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Objectives: Recurrent laryngeal nerve (RLN) injury is a well-known complication of parathyroid surgery. Despite ample data, there is still uncertainty about the role of intraoperative monitoring (IONM) in mitigating RLN damage. Study Design: A retrospective review. Methods: We included all patients presenting for total, subtotal, or completion parathyroidectomy at a tertiary referral hospital from 2013 to 2018. Information about demographics, previous neck surgery, perioperative data, pathology, and possible RLN injury was collected. Two groups were formed for analysis: IONM vs. nonmonitored (NM). Results: 105 patients underwent 107 surgeries with IONM utilized in 71 cases. The groups were similar in demographics, but significantly differed (all P < 0.05) in preincision parathyroid hormone level (IONM = 2091.44 vs NM = 1334.87), surgery type (IONM = 62.9% vs NM = 27.8% subtotal), and surgery length in minutes (IONM = 155.21 vs NM = 182.22). We observed six cases (6/71 = 8.45%) of persistent RLN complaints (three or more weeks postoperatively) and four cases (4/71 = 5.63%) of temporary complaints with the use of IONM compared with only one temporary complaint (1/36 = 2.78%) in unmonitored procedures (P = 0.129). Conclusions: These results suggest that the use of IONM does not provide a protective effect on the RLN in patients with secondary or tertiary hyperparathyroidism undergoing total, subtotal, or completion parathyroidectomy. Prospective, randomized studies with pre-and postoperative flexible laryngoscopy are needed to explore the use of IONM in this patient population further.

Author Contributions: Drs Cabrera and Fowler had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Background: Insulinomas are rare functional pancreatic neuroendocrine tumors. In this large single-institution retrospective series we assess the surgical outcomes of resected insulinoma cases. Methods: The institutional pathology database was utilized for identification of all resected insulinoma cases within the last 10 years. Clinicopathological information and followup data were collected and assessed for postoperative patient outcomes. Results: In the studied period, 40 patients with resected insulinoma were identified; they were predominantly white (80%) and female (65%), with a median age of 50 years . All patients presented with Whipple's triad (symptomatic hypoglycemia, blood glucose level <50 mg/ dL, and symptom relief with glucose administration), accompanied occasionally by weight gain (n = 18, 45%), personality changes (n = 33, 82.5%), or syncopal episodes (n = 18, 45%). In four cases (10%) the lesion was associated with MEN-1 syndrome and the rest were sporadic.Endoscopic ultrasound was the main diagnostic tool for tumor localization; lesion enucleation was performed for smaller lesions in 25% of the patients. The median tumor size was 13 mm (IQR 10-21), and most lesions were unifocal (n = 34, 85%) and located in the distal pancreas (n = 23, 57.5%). One patient (2.5%) had a distant liver metastasis at diagnosis that was also resected; he underwent a second liver resection for recurrence 3 years later and the patient is alive 9 years after initial presentation. Insulinoma recurrence was also identified locally in a patient with a previous R1 resection 2 years later (2.5%). Median patient follow-up was 16 months (IQR 4-57) and disease-associated mortality was zero. Conclusion: Insulinomas are rare pancreatic neuroendocrine tumors with favorable biology. Surgical resection is the treatment of choice with excellent prognosis. P 50.