Pradeep Jacob

Hypocalcaemia following total thyroidectomy: An analysis of 806 patients.

Background: Permanent hypocalcaemia following thyroidectomy causes considerable morbidity. This prospective observational study aims to define the factors likely to predict hypocalcaemia following total thyroidectomy. Materials and Methods: Patients who were subjected to total thyroidectomy during January 2005 to December 2009 were followed up for a minimum period of 1 year. Efficacy of an intraoperative parathyroid hormone assay to predict hypocalcaemia was validated. Results: Overall incidence of hypocalcaemia was 23.6% (n = 190) and that of permanent hypocalcaemia was 1.61% (n = 13). Onset was delayed up to 3rd postoperative day in 13 patients. Hypocalcaemia was significantly associated with thyroidectomy for Graves Disease (P = 0.001), Hashimotos thyroiditis (P = 0.003), and with incidental parathyroidectomy (P = 0.006). The intraoperative assay of parathyroid hormone showed low sensitivity (0.5) and satisfactory specificity (0.9) in predicting hypocalcemia. Conclusion: Hypocalcemia could manifest late in the immediate postoperative period and this may explain latent hypocalcemia. High incidence of hypocalcaemia noted in Graves Disease could be due to the autoimmunity since same feature was noted associated with Hashimotos thyroiditis and the incidence of hypocalcaemia was not high in the subgroup with toxic nodular goiter. The incidence of hypocalcemia was not affected by age or sex.

Lithium-induced parathyroid dysfunction: A new case.

Lithium salts are widely used in psychiatric practice and are known to induce thyroid dysfunction. Lithium-induced parathyroid dysfunction is rare. We are reporting a case of hyperparathyroidism in a 28-year-old female patient who was on lithium carbonate for 2 years, when she developed osteopenia and girdle girdle-type muscle weakness. Biochemical parameters showed hyperparathyroidism with shift of calcium creatinine clearance ratio to 0.013, indicating an error in threshold of calcium sensing receptor. The patient eventually required parathyroidectomy and the histology of the gland showed atypical features.

Is intraoperative parathyroid hormone monitoring necessary in symptomatic primary hyperparathyroidism with concordant imaging

Introduction: Symptomatic primary hyperparathyroidism (PHPT) is still seen frequently in referral centers all over India. These patients require parathyroidectomy and this study aimed to assess the roll of intraoperative parathyroid hormone (PTH) assay when concordant results of two localization studies were available. Study Design: We analyzed the case records of patients who underwent parathyroidectomy for PHPT from January 2005 to June 2015. Results: Of 143 patients included in the study, technetium 99m methoxyisobutylisonitrate dual phase scintigraphy showed true positive images in 93.7% and high definition ultrasonography in 84.6% of patients. Concordance in localization studies was observed in 121 (84.6%) patients, successful parathyroidectomy was done in 117 (96.7%) patients with concordant localization studies. Intraoperative PTH monitoring showed 97.84% sensitivity and 75% specificity and predicted failure in 2 patients with concordant imaging. However, re-exploration was not successful in these patients. Conclusion: When concordant result is available between parathyroid scintigraphy and anatomical imaging surgical cure rate is high in trained hands. Re-exploration is unlikely to be successful since these patients require higher imaging.

Correlation between the cernea classification of external branch of superior laryngeal nerve in relation to the ultrasound-based volume of thyroid gland

Introductíon: Goiter is a very common problem dealt with by surgeons. Surgical treatment of thyroid requires removal of a part (hemi) or whole of the gland (total thyroidectomy). The external branch of the superior laryngeal nerve (EBSLN) is an important but less researched structure to be preserved during surgery. Various studies have described the incidence of different types of EBSLN, but have not described regarding the relationship between the change in volume of the gland to the nerve. Materials and Methods: A prospective analysis of 100 patients who underwent total thyroidectomy in our department was done. All patients underwent preoperative ultrasonography and the volume of the gland was calculated. Intraoperatively, the EBSLN was identified and preserved prior to ligating the superior thyroid vessels. The nerve was classified as per the Cernea classification. The gland was divided into high and low volume, taking 20 ml as the cutoff. The incidence of Type 2 nerve in a low-volume gland was compared with that of a high-volume gland. Results: In 100 patients (200 nerves), 191 nerves were identified. The nerve was type 1 in 56/200 (28%), Type 2a in 116/200 (58%), and Type 2b in 19/200 (9%) patients. In large-volume glands, Type 2 nerve was more common (87%). Conclusion: Dissection of thyroid gland requires expertise to preserve the EBSLN. Large volume glands pose a more difficult challenge, as the gland is more closer to the nerve.

Lack of association of B-type raf kinase V600E mutation with high-risk tumor features and adverse outcome in conventional and follicular variants of papillary thyroid carcinoma

Introduction: Somatic B-type Raf kinase (BRAF) V600E mutation in exon 15 was frequently found in high frequencies associated with papillary thyroid cancer (PTC). The phenotype of these cancers expressed aggressive clinical and pathological features. The present study aimed to assess the prevalence of BRAF V600E mutation among conventional and follicular variants of PTC and its association with aggressive tumor factors and outcome. Study Design: Patients who were operated and received further treatment for PTC during 2012 were included in the study. BRAF V600E mutation analysis was done by extracting genomic DNA from tumor tissue. Results: Of the 59 patients included in the study, 51% harbored BRAF V600E mutation, but the mutation status was not associated with aggressive tumor factors and adverse outcome. Conclusion: BRAF V600E mutation was not significant predictor of aggressive tumor behavior in conventional and follicular variants of PTC.

Epidemiology and Risk Factors

Venous diseases of the lower limbs are common problems in clinical practice. The disease has a global prevalence and has been extensively studied and reported. But there is a paucity of literature pertaining to the prevalence of the disease in the Indian subcontinent.

Primary Varicose Veins: Symptoms and Diagnosis

Varicose veins are a common problem in clinical practice. The condition is so common that many clinicians brush it aside as a “mundane” problem not deserving serious attention. However, it is now realized that varicose veins and its complications can impose considerable fiscal and social burden on the individual and community. Many newer developments in the field of phlebology like newer diagnostic technologies and minimally invasive interventions have all changed the face of care for venous disease.

Recurrent Varicose Veins

Recurrence of varicose veins after surgery is a common problem. Many surgeons have a pessimistic view on the outcome of surgery for varicose veins and consider recurrence inevitable. The problem is confounded by the inability to clearly define recurrence. Variations in the definition of recurrent varicose veins result from the multiple modalities of interventions employed for the initial treatment of chronic venous disorders (CVD). To streamline these issues, an international consensus meeting was held in Paris in 1998 to provide guidelines for the definition and management of recurrent varicose veins after surgery (REVAS).

Open Surgery for Primary Varicose Veins

High ligation and stripping [HL/S] is still the standard of care for patients with primary varicose veins. Historically, Friedrich Trendelenburg in 1891, advocated ligation of great saphenous vein (GSV) at the mid thigh. Tavel in the early twentieth century recommended high ligation. Keller and Mayo recommended the procedure of stripping. These were the major milestones in the evolution of surgical treatment of varicose veins.

Toxic thyroid carcinoma: A new case

blood urea nitrogen level. [11, 12] Intravenous calcium in symptomatic patients should be administrated in low rate of 93–186 mg of calcium gluconate. A continuous intravenous calcium gluconate is administrated in severe or prolonged hypocalcemia cases according to the feedback of the calcemia assessment. Our case showed an improvement of BMD in postoperative stage. Authors demonstrated severe bone loss recovering after successful surgery treatment.