Most Downloaded Articles


Oral Presentations

[Year:2018] [Month:January-April] [Volumn:10 ] [Number:1] [Pages:97] [Pages No:8-49][No of Hits : 679]


Management of lymph nodes (LN) in medullary thyroid carcinoma (MTC) is an ongoing debate. The aim was to analyze usefulness of sentinel lymph node biopsy (SLNB) of jugulo-carotid regions after methylene blue dye (MBD) mapping for detecting true positive patients in cN0 group of micro-MTCs, providing them one-time lateral neck dissection (LND).


Poster Presentations

[Year:2018] [Month:January-April] [Volumn:10 ] [Number:1] [Pages:97] [Pages No:50-95][No of Hits : 604]


It has been well known that thyroid-stimulating hormone (TSH) stimulated the growth or development of thyroid malignancy and higher serum TSH is also associated with thyroid cancer incidence and advanced tumor stage. The purpose of this study was to evaluate the association of preoperative hypothyroidism with the prognosis of papillary thyroid cancer (PTC).

Roma Pradhan, Sushil Gupta, Niraj Kumari, Amit Agarwal

Adrenocorticotropic Hormone-producing Neuroendocrine Tumors of Thymus: Case Series and Review of Literature

[Year:2018] [Month:January-April] [Volumn:10 ] [Number:1] [Pages:97] [Pages No:1-4][No of Hits : 519]


Since the first description of thymic carcinoid as a specific entity in 1972 by Rosai and Higa, approximately 92 cases of adrenocorticotropic hormone (ACTH)-producing thymic neuroendocrine associated with Cushing’s syndrome (CS) have been described between 1980 and 2011. We report here three new cases of neuroendocrine tumor (NET) of thymus associated with ectopic production of ACTH along with review of recent literature.
All our three cases were middle age (2 male and 1 female) with clinical features of CS. Two of the three patients had hyperpigmentation. All the three underwent transsternal excision of thymic tumor.
The NET of the thymus associated with CS can occur at any age from 4 to 64 years; however, meta-analysis revealed that majority of cases occur between 18 and 40 years. There is no sex predilection for these tumors except for the NETs which are associated with MEN-1, which occurred predominantly in males.
Majority of these patients would present with clinical features of CS, although the severity and rapidity of onset would vary.
The ACTH-producing NET is a rare cause of CS and requires high suspicion to make an early diagnosis and is a locally aggressive disease that requires aggressive surgical resection. Adjuvant radiotherapy may be beneficial.

Keywords: Adrenocorticotropic hormone, Cushing’s syndrome, Neuroendocrine tumors.

How to cite this article: Pradhan R, Gupta S, Kumari N, Agarwal A. Adrenocorticotropic Hormone-producing Neuroendocrine Tumors of Thymus: Case Series and Review of Literature. World J Endoc Surg 2018;10(1):1-4.

Source of support: Nil

Conflict of interest: None

Vikas Jain

Beahrs’ Triangle: The Surgical Anatomy

[Year:2017] [Month:January-April] [Volumn:9 ] [Number:1] [Pages:35] [Pages No:35][No of Hits : 3848]


Thyroidectomy is a commonly performing surgery worldwide with known complications of recurrent laryngeal nerve injury (RLN) and vocal cord paralysis. To avoid RLN palsy, various methods of RLN identification have been defined, one of which is called as defining Beahrs’ triangle.

Keywords: Beahrs’ triangle, Landmark, Thyroidectomy.

How to cite this article: Jain V. Beahrs’ Triangle: The Surgical Anatomy. World J Endoc Surg 2017;9(1):35.

Source of support: Nil

Conflict of interest: None

Anand K Mishra, Amit Agarwal, Sudeep Kumar, SK Mishra

Assessment of Cardiovascular System Abnormalities in Patients with Advanced Primary Hyperparathyroidism by Detailed Echocardiographic Analysis: A Prospective Study.

[Year:2017] [Month:May-August] [Volumn:9 ] [Number:2] [Pages:41] [Pages No:46-50][No of Hits : 2234]


Aim: Recognizing the paucity of data regarding the incidence of cardiovascular abnormalities in severe primary hyperparathyroidism (PHPT), a prospective study was done for left ventricular (LV) systolic and diastolic function by echocardiography in patients with hyperparathyroidism (HPT) before surgery.

Materials and methods: A total of 18 consecutive patients with HPT and an equal number of age- and sex-matched controls were studied by two-dimensional and Doppler echocardiography.

Results: Patients with HPT had higher systolic and diastolic blood pressures (BPs). Despite severe bone disease, nephropathy, and vitamin D deficiency, none had metastatic calcification in myocardium. There was no significant increase in LV systolic dimensions and volume, but decreased ejection fraction (EF) and significant diastolic dysfunction were observed.

Conclusion: Despite an asymptomatic cardiac status, there were decreased EF and significant diastolic dysfunction. The HPT patients despite having severe disease, did not have metastatic calcification.

Keywords: Cardiovascular risk, Echocardiography, Hyperparathyroidism, Parathyroidectomy.

How to cite this article: Mishra AK, Agarwal A, Kumar S, Mishra SK. Assessment of Cardiovascular System Abnormalities in Patients with Advanced Primary Hyperparathyroidism by Detailed Echocardiographic Analysis: A Prospective Study. World J Endoc Surg 2017;9(2):46-50.

Source of support: Nil

Conflict of interest: None

Ashu Singh, Deep Shikha, Shipra Agarwal, Nita Khurana, Shyam Lata Jain, NS Hadke

Multiple Retroperitoneal Paragangliomas: An Uncommon Entity

[Year:2017] [Month:January-April] [Volumn:9 ] [Number:1] [Pages:35] [Pages No:20-23][No of Hits : 1206]


Introduction: Paragangliomas are neuroendocrine tumors and occur commonly in head and neck region and less frequently in the retroperitoneum. Multifocal paragangliomas are even rarer and highly suggestive of familial disease. To the best of our search, there are only two case reports of multiple retroperitoneal paragangliomas with no known familial association. This is the third report of this kind in the English literature.

Case report: A young adult with no significant past or family history presented with abdominal pain and anorexia. Abdominal examination revealed a soft nontender mass in the right hypochondrium. Contrast-enhanced computed tomography showed multiple retroperitoneal mass lesions. A clinicoradiological diagnosis of multicentric Castleman’s disease/Lymphoma was made. Guided fine needle aspiration of the mass was suggestive of a neuroendocrine neoplasm. Tru-cut biopsy showed features of paraganglioma. Following this, the masses were excised and the diagnosis of paraganglioma was confirmed.

Conclusion: Multicentric retroperitoneal paragangliomas without any familial association are very rare with only two case reports in the English literature. Lack of symptoms makes the diagnosis difficult and also makes our case unique. Biopsy from paragangliomas and surgical intervention are known to cause life-threatening complications, such as profuse bleeding and abrupt changes in blood pressure. Hence, paragangliomas should be considered as a possibility, even if a remote one, in case of multicentric retroperitoneal tumors. This case also highlights the importance of cytology in the early diagnosis of retroperitoneal masses.

Keywords: Multiple, Paragangliomas, Retroperitoneal.

How to cite this article: Singh A, Shikha D, Agarwal S, Khurana N, Jain SL, Hadke NS. Multiple Retroperitoneal Paragangliomas: An Uncommon Entity. World J Endoc Surg 2017;9(1):20-23.

Source of support: Nil

Conflict of interest: None

Anish Kolly, Vijaya Sarathi, Sapana Bothra, Aromal Chekavar, Mayilvaganan Sabaretnam, Amit Agarwal

Hypocalcemia: What a Surgeon should know.

[Year:2017] [Month:May-August] [Volumn:9 ] [Number:2] [Pages:41] [Pages No:72-77][No of Hits : 818]


Hypocalcemia is one of the sequelae following thyroidectomy (TT) and becomes a complication when it becomes permanent. Parathyroid preservation is a crucial step in the skillful operative procedure of TT. When due care is not taken, the surgeon and the treating physician are faced with the issue of treating the dreaded complication of permanent hypocalcemia. In this article, we address the issue of hypocalcemia following thyroid surgery and its management.

Keywords: Hypocalcemia, Parathyroid, Thyroidectomy.

How to cite this article: Kolly A, Sarathi V, Bothra S, Chekavar A, Sabaretnam M, Agarwal A. Hypocalcemia: What a Surgeon should know. World J Endoc Surg 2017;9(2):72-77.

Source of support: Nil

Conflict of interest: None

Tobias W James, Michael J Stechman, David M Scott-Coombes

The CaPTHUS Scoring Model revisited: Applicability from a UK Cohort with Primary Hyperparathyroidism

[Year:2017] [Month:January-April] [Volumn:9 ] [Number:1] [Pages:35] [Pages No:7-12][No of Hits : 687]


Introduction: Focused parathyroidectomy for primary hyperparathyroidism (pHPT) in patients with a single positive localizing scan may have an unacceptably high recurrence rate unless intraoperative parathyroid hormone (ioPTH) is used. The CaPTHUS score was previously developed to predict singlegland disease in such instances. We evaluated the accuracy of this model in a cohort of patients with pHPT in the UK.

Materials and methods: CaPTHUS scores were calculated from prospectively collected data on consecutive patients undergoing surgery for pHPT [(1 point each for: Preoperative calcium ≥3 mmol/L; PTH ≥2 times upper limit; ultrasound (1 point) and sestamibi (1 point) positive for single enlarged gland; concordant positive scans]. Diagnosis of single or multigland disease was confirmed on pathology.

Results: From June 2007 to October 2011, 324 patients (251 female, median age 66, 10.89) underwent surgery for pHPT guided with ioPTH. Single-gland pathology was observed in 291 (89.8%) patients and multi-gland disease seen in 33 (10.2%). In single-gland disease patients, significantly higher preoperative calcium (p = 0.030) and PTH levels (p = 0.033) were seen with sensitivities of 65.6% for ultrasound and 66.0% for sestamibi scanning. A CaPTHUS score ≥3 was seen in 51.2% of all patients with a positive predictive value (PPV) for single-gland disease of 99.4%.

Conclusion: A CaPTHUS score ≥3 was accurate at predicting single-gland disease in >50% of patients with pHPT, providing a similar PPV and reducing the need for ioPTH implementation in this population. However, recent conflicting literature suggests the CaPTHUS score may not be universally applicable, local audit is recommended before implementation.

Keywords: C aPTHUS, E ndocrine s urgery, F ocused p arathyroidectomy, Intraoperative parathyroid hormone, Minimally invasive parathyroidectomy, Primary hyperparathyroidism.

How to cite this article: James TW, Stechman MJ, Scott- Coombes DM. The CaPTHUS Scoring Model revisited: Applicability from a UK Cohort with Primary Hyperparathyroidism. World J Endoc Surg 2017;9(1):7-12.

Source of support: Nil

Conflict of interest: None

KS Thalavai Sundarram, Dhalapathy Sadacharan, Krishnan Ravikumar, S Kalpana, RV Suresh

Role of Color Doppler Ultrasonography in Differentiation of Graves’ Disease from Thyroiditis: A Prospective Study

[Year:2017] [Month:May-August] [Volumn:9 ] [Number:2] [Pages:41] [Pages No:41-45][No of Hits : 609]


Introduction: Thyrotoxicosis due to Graves’ disease (GD) and destructive thyroiditis (DT) needs differentiation, as management strategy differs. Factors that help in diagnosis are biochemical and nuclear imaging. Utility of high-resolution ultrasonography (HRUSG) and color Doppler (CD) in differentiation is not widely practiced. We undertook the prospective study in the Department of Endocrine Surgery at a tertiary care center among South Indian population in 1 year as a cost-effective model

Materials and methods: Out of 120 newly diagnosed thyrotoxicosis patients, 54 were GD (group I) and 66 were DT (group II) patients. Totally, 55 euthyroid patients served as controls. Parameters analyzed were demography, free thyroid function test (TFT) anti-thyroid-stimulating hormone receptor antibody (TSHrAB), antithyroid peroxidase antibody (ATPO), anti-thyroglobulin antibody (ATG), and Tc-99m thyroid scintigraphy. Parameters analyzed using HRUSG and CD were peak systolic velocity (PSV), end-diastolic volume (EDV), pulsatility index (PI), resistive index (RI) of bilateral superior thyroid artery (STA) and inferior thyroid artery (ITA).

Results: Both groups were age and sex matched. The TFT, ATPO, and ATG were comparable between both groups (p = 0.609). The TSHrAB (IU/mL) was significantly higher in group I (36.11 ± 0.82) than group II (1.23 ± 0.24) (p < 0.001). Mean thyroid volume (mL) was higher in group I (28.9 ± 14.9) than group II (26.2 ± 8.81) (p = 0.022). Mean PSV-STA (cm/s) was statistically higher in group I (54.09 ± 4.67) than group II (28.92 ± 4.39) (p . 0.001). Mean PSV-ITA (cm/s) was higher in group I (32.11 ± 2.45) than group II (25.23 ± 3.45) (p = 0.006). Other parameters measured in both arteries like mean EDV (cm/s), mean RI, and mean PI were comparable between both groups.

Conclusion: The HRUSG with CD evaluation of PSV STA and ITA is a cost-effective alternative to TSHrAB and thyroid scintigraphy in differentiating GD from DT patients. Additionally, we observed that PSV in STA was higher than in ITA in patients with GD. To conclude, HRUSG and CD are simple, cost-effective, and widely available tools in the differentiation of GD from DT.

Keywords: Color doppler ultrasonography, Destructive thyroiditis, Graves’ disease, Peak systolic velocity, Superior thyroid artery, Thyroid blood flow.

How to cite this article: Sundarram KST, Sadacharan D, Ravikumar K, Kalpana S, Suresh RV. Role of Color Doppler Ultrasonography in Differentiation of Graves’ Disease from Thyroiditis: A Prospective Study. World J Endoc Surg 2017; 9(2):41-45.

Source of support: Nil

Conflict of interest: None

Veeramaneni S Teja, Ramya Ramakrishnan

Unusual Presentation of Primary Hyperparathyroidism: A Rare Case Report

[Year:2017] [Month:January-April] [Volumn:9 ] [Number:1] [Pages:35] [Pages No:13-15][No of Hits : 561]


Aim: The aim of this case report is to highlight an exceptional presentation of primary hyperparathyroidism.

Background: Asymptomatic maternal hyperparathyroidism manifesting in the neonate as hypocalcemic convulsions is exceedingly rare.

Case report: Primary hyperparathyroidism has got a varied presentations. We present a case report of neonatal hypocalcemic convulsions secondary to asymptomatic maternal hyperparathyroidism. Here, the challenge in diagnosing this condition and management will be discussed in the context of available literature.

Conclusion: In the event of nonfebrile seizures in the neonate due to hypocalcemia, the mother has to be evaluated for primary hyperparathyroidism.

Clinical significance: Physicians’ awareness of this unique manifestation of primary hyperparathyroidism is essential for the appropriate management of both the mother and the neonate.
Timely identification and treatment of this condition will prevent complications in both.

Keywords: Neonatal hypocalcemia, Primary hyperparathyroidism, Seizures

How to cite this article: Teja VS, Ramakrishnan R. Unusual Presentation of Primary Hyperparathyroidism: A Rare Case Report. World J Endoc Surg 2017;9(1):13-15.

Source of support: Nil

Conflict of interest: None

Gilbert Soh, James Wai Kit Lee, Oh Han Boon, Tan Wee Boon, Rajeev Parameswaran, Ngiam Kee Yuan

Experience of Intraoperative Recurrent Laryngeal Nerve monitoring in a Single Center-normative Recurrent Laryngeal Nerve Electromyographic Data

[Year:2017] [Month:January-April] [Volumn:9 ] [Number:1] [Pages:35] [Pages No:1-6][No of Hits : 527]


Introduction: Injury to the recurrent laryngeal nerve (RLN) remains a significant morbidity during thyroid and parathyroid surgery. The aim of this study is to elucidate normative RLN electromyographic (EMG) parameters.

Materials and methods: This is a retrospective cohort study of patients who underwent Intraoperative neuromonitoring during thyroid and parathyroid surgery from February 2014 to March 2015. The inomed C2 NerveMonitor was used. We recorded the stimulation current, amplitude, and latency of the RLN before and after nerve dissection. We also observed the number of patients who had hoarse voice after surgery.

Results: A total of 46 patients (14 male, 32 female) averaging 51 years old in age (20-77 years) were analyzed. The most commonly performed surgical procedure was total thyroidectomy (53.2%).
The median stimulation current for both the right and left RLN was 0.500 mA. The median amplitude for the left RLN was 1.060 mV and greater than that for the right RLN (0.930 mV) (p = 0.30). The median latency for the right RLN and left RLN was 2.40 ms with no difference between the sides. (p = 0.58).
Post dissection, the right RLN amplitude remained identical whereasthe left RLN amplitude decreased. Latencies of both RLNs decreased although the difference was not significant. Nature of pathology and site of surgery did not influence RLN latency and amplitude. No patients had hoarse voice.

Conclusion: This study highlights the normative EMG parameters for bilateral RLN nerve stimulation in an Asian population. No significant difference was noted in both pre- and postdissection RLN EMG parameters.

Keywords: Amplitude, Intraoperative nerve monitoring, Latency, Normative electromyographic values, Recurrent laryngeal nerve palsy, Stimulation current.

How to cite this article: Soh G, Lee JWK, Boon OH, Boon TW, Parameswaran R, Yuan NK. Experience of Intraoperative Recurrent Laryngeal Nerve monitoring in a Single Centernormative Recurrent Laryngeal Nerve Electromyographic Data. World J Endoc Surg 2017;9(1):1-6.

Source of support: Nil

Conflict of interest: None

How I Do It
Gyan Chand, SK Mishra

Transoral Endoscopic Thyroid Surgery through Vestibular Approach

[Year:2016] [Month:May-August] [Volumn:8 ] [Number:2] [Pages:52] [Pages No:179-182][No of Hits : 2172]


Scarless neck surgery for thyroid became popular after the advancement of endoscopic and robotic thyroid surgery. Different approaches have been practiced for endoscopic thyroid surgery in different parts of the world.

Keywords: Endoscopic thyroid surgery, Endoscopic thyroid surgical techniques, Transoral thyroid surgery.

How to cite this article: Chand G, Mishra SK. Transoral Endoscopic Thyroid Surgery through Vestibular Approach. World J Endoc Surg 2016;8(2):179-182.

Source of support: Nil

Conflict of interest: None

15th Biennial Congress of the Asian Association of Endocrine Surgeons, April 2016

Poster Presentation on Adrenal, Pituitary, and Other Endocrine Glands, Parathyroid Gland, Thyroid Gland

[Year:2016] [Month:January-April] [Volumn:8 ] [Number:1] [Pages:136] [Pages No:55-127][No of Hits : 1265]



Gastrointestinal and pancreatic neuroendocrine tumors (NET) are classified as low grade (G1), intermediate grade (G2), and high grade (G3) by mitotic rate and/or Ki-67 index. The basic treatment for neuroendocrine carcinoma (NEC, G3) with remote metastasis is platinum-based systemic chemotherapy. In contrast, for patients with NET G1 or G2 with remote metastasis, multidisciplinary treatment is necessary in order to prolong patients’ survival and relieve symptoms. We report here a patient with pancreatic G1 gastrinoma and its multiple liver metastases.


The patient was a 42 years old male who had been suffering from diarrhea for 2 years, and his serum level of gastrin was as high as 4200 pg/mL before treatment. Needle biopsy of the liver proved the tumor was positive for chromogranin A, gastrin, and somatostatin receptor type 2A.


First, we chose an induction drug therapy with sunitinib and octreotide. The size of the liver tumors decreased dramatically and the serum gastrin level became lower than 500 pg/mL. About 1 year after diagnosis, we performed distal pancreatectomy and right hepatic lobectomy. After surgery, the serum gastrin level was normalized, and the activity of daily living (ADL) of the patient was much improved by the consecutive therapies. During the 2-year postoperative follow-up time, the course was favorable and no recurrent lesion was found.


Even when there are remote metastases, multidisciplinary treatment including surgical resection should be considered for G1/G2 NET. Further, it should be necessary to study in a larger number of patients if perioperative drug therapy for G1/G2 NET with remote metastases is effective.

Anish J Cherian, Pooja Ramakant, Thomas V Paul, Deepak T Abraham, MJ Paul

Next-day Parathyroid Hormone as a Predictor of Post-thyroidectomy Hypocalcemia

[Year:2016] [Month:September-December] [Volumn:8 ] [Number:3] [Pages:31] [Pages No:203-207][No of Hits : 919]


Aim: Total thyroidectomy is significantly complicated by parathyroid dysfunction and hypocalcemia. These aspects impact the decision regarding the timing of discharge and quantum of calcium supplementation required. Therefore, we aimed at evaluating the accuracy of next-day parathyroid hormone (PTH) level as a predictor of post-thyroidectomy hypocalcemia. Secondly, we aimed at establishing our institution’s postoperative PTH level, which can accurately predict the development of post-thyroidectomy hypocalcemia to help us ensure the safe and early discharge of patients.

Materials and methods: A prospective observational study of 50 continuous patients undergoing thyroidectomy was conducted at a tertiary hospital in South India. Postoperative blood samples were collected for estimation of PTH, calcium, albumin, and phosphorous. The data were collated and results analyzed using Stata I/C 10.1.

Results: A total of 30% (15/50) of the patients had postoperative hypocalcemia (serum calcium >8 mg/dL). Postoperative PTH was low (>8 pg/mL) in 40% (20/50) of patients. There was a significant association between PTH > 8 pg/mL and the presence of postoperative hypocalcemia (p = 0.029). The area under the receiver operating characteristic (ROC) curve was 0.7, and a next-day PTH of >6 pg/mL showed the highest sensitivity and specificity (83 and 60% respectively) for the development of postoperative hypocalcemia, with a positive predictive value (PPV) and negative predictive value (NPV) of 83 and 60 respectively.

Conclusion: The PTH assessment performed the day after surgery is an acceptable test to predict post-thyroidectomy hypocalcemia; PTH >6 pg/mL can be used as our institution’s cutoff value. Department protocols for calcium and vitamin D supplementation following total thyroidectomy may be formulated based on the appropriately timed local postoperative PTH value to assist safe and early discharge of patients.

Clinical significance: Discharge protocols for patients undergoing thyroidectomy may be formulated based on the postoperative PTH values, thus enabling safe and early discharge of patients.

Keywords: Calcium, Hypocalcemia, Observational study, Parathyroid hormone, Thyroidectomy.

How to cite this article: Cherian AJ, Ramakant P, Paul TV, Abraham DT, Paul MJ. Next-day Parathyroid Hormone as a Predictor of Post-thyroidectomy Hypocalcemia. World J Endoc Surg 2016;8(3):203-207.

Source of support: Dr MGR Medical University research grant; Fluid research grant – CMC, Vellore.

Conflict of interest: None

Original Article
Duminda DMC Dissanayake, Ranil F Fernando, Iresha J Dissanayake

Lateral approach to Thyroid (LATT): A Good Technique for Re-operative Thyroid Surgery

[Year:2016] [Month:May-August] [Volumn:8 ] [Number:2] [Pages:52] [Pages No:141-142][No of Hits : 805]


Introduction: Thyroidectomy is the commonest endocrine surgical procedure undertaken throughout the world. Redo thyroidectomies are challenging procedures with a higher morbidity rate. Lateral approach to thyroid (LATT) is a good alternative to the standard midline exploration. The key to the technique is the development of the natural tissue plane between the strap muscle and the ipsilateral sternocleidomastoid muscle to explore the thyroid bed. A study was carried out to assess the efficacy, safety, and complication of LATT.

Materials and methods: Data on patients undergoing LATT in professorial surgical unit, Ragama from 2008 to 2015, were collected prospectively and analyzed. All procedures were done by a single surgeon.

Results: A total of 36 LATTs were done. Data from 32 people were collected, as 4 patients lost follow-up; 29 (90.6%) were females and 3 (9.4%) were males. Their age ranges between 28 and 61 (median 43.37). Three (9.4%) LATTs for parathyroid explorations and out of it one (3.1%) for redo parathyroid explorations were done. Nine (28.1%) cases were redo thyroidectomies and 18 (56.2%) were done with mini incision with lateral approach. Hemithyroidectomies were performed on 28 (87.5%) patients. Bilateral explorations were done on three (9.4%) patients and four (12.5%) lateral approaches were done for completion thyroidectomies for follicular malignant lesions. Transient clinical hypocalcemia was noticed in four (12.5%) patients and one (3.1%) developed hoarseness of voice, which was temporary; and none of them had complications like hematoma and postsurgical stridor.

Conclusion: Lateral approach to thyroid is a safe alternative to the standard approach for reexplorative thyroid surgery.

Keywords: Lateral approach, Reoperative, Thyroid.

How to cite this article: Dissanayake DDMC, Fernando RF, Dissanayake IJ. Lateral approach to Thyroid: A Good Technique for Reoperative Thyroid Surgery. World J Endoc Surg 2016;8(2):141-142.

Source of support: Nil

Conflict of interest: None

Daniel W Nelson, Melissa LoPinto, Charif Sidani, John I Lew

Large Substernal Thyroid Goiter Associated with Saddle Pulmonary Embolism

[Year:2016] [Month:September-December] [Volumn:8 ] [Number:3] [Pages:31] [Pages No:214-216][No of Hits : 706]


A 75-year-old woman with a longstanding history of a substernal thyroid goiter presented with acute shortness of breath, and she was intubated due to respiratory distress. Computed tomography (CT) scan revealed a compressive substernal goiter with associated vascular compression, axillosubclavian thrombosis, and saddle pulmonary embolism. Weight-based heparin was immediately administered, and the patient subsequently underwent successful thyroidectomy via a cervical incision. This case report of a rare saddle pulmonary embolism associated with a substernal thyroid goiter underscores the importance of early elective thyroidectomy. Successful management of these potentially devastating pulmonary emboli (PE) associated with large substernal goiters is possible.

Keywords: Cervical thyroidectomy, Saddle pulmonary embolism, Substernal goiter, Thromboemboilc disease.

How to cite this article: Nelson DW, LoPinto M, Sidani C, Lew JI. Large Substernal Thyroid Goiter Associated with Saddle Pulmonary Embolism. World J Endoc Surg 2016;8(3):214-216.

Source of support: Nil

Conflict of interest: None

Jamie E Anderson, Jennifer L Olson, Michael J Campbell

Parathyroidectomy in Dialysis Patients: What is the Risk?

[Year:2016] [Month:September-December] [Volumn:8 ] [Number:3] [Pages:31] [Pages No:193-198][No of Hits : 694]


Aim: Patients with chronic kidney disease (CKD) on dialysis commonly develop hyperparathyroidism (HPT), but are often not referred for surgical evaluation because of the belief that the cardiopulmonary risks of a parathyroidectomy are prohibitively high. Previous studies have not adequately determined the surgical risks of parathyroidectomy in this population.

Materials and methods: We used the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2013 to evaluate risk of complications for dialysis vs nondialysis patients undergoing parathyroidectomy using univariate and multivariate logistic regressions. We also compared outcomes between dialysis patients undergoing parathyroidectomy and arteriovenous fistula (AVF) creation to understand the relative risk between these procedures.

Results: A total of 28,438 patients underwent parathyroidectomy; 1,833 (6.5%) were on dialysis. Among patients undergoing parathyroidectomy, unadjusted mortality and complication rates were higher for patients on dialysis compared to those not on dialysis (1.4% vs 0.1%, p > 0.001; 7.9% vs 1.4%, p > 0.001). Multivariate analysis found increased odds of mortality, all complications, and cardiopulmonary complications among patients on dialysis compared to those not on dialysis [odds ratio (OR) 5.28, p = 0.004; 2.10, p > 0.001; 5.14, p > 0.001]. When compared to patients undergoing parathyroidectomy, dialysis patients undergoing AVF had no difference in odds of death (p = 0.392) or cardiopulmonary complications (p = 0.138), but did have an increased risk of any complication (OR 1.66, p = 0.035).

Conclusion: Dialysis patients undergoing parathyroidectomy have an increased risk of cardiopulmonary complications and mortality compared to patients not on dialysis; however, these risks are similar to patients undergoing AVF creation. The risks of parathyroidectomy in dialysis patients are likely similar to other commonly performed procedures for dialysis patients.

Clinical significance: The risk of mortality and complications should be discussed during informed consent with dialysis patients undergoing parathyroidectomy. These findings can also assist in preoperative risk assessments.

Keywords: Dialysis, Hyperparathyroidism, National surgical quality improvement program, Parathyroidectomy, Secondary hyperparathyroidism, Surgical outcomes.

How to cite this article: Anderson JE, Olson JL, Campbell MJ. Parathyroidectomy in Dialysis Patients: What is the Risk? World J Endoc Surg 2016;8(3):193-198.

Source of support: Nil

Conflict of interest: None Author contributions: MJC conceived the study idea. JEA and MJC created the study design and JEA performed the analysis. JEA and JLO authored the initial drafts. JEA and MJC performed critical revisions.

Special Article
Akira Miyauchi

The History of the Asian Association of Endocrine Surgeons

[Year:2016] [Month:May-August] [Volumn:8 ] [Number:2] [Pages:52] [Pages No:147-155][No of Hits : 614]


The Asian Association of Endocrine Surgeons (AsAES) was established in 1986, 30 years ago. Its history was never described in detail. This article describes its establishment and development in detail with many memorial pictures. This article was read at the 15th Congress of the AsAES held in Seoul in April 8, 2016.

Keywords: Asian association of endocrine surgeons, Chairman, History, Officers, President.

How to cite this article: Miyauchi A. The History of the Asian Association of Endocrine Surgeons. World J Endoc Surg 2016;8(2):147-155.

Source of support: Nil

Conflict of interest: None

Case Report
Reyaz M Singaporewalla, Anuradha Negi, Dominique YB Seow, Dinesh Chinchure

An Unusual Cause of Hot Spot on Parathyroid Imaging

[Year:2016] [Month:May-August] [Volumn:8 ] [Number:2] [Pages:52] [Pages No:164-167][No of Hits : 602]


Background and aim: Radiological imaging is routinely used in patients with primary hyperparathyroidism to localize the abnormal adenoma and to plan surgical approach. We report an unusual cause of false-positive localization on parathyroid sestamibi scan, i.e., not previously described in the literature.

Case report: A 66-year-old man with primary hyperparathyroidism showed a discrete persistent focus in the left infraclavicular area during localization using sestamibi scan. Ultrasound of the neck was negative showing only small bilateral thyroid nodules. Single-photon emission and four-dimensional computed tomography (CT) scans showed an intense focus of the tracer uptake and a 1-cm lesion near the left subclavian vein (SCV), corresponding to the infraclavicular hot spot. Initial infraclavicular exploration showed the lesion to be a collapsible saccular varix of the left SCV. Bilateral neck exploration led to the discovery of the actual right parathyroid adenoma beneath an exophytic thyroid nodule. The patient made an uneventful recovery and remains normocalcemic at 1-year follow up.

Conclusion and clinical significance: Hot spot on parathyroid imaging outside the line of embryological descent should be interpreted with caution. Vascular retention of injected isotope within a saccular varix of the neck vein can give rise to falsepositive results on sestamibi scans. Bilateral neck exploration remains the “gold standard” procedure when localization scans either are negative or turn out to have false-positive findings.

Keywords: Ectopic adenoma, Parathyroid imaging, Saccular varix, Sestamibi, Subclavian vein.

How to cite this article: Singaporewalla RM, Negi A, Seow DYB, Chinchure D. An Unusual Cause of Hot Spot on Parathyroid Imaging. World J Endoc Surg 2016;8(2):164-167.

Source of Support: Nil

Conflicts of Interest: None

Anil D Rao, Reyaz M Singaporewalla, Arunesh Majumder

Minimally Invasive Video-assisted Thyroidectomy vs Conventional Open Hemithyroidectomy in Asian Patients

[Year:2016] [Month:September-December] [Volumn:8 ] [Number:3] [Pages:31] [Pages No:189-192][No of Hits : 564]


Introduction: Although the technique of minimally invasive video assisted thyroidectomy (MIVAT) is well established in continental Europe, data on it’s role in Asian patients is limited. We compared the results of MIVAT with conventional open hemithyroidectomy in Asian patients.

Materials and methods: Over a 1-year period, patients undergoing hemithyroidectomy for benign symptomatic goiters were selected. Inclusion criteria for MIVAT were benign colloid goiters, recurrent cysts or follicular lesions and neoplasms with lobe volume of less than 40 cc or nodule diameter less than 35 mm. Larger goiters underwent conventional open surgery. Patients with previous neck surgery and proven malignancy were excluded. Operative time, complications, postoperative pain score, incision length and cosmetic satisfaction at 6 months were recorded.

Results: Thirty-six patients (MIVAT-21, Conventional-15) were included. Both groups were comparable in terms of demographic profile and co-morbidities. The mean operating time for both groups showed no significant difference (MIVAT = 111.67 ± 19.4 min, Conventional = 112.40 ± 25.06 min; p = 0.925). Minimally invasive video assisted thyroidectomy patients had significantly less pain in the immediate postoperative period (mean pain score 2.38 vs 4.8, p > 0.001). Mean incision length at end of surgery was significantly smaller in the MIVAT group (2.58 vs 6.3 cm; p > 0.001). Neck scar satisfaction at 6 months was excellent in 71.4% of MIVAT cases vs 26.6% of conventional hemithyroidectomy cases. There were no complications in any of the treatment groups.

Conclusion: In selected cases, MIVAT is as safe as conventional open surgery with distinct advantages of better postoperative pain control and cosmesis.

Keywords: Cosmesis, Minimally invasive, Pain, Thyroidectomy, Video-assisted.

How to cite this article: Rao AD, Singaporewalla RM, Majumder A. Minimally Invasive Video-assisted Thyroidectomy vs Conventional Open Hemithyroidectomy in Asian Patients. World J Endoc Surg 2016;8(3):189-192.

Source of support: Nil

Conflict of interest: None

Indu Lata, Deepa Kapoor

A Rare Case of Functional Ectopic Hyperthyroidism: Struma Ovarii

[Year:2016] [Month:September-December] [Volumn:8 ] [Number:3] [Pages:31] [Pages No:212-213][No of Hits : 556]


Struma ovarii (SO) is a rare special type of monodermal teratoma of ovary that predominantly consists of thyroid tissue (< 50%). In only 5 to 20% of cases hyperthyroidism is seen due to functional SO. We are reporting here a case of unilateral benign cystic SO in a 50-year-old postmenopausal lady presented with pain and heaviness in lower abdomen without any signs and symptoms of hyperthyroidism. Pelvic ultrasonogram showed right side tubo-ovarian mass and was planned for laparotomy. In preoperative investigation subclinical hyperthyroidism was diagnosed. Abdominal exploration showed cystic mass lesion in right ovary. She underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy. Histopathological examination diagnosed the mass as benign cystic SO. Patient became euthyroid after surgical removal of tumor.

Keywords: Hyperthyroidism, Monodermal teratoma, Struma ovarii.

How to cite this article: Lata I, Kapoor D. A Rare Case of Functional Ectopic Hyperthyroidism: Struma Ovarii. World J Endoc Surg 2016;8(3):212-213.

Source of support: Nil

Conflict of interest: None

Photo Asaay
Suganya Sekar, Anuradha Chandramohan, Pooja Ramakant, Deepak Thomas Abraham, Mazhuvanchary Jacob Paul

Broken Eggshell Sign: A Marker of Aggressive Thyroid Cancer

[Year:2016] [Month:May-August] [Volumn:8 ] [Number:2] [Pages:52] [Pages No:183-184][No of Hits : 551]


Broken eggshell calcification on CT scan of the neck represents malignant transformation of a longstanding benign thyroid nodule. It usually implies aggressive cancer and poor prognosis. The presence of a soft tissue component on the scan increases the sensitivity and specificity of the sign. We report three cased with the representative CT images to illustrate the sign.

Keywords: Broken eggshell calcification, Aggressive thyroid cancer.

How to cite this article: Sekar S, Chandramohan A, Ramakant P, Abraham DT, Paul MJ. Broken Eggshell Sign: A Marker of Aggressive Thyroid Cancer. World J Endoc Surg 2016;8(2): 183-184.

Source of support: Nil

Conflict of interest: None

Jesse D Pasternak, Wouter Kluijfhout, Natalie Seiser, Jessica E Gosnell, Insoo Suh, Quan-Yang Duh, Wen T Shen

Ultrasound-guided Ethanol Ablation: Where does It fit in the Treatment of Recurrent Metastatic Papillary Thyroid Cancer?

[Year:2016] [Month:September-December] [Volumn:8 ] [Number:3] [Pages:31] [Pages No:199-202][No of Hits : 520]


Introduction: Ethanol (ETOH) ablation of metastatic neck nodes has been described as a potentially safe and effective alternative to surgical excision. We sought to describe a subset of these patients well suited for ETOH ablation.

Materials and methods: We report ultrasound-guided ETOH ablation of metastatic papillary thyroid cancer (PTC) at a Tertiary Care Endocrine Surgery Unit over 5 years. A retrospective review of all reoperative lymph node dissections was undertaken. Ethanol injection was used as second-line treatment to operative excision and was standardized with ultrasound guidance and the use of 1 cc/cm3 of 100% ETOH solution.

Results: Five treatments of ultrasound-guided ETOH ablation were studied. All patients had been previously treated with radioactive iodine (RAI) (mean: 1.25 treatments of 174mCi), however, in three cases with pretreatment I-131 scan, no uptake of radioiodine was seen in the treated disease. In four cases with pretreatment fludeoxyglucose-positron emission tomography (FDG-PET), treated lesions were avid. Median follow-up time for treatment was 28.5 months, with no disease progression in all ablated lesions. Serum thyroglobulin (Tg) values in patients without Tg-antibody were lower after treatment. There were no complications.

Conclusion: Surgeons seeking a less-invasive approach for nodal metastases in the neck can consider ETOH ablation. Small ultrasound detectable lesions in scarred necks (irradiated and/or reoperative) which are radioiodine non-avid and FDG-PET avid may be best suited for this treatment. As demonstrated by a small set of patients in a Tertiary Care Endocrine Surgery Unit, ETOH ablation is safe and effective at controlling progression of targeted local disease.

Keywords: Papillary thyroid cancer, Recurrent thyroid cancer, Surgeon performed ultrasound, Ultrasound-guided ethanol ablation.

How to cite this article: Pasternak JD, Kluijfhout W, Seiser N, Gosnell JE, Suh I, Duh Q-Y, Shen WT. Ultrasound-guided

Ethanol Ablation: Where does It fit in the Treatment of Recurrent Metastatic Papillary Thyroid Cancer? World J Endoc Surg 2016;8(3):199-202.

Source of support: Nil

Conflict of interest: None

Review Article
Sandra Tan, Ngiam K Yuan, Diana GZ Lim, Rajeev Parameswaran

Calciphylaxis in Renal Hyperparathyroidism: A Case-based Review

[Year:2016] [Month:May-August] [Volumn:8 ] [Number:2] [Pages:52] [Pages No:156-159][No of Hits : 502]


Calciphylaxis is a rare fatal condition associated with chronic renal failure, with a prevalence of about 4%. The condition is associated with microcalcification of small- and medium-sized arteries, leading to skin ischemia, necrosis, and gangrene. Any part of the body may be involved, but it is predominant in the lower extremities. Severe pain is usually associated with ulcers and may be difficult to manage. Although parathyroidectomy may improve the symptoms, the prognosis remains dismal with a high mortality. We present a case of severe calciphylaxis associated with renal hyperparathyroidism and briefly review the literature on the condition.

Keywords: Calciphylaxis, Hyperparathyroidism, Renal.

How to cite this article: Tan S, Yuan NK, Lim DGZ, Parameswaran R. Calciphylaxis in Renal Hyperparathyroidism: A Case-based Review. World J Endoc Surg 2016;8(2):156-159.

Source of support: Nil

Conflict of interest: None

Case Report
Heather Player, Robert Babkowski, Xiang Dong

A Cautionary Case: Adrenal Insufficiency after Unilateral Adrenalectomy for Adrenocortical Carcinoma

[Year:2015] [Month:January-April] [Volumn:7 ] [Number:1] [Pages:27] [Pages No:17-20][No of Hits : 2475]


Subclinical Cushing’s syndrome among patients with incidentally discovered adrenal masses has been well documented in the literature. This population does not exhibit the classic signs of Cushing’s syndrome, but nonetheless present with postoperative adrenal insufficiency after unilateral adrenalectomy of nonfunctioning incidentalomas. Further, the results of extensive preoperative testing do not correlate with postoperative hypoadrenalism with adequate sensitivity. The patient is an 84-year-old male, who presented with vague complaints of abdominal pain and fatigue, with computed tomography (CT) scan demonstrating an enlarging left adrenal gland up to 5.5 cm. The patient had no evidence of hypothalamic-pituitary-adrenal axis dysfunction based on history, physical examination and preoperative testing. Thus, the lesion was presumed nonfunctional and was excised laparoscopically. Pathology demonstrated an unfortunate diagnosis of adrenocortical carcinoma (ACC). On postoperative day 1, the patient exhibited hypotension and hypoglycemia, with a cortisol level of 0.3 mg/dl. The patient responded to hydrocortisone, supporting the presumed diagnosis of hypoadrenalism. ACC is a rare and aggressive tumor, with only 300 documented cases per year in the United States. Thus, there is a paucity of data related to pre- and postoperative management. Since a third of the patients present with nonfunctioning tumors, postsurgical care are based on literature from nonfunctional incidentalomas until further research establishes guidelines. Our experience with acute hypoadrenalism after unilateral adrenalectomy in the setting of ACC suggests the need for routine postoperative testing of cortisol levels.

Keywords: Adrenocortical carcinoma, adrenal insufficiency, Adrenalectomy, Steroid replacement, Hypoadrenalism.

How to cite this article: Player H, Babkowski R, Dong X. A Cautionary Case: Adrenal Insufficiency after Unilateral Adrenalectomy for Adrenocortical Carcinoma. World J Endoc Surg 2015;7(1):17-20.

Source of support: Nil

Conflict of interest: None

Review Article
Anish Cherian, Pooja Ramakant, Mazhuvanchary Jacob Paul, Deepak Thomas Abraham

Management of Chyle Leak in the Neck Following Thyroid Cancer Surgery: A Single Center Experience

[Year:2015] [Month:January-April] [Volumn:7 ] [Number:1] [Pages:27] [Pages No:6-9][No of Hits : 2396]


Introduction: Surgery for thyroid cancers often necessitates a neck dissection. This is usually a safe procedure, but can be associated with complications. Chyle leak is one such complication, fortunately rare. There is a dearth of literature with regard to the management of chyle leak in the neck. We present a single center experience in the management of chyle leak in the neck, to improve the understanding of its management.

Materials and methods: A retrospective analysis of patients with thyroid cancer, managed between January 1st 2005 and December 31st 2011, in a single institution was performed. Among these, patients with chyle leak were identified. All pertinent data collected and results analyzed using STATA (v10).

Results: Three hundred and seventy-three/eight hundred and twenty-one (45.4%) patients surgically managed for thyroid cancer underwent a neck dissection. Thoracic duct injury was recog- nized and managed intraoperatively in 20/373 (5.4%) patients. The leak was prevented in the majority (66.6%) of patients in whom a combination of methods were employed. 25/373 (6.7%) patients were diagnosed and managed for chyle leak postoperatively. Seven patients required re-exploration. This included patients with low output chyle leaks who may have settled in a week to 10 days with conservative management. A combination of techniques was successful in the majority (71.4%). The remaining patients were successfully managed conservatively.

Conclusion: We conclude that using a combination of methods to manage thoracic duct injury may be better than using a single modality alone. Early re-exploration was more economical and acceptable for a subset of our patients, as they come from long distances at personal cost.

Keywords: Thyroidectomy, Chyle leak, Thyroid cancer, Modified radical neck dissection.

How to cite this article: cherian a, Ramakant P, Paul MJ, Abraham DT. Management of Chyle Leak in the Neck Following Thyroid Cancer Surgery: A Single Center Experience. World J Endoc Surg 2015;7(1):6-9.

Source of support: Nil

Conflict of interest: None

Original Article
Pinar Yazici, Mehmet Mihmanli, Emre Bozdag, Nurcihan Aygun, Mehmet Uludag

Location of Parathyroid Adenomas in Primary Hyperparathyroidism: Where to look?

[Year:2015] [Month:January-April] [Volumn:7 ] [Number:1] [Pages:27] [Pages No:1-5][No of Hits : 1468]


Purpose: Preoperative localization studies for parathyroid adenomas are very essential to perform minimal invasive parathyroidectomy (MIP) with decreased operative time and potential complications. Although most of these studies based on radiological imaging, intraoperative assessment provides the most accurate anatomical description of the location of parathyroid adenomas. In this study, we aim to evaluate the surgical variations of locations of parathyroid adenomas in patients performed parathyroid surgery for primary hyperparathyroidism (PHPT).

Materials and methods: Between January 2010 and December 2013, 243 patients (201 women/42 men) who underwent parathyroid surgery due to phPT were included. A total of 254 parathyroid adenomas were detected. Demographic features, preoperative work-up, surgical approach, types of procedures and postoperative complications were noted. Locations of parathyroid adenomas were recorded from operative notes. Statistical analysis was performed using t-test and chi-square. continuous data are expressed as mean ± standard deviation.

Results: With regard to the most frequently observed, location of adenomas were as follows; right inferior (n = 89, 37.7%), left inferior (n = 78, 33%), right superior (n = 44, 18.6%), left superior (n = 25, 10.5%) and ectopic locations (n = 18). Ectopic adenomas were mostly located in the thymus (n = 9) and intrathyroidal tissue (n = 6) at a rate of 83%. Postoperative hypocalcemia (11%) was mostly seen in those with parathyroid adenoma located around the inferior lobes of the thyroid (86%) and undergoing bilateral neck exploration (75%).

Conclusion: The most of the parathyroid adenomas were found in orthotopic position and located around the lower pole of the thyroid gland. Ectopic adenomas were mostly located in thymus or intrathyroidal. Postoperative hypocalcemia was also higher in those with parathyroid adenoma located around the inferior lobe of the thyroid.

Keywords: Parathyroid anatomy, Primary hyperparathyroidism, Parathyroid adenoma, Surgical Approach.

How to cite this article: Yazici P, Mihmanli M, Bozdag E, Aygun N, Uludag M. Location of Parathyroid Adenomas in Primary Hyperparathyroidism: Where to look? World J Endoc Surg 2015;7(1):1-5.

Source of support: Nil

Conflict of interest: None

Sabaretnam Mayilvaganan, Naval Bansal, Navneet Tripathi, Ashwini Reddy, Amit Agarwal

Tubercle of Zuckerkandl

[Year:2015] [Month:May-August] [Volumn:7 ] [Number:2] [Pages:25] [Pages No:33-35][No of Hits : 1433]


Endocrine Surgeon must have intimate knowledge about all anatomic variations of thyroid gland for performing safe thyroid surgery. Tubercle of Zuckerkandl is a posterior extrusion of the lateral thyroid lobes and it is a pointer to the recurrent laryngeal nerve and inferior parathyroid glands. We have discussed pertinent issues regarding tubercle of Zuckerkandl in this mini review.

Keywords: Pointer, Recurrent laryngeal nerve, Tubercle of Zuckerkandl.

How to cite this article: Mayilvaganan S, bansal N, Tripathi N, Reddy A, Agarwal A. Tubercle of Zuckerkandl. World J Endoc Surg 2015;7(2):33-35.

Source of support: Nil

Conflict of interest: None

Baki Tastan, Alper Dogu, Yusuf Sevim

Thyroid Cancer in Patients with Hyperthyroidism

[Year:2015] [Month:May-August] [Volumn:7 ] [Number:2] [Pages:25] [Pages No:29-32][No of Hits : 1275]


Background and objective: Malignant tumors of the thyroid gland are the most common of the endocrine malignancies. Although, patients with thyroid cancer have high 5 years survival rate, thyroid cancer is the most seen cause of mortality among cancers of the endocrine organs. The incidence of thyroid cancer in hyperthyroid patients varies from 0.1 to 21% in the literature. We aimed in this study to analyze the frequency of coexisting thyroid cancer and hyperthyroidism in our experience.

Results: Total 230 patients, who were operated for hyperthyroidism without the suspicion of thyroid malignancy between January 2005 and September 2010 were included in our study. Toxic multinodular goiter, toxic adenoma and Graves’ disease were diagnosed preoperatively in 187, 16 and 27 patients respectively. Histopathological thyroid malignancy was detected in 13 patients (5.7%).

Conclusion: Thyroid cancer with variable incidence up to 21% should be remembered in differential diagnosis of hyperthyroid patients.

Keywords: Graves’ disease, Hyperthyroidism, thyroid cancer.

How to cite this article: Tastan B, Dogu A, Sevim Y. Thyroid Cancer in Patients with Hyperthyroidism. World J Endoc Surg 2015;7(2):29-32.

Source of support: Nil

Conflict of interest: None

Case Report
Ramesh Maturi, Hemanth Makineni, Sri Santhosh Keerthi Marri

A Unique Case of O steitis Fibrosa Cystica with Postoperative Hungry Bone Syndrome and Hypocalcemic Cardiac Failure

[Year:2015] [Month:January-April] [Volumn:7 ] [Number:1] [Pages:27] [Pages No:10-13][No of Hits : 1258]


Osteitis fibrosa cystica, a manifestation of severe hyperparathyroidism presenting with crippling bone deformities is a rare presentation these days. We report a case of 40-year-old male patient who presented with generalized aches and pains and bony deformities. Radiographs showed diffuse osteopenia, brown tumors and pathological fractures of phalanges but common manifestations associated with hyperparathyroidism like pancreatic calcifications and nephrolithiasis were absent. Serum calcium and parathyroid hormone levels were elevated while ultrasound imaging of neck showed the presence of a left lower parathyroid adenoma and was confirmed by Tc99- sestamibi scan. Large parathyroid lesion along with high calcium levels and severely elevated PTH puts this patient in high-risk category for postoperative hungry bone syndrome leading to severe hypocalcemia postoperatively. Hypocalcemia usually results in neuromuscular irritability manifesting as paresthesia, Chvostek and Trousseau sign, carpopedal spasm and even convulsions in severe cases. However, our patient had none of the common manifestations, but developed hypocalcemic cardiac failure postoperatively. Case history and management of case is presented.

Keywords: Hyperparathyroidism, Parathyroid adenoma, Hypocalcemia, Hypocalcemic cardiac failure, Hungry bone syndrome.

How to cite this article: Maturi R, Makineni H, Marri SSK. A Unique Case of Osteitis Fibrosa Cystica with Postoperative Hungry Bone Syndrome and Hypocalcemic Cardiac Failure. World J Endoc Surg 2015;7(1):10-13.

Source of support: Nil

Conflict of interest: None

How We Do It
Prabhaker Mishra, Sabaretnam Mayilvaganan, Amit Agarwal

Statistical Methods in Endocrine Surgery Journal Club

[Year:2015] [Month:January-April] [Volumn:7 ] [Number:1] [Pages:27] [Pages No:21-23][No of Hits : 1233]


Endocrine surgery is a relatively newer surgical subspecialty with few dedicated endocrine surgery departments and journals. To understand the published literature, knowledge of some common statistical methods are not only useful but also significant to publish own research successfully. This paper present a brief review of common statistical methods, used for data analysis in conducting medical research.

Keywords: endocrine surgery, statistical methods, journal club, normal data, parametric test, survival analysis, regression analysis, roc curve.

How to cite this article: Mishra P, Mayilvaganan S, Agarwal A. Statistical Methods in Endocrine Surgery Journal Club. World J Endoc Surg 2015;7(1):21-23.

Source of support: Nil

Conflict of interest: None

Endocrine Image
Dhalapathy Sadacharan, Shriraam Mahadevan, Krishnan Ravikumar, Sankaran Muthukumar

Primary Pigmented Nodular Adrenocortical Disease: A Rare Cause of Cushing’s Syndrome

[Year:2015] [Month:January-April] [Volumn:7 ] [Number:1] [Pages:27] [Pages No:24-25][No of Hits : 916]


Primary pigmented nodular adrenocortical disease (PPNAD) is one of the rare cause of adrenocorticotropic hormone (ACTH) independent Cushing’s syndrome. More than 90% of the reported PPNAD have been associated with Carney’s complex. Primary pigmented nodular adrenocortical disease is one of the major criteria for the diagnosis of Carney’s complex (CNC). We report a case of PPNAD which is not associated with CNC.

Keywords: Cushing’s syndrome, Primary pigmented nodular adrenocortical disease, Bilateral adrenalectomy.

How to cite this article: Sadacharan D, Mahadevan S, Ravikumar K, Muthukumar S. Primary Pigmented Nodular Adrenocortical Disease: A Rare Cause of Cushing’s Syndrome. World J Endoc Surg 2015;7(1):24-25.

Source of support: Nil

Conflict of interest: None

Sabaretnam Mayilvaganan, Amit Agarwal

Safety and Cost Efficiency in Thyroid Surgery

[Year:2015] [Month:January-April] [Volumn:7 ] [Number:1] [Pages:27] [Pages No:26-27][No of Hits : 907]


Dear editor,
We read with interest the article ‘safety and cost efficiency in thyroid surgery’ by Young-Chul OT and Gough I.1 We congratulate the authors on their work which is aimed toward reducing the cost and also providing a safe approach with acceptable clinical indicators for the outcome of thyroid surgery. This is more so relevant in the developing world, where the endocrine surgeon has to balance between the usage of newer technology as well as curtailing the cost of the procedure. Sutureless thyroidectomy using vessel sealing devices which have become a routine in most centers.2

Dimitrios Linos

Minimally Invasive Non-Endoscopic Thyroidectomy: A Very High in the Neck Thyroidectomy Incision

[Year:2015] [Month:May-August] [Volumn:7 ] [Number:2] [Pages:25] [Pages No:51-52][No of Hits : 891]


We propose the adoption of a very high in the neck thyroi- dectomy incision, as high as the cricoid and/or thyroid cartilage, placed in an existing skin crease. This is a minimally invasive non-endoscopic thyroidectomy (MINET) approach that allows a safer, easier and more complete thyroidectomy.

Keywords: Incision, Neck, Thyroid.

How to cite this article: Linos D. Minimally Invasive Non- Endoscopic Thyroidectomy: A Very High in the Neck Thyroidectomy Incision. World J Endoc Surg 2015;7(2):51-52.

Source of support: Nil

Conflict of interest: None

Basant Kumar, Vijai D Upadhyaya, Ram Nawal Rao, Sheo Kumar

Ganglioneuroblastoma as Vasoactive Intestinal Polypeptide-secreting Tumor: Rare Case Report in a Child

[Year:2015] [Month:May-August] [Volumn:7 ] [Number:2] [Pages:25] [Pages No:47-50][No of Hits : 855]


Pathologically elevated vasoactive intestinal polypeptide (VIP) plasma levels cause secretory diarrhea with excessive loss of water and electrolyte and is characterized by the typical symptoms of hypokalemia and metabolic acidosis. It rarely occurs in patients with non-pancreatic disease. Despite the clinical severity, diagnosis of a VIP-secreting tumor is often delayed. We herein present a 14-month-old boy having prolonged therapy-resistant secretory diarrhea, persistent hypokalemia with tissue diagnosis of ganglioneuroblastoma and raised plasma VIP-levels.

Keywords: Ganglioneuroblastoma, Secretory diarrhea, VIPoma.

How to cite this article: Kumar B, Upadhyaya VD, Rao RN, Kumar S. Ganglioneuroblastoma as Vasoactive Intestinal Polypeptide-secreting Tumor: Rare Case Report in a Child. World J Endoc Surg 2015;7(2):47-50.

Source of support: Nil

Conflict of interest: None

Case Report
Krishnan Ravikumar, Dhalapathy Sadacharan, RV Suresh

Surgical Delight: Nonrecurrent Laryngeal Nerve

[Year:2015] [Month:January-April] [Volumn:7 ] [Number:1] [Pages:27] [Pages No:14-16][No of Hits : 821]


Introduction: A nonrecurrent course is an unusual anatomic variation of the recurrent laryngeal nerve. It is seen usually on the right side, and it is very rare on the left side. Nonrecurrent laryngeal nerve if present is mostly associated with vascular anomalies.

Case report: A 55-year-old female was referred to us with thyrotoxic symptoms for a period of 6 months. She was rendered euthyroid with antithyroid medications. After complete evaluation, she was posted for total thyroidectomy. Intraoperatively, right recurrent nerve could not be identified in usual position. On careful dissection, a nonrecurrent laryngeal nerve was identified. The recurrent laryngeal nerve on the left side showed normal course. The intraoperative and postoperative period were uneventful. Postoperative vocal cord status was normal.

Conclusion: This case was presented for its rarity and to stress the need for orderly meticulous surgical dissection.

Keywords: Nonrecurrent laryngeal nerve, Recurrent laryngeal nerve, Inferior laryngeal nerve.

How to cite this article: Ravikumar K, Sadacharan D, Suresh Rv. Surgical Delight: Nonrecurrent Laryngeal Nerve. World J Endoc Surg 2015;7(1):14-16.

Source of support: Nil

Conflict of interest: None

Research Article
Pramodh Chandrasinghe, Ranil Fernando, Sumal Nandasena, Arunasalam Pathmeswaran

Epidemiology of Goiters in Sri Lanka with Geographic Information System Mapping: Population-based Cross-sectional Study

[Year:2015] [Month:September-December] [Volumn:7 ] [Number:3] [Pages:25] [Pages No:55-59][No of Hits : 766]


Background: Sri Lanka is considered an endemic region for goiter. Early researchers have suggested the existence of a goiter belt based on rainfall pattern. Subsequent studies done in school children have challenged this theory. Current study is a community-based cross-sectional study done to assess the epidemiology of goiters. Geographic information system (GIS) mapping of the goiter prevalence is developed for the first time in Sri Lanka.

Methods: Study subjects were selected using a multi-staged cluster sampling with probability proportionate to size (PPS) method. Examination for the presence of goiters was done by two trained investigators and graded. ArcGIS 10 software was used for geostatistical analysis and developing a map by interpolating the data collected for the first time in Sri Lanka.

Results: A total of 5200 individuals (female-66%, median age-38 years; range 10-92 years) were assessed and 426 goiters were detected. The adjusted prevalence rate of goiters was 6.8%. Kriging interpolation method was used to develop the most appropriate epidemiological map clustering of high prevalence areas with scattered pockets of high prevalence was observed. Current map does not show a prevalence pattern in relation to the rainfall or elevation above sea level as proposed in the past.

Conclusion: Goiter prevalence in Sri Lanka appears to be different from earlier proposed patterns. Use of GIS has contributed to develop a comprehensive epidemiological map of goiters demonstrating the absence of an endemic goiter belt in the wet zone as proposed earlier.

Keywords: Epidemiology, GIS mapping, Goiter prevalence.

How to cite this article: Chandrasinghe P, Fernando R, Nandasena S, Pathmeswaran A. Epidemiology of Goiters in Sri Lanka with Geographic Information System Mapping: Population-based Cross-sectional study. World J Endoc Surg 2015;7(3):55-59.

Source of support: National Science Foundation. Grant no: 2006/04.

Conflict of interest: None

Review Article
Rajeev Parameswaran, Dedrick Kok Hang Chan, Poon Li Mei Michelle, Shi Wang

Primary Adrenal Diffuse Large B-cell Lymphoma: A Mini Review

[Year:2015] [Month:September-December] [Volumn:7 ] [Number:3] [Pages:25] [Pages No:65-68][No of Hits : 758]


Background: Primary adrenal diffuse large B-cell lymphoma are aggressive high grade lymphomas affecting elderly gentlemen and mostly present with bilateral enlarged adrenal masses associated with B symptoms, adrenal insufficiency and elevated lactate dehydrogenase. When imaged with CT or ultrasound, these lesions usually appear as heterogeneous complex large masses with low density. They appear metabolically active on PET scan. Confirmatory diagnosis is established by image guided biopsy or surgical excision. Treatment is usually with rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone (R-CHOP) or CHOP like regimes. Surgery has very limited role, if any in the management of this condition. The prognosis is generally poor with only about a third of patients achieving partial or complete remission following treatment. A concise review of the literature (PubMed database; 1990-2014) on the clinical management of primary adrenal lymphoma along with a case example is discussed.

Keywords: Adrenal, Adrenal tumor, Lymphoma.

How to cite this article: Parameswaran R, Chan DKH, Michelle PLM, Wang S. Primary Adrenal Diffuse Large B-cell Lymphoma: A Mini Review. World J Endoc Surg 2015;7(3):65-68.

Source of support: Nil

Conflict of interest: None

Original Article
Narendra Krishnani, Niraj Kumari, Rajneesh K Singh, Pooja Shukla

The Dominant Somatostatin Receptor in Neuroendocrine Tumors of North Indian Population

[Year:2015] [Month:September-December] [Volumn:7 ] [Number:3] [Pages:25] [Pages No:60-64][No of Hits : 749]


Introduction: Neuroendocrine tumors (NET) express different types of somatostatin receptors (SSTRs) that bind to synthetic analogs with variable affinity. It is important to know the expression profile of SSTRs to predict biological effect of somatostatin analogues. We studied SSTR2 and SSTR5 expression by immunohistochemistry (IHC) to assess the dominant subtype in NETs and correlate the expression with histological prognostic parameters.

Materials and methods: Fifty-three consecutive cases of NET from all sites were evaluated for SSTR2 and SSTR5 expression by IHC. The expression was correlated with histological features of NETs.

Results: Forty-four cases were resected specimens and 9 were small biopsies. Nine of 53 cases (16.9%) were functional tumors. There were 24 NETs from gastrointestinal tract (GIT), 19 from pancreas and 10 from miscellaneous sites. Overall SSTR expression was seen in 43 NETs (79.2%). Somatostatin receptor 2 was expressed in 30 cases (56.6%) and SSTR5 in 39 cases (73.6%). Somatostatin receptor 2 expression showed near significant negative correlation with tumor grade and lymph node metastasis (p = 0.05). Somatostatin receptor 5 expression showed significant negative correlation with lymph node metastasis (p = 0.008) and tumor size (p = 0.02). Anatomic location and tumor necrosis were not significantly different. Somatostatin receptor 5 was dominant subtype expressed in all NETs with intense expression.

Conclusion: Somatostatin receptor 5 expression was the dominant subtype and expressed in small sized tumors. Somatostatin receptor 2 was expressed more in low grade NETs. Somatostatin analogs can be effective both in functional and nonfunctional NETs and can be useful in both resectable and nonresectable or metastatic tumors.

Keywords: Neuroendocrine tumors, Somatostatin analog, SSTR2, SSTR5.

How to cite this article: Krishnani N, Kumari N, Singh RK, Shukla P. The Dominant Somatostatin Receptor in Neuroendocrine Tumors of North Indian Population. World J Endoc Surg 2015;7(3):60-64.

Source of support: Nil

Conflict of interest: None

How We Do It
Sabaretnam Mayilvaganan, Aromal Chekavar, Rakesh Kapoor, Amit Agarwal

Conservative Management of Chyle Leak following Thyroid Surgery

[Year:2015] [Month:September-December] [Volumn:7 ] [Number:3] [Pages:25] [Pages No:76-78][No of Hits : 718]


Lymphatic injury leading to chyle leak is a potential complication that may arise following thyroid surgery especially when there is a high nodal burden. Although the incidence of chyle leak post surgery is low (1 to 4%), this complication can present significant challenges to both the surgeon and patient. Multiple approaches to the treatment of chyle leak have emerged, including nutrition, surgical, and pharmacological therapies. Although there are strong feelings among clinicians about the use of bowel rest, parenteral nutrition, or a low-fat enteral formula for the treatment of chyle leak, definitive evidence supporting any nonsurgical methods vs surgical approach is lacking. The lack of a clear consensus on the optimal management of chyle leaks makes this problem more challenging for the treating surgeon.

Keywords: Chyle leak, Conservative management, Thyroid surgery.

How to cite this article: Mayilvaganan S, Chekavar A, Kapoor R, Agarwal A. Conservative Management of Chyle Leak following Thyroid Surgery. World J Endoc Surg 2015;7(3):76-78.

Source of support: Nil

Conflict of interest: Sabaretnam Mayilvaganan and Aromal Chekavar have contributed equally to this manuscript.

Rajan Garg, Ankur Mandelia, Sandeep Agarwala, Veereshwar Bhatnagar, MK Singh, Manisha Jana

Antenatally Diagnosed Suprarenal Cystic Teratoma

[Year:2015] [Month:May-August] [Volumn:7 ] [Number:2] [Pages:25] [Pages No:44-46][No of Hits : 703]


A two months old female child presented to us with an antenatal diagnosis of left suprarenal mass. Laparotomy revealed a large cystic mass in the left suprarenal location which was completely excised. The histological diagnosis was a mature, cystic teratoma. Although, the diagnosis of adrenal teratoma is rare, it should be considered in the differential diagnosis of antenatally diagnosed suprarenal lesions.

Keywords: Adrenal teratoma, antenatal diagnosis, suprarenal teratoma.

How to cite this article: Garg R, Mandelia A, Agarwala S, Bhatnagar V, Singh MK, Jana M. Antenatally Diagnosed Suprarenal Cystic Teratoma. World J Endoc Surg 2015;7(2):44-46.

Source of support: Nil

Conflict of interest: None

Endocrine image
Anand Mishra, Arpit Agarwal, Ravi K Singh, Sandeep Tewari

Pemberton Sign in Diagnosis of Retrosternal Goiter

[Year:2015] [Month:September-December] [Volumn:7 ] [Number:3] [Pages:25] [Pages No:79-80][No of Hits : 638]


The Pemberton maneuver (elevating both arms until they touch the sides of the head for a minute) is a method to increase pressure in the thoracic inlet and further narrow the aperture.1 If congestion, cyanosis of face or distension of neck veins or distress become apparent, it is suggestive of retrosternal goiter. We describe two patients with Pemberton sign.

Keywords: Goiter, Intrathoracic, Thyroidectomy, Thyroid surgery.

How to cite this article: Mishra A, Agarwal A, Singh RK, Tewari S. Pemberton Sign in Diagnosis of Retrosternal Goiter. World J Endoc Surg 2015;7(3):79-80.

Source of support: Nil

Conflict of interest: None

R Harsvardhan

Patient Safety vis-a-vis Safe Surgery: The Road Less traveled

[Year:2015] [Month:January-April] [Volumn:7 ] [Number:1] [Pages:27] [Pages No:v-vii][No of Hits : 592]


Patient Safety vis-à-vis Safe Surgery: The Road Less traveled

In October 2004, the World Health Organization (WHO) launched the World Alliance for patient safety in response to World Health Assembly Resolution 55.18 urging WHO and member states to pay the closest possible attention to the problem of patient safety. The Alliance raised awareness and political commitment to improve the safety of care and supports member states to develop patient safety policy and practice.

Aoife Lowery, Charles Vanbrugghe, Claudio Golffier, Frederic Sebag, Jean Francois Henry

Recurrent Primary Hyperparathyroidism: A Diagnostic Challenge in a Supernumerary Intrathyroidal Dormant Adenoma

[Year:2015] [Month:May-August] [Volumn:7 ] [Number:2] [Pages:25] [Pages No:39-43][No of Hits : 587]


Introduction: Recurrent primary hyperparathyroidism is a rare entity and presents a significant surgical challenge.

Presentation of case: We present the case of a 53-year-old female with recurrent primary hyperparathyroidism, which was caused by the very rare occurrence of a metachronous parathyroid adenoma in a supernumerary intrathyroidal parathyroid.

Discussion: This unique case highlights the challenges that arise in the evaluation of recurrent hyperparathyroidism in which even a thorough preoperative evaluation including radiographic, nuclear medicine studies and fine needle aspiration cytology did not facilitate a definitive preoperative diagnosis.

Conclusion: The management approach for these patients requires meticulous planning, experience and appropriate use of intraoperative adjuncts to guide surgical strategy.

Keywords: Hyperparathyroidism, Parathyroid, Radiographic study.

How to cite this article: Lowery A, Vanbrugghe C, Golffier C, Sebag F, Henry JF. Recurrent Primary Hyperparathyroidism: A Diagnostic Challenge in a Supernumerary Intrathyroidal Dormant Adenoma. World J Endoc Surg 2015;7(2):39-43.

Source of support: Nil

Conflict of interest: None

Case Report
TK Pandian, Geoffrey Thompson, DY Benzon

Extreme Nausea due to Hyperparathyroidism in Multiple Endocrine Neoplasia-1

[Year:2015] [Month:September-December] [Volumn:7 ] [Number:3] [Pages:25] [Pages No:69-71][No of Hits : 583]


We describe a young woman with multiple endocrine neoplasia-1 (MEN-1) who presented with severe nausea as a result of hyperparathyroidism (HPT). We present a case report, review the relevant literature in regards to physiology, and offer a target source for symptom control.
A 19-year female with MEN-1 initially presented with neuroglycopenia and hyperinsulinism. She had concomitant HPT. She underwent a distal pancreatectomy with enucleation of neuroendocrine tumors from the pancreatic head. Postoperatively, she developed severe nausea and was found to have worsening HPT. She was placed on a calcimimetic and had immediate resolution of symptoms. She ultimately underwent a subtotal parathyroidectomy and has been symptom-free since that time.
Severe nausea can occur in up to 25% of patients with HPT. Two theories exist regarding the mechanism behind this symptomatology. The first involves destruction of gastric mucosa leading to peptic ulcer disease. The second su