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Factors affecting the course of Graves' orbitopathy and poor response to glucocorticoid treatment followed by orbital radiotherapy

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Jagiełło-Korzeniowska A., Sokołowski A., Hubalewska-Dydejczyk A., Romanowska-Dixon B., Bałdys-Waligórska A.
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issue 2
98-105
EN
Graves’ orbitopathy is a rare autoimmune disorder characterized by the inflammation of orbital tissues. The course of disease can be described in terms of its activity and severity. Aim: The aim of our study was to determine the factors affecting the activity and severity of Graves’ orbitopathy, as well as to identify the predictive factors of poor response to glucocorticoid treatment followed by orbital irradiation. Methods: We performed a prospective observational study of 214 patients with Graves’ orbitopathy who were divided into two groups depending on the treatment they had previously obtained for their Graves’ disease. They received i.v. methylprednisolone pulses followed by orbital radiotherapy. They were examined and had their TSH, TRAb and FT4 levels evaluated prior to treatment and after 1, 6 and 12 months. Results: A pre-treatment TRAb concentration higher by one unit (U/L) implied a mean increase in the relative risk of active orbitopathy by 4.7% (p = 0.0362). A TRAb concentration higher by one U/L 1 month after treatment implied a mean increase in the relative risk of moderate-to-severe and severe GO by 8.7% (p = 0.0167) 6 months after treatment. As regards poor response to treatment, patients with moderate-to-severe and severe Graves’ orbitopathy on admission carried a higher risk of being non-responders. Each point scored on the NOSPECS scale prior to treatment increased the relative risk of the patient being a non-responder by 30%. Conclusions: Patients with higher TRAb levels have a higher risk of active Graves’ orbitopathy and moderate-to-severe and severe Graves’ orbitopathy. Monitoring TRAb serum concentration in those patients is of great importance. Patients with more severe Graves’ orbitopathy carry a higher risk of being poor responders to immunosuppressive treatment. Therefore, careful monitoring of patients with Graves’ orbitopathy and their early referral to specialized centers is essential.
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Posterior Retroperitoneoscopic Adrenalectomy - Clnical Evaluation of the Method Based on the Four-Year Experience

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Barczyński M., Konturek A., Cichoń S., Gołkowski F., Hubalewska-Dydejczyk A.
Polish Journal of Surgery
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2008
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vol. 80
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issue 9
446-454
EN
The aim of the study was to present the authors' four-year experience in employing posterior retroperitoneoscopic adrenalectomy according to Walz (PRA) in surgical treatment of adrenal tumors up to 6 cm in size.Material and methods. A prospective analysis included 83 procedures of unilateral PRA (40 rightsided and 43 left-sided adrenalectomies) performed in patients (the M:F ratio = 22:61; mean age 58.1±10.3 years; mean tumor size 41±14 mm) operated on in the Department in the period from January 2004 to December 2007. Indications for surgery included: glucocorticoid adenomas (10), aldosteronomas (18), pheochromocytomas (16) and hormonally inactive adrenal cortex tumors (39). The operators used the PRA surgical technique according to Walz. The learning curve was evaluated taking into consideration the operative time, percentage of conversions and complications. The statistical analysis assessed the correlation between the operative time and body mass index (BMI), location and size of the tumor and its hormonal activity. The results of surgical treatment employed in patients with hormonally active tumors were evaluated in a 6-month follow-up.Results. The mean operative time was 73.7±22.3 min. A single conversion (1.2%) was required, as well as a single early reoperation (1.2%) due to bleeding. Following the initial 20 operations with the mean operative time of 86.5±34.6 min, the mean operative time of the remaining 63 procedures was 69.7±14.9 min (p=0.046) and did not exceed 90 min in any case. No correlation was noted between the operative time and BMI, tumor location and size. The procedures performed in patients with pheochromocytomas were not significantly longer in comparison to operations in hormonally inactive adrenocortical adenomas. Normalization of arterial blood pressure was achieved in all the patients with pheochromocytomas, aldosteronomas and subclinical glucocorticoidism aged below 50 years and with less than one-year history of secondary hypertension.Conclusions. Despite its seeming complexity resulting from operating in an "upside down" surgical field, the PRA surgical technique is easy to master and safe, also during the learning period. After the surgeon has performed approximately 20 operations, the operative time does not exceed 90 min. PRA is worthy of recommending in the case of adrenal tumors qualified for surgical treatment and not exceeding 6 cm in size.
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Minimally Invasive Radio-Guided Reoperative Surgery with Intraoperative ipth Assay in Primary Hyperparathyroidism

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Barczyński M., Hubalewska-Dydejczyk A., Konturek A., Sowa-Staszczak A., Cichoń S.
Polish Journal of Surgery
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2008
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vol. 80
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issue 9
469-477
EN
The aim of the study was to present the experience of the authors in employing minimally invasive radio-guided parathyroid reoperative surgery (MIRP) combined with intraoperative iPTH assay (IOPTH) in persistent and recurrent primary hyperparathyroidism (PHP) and in patients with a history of thyroidectomy.Material and methods. A prospective analysis included the results of 12 reoperations performed employing the minimally invasive method using an intraoperative hand-held gamma camera (Gamma Finder II) following IV administration of 10 mCi 99mTc-MIBI, combined with IOPTH (Future Diagnostics) in six patients with persistent PHP, one patient with recurrent PHP and five patients after subtotal strumectomies without planned parathyroidectomies (F: M = 10 : 2; mean age 54±10.7 years; mean preoperative iPTH concentration 233.3±80.6 ng/L). Prior to surgery, all the patients had been subjected to diagnostic imaging studies (parathyroid scintiscans, USG of the neck, in selected cases, SPECT and CT of the neck and mediastinum). The validity of MIRP and IOPTH in minimizing the extent of intraoperative neck exploration was assessed. Therapeutic results were evaluated in six-month postoperative follow-up.Results. All the patients were cured. The mean incision length was 3.5±0.5 cm. The mean operative time was 49±10 min. All the patients had a single parathyroid adenoma (in five cases - in the tracheoesophageal groove, in 3 - in the retroesophageal region in the neck, in one - in the retroesophageal region in the superior posterior mediastinum, in one - in the thyrothymic ligament and in two - in the thymus). The mean ratio of adenoma to background neck radioactivity was 25.7±5.4%. The mean iPTH concentration 10 min after adenoma resection was 38.5±17.4 ng/L. No postoperative complications were noted. In six-month postoperative follow-up, all the patients demonstrated normal serum calcium values.Conclusions. MIRP has proven to be highly successful in reoperations in patients with PHP. The procedure performed using a hand-held gamma camera allows for a safe execution of a minimally invasive procedure focused on resection of a single parathyroid adenoma, eliminating the need for bilateral neck exploration, which is extensive, time-consuming and associated with a higher risk of damaging the recurrent laryngeal nerve and normal parathyroids.
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Laparoscopic Transperitoneal Approach to Adrenal Gland Malignancies

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Rembiasz K., Budzyński A., Kulawik J., Matłok M., Migaczewski M., Hubalewska-Dydejczyk A., Gołkowski F.
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issue 12
609-618
EN
Even though there is not enough good data, the use of laparoscopic approach in malignant disease is regarded by some controversial issue. On the other hand it seems that transperitoneal access to the adrenal gland allows for effective and safe oncological removal of adrenal gland neoplasms.The aim of the study was to present our experience with the use of transperitoneal approach in patients with adrenal gland malignancies.Material and methods. From March 2003 till May 2009 we performed 200 laparoscopic transperitoneal adrenalectomies. There were 82 hormonally silent tumors (1.5-14 cm in diameter) and 118 hormonally active (63 pheochromocytomas, 26 Conn's syndrome, 25 Cushing's syndrome and 4 virylizing tumors).Results. 197 procedures were completed laparoscopically and 3 were converted (including one for inability to assess resectablility of the tumor). 14 tumors (7%) were overtly malignant; 7 arising form the adrenal (adrenal cortex - 3, pheochromocytoma - 3, lymphoma - 1) and 7 metastatic (squamous cell cancer of the lungs - 2, clear cell carcinoma of the kidney - 2, collecting duct carcinoma of the kindey - 1, hepatocellular cancer - 1, NET lung tumor - 1). Further 19 tumors (9.5%) were assessed histologically as potentially malignant (pheochromocytomas - 16, tumors of neural origin - 2, oncocytomas - 1). One malignant tumor was unresectable other were operated radically. Progression of the cancer was observed in 3 patients with metastatic tumors.Conclusions. Laparoscopic transperitoneal adrenalectomy allows for safe and radical removal of adrenal gland malignancies. Longer follow-up and larger patients volume are needed for better evaluation of long-term results.
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Clinical Value of Intraoperative Neuromonitoring of the Recurrent Laryngeal Nerves in Improving Outcomes of Surgery for Well-Differentiated Thyroid Cancer

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Barczyński M., Konturek A., Stopa M., Hubalewska-Dydejczyk A., Richter P., Nowak W.
Polish Journal of Surgery
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2011
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vol. 83
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issue 4
196-203
EN
The recurrent laryngeal nerve (RLN) is particularly prone to injury during thyroidectomy in case of extralaryngeal bifurcation being present in approximately one-third of patients near the inferior thyroid artery or ligament of Berry. Meticulous surgical dissection in this area may be additionally facilitated by the use of intraoperative neuromonitoring (IONM) to assure safe and complete removal of thyroid tissue.The aim of the study was to verify the hypothesis that meticulous surgical technique of tissue dissection in the area of the posterior surface of the thyroid capsule and adjacent RLN may be additionally facilitated by intraoperative neuromonitoring (IONM), and may contribute to increasing the safety and radicalness of total thyroidectomy in patients with well-differentiated thyroid cancer.Material and methods. The outcomes of total thyroidectomy with level VI lymph node clearance for well-differentiated thyroid cancer (WDTC; pT1-3, N0-1, Mx) were retrospectively compared between 151 patients undergoing surgery with IONM (01/2005-06/2009) and 151 patients undergoing surgery without IONM (2003-2004). RLN morbidity (calculated for nerves at risk) was assessed by videolaryngoscopy or indirect laryngoscopy (mandatory before and after surgery and at 12-month follow-up). The anatomical course of the extralaryngeal segment of RLNs were analyzed in detail in each operation. Thyroid iodine uptake (131I) was measured during endogenous TSH stimulation test a week before radioiodine therapy.Results. Among patients operated with vs. without IONM, the early RLN injury rate was 3% vs. 6.7% (p=0.02), including 2% vs. 5% (p=0.04) of temporary nerve lesions, and 1% vs. 1.7% of permanent nerve events (p=0.31), respectively. Extralaryngeal RLN bifurcation was identified in 42 (27.8%) vs. 25 (16.6%) of patients operated with vs. without IONM, respectively (p=0.001). Mean I-131 uptake following total thyroidectomy with vs. without IONM was 0.67 ± 0.39% vs. 1.59 ± 0.69% (p<0.001). 131I uptake lower than 1% was found in 106 (70.2%) vs. 38 (25.2%) patients operated with vs. without IONM, respectively (p<0.001).Conclusions. Most patients with WDTC who undergo total thyroidectomy have a small amount of residual thyroid tissue. The use of IONM may improve the outcomes of surgery among these patients by both increasing the completeness of total thyroidectomy and significantly reducing the prevalence of temporary RLN injury. The possible mechanism of this improvement is the aid in dissection at the level of the Berry's ligament offered by IONM which enhances the surgeon's ability to identify a branched RLN, and allows for reduction of traction injury and neuropraxia of the anterior branch of bifid nerves.
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Bilateral Neck Exploration with Intraoperative iPTH Assay in the ERA of Minimaly Invasive Parathyroidectomy

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Barczyński M., Konturek A., Stopa M., Gołkowski F., Hubalewska-Dydejczyk A., Cichoń S., Nowak W.
Polish Journal of Surgery
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2010
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vol. 82
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issue 1
29-37
EN
At present, the majority of patients with sporadic primary hyperparathyroidism (pHPT) qualify to minimally invasive parathyroidectomy (MIP). Nevertheless, in some patients, especially those with multiglandular parathyroid disease, achieving normocalcemia necessitates bilateral neck exploration (BNE).The aim of the study was evaluation of current indications for BNE and results obtained employing this method in an endocrine surgery referral center.Material and methods. A prospective analysis included 385 patients with pHPT qualified to parathyroidectomy (300 to MIP and 85 to BNE procedures) in the period between 12/2002 and 05/2008. Prior to the procedure, all the patients underwent preoperative imaging diagnostic studies (scintiscans of the parathyroids and ultrasound of the neck). Intraoperative parathormone assay was carried out in the course of all the operations. Indications for BNE and therapeutic results were evaluated.Results. The most common indication for BNE was lack of preoperative location of a parathyroid adenoma in imaging studies aiming either at lateralization or regionalization (49.4%), followed by concomitant thyroid pathology that required surgical treatment (23.5%), MEN 1 syndrome (12.9%), long-term lithium therapy (5.9%), refusal of the patient to grant informed consent to a minimally invasive parathyroidectomy (5.9%) and MEN 2A syndrome (2.4%). In the discussed group, 31 subtotal parathyroidectomies were performed, along with ten resections of two parathyroid adenomas and 44 resections of single parathyroid adenomas. Intraoperative iPTH assay affected the extent of parathyroid tissues resection in eight (9.4%) cases. One case of persistent and one case of recurrent hyperparathyroidism were noted in the follow-up of mean 37.4 ± 19.4 months postoperatively.Conclusions. In an endocrine surgery referral center, BNE is a procedure of choice in patients suspected of multiglandular parathyroid disease (MEN 1 and 2A, familial pHPT, long-term lithium therapy), in cases when a pathological parathyroid has not been located preoperatively and in patients which refuse their consent to MIP. Supplementing BNE with intraoperative iPTH assay allows for maintaining the highest quality of surgical treatment.
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