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Abstract The study investigated the feasibility of robotic bilateral axillo-breast approach (BABA) thyroidectomy for patients with thyroid tumors larger than 4 cm. BABA thyroidectomy has previously shown safety and effectiveness for thyroid surgeries but lacked extensive data on its application to larger tumors. Between October 2008 and August 2022, there were 74 patients underwent robotic BABA thyroidectomy due to thyroid nodules exceeding 4 cm in size. The mean patient age was 40.3 years. Fine needle aspiration results classified the tumors as benign (50.0%), atypia of undetermined significance (27.0%), follicular neoplasm (16.2%), suspicious for malignancy/malignancy (5.4%), or lymphoma (1.4%). The average tumor size was 4.9 cm, with the majority (85.1%) undergoing thyroid lobectomy, and the rest (14.9%) receiving total thyroidectomy. The mean total operation time was 178.4 min for lobectomy and 207.3 min for total thyroidectomy. Transient vocal cord palsy (VCP) was found in 3 patients (4.1%), and there was no permanent VCP. Among patients who underwent total thyroidectomy, transient hypoparathyroidism was observed in three (27.2%), and permanent hypoparathyroidism was observed in one (9.1%). There were no cases of open conversion, tumor spillage, bleeding, flap injury, or tumor recurrence. In conclusion, robotic BABA thyroidectomy may be a safe treatment option for large-sized thyroid tumors that carries no significant increase in complication rates.

Objective: Active surveillance (AS) is generally accepted as an alternative to immediate surgery for papillary thyroid carcinoma (PTC) measuring ≤1.0 cm (cT1a) without risk factors. This study investigated the clinicopathologic characteristics of PTCs measuring ≤2.0 cm without cervical lymph node metastasis (cT1N0) by tumor size group to assess the feasibility of AS for PTCs between 1.0 cm and 1.5 cm (cT1b≤1.5). Design: This study enrolled clinically T1N0 patients with preoperative ultrasonography information (n = 935) from a cohort of 1259 patients who underwent lobectomy and were finally diagnosed with PTC from June 2020 to March 2022. Results: The cT1b≤1.5 group (n = 171; 18.3 %) exhibited more lymphatic invasion and occult central lymph node (LN) metastasis with a higher metastatic LN ratio than the cT1a group (n = 719; 76.9 %). However, among patients aged 55 years or older, there were no significant differences in occult central LN metastasis and metastatic LN ratio between the cT1a, cT1b≤1.5, and cT1b>1.5 groups. Multivariate regression analyses revealed that occult central LN metastasis was associated with age, sex, tumor size, extrathyroidal extension, and lymphatic invasion in patients under 55, while in those aged 55 or older, it was associated only with age and lymphatic invasion. Conclusion: For PTC patients aged 55 years or older with cT1b≤1.5, AS could be a viable option due to the absence of a significant relationship between tumor size and occult central LN.

Abstract The role of the serine/glycine metabolic pathway (SGP) has recently been demonstrated in tumors; however, the pathological relevance of the SGP in thyroid cancer remains unexplored. Here, we perform metabolomic profiling of 17 tumor-normal pairs; bulk transcriptomics of 263 normal thyroid, 348 papillary, and 21 undifferentiated thyroid cancer samples; and single-cell transcriptomes from 15 cases, showing the impact of mitochondrial one-carbon metabolism in thyroid tumors. High expression of serine hydroxymethyltransferase-2 (SHMT2) and methylenetetrahydrofolate dehydrogenase 2 (MTHFD2) is associated with low thyroid differentiation scores and poor clinical features. A subpopulation of tumor cells with high mitochondrial one-carbon pathway activity is observed in the single-cell dataset. SHMT2 inhibition significantly compromises mitochondrial respiration and decreases cell proliferation and tumor size in vitro and in vivo. Collectively, our results highlight the importance of the mitochondrial one-carbon pathway in undifferentiated thyroid cancer and suggest that SHMT2 is a potent therapeutic target.

Objective The significance of big data is increasingly acknowledged across all sectors, including medicine. Moreover, the trend of data trading is on the rise, particularly in exchanging other data for medical data to rejuvenate the medical industry. This study aimed to discern the facilitating factors of healthcare data trade. Methods We assessed five medical data market platforms on October, 2022, based on three criteria: (a) clarity in articulating the data for sale; (b) transparency in specifying the data costs; and (c) explicit indication that payment grants data access. This helped identify the traded medical data types. Additionally, we anonymously surveyed 43 representatives from medical device companies about their demand for medical data trading, achieving a response rate of 66%. Results Of the medical data traded on these platforms, 93.34% was structured, while 5.66% was unstructured, indicating an imbalance. Although there was a higher demand for structured medical data, there was also interest in purchasing unstructured medical data. Conclusion Unstructured big data are crucial for medical device development, fueling the demand for trading such data. Many stakeholders view the data market as essential and are willing to procure medical data. Consequently, medical device companies will need methods to acquire unstructured medical data for developing innovative and enhanced medical devices.

Abstract Background Skin metastasis from papillary thyroid cancer (PTC) is a rare entity that can occur up to decades after treatment of the primary tumor. Here, we present a patient who developed skin metastasis 10 years after treatment of her primary tumor and describe the molecular findings of the metastatic lesion. Case presentation A 44-year-old female with a history of PTC who underwent a total thyroidectomy and radioactive iodine (RAI) treatment 10 years ago presented with a 1.3-cm skin lesion along the prior thyroidectomy scar. A biopsy revealed metastatic PTC, and the patient underwent surgical excision of the lesion. ThyroSeq molecular testing showed the copresence of BRAFV600E mutation and TERT promoter C228T mutation. The patient subsequently received one round of adjuvant RAI therapy. Conclusions A high index of suspicion is warranted in patients with a history of PTC who develop a skin lesion, even several years after remission of the primary disease. In patients with high-risk mutations, such as BRAFV600E and TERT promoter C228T mutations, long-term surveillance of disease recurrence is particularly important.

Demand for minimally invasive surgery has driven the development of new gadgets and surgical techniques. Yet, questions about safety and skeptical views on new technology have prevented proliferation of new modes of surgery. This skepticism is perhaps due to unfamiliarity of new fields. Likewise, there are currently various remote-access techniques available for thyroid surgeons that only few regions in the world have adapted. This review will explore the history of minimally invasive techniques in thyroid surgery and introduce new technology to be implemented.

Abstract Many patients experience cervical adhesions after thyroid surgery. To date, however, no studies have objectively measured the effects of anti-adhesion agents on cervical adhesion symptoms. This study evaluated the effects of an anti-adhesion agent on cervical adhesions after thyroid surgery, as determined using a system that measures the extent of marker movement objectively. One hundred patients were randomized in a 1:1 ratio to undergo thyroid surgery with or without the anti-adhesion agent Collabarrier. Using specially manufactured recording equipment, the position of the marker on neck skin was measured before surgery, and 2 weeks, 3 months, and 9 months after surgery. Relative change in marker distance, calculated by subtracting the marker position before surgery from the marker positions 2 weeks, 3 months, and 9 months after surgery, differed significantly in the groups of patients who underwent thyroid surgery with and without the anti-adhesion agent (P

Background Heart rate (HR) monitored by a wearable device (WD) has demonstrated its clinical feasibility for thyrotoxicosis subjects. However, the association of HR monitored by wearables with hypothyroidism has not been examined. We assessed the association between serum thyroid hormone concentration and three WD-HR parameters in hypothyroid subjects. Methods Forty-four subjects scheduled for radioactive iodine therapy (RAI Tx) after thyroid cancer surgery were included. Thirty subjects were prepared for RAI Tx by thyroid hormone withdrawal (hypothyroidism group) and 14 subjects by recombinant human thyrotropin (control group). Three WD-HR parameters were calculated from the HR data collected during rest, during sleep, and from 2:00 AM to 6:00 AM, respectively. We analyzed the changes in conventionally measured resting HR (On-site rHR) and WD-HR parameters relative to thyroid hormone levels. Results Serum free thyroxine (T4) levels, On-site rHR, and WD-HR parameters were lower in the hypothyroid group than in the control group at the time of RAI Tx. WD-HR parameters also reflected minute changes in free T4 levels. A decrease in On-site rHR and WD-HR parameters by one standard deviation (On-site rHR, approximately 12 bpm; WD-HR parameters, approximately 8 bpm) was associated with a 0.2 ng/dL decrease in free T4 levels (P

Abstract For pheochromocytoma and sympathetic paraganglioma (PPGL), surgery can be used as a curative treatment; however, the life-threatening risk of perioperative hemodynamic instability (HI) presents challenges. This study aimed to analyze the incidence and predictive factors of perioperative HI. The electronic medical records of 114 consecutive patients who underwent surgery for PPGLs at our institution were retrospectively reviewed. HI was defined as one or more episodes of systolic blood pressure > 200 mmHg or mean blood pressure

Background Postoperative thyroid stimulating hormone (TSH) suppression therapy is recommended for patients with intermediate- and high-risk differentiated thyroid cancer to prevent the recurrence of thyroid cancer. With the recent increase in small thyroid cancer cases, the extent of resection during surgery has generally decreased. Therefore, questions have been raised about the efficacy and long-term side effects of TSH suppression therapy in patients who have undergone a lobectomy. Methods This is a multicenter, prospective, randomized, controlled clinical trial in which 2,986 patients with papillary thyroid cancer are randomized into a high-TSH group (intervention) and a low-TSH group (control) after having undergone a lobectomy. The principle of treatment includes a TSH-lowering regimen aimed at TSH levels between 0.3 and 1.99 μIU/mL in the low-TSH group. The high-TSH group targets TSH levels between 2.0 and 7.99 μIU/mL. The dose of levothyroxine will be adjusted at each visit to maintain the target TSH level. The primary outcome is recurrence-free survival, as assessed by neck ultrasound every 6 to 12 months. Secondary endpoints include disease-free survival, overall survival, success rate in reaching the TSH target range, the proportion of patients with major cardiovascular diseases or bone metabolic disease, the quality of life, and medical costs. The follow-up period is 5 years. Conclusion The results of this trial will contribute to establishing the optimal indication for TSH suppression therapy in low-risk papillary thyroid cancer patients by evaluating the benefit and harm of lowering TSH levels in terms of recurrence, metabolic complications, costs, and quality of life.

Background The use of intraoperative neuromonitoring (IONM) in thyroid surgery to preserve recurrent laryngeal nerve (RLN) function has been widely accepted. We aimed to evaluate the usefulness of IONM in reoperation for recurrent thyroid cancer patients to help identify the RLN and prevent vocal cord palsy (VCP). Methods We analyzed 121 consecutive patients (with IONM group, 48 patients; without IONM group, 73 patients) who underwent reoperation for recurrent thyroid cancer after total thyroidectomy from January 2009 to March 2019 in our institution without VCP due to previous operations. Data including age, sex, number of previous operations, histologic subtype of the malignancy at the initial operation, operation time, RLNs at risk, difficulty of RLN identification, surgical procedure, VCP, and other postoperative complications were reviewed. Vocal cord movement evaluations were performed preoperatively and at 2 weeks postoperatively to evaluate RLN function. In patients with VCP, additional evaluations were performed. VCP exceeding 12 months after surgery was considered permanent VCP. Results VCP was observed in six (12.5%) and 16 (21.9%) patients with and without IONM (P=0.189). Transient and permanent VCP were found in three (6.3%) and three (6.3%) patients with IONM (P=0.098 and P=0.982, respectively) versus in 12 (16.4%) and four (5.5%) patients without IONM. Conclusion The incidence of transient VCP seems to be lower in reoperations with IONM; however, there was no statistical significances. Further study will be needed to ascertain the efficacy of IONM in reoperation for recurrent thyroid cancer patients.

Hypothyroidism is a recognized sequela of conventional thyroid lobectomy. However, there have been no studies on the incidence of hypothyroidism following the preservation of the isthmus and pyramid during lobectomy. Therefore, in the present study, we compared the incidence of hypothyroidism following conventional lobectomy and lobectomy during which the isthmus and pyramidal lobe were preserved. Data for a total of 65 patients collected between September 2018 and April 2019 were reviewed retrospectively. Circulating thyroid-stimulating hormone (TSH) concentration was measured before and after surgery in a group who underwent conventional thyroid lobectomy (n = 29) and in a group in which the isthmus and pyramid were preserved (n = 36). We found no significant difference in TSH concentration between the two groups before surgery, or 3 months or 1 year after surgery. Thus, there might be no difference in the incidence of postoperative hypothyroidism between patients who undergo conventional thyroid lobectomy and those in which the isthmus and pyramid are preserved.

Cytologic diagnosis of thyroid follicular adenoma and carcinoma, and Hurthle cell adenoma and carcinoma (FACHAC) is challenging due to cytomorphologic features that overlap with other follicular-patterned lesions. This study was designed to analyze diagnostic categories (DCs) of preoperative fine needle aspiration cytology (FNAC) of histologically proven thyroid FACHACs to evaluate under- or misdiagnoses in FNAC and elucidate potential causes for such phenomena. A total of 104 thyroid nodules with preoperative FNAC which were diagnosed as FACHAC in resection specimens were included in this study. Of these, 66 cases had also undergone thyroid core needle biopsy (CNB); FNAC and CNB DCs were compared in these cases. Various cytologic and histologic parameters were compared between the nodules with different FNAC DCs. After a review of FNAC slides, DCs were re-assigned in 20 (19.2%) out of the 104 cases. Of the 66 cases with CNB diagnoses which were mostly classified as lower DCs in FNAC, 31 (47.0%) were diagnosed as suspicious for a follicular neoplasm in CNB. Cases which were underdiagnosed in FNACs were associated with lower cellularity, predominant macrofollicular pattern, absence of microfollicles arranged in trabecular pattern, and absence of transgressing vessels in cytology smears. High cellularity, microfollicles arranged in trabecular pattern, nucleolar prominence, and large cell dysplasia were more frequently found in malignancy than in benign neoplasm. In conclusion, thyroid FACHACs seem to be under- and misdiagnosed in preoperative FNAC. Innate characteristics of the nodules were associated with under-diagnosis as well as the quality of the FNAC specimens. Certain cytomorphologic features can be helpful in differentiating malignancy among FACHACs.

Background and Objectives: Robotic thyroidectomy via the bilateral axillo-breast approach (BABA), first introduced in Korea in 2008, has become a standard method of thyroid removal worldwide. The introduction of robotic surgical systems has enabled more patients to benefit from BABA robotic thyroidectomy, with good postoperative and excellent cosmetic results. To date, no studies have compared the benefits of the four currently available da Vinci robotic systems (S, Si, X, and Xi) for BABA robotic thyroidectomy. To determine the da Vinci model most suitable for BABA robotic thyroidectomy, the present study compared the perioperative outcomes in patients who underwent BABA robotic thyroidectomy using the four da Vinci models. Materials and Methods: This retrospective study evaluated outcomes in patients (n = 750) who underwent BABA robotic thyroidectomy using the four da Vinci systems from 2013 to 2019. The clinicopathologic data, including operation time, were compared. Substudy A compared the da Vinci models S and Si from 2013 to 2017, and substudy B compared models Si, X, and Xi from 2018 to 2019. Results: Substudy A, comparing the da Vinci S and Si systems, found no statistically significant differences between the two groups, whereas substudy B found that operation time was shorter in patients who underwent BABA robotic thyroidectomy with the da Vinci Xi system than with the Si and X systems. Conclusions: The da Vinci model Xi system can benefit patients undergoing BABA robotic thyroidectomy by shortening the operation time.

Post-thyroidectomy hypoparathyroidism may result in various transient or permanent symptoms, ranging from tingling sensation to severe breathing difficulties. Its incidence varies among surgeons and institutions, making it difficult to determine its actual incidence and associated factors. This study attempted to estimate the incidence of post-operative hypoparathyroidism in patients at two tertiary institutions that share a common data model, the Observational Health Data Sciences and Informatics. This study used the Common Data Model to extract explicitly specified encoding and relationships among concepts using standardized vocabularies. The EDI-codes of various thyroid disorders and thyroid operations were extracted from two separate tertiary hospitals between January 2013 and December 2018. Patients were grouped into no evidence of/transient/permanent hypoparathyroidism groups to analyze the likelihood of hypoparathyroidism occurrence related to operation types and diagnosis. Of the 4848 eligible patients at the two institutions who underwent thyroidectomy, 1370 (28.26%) experienced transient hypoparathyroidism and 251 (5.18%) experienced persistent hypoparathyroidism. Univariate logistic regression analysis predicted that, relative to total bilateral thyroidectomy, radical tumor resection was associated with a 48% greater likelihood of transient hypoparathyroidism and a 102% greater likelihood of persistent hypoparathyroidism. Moreover, multivariate logistic analysis found that radical tumor resection was associated with a 50% greater likelihood of transient hypoparathyroidism and a 97% greater likelihood of persistent hypoparathyroidism than total bilateral thyroidectomy. These findings, by integrating and analyzing two databases, suggest that this analysis could be expanded to include other large databases that share the same Observational Health Data Sciences and Informatics protocol.

Background and Objectives: Preserving the recurrent laryngeal nerve (RLN) is important in thyroid surgery. However, no standardized surgical method for locating the RLN has been established. We defined a new anatomical definition termed “lower central triangle” (LCT) for consistent identification of RLN and used intraoperative nerve monitoring (IONM) to aid in identification and dissection of RLN. Materials and Methods: Patients undergone thyroidectomy were reviewed retrospectively in Seoul National University Bundang Hospital from January to September 2017. Patients with papillary thyroid carcinoma, follicular neoplasm, and Graves’ Disease were included while right side non-RLN in arteriosus lusoria, cancer invasion, pre-existing vocal cord palsy, or under the age of 18 were excluded. RLNs were tested with IONM within LCT consisting of the lower pole as the apex and the common carotid artery as the opposite side. The samples were divided into two groups, IONM and non-IONM. Results: Forty lobes in total were included, 22 in IONM group and 18 in non-IONM group. Groups were not significantly different in age, cancer proportion, and accompanying thyroiditis while sex and nodule size differed. RLN detection time was 10.43 s shorter (p < 0.001), and confirmation time was 10.67 s shorter (p = 0.09) in IONM group than in non-IONM group. Both right and left RLNs were located predominately in the middle of LCT. No transient or permanent vocal cord palsy occurred. Conclusions: While IONM is an appropriate aid for thyroidectomy, our approach using LCT to locate the RLN is a novel definition of anatomy that provides prompt identification of the RLN in thyroid surgery.

Background: Bilateral axillo-breast approach (BABA) robotic thyroidectomy has been successfully performed for thyroid cancer patients with excellent cosmetic results. Completion thyroidectomy is sometimes necessary after thyroid lobectomy, and whether it has a higher complication rate than the primary operation due to the presence of adhesions remains controversial. The aim of this study was to evaluate surgical outcomes, including operation time and postoperative complications, in patients who underwent BABA robotic completion thyroidectomy. Methods: From Jan 2012 to Aug 2020, 33 consecutive patients underwent BABA robotic completion thyroidectomy for a thyroid malignancy after BABA robotic thyroid lobectomy. The procedures were divided into five steps: (1) robot setting and surgical draping, (2) flap dissection, (3) robot docking, (4) thyroidectomy, and (5) closure. Clinicopathological characteristics, operation time, and postoperative complications were reviewed. Results: The total operation time was shorter for completion thyroidectomy than for the initial operation (164.8 ± 31.7 min vs. 179.8 ± 27.1 min, p = 0.043). Among the robotic thyroidectomy steps, the duration of the thyroidectomy step was shorter than that of the initial operation (69.6 ± 20.9 min vs. 83.0 ± 19.5 min, p = 0.009. One patient (1/33, 3.0%) needed hematoma evacuation under the flap area immediately after surgery. Three patients (3/33, 9.1%) showed transient hypoparathyroidism, and one patient (1/33, 3.0%) had permanent hypoparathyroidism. Two patients (2/33, 6.1%) showed transient vocal cord palsy and recovered within 3 months following the completion thyroidectomy. There were no cases of open conversion, tracheal injury, flap injury or wound infection. Conclusions: BABA robotic completion thyroidectomy could be performed safely without completion-related complication.

Background and objectives: The study assesses quality of life (QoL) in patients who underwent thyroidectomy compared to the general population. Materials and Methods: QoL data from post-thyroidectomy patients and individuals with no subjective health concerns, who had attended a routine health screening visit, were evaluated. QoL was assessed using the modified version of Korean Short Form 12 questionnaire (SF-12). Patients and controls were matched using the propensity score approach and a ratio of 1:4. Results: Data from a total of 105 patients and 420 controls were analyzed. For five SF-12 items, lower QoL was found in patients (p < 0.05). Multivariate analysis revealed that a follow-up duration of 50 years were independent risk factors. No significant difference was found between controls and patients who were >1-year post-surgery. Conclusions: For specific SF-12 items, QoL was lower in post-thyroidectomy patients than in controls. No intergroup difference in QoL was found >1-year post-surgery.

Background and objectives: Currently, few studies have been conducted on postoperative chylothorax, specifically in total thyroidectomy with modified radical neck dissection (MRND) in papillary thyroid carcinoma patients. This study provides the actual incidence, etiology, and clinical features of postoperative chylothorax and reports the clinical outcomes after treatment, which were dependent upon the severity of the complications. Materials and Methods: The medical charts of 111 papillary thyroid cancer (PTC) patients who underwent total thyroidectomy with modified radical neck dissection from January 2016 to December 2018 were reviewed retrospectively. The results were compared in three groups: the no chylothorax group, the subclinical (asymptomatic) group, and the clinical (symptomatic) group. Results: Chylothorax occurred in 23 patients (20.7%, 23/111). Nineteen (82.6%, 19/23) were subclinical chylothorax cases, which implies a small amount of chyle leakage with no respiratory symptoms. Four (17.4%, 4/23) were clinical, meaning they had either respiratory symptoms, such as dyspnea, desaturation, or a large amount of chylothorax in the images. The incidence was significantly higher in patients who underwent left modified radical neck dissection, and this corresponds to the side in which chylothorax occurred. There were also statistical differences in the drainage color, peak amount, or drain removal time. Conclusions: Postoperative chylothorax is a rare complication following neck dissection. However, it can be fatal if the condition progresses. Therefore, patients who undergo total thyroidectomy with modified radical neck dissection, especially on the left side, should be monitored for respiratory symptoms, and serial chest x-ray images obtained.

As the number of robotic surgery procedures has increased, so has the importance of evaluating surgical skills in these techniques. It is difficult, however, to automatically and quantitatively evaluate surgical skills during robotic surgery, as these skills are primarily associated with the movement of surgical instruments. This study proposes a deep learning-based surgical instrument tracking algorithm to evaluate surgeons’ skills in performing procedures by robotic surgery. This method overcame two main drawbacks: occlusion and maintenance of the identity of the surgical instruments. In addition, surgical skill prediction models were developed using motion metrics calculated from the motion of the instruments. The tracking method was applied to 54 video segments and evaluated by root mean squared error (RMSE), area under the curve (AUC), and Pearson correlation analysis. The RMSE was 3.52 mm, the AUC of 1 mm, 2 mm, and 5 mm were 0.7, 0.78, and 0.86, respectively, and Pearson’s correlation coefficients were 0.9 on the x-axis and 0.87 on the y-axis. The surgical skill prediction models showed an accuracy of 83% with Objective Structured Assessment of Technical Skill (OSATS) and Global Evaluative Assessment of Robotic Surgery (GEARS). The proposed method was able to track instruments during robotic surgery, suggesting that the current method of surgical skill assessment by surgeons can be replaced by the proposed automatic and quantitative evaluation method.

Preoperative diagnosis of thyroid nodules reduces unnecessary surgery. Circulating tumor cells (CTCs) may contain information of primary tumor(s). We asked whether the peripheral blood expression of genes specific for circulating tumor cells (CTCs) differentiates benign thyroid nodules from malignant nodules. Peripheral blood mononuclear cells from thyroid nodule patients (n = 20) were isolated preoperatively and the expression of seven CTC-associated genes was measured in patients with thyroid nodule(s) (n = 20). Among the tested genes, the expression of SLC5A5 and LGALS3 were validated in a larger number of patients (n = 64) and our results show that SLC5A5 expression differentiated follicular adenomas from follicular carcinomas (area under the curve (AUC) = 0.831). The expression of SLC5A5 in CTCs may preoperatively distinguish thyroid follicular adenomas from follicular carcinomas.

While multiple studies show that simulation methods help in educating surgical trainees, few studies have focused on developing systems that help trainees to adopt the most effective body motions. This is the first study to use a Perception Neuron® system to evaluate the relationship between body motions and simulation scores. Ten medical students participated in this study. All completed two standard tasks with da Vinci Skills Simulator (dVSS) and five standard tasks with thyroidectomy training model. This was repeated. Thyroidectomy training was conducted while participants wore a perception neuron. Motion capture (MC) score that indicated how long the tasks took to complete and each participant’s economy-of-motion that was used was calculated. Correlations between the three scores were assessed by Pearson’s correlation analyses. The 20 trials were categorized as low, moderate, and high overall-proficiency by summing the training model, dVSS, and MC scores. The difference between the low and high overall-proficiency trials in terms of economy-of-motion of the left or right hand was assessed by two-tailed t-test. Relative to cycle 1, the training model, dVSS, and MC scores all increased significantly in cycle 2. Three scores correlated significantly with each other. Six, eight, and six trials were classified as low, moderate, and high overall-proficiency, respectively. Low- and high-scoring trials differed significantly in terms of right (dominant) hand economy-of-motion (675.2 mm and 369.4 mm, respectively) (p = 0.043). Perception Neuron® system can be applied to simulation-based training of surgical trainees. The motion analysis score is related to the traditional scoring system.

Thyroid storm (TS) is a life-threatening emergency endocrine condition. Thyroid hormones should be normalized before thyroidectomy is performed in patients with Graves’ disease. However, thyroid hormone levels are inevitably high in patients undergoing surgery. This study analyzed differences in vital sign changes during thyroidectomy between patients with controlled and uncontrolled Graves’ disease and assessed thyroid hormone cutoffs for TS. Preoperative levels of the thyroid hormones free T4 (FT4), T3, and thyroid stimulating hormone (TSH) were retrospectively analyzed in patients who underwent total thyroidectomy for Graves’ disease. Patients were divided into those with uncontrolled Graves’ (UG) disease, defined as preoperative TSH 1.7 ng/dL, those with controlled Graves’ (CG) disease, those with extremely uncontrolled Graves’ (EUG) disease, defined as TSH 3.4 ng/dL, and finally, those without EUG (non-EUG). The 29 patients with Graves’ disease included 12 with CG group and 17 with UG. FT4 and T3 concentrations were significantly higher in the UG group. There were no differences in vital sign and anesthetic agent. These 29 patients could also be divided into those with (n = 4) and without EUG (n = 25). The mean age was lower (21.5 vs. 40.9 years, p < 0.001) and the mean operation time was shorter (121.4 vs. 208.8 min, p = 0.003) in the EUG group. Requirements for anesthetic agents were greater in the EUG group. Mean FT4 concentration in the EUG group was 3.8 ng/dL, and there were no changes in vital signs during surgery. Vital sign change during thyroid surgery was not observed in patients with uncontrolled Graves’ disease up to the twice upper normal limit of T4 level.

Background. Laparoscopic lateral transperitoneal adrenalectomy (LTA) has been the standard method for resecting benign adrenal gland tumors. Recently, however, laparoscopic posterior retroperitoneal adrenalectomy (PRA) has been more popular as an alternative method. This systematic review evaluates current evidence on adrenalectomy techniques, comparing laparoscopic LTA with PRA and laparoscopic adrenalectomy with robotic adrenalectomy. Methods. PubMed, Embase, and ISI Web of Knowledge databases were searched systematically for studies comparing surgical outcomes of laparoscopic LTA versus PRA and laparoscopic versus robotic adrenalectomy. The studies were evaluated according to the PRISMA statement. Results. Eight studies comparing laparoscopic PRA and LTA showed that laparoscopic PRA was superior or at least comparable to laparoscopic LTA in operation time, blood loss, pain score, hospital stay, and return to normal activity. Conversion rates and complication rates were similar. Six studies comparing robotic and laparoscopic adrenalectomy found that outcomes and complications were similar. Conclusion. Laparoscopic PRA was more effective than LTA, especially in reducing operation time and hospital stay, but there was no evidence showing that robotic adrenalectomy was superior to laparoscopic adrenalectomy. Cost reductions and further technical advances are needed for wider application of robotic adrenalectomy.

Purpose: This study aimed to investigate the effectiveness of a novel wound protector in enhancing the cosmetic outcomes of thyroidectomy. Material and methods: This multicenter, double-blinded randomized controlled trial enrolled 129 patients undergoing open thyroidectomy. The patients were divided into a wound protector group and a control group. Subjective patient assessments were conducted, measuring wound satisfaction, pain, and itchiness. Additionally, blinded observers evaluated scars using the Vancouver Scar Scale. Results: The Vancouver Scar Scale revealed significant advantages for the wound protector group, demonstrating improvements in pigmentation (P=0.002), vascularity (P= 0.014), pliability (P =0.001), and height (P=0.001). Conclusion: The thyroid wound protector offers a potential to improve postoperative cosmetic outcomes. Further research is warranted to explore patient experiences and optimize the application of this innovative wound protector across diverse surgical contexts. [ABSTRACT FROM AUTHOR]

Background: This study investigated the prevalence and subtype distribution of circulating tumor cells (CTCs) in patients with papillary thyroid cancer (PTC) before and after thyroidectomy to determine the potential of CTC count as a noninvasive marker of the efficacy of surgical treatment in PTC. Materials and methods: Between January 2021 and January 2022, 62 PTC patients who underwent thyroidectomy at Seoul National University Bundang Hospital were prospectively evaluated. Peripheral blood samples (7.5 ml) were collected from each patient for CTC analysis before surgery and at 2 weeks and 3 months after surgery. CTC count and the distribution of CTC subtypes, including epithelial, epithelial-mesenchymal, and mesenchymal phenotypes, were analyzed using the negative selection method and immunofluorescence staining. The relationship between CTC count and clinicopathological characteristics was analyzed before and after surgery. Results: Before surgery, CTCs were detected in 87% (54/62) of patients; the mean CTC count was 8.0 and the median was 5.0 in 7.5 ml of peripheral blood. The mesenchymal or epithelial-mesenchymal phenotypes were predominant. After thyroidectomy, the mean and median CTC count values decreased to 5.3 and 2.5, respectively, at 2 weeks and to 4.3 and 3.0, respectively, at 3 months. This postoperative reduction in CTCs was more pronounced in patients with lymphatic invasion, lymph node metastasis, or BRAF V600E mutation. Conclusion: CTCs were detected in patients with PTC with a predominance of cells undergoing epithelial-mesenchymal transition. The CTC count decreased postoperatively, suggesting that liquid biopsy with CTC detection could be a valuable noninvasive tool for monitoring the efficacy of surgery in PTC. [ABSTRACT FROM AUTHOR]

Objective: To investigate surgical, and clinical outcomes in patients with low-risk papillary thyroid microcarcinoma (PTMC) according to treatment options [immediate operation (IOP) vs delayed operation after active surveillance (AS) (DOP)]. Background: AS has been adopted as an alternative to immediate surgery in patients with low-risk PTMC. Although some patients undergo surgery during AS, there is little information on surgical, and clinical outcomes after delayed operation after AS. Methods: A multicenter prospective cohort study including 1177 patients was conducted at 3 tertiary hospitals in Korea from June 2016 to January 2020. Patients with low-risk PTMC were enrolled. The participants were self-assigned into AS or IOP, and during AS, the patients underwent surgery if there were signs of disease progression or if the patient's choice changed. Results: A total of 516 patients underwent operation; 384 (74.4%) in the IOP group and 132 (25.6%) in the DOP group. Compared with the IOP group, the DOP group was significantly associated with a larger tumor size (P= 0.002), higher rates of lymphatic invasion (P=0.002), and multifocality (P=0.008). However, the rates of total thyroidectomy, postoperative hypoparathyroidism and vocal cord palsy did not differ significantly between the groups (P= 0.283, P=0.184, and P=0.284, respectively). Of the 132 patients in the DOP group, disease progression was present in 39 (29.5%) patients. The DOP group with disease progression had a significantly higher rate of lymph node metastasis (P= 0.021) and radioiodine therapy (P=0.025) than the DOP group without disease progression. Conclusions: These results suggest that AS might be considered an alternative treatment option for patients with low-risk PTMC regarding the extent of thyroidectomy and postoperative complications in the DOP group. To assess oncologic outcomes, long-term follow-up will be needed. [ABSTRACT FROM AUTHOR]