P heochromocytoma (PCC) and paraganglioma (PGL) are rare neuroendocrine tumors. Pheochromocytomas arise from chromaffin cells in the adrenal medulla, and PGLs arise from chromaffin cells in the ganglia of the autonomic nervous system. [1, 2] Paragangliomas originate from sympathetic or parasympathetic ganglia in the abdomen, thorax, and pelvis. Paragangliomas may also originate from parasympathetic ganglia at the base of the skull and along the glossopharyngeal nerve and vagus nerve in the neck. [2] The majority of PCCs and sympathetic PGLs are endocrine active tumors, and they cause clinical symptoms by secreting excess catecholamines (norepinephrine, epinephrine, Pheochromocytomas (PCC) and paragangliomas (PGL) are rare neuroendocrine tumors. Pheochromocytomas arise from chromaffin cells in the adrenal medulla, and PGLs arise from chromaffin cells in the ganglia of the autonomic nervous system. Paragangliomas originate from sympathetic or parasympathetic ganglia in the abdomen, thorax, and pelvis. The majority of PCC and sympathetic PGL are endocrine active tumors causing clinical symptoms by secreting excess catecholamines (norepinephrine, epinephrine, dopamine) and their metabolites. The incidence of PCC and PGL ranges between 2 and 8 per million, with a prevalence between 1:2500 and 1:6500. It peaks between the 3rd and 5th decades of life, and approximately 20% of cases are pediatric patients. The prevalence among patients with hypertension in outpatient clinic ranges between 0.1-0.6% in adults and between 2-4.5% in the pediatric age group. 10-49% of these tumors is detected incidentally in imaging techniques performed for other reasons. However, 4-8% of adrenal incidentalomas are PCCs. Of these neuroendocrine tumors, 80-85% are PCCs and 15-20% are PGLs. Up to 40% of patients with PCC and PGL has disease-specific germline mutations and the situation is hereditary. Of 60% of the remaining sporadic patients, at least 1/3 has a somatic mutation in predisposing genes. 8% of the sporadic cases, 20-75% of the hereditary cases, 5% of the bilateral, adrenal cases, and 33% of the extra-adrenal cases at first presentation are metastatic. Although PCCs and PGLs have scoring systems for histological evaluation of the primary tumor, it is not possible to diagnose whether the tumor is malignant since there is no histological system approved for the biological aggressiveness of this tumor group. Metastasis is defined as the presence of chromaffin tissue in non-chromaffin organs, such as lymph nodes, liver, lungs and bone. Although most of the PCC and PGL are benign, the metastatic disease may develop in 15-17%. Metastatic disease is reported between 2-25% in PCCs and 2.4-60% in PGLs. The TNM staging system of the American Joint Committee on Cancer (AJCC) was developed to predict the prognosis, based on the specific anatomical features of the primary tumor and the occurrence of metastasis.

IONM contributes to visual and functional identification of the EBSLN and decreases the rate of EBSLN injury during superior pole dissection. Routine use of IONM to identify the EBSLN will minimize the risk of injury during thyroidectomy.

No abstract

B aşta primer hiperparatiroidizm (pHPT) olmak üzere paratiroit hastalıkları için planlanan paratiroidektomi ameliyatlarında başarı oranını arttıran en önemli değişkenler; multidisipliner yaklaşımla doğru tanı konması ve hastalığa uygun cerrahi girişimin yapılmasıdır. Bu bağlamda, başarılı bir paratiroidektomi için paratiroitlerin embriyolojisi ve anatomisi iyi bilinmeli ve özümsenmelidir. [1] Primer hiperparatiroidizm (pHPT)'in tek küratif tedavisi cerrahidir. Paratiroidektomide başarı oranını arttıran en önemli faktörler; tanının doğru konulması ve cerrahın iyi anatomi ve embriyo-loji bilgisine sahip olmasıdır. Alt paratiroit bezler üçüncü faringeal poşun, üst paratiroit bezler ise dördüncü faringeal poşun dorsal parçasından gelişir. İnsanda tipik olarak 4 paratiroit bulunmaktadır. Geniş otopsi serilerinde %80-93 arasında dört, %3.7-13 arasında dörtten fazla (süpernumara bez), %2-13 arasında ise dörtten az paratiroit saptanmıştır. Üst paratiroidlerin tipik yerleşim yeri tiroidin 1/3 orta ve üst kesiminin posterolateralinde krikotiroit bileşke bölgesinde, alt paratiroitlerin tipik yerleşimi ise tiroit alt kutbunun posterioru, lateral veya anterolateralinde, 1 cm çaplı alan içinde bulunur. Paratiroitlerin; embriyolojik anormal göçüne bağlı olarak konjenital ektopi ve büyümüş paratiroitlerin göçüne bağlı olarak edinsel ektopi şeklinde normal yerleşim alanları dışında, farklı anatomik bölgelerde ektopik olarak bulunması nadir değildir. Hiperparatiroidizmin cerrahi tedavisinde farklı ameliyat teknikleri tanımlanmasına rağmen kullanılabilecek iki temel cerrahi seçenek; bilateral boyun eksplorasyonu (BBE) ve minimal invaziv paratiroiektomi (MİP) adı altında toplanabilen daha sınırlı cerrahilerdir. MİP açık, endoskopik veya video yardımlı (MIVAP) olarak uygulanabilmekte olup, genellikle lateral açık MİP uygulanmaktadır. Ayrıca boyun dışında bulunan uzak bölgelerden yapılan endoskopik veya robotik paratiroidektomi yöntemleri de bildirilmiştir. Günümüzde görüntüleme pozitif olan seçilmiş hastalarda MİP standart tedavi seçeneği olmakla birlikte, paratiroit cerrahisinde BBE altın standart bir girişim olarak yerini korumaktadır. pHPT'li hastaların %80-90'ında patolojik paratiroit bezi preoperatif görüntüleme yöntemleri ile belirlenebilmekte ve MİP uygulanabilmektedir. Bununla birlikte MİP uygulanan hastalarda yanlış pozitifliğe bağlı olarak patolojik bez bulunamayabilir. Bu nedenle paratiroit cerrahı MİP tekniği kadar BBE tekniğini de iyi bilmeli ve uygulamalı, gerektiğinde stratejiyi değiştirerek BBE'ye geçebilmelidir. Eğer aranan paratiroit normal anatomik yerinde bulunamazsa bezin olası embriyolojik ve edinsel ektopik yerleşimleri araştırılır. Paratiroit cerrahisinde MİP ve BBE'nin birbirinin alternatifi değil, başarılı tedavi için birbirini tamamlayan teknikler olduğu unutulmamalıdır. Anahtar sözcükler: Bilateral boyun eksplorasyonu; cerrahi yöntemler; primer hiperparatiroidizm; minimal invaziv paratiroidektomi.

The 2019 novel coronavirus disease (COVID-19) was initially seen in Wuhan, China, in December 2019. World Health Organization classified COVID-19 as a pandemic after its rapid spread worldwide in a few months. With the pandemic, all elective surgeries and non-emergency procedures have been postponed in our country, as in others. Most of the endocrine operations can be postponed for a certain period. However, it must be kept in mind that these patients also need surgical treatment, and the delay time should not cause a negative effect on the surgical outcome or disease process. It has recently been suggested that elective surgical interventions can be described as medically necessary, time-sensitive (MeNTS) procedures. Some guidelines have been published on proper and safe surgery for both the healthcare providers and the patients after the immediate onset of the COVID-19 pandemic. We should know that these guidelines and recommendations are not meant to constitute a position statement, the standard of care, or evidence-based/best practice. However, these are mostly the opinions of a selected group of surgeons. Generally, only life-threatening emergency operations should be performed in the stage where the epidemic exceeds the capacity of the hospitals (first stage), cancer and transplantation surgery should be initiated when the outbreak begins to be controlled (second stage), and surgery for elective cases should be performed in a controlled manner with suppression of the outbreak (third stage). In this rapidly developing pandemic period, the plans and recommendations to be made on this subject are based on expert opinions by considering factors, such as the course and biology of the disease, rather than being evidence-based. In the recent reports of many endocrine surgery associations and in various reviews, it has been stated that most of the cases can be postponed to the third stage of the epidemic. We aimed to evaluate the risk reduction strategies and recommendations that can help plan the surgery, prepare for surgery, protect both patients and healthcare workers during the operation and care for the patients in the postoperative period in endocrine surgery.