Transoral endoscopic parathyroidectomy vestibular approach (TOEPVA) for primary hyperparathyroidism: Turkey's experience.

AIM: Parathyroid surgery has witnessed a significant evolution with the introduction of more efficacious preoperative localization imaging techniques and the use of rapid intraoperative parathormone assays. Parathyroid surgery can now be performed with the minimum of invasion. Through the adaptation of the transoral endoscopic thyroidectomy vestibular approach (TOETVA), the technique has now been adopted for parathyroid surgery, known as the transoral endoscopic parathyroidectomy vestibular approach (TOEPVA). We present here the initial experiences of 11 centers carrying out TOEPVA surgery in Turkey. MATERIALS AND METHODS: Participating in the study were 11 centers, all of which were tertiary care institutions carrying out endocrine surgery. A retrospective review was made of 35 primary hyperparathyroidism patients who underwent the TOEPVA procedure between July 2017 and January 2020. RESULTS: Of the total 35 patients, 32 patients underwent the TOEPVA procedure successfully. All patients but one were female, and the mean age was 47.2 (20-73) years. According to localization studies, 18 of the lesions were lower left, 12 were lower right, 3 were upper right and 2 were upper left. The mean operative time was 116 (30-225) min, and three cases were converted to an open procedure. Simultaneous thyroidectomy was performed in seven cases. The average PTH level dropped to normal within 20 min. after the resection in all cases. The complication rate was 19% (ecchymosis, subcutaneous emphysema, nasal bleeding, surgical site infection and seroma). There were neither recurrent nerve palsies, nor mental nerve root or branch injuries. The average hospital stay was 1 day. No persistence was documented on follow up. CONCLUSION: TOEPVA is a "hidden scar" parathyroidectomy procedure that can be safely performed on parathyroid adenomas, in cases that have scar-related concerns. Having its own procedure-related complications, the procedure provides satisfactory objective results, particularly in centers experienced in endoscopic and endocrine surgery.

Transient asystole related to carbon dioxide embolism during transoral endoscopic parathyroidectomy vestibular approach.

BACKGROUND: Rarely, during the endoscopic thyroidectomy, carbon dioxide (CO2 ) embolism may occur. METHODS: Case 1: A 65-year-old female who was seen with prolonged fatigue and generalized bone pain was diagnosed primary hyperparathyroidism (PHPT) based on her preoperative biochemical profile. Transoral endoscopic parathyroidectomy vestibular approach (TOEPVA) was planned. Case 2: A 52-year-old male patient was seen with weakness and hepatosteatosis and was diagnosed PHPT based on the laboratory workup. TOEPVA was planned. RESULTS: After subplatysmal dissection with vascular tunnel probe, both of the patients developed severe bradycardia and hypotension leading to asystole during the CO2 insufflation. The possibility of CO2 embolism was considered and insufflation was terminated. After a successful cardiac massage, sinus rhythm returned. CONCLUSION: TOEPVA may develop CO2 embolism leading to asystole during the CO2 insufflation.

Association between Tumor Size and Malignancy Risk in Hormonally Inactive Adrenal Incidentalomas.

Introduction Adrenal incidentalomas (AI) are adrenal masses that are discovered during radiological examinations conducted for other reasons. In this study, we focused on the pathological and radiological properties of nonfunctional AI(NFAI) and the association with malignancy risk in our clinical series. Methods A total of 186 patients underwent adrenalectomy between 2010 and 2017; of these, 76 (40.8%) patients with non-functional AI were included in the current study. The radiological and pathologic characteristics of these AIs were retrospectively analyzed to determine the malignancy rate. Results There were 22 (28.9%) male and 54 (71.1%) female patients with nonfunctional AI included in this study. The median age was 55 (range: 24-85) years. Of the patients included, 37 (48.6%) had AI on the left and 39 (51.3%) had AI on the right adrenal gland. Sixty-one (80.2%) cases were treated laparoscopically, four (5.3%) required conversion to open surgery due to intraoperative difficulties such as bleeding and adhesions, and 11 (14.4%) were managed with open adrenalectomy. The rate of malignancy in the tumors with diameters of <4 cm, 4-6 cm, and >6 cm was found to be 0%, 2.9%, and 13.6%, respectively. Conclusions Determining the ideal cutoff value for surgical indication in an NFAI is challenging. Besides the malignancy risk, the rate of silent pheochromacytomas must be taken into account in the surgical decision.