Protocol design and current status of CLIVIT: a randomized controlled multicenter relevance trial comparing clips versus ligatures in thyroid surgery

Differences in Thyroidectomy Outcomes Based on Surgical Method: A Comparison of LigaSure Precise, Harmonic Focus, and Traditional Methods

New surgical devices have been developed to improve haemostatic control and vascular closure in thyroid surgery. Here, we compare the efficacy and clinical outcomes of 3 surgical methods, Harmonic Focus, LigaSure Precise, and the traditional suture-ligation method, in patients undergoing total thyroidectomies. This retrospective study compared total thyroidectomies performed between July 2008 and August 2012. Thyroidectomies were performed in 243 patients using Harmonic Focus (n = 81), LigaSure Precise (n = 81), and traditional suture-ligation (n = 81). No significant differences were observed among groups in terms of patient demographics, thyroid weight, pathological diagnoses, pre- and postoperative calcium levels, postoperative complications, length of hospitalization, and clinical outcomes. The Harmonic Focus approach showed an ∼15% shortening in operating time relative to the suture-ligation group; no statistically significant differences were detected between the LigaSure and traditional suture-ligation groups. All 3 methods were found to be both safe and effective. Operating time was significantly shorter in the Harmonic Focus group; no differences in terms of postoperative complications were observed among groups.

Vascular clips versus ligatures in thyroid surgery--results of a multicenter randomized controlled trial (CLIVIT Trial)

BACKGROUND

New techniques using vascular clips or ultrasonically activated shears have been suggested to shorten operation time without compromising safety. The objective of the CLIVIT Trial was to compare ligatures with vascular clips for hemostasis in elective benign thyroid surgery.

METHODS

This multicenter, randomized, controlled, parallel group superiority trial was conducted in 13 German surgical centers. Patients scheduled for at least subtotal resection bilaterally were intraoperatively randomized. The primary endpoint was resection time. Secondary endpoints were the amount of postoperative bleeding, reoperation due to bleeding, wound infection, temporary (reversal within 12 months) and permanent (over 1 year) recurrent laryngeal nerve (RLN) paralysis, length of hospital stay, and safety.

REGISTRATION

ISRCTN 96901396.

RESULTS

Two hundred fifty patients were treated with ligatures and 241 with vascular clips. No differences in patients' baseline and surgical characteristics were observed. No difference was detected for mean resection time (clip 63.5 min ± 29.6, ligature 66.1 min ± 29.3, P = 0.258). Postoperative bleeding (mean 86 ml ± 93), reoperation due to bleeding (clips 4, ligature 2), wound infections (clips 4, ligature 4), postoperative hospital stay (mean 3.0 ± 1.9), and safety data also did not vary significantly. The rates of temporary and permanent RLN paralysis were 6.9 % (34/491) and 2.9 % (14/491), respectively. Not using a surgical drain (123 patients) was not associated with a higher rate of complications.

CONCLUSION

Vascular clips did not reduce the resection time. However, a 2.9 % rate of permanent RLN paralysis is of concern. Drains in elective surgery may be of no benefit.

[Contribution of the Study Center of the German Surgical Society to evidence based surgery]

Since the Study Center of the German Surgical Society (SDGC) was established in 2003 it has been supporting surgeons to implement their ideas for multicenter randomized studies. Assistance is provided for development (sample size calculation, protocol, funding application) implementation (submission to ethics committee, data management, monitoring) and analysis (statistical analysis, publication) in close collaboration with biometricians and data managers. Currently more than 2,500 patients have been included in 11 trials. The most complex SDGC study (SYNCHRONOUS) so far with up to 80 participating centers has been activated in September 2011. Furthermore, there is an increasing relevance for systematic reviews and meta analyses with regard to the development of studies and aggregation of results. For this reason a systematic review working group was established within the SDGC. To date 13 publications have been completed and 8 more are underway.

Thyroid surgery with harmonic focus, ligasure precise and conventional technique: a retrospective case-matched study

BACKGROUND

New surgical technologies have been introduced in thyroid surgery, to achieve vessel sealing and hemostasis. The aim of the study was to examine their effectiveness and compare the outcome of total thyroidectomy using the Harmonic Focus™, the LigaSure® Precise and the conventional technique of suture ligation.

METHODS

A retrospective case-matched study of all total thyroidectomies between October 2008 through May 2010 was conducted. Patients (n=240) underwent total thyroidectomy using three different methods; the Harmonic Focus™ (Group F, n=80), the LigaSure Precise® (Group L, n=80) and the conventional technique of suture ligation (Group C, n=80).

RESULTS

No significant differences were identified between the 3 groups in terms of demographics, thyroid gland weight, pathologic diagnosis, preoperative and postoperative calcium levels, postoperative complications, duration of hospital stay, and final outcome. The operative time was shorter with Harmonic Focus® by about 15%. Statistical analysis revealed a statistically significant difference between operations with F (62.7±14.1 minutes) and C (72.7±13.6minutes) with (p=0.019).

CONCLUSION

Both devices were safe and efficient. A significant reduction of the operative time was found with Harmonic Focus® compared to the other two techniques with no statistically significant differences in postoperative complications in the 3 groups.

Clustering in surgical trials--database of intracluster correlations

BACKGROUND

Randomised trials evaluation of surgical interventions are often designed and analysed as if the outcome of individual patients is independent of the surgeon providing the intervention. There is reason to expect outcomes for patients treated by the same surgeon tend to be more similar than those under the care of another surgeon due to previous experience, individual practice, training, and infrastructure. Such a phenomenon is referred to as the clustering effect and potentially impacts on the design and analysis adopted and thereby the required sample size. The aim of this work was to inform trial design by quantifying clustering effects (at both centre and surgeon level) for various outcomes using a database of surgical trials.

METHODS

Intracluster correlation coefficients (ICCs) were calculated for outcomes from a set of 10 multicentre surgical trials for a range of outcomes and different time points for clustering at both the centre and surgeon level.

RESULTS

ICCs were calculated for 198 outcomes across the 10 trials at both centre and surgeon cluster levels. The number of cases varied from 138 to 1370 across the trials. The median (range) average cluster size was 32 (9 to 51) and 6 (3 to 30) for centre and surgeon levels respectively. ICC estimates varied substantially between outcome type though uncertainty around individual ICC estimates was substantial, which was reflected in generally wide confidence intervals.

CONCLUSIONS

This database of surgical trials provides trialists with valuable information on how to design surgical trials. Our data suggests clustering of outcome is more of an issue than has been previously acknowledged. We anticipate that over time the addition of ICCs from further surgical trial datasets to our database will further inform the design of surgical trials.

Prospective trial of the ultrasonic dissector in thyroid surgery

BACKGROUND

Use of the ultrasonic dissector in thyroid surgery is becoming more prevalent, with reduced operative time and incision size reported. We assessed the value of the harmonic scalpel in routine thyroid lobectomy.

METHODS

We conducted a single blind, prospective pilot study of 52 euthyroid patients requiring thyroid lobectomy. Those with lesions not suitable for resection through a 4-cm incision, a history of thyroiditis, or uncontrolled thyroid dysfunction were excluded. Patients were allocated to 1 of 2 groups: group I (n = 31), thyroid lobectomies using conventional surgical techniques; or group II (n = 21), thyroid lobectomies using the ultrasonic dissector.

RESULTS

Outcomes for the 2 patient groups were comparable. There was no significant difference in operative time or incision size.

CONCLUSIONS

The ultrasonic dissector does not confer any quantifiable benefit in routine thyroid lobectomy when compared with conventional techniques. This is the first reported series in which its use has not reduced operative time.

A concept for trial institutions focussing on randomised controlled trials in surgery

Background

Although considered the reference standard for generating valid scientific evidence of a treatment's benefits and harms, the number of Randomised Controlled Trials (RCT) comparing surgical techniques remains low. Much effort has been made in order to overcome methodological issues and improve quality of RCTs in surgery. To the present there has been, however, only little emphasis on development and maintenance of institutions for implementation of adequately designed and conducted surgical RCTs.

Mehods/Design

Description of the developments in surgical RCT infrastructure in Germany between 2001 and 2006. Cross sectional evaluation of completed and ongoing surgical RCTs within the German Surgical Society and the Clinical Study Centre, Department of Surgery, University of Heidelberg.

Results

Foundation of a national Clinical Trial Centre (CTC) for the organisation of multi-centre RCTs in the surgical setting (Study Center of the German Surgical Society, SDGC). Establishment of a network of CTCs with affiliated Clinical Sites (CSs) to enhance patient recruitment and shorten the duration of RCTs. Since its foundation four surgical RCTs with a total sample size of 1650 patients (1006 of these randomised) have been supervised by the SDGC with 35 CSs involved in patient recruitment. Five further CTCs were set up in 2006. Together with their affiliated CSs a network has been organised providing improved conditions for the conduction of surgical RCTs.

Conclusion

Improvement of infrastructure substantially facilitates integration of RCTs into routine surgical practice. A network of collaborating CTCs and CSs can provide an adequate infrastructure for the conduction of multi-centre RCTs.