Endocrine Surgery: Management of Postoperative Complications Following Endocrine Surgery of the Neck.

Cervical endocrine operations include parathyroidectomy, thyroid lobectomy, thyroidectomy, central neck dissection, and lateral neck dissection. The vital structures at risk include the recurrent laryngeal nerves to the intrinsic muscles of the larynx, additional cranial nerves, parathyroid glands essential for calcium homeostasis, aerodigestive structures, and great vessels. Here, the authors discuss complications of endocrine neck surgery, including cervical hematoma and other fluid collections, hypocalcemia from hypoparathyroidism, and nerve injuries, along with their prevention, mitigation, and management. Significant and permanent morbidity can result, but fortunately the overall rate of complications remains low, especially when surgery is performed by high-volume surgeons.

Outcome Squares Integrating Efficacy and Safety, as Applied to Functioning Pituitary Adenoma Surgery.

CONTEXT: Transsphenoidal surgery is standard care in the treatment of hormone-secreting pituitary adenomas. Current clinician-reported surgical outcome measures are one-dimensional, typically focusing primarily on complete or partial resection, and secondarily on complication rates. However, outcomes are best reflected by the delicate balance of efficacy and complications at patient level. OBJECTIVE: This study proposes a novel way to classify and report outcomes, integrating efficacy and safety at the patient level. METHODS: Retrospective chart review of all pure endoscopic transsphenoidal surgical procedures for acromegaly, Cushing's disease, and prolactinoma between 2010 and 2018 in a single tertiary referral center. We present our results in a classic (remission and complications separate) and in a novel outcome square integrating both outcomes, focusing on intended and adverse effects (long-term complications). This resulted in 4 outcome groups, ranging from good to poor. We use this approach to present these outcomes for several subgroups. RESULTS: A total of 198 surgical procedures were included (44 reoperations). Remission was achieved in 127 operations (64%). Good outcome was observed after 121 (61%), and poor outcome after 6 (3%) operations. When intended effect of surgery was applied (instead of remission), good outcome as intended was achieved after 148 of 198 surgeries (75%) and poor outcome after 4 (2%). CONCLUSION: Quality of a surgical intervention can be presented in 4 simple categories, integrating both efficacy and safety with flexibility to adapt to the individualized situation at patient, disease, and surgical strategy and to the outcome of interest.

Impact of opioid prescribing guidelines on prescribing at discharge from endocrine surgery.

INTRODUCTION: In 2018, our institution implemented opioid prescribing guidelines for endocrine surgery. METHODS: We evaluated prescribing trends before and after the guidelines (60 MME following adrenal procedures and 37.5 MME for thyroid/parathyroid procedures) using chi-squared and Wilcoxon Rank-Sum tests. RESULTS: We identified 357 patients in the pre-guideline and 397 in the post-guideline period. The proportion discharged with any opioid prescription decreased from 96.1% to 77.3%, p < 0.01, and the median (IQR) prescribed amount decreased from 150.0 (100.0, 200.0) to 50.0 (25.0, 75.0), p < 0.01 overall and within each category. The proportion receiving prescription above the upper guidelines limit also decreased, while opioid refills within 30-day of discharge remained stable (2.8% before and 4.5% after the guidelines, p = 0.21). CONCLUSION: Opioid prescribing guidelines for endocrine surgical procedures decreased both the proportion of patients receiving opioids and the amount when prescribed, therefore further supporting the utility of opioid prescribing guidelines in decreasing over-prescription.

Reducing Opioid Use in Endocrine Surgery Through Patient Education and Provider Prescribing Patterns.

BACKGROUND: Postoperative opioid use can lead to dependence, contributing to the opioid epidemic in the United States. New persistent opioid use after minor surgeries occurs in 5.9% of patients. With increased documentation of persistent opioid use postoperatively, surgeons must pursue interventions to reduce opioid use perioperatively. METHODS: We performed a prospective cohort study to assess the feasibility of a preoperative intervention via patient education or counseling and changes in provider prescribing patterns to reduce postoperative opioid use. We included adult patients undergoing thyroidectomy and parathyroidectomy from January 22, 2019 to February 28, 2019 at a tertiary referral, academic endocrine surgery practice. Surveys were administered to assess pain and patient satisfaction postoperatively. Prescription, demographic, and comorbidity data were collected from the electronic health record. RESULTS: Sixty six patients (74.2% women, mean age 58.6 [SD 14.9] y) underwent thyroidectomy (n = 35), parathyroidectomy (n = 24), and other cervical endocrine operations (n = 7). All patients received a preoperative educational intervention in the form of a paper handout. 90.9% of patients were discharged with prescriptions for nonopioid pain medications, and 7.6% were given an opioid prescription on discharge. Among those who received an opioid prescription, the median quantity of opioids prescribed was 135 (IQR 120-150) oral morphine equivalents. On survey, four patients (6.1%) reported any postoperative opioid use, and 94.6% of patients expressed satisfaction with their preoperative education and postoperative pain management. CONCLUSIONS: Clear and standardized education regarding postoperative pain management is feasible and associated with high patient satisfaction. Initiation of such education may support efforts to minimize unnecessary opioid prescriptions in the population undergoing endocrine surgery.

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.

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.

Hemodynamic instability during surgery for pheochromocytoma: comparing the transperitoneal and retroperitoneal approach in a multicenter analysis of 341 patients.

BACKGROUND: Intraoperative hemodynamic instability is a major challenge during adrenalectomy for pheochromocytoma. Typically, pheochromocytoma is performed laparoscopically either through the retroperitoneal or transperitoneal approach. We aimed to determine if the operative approach affects intraoperative hemodynamic instability during surgery for pheochromocytoma in a large multicenter multicenter cohort. METHODS: Retrospective, multicenter analysis of consecutive patients with pheochromocytoma who underwent total unilateral laparoscopic adrenalectomy without conversion were included. Statistical analysis was performed using established intraoperative criteria for intraoperative hemodynamic instability: 1) systolic blood pressure >160 mm Hg; 2) systolic blood pressure > 200 mm Hg; 3) mean arterial pressure <60 mm Hg; 4) systolic blood pressure >160 mm Hg + mean arterial pressure <60 mm Hg; and 5) systolic blood pressure >200 mm Hg + mean arterial pressure <60 mm Hg; and 6) intravenous vasopressor + vasodilator. RESULTS: In total, 341 patients met the inclusion criteria, 101 (29.6%) underwent retroperitoneal adrenalectomy and 240 (70.4%) transperitoneal adrenalectomy. Multivariate analysis showed that retroperitoneal adrenalectomy carries greater risk for mean arterial pressure <60 mm Hg (odds ratio 6.255, confidence interval 1.134-34.235, P = .035) compared with transperitoneal adrenalectomy. Overall and cardiovascular morbidity rates were comparable between the 2 approaches. The medical center was a significant independent influencing factor for all 6 intraoperative hemodynamic instability definitions. CONCLUSION: Variability in institutional management of pheochromocytoma intraoperatively has significant impact on all 6 intraoperative hemodynamic instability definitions. Standardization of anesthesia should be considered to reduce this variability.

Large and giant pituitary adenoma resection by microscopic trans-sphenoidal surgery: Surgical outcomes and complications in 123 consecutive patients.

To evaluate surgical outcomes and complications of patients who underwent microscopic trans-sphenoidal surgery (MTS) for large and giant pituitary adenomas (PAs). A retrospective study of electively operated cases of PA over a six year period was performed. Surgical outcomes and complications of 64 patients with large PAs (≥3cm) and 59 patients with giant PAs (>4cm), who underwent MTS at same period, were reviewed. Medical reports of all selected patients were assessed to collect demographic information such as age, sex, clinical symptoms, PA size, the extent of PA extension and resection, outcomes and complications. Patients with large PAs had improvement in visual improvement (78.1%; 50/64), gross total resection (84.4%; 54/64) compared to patients with giant PAs who had improvement in visual (71.2%; 42/59) and gross total resection (74.6%; 44/59). The rate of CSF leakage was 7.8% and 23.7% for large and giant PAs (p=0.0399). After a mean follow-up period of 40.8 (6-75) months, 10 (15.6%) patients with large PAs experienced tumor recurrence, while 2 giant PA patients (3.4%) experienced tumor recurrence after a mean follow-up period of 40.6 (3-70) months (p=0.0314). Resection of both large and giant pituitary adenomas by microscopic trans-sphenoidal surgery may be safe and effective surgical technique with low morbidity and mortality.

An update on the status of nerve monitoring for thyroid/parathyroid surgery.

PURPOSE OF REVIEW: Recurrent laryngeal nerve (RLN) injury is one of the most common and serious complications associated with thyroid and parathyroid surgery. Although routine visual identification of the RLN is considered the current standard of care, the role of intraoperative neuromonitoring (IONM) of the RLN is more controversial. RECENT FINDINGS: Despite initial enthusiasm that IONM might substantially reduce the rate of RLN injury, most studies failed to show a significant difference in the rate of RLN injury when the use of IONM was compared with visualization of the RLN alone. However, a small number of investigators have reported statistically significant differences in the rates of nerve injury when IONM is used to augment visualization alone, particularly in certain high-risk situations. Despite a lack of conclusive data showing benefit, the use of IONM as an adjunct to visual identification of the RLN has gained increasing acceptance among surgeons. IONM remains an excellent tool to help verify the identity of the RLN, confirm its functional integrity, and pinpoint the site of nerve injury in the event of dysfunction. SUMMARY: The utility of IONM in reducing the rate of RLN injury is largely unproven and remains controversial. However, the use of IONM may be helpful in certain high-risk cases. Promising new technology, such as vagal nerve monitoring, may allow more real-time monitoring of the functional integrity of the RLN and allow the surgeon to react in a timely manner to evolving dysfunction in order to abort maneuvers that may risk definitive injury.

Cervical hematoma following an endocrine surgical procedure: The MD Anderson experience.

BACKGROUND: Airway compromise from postoperative neck hematoma remains the most feared complication after cervical endocrine operative procedures. Events are rare and potentially lethal, and clear multidisciplinary guidelines for management of these patients are lacking. The aim of our study was to review the experience of a tertiary cancer center in this scenario. METHODS: Data prospectively collected over a 10-year period, between 2005 and 2014, were retrospectively analyzed. We included all adult patients who had had a neck operation and needed reoperation for postoperative neck hematoma after an endocrine procedure. We excluded pediatric patients and cases with incomplete records. RESULTS: The inclusion criteria were met for 21 patients (21/2,930; 0.7%). The median age at operation was 56.2 years (SD: 16.7). The M:F ratio was 1:2. All 21 patients presented with a neck swelling at the time of reoperation. Eight of 21 patients (38%) underwent emergency bedside clot evacuation. Presentation was within 6 hours for two thirds (14/21) of the patients; the remaining one third of the patients had the hematoma develop during the evening/night (from 1700-0500). The mean estimated hematoma size was 98 cc (SD: 58). A source of bleeding was identified in 12 of 21 cases (57%). A total of 15.8% of patients had an airway classified as difficult/awkward under the American Society of Anesthesiologists classification for their wound re-exploration. CONCLUSION: Postoperation, increased vigilance is needed for the first 6 hours to detect patients with neck swelling. Emergency drainage by the bedside was performed in 38% of patients. A difficult airway was uncommon in our series.

Health-related quality of life in patients treated for nonfunctioning pituitary adenomas during the years 2000-2010.

OBJECTIVE: The published data on health-related quality of life (HRQoL) after treatment of nonfunctioning pituitary adenomas (NFPAs) are conflicting. We evaluated HRQoL in a recent series of patients who had surgery for an NFPA. DESIGN: Cross-sectional study including a large control population. PATIENTS AND MEASUREMENTS: A HRQoL questionnaire (15D) was sent to all patients (n = 161) having undergone transsphenoidal surgery for NFPA in the years 2000-2010 at the Helsinki University Hospital. The 15D score and dimension scores of the study population (n = 137) were compared with those of a large (n = 4967) gender- and age-standardized control population. Possible independent predictors of HRQoL in the patients were estimated with multivariate regression analysis. RESULTS: Postoperatively, 57% of the patients had normal visual function. After a mean follow-up of 7·4 ± 3·2 years (mean ± SD), 62% suffered from hypopituitarism. Overall, HRQoL was near-normal in patients compared to controls (15D scores 0·885 ± 0·114 vs 0·903 ± 0·093, respectively, P = 0·07). On single dimensions, patients had impaired vision and sexual activity (both P < 0·0005), more depression and distress (both P < 0·005) and less discomfort and symptoms (P < 0·05). Age, body mass index, diabetes, depression and reoperation were independent predictors of impaired HRQoL (all P < 0·05). Thyroxine substitution was associated with impaired and hydrocortisone and testosterone substitution (males only) with better HRQoL (all P < 0·05). CONCLUSIONS: This recent series of NFPA patients demonstrates that overall HRQoL is near-normal after medium term follow-up; the most impaired dimensions were in vision and sexual activity. Comorbidities are strong predictors of impaired HRQoL.

Possibilities of surgical correction of vocal cord palsy after thyroid gland operations.

INTRODUCTION: Surgery of the thyroid gland remains the main cause of bilateral vocal cord palsy (VCP). Ventilation problem is the main problem in such situations. There are a couple of corrective surgical procedures in the case of VCP. The aim of our study was to show the possibility of widening of the glottis, and to evaluate the techniques and effects of surgical treatments due to bilateral VCP resulting from thyroid gland surgery. MATERIAL AND METHODS: Five methods of surgical treatment were used: laser-assisted posterior cordectomy, according to Denis and Kashima; laser-assisted bilateral medial arytenoidectomy, as proposed by Crumley; laser-assisted posterior ventriculocordectomy, as described by Pia; laser-assisted total arytenoidectomy with posterior cordectomy, as presented by Ossoff; and laterofixation, according to Lichtenberger. The postoperative patient's subjective improvement was assessed using visual analogue scale. RESULTS: Between 1998 and 2014 we operated on 270 patients with bilateral VCP. Paresis occurred as the result of the iatrogenic effect of thyroid gland surgery in 255 patients (94.4%) vs. 15 (7.6%) from other causes. The majority of our patients (77.6%) had undergone laser arytenoidectomy with posterior partial cordectomy, and in 13.7% of them Lichtenberger laterofixation had been performed. Ossoff 's surgery gives good ventilation results: successful decannulation (62.9% after first surgery; 97.6% final rate) and significant subjective ventilation improvement in 96% of patients. CONCLUSIONS: Ossoff 's laser arytenoidectomy with posterior cordectomy is a safe procedure that gives acceptable ventilation improvement. Patients report satisfactory quality of life and the possibility of returning to active professional life. Laterofixation should be considered as an alternative for tracheotomy rather than permanent procedure.

Intrasellar abscess following pituitary surgery.

PURPOSE: Intrasellar abscess is an uncommon cause of mass lesions in the sella turcica. Few cases have been reported in the literature, and much remains unknown about the etiology and diagnosis of these lesions. We sought to review a series of patients with intrasellar abscess encountered at our institution and identify defining characteristics of their presentation and management. METHODS: We conducted a retrospective chart review for intrasellar infection cases associated with a mass lesion. Included cases had clear demonstration of a mass lesion on imaging with subsequent positive microbiological cultures. Clinical presentation, management, post-operative course, neuroimaging, microbiology, and any perturbations in serum pituitary biochemical markers were examined. RESULTS: All examined patients had a history of antecedent transsphenoidal pituitary surgery within the preceding 10 months. All presented with headaches, three with progressive visual loss, one with meningismus, one with fever in the setting of an active cerebrospinal fluid leak, and one with fever, meningismus, hypotension, and progressive somnolence. No patient presented with acute endocrine abnormalities. A majority did not initially have any diffusion restriction present on MRI, but in one case we were able to track the evolution of diffusion restriction over sequential MRI scans. Two patients had complete resolution of presenting symptoms, while three experienced improvement or stabilization of their neurologic deficit. There were no mortalities. CONCLUSIONS: Pituitary abscess remains a rare diagnosis that can be difficult to make and to confirm. In our series we found a strong association between culture-positive abscess and recent pituitary surgery. When present, prompt treatment with surgical drainage and aggressive post-operative antibiotics can lead to a favorable outcome.

Perioperative kinetics of parathyroid hormone in unilateral, primary thyroid surgery.

Dysfunction of the parathyroid glands is an important cause of complications after thyroid surgery. Intraoperative monitoring of the function of the parathyroid glands can be performed using parathyroid hormone (PTH) kinetics. Unilateral thyroid surgery is associated with a decreased risk for postoperative hypocalcemia (POH) and permanent hypoparathyroidism (PEH). We focused on unilateral thyroid surgery by monitoring the functionality of the parathyroid glands and comparing the perioperative PTH kinetics of patients with and without POH. In a prospective study, 143 patients scheduled for unilateral thyroid surgery underwent monitoring of perioperative changes in serum PTH and serum calcium levels, and of clinical symptoms of hypocalcemia. The rates of POH and PEH were 18.2 and 0%, respectively. In patients without POH, PTH significantly increased from the time of skin incision to the end of the operation and after the operation (20.1 pg/ml, IQR 15.5-26.8 vs. 21.4 pg/ml, IQR 16.4-29.5; p=0.005), which was not the case in patients who developed POH. In a multivariate analysis of predictive factors for POH, two parameters became significant, namely female gender (odds ratio 6.87, 95% confidence interval 0.92-51.01) and lower initial serum calcium levels (odds ratio 3.54*e(-8), 95% confidence interval 3.63*e(-12); 0.00). The rate of POH was unexpectedly high. Rather than intraoperative PTH declines, an unstable balance of factors that influence calcium metabolism likely is the major contributor to POH after unilateral thyroid surgery. There was no case of PEH after unilateral, primary thyroid surgery, which underlines the need for an individualized approach to the extent of resection.

Risk scoring can predict readmission after endocrine surgery.

BACKGROUND: Hospitals and surgeons simultaneously are pressured to decrease readmissions and duration of stay. We hypothesized that readmissions after endocrine surgery could be predicted by using a novel risk-score. METHODS: The National Surgical Quality Improvement Program database was queried for cervical endocrine operations performed during 2011 and 2012. The primary end point was unplanned readmission within 30 days. Multivariable logistic regression was used to create and validate a scoring system to predict unplanned readmissions. RESULTS: Overall, 34,046 cases were included with a readmission rate of 2.8% (n = 947). The most frequent reasons for readmission were hypocalcemia (32.4%) surgical-site infection (8.4%), and hematoma (8.0%) (2012 data only). The readmission risk score was created using the following factors: thyroid malignancy, hypoalbuminemia, renal insufficiency, American Society of Anesthesiologists class, and duration of stay >1 day. Predicted readmission rate by number of risk factors was 1.7 % for 0 risk factors, 3.2% for 1 risk factor (5-11 points), 5.8% for 2 risk factors, 10.5% for 3 risk factors, and 18.0% for 4 risk factors. The model had good predictive ability with c = 0.646. CONCLUSION: Readmissions after cervical endocrine operations can be predicted. This risk score could be used to direct resource use for preoperative, inpatient, and outpatient care delivery to reduce readmissions.

[Methods for the surgical treatment of chronic sphenoiditis and ethmoiditis].

The objective of the present study was to design tools for the enhancement of safety of the surgical instruments used in the treatment of chronic sphenoiditis and ethmoiditis. The proposed instruments for endonasal surgery on sphenoidal sinuses and posterior cells of the ethmoidal labyrinth make it possible to improve the quality of surgical interventions, decrease their duration , and reduce the risk of damage to the important anatomical structures. The instruments were used for the surgical treatment of 120 patients that produced no complications. 98 patients were followed up for 3 years; five of them (5.2%) developed relapses compared with 38 (24.2%) patients operated by the traditional techniques. It is concluded that the proposed surgical instruments for the treatment of sphenoidal sinuses and posterior cells of the ethmoidal labyrinth help to increase the effectiveness and safety of surgical interventions on these structures.

Morbidity following thyroid surgery: does surgeon volume matter?

PURPOSE: The aim of our study was to analyze the relationship between surgeon volume and morbidity in patients operated on by surgeons with endocrine specialization (EndS group) and those operated on by general surgeons (GenS group) in a single tertiary institution. METHODS: We present the results of a prospective cohort study of all patients undergoing thyroid surgery in our institution between January 2008 and January 2010, all of whom attended for follow-up for at least 12 months. We assessed pre- and postoperative recurrent laryngeal nerve (RLN) function by laryngoscopy. We monitored serum calcium concentrations in all patients until these values were normal without vitamin D and oral calcium supplementation. RESULTS: We studied 225 patients: 30 in the GenS group (six surgeons performing <5 procedures per surgeon per year) and 195 in the EndS group (two surgeons performing >40 procedures per surgeon per year). The total number of exposed RLN was 46 and 325, respectively. The incidence of RLN palsy persisting beyond 12 months was higher in the GenS group (2/46 vs. 1/325 exposed RLNs, p = 0.04). The incidence of hypocalcaemia persisting beyond 12 months (bilateral procedures) was also higher in the GenS group (3/16 vs. 3/130 patients, p = 0.028). CONCLUSIONS: Morbidity in terms of permanent RLN palsy and hypocalcaemia was less frequent among patients operated on by endocrine-dedicated surgeons. Differences in surgical volume and specialized training in neck endocrine surgery may explain these variations in morbidity.

[Review of 300 cases of parotidectomy for benign parotid tumors].

OBJECTIVE: The objective of this study was to analyze the diagnosis and postoperative complications of benign parotid tumors for a series of 300 patients who underwent the same diagnostic methods and operation procedure in a single institute. MATERIALS & METHODS: A series of 300 patients who underwent primary parotidectomy for benign parotid tumors over a 12-year period was reviewed. RESULTS: There were 145 female and 155 male paitents. The site of the tumors was divided into three groups, superficial, deep, and lower pole tumor. The number of each type of the tumor was 152, 45, 103 cases, respectively. The most common pathology of the parotid tumor was a pleomorphic adenoma (147 cases) followed by a Warthin tumor (111 cases). Pleomorphic adenomas and Warthin tumors accounted for 86% of all benign tumors. The accuracy rate of fine needle aspiration cytology (FNAC) for all benign tumors was 66%, 80% for pleomorphic adenoma and 67% for Warthin tumor. Transient facial nerve dysfunction was observed in 63 patients (20.3%) in all benign parotid tumors, and no patients developed a permanent weakness. The incidence of transient facial nerve dysfunction was 16.4% in superficial tumors, 55.3% in deep tumors, and 10.7% in lower pole tumors. Significant risk factors for development of a transient facial palsy were the site of tumors, operation time, and bleeding volume. Transient facial nerve dysfunction recovered with 1.7 months and 2.8 months in superficial and deep tumors, respectively. CONCLUSIONS: The accuracy rate of FNAC for benign parotid benign tumors was 66%. The incidence of transient facial nerve dysfunction in deep tumors was significantly higher compared to that in superficial and lower pole tumors. According to the rate of facial palsy, operation time, and bleeding volume, benign parotid tumor should be divided into three groups, superficial, deep, and lower pole tumors.