1
|
Musholt TJ, Staubitz JI, Musholt PB. Evaluation of intraoperative neuromonitoring (IONM) data with the Mainz IONM Quality Assurance and Analysis tool. BJS Open 2023; 7:zrad051. [PMID: 37428557 DOI: 10.1093/bjsopen/zrad051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 02/16/2023] [Accepted: 04/05/2023] [Indexed: 07/11/2023] Open
Abstract
BACKGROUND Intraoperative neuromonitoring is widely used in thyroid and parathyroid surgery to prevent unilateral and especially bilateral recurrent nerve paresis. Reference values for amplitude and latency for the recurrent laryngeal nerve and vagus nerve have been published. However, data quality measures that exclude errors of the underlying intraoperative neuromonitoring (IONM) data (immanent software errors, false data labelling) before statistical analysis have not yet been implemented. METHODS The authors developed an easy-to-use application (the Mainz IONM Quality Assurance and Analysis tool) using the programming language R. This tool allows visualization, automated and manual correction, and statistical analysis of complete raw data sets (electromyogram signals of all stimulations) from intermittent and continuous neuromonitoring in thyroid and parathyroid surgery. The Mainz IONM Quality Assurance and Analysis tool was used to evaluate IONM data generated and exported from 'C2' and 'C2 Xplore' neuromonitoring devices (inomed Medizintechnik GmbH) after surgery. For the first time, reference values for latency and amplitude were calculated based on 'cleaned' IONM data. RESULTS Intraoperative neuromonitoring data files of 1935 patients consecutively operated on from June 2014 to May 2020 were included. Of 1921 readable files, 34 were excluded for missing data labelling. Automated plausibility checks revealed: less than 3 per cent device errors for electromyogram signal detection; 1138 files (approximately 60 per cent) contained potential labelling errors or inconsistencies necessitating manual review; and 915 files (48.5 per cent) were indeed erroneous. Mean(s.d.) reference onset latencies for the left vagus nerve, right vagus nerve, recurrent laryngeal nerve, and external branch of the superior laryngeal nerve were 6.8(1.1), 4.2(0.8), 2.5(1.1), and 2.1(0.5) ms, respectively. CONCLUSION Due to high error frequencies, IONM data should undergo in-depth review and multi-step cleaning processes before analysis to standardize scientific reporting. Device software calculates latencies differently; therefore reference values are device-specific (latency) and/or set-up-specific (amplitude). Novel C2-specific reference values for latency and amplitude deviate considerably from published values.
Collapse
Affiliation(s)
- Thomas J Musholt
- Section of Endocrine Surgery, Department of General, Visceral and Transplantation Surgery, University Medical Centre, Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Julia I Staubitz
- Section of Endocrine Surgery, Department of General, Visceral and Transplantation Surgery, University Medical Centre, Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Petra B Musholt
- Section of Endocrine Surgery, Department of General, Visceral and Transplantation Surgery, University Medical Centre, Johannes Gutenberg-University Mainz, Mainz, Germany
| |
Collapse
|
2
|
Staubitz JI, Müller C, Heymans A, Merten C, Roos B, Poplawski A, Ludt A, Strobl S, Springer E, Schad A, Roth W, Musholt TJ, Hartmann N. Approach to risk stratification for papillary thyroid carcinoma based on molecular profiling: institutional analysis. BJS Open 2023; 7:7153160. [PMID: 37146205 PMCID: PMC10162683 DOI: 10.1093/bjsopen/zrad029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 01/19/2023] [Accepted: 02/11/2023] [Indexed: 05/07/2023] Open
Abstract
BACKGROUND Currently, treatment recommendations for papillary thyroid carcinoma are not based on the genetic background causing tumourigenesis. The aim of the present study was to correlate the mutational profile of papillary thyroid carcinoma with clinical parameters of tumour aggressiveness, to establish recommendations for risk-stratified surgical treatment. METHOD Papillary thyroid carcinoma tumour tissue of patients undergoing thyroid surgery at the University Medical Centre Mainz underwent analysis of BRAF, TERT promoter and RAS mutational status as well as potential RET and NTRK rearrangements. Mutation status was correlated with clinical course of disease. RESULTS One hundred and seventy-one patients operated for papillary thyroid carcinoma were included. The median age was 48 years (range 8-85) and 69 per cent (118/171) of patients were females. One hundred and nine papillary thyroid carcinomas were BRAF-V600E mutant, 16 TERT promotor mutant and 12 RAS mutant; 12 papillary thyroid carcinomas harboured RET rearrangements and two papillary thyroid carcinomas showed NTRK rearrangements. TERT promoter mutant papillary thyroid carcinomas had a higher risk of distant metastasis (OR 51.3, 7.0 to 1048.2, P < 0.001) and radioiodine-refractory disease (OR 37.8, 9.9 to 169.5, P < 0.001). Concomitant BRAF and TERT promoter mutations increased the risk of radioiodine-refractory disease in papillary thyroid carcinoma (OR 21.7, 5.6 to 88.9, P < 0.001). RET rearrangements were associated with a higher count of tumour-affected lymph nodes (OR 7950.9, 233.7 to 270495.7, P < 0.001) but did not influence distant metastasis or radioiodine-refractory disease. CONCLUSIONS Papillary thyroid carcinoma with concomitant BRAF-V600E and TERT promoter mutations demonstrated an aggressive course of disease, suggesting the need for a more extensive surgical strategy. RET rearrangement-positive papillary thyroid carcinoma did not affect the clinical outcome, potentially obviating the need for prophylactic lymphadenectomy.
Collapse
Affiliation(s)
- Julia I Staubitz
- Section of Endocrine Surgery, Department of General, Visceral and Transplantation Surgery, University Medical Centre, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Celine Müller
- Institute of Pathology, University Medical Centre, Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Antonia Heymans
- Institute of Pathology, University Medical Centre, Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Christina Merten
- Institute of Pathology, University Medical Centre, Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Bianca Roos
- Section of Endocrine Surgery, Department of General, Visceral and Transplantation Surgery, University Medical Centre, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Alicia Poplawski
- Institute for Medical Biometry, Epidemiology and Informatics, University Medical Centre Mainz, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Annekathrin Ludt
- Institute for Medical Biometry, Epidemiology and Informatics, University Medical Centre Mainz, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Stephanie Strobl
- Institute of Pathology, University Medical Centre, Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Erik Springer
- Institute of Pathology, University Medical Centre, Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Arno Schad
- Institute of Pathology, University Medical Centre, Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Wilfried Roth
- Institute of Pathology, University Medical Centre, Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Thomas J Musholt
- Section of Endocrine Surgery, Department of General, Visceral and Transplantation Surgery, University Medical Centre, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Nils Hartmann
- Institute of Pathology, University Medical Centre, Johannes Gutenberg-University Mainz, Mainz, Germany
| |
Collapse
|
3
|
Staubitz JI, Musholt TJ. [Current indications and operative strategy for renal hyperparathyroidism]. Chirurgie (Heidelb) 2023:10.1007/s00104-023-01878-x. [PMID: 37140660 DOI: 10.1007/s00104-023-01878-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/05/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND Renal hyperparathyroidism results from pathophysiologic changes induced and maintained by terminal renal failure. Surgical treatment is possible using various resection strategies. AIM OF THE WORK (RESEARCH QUESTION) The aim of this work is to illustrate the indications, techniques and resection strategies for surgical treatment of renal hyperparathyroidism. MATERIAL AND METHODS National and international guidelines regarding the surgical treatment of renal hyperparathyroidism were analyzed. Furthermore, our own practical experience was integrated into the article. RESULTS While the indications for surgery according to the Surgical Working Group Endocrinology (CAEK) guidelines are given in cases of clinical impairment and renal hyperparathyroidism that cannot be controlled by medication, international guidelines additionally refer to the absolute parathyroid hormone level for deciding for surgery. DISCUSSION Individual patient consultation is necessary in the case of renal hyperparathyroidism in order to determine the right time for surgical treatment as well as the most suitable surgical technique, taking into account the individual risk profile and other therapeutic perspectives, including renal transplantation.
Collapse
Affiliation(s)
- Julia I Staubitz
- Sektion Endokrine Chirurgie, Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsmedizin Mainz, Johannes-Gutenberg-Universität Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland
| | - Thomas J Musholt
- Sektion Endokrine Chirurgie, Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsmedizin Mainz, Johannes-Gutenberg-Universität Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland.
| |
Collapse
|
4
|
Kriege M, Hilt JA, Dette F, Wittenmeier E, Meuser R, Staubitz JI, Musholt TJ. Impact of direct laryngoscopy vs. videolaryngoscopy on signal quality of recurrent laryngeal nerve monitoring in thyroid surgery: a randomised parallel group trial. Anaesthesia 2023; 78:55-63. [PMID: 36166515 DOI: 10.1111/anae.15865] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/19/2022] [Indexed: 12/24/2022]
Abstract
In thyroid surgery, intra-operative neuromonitoring signals of the recurrent laryngeal nerve can be detected by surface electrodes on a tracheal tube positioned at the vocal fold level. The incidence of difficult tracheal intubation in patients undergoing thyroidectomy for nodular goitre ranges from 5.3% to 20.5%. The aim of this study was to compare videolaryngoscopy with conventional direct laryngoscopy as methods for proper placement of the surface electrode to prevent insufficient intra-operative nerve signal quality. In this prospective randomised trial, adult patients requiring tracheal intubation during thyroid surgery were randomly allocated to two groups of C-MAC® (Macintosh style blade) videolaryngoscope or direct laryngoscopy using the Macintosh laryngoscope. Primary outcome was the incidence of insufficient signal electromyogram amplitude level (< 500 μV) after successful tracheal intubation. A total of 260 (130 per group) participants were analysed. An insufficient signal was more frequent with direct laryngoscopy (35/130, 27%), compared with C-MAC (12/130, 9%, p < 0.001). First-pass tracheal intubation success rate was lower with direct laryngoscopy (86/130 (66%)) compared with the C-MAC (125/130 (96%)) (p < 0.0001). Cormack and Lehane grade ≥ 3 was observed more frequently with direct laryngoscopy (16/130 (12%)), compared with the C-MAC (0/130, (0%)) (p < 0.0001). The results suggest that videolaryngoscopy has an impact on the quality of the initial intra-operative neuromonitoring signal in patients undergoing thyroid surgery, and this technique can provide optimised surface electrode positioning.
Collapse
Affiliation(s)
- M Kriege
- Department of Anesthesiology, University Medical Centre of the Johannes Gutenberg University Mainz, Germany
| | - J A Hilt
- Department of Anesthesiology, University Medical Centre of the Johannes Gutenberg University Mainz, Germany
| | - F Dette
- Department of Anesthesiology, University Medical Centre of the Johannes Gutenberg University Mainz, Germany
| | - E Wittenmeier
- Department of Anesthesiology, University Medical Centre of the Johannes Gutenberg University Mainz, Germany
| | - R Meuser
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Centre of the Johannes Gutenberg University Mainz, Germany
| | - J I Staubitz
- Section of Endocrine Surgery, Department of General, Visceral and Transplantation Surgery, University Medical Centre of the Johannes Gutenberg University Mainz, Germany
| | - T J Musholt
- Section of Endocrine Surgery, Department of General, Visceral and Transplantation Surgery, University Medical Centre of the Johannes Gutenberg University Mainz, Germany
| |
Collapse
|
5
|
Staubitz JI, Poplawski A, Watzka F, Musholt TJ. Real-world EUROCRINE ® registry data challenge the reliability of Bethesda cytopathology for thyroid surgery indication. Innov Surg Sci 2022; 7:99-106. [PMID: 36561503 PMCID: PMC9742262 DOI: 10.1515/iss-2021-0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 05/19/2021] [Indexed: 12/25/2022] Open
Abstract
Objectives Fine-needle aspiration cytology (FNAC) is recommended by international guidelines for the preoperative evaluation of suspicious thyroid nodules >1 cm. Despite robust evidence from endocrine centers demonstrating the key role of FNAC results for the indication of surgery, the method is not routinely used in European clinics. The database EUROCRINE®, which was introduced in 2015 with the scope of registering operations of the endocrine system, allows for a large-scale analysis of the current service reality in Europe concerning FNAC use and associated accuracy. Methods Operations performed to "exclude malignancy", registered from January 2015 to December 2018 in EUROCRINE®, were analyzed. Parameters of accuracy were calculated for FNAC. FNAC results were considered "test positive" in the case of Bethesda category IV, V, and VI, since these categories usually prompt surgical interventions in European centers for thyroid surgery. Bethesda category II and III were considered "test negative". Results Of 8,791 operations, 5,780 had preoperative FNAC (65.7%). The overall malignancy rate was 28.3% (2,488/8,791). Malignancy rates were 68.8% for Bethesda VI, 69.9% for Bethesda V, 32.6% for Bethesda IV, 28.2% for III, 20.2% for Bethesda II, and 24.5% for Bethesda I. After exclusion of papillary microcarcinomas (PTMCs), the sensitivity of FNAC was 71.7% and specificity 43.5%, the positive predictive value was 29.1% and the negative predictive value 82.7%. Conclusions Although the indication to "exclude malignancy" was the predominant reason that prompted thyroid resection in the present cohort, FNAC was only used in about 65.7% of cases. When performed, FNAC was associated with unexpectedly low accuracy. Interestingly, in Bethesda II, 20.2% of malignant entities were present (13.3% after the exclusion of PTMCs).
Collapse
Affiliation(s)
- Julia I. Staubitz
- Section of Endocrine Surgery, Department of General, Visceral and Transplantation Surgery, University Medical Center Mainz, Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Alicia Poplawski
- Institute for Medical Biometry, Epidemiology and Informatics, University Medical Centre Mainz, Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Felix Watzka
- Section of Endocrine Surgery, Department of General, Visceral and Transplantation Surgery, University Medical Center Mainz, Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Thomas J. Musholt
- Section of Endocrine Surgery, Department of General, Visceral and Transplantation Surgery, University Medical Center Mainz, Johannes Gutenberg-University Mainz, Mainz, Germany
| |
Collapse
|
6
|
Staubitz JI, Clerici T, Riss P, Watzka F, Bergenfelz A, Bareck E, Fendrich V, Goldmann A, Grafen F, Heintz A, Kaderli RM, Karakas E, Kern B, Matter M, Mogl M, Nebiker CA, Niederle B, Obermeier J, Ringger A, Schmid R, Triponez F, Trupka A, Wicke C, Musholt TJ. [EUROCRINE®: adrenal surgery 2015-2019- surprising initial results]. Chirurg 2021; 92:448-463. [PMID: 32945919 PMCID: PMC8081706 DOI: 10.1007/s00104-020-01277-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Hintergrund Seit 2015 erfolgt in Europa mithilfe des EUROCRINE®-Registers eine systematische Dokumentation endokrin-chirurgischer Operationen. Ziel dieser ersten Auswertung war eine Darstellung der Versorgungsrealität für Nebenniereneingriffe in einem homogenen Versorgungsumfeld, entsprechend des deutschsprachigen Raums – bzw. des Präsenzgebiets der Chirurgischen Arbeitsgemeinschaft Endokrinologie (CAEK) der Deutschen Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV) – einschließlich einer Analyse der Adhärenz zu geltenden Therapieempfehlungen. Methodik Es erfolgte eine deskriptive Analyse der präoperativen Diagnostik, der angewandten Operationstechniken sowie der zugrunde liegenden histologischen Entitäten der zwischen den Jahren 2015 und 2019 über EUROCRINE® in Deutschland, Österreich und der Schweiz dokumentierten Nebennierenoperationen. Ergebnisse In den insgesamt 21 teilnehmenden Kliniken des deutschsprachigen EUROCRINE®-Gebiets wurden 658 Operationen an Nebennieren durchgeführt. In 90 % erfolgten unilaterale, in 3 % bilaterale Adrenalektomien und in 7 % andere Resektionsverfahren. Die in 41 % der Operationen dokumentierte histologische Hauptdiagnose war das adrenokortikale Adenom. In 15 % lagen maligne Befunde zugrunde (einschließlich 6 % Nebennierenrindenkarzinome (ACC) und 8 % Nebennierenmetastasen). 23 % der Operationen erfolgten bei Phäochromozytomen. Diese wurden zu 82 % minimal-invasiv operiert, Nebennierenrindenkarzinome lediglich zu 28 % und Nebennierenmetastasen zu 66 %. Schlussfolgerung Überraschenderweise wurden nach Nebennierenadenomen und Phäochromozytomen an dritthäufigster Stelle Nebennierenmetastasen unterschiedlicher Primärtumoren reseziert. 28 % der ACC waren für minimal-invasive Techniken vorgesehen, wobei 20 % dieser Fälle eine Konversion zur offenen Operation erforderten. Die aktuelle Analyse deckte Diskrepanzen zwischen Versorgungsrealität und Leitlinienempfehlungen auf, aus denen sich zahlreiche Fragestellungen ergeben, welche nun in ein überarbeitetes EUROCRINE®-Modul zur Dokumentation von Nebennierenoperationen einfließen werden.
Collapse
Affiliation(s)
- J I Staubitz
- Sektion Endokrine Chirurgie der Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsmedizin Mainz, Langenbeckstraße 1, Mainz, 55131, Deutschland
| | - T Clerici
- Kantonsspital St. Gallen, St. Gallen, Schweiz
| | - P Riss
- Universitätsklinik für Chirurgie, Medizinische Universität Wien, Wien, Österreich
| | - F Watzka
- Sektion Endokrine Chirurgie der Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsmedizin Mainz, Langenbeckstraße 1, Mainz, 55131, Deutschland
| | | | - E Bareck
- Abteilung für Chirurgie, KRAGES Burgenländische Krankenanstalten-Ges.m.b.H., Oberpullendorf, Österreich
| | - V Fendrich
- Klinik für Endokrine Chirurgie, Schön Klinik Hamburg Eilbek, Hamburg, Deutschland
| | - A Goldmann
- Viszeral- und Thoraxchirurgie, Kantonsspital Winterthur, Winterthur, Schweiz
| | - F Grafen
- Chirurgische Klinik, Spital Limmattal, Schlieren, Schweiz
| | - A Heintz
- Allgemein- und Viszeralchirurgie, Katholisches Klinikum Mainz, Mainz, Deutschland
| | - R M Kaderli
- Viszerale Chirurgie, Universitätsspital Bern, Bern, Schweiz
| | - E Karakas
- Klinik für Allgemein‑, Visceral- und Endokrine Chirurgie, Krankenhaus Maria Hilf Krefeld, Krefeld, Deutschland
| | - B Kern
- Viszeralchirurgie, St. Claraspital Basel, Basel, Schweiz
| | - M Matter
- Chirurgie Viscérale, Centre Hospitalier Universitaire Vaudois, Lausanne, Schweiz
| | - M Mogl
- Chirurgische Klinik, Charité Universitätsmedizin Berlin, Berlin, Deutschland
| | - C A Nebiker
- Viszeralchirurgie, Kantonsspital Aarau, Aarau, Schweiz
| | - B Niederle
- Abteilung für Chirurgie, Franziskus Spital Wien, Wien, Österreich
| | - J Obermeier
- Klinik für Chirurgie, Klinikum Dortmund gGmbH, Dortmund, Deutschland
| | - A Ringger
- Chirurgie, Solothurner Spitäler AG, Solothurn, Schweiz
| | - R Schmid
- Viszeralchirurgie, Spitalzentrum Biel, Biel, Schweiz
| | - F Triponez
- Chirurgie thoracique et endocrinienne, Hôpitaux Universitaires Genève, Genève, Schweiz
| | - A Trupka
- Chirurgische Klinik, Klinikum Starnberg, Starnberg, Deutschland
| | - C Wicke
- Kantonsspital Luzern, Luzern, Schweiz
| | - T J Musholt
- Sektion Endokrine Chirurgie der Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsmedizin Mainz, Langenbeckstraße 1, Mainz, 55131, Deutschland.
| |
Collapse
|
7
|
Staubitz JI, Elmrich I, Musholt PB, Cámara RJA, Watzka F, Dralle H, Sekulla C, Lorenz K, Musholt TJ. Targeted use of intraoperative frozen-section analysis lowers the frequency of completion thyroidectomy. BJS Open 2021; 5:6225742. [PMID: 33851986 PMCID: PMC8045471 DOI: 10.1093/bjsopen/zraa058] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 11/30/2020] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND The impact of intraoperative frozen section (iFS) analysis on the frequency of completion thyroidectomy for the management of thyroid carcinoma is controversial. Although specialized endocrine centres have published their respective results, there are insufficient data from primary and secondary healthcare levels. The aim of this study was to analyse the utility of iFS analysis. METHODS In the Prospective Evaluation Study Thyroid Surgery (PETS) 2 study, 22 011 operations for benign and malignant thyroid disease were registered prospectively in 68 European hospitals from 1 July 2010 to 31 December 2012. Group 1 consisted of 569 patients from University Medical Centre (UMC) Mainz, and group 2 comprised 21 442 patients from other PETS 2 participating hospitals. UMC Mainz exercised targeted but liberal use of iFS analysis for suspected malignant nodules. iFS analysis was compared with standard histological examination regarding the correct distinction between benign and malignant disease. The percentage of completion thyroidectomies was assessed for the participating hospitals. RESULTS iFS analysis was performed in 35.70 per cent of patients in group 1 versus 21.80 per cent of those in group 2 (risk ratio (RR) 1.6, 95 per cent c.i. 1.5 to 1.8; P < 0.001). Sensitivity of iFS analysis was 75.0 per cent in group 1 versus 63.50 per cent in group 2 (RR 1.2, 1.2 to 1.3; P = 0.040). Completion surgery was necessary in 8.10 per cent of patients in group 1 versus 20.8 per cent of those in group 2 (RR 0.4, 0.2 to 0.7; P = 0.001). CONCLUSION iFS analysis is a useful tool in determining the appropriate surgical management of thyroid disease. Targeted use of iFS was associated with a significantly higher sensitivity for the detection of malignancy, and with a significantly reduced necessity for completion surgery.
Collapse
Affiliation(s)
- J I Staubitz
- Section of Endocrine Surgery, Department of General, Visceral and Transplantation Surgery, University Medical Centre Mainz, Johannes Gutenberg University Mainz, Mainz, Germany
| | - I Elmrich
- Section of Endocrine Surgery, Department of General, Visceral and Transplantation Surgery, University Medical Centre Mainz, Johannes Gutenberg University Mainz, Mainz, Germany
| | - P B Musholt
- Section of Endocrine Surgery, Department of General, Visceral and Transplantation Surgery, University Medical Centre Mainz, Johannes Gutenberg University Mainz, Mainz, Germany
| | - R J A Cámara
- Institute for Medical Biometry, Epidemiology and Informatics, University Medical Centre Mainz, Johannes Gutenberg University Mainz, Mainz, Germany
| | - F Watzka
- Section of Endocrine Surgery, Department of General, Visceral and Transplantation Surgery, University Medical Centre Mainz, Johannes Gutenberg University Mainz, Mainz, Germany
| | - H Dralle
- Department of General, Visceral and Transplantation Surgery, University Medical Centre Essen, University Duisburg-Essen, Essen, Germany
| | - C Sekulla
- Department of Visceral, Vascular and Endocrine Surgery, University Medical Centre Halle (Saale), Martin Luther University Halle-Wittenberg, Halle, Germany
| | - K Lorenz
- Department of Visceral, Vascular and Endocrine Surgery, University Medical Centre Halle (Saale), Martin Luther University Halle-Wittenberg, Halle, Germany
| | - T J Musholt
- Section of Endocrine Surgery, Department of General, Visceral and Transplantation Surgery, University Medical Centre Mainz, Johannes Gutenberg University Mainz, Mainz, Germany
| | | |
Collapse
|
8
|
Grimminger PP, Staubitz JI, Perez D, Ghadban T, Reeh M, Scognamiglio P, Izbicki JR, Biebl M, Fuchs H, Bruns CJ, Lang H, Becker T, Egberts JH. Multicenter Experience in Robot-Assisted Minimally Invasive Esophagectomy - a Comparison of Hybrid and Totally Robot-Assisted Techniques. J Gastrointest Surg 2021; 25:2463-2469. [PMID: 34145494 PMCID: PMC8523396 DOI: 10.1007/s11605-021-05044-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 05/17/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Oncological esophageal surgery has evolved significantly in the last decades. From open esophagectomy over (hybrid) minimally invasive surgery, nowadays, robot-assisted minimally invasive esophagectomy (RAMIE) approaches are applied. Current techniques require an analysis of possible advantages and disadvantages indicating the direction towards a novel gold standard. METHODS Robot-assisted Ivor Lewis esophagectomies, performed in the period from April 2017 to June 2019 in five German centers (Berlin, Cologne, Hamburg, Kiel, Mainz), were included in this study. Pre-, intra-, and postoperative parameters were assessed. Cases were grouped for hybrid (H-RAMIE) versus totally robot-assisted (T-RAMIE) approaches. Postoperative parameters and complications were compared using risk ratios. RESULTS A total of 175 operations were performed as T-RAMIE and 67 as H-RAMIE. Patient age (median age 62 years) and sex (83.1% male) were similarly distributed in both groups. Median duration of esophagectomy was significantly lower in the T-RAMIE group (385 versus 427 min, p < 0.001). The risks of "overall morbidity" (32.0 versus 47.8%; risk ratio [RR], 95% confidence interval (CI): 1.5, 1.1-2.1; p = 0.026), "anastomotic leak" (10.3 versus 22.4%; RR, CI: 2.2, 1.2-4.1; p = 0.020), and "respiratory failure" (1.1 versus 7.5%; RR, CI: 6.5, 1.3-32.9; p = 0.019) were significantly higher in case of H-RAMIE. CONCLUSIONS In the five participating German centers, T-RAMIE was the preferred procedure (72.3% of operations). In comparison to H-RAMIE, T-RAMIE was associated with a significantly reduced risk of postoperative morbidity, anastomotic leak, and respiratory failure as well as a significantly reduced time necessary for esophagectomy.
Collapse
Affiliation(s)
- Peter P Grimminger
- Department of General, Visceral and Transplantation Surgery, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstrasse 1, D-55131, Mainz, Germany.
| | - Julia I Staubitz
- Department of General, Visceral and Transplantation Surgery, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstrasse 1, D-55131, Mainz, Germany
| | - Daniel Perez
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tarik Ghadban
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Reeh
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Pasquale Scognamiglio
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Biebl
- Department of Surgery, Charité University Hospital, Berlin, Germany
| | - Hans Fuchs
- Department of General, Visceral and Tumor Surgery, University Medical Center Cologne, Cologne, Germany
| | - Christiane J Bruns
- Department of General, Visceral and Tumor Surgery, University Medical Center Cologne, Cologne, Germany
| | - Hauke Lang
- Department of General, Visceral and Transplantation Surgery, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstrasse 1, D-55131, Mainz, Germany
| | - Thomas Becker
- Department for General, Visceral, Thoracic, Transplantation, and Pediatric Surgery, University Hospital Schleswig Holstein, Kiel, Germany
| | - Jan-Hendrik Egberts
- Department for General, Visceral, Thoracic, Transplantation, and Pediatric Surgery, University Hospital Schleswig Holstein, Kiel, Germany
| |
Collapse
|
9
|
Watzka FM, Meyer F, Staubitz JI, Fottner C, Schad A, Lang H, Musholt TJ. Prognostic Assessment of Non-functioning Neuroendocrine Pancreatic Neoplasms as a Basis for Risk-Adapted Resection Strategies. World J Surg 2020; 44:594-603. [PMID: 31605171 DOI: 10.1007/s00268-019-05220-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND In contrast to exocrine pancreatic carcinomas, prognosis and treatment of pancreatic neuroendocrine neoplasms (PNEN) are significantly different. The variable growth pattern and associated clinical situation of functioning and non-functioning PNEN demand an individualized surgical approach. However, due to the scarce evidence associated with the rare disease, guidelines lack detailed recommendations for indication and for the required extent of surgical resection. METHODS In a retrospective single-center study from 1990 to 2018, 239 patients with PNEN were identified. Clinical data were collected in the MaDoc database of the University Medical Center Mainz. A total of 155 non-functional PNEN were selected for further analysis. RESULTS According to the classification of NET by the WHO in 2017, 28.8% (n = 40) of the tumors were G1, 61.9% (n = 86) G2, and 9.4% (n = 13) G3. In 73 patients, hepatic metastases were present. Sixty patients had lymph node metastasis. An R0 resection was achieved in 98 cases, an R1 situation in 10 cases. Five times, a tumor debulking was carried out (R2) and 5 times the operation was aborted without any resection because of the advanced tumor stage. A relapse occurred in 29 patients. Different prognostic factors (grade, tumor size, age) were analyzed. Grade-dependent 10-year overall survival rates were 79.5% (grade 1) and 60.1% (grade 2), respectively. The survival rate of grade 3 patients was limited to 66.7% after 13 months. CONCLUSION In our study, patients with non-functioning PNEN had a longer overall survival after successful R0 resection. The risk analysis confirmed a Ki-67 cutoff value of 5%, which divided a high- and low-risk group. Patients with a PNEC G3 (Ki-67 index > 50%) had a very poor prognosis.
Collapse
Affiliation(s)
- F M Watzka
- Endocrine Surgery, Clinic of General, Visceral- and Transplantation Surgery, University Medical Center University Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - F Meyer
- Endocrine Surgery, Clinic of General, Visceral- and Transplantation Surgery, University Medical Center University Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - J I Staubitz
- Endocrine Surgery, Clinic of General, Visceral- and Transplantation Surgery, University Medical Center University Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - C Fottner
- Endocrinology and Metabolic Diseases, University Medical Center University Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - A Schad
- Institute of Pathology, University Medical Center University Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - H Lang
- Institute of Pathology, University Medical Center University Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - T J Musholt
- Endocrine Surgery, Clinic of General, Visceral- and Transplantation Surgery, University Medical Center University Mainz, Langenbeckstr. 1, 55131, Mainz, Germany.
| |
Collapse
|
10
|
Staubitz JI, Watzka F, Poplawski A, Riss P, Clerici T, Bergenfelz A, Musholt TJ. Effect of intraoperative nerve monitoring on postoperative vocal cord palsy rates after thyroidectomy: European multicentre registry-based study. BJS Open 2020; 4:821-829. [PMID: 32543773 PMCID: PMC7528513 DOI: 10.1002/bjs5.50310] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 05/11/2020] [Indexed: 12/11/2022] Open
Abstract
Background Intraoperative nerve monitoring (IONM) of the recurrent laryngeal nerve (RLN) predicts the risk of vocal cord palsy (VCP). IONM can be used to adapt the surgical strategy in order to prevent bilateral VCP and associated morbidity. Controversial results have been reported in the literature for the effect of IONM on rates of VCP, and large multicentre studies are required for elucidation. Methods Patients undergoing first‐time thyroidectomy for benign thyroid disease between May 2015 and January 2019, documented prospectively in the European registry EUROCRINE®, were included in a cohort study. The influence of IONM and other factors on the development of postoperative VCP was analysed using multivariable regression analysis. Results Of 4598 operations from 82 hospitals, 3542 (77·0 per cent) were performed in female patients. IONM was used in 4182 (91·0 per cent) of 4598 operations, independent of hospital volume. Postoperative VCP was diagnosed in 50 (1·1 per cent) of the 4598 patients. The use of IONM was associated with a lower risk of postoperative VCP in multivariable analysis (odds ratio (OR) 0·34, 95 per cent c.i. 0·16 to 0·73). Damage to the RLN noted during surgery (OR 24·77, 12·91 to 48·07) and thyroiditis (OR 2·03, 1·10 to 3·76) were associated with an increased risk of VCP. Higher hospital volume correlated with a lower rate of VCP (OR 0·05, 0·01 to 0·13). Conclusion Use of IONM was associated with a low rate of postoperative
VCP.
Collapse
Affiliation(s)
- J I Staubitz
- Department of General, Visceral and Transplantation Surgery, Section of Endocrine Surgery, Mainz, Germany
| | - F Watzka
- Department of General, Visceral and Transplantation Surgery, Section of Endocrine Surgery, Mainz, Germany
| | - A Poplawski
- Institute for Medical Biometry, Epidemiology and Informatics, University Medical Centre Mainz, Mainz, Germany
| | - P Riss
- Department of Surgery, Medical University of Vienna, Austria
| | - T Clerici
- Department of General, Visceral,Visceral, Endocrine and Transplantation Surgery, Kantonsspital St Gallen, St Gallen, Switzerland
| | - A Bergenfelz
- Department of Surgery, Skåne University Hospital, Lund, Sweden.,Department of Clinical Sciences, Lund University, Lund, Sweden
| | - T J Musholt
- Department of General, Visceral and Transplantation Surgery, Section of Endocrine Surgery, Mainz, Germany
| | | |
Collapse
|
11
|
Watzka FM, Meyer F, Staubitz JI, Fottner C, Schad A, Lang H, Musholt TJ. Correction to: Prognostic Assessment of Non-functioning Neuroendocrine Pancreatic Neoplasms as a Basis for Risk-Adapted Resection Strategies. World J Surg 2020; 44:1681. [PMID: 32052103 DOI: 10.1007/s00268-020-05418-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
This article contains parts of the doctoral thesis of F. Meyer.
Collapse
Affiliation(s)
- F M Watzka
- Endocrine Surgery, Clinic of General, Visceral- and Transplantation Surgery, University Medical Center University Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - F Meyer
- Endocrine Surgery, Clinic of General, Visceral- and Transplantation Surgery, University Medical Center University Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - J I Staubitz
- Endocrine Surgery, Clinic of General, Visceral- and Transplantation Surgery, University Medical Center University Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - C Fottner
- Endocrinology and Metabolic Diseases, University Medical Center University Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - A Schad
- Institute of Pathology, University Medical Center University Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - H Lang
- Institute of Pathology, University Medical Center University Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - T J Musholt
- Endocrine Surgery, Clinic of General, Visceral- and Transplantation Surgery, University Medical Center University Mainz, Langenbeckstr. 1, 55131, Mainz, Germany.
| |
Collapse
|
12
|
Staubitz JI, Musholt TJ. [Individualization of the surgical procedure in response to overdiagnosis and overtreatment in differentiated thyroid carcinomas]. Pathologe 2020; 40:342-346. [PMID: 31705233 DOI: 10.1007/s00292-019-00699-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Advances in diagnostic methods have led to an early detection of thyroid nodules with debatable malignant potential in numerous cases. This can result in a potential overtreatment of thyroid lesions with very good prognosis. OBJECTIVES To avoid surgical overtreatment, an individualized, risk-adapted management is required that respects the different tumor biology of the underlying histological entities. METHODS The current guidelines of the leading professional societies, the American Thyroid Association (ATA) and the German Association of Endocrine Surgeons (CAEK), were compared and critically studied, to describe risk-adapted, more conservative treatment options for certain types of thyroid neoplasms according to the 2017 WHO definition. RESULTS The German CAEK recommends thyroidectomy as a routine operation in the case of thyroid carcinoma. Exceptions are papillary thyroid microcarcinoma and minimally invasive follicular thyroid carcinoma, which can be treated by lobectomy. The ATA proposes an "active surveillance" for papillary thyroid microcarcinoma and lobectomy in cases of differentiated thyroid carcinoma <4 cm in diameter in the absence of clearly predefined risk factors. CONCLUSIONS The pre- or intraoperative pathological diagnosis of the underlying tumor entity is the key point, which allows for an adaption of the resection strategy for thyroid malignancy. Depending on the type of carcinoma, the current guidelines of international expert societies allow for parenchyma-sparing operations and, according to the ATA, even an "active surveillance."
Collapse
Affiliation(s)
- J I Staubitz
- Sektion Endokrine Chirurgie, Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsmedizin Mainz, Johannes Gutenberg-Universität Mainz, Langenbeckstraße 1, 55131, Mainz, Deutschland
| | - T J Musholt
- Sektion Endokrine Chirurgie, Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsmedizin Mainz, Johannes Gutenberg-Universität Mainz, Langenbeckstraße 1, 55131, Mainz, Deutschland.
| |
Collapse
|
13
|
Abstract
Follicular thyroid carcinoma is the second most prevalent form of differentiated thyroid carcinoma, following papillary thyroid carcinoma. Preoperative diagnosis is hampered by the fact that fine-needle aspiration cytology as well as supplemental molecular analysis cannot unambiguously distinguish between follicular thyroid carcinoma and benign follicular thyroid adenoma. The 2017 WHO classification defines three histological subtypes of follicular thyroid carcinoma: minimally invasive (excellent prognosis), encapsulated angioinvasive, and widely invasive type (higher risk of recurrence and metastatic spread). The fact that definite characterization of follicular neoplasms is predominantly a postoperative histological diagnosis (core criteria: capsular, vascular and adjacent tissue invasion) translates into the challenge for the thyroid surgeon to plan preoperatively for presence of malignancy and, if required, to adapt the surgical strategy according to intraoperative (frozen section) or postoperative histological findings. Until improved tools for pre-/intraoperative diagnosis are available, the malignant potential of a follicular thyroid lesion can be assessed by stratifying the patient according to clinical risk factors (presence of metastases, advanced patient age, tumor size). A stepwise, escalating surgical approach with restricted primary resection (hemithyroidectomy) and completion surgery based on the definite histopathology is another option to solve this dilemma. The currently recommended surgical treatment strategies for FTCs as published by ATA, BTA, CAEK and ESES are discussed. There is consensus that prophylactic lymphadenectomy is not required for FTCs and that hemithyroidectomy is sufficient in low-risk FTCs (capsular invasion only) whereas thyroidectomy with postoperative radioiodine therapy is indicated in high-risk FTCs (angioinvasion; widely invasive FTC).
Collapse
Affiliation(s)
- Julia I Staubitz
- Section of Endocrine Surgery, Department of General, Visceral and Transplantation Surgery, University Medicine Mainz, Langenbeckstraße 1, 55131, Mainz, Germany.
| | - Petra B Musholt
- Section of Endocrine Surgery, Department of General, Visceral and Transplantation Surgery, University Medicine Mainz, Langenbeckstraße 1, 55131, Mainz, Germany.
| | - Thomas J Musholt
- Section of Endocrine Surgery, Department of General, Visceral and Transplantation Surgery, University Medicine Mainz, Langenbeckstraße 1, 55131, Mainz, Germany.
| |
Collapse
|
14
|
Kauff DW, Staubitz JI, Musholt TJ, Lang H. Synchronous Antithyroid Drug-Induced Agranulocytosis and Fournier Gangrene. AACE Clin Case Rep 2018. [DOI: 10.4158/ep171801.cr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|