Thyroid and Parathyroid Surgery: new and emerging concepts

Rita Laforgia^1*Giovanna Pavone²Ferdinando Massimiliano Anelli¹Giovanni Docimo³Antonio Ambrosi²Angela Pezzolla¹Nicola Tartaglia²

• ¹Azienda Ospedaliero Universitaria Consorziale Policlinico di Bari, Bari, Italy
• ²Universita degli Studi di Foggia Dipartimento di Scienze Mediche e Chirurgiche, Foggia, Italy
• ³Universita degli Studi della Campania Luigi Vanvitelli, Caserta, Italy

New technologies and knowledge completely changed diagnosis and surgical approach to thyroid and parathyroid diseases in the last decades. Actually, the number of detected thyroid nodules has increased significantly thanks to the ultrasound accuracy. In addition, the management of hyperparathyroidism has similarly evolved with an increase of endocrine diseases. Prompt recognition and treatment of thyroid and parathyroid disorders could have a beneficial impact on health outcomes and could reduce the economic and social burden associated with the treatment of advanced disease. The practice of surgery for thyroid disease has seen many advances over the past decade, with most developments related to technologies focusing on the reduction of complications. Devices developed for surgical dissection with improved haemostasis and reduced heat transfer (and hence collateral tissue damage) is of particular interest in thyroid surgery. Laryngeal nerve injury and parathyroid gland dysfunction are complications of surgery with potentially devastating consequences and hence have been an area of focus for recent technological developments. Conventional thyroidectomy and parathyroidectomy are still considered the standard of care, but other innovative and minimally invasive techniques have been pioneered such as a gasless endoscopic transaxillary approach, the bilateral axillary-breast approach (BABA), behind-the-ear (RA) facelift approach and transoral endoscopic thyroidectomy via vestibular approach (TOETVA), Minimally Invasive Video-Assisted Thyroidectomy (MIVAT) or parathyroidectomy (MIVAP). The role of multidisciplinary team with endocrine surgeon, endocrinologist, oncologist, nuclear radiologists, radiotherapist is essential to find the right management of those patients. The aim of this special issue was to provide a focus on new and emerging concepts about Thyroid and Parathyroid Surgery, including surgical technique with possible complications, referral centres' experience, oncological outcomes and multidisciplinary approach. The contributions by leading experts in this field would reach this objective, especially with state of the arte reviews on minimally invasive surgery or novel approaches to thyroid and parathyroid cancer. This topic about Endocrine Surgery reached excellent results with 11 manuscripts accepted, with high quality and scientific level, on 22 manuscript presented to editors' attention. The authors belong to referral centers for thyroid and parathyroid disease from different countries. All the accepted manuscript contributed to the improvement of literature in this field. Pacilli et al1 reported the importance of the surgical approach in case of lymph node disease for recurrence DTC and demonstrated the safety and effectiveness of the ultrasound-guided approach. The aim of this method is to identify all pathological nodes and to facilitate the exact localization and the best outcome is to perform a curative surgery. Sang et al 2 considered as innovative approach in parathyroidectomy the application of artificial intelligence (AI) to recognize the parathyroid glands (PGs). This technique can be very useful for young unexperienced surgeons. The authors proposed a retrospective study, based on a new AI model to detect PGs, which demonstrated improved performance with superior accuracy and precision than other models. Cianci et al 3 underlined the safety of Fine-needle aspiration cytology (FNAC) technique, performed with 25 G caliber needles. In fact, FNAC presents a crucial role in the diagnosis of thyroid nodules and it is an easy and cost-effective method. The proposed technique by the Authors is less painful for patients, with low and not relevant complication rate. Staibano et al 4 reported a protocol of a systematic review and network meta-analysis of diagnostic test accuracy to identify the Intraoperative parathyroid hormone (iPTH) criteria and post-gland excision timepoint. The main aim is to best predict surgical cure in hyperparathyroidism and to unify the existing several iPTH monitoring criteria and to reduce lack of standardization in the timing of post-parathyroid gland excision samples. He et al5 conducted with accuracy a comprehensive systematic review and meta-analysis about the application of carbon nanoparticles in thyroid surgery in order to detect intraoperative and/or metastatic lymph nodes and improve the surgical skills, also protecting the integrity and function of the parathyroid glands. The authors demonstrated that the application of carbon nanoparticles can effectively improve the effects of surgical treatment, reducing post-operative complications such as hypocalcemia and re-do surgery for undetected intraoperative and metastatic nodes. Ünlü et al6 reported a non-randomized prospective clinical study about the comparison between the severity of surgical trauma in TOETVA versus Conventional open thyroidectomy (COT), using the inflammatory surgical stress markers as interleukine-6 (IL-6), C-reactive protein (CRP), and white blood cells (WBC). The secondary objective was the evaluation of operative time, post-operative pain and hospital stay. The results suggested that the higher postoperative CRP level and VAS score were in in the TOETVA group balanced by a postoperative aesthetic satisfaction. Jin et al 7 documented a very interesting clinical case about a Nonrecurrent laryngeal nerve (NRLN), well-known as a rare variation of the recurrent laryngeal nerve, with overall incidence of 0.7%. This variation leads to intraoperative nerve injury. The authors detected the NRLN during an areola approach for radical thyroidectomy after an accurate intraoperative research of the nerve. Wang et al8 reported a systematic review and meta-analysis about the global prevalence of secondary hyperparathyroidism (SHPT) due to chronic kidney disease (CKD). In fact, this review demonstrated a high prevalence of SHPT in patients with CKD, highlighting the importance of therapeutic approach for primary care. Yamashita et al9 reported a prospective cohort study about the treatment of hypocalcemia after total thyroidectomy. This condition represents a comprehensive post operative complication. The use of 1,25-dihydroxyvitamin D represents a preventive sudden therapy for burden hypocalcemia. Zhao et al 10 considered, with an accurate Mendelian randomization, the genetic connection between immune cell traits and Hashimoto's Thyroiditis. Those finding provide guidance and direction for future treatment and clinical research. Laforgia et al 11 described a retrospective observational study about parathyroid carcinoma (PC) which represents less than 1% of malignant neoplasms among endocrinological diseases. PC has still considered as a great challenge in terms of preoperative diagnosis, management and treatment. A surgical approach represents the first best option for PC in referral endocrine surgery units.