Sanjay Kumar Yadav

Comment on Article Entitled “Parathyroid Autotransplantation During Thyroid Surgery: A Novel Technique Using a Cell Culture Nutrient Solution”

We read with interest the article entitled ‘‘Parathyroid Autotransplantation during Thyroid Surgery: A Novel Technique Using a Cell Culture Nutrient Solution’’ by Famà et al. published in World Journal of Surgery [1]. Parathyroid autotransplantation and its effect on postoperative hypoparathyroidism has been widely debated in the past, but as of now, most of the endocrine surgeons agree that at least for an inadvertently removed or obviously devascularized gland, the best strategy is its immediate autotransplantation. Although, previous studies have shown that resorting to a policy of routine autotransplantation of at least one gland can reduce the incidence of permanent hypoparathyroidism to zero [2], the policy of routine autotransplantation is not uniformly accepted by all because of higher incidence of temporary hypoparathyroidism reported with this policy in some studies. One of the problems associated with validation of any technique of parathyroid autotransplantation is the difficulty encountered in assessing the functionality of the autotransplanted gland. To prove the functionality of the autotransplanted gland, one has to get a confirmatory biopsy or test it for PTH secretion [3–5]. None of these methods are straightforward to be performed in patients in the follow-up period for ethical and practical reasons. Coming to the issue of preservatives used for preserving the resected parathyroid glands ex vivo before they are autotransplanted, iced saline has been used commonly because of its easy availability, low cost and excellent results [6, 7]. The other preservative that has shown excellent result is ‘‘no preservative’’ where by the gland to be transplanted is minced immediately after resection and autotransplanted without being transferred into any preservative solution. With the use of this technique, zero incidence of permanent hypoparathyroidism has been reported in the literature [2] and as of now, this technique seems to be the standard, as the authors have also mentioned. We think that one should try to find out the answers to two questions before considering the use of cell culture nutrient solution for preserving the parathyroid glands: (a) why do we need a preservative at all? (b) Even if we need to maintain the parathyroids for some time ex vivo in a preservative, why do we need something different from the ubiquitous iced saline? Other than this, we would like to have some more of our queries answered by the authors:

Comment on: Can we consider immediate complications after thyroidectomy as a quality metric of operation?

To the Editors: We read with interest the article entitled “Can we consider immediate complications after thyroidectomy as a quality metric of operation?” by Lifante et al. Congratulations to the authors for trying to define some quality indicators for thyroid operation through a very well-designed study with an honest presentation of the data. There is no way surgeons can overlook their complications, and this study has provided us with the insight that the complication rates are usually greater than the surgeon’s own estimate; hence, we must develop ways and means to monitor and improve on metrics of outcomes and recognition of complications. We share the authors view that the incidence of temporary recurrent laryngeal nerve (RLN) injury can serve as an indicator of quality of thyroid operation. In contrast, we believe that temporary hypoparathyroidism, as opposed to permanent hypoparathryoidism, is too complex a phenomenon to be considered as an indicator for the same. A host of patient, tumor, and technical factors, in addition to surgeon-related factors, have a bearing on the incidence of hypoparathyroidism, more so on temporary hypoparathyroidism. Compared to this, RLN injury is one complication that can be reduced by proper training, meticulous dissection during the operation, and use of neuromonitoring if available in difficult cases. The authors have mentioned that one of the limitations of their study was that they did not assess the quality of the voice. We would like to add that assessment of the quality of voice may be a very important quality indicator of a thyroid operation, but like temporary hypoparathyroidism, the quality of the voice is affected by a number of factors that are difficult for the surgeon to control. The other issue with assessing the quality of the voice is that it is not as straightforward as assessing vocal cord mobility or hypoparathyroidism, meaning that it is unlikely to be widely applied as a quality indicator especially in resourcelimited developing countries. In our view, temporary RLN palsy and permanent hypoparathyroidism should be the 2 minimum indicators that all thyroid surgeons should monitor routinely to assess their own practice.

The L-shaped tunneling technique for implantable port positioning avoids kinking

We read with interest the article entitled ‘The “L-shaped tunneling technique”: a modified technique facilitating a more discreet implantable port positioning’ by Kehagias E and Tsetis D (1). The authors have comprehensively described a configuration of the TIVAD catheter that at least is very helpful in avoiding the kinking of the catheter. The classical teaching is that the TIVAD catheters should be placed in a way that the apex of the catheter should lay in the supra-clavicular fossa and the catheter should appear in a shape of an “inverted V” on post procedural imaging (either x-ray chest or fluoroscopy). In fact, we were used to it until recently and it was not uncommon to find a kink at the apex of the V. This usually resulted in increased operative time for manipulation of the catheter and sometimes even the incision at the venous access site had to be enlarged to manipulate the catheter. What the authors have suggested in the “L-shaped tunnelling technique” appears very logical considering that it just aims at increasing the angle of the “V” and thereby converting an acute angle into a right angle, so that the final shape on imaging will appear as an “L” rather than an inverted “V”. Not sure why it took us so long to realise this simple physics? Having said all this, we would also like to make a comment on the positioning of the port suggested by the authors. The authors have said that they implant the port in a pocket created in the deltopectoral groove (1). We also had some cases where the pockets were created in a similar position, of course by mistake rather than by protocol, and we observed that assessing such ports at the time of drug infusion becomes a bit tricky due to more subcutaneous fat, relatively deeper location of the bony chest wall and curvature of the chest wall at that site. This makes the fixation of port for putting a needle into it more difficult compared to a port that is situated a bit more medially than the deltopectoral groove at the same level on the chest wall that the authors have suggested. Regarding the issue of cosmesis, we would like to add that cosmetic appearance is suitable in both positions of port placement, but in making a choice of one over the other, we would suggest that the patient’s preferred clothing style should be considered before deciding how laterally the port should be placed.

Fournier's Gangrene

A two-month-old male infant presented with progressive swelling over both sides of scrotum, moderate to high fever and listlessness since five days. The scrotal skin was reddened, edematous, tense, and shiny. There was an ulcerated lesion of size 5 × 5 centimeters present over both sides of the scrotum. The edges of the ulcer were edematous, reddened, and irregular. The floor had slough, with a purulent, fowl smelling discharge. Both the testes were exposed. Perineal and perianal area was otherwise normal (Fig. 1). A disgnosis of Fournier’s gangrene was made. The patient was treated with antibiotics in addition to wide surgical debridement. The surgical wound healed well after secondary suturing (Fig. 2).