Introduction: Intraoperative neural monitoring of the recurrent laryngeal nerve has been widely used to avoid nerve injury during thyroidectomy. We discuss the results of the change in surgical strategy after unilateral signal loss surgeries using intermittent intraoperative neural monitoring in a high-volume referral centre. Materials and methods: Details of consecutive patients who underwent thyroidectomy with intermittent intraoperative neural monitoring between January 2014 and December 2017 were prospectively recorded and retrospectively reviewed. Loss of signal was defined as recurrent laryngeal nerve amplitude level lower than 100 μV during surgery. The rate of loss of signal and change in surgical strategy during the operation were evaluated. Results: Loss of signal was detected in 25 (5.4%) of 456 patients for whom intermittent intraoperative neural monitoring was performed. Four patients had anatomic nerve disruption and surgery was completed by an experienced endocrine surgeon making use of intraoperative neural monitoring with continuous vagal stimulation. Staged thyroidectomy was performed on 16 patients with unilateral loss of signal in whom the nerves were intact visually. Postoperative vocal cord paralysis was encountered in 18 of 21 (85.7%) patients with loss of signal, and 16 of 18 (88.8%) were improved during the follow-up period. Patients’ voices were subjectively normal to the surgeon postoperatively in 9 of 21 (42.8%) patients who were found to have loss of signal with intact nerves. Conclusions: Intraoperative neural monitoring can be used safely in thyroid surgery to avoid recurrent laryngeal nerve injury. It enables the surgeon to diagnose recurrent laryngeal nerve injury intraoperatively to estimate the postoperative nerve function and to modify the surgical strategy to avoid bilateral vocal cord paralysis.

Papillary thyroid carcinoma (PTC) is the main type of the well-differentiated thyroid carcinomas. Multifocality is regarded as a poor prognostic factor for PTC. Documents of 777 patients who underwent thyroidectomy were reviewed retrospectively. A total of 305 PTC patients were included. Patients with multifocal PTC were included in Group 1, and patients with unifocal PTC were included in Group 2. There were 165 patients (54.0%) in Group 1 and 140 patients (46%) in Group 2. The pathological mixed variant of PTC was significantly higher in Group 1 (p = 0,005). Lymph node metastasis (LNM) was detected at 9.6% and 3.5% in Group 1 and Group 2, respectively (p = 0,028). Micro PTC rates were 28.4% and 40.7% in Group 1 and Group 2, respectively (p = 0,017). Tumor size and pathologically mixed-type and fine-needle aspiration biopsy (FNAB) results were significantly different between multifocal and unifocal Micro PTC (p < 0.05). Multifocality is more frequent in patients with tumors ≥1 cm and mixed-type tumors. LNM is found more often in multifocal tumors. The presence of micropapillary tumors can be predicted preoperatively by ultrasound-guided FNAB. Mixed-type pathology is also a predictive factor for multifocality.

Parathyromatosis is a rare entity and usually appears as a consequence of the seeding on previous parathyroid surgery which was applied for the secondary hyperparathyroidism. A 63-year-old woman presented with a history of subtotal thyroidectomy 20 years ago and parathyroidectomy due to primary hyperparathyroidism (PHPT) four years ago. Imaging methods revealed multiple parathyromatosis foci on subcutaneous tissue of the neck. En-bloc resection was performed and pathological examination confirmed the diagnosis of parathyromatosis. After an uneventful 10 months, biochemical and radiological tests revealed recurrence on bilateral thyroid lodges. En-bloc resection was performed. The patient has remained well for 24 months after the second operation and has been followed-up with normal parathormone and serum calcium values. To the best of our knowledge, this report describes the twenty-first case of parathyromatosis in PHPT setting in the literature. It should be kept in mind that parathyromatosis may recur at different sites in the neck even in patients with PHPT.

Hydatid cyst of the pancreas is a rarely seen entity even in endemic countries. Cyst may causes several symptoms due to external compression or fistulisation to pancreaticobiliary tract or small bowel. A 23-year-old female patient was referred with a complaint of abdominal pain. Preoperative imaging revealed an undefined cyst in the tail of pancreas. She underwent distal pancreatectomy and splenectomy, with a diagnosis of acute pancreatitis due to cystopancreatic duct fistula and also left-sided portal hypertension due to splenic vein thrombosis. Pathological examination reported a final diagnosis of hydatid cyst. To the best of our knowledge, coincidence of cystopancreatic duct fistula and splenic vein thrombosis due to pancreatic hydatid cyst has not previously been reported.