A comparison of surgical outcomes and complications between hemostatic devices for thyroid surgery: a network meta-analysis

"In Vitro" Evaluation of Energy-Based Sealing of Graft Side Branches in Bypass Surgery

INTRODUCTION

Our objective was to compare the in vitro efficacy of electrothermal bipolar [EB] vessel sealing and ultrasonic harmonic scalpel [HS] versus mechanical interruption, with conventional ties or surgical clips (SC), in sealing saphenous vein (SV) collaterals, during its eventual preparation for bypass surgery.

METHODS

Experimental in vitro study on 30 segments of SV. Each fragment included two collaterals at least 2 mm in diameter. One of them was sealed by ligation with 3/0 silk ties (control) and the other one with EB (n = 10), HS (n = 10) or medium-6 mm SC (n = 10). After incorporation in a closed circuit with pulsatile flow, the pressure was progressively increased until causing rupture. Collateral diameter, burst pressure, leak point, and histological study were recorded.

RESULTS

Burst pressure was higher for SC (1320.20 ± 373.847 mmHg) as compared with EB (942.2 ± 344.9 mmHg, p = 0.065), and especially with HS (637.00 ± 320.61 mmHg, p = 0.0001). No statistically significant difference between EB and HS was found, and bursting always happened at supraphysiological pressures. The leak point for HS was always detected in the sealing zone (10/10), while for EB and SC, it occurred in the sealing zone only in 6/10(60%) and 4/10(40%), respectively (p = 0.015).

CONCLUSIONS

Energy delivery devices showed similar efficacy and safety in sealing of SV side branches. Although bursting pressure was lower than with tie ligature or SC, non-inferiority efficacy was shown at the range of physiological pressures in both, EB and HS. Due to their speed and easy handling, they may be useful in the preparation of the venous graft during revascularization surgery. However, remaining questions about healing process, potential spread of tissue damage and sealing durability, will require further analysis.

The Use of Harmonic Focus and Thunderbeat Open Fine Jaw in Thyroid Surgery: Experience of a High-Volume Center

Background: In thyroid surgery, achieving accurate haemostasis is fundamental in order to avoid the occurrence of complications. Energy-based devices are currently extensively utilized in this field of surgery. This study aims to compare Harmonic Focus and Thunderbeat Open Fine Jaw with regard to surgical outcomes and complications. Methods: Patients submitted to total thyroidectomy in our center, between January 2017 and June 2020, were retrospectively analysed. Based on the energy-based device utilized, two groups were identified: Group A (Harmonic Focus) and Group B (Thunderbeat Open Fine Jaw). Results: A total of 527 patients were included: 409 in Group A and 118 in Group B. About surgical outcomes, the mean operative time was significantly shorter in Group B than in Group A (p < 0.001), while as regards complications, the occurrence of transient recurrent laryngeal nerve injury was significantly greater in Group B than in Group A (p = 0.019). Conclusions. Both Harmonic Focus and Thunderbeat Open Fine Jaw have proven to be effective devices. Operative times were significantly shorter in thyroidectomies performed with Thunderbeat Open Fine Jaw; however, the occurrence of transient recurrent laryngeal nerve injury was significantly greater in patients operated on with this device.

Comparing Two Approaches for Thyroidectomy: A Health Technology Assessment through DMAIC Cycle

Total thyroidectomy is very common in endocrine surgery and the haemostasis can be obtained in different ways across surgery; recently, some devices have been developed to support this surgical phase. In this paper, a health technology assessment is conducted through the define, measure, analyse, improve, and control cycle of the Six Sigma methodology to compare traditional total thyroidectomy with the surgical operation performed through a new device in an overall population of 104 patients. Length of hospital stay, drain output, and time for surgery were considered the critical to qualities in order to compare the surgical approaches which can be considered equal regarding the organizational, ethical, and security impact. Statistical tests (Kolmogorov–Smirnov, t test, ANOVA, Mann–Whitney, and Kruskal–Wallis tests) and visual management diagrams were employed to compare the approaches, but no statistically significant difference was found between them. Considering these results, this study shows that the introduction of the device to perform total thyroidectomy does not guarantee appreciable clinical advantages. A cost analysis to quantify the economic impact of the device into the practice could be a future development. Healthy policy leaders and clinicians who are requested to make decisions regarding the supply of biomedical technologies could benefit from this research.

Parathyroid hormone level after total thyroidectomy using conventional versus harmonic focus technique: Prospective randomized study

Background

Total thyroidectomy is a common procedure, we wish to examine the effects of utilizing a harmonic scalpel with traditional procedures on parathyroid hormone levels.

Patients and methods

100 patients who underwent total thyroidectomy at the Department of General Surgery, were enrolled in this prospective randomized study, were randomly allocated into two equal groups: Group I: total thyroidectomy using a harmonic scalpel (HS) and Group II: total thyroidectomy using conventional technique.

Results

There is a significant association between the technique of surgery and the decrease in Postoperative PTH, Mean Difference, Pre and Postoperative and the change Pre PTH (p-value <0.001).

Conclusion

The postoperative serum level of parathyroid hormone declined significantly after thyroidectomy if the conventional method was used. Using HS during thyroidectomy is safe and effective with low rates of hypoparathyroidism.

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In treatment of many thyroid disease, total thyroidectomy is a viable option.

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The biggest disadvantage is the potential for complications, but it also avoids recurrence.

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Hypoparathyroidism after thyroid surgery is a common problem.

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Using a harmonic scalpel may help to decrease the reduction in parathyroid hormone levels after surgery.

Clinical benefits of vessel sealing system (LigaSure™) during surgery for soft tissue sarcoma: a propensity score matching analysis

BACKGROUND

Soft tissue sarcomas arise in the deep sites of the buttocks and lower extremities. Since a tourniquet is not applied during surgery for soft tissue sarcomas at such sites, excessive intraoperative blood loss may occur. Various devices, including LigaSure™ (Medtronic, Dublin, Ireland), are used as electrothermal bipolar vessel sealers. However, its clinical relevance in soft tissue sarcomas surgery remains unclear. This study aimed to assess the effectiveness of LigaSure™ in soft tissue sarcomas surgery.

METHODS

This study included 168 patients who underwent surgeries for soft tissue sarcomas in the deep sites in the buttocks and lower extremities between January 2004 and March 2018. The primary outcome was intraoperative blood loss, and secondary outcomes were surgery duration, wound complications, perioperative haemoglobin concentrations and intraoperative blood transfusion. To reduce selection biases, propensity score matching was applied. We defined the matched cases wherein LigaSure™ was used as the 'using group' and the other matched cases as the 'non-using group'. Outcomes were compared between both groups.

RESULTS

From each group, 35 cases were selected using propensity score matching. The intraoperative blood loss was significantly smaller statistically in the using group (181.5 ± 240.4 ml vs. 394.7 ± 547.3 ml, respectively; P = 0.041). The duration of operation was longer in the using group (189.9 ± 97.6 min vs. 140.6 ± 75.7 min, respectively; P = 0.007). There were no significant differences in other outcomes.

CONCLUSION

By using LigaSure™ for soft tissue sarcomas occurring in the buttocks and lower extremities, we observed a trade-off between reduced intraoperative blood loss and longer operative time.

A device category economic model of electrosurgery technologies across procedure types: a U.S. hospital budget impact analysis

AIMS

The electrosurgical technology category is used widely, with a diverse spectrum of devices designed for different surgical needs. Historically, hospitals are supplied with electrosurgical devices from several manufacturers, and those devices are often evaluated separately; it may be more efficient to evaluate the category holistically. This study assessed the health economic impact of adopting an electrosurgical device-category from a single manufacturer.

METHODS

A budget impact model was developed from a U.S. hospital perspective. The uptake of electrosurgical devices from EES (Ethicon Electrosurgery), including ultrasonic, advanced bipolar, smoke evacuators, and reusable dispersive electrodes were compared with similar MED (Medical Energy Devices) from multiple manufacturers. It was assumed that an average hospital performed 10,000 annual procedures 80% of which involved electrosurgery. Current utilization assumed 100% MED use, including advanced energy, conventional smoke mitigation options (e.g. ventilation, masks), and single-use disposable dispersive electrode devices. Future utilization assumed 100% EES use, including advanced energy devices, smoke evacuators (i.e. 80% uptake), and reusable dispersive electrodes. Surgical specialties included colorectal, bariatric, gynecology, thoracic and general surgery. Systematic reviews, network meta-analyses, and meta-regressions informed operating room (OR) time, hospital stay, and transfusion model inputs. Costs were assigned to model parameters, and price parity was assumed for advanced energy devices. The costs of disposables for dispersive electrodes and smoke-evacuators were included.

RESULTS

The base-case analysis, which assessed the adoption of EES instead of MED for an average U.S. hospital predicted an annual savings of $824,760 ($101 per procedure). Savings were attributable to associated reductions with EES in OR time, days of hospital stay, and volume of disposable electrodes. Sensitivity analyses were consistent with these base-case findings.

CONCLUSIONS

Category-wide adoption of electrosurgical devices from a single manufacturer demonstrated economic advantages compared with disaggregated product uptake. Future research should focus on informing comparisons of innovative electrosurgical devices.

Considerations for environmentally sustainable head and neck surgical oncology practice

OBJECTIVE

To evaluate the potential role of head and neck oncologic surgeons in environmental protection, sustainability of health-care systems and avoidance of procedures contributing to climate change in the future.

REVIEW METHODS

This literature review searched for relevant literature about the relevance of waste in surgical head and neck oncology practice and the innovative alternatives to decrease its effect on environment.

CONCLUSIONS

Head and neck oncologic surgeons have a role in environmental protection, sustainability of health-care systems and avoidance of procedures contributing to climate change in the future. However, there exist only limited data on waste management and other procedures in surgical oncology to promote these practices.

IMPLICATIONS FOR PRACTICE

By increasing awareness of the corresponding issues of waste production within the healthcare environment, head and neck surgeons can have a pioneering role in considering how to reduce, recycle and reuse in a more efficient manner. As research in this field accumulates, healthcare providers can engage both managers and clinicians in this process. It remains imperative to provide these professionals opportunities for their work force to rethink current practices in a manner that prioritizes environmentally sustainable head and neck surgical practices.

Antibiotic Prophylaxis for Thyroid and Parathyroid Surgery: A Systematic Review and Meta-analysis

Objective

Although thyroid and parathyroid surgery is considered a clean procedure with a low incidence of surgical site infections (SSIs), a great number of endocrine surgeons use antibiotic prophylaxis (AP). The aim of this study was to assess whether AP is significantly effective in reducing the incidence of SSIs in this kind of surgery.

Data Sources

A systematic literature search was performed with PubMed, Scopus, and ISI–Web of Science. Studies addressing the efficacy of AP in reducing the incidence of SSIs in thyroid and parathyroid surgery were included in the systematic review and meta-analysis.

Review Methods

The random effects model was assumed to account for different sources of variation among studies. The overall effect size was computed through the inverse variance method. Heterogeneity across studies, possible outlier studies, and publication bias were evaluated.

Results

A total of 6 studies with 4428 patients were included in the quantitative analysis. The incidence of SSI was 0.6% in the case group and 0.4% in the control group (odds ratio, 1.07; 95% CI, 0.3-3.81; P = .915). There was no evidence of heterogeneity among the studies ( Q = 8.36, P = .138; I2 = 40.17). The analysis of several continuous moderators, including age, use of drain, and duration of surgery, did not generate any significant result.

Conclusion

AP is not effective in reducing the incidence of SSI in thyroid and parathyroid surgery and should be avoided, notwithstanding the negative impact on social costs and the risk of development of antibiotic resistance.

Thyroidectomy with energy-based devices: surgical outcomes and complications-comparison between Harmonic Focus, LigaSure Small Jaw and Thunderbeat Open Fine Jaw

Background

Being the thyroid gland a highly vascularized organ, achieving a meticulous hemostasis is essential to avoid serious complications. Currently, energy-based devices are widely used in thyroid surgery. The aim of this study was to compare Harmonic Focus (HF), LigaSure Small Jaw (LSJ) and Thunderbeat Open Fine Jaw (TB) in terms of surgical outcomes and complications.

Methods

Patients undergoing thyroidectomy in our Unit between January 2012 and June 2018 were retrospectively analyzed. According to the type of energy-device used, patients were divided into three groups: Group A (HF), Group B (LSJ) and Group C (TB).

Results

A total of 1,165 patients were included in this study: 1,012 in Group A, 96 in Group B and 57 in Group C. Demographic data and histopathological findings were comparable between the three groups. About the postoperative stay and complications, no statistically significant difference was found. The mean operative time was 89.41±20.60 minutes in Group A, 85.57±15.91 minutes in Group B and 78.07±17.67 minutes in Group C (P<0.01). However, the post-hoc test for all pairwise comparisons showed a statistically significant difference only between Group A and Group C.

Conclusions

HF, LSJ and TB have proved to be safe and effective. The postoperative stay and complications were comparable between the three groups. Considering the limits of our investigation, further studies are needed to investigate the effect of TB on operative times.

Novel Energy Devices in Head and Neck Robotic Surgery - A Narrative Review

The advent of trans-oral robotic surgery (TORS) has facilitated removal of tumors previously deemed unresectable, by providing access to the deep structures of the head and neck. Despite this, the wider dissemination of TORS has been restricted due to issues with line of access, as the da Vinci robot was never designed with head and neck surgery in mind. Flexible instruments and novel energy delivery devices offer great potential in overcoming some of the existing challenges surrounding TORS. This review aimed to summarize the existing literature surrounding energy delivery in TORS and highlight areas of future innovation. MEDLINE was searched for studies relating to energy delivery in TORS in November 2019. The existing literature surrounding monopolar and bipolar electrocautery, LASER (CO₂, Tm:YAG and blue LASER), Ligasure and Harmonic was reviewed. Additionally, the latest iteration of the da Vinci; the SP, and the FLEX robot were evaluated as novel methods of energy delivery in TORS. Overall, these novel energy devices and robotic systems are predicted to further improve energy delivery to the head and neck. The use of flexible LASER in particular is well substantiated in the literature. This has the potential to achieve treatment de-escalation, based on the excellent outcomes demonstrated for disease-free margins and post-operative morbidity.

Energy-based devices in thyroid surgery-an overview

In the mid-20^th century Theodor Kocher standardized the conventional clamp-and-tie thyroidectomy, and a procedure that was banned or prohibited for so long was labeled as "extremely safe and efficient". Ever since, innovations and refinements in the field of thyroid surgery have focused on improving patient clinical outcome profiles, and offering patients procedures that are tailored to their concerns and desires without compromising the concepts of safety and efficacy. This led to a paradigm shift in thyroid surgery and the introduction of minimal access thyroid procedures. Unsurprisingly, this paralleled the constant technological evolution in surgical devices. Advanced energy-based devices were introduced into thyroid surgery more than a decade ago. Initially, their introduction was surrounded by sckepticism, and was considered a double-edged sword equally giving accolade and criticism. Ultimately, they have proved to be very useful in thyroid surgery, and pivotal to its evolution. In experienced hands, thyroid surgery performed using an advanced energy-based device is considered 'at least' as safe and effective as its conventional clamp-and-tie counterpart. Furthermore, it offers additional advantages that meet the best interest of the patient, surgeon, health care facility, and the society. This article provides an overview on the introduction of innovative technology into thyroid surgery.

Impact of scalpel type on operative time and acute complications in thyroidectomies

INTRODUCTION

Thyroidectomy is the most common surgery in the cervical region. Currently, several techniques are available for intraoperative hemostasis.

OBJECTIVE

To compare the performance of three techniques (monopolar and bipolar electrical and ultrasonic) on operative time and postoperative complications.

METHODS

Patients submitted to total thyroidectomy without prior treatment were included in this prospective series study, using a scientific design.

RESULTS

A total of 834 patients were included; 661 women (79.3%) and 173 men (20.7%). The diagnosis was malignant neoplasia in 528 patients (63.3%) and benign disease in 306 patients (36.7%). The monopolar electric scalpel was used in 280 patients (33.6%), bipolar scalpel in 210 patients (25.2%) and ultrasonic scalpel in 344 patients (41.3%). The operative time was significantly shorter with the ultrasonic or bipolar scalpel when compared to the electric scalpel. In a linear regression model, gender, malignancy diagnosis and power energy type were significant for the procedure duration. Patients who underwent surgery with an ultrasound or bipolar scalpel had a significantly lower incidence of hypoparathyroidism.

CONCLUSION

The use of ultrasonic or bipolar scalpel significantly reduces operative time and the incidence of transient hypoparathyroidism.

Comparing Hematoma Incidence between Hemostatic Devices in Total Thyroidectomy: A Systematic Review and Meta-analysis

OBJECTIVE

Alternative energy devices have become a popular alternative to conventional hemostasis in thyroid surgery. These devices have been shown to reduce operative time and thermal nerve injury. As hemostasis is paramount in thyroid surgery, we sought to examine the relative efficacy of 2 alternate energy devices compared to conventional hemostasis in preventing postoperative hematoma following total thyroidectomy.

DATA SOURCES

Ovid MEDLINE, EMBASE, PubMed, and Cochrane Central Register of Controlled Trials.

REVIEW METHODS

A systematic literature search was performed for all relevant English-language studies published between 1946 and July 2018. Two authors independently extracted data and analyzed articles for quality using the National Institute of Health Quality Assessment Scale. Our primary outcome of interest was hematoma requiring reoperation.

RESULTS

A total of 348 studies were screened, with 23 meeting the inclusion criteria. We found no significant difference in postoperative hematoma rates using alternate energy devices compared to conventional hemostasis (P = .370, .317). Network meta-analysis echoed the results of conventional meta-analysis, demonstrating no significant difference in hematoma rates.

CONCLUSIONS

We found no significant difference in postoperative hematoma rates following total thyroidectomy for any indication with the use of alternate energy devices compared to conventional hemostatic techniques. This suggests that hematoma occurrence does not necessarily need to be considered when choosing between these hemostatic devices. This information may help guide surgeons' decisions regarding choice of hemostatic technique during thyroid surgery.

The harmonic scalpel versus electrocautery for parotidectomy: A meta - analysis

OBJECTIVE

Parotidectomy is the most classic and unequivocal intervention for parotid neoplasm. The operative outcomes and postoperative complications of parotidectomy between harmonic scalpel and electrocautery gained more prominence in physician. In spite of much research work within the past years, there was an obvious lack of randomized controlled trial to resolve this question. Hence, a quantitative and qualitative meta-analysis was essential to evaluate the differences in these two types of hemostasis method.

METHOD

The major electronic databases, including Pubmed, Embase, Cochrane library, Google Scholar, China National Knowledge Infrastructure and Chinese Scientific and Technological Journal databases were using the key words "electrocautery", "electrocoagulation", "harmonic scalpel", "ultrasonic scalpel", "ultrasonic dissector", "parotidectomy" and "parotid surgery". 9 articles were included in our systematic review and meta-analysis. The operative time, intraoperative blood loss, hospital stay, salivary fistula and transient facial nerve paralysis were the outcome measures. Odds ratios (ORs) with 95% confidence intervals (CIs) were employed to evaluate the effect size for categorical outcomes and mean differences (MDs) with 95% confidence intervals (CIs) for continuous outcomes.

RESULTS

In our meta-analysis, there was a significant reduction in operation time [mean difference: -20.97; 95%CI=(-24.02,-17.92); P < 0.00001], intraoperative blood loss [mean difference: -20.75, 95%CI=(-22.32,-19.18); P < 0.00001], hospital stay [mean difference: -0.83; 95%CI=(-1.10,-0.57); P < 0.00001], salivary fistula [ORs: 0.30, 95%CI=(0.08,1.14)] and transient facial nerve paralysis [OR:0.33, 95%CI=(0.19,0.58),P = 0.0001] in harmonic scalpel group compared with electrocautery group.

CONCLUSION

This meta-analysis indicated that compared with electrocautery, harmonic scalpel (HS)was transcendent in the aspects of operative time, intraoperative blood loss, hospital stay, salivary fistula and transient facial nerve paralysis. The harmonic scalpel, as an efficient and useful instrument, was advocated in parotidectomy.

Update on sutureless thyroidectomy

INTRODUCTION

The Harmonic scalpel ("Focus" and the new version "Focus+") is one of the first devices for surgical simultaneous cutting and tissue coagulation which allows to obtain dissection and hemostasis by direct application of ultrasound and allows minimally invasive surgical procedures with minimal lateral thermal spread and, thus, minimal adjacent tissue destruction. The aim of the study is to complete the previous study that we made in 2014, based on the TT performed between January 2008 and December 2013, with new data about TT performed in our Surgical Division between January 2014 and December 2016 and compare the outcome using the Ultrasonic scalpel versus the device Ligasure in term of safety, operative time, overall drainage volume, complications, hospital stay.

PATIENTS AND METHODS

250 patients were randomized into two groups: Group A where Ultracision were used and Group B where the Ligasure device was used.

RESULTS

The results of the group A and of the Group B 2014-2016 have been compared with the results of the previous study and we found that they are similar, but asymptomatic hypocalcaemia increased in the patients of the new study.

CONCLUSIONS

We found that the use of Ultrasonic scalpel and Ligasure is effective both in the hemostasis of all vessels and in dissection of tissues and confirm the results of our first study without significant difference in the rate of post-operative morbidity with these two different energy based devices used.

Effect of fibrin vs cellulose based haemostatic agents with traditional haemostatic procedures in thyroid surgery

Objective:

To compare the efficacy of fibrin-based hemostat and cellulose-based hemostat with traditional procedures in patients undergoing thyroid surgery.

Methods:

Between January 2012 and December 2016, 255 patients were scheduled to undergo total thyroidectomy at Surgical Clinic Nis. The patients were randomized to: Group-I use of classic surgical procedures to achieve hemostasis, Group-II use Surgicel and Group-III use Beriplas

Results:

A statistically significant reduction of surgical time was found for Group-I compared with Group-II and III (p≤0.01 for both groups). Statistically significant reduction of intraoperative blood loss was found for Group-I compared with Group-II from 102.3mL vs. 86.1mL (p≤0.01) as well as compared to Group-III (mean 77.4mL, p≤0.01). Removal of the wound drain occurred sooner in the Group-II and III compared with Group-I (mean 37.1h vs. 40.1h, p≤0.05; mean 31.2h vs. 40.1h, p≤0.01). There were no significant differences in terms of postoperative morbidity among the groups.

Conclusions:

Fibrin based haemostat seems to be an effective hemostatic agent for patients undergoing thyroid surgery. We suggest that, where appropriate, this fibrin-based haemostat should be used as a first line hemostatic agent in thyroidectomy in combination with conventional surgical means of hemostasis.

Antibiotic prophylaxis in thyroid surgery

Use of antibiotic prophylactic (AP) in clean surgery is still controversial. We reviewed the literature of the last 10 years to identify the best way to approach the use of prophylactic antibiotic in thyroid surgery. In thyroid surgery, it is a highly controversial topic primarily due to the lack of evidence in "support" of or "against" antibiotic use. In this review, the authors analyze the literature on the use of AP in thyroid surgery in order to evaluate if the available data support or contradict this use routinely.