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Introducción: La tiroidectomía endoscópica transoral por vía vestibular permite el acceso al tiroides sin cicatrices visibles y con el mejor resultado cosmético posible. Métodos: Estudio observacional prospectivo de 53 pacientes sometidos a tiroidectomía endoscópica transoral desde julio de 2017 hasta junio de 2021. Resultados: Cincuenta y dos casos (98,1%) fueron mujeres con una mediana de edad de 44 años. El nódulo tiroideo fue la indicación quirúrgica más frecuente (73,6%). Se realizaron 42 lobectomı´as,11 tiroidectomías totales y en 4 casos se asoció vaciamiento ganglionar del compartimento central izquierdo. La mediana de tiempo para la colocación de trocares fue de 14 min, y para la lobectomía, la tiroidectomía total y el vaciamiento ganglionar del compartimento central izquierdo, de 80, 140 y 30 min, respectivamente. La mediana de estancia hospitalaria fue de 2 días. Cuatro pacientes presentaron disfonía (7,5%), pero la laringoscopia solo confirmó lesión del recurrente en 2 casos, una de ellas permanente (1,6%). En los pacientes con tiroidectomía total la frecuencia de hipoparatiroidismo transitorio fue del 18,2% y el permanente de 0%. Dentro de las complicaciones asociadas al abordaje, en todos los pacientes se presento´ anestesia de la región mentoniana transitoria y de intensidad variable. Conclusiones: La cirugía transoral es un abordaje de aplicación reciente en nuestra unidad. Los resultados en nuestros primeros pacientes muestran que es un abordaje eficaz y seguro cuando se realiza en pacientes bien seleccionados, con el mejor resultado cosmético y con complicaciones nuevas, asociadas al abordaje, transitorias en nuestra serie.

We compared the reliability of indocyanine green (ICG) angiography and intraoperative PTH levels for predicting early post-thyroidectomy hypocalcemia. Prospective study of 94 patients (71% women, mean age 53.7 years) undergoing total thyroidectomy. An ICG score of 2 (white) indicated a well-vascularized gland. PTH preoperative levels—PTH postresection levels divided by preoperative PTH × 100 was used to determine the PTH decline percentage. A decrease of at least 62.5% or

Resumen La tiroidectomia es el procedimiento mas comun en cirugia endocrina. La incision cervical de Kocher es el «gold standard» para abordar el tiroides desde que fuera presentado por este a finales del siglo xix . Desde entonces, la tiroidectomia tal y como ahora la conocemos ha demostrado ser una tecnica eficaz y segura, pero no por ello ha dejado de evolucionar habiendo conseguido ademas unos indicadores de calidad dificiles de superar. El advenimiento de nuevas tecnologias y un intento constante por mejorar la cosmetica de la cirugia han dado lugar a «nuevos abordajes». En este articulo hacemos una revision de estos intentando mostrar sus beneficios y limitaciones. Actualmente, ninguno ha demostrado ser mejor que la cirugia convencional mas alla del valor anadido del beneficio cosmetico, pero permaneceran si demuestran que han sido eficientes en el tratamiento de la enfermedad y en mejorar la calidad de vida de nuestros pacientes.

Hypoparathyroidism is the most frequent complication after total thyroidectomy and, when permanent, it becomes a severe chronic disease. We assessed the usefulness of indocyanine green (ICG) angiography-guided thyroidectomy to reduce the postoperative hypocalcemia.Prospective study with two consecutive cohorts of patients who underwent total thyroidectomy: historical control group (CG) and angiography-guided thyroidectomy group (AG). In all patients, ICG-angiography was performed at the end of the surgery to predict immediate parathyroid gland (PG) function. In the AG, ICG-angiography was also done after PG identification to show their vascular supply. We compared the rate of postoperative hypocalcemia (calcium supplementation needed due to hypocalcemia symptoms or calcium levels 1.8 mmol/L on the first postoperative day) and permanent hypocalcemia (need of calcium ± vitamin D supplementation 12 months after thyroidectomy).We included 120 consecutive patients (84 CG; 36 AG). Thyroid cancer was the most common diagnostic (63.1% CG-69.4% AG; p = 0.646) and central neck dissection was also frequent (54.8% CG-64.3% AG; p = 0.468). The AG developed a lower rate of postoperative (26.2-5.6%; p = 0.011) and permanent hypocalcemia (11.9-0%; p = 0.032). The OR for permanent hypocalcemia was 0.673 (95% CI 0.591-0.766). A significant higher rate of well vascularized PG at the end of the surgery (score 2) in the AG (39.2-52.9%; p = 0.018) was also seen.ICG angiography-guided thyroidectomy is a useful tool to identify PG vascularization, allowing a better PG preservation and a significant decrease in hypocalcemia rates.

Resumen La tiroidectomia endoscopica transoral por via vestibular (TOETVA) es una tecnica novedosa que permite abordar el tiroides sin cicatrices visibles, ya que se realiza a traves de un orificio natural. Tiene su origen en Asia debido a que, por motivos culturales, una cicatriz en el cuello puede ser considerada un estigma. Esta tecnica, tal y como la conocemos ahora y sus resultados preliminares, fueron comunicados por primera vez por Angkoon Anuwong en agosto del 2015 en el congreso mundial de cirugia de la International Association of Endocrine Surgeons (IAES) en Bangkok. Con el objetivo de difundir el abordaje transoral, lo explicamos paso a paso para que pueda ser reproducido con seguridad y considerado como uno mas en el contexto terapeutico de la cirugia endocrina. No obstante, somos conscientes de que, como ocurre con la mayoria de los accesos remotos, solo es aplicable para un pequeno porcentaje de pacientes.

Trans Oral Endoscopic Thyroidectomy through Vestibular Approach (TOETVA) allows access to the thyroid with the best cosmetic results as there are no visible scars.Here we present a prospective observational study of 53 patients which underwent TOETVA from July 2017 to June 2021.Fifty-two cases (98.1%) cases were women (median age 44 years old). Thyroid nodule was the main surgical indication accounting 73.6% of cases. We performed 42 lobectomies and 11 total thyroidectomies; 4 left Central Neck Dissection (CND) were also associated. The median surgical time for port placement was 14 min and for lobectomy, total thyroidectomy and left CND were 80, 140 and 30 min, respectively. The median of hospital stay was 2 days. Dysphonia was present in 4 patients; however, laryngoscopy only confirmed laryngeal nerve impairment in 2 cases, one of them classified as permanent (1.6%). In those patients that underwent total thyroidectomy, the rate of transient hypoparathyroidism was 18.2% whereas permanent was 0%. Regarding complications associated to the new approach, transient chin numbness appeared in all patients with a variable degree of intensity.Transoral surgery is a recent approach in our Unit. Our results, based on the first 53 patients, show that it is a safe and effective approach when performed in appropriately selected patients offering the best cosmetic result. Besides, new complications associated to the approach has been shown to be transient.

Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) is a novel technique that allows the thyroid to be approached without visible scars, as it is performed through a natural orifice. It was first described and developed in Asia where due to sociocultural reasons neck scars are considered a stigma. This technique, as we now nowadays, and its preliminary results, were first reported by Angkoon Anuwong in August 2015 at the International Association of Endocrine Surgeons (IAES) world surgery congress held in Bangkok. Here we present the TOETVA approach, step-by-step, in order it could be safely replicated, aiming also it can be spread within the therapeutic framework of endocrine surgery. However, it is important to remark that, as happens in most of remote approaches, it is only suitable for a small percentage of patients.

Resumen Introduccion La angiografia de las glandulas paratiroides con verde de indocianina (ICG) es util para predecir la hipocalcemia postiroidectomia. En este estudio se ha comparado la exactitud diagnostica del sistema ICG-2, basado en la presencia de glandulas bien perfundidas (puntuacion igual a 2), con el sistema ICG-4 basado en la suma del valor de la puntuacion de las 4 glandulas. Metodos Un total de 50 pacientes (66% mujeres, mediana de edad: 49,4 anos) fueron operadas practicandose una tiroidectomia total con identificacion de las 4 glandulas paratiroides. El grado de la ICG se clasifico como 0: color negro (no vascularizada), 1: color gris/heterogeneo (parcialmente vascularizada) y 2: color blanco (bien vascularizada). Resultados La exactitud diagnostica de ICG-4 para un punto de corte ≤ 3 fue del 85% (intervalo de confianza del 95%: 70,9-92,8), inferior al 92% (80,8-97,8) del ICG-2. Con ambas puntuaciones se detectaron 2 casos de falsos negativos, pero las tasas de falsos positivos fueron menores con el ICG-2 (18,2 vs. 57,1%). Conclusiones El sistema ICG-2 predice la funcion paratiroidea en el postoperatorio inmediato mejor que el ICG-4 para valores de punto de corte ≤ 2 y ≤ 3.

Introduction Indocyanine green (ICG) angiography of the parathyroids is useful in prediction of postthyroidectomy hypocalcemia. We compared the diagnostic accuracy of a single-gland ICG score of 2 with a score estimated by adding the viability value of the four glands (4-ICG). Methods Fifty patients (66% women, median age 49.4 years) underwent total thyroidectomy with identification of all 4 glands. The degree of ICG was classified as 0, black (nonvascularized), 1, gray/heterogeneous (partially vascularized), and 2, white (well vascularized). Results The diagnostic accuracy of the optimal cut-off of the 4-ICG sum score ≤3 was 84% (95% CI 70.9–92.8) lower than the diagnostic accuracy of 92% (80.8–97.8) of the ICG score 2. Both scores identified 2 false negative cases, but the rates of false positives were lower with the ICG score 2 (18.2% vs. 57.1%). Conclusions Identification of single-gland ICG score of 2 has a higher diagnostic accuracy than 4-ICG sum score to predict immediate hypocalcemia after total thyroidectomy.

Tertiary hyperparathyroidism is a common cause of hypercalcemia after kidney transplantation (KT) and has been associated with renal dysfunction, bone mineral density loss, and increased risk of fracture and cardiovascular events. In a previous 12-month clinical trial, we demonstrated that subtotal parathyroidectomy was more effective than cinacalcet for controlling hypercalcemia. In the current study, we retrospectively evaluate whether this effect is maintained after 5 years of follow-up. In total, 24 patients had data available at 5 years, 13 in the cinacalcet group and 11 in the parathyroidectomy group. At 5 years, 7 of 11 patients (64%) in the parathyroidectomy group and 6 of 13 patients (46%) in the cinacalcet group (P = .44) showed normocalcemia. However, recurrence of hypercalcemia was only observed in the cinacalcet group (P = .016). Subtotal parathyroidectomy retained a greater reduction in intact parathyroid hormone (iPTH) compared with cinacalcet group. No differences were observed in kidney function and incidence of fragility fractures between both groups. Cinacalcet was discontinued in 5 out of 13 patients. In conclusion, in kidney transplant patients with tertiary hyperparathyroidism recurrence of hypercalcemia after 5-year follow-up is more frequent in cinacalcet than after subtotal parathyroidectomy.

This study compares the efficacy of intraoperative parathyroid hormone measurement vs indocyanine green angiography of parathyroid glands in predicting early postthyroidectomy hypocalcemia.

Resumen La anemia representa una entidad o comorbilidad extremadamente frecuente dentro de la poblacion de pacientes quirurgicos. Su manejo implica un abordaje multidisciplinar con el fin de optimizar los recursos terapeuticos disponibles de forma individualizada en cada situacion clinica. El uso racional por parte del clinico de transfusiones sanguineas, ferroterapia (oral y endovenosa), agentes estimuladores de la eritropoyesis y otras alternativas terapeuticas ha de proporcionar el maximo beneficio a nuestros pacientes con las minimas complicaciones posibles. El presente articulo de revision resume las principales caracteristicas de la anemia, metabolismo ferrico, eritropoyesis y alternativas terapeuticas desde una perspectiva quirurgica, a la luz de los conocimientos actuales.

Parenteral iron is a useful and safe therapeutic measure to treat anaemia, and is a proven clinical alternative to blood transfusion. This review article summarises the main characteristics of the different formulations of parenteral iron, their advantages, indications, dosages and adverse effects. Moreover, we analyse some of the most important published articles on parenteral iron therapy in General Surgery and other surgical specialties, as well as providing information about new formulations that will soon be available.

Parenteral iron is a useful and safe therapeutic measure to treat anaemia, and is a proven clinical alternative to blood transfusion. This review article summarises the main characteristics of the different formulations of parenteral iron, their advantages, indications, dosages and adverse effects. Moreover, we analyse some of the most important published articles on parenteral iron therapy in General Surgery and other surgical specialties, as well as providing information about new formulations that will soon be available.

El transporte de drogas ilegales en el interior del organismo (body packer) representa un problema m?dico-legal en claro aumento en las ?ltimas d?cadas. Los facultativos, especialmente aquellos con actividad en los servicios de urgencias, han de familiarizarse con el manejo diagn?stico y terap?utico ?habitualmente conservador? de este tipo de pacientes y de sus posibles complicaciones. El presente art?culo revisa los conceptos y fisiopatolog?a generales asociados al transporte de paquetes en el tracto digestivo y describe la experiencia de un centro sanitario de referencia con un protocolo espec?ficamente dise?ado para estos enfermos.

Resumen Introduccion La adrenalectomia laparoscopica es una opcion que ofrece garantias y, asumiendo ciertas limitaciones, es la tecnica de eleccion para el tratamiento quirurgico de la glandula suprarrenal. Objetivos. Revision de nuestros resultados en 77 adrenalectomias laparoscopicas, sus complicaciones y las causas de conversion a laparotomia, a partir de la bibliografia de reciente publicacion. Pacientes y metodo. Desde septiembre de 1995 a mayo de 2003, realizamos 77 adrenalectomias laparoscopicas en 71 pacientes, con una edad media de 51 anos. Se practico una adrenalectomia bilateral en 6 pacientes, derecha en 30 ocasiones e izquierda en 35. El abordaje fue transperitoneal lateral en todos los casos excepto en el primero. Las indicaciones fueron: 22 aldosteronomas, 16 feocromocitomas, 17 incidentalomas, 6 metastasis y 10 hipercortisolismos. Resultados. El tamano medio glandular fue de 6,1 cm y el peso medio de 56 g. De las 77 adrenalectomias, hubo 7 conversiones (9%) por causas relacionadas con la dificultad de diseccion de la masa adrenal y por una fisura esplenica. Las complicaciones de esta tecnica en nuestra serie afectaron a 7 pacientes (9%), y fueron fundamentalmente hemorragicas y aereas. El tiempo medio de estancia postoperatoria fue de 2,5 dias, excluidas las conversiones. No hubo mortalidad. Revisamos la bibliografia en series de mas de 30 adrenalectomias por equipo quirurgico desde 1995 a 2002. Las causas descritas de conversion fueron: experiencia del equipo quirurgico (mas de 10 adrenalectomias), tamano adrenal (mas de 10 cm) y diagnostico (feocromocitomas, confirmacion de neoplasia adrenal). Conclusiones. La adrenalectomia laparoscopica es una tecnica segura y eficaz que ofrece los beneficios de la cirugia minimamente invasiva, y acepta un indice de complicaciones del 6-25% y de conversiones del 4-21%, segun las series.

To analyse the potential advantages and outcomes of the new Harmonic Focus™ (Focus) device compared to the Harmonic Scalpel™ ACS-14C in benign thyroid surgery.A controlled randomised study was conducted in which the Focus was compared to former ACS-14C device in patients undergoing total thyroidectomy for multinodular goitre. The primary endpoint was time of surgery. The secondary endpoints were time of use of the device, number of ligatures, blood loss, hypocalcaemia, laryngeal nerve impairment, postoperative pain and quality of life.Two groups of patients were included, 26 patients in group i (ACS-14C) and 28 in group ii (Focus). There was a 16% reduction in surgical time (78.7 ± 22.01 vs. 66 ± 17.0 min; P.05) between group i and ii respectively. The Focus was used longer than ACE-14S, both in absolute time (26.0 ± 7.7 vs. 10.0 ± 3.5 minutes; P.05), as well as in relative time (40.7 ± 11.8% vs. 13.1 ± 4.1%; P.05), respectively. A significant reduction in number of ligatures in Focus patients was also observed (0,3 ± 0,8 vs. 2.9 ± 3.6; P.05). Budget impact analysis showed an additional average savings per procedure of 179.74 €.Focus ergonomics significantly improved the operation time in thyroidectomy causing a positive impact on the budget. Focus also adds further benefits to those previously achieved by Harmonic technology, and it is by itself more cost-effective in total thyroidectomy than ACS-14C.

Anemia is very common entity or comorbidity in surgical patients. Its management involves a multidisciplinary approach with the aim of optimizing the available therapeutic resources with individualized care for each clinical situation. Rational use of blood transfusions, iron therapy (oral and intravenous), erythropoiesis stimulating agents and other therapeutic alternatives by physicians must achieve maximal benefit with minimal complications for our patients. This review article summarizes the main characteristics of anemia, iron metabolism, erythropoiesis and therapeutic alternatives from a surgical perspective in the light of present knowledge

Smuggling of illicit drugs by concealing them within the human body (body packer) is a medical-legal issue that has increased in the last few decades. Physicians, especially those working in the emergency department, should be familiar with the diagnostic and therapeutic management -usually conservative management- of this type of patient and their possible complications. The present article reviews the general concepts and physiopathology associated with transport of packages in the digestive tract and describes the experience of a referral hospital with a protocol specifically designed for these patients.

Tertiary hyperparathyroidism is a common cause of hypercalcemia after kidney transplant. We designed this 12-month, prospective, multicenter, open-label, randomized study to evaluate whether subtotal parathyroidectomy is more effective than cinacalcet for controlling hypercalcemia caused by persistent hyperparathyroidism after kidney transplant. Kidney allograft recipients with hypercalcemia and elevated intact parathyroid hormone (iPTH) concentration were eligible if they had received a transplant ≥6 months before the study and had an eGFR>30 ml/min per 1.73 m(2) The primary end point was the proportion of patients with normocalcemia at 12 months. Secondary end points were serum iPTH concentration, serum phosphate concentration, bone mineral density, vascular calcification, renal function, patient and graft survival, and economic cost. In total, 30 patients were randomized to receive cinacalcet (n=15) or subtotal parathyroidectomy (n=15). At 12 months, ten of 15 patients in the cinacalcet group and 15 of 15 patients in the parathyroidectomy group (P=0.04) achieved normocalcemia. Normalization of serum phosphate concentration occurred in almost all patients. Subtotal parathyroidectomy induced greater reduction of iPTH and associated with a significant increase in femoral neck bone mineral density; vascular calcification remained unchanged in both groups. The most frequent adverse events were digestive intolerance in the cinacalcet group and hypocalcemia in the parathyroidectomy group. Surgery would be more cost effective than cinacalcet if cinacalcet duration reached 14 months. All patients were alive with a functioning graft at the end of follow-up. In conclusion, subtotal parathyroidectomy was superior to cinacalcet in controlling hypercalcemia in these patients with kidney transplants and persistent hyperparathyroidism.