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Background/purpose: In Europe, the Division of Endocrine Surgery (DES) determines the number of operations (thyroid, neck dissection, parathyroids, adrenals, neuroendocrine tumors of the gastro-entero-pancreatic tract (GEP-NETs)) to be required for the European Board of Surgery Qualification in (neck) endocrine surgery. However, it is the national surgical boards that determine how surgical training is delivered in their respective countries. There is a lack of knowledge on the current situation concerning the training of surgical residents and fellows with regard to (neck) endocrine surgery in Europe., Methods: A survey was sent out to all 28 current national delegates of the DES. One questionnaire was addressing the training of surgical residents while the other was addressing the training of fellows in endocrine surgery. Particular focus was put on the numbers of operations considered appropriate., Results: For most of the operations, the overall number as defined by national surgical boards matched quite well the views of the national delegates even though differences exist between countries. In addition, the current numbers required for the EBSQ exam are well within this range for thyroid and parathyroid procedures but below for neck dissections as well as operations on the adrenals and GEP-NETs., Conclusions: Training in endocrine surgery should be performed in units that perform a minimum of 100 thyroid, 50 parathyroid, 15 adrenal, and/or 10 GEP-NET operations yearly. Fellows should be expected to have been the performing surgeon of a minimum of 50 thyroid operations, 10 (central or lateral) lymph node dissections, 15 parathyroid, 5 adrenal, and 5 GEP-NET operations.

Background: Published data in the last decade showed that a majority of adrenal operations are done by surgeons performing only one such case per year and based on the distribution of personal workloads 'high-volume' surgeons are defined as those doing 4 or more cases/year., Purpose: This paper summarises literature data identified by a working group established by the European Society of Endocrine Surgeons (ESES). The findings were discussed during ESES-2019 conference and members agreed on a consensus statement., Results: The annual of adrenal operations performed yearly in individual countries was reported to be 800/year in UK and over 1600/year in France. The learning curve of an individual surgeon undertaking laparoscopic, retroperitoneoscopic or robotic adrenalectomy is estimated to be 20-40 cases. Preoperative morbidity and length of stay are more favourable in high-volume centres., Conclusion: The main recommendations are that adrenal surgery should continue only in centres performing at least 6 cases per year, surgery for adrenocortical cancer should be restricted to centres performing at least 12 adrenal operations per year, and an integrated multidisciplinary team should be established in all such centres. Clinical information regarding adrenalectomies should be recorded prospectively and contribution to the established EUROCRINE and ENSAT databases is strongly encouraged. Surgeons wishing to develop expertise in this field should seek mentorship and further training from established adrenal surgeons.

Background: Permanent hypoparathyroidism (hypoPT) represents the most common postoperative complication associated with total thyroidectomy. Current treatment relies on high-dose calcium and/or vitamin D supplementation, but often this is insufficient and some patients remain symptomatic. Parathyroid allotransplantation is a new therapeutic option described recently in the literature. This study aims to investigate the patients' acceptability of parathyroid transplantation as a potential new treatment for hypoPT., Method: Online survey of members of HypoParaUK, a support group for individuals affected by hypoPT., Results: Responses were received from 252 hypoPT patients. Majority declared to experience severe symptoms despite regular medical treatment. On a severity scale of 0-5, symptoms that were most troublesome were fatigue (3.8), low sense of well-being (3.5), and numbness/tingling (2.9). On a scale of 0-10, on average, their current quality of life (QoL) was 5 ± 3 and they expected this would improve to 7 ± 2 with correction of their hypoPT. Forty-four percent of patients were extremely interested in a potential technique involving intramuscular injection of parathyroid cell suspension compared to just 14% who were interested in the more invasive procedure of implantation of a parathyroid allograft into the forearm. The main concerns expressed were related to the possible need for immunosuppressive therapy., Conclusion: Patients with severe symptomatic hypoPT seem interested to consider participation in a clinical trial exploring the feasibility and success rate of parathyroid transplantation.

In recent years, there has been increasing interest in understanding the implications of diagnosing normocalcaemic primary hyperparathyroidism (nPHPT). Many patients hope that nPHPT might explain some of their symptoms, but surgeons hesitate to offer treatment to patients whose calcium levels are normal but whose parathyroid hormone (PTH) levels are elevated in the absence of secondary causes of hyperparathyroidism. This potential new diagnosis is not well understood and may lead to inappropriate investigation and possible unnecessary operations. However, because a significant number of patients with nPHPT progress to hypercalcaemic primary hyperparathyroidism (PHPT), some consider nPHPT to be an early or mild form of hypercalcaemia. Rather than being an indolent disease, nPHPT was reported to be associated with systemic complications similar to 'classical' PHPT, and hence there is growing interest to understand who should be offered surgical treatment and who should be monitored. Further standardisation of diagnostic definition, associated complications, patient selection, surgical management and long-term outcomes are necessary. The recommendations outlined in this review are based on limited evidence from non-randomised cohort studies and expert opinion.

Background: Sporadic multiglandular disease (MGD) has been reported in literature in 8-33 % of patients with primary hyperparathyroidism (pHPT). This paper aimed to review controversies in the pathogenesis and management of sporadic MGD., Methods: A literature search and review was made to evaluate the level of evidence concerning diagnosis and management of sporadic MGD according to criteria proposed by Sackett, with recommendation grading by Heinrich et al. and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Results were discussed at the 6th Workshop of the European Society of Endocrine Surgeons entitled 'Hyperparathyroidism due to multiple gland disease: An evidence-based perspective'., Results: Literature reports no prospective randomised studies; thus, a relatively low level of evidence was achieved. Appropriate surgical therapy of sporadic MGD should consist of a bilateral approach in most patients. Unilateral neck exploration guided by preoperative imaging should be reserved for selected patients, performed by an experienced endocrine surgeon and monitored by intraoperative parathormone assay (levels of evidence III-V, grade C recommendation). There is conflicting or equally weighted levels IV-V evidence supporting that cure rates can be similar or worse for sporadic MGD than for single adenomas (no recommendation). Best outcomes can be expected if surgery is performed by an experienced parathyroid surgeon working in a high-volume centre (grade C recommendation). Levels IV-V evidence supports that recurrent/persistence pHPT occurs more frequently in patients with double adenomas hence in situations where a double adenoma has been identified, the surgeon should have a high index of suspicion during surgery and postoperatively for the possibility of a four-gland disease (grade C recommendation)., Conclusions: Identifying preoperatively patients at risk for MGD remains challenging, intraoperative decisions are important for achieving acceptable cure rates and long-term follow-up is mandatory in such patients.

Background: Central compartment lymph node (CCLN) metastasis in papillary thyroid cancer (PTC) is associated with higher risk of loco-regional recurrence and distant metastasis. This study evaluated the prognostic implication of the number of metastatic CCLN in PTC., Methods: Prospective data collection on 91 patients with PTC who underwent total thyroidectomy and CCLN dissection with or without lateral neck dissection between January 2005 and December 2010 was made. Number of positive CCLN was correlated with known prognostic factors (age, gender, tumour size, extrathyroidal extension and lateral node metastasis)., Results: Patients were divided into three groups according to the number of positive CCLN: group A = 0 (n = 35); B = 1-2 nodes (n = 32) and C = >3 nodes (n = 24). The risk of lateral compartment disease increased in parallel with the number of positive CCLN (31 vs. 50 vs. 75 % in groups A-B-C, respectively; p < 0.004). Gender/age/tumour size/extrathyroidal extension did not correlate with number of positive CCLN. The increasing number of positive CCLN did not influence post-ablation iodine uptake (1.25 vs. 1.14 vs. 2.63 %) and correlated with mean thyroglobulin values at 1-year post-ablation (12.3 vs. 42.3 vs. 91.48 μg/L) CONCLUSIONS: The number of CCLN metastasis is a risk factor for lateral compartment disease with no correlation with other prognostic markers.

Background: Most patients with adrenocortical cancer (ACC) continue to present with advanced disease. Invasion into the inferior vena cava (IVC) defines stage III disease and the management of such patients raises additional difficulties., Method: A multicentre survey was organized by emailing a standardized proforma to members of the European Society of Endocrine Surgery (ESES). Anonymised retrospective clinical data were collected., Results: Replies were received from 18 centres in nine countries. ACC with IVC invasion was encountered in 38 patients (18F:20M, age 15-84 years, median 54 years). There were 16 nonfunctioning tumours and 22 functioning tumours predominantly right-sided (26R:12L) and measuring 18-255 mm (median 115 mm). Fourteen patients had metastatic disease at presentation. Tumour thrombus extended in the prehepatic IVC (n = 21), subdiaphragmatic IVC (n = 6) or into the SVC/right atrium (n = 3). Open adrenalectomy was associated with resection of surrounding viscera in 24 patients (nephrectomy n = 16, liver resection n = 14, splenectomy n = 3, Whipple procedure n = 2). IVC was controlled locally (n = 27), at suprahepatic levels (n = 6) or necessitated cardiac bypass (n = 5). Complete resection (R0, n = 20) was achieved in the majority of patients, with a minority having microscopic persistent disease (R1, n = 7) or macroscopic residual disease (R2, n = 4). Perioperative 30-day mortality was 13% (n = 5). Postoperative Mitotane was used in 23 patients and chemotherapy in eight patients. Twenty-five patients died 2-61 months after their operation (median 5 months). Currently, 13 patients are alive at 2-58 months (median 16 months) with known metastatic disease (n = 7) or with no signs of distant disease (n = 6)., Conclusion: This dataset is limited by the lack of a denominator as it remains unknown how many other patients with ACC presenting with IVC invasion did not undergo surgery. The relatively low perioperative mortality and the long disease-free survival achieved by some patients should encourage surgeons with adequate experience to offer surgical treatment to patients presenting with advanced adrenocortical cancers.

Background: Parathyroidectomy for primary hyperparathyroidism (PHPT) is followed by a decrease in the severity of symptoms reported on the Pasieka's parathyroid symptoms score (PPSS) and SF-36 questionnaires. Some argue that such benefits are short-lived. This study investigates the severity of symptoms at more than 12 months after parathyroidectomy., Methods: A prospective database collected clinical/operative data on consecutive patients with PHPT. PPSS was calculated as the sum of the 13 parameters self-assessed using a visual analog scale. SF-36(v2) was analyzed using commercially available software (QualityMetric Inc., Lincoln, USA)., Results: Over 3-year interval, 166 patients (119 F/47 M, age 15-89 years) were operated for with PHPT (Ca 2.90 ± 0.25 mmol/L, PTH 21.64 ± 23.05 pmol/L). Their preoperative PPSS ranged 0-1,260 (median 413) and did not correlate with the severity of hypercalcemia. One hundred and seven patients responded when contacted by post at 18 ± 6 months postoperatively. Their postoperative PPSS was significantly lower (398 ± 226 to 231 ± 203, p < 0.001) and in 55 of 107 patients the severity of symptoms reduced by at least 50%. Most significant improvements were for mood (36 ± 33 vs. 16 ± 23), weakness/tiredness (37 ± 32 vs. 17 ± 23), irritability (35 ± 31 vs. 17 ± 21), and thirst (37 ± 32 vs. 18 ± 25; p < 0.0001). Physical and mental component scores of SF-36 questionnaire improved in patients whose PPSS decreased postoperatively., Conclusion: Symptomatic benefits persist for at least 1 year after parathyroidectomy in the majority of patients with PHPT.

Purpose: Progress in parathyroid imaging has brought substantial changes in the surgical strategy to approach patients with sporadic primary hyperparathyroidism (pHPT). The present review is focused on the safety and efficacy of limited parathyroid exploration., Materials and Methods: Review of the literature focused on studies dealing with unilateral (two-gland exploration) or selective parathyroidectomy (one-gland exploration) in selected patients with pHPT and on the classification of published reports according to the degree of evidence., Results: Parathyroid exploration limited to a solitary parathyroid adenoma can be considered a minimally invasive procedure that can be performed by the minicervicotomy, video-assisted, or endoscopic approaches. In properly selected patients, it affords results comparable to those of four-gland bilateral exploration in terms of cure and recurrence. It causes less postoperative hypocalcemia., Conclusions: Selective parathyroidectomy is an option for patients with positive preoperative localization tests undergoing first-time surgery who have no family history of pHPT, no goiter for which surgical therapy is proposed, and are not on lithium therapy.

Objective: Imaging in patients with primary hyperparathyroidism has been proven difficult. During the last decade, sestamibi scintigraphy and ultrasound (US) have been used with various success. The importance of these procedures has risen since minimal invasive parathyroid (MIP) surgery also has developed, and it is claimed that preoperative localization usually is needed before embarking on such a procedure., Methods: We have scanned the most recent literature in this matter in order to identify evidence, using commonly accepted grading, and also concluded a number of recommendations., Results and Conclusions: We found evidence at level III leading to recommendations at grade B, that sestamibi scintigraphy is a recommended first test, but that US by an experienced investigator may be an alternative. MIP may be performed when both tests are concordant, and in case of only one test being positive, unilateral exploration and use of intraoperative PTH measurements are recommended. Bilateral neck exploration is used when both tests are negative. For reoperative procedures, repeat investigations are recommended, but also to use US-guided fine needle aspiration and PTH measurements as well as venous sampling. However, for reoperative procedures, the level of evidence is weaker-level IV, but recommendations still at grade B.

Background: Functional imaging using (123)I-meta-iodo-benzyl-guanetidine (MIBG) scintigraphy has alleged 100% specificity for phaeochromocytoma (PHAEO). Its benefit in patients with biochemical diagnosis of PHAEO is arguable when cross-sectional radiology can demonstrate the side-size of the adrenal tumours., Materials and Methods: This is a retrospective review of clinical notes of patients undergoing adrenalectomy for PHAEO in a University centre., Results: Between January 2000 and December 2007, adrenalectomy for PHAEO was performed on 66 patients (28 M and 38 F, aged 24-82 years). Diagnosis was demonstrated by raised 24-h urine catecholamines (n = 14) or metanephrines (n = 52). The side and size of adrenal tumours were demonstrated on computed tomography (n = 58) and/or magnetic resonance imaging (n = 20) scans. MIBG scans were performed in 38 patients. Four of these patients were found to have non-adrenal pathology (haemangioblastomas, haemangioma, a bronchogenic cyst and an angiomyolipoma); hence, the positive predictive value of MIBG scan was 90%. In a further five patients, MIBG raised the suspicion of local metastatic disease but this was not confirmed on operative findings and no recurrence was detected in these patients during 6-92-month follow-up. This led to an overall rate of false-positive rate of 23%., Conclusion: MIBG scintigraphy adds little to the routine preoperative management of patients with suspected PHAEO. Its use should be limited to the small minority of patients with negative cross-sectional imaging and those with recurrent or metastatic disease.

Background: Concordant parathyroid localization with sestamibi and ultrasound scans allows minimally invasive parathyroidectomy (MIP) to be performed in patients with non-familial primary hyperparathyroidism (PHPT)., Aim: To investigate the financial implications of scan-directed parathyroid surgery., Methods: Analysis of hospital records for a cohort of consecutive unselected patients treated in a tertiary referral centre., Results: Two hundred patients (138F:62M, age 18-91years) were operated for non-familial PHPT between Jan 2003 and Oct 2007. MIP was performed in 129 patients, with a mean operative time was 35 +/- 18min. Some 75 patients were discharged the same day and the others had a total of 72 in-patient days. Bilateral neck exploration (BNE) was performed in 71 patients with negative/non-concordant scans. Mean operative time was 58 +/- 25min. Only nine patients were discharged the same day and a total of 93 in-patient days were used ( approximately 1.3days/patient). The estimated total costs incurred were pound215,035 ( approximately 290,000). These costs would have been covered by the National Tariff ( pound2,170 per parathyroidectomy) but were higher than those possibly incurred if all 200 patients would have undergone BNE without any radiological investigations ( pound166,000 approximately 224,100euro)., Conclusion: Shorter operative time and day-case admission for MIP generate costs savings that compensate only partially for the additional costs associated with parathyroid imaging studies.