemia. This condition has high morbidity; patients present with a heterogeneous range of emotional, mental, and physical symptoms. We present our experience with PTH transplantation, using parathyroid glands surgically removed in the setting of secondary hyperparathyroidism, with a description of the clinical course, immunosuppressive management, and surgical technique. METHODS: Between 2017 and 2021, 3 patients underwent parathyroid allotransplantation at the University of Illinois at Chicago. The 2 outcomes of interest were (1) symptomatic relief and improvement in calcium levels and (2) time to graft failure, defined as the presence of undetectable PTH levels. RESULTS: All 3 patients experienced dramatic improvement in their debilitating symptoms, even though 2 patients required repeated PTH transplantation procedures. One patient had a remarkable course with symptom resolution, normalization of PTH levels, and a great reduction in calcium supplementation. CONCLUSION: The use of hyperplastic glands from patients with secondary hyperparathyroidism undergoing 4-gland parathyroidectomy with autotransplantation represents an important source. However, a uniform definition of graft viability and prospective studies with long follow-ups are needed to address how much parathyroid tissue is optimally transplanted and the need for immunosuppression. Most patients affected by hypoparathyroidism are successfully managed by medical treatment; however, some do not respond to therapy and present debilitating symptoms related to hypocalcemia. This subgroup may benefit from parathyroid allotransplantation. Our 3 patients had remarkable improvement in their symptoms with the adoption of hyperplastic glands. Two out of 3 patients required multiple procedures to sustain symptom control.

[Clinical application of retrograde thyroidectomy from top to bottom in retrosternal thyroid surgery].

Objective:To investigate the value of retrograde thyroidectomy from top to bottom in the operation of retrosternal thyroid surgery. Methods:Retrospective analysis was performed on the cases of retrosternal goiter excised by our surgeons from January 2017 to June 2022,the technical points, feasibility and advantages of the operation were summarized. Results:A total of 15 cases of retrosternal goiter treated by retrograde thyroidectomy were collected, including 5 cases of type Ⅰ retrosternal goiter and 10 cases of type Ⅱ retrosternal goiter.The postoperative pathology was benign. The surgical time is 40-60 minutes for unilateral retrosternal goiter and 70-90 minutes for bilateral goiter. All patients were discharged normally within 7 days after operation, and no operative complications were observed such as bleeding, hoarseness or hypoparathyroidism. Conclusion:This surgical excision method of thyroid is suitable for the type Ⅰ and type Ⅱ retrosternal goiter surgery, which can avoid the difficulties in exposing and separating the the inferior thyroid behind the sternum in conventional surgical method, speed up the operation and reduced the difficulty of operation, and has certain promotion value in clinic.

Incidental parathyroidectomy is a frequent complication of thyroid surgery. A retrospective study of 3065 patients.

AIM: The aim of the present study is to investigate the incidence of accidental parathyroidectomy and the connection between the type of surgery, or the resected piece sent for histopathological examination and the number of accidentally excised parathyroid glands. MATERIAL AND METHODS: Patients who had thyroid surgery between January 2005 and December 2014 and were admitted to a surgery clinic from Targu Mures, Romania, were enrolled in this study. For statistical analysis we used Chi-squared test, Student's t-test and ANOVA test, with a p value < 0.05 considered statistically significant. RESULTS: A total of 3065 patients (315 males, 2750 females) were included in our study, with a mean age of 49.66±13.73. The frequence of incidental parathyroidectomy was 15.36%, most patients with IPT (88.95%) had only one parathyroid gland removed and we found a statistically significant association (p = 0.01) between the incidence of IPT and the type of surgery. DISCUSSION: Iatrogenic injury of the parathyroid glands cause hypoparathyroidism which can be transient in majority and permanent in 1.5% of the patients. The most frequent cases with accidental removal of the parathyroid glands were total and subtotal thyroidectomies (79.6%), respectively reinterventions or completion thyroidectomies (10.62%). CONCLUSIONS: Incidental parathyroidectomy is not uncommon following thyroid surgery, even in the hands of experienced surgeons and it is more often seen in female patients with polynodular goiter according to our study. Total thyroidectomies and reinterventions on the thyroid gland increase the risk of incidental parathyroidectomy. KEY WORDS: Incidental parathyroidectomy, Hypoparathyroidism, Parathyroid glands.

New Techniques for Intraoperative Parathyroid Localization.

Accurate identification of abnormal parathyroid glands (PGs) during parathyroidectomy and thyroidectomy can be challenging even for experienced surgeons given PGs variable location, size, and similar appearance to surrounding tissue. Inadvertent removal or devascularization of healthy PGs can lead to transient or permanent hypoparathyroidism. Permanent hypoparathyroidism is associated with increased rates of renal insufficiency, seizures, skeletal abnormalities, increased costs, decreased quality of life, and increased mortality. Conversely, the inability to identify and remove hyperfunctioning PGs results in failed parathyroidectomy which can result in need for reoperations that are associated with increased technical difficulty, operative duration, rates of hypoparathyroidism and recurrent laryngeal nerve damage, and cost.

Prophylaxis of postoperative hypoparathyroidism in thyroid surgery.

INTRODUCTION: There are a number of thyroid gland diseases that require surgical treatment. Therefore, it is important to improve the surgical approaches and treatment tactics in patients that need such surgery. AIM: To provide an algorithm to prevent parathyroid gland damage during surgery. MATERIALS AND METHODS: This work was based on treatment results of 226 patients with different thyroid diseases. All patients received extrafascial surgical interventions using modern methodological approaches. For prevention of postoperative hypoparathyroidism, we used the "stress-test", 5-aminolevulenic acid, and a method of double visual-instrumental registration of photosensitizer-induced fluorescence of parathyroid glands. RESULTS: Transient hypoparathyroidism was registered in four (1.8%) cases after surgery. Permanent hypocalcemia in patients was not recorded. Autotransplantation of parathyroid gland was required only in one case (0.44%). A deficiency or low level of vitamin D was detected in 35% of the cases, and in the majority of those cases, it was due to secondary hyperparathyroidism. The deficiency was corrected with the administration of vitamin D in all cases. In 10.17% (23 patients) of cases, there was no proper visual glow effect after administration of 5-aminolevulinic acid (5-ALA), which required proceeding to the second part of the proposed method (a helium-neon laser and registration of fluorescence using a laser spectrum analyzer). CONCLUSIONS: The proposed methodological approach allows prevention of persistent hypoparathyroidism and reduces the frequency of transient hypoparathyroidism and other complications in surgical treatment of patients with various thyroid gland diseases.

[Predictive value of PTH level on day 1 after surgery for papillary thyroid carcinoma in patients with permanent hypoparathyroidism].

Objective:To investigate the relationship between parathyroid hormone（PTH） level and permanent hypoparathyroidism（PHPP） on the first day after radical papillary thyroidectomy, and its predictive value. Methods:A total of 80 patients with papillary thyroid cancer who underwent total thyroid resection and central lymph node dissection were collected and analyzed from January 2021 to January 2022. According to whether PHPP occurred after surgery, the patients were divided into hypoparathyroidism group and normal parathyroid function group, and univariate and binary logistics regression were used to analyze the correlation between PTH and serum calcium levels and PHPP on the first day after surgery in two groups. The dynamic changes of PTH at different time points after operation were analyzed. The area under the receiver operating characteristic was used to evaluate the predictive power of PTH on the development of PHPP after surgery. Results:Among the 80 patients with papillary thyroid cancer, 10 cases developed PHPP, with an incidence rate of 12.5%. Binary logistics regression analysis showed that PTH on the first postoperative day（OR=14.534, 95%CI: 2.377-88.858, P=0.004） was an independent predictive risk factor for postoperative PHPP. Taking PTH=8.75 ng/L on the first postoperative day as the cut-off value, the AUC of the area under the curve was 0.874（95%CI: 0.790-0.958, P<0.001）, the sensitivity was 71.4%, the specificity was 100%, and the Yoden index was 0.714. Conclusion:PTH level on the first day after total thyroid papillary carcinoma surgery is closely related to PHPP, and is an independent predictor of PHPP.

Distribution of inadvertently excised parathyroid glands during thyroid surgery and the link with post-surgical hypoparathyroidism.

OBJECTIVES: To evaluate the incidence of inadvertent parathyroidectomy, identify risk factors, determine the location of inadvertently excised glands, review pathology reporting in inadvertent parathyroidectomy, and explore relationships between inadvertent parathyroidectomy and post-surgical hypoparathyroidism or hypocalcaemia. METHODS: A retrospective cohort study of 899 thyroidectomies between 2015 and 2020 was performed. Histopathology slides of patients who had an inadvertent parathyroidectomy and a random sample of patients without a reported inadvertent parathyroidectomy were reviewed. RESULTS: Inadvertent parathyroidectomy occurred in 18.5 per cent of thyroidectomy patients. Central neck dissection was an independent risk factor (inadvertent parathyroidectomy = 49.4 per cent with central neck dissection, 12.0 per cent without central neck dissection, p < 0.001). Most excised parathyroid glands were extracapsular (53.3 per cent), followed by subcapsular (29.1 per cent) and intrathyroidal (10.9 per cent). Parathyroid tissue was found in 10.2 per cent of specimens where no inadvertent parathyroidectomy was reported. Inadvertent parathyroidectomy was associated with a higher incidence of six-month post-surgical hypoparathyroidism or hypocalcaemia (19.8 per cent who had an inadvertent parathyroidectomy, 7.7 per cent without inadvertent parathyroidectomy). CONCLUSION: Inadvertent parathyroidectomy increases the risk of post-surgical hypoparathyroidism or hypocalcaemia. The proportion of extracapsular glands contributing to inadvertent parathyroidectomy highlights the need for preventative measures.

Novel suspension system for gasless transoral vestibular thyroidectomy.

BACKGROUND: The transoral endoscopic thyroidectomy vestibular approach (TOETVA) is receiving increased attention, frequently due to growing requirements for cosmetic incisions. Here, we report our initial experience and discuss the safety and efficacy of the innovative surgical working space suspension system for gasless TOETVA. METHODS: We retrospectively analyzed 75 consecutive patients for whom gasless TOETVA with our novel working space suspension system was used. This suspension system included self-developed retractors, a sterile bandage, and an anesthesia stand. We also improved some main surgical instruments in gasless TOETVA. RESULTS: The study included 75 patients who successfully underwent thyroidectomy and central neck dissection via gasless TOETVA. The mean operating time was 143.27 ± 34.60 min. The mean number of retrieved lymph nodes was 8.00 ± 5.39. Conversion to open surgery did not occur, nor did patients exhibit serious postoperative complications. Postoperative complications included 4 cases of transient recurrent laryngeal nerve (RLN) palsy, 9 of transient hypoparathyroidism, and 3 of transient mental nerve injury. One patient with subcutaneous fluid after surgery recovered after aspiration. Another patient with submental minor perforation recovered well after suturing. There was no evidence of specific complications related to self-designed retractors. CONCLUSION: The innovative working space suspension system for gasless TOETVA provided enough and stable working space and optimized the clarity of the surgical field without CO2-related complications.

Outcomes of Early Versus Delayed Completion Thyroidectomy for Malignancy.

PURPOSE: To determine whether time interval between hemi-thyroidectomy and subsequent completion thyroidectomy impacts outcomes. METHODS: Retrospective review of 68 patients having completion thyroidectomy from August 2012 to December 2019. Patients were separated into two groups based on the time interval between surgeries: early (≤10 days) or delayed (≥90 days). RESULTS: Patients who underwent delayed completion thyroidectomy (n = 17) had significantly higher rates of hypocalcemia and/or hypoparathyroidism (P = .03) and higher rates of requiring postoperative hospitalization (P=.07) compared to those who underwent early completion thyroidectomy (n = 51). Delayed completion had significantly lower risk of developing one or more of dysphonia, dysphagia, or vocal cord paresis postoperatively (P=.02). No patients developed hematoma or wound infection. CONCLUSIONS: Delayed completion thyroidectomy is associated with increased rates of hypocalcemia, but lower rates of dysphonia and dysphagia. Given the low risk of long-term complications in both groups, it may be beneficial to perform completion thyroidectomy early in order to expedite cancer treatment.

Predictive value of PTH level on day 1 after surgery for papillary thyroid carcinoma in patients with permanent hypoparathyroidism / 临床耳鼻咽喉头颈外科杂志

Objective:To investigate the relationship between parathyroid hormone（PTH） level and permanent hypoparathyroidism（PHPP） on the first day after radical papillary thyroidectomy, and its predictive value. Methods:A total of 80 patients with papillary thyroid cancer who underwent total thyroid resection and central lymph node dissection were collected and analyzed from January 2021 to January 2022. According to whether PHPP occurred after surgery, the patients were divided into hypoparathyroidism group and normal parathyroid function group, and univariate and binary logistics regression were used to analyze the correlation between PTH and serum calcium levels and PHPP on the first day after surgery in two groups. The dynamic changes of PTH at different time points after operation were analyzed. The area under the receiver operating characteristic was used to evaluate the predictive power of PTH on the development of PHPP after surgery. Results:Among the 80 patients with papillary thyroid cancer, 10 cases developed PHPP, with an incidence rate of 12.5%. Binary logistics regression analysis showed that PTH on the first postoperative day（OR=14.534, 95%CI: 2.377-88.858, P=0.004） was an independent predictive risk factor for postoperative PHPP. Taking PTH=8.75 ng/L on the first postoperative day as the cut-off value, the AUC of the area under the curve was 0.874（95%CI: 0.790-0.958, P<0.001）, the sensitivity was 71.4%, the specificity was 100%, and the Yoden index was 0.714. Conclusion:PTH level on the first day after total thyroid papillary carcinoma surgery is closely related to PHPP, and is an independent predictor of PHPP.

Predictors of impaired effectiveness of carbon nanoparticle-based central lymph node tracing in patients who underwent surgery for papillary thyroid cancer: A retrospective cohort study.

Carbon nanoparticles (CNs) are used in papillary thyroid cancer (PTC) surgery to facilitate central lymph node dissection (CLND) and protect the parathyroid glands (PGs). However, some cases develop hypoparathyroidism after using CNs. This cohort study was undertaken to explore the predictors of the reduced effectiveness of CNs. Data on patients with PTC who underwent surgery wherein CNs were used during CLND were reviewed retrospectively. Patients who did not develop hypoparathyroidism and developed hypoparathyroidism were classified into Group A and B, respectively. Demographic and clinical characteristics were compared between the 2 groups. Univariate and multivariate logistic regression analysis were performed on related variables. The receiver operating characteristic curve was used to evaluate the predictors of the binary logistic model and the cutoff value of each predictor was obtained. A total of 265 patients were included. Compared with Group A, the patients in Group B had a higher body mass index (BMI) (P = .003), were more frequently associated with Hashimoto thyroiditis (HT) (P = .001), and tumors were larger in size (P = .026). Multivariate logistic regression analyses were performed on these variables and showed that HT (P = .001) and tumor size (P = .001) predicted the impaired role of CNs. CNs are not always useful in protecting PG function in patients who undergo CLND for PTC. In patients with coexisting HT (blood thyroid peroxidase antibody [TPOAb] level higher than 44.0 IU/mL or blood anti-thyroglobulin antibody [ATG] level higher than 125.0 IU/mL) or a tumor size exceeding 1.1 cm in diameter, the protective role of CNs may be impaired.

Gauze blotting technique: a novel method to identify parathyroid glands during thyroid surgery without tissue damage.

Hypoparathyroidism is a major complication of thyroid surgery. To avoid this complication, visual identification of the parathyroid glands is essential. However, its effectiveness depends heavily on the surgeon's expertise. Here, we describe a novel method, the gauze blotting technique, to immunochemically identify the parathyroid glands during thyroid surgery. Twenty-three patients who underwent thyroid lobectomy were enrolled in this study; 16 and 7 had benign and malignant thyroid diseases, respectively. After visually identifying candidate nodules for the parathyroid gland, a piece of dry gauze (5 mm × 10 mm) was applied to each tissue until it was moistened by exudates from the tissue. Pieces of gauze were also applied to the thyroid gland and adipose tissue located away from the candidate nodules. The gauze was immersed in saline, and the intact PTH (i-PTH) level of the supernatant was measured. The median PTH level for the parathyroid glands was 1,060 pg/mL, which was significantly higher than that for the thyroid gland (34 pg/mL) and adipose tissue (28 pg/mL) (p < 0.001). The cut-off value to distinguish the parathyroid gland from other tissues was 68 pg/mL with a positive predictive value, negative predictive value, sensitivity, and specificity of 84.6%, 88.8%, 86.8%, and 86.7%, respectively. A value ≥250 pg/mL yielded a 100% positive predictive value. Our novel gauze blotting technique can identify the parathyroid glands without damaging tissues during thyroid surgery.

[Research progress of autofluorescence imaging of parathyroid glands].

The main causes of hypoparathyroidism are unintentional parathyroidectomy and/or impaired blood supply. Therefore, accurate identification and preservation of parathyroid glands in situ during thyroid or parathyroid surgery has become one of the problems that plague endocrine surgeons. In recent years, near-infrared autofluorescence imaging technology has gradually attracted more and more attention from surgeons because of its simplicity, safety, accuracy, real-time, no-contrast agent, and non-invasiveness. This article reviews the development history, clinical application, and application prospects of the parathyroid gland autofluorescence imaging technology in recent years.

Parathyroid allotransplantation for the treatment of permanent hypoparathyroidism: A systematic review.

BACKGROUND: Hypoparathyroidism is the most common complication of bilateral operations in the central neck. No formal guidelines exist for the management of permanent hypoparathyroidism. Current treatment involving medical supplementation increases resource utilization and patient morbidity while decreasing quality of life. Parathyroid allotransplant (PA) offers a promising therapy; however, the optimal technique and role of immunosuppression (IS) in PA remain unclear. METHODS: We performed a systematic search of the Embase, MEDLINE, and Cochrane Library databases to identify studies investigating PA for treatment of hypoparathyroidism. RESULTS: A total of 24 studies including 186 individual allograft transplants in 146 patients were identified. Pooled graft survival for allotransplants in transplant-naïve vs prior transplant recipients was 29.9% and 80%, respectively. CONCLUSIONS: PA using normocellular, fresh parathyroid donor tissue that is ABO-compatible, with induction and, at minimum, short-term maintenance IS presents a potentially safe and effective therapeutic option for permanent hypoparathyroidism in patients tolerating IS.

Complications of transoral endoscopic thyroidectomy vestibular approach (TOETVA).

The thyroidectomy is the most frequently executed procedure in head and neck surgery. Since its first description by Kocher, the transverse cervical incision has been the main access to the thyroid site, as it provides broad exposure of the central neck compartment. Despite the meticulous suture of the incision, the development of a scar with variable dimensions is unavoidable and, hence, some patients might not agree to the approach, due to this consequence. The transoral endoscopic thyroidectomy vestibular access (TOETVA) gains importance as an alternative to the traditional surgery, since it avoids the formation of visible scars. The objective of this study is to develop a systematic review on the currently available literature to evaluate possible complications related to the TOETVA. The systematic review was based on the databases of Medline, Cochrane library, Embase and Scielo/Lilacs, resulting in the selection of six studies, which were compared in regard of the type of study duration of the study and identified complications. Our study showed that TOETVA is related to complications similar to the ones identified in the conventional approach, such as hematoma, seroma, recurrent laryngeal nerve injury, hypoparathyroidism, surgical site infection. The TOETVA was associated to a higher risk of thermic injury of the skin and mentual nerve paresthesia. Moreover, it was possible to conclude that TOETVA is a safe procedure for well selected patients, with favorable conditions and concerned about the aesthetic outcome. The risk of complications of the procedure should always be explained to those patients.

Indocyanine Green Fluorescence Angiography Can Guide Intraoperative Localization During Parathyroid Surgery.

BACKGROUND AND AIMS: Intraoperative localization of pathologic parathyroid glands is of major importance for the hyperparathyroidism treatment. Based on the small size and the anatomic variability, the localization can be very challenging. The current practice is to compare preoperative ultrasonography with Technetium-99m sestamibi scintigraphy (MIBI) and plan the resection accordingly. In this study, we implemented indocyanine green angiography for the intraoperative localization of parathyroid glands. MATERIALS AND METHODS: This is a retrospective analysis of 37 patients with primary, secondary, or tertiary hyperparathyroidism who were operated using indocyanine green angiography for the intraoperative localization of pathological parathyroid glands. An indocyanine green solution of 2.5 mg was were intravenously administered for parathyroid gland visualization. Different fluorescence scores were correlated with changes in postoperative parathyroid hormone levels. RESULTS: Patients were divided into two groups depending on the presence of uniglandular or multiglandular disease. Sixty-four lesions were resected, and the final histopathologic analysis confirmed the parathyroid origin in 62 of them (96.8%). None of the patients with uniglandular disease developed postoperative hypoparathyroidism, whereas three patients in the multiglandular group developed temporary hypoparathyroidism symptoms. Indocyanine green imaging had higher sensitivity for the intraoperative detection of parathyroid glands compared with ultrasonography and MIBI (p < 0.001). CONCLUSION: Indocyanine green angiography indicated high sensitivity for the intraoperative identification of pathologic parathyroid glands leading to a resection rate of 95.16%. The modality was useful, especially in cases of revisional surgery or ectopic parathyroid glands. Randomized trials have already proven the value of indocyanine green imaging in predicting postoperative hypocalcemia. Our results support the regular use of this method during parathyroid surgery.

Parathyroid allotransplantation to treat post-thyroidectomy hypoparathyroidism: A review of case studies.

OBJECTIVE: Symptomatic long-term hypoparathyroidism following thyroid surgery requires an alternative and permanent therapy that would effectively restore parathyroid function and eliminate the need for substitution drug therapy. The aim of this study was to systematically review the literature on the efficacy and safety of parathyroid allotransplantation to treat post-operative hypoparathyroidism. METHODS: MEDLINE, Embase, BIOSIS and the Cochrane Library were searched for published articles (from inception of each database to September 30, 2018). A total of 9 studies comprising 146 patients (177 allotransplantations) with post thyroidectomy hypoparathyroidism were identified. RESULTS: Parathyroid tissues used for allotransplant were cultured parathyroid cells, cryopreserved parathyroid cells and encapsulated microspheres. Post-transplant immunosuppression was only reported in three studies, mainly with oral prednisolone for 2 weeks to 6 months. Mean graft survival following allotransplantation was 47% (95% CI 24%-71%) when patients were followed-up to 6 months and 41% (95% CI 2.3%-80%) at 12 months. There was significant unexplained heterogeneity observed between studies in both these groups (I2 > 50%). Parathyroid hormone (PTH) levels, and serum calcium levels post intervention was not reported in all studies, but available evidence suggests the levels remains higher (PTH level around 12 pg/ml; Ca level around 8 mg/dl) post-allotransplantation for up to 24 months. CONCLUSIONS: Long-term benefit and harms of allotransplantation is still unclear due to the clinical and statistical heterogeneity observed among the studies. Therefore, conduct of a well-designed controlled clinical trial in the immediate future on allotransplantation is of paramount importance.

Complications of transoral endoscopic thyroidectomy vestibular approach (TOETVA) / Tireoidectomia endoscópica transoral por acesso vestibular (TOETVA) e complicações

ABSTRACT The thyroidectomy is the most frequently executed procedure in head and neck surgery. Since its first description by Kocher, the transverse cervical incision has been the main access to the thyroid site, as it provides broad exposure of the central neck compartment. Despite the meticulous suture of the incision, the development of a scar with variable dimensions is unavoidable and, hence, some patients might not agree to the approach, due to this consequence. The transoral endoscopic thyroidectomy vestibular access (TOETVA) gains importance as an alternative to the traditional surgery, since it avoids the formation of visible scars. The objective of this study is to develop a systematic review on the currently available literature to evaluate possible complications related to the TOETVA. The systematic review was based on the databases of Medline, Cochrane library, Embase and Scielo/Lilacs, resulting in the selection of six studies, which were compared in regard of the type of study duration of the study and identified complications. Our study showed that TOETVA is related to complications similar to the ones identified in the conventional approach, such as hematoma, seroma, recurrent laryngeal nerve injury, hypoparathyroidism, surgical site infection. The TOETVA was associated to a higher risk of thermic injury of the skin and mentual nerve paresthesia. Moreover, it was possible to conclude that TOETVA is a safe procedure for well selected patients, with favorable conditions and concerned about the aesthetic outcome. The risk of complications of the procedure should always be explained to those patients.

RESUMO A tireoidectomia é o procedimento cirúrgico mais frequentemente realizado na cirurgia de cabeça e pescoço. Desde sua descrição por Kocher, a incisão cervical transversa constitui o principal acesso à loja tireoideana e permite ampla exposição à região central do pescoço. Apesar do fechamento meticuloso da incisão, uma cicatriz de dimensões variáveis é inevitável, e certos pacientes podem discordar de tal abordagem. A tireoidectomia vestibular endoscópica transoral (TOETVA) ganha importância como alternativa à cirurgia tradicional, pois evita a formação de cicatrizes visíveis. O objetivo de estudo é realizar uma revisão sistemática da literatura das possíveis complicações da TOETVA. Foi realizada revisão sistemática da literatura nas bases de dados Medline, The Cochrane Library, Embase e SciElo/Lilacs, sendo selecionados seis artigos e tabulados os dados de tipo de estudo, período do estudo e complicações apresentadas. O estudo mostra que a TOETVA apresenta complicações semelhantes à técnica convencional, como hematoma, seroma, lesão de nervo laríngeo recorrente, hipoparatireoidismo, além de infecção de sítio cirúrgico, com maior risco de lesão térmica da pele e parestesia por lesão do nervo mentual. Em adição, foi possível concluir que a TOETVA é uma técnica segura para pacientes bem selecionados, com condições favoráveis e com especial preocupação com resultados estéticos, devendo sempre ser orientados sobre possíveis complicações.

Neurologic Clinical Manifestations of Fahr Syndrome and Hypoparathyroidism.

A 41-year-old female with a history of chronic hypoparathyroidism with Fahr syndrome presented with complaints of weakness and muscle spasticity. Brain imaging demonstrated diffuse intracranial calcifications. In addition, cervical spine imaging revealed extensive calcification along the anterior and posterior cervical vertebral bodies causing multilevel stenosis and cord compression. The patient underwent a multilevel posterior cervical decompression and fusion. Postoperatively, the patient had noted improvement in her upper and lower extremity strength and spasticity. This illustrative case demonstrates rare clinical and radiographic neurologic sequelae of long-standing hypoparathyroidism.