Category Archives: Endocrinology

Direct Anastomosis of Recurrent Laryngeal Nerves Injured During Thyroidectomy

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“Recurrent laryngeal nerve (RLN) paralysis is the most common and significant complication of thyroid or parathyroid cancer surgery. Unilateral RLN paralysis is often due to the adhesions that accompany thyroid cancer. Even with no signs of paralysis preoperatively, a cancerous thyroid gland may be found firmly adherent to RLN intraoperatively, in which case a segment of RLN must be sacrificed for the sake of cancer eradication.””Recurrent laryngeal nerve (RLN) paralysis is the most common and significant complication of thyroid or parathyroid cancer surgery. Unilateral RLN paralysis is often due to the adhesions that accompany thyroid cancer. Even with no signs of paralysis preoperatively, a cancerous thyroid gland may be found firmly adherent to RLN intraoperatively, in which case a segment of RLN must be sacrificed for the sake of cancer eradication.”

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The Landmark Series: Pancreatic Neuroendocrine Tumors

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“Pancreatic neuroendocrine tumors (PNETs) comprise a heterogeneous group of neoplasms arising from pancreatic islet cells that remain relatively rare but are increasing in incidence worldwide. While significant advances have been made in recent years with regard to systemic therapies for patients with advanced disease, surgical resection remains the standard of care for most patients with localized tumors. Although formal pancreatectomy with regional lymphadenectomy is the standard approach for most PNETs, pancreas-preserving approaches without formal lymphadenectomy are acceptable for smaller tumors at low risk for lymph node metastases.”

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Parathyroidectomy in the management of tertiary hyperparathyroidism

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Ferreira GF, et al. Parathyroidectomy after kidney transplantation: short-and long-term impact on renal function. Clinics (Sao Paulo). 2011;66(3):431-5. Free full-text.

Materials and methods: This was a retrospective case-controlled study. Nineteen patients with persistent hyperparathyroidism underwent parathyroidectomy due to hypercalcemia. The control group included 19 patients undergoing various general and urological operations.

Results: In the parathyroidectomy group, a significant increase in serum creatinine from 1.58 to 2.29 mg/dl (P < 0.05) was noted within the first 5 days after parathyroidectomy. In the control group, a statistically insignificant increase in serum creatinine from 1.49 to 1.65 mg/dl occurred over the same time period. The long-term mean serum creatinine level was not statistically different from baseline either in the parathyroidectomy group (final follow-up creatinine = 1.91 mg/dL) or in the non-parathyroidectomy group (final follow-up creatinine = 1.72 mg/dL).

Conclusion: Although renal function deteriorates in the acute period following parathyroidectomy, long-term stabilization occurs, with renal function similar to both preoperative function and to a control group of kidney-transplanted patients who underwent other general surgical operations by the final follow up.

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Postoperative calcium requirements in 6,000 patients undergoing outpatient parathyroidectomy: easily avoiding symptomatic hypocalcemia.

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Vasher M, Goodman A, Politz D, Norman J. Postoperative calcium requirements in 6,000 patients undergoing outpatient parathyroidectomy: easily avoiding symptomatic hypocalcemia. J Am Coll Surg. 2010 Jul;211(1):49-54. Full-text for Emory users.

Background: To determine the amount and duration of supplemental oral calcium for patients with varying clinical presentations discharged immediately after surgery for primary hyperparathyroidism.

Study design: A 4-year, prospective, single-institution study of 6,000 patients undergoing parathyroidectomy for primary hyperparathyroidism and discharged within 2.5 hours. Based on our previous studies, patients are started on a sliding scale of oral calcium determined by a number of preoperative measures (ie, serum calcium, body weight, osteoporosis) beginning 3 hours postoperation and decreasing to a maintenance dose by week 3. Patients reported all hypocalcemia symptoms daily for 2 weeks.

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Practice Guideline: The AAES guidelines for the definitive surgical management of thyroid disease in adults

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Patel KN, Yip L, Lubitz CC, et al. The American Association of Endocrine Surgeons (AAES) Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults. Ann Surg. 2020 Mar;271(3):e21-e93. Full-text for Emory users.

See also: Patel KN, Yip L, Lubitz CC, et al. Executive Summary of the American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults. Ann Surg. 2020 Mar;271(3):399-410. Full-text for Emory users.

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Sodium-Glucose Cotransporter 2 (SGLT2) Inhibitor Associated Euglycemic Diabetic Ketoacidosis

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Thanks to LeslieAnn S. Kao, MD (General Surgery PGY-4) for suggesting this topic.

Somagutta MR, et al. Euglycemic Diabetic Ketoacidosis and Sodium-Glucose Cotransporter-2 Inhibitors: A Focused Review of Pathophysiology, Risk Factors, and Triggers. Cureus. 2021 Mar 3;13(3):e13665.

The underlying mechanism is mainly enhanced lipolysis and ketone body reabsorption. SGLT2i also stimulates pancreatic alpha cells and inhibits beta cells, causing an imbalance in glucagon/insulin levels, further contributing to lipolysis and ketogenesis. Most patients were diagnosed with blood glucose less than 200 mg/dL, blood pH <7.3, increased anion gap, increased blood, or urine ketones. Perioperative fasting, pancreatic etiology, low carbohydrate or ketogenic diet, obesity, and malignancy are identified precipitants in this review. As normoglycemia can conceal the underlying acidosis, physicians should be cognizant of the EDKA diagnosis and initiate prompt treatment. Patient education on risk factors and triggers is recommended to avoid future events.

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Surgical management of pheochromocytoma

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Fu SQ, Wang SY, Chen Q, Liu YT, Li ZL, Sun T. Laparoscopic versus open surgery for pheochromocytoma: a meta-analysis. BMC Surg. 2020 Jul 25;20(1):167.

Results: Fourteen studies involving 626 patients were included in this meta-analysis. LS was associated with lower rates of intraoperative haemodynamic instability (IHD) [odds ratio (OR) = 0.61, 95% CI: 0.37 to 1.00, P = 0.05], less intraoperative blood loss [weighted mean difference (WMD) = – 115.27 ml, 95% confidence interval (CI): – 128.54 to – 101.99, P < 0.00001], lower blood transfusion rates [OR = 0.33, 95% CI: 0.21 to 0.52, P < 0.00001], earlier ambulation (WMD = – 1.57 d, 95% CI: – 1.97 to – 1.16, P < 0.00001) and food intake (WMD = – 0.98 d, 95% CI: – 1.36 to – 0.59, P < 0.00001), shorter drainage tube indwelling time (WMD = – 0.51 d, 95% CI: – 0.96 to – 0.07, P = 0.02) and postoperative stay (WMD = – 3.17 d, 95% CI: – 4.76 to – 1.58, P < 0.0001), and lower overall complication rates (OR = 0.56, 95% CI: 0.35 to 0.88, P = 0.01). However, no significant differences in operative time, postoperative blood pressure control, rates of severe complications, postoperative hypotension or cardiovascular disease (CVD) were found between the two groups.

Conclusions: LS is safe and effective for PHEO resection. Compared with OS, LS caused less IHD, providing an equal chance to cure hypertension while also yielding a faster and better postoperative recovery.

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