1
|
Leung T, Ronellenfitsch U, Partsakhashvili J, John E, Sekulla C, Krug S, Rosendahl J, Michl P, Ukkat J, Kleeff J. Postoperative Sigmoidoscopy and Biopsy After Elective Endovascular and Open Aortic Surgery for Preventing Mortality by Colonic Ischemia (PSB-Aorta-CI): Protocol for a Prospective Study. JMIR Res Protoc 2022; 11:e39071. [PMID: 36512391 PMCID: PMC9795394 DOI: 10.2196/39071] [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: 04/27/2022] [Revised: 09/17/2022] [Accepted: 09/24/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Endovascular aortic repair is considered the standard procedure in treating patients diagnosed with pathologies of the abdominal aorta with suitable anatomy. Open surgery remains an option mostly for patients not suitable for endovascular surgery. Colonic ischemia is an important and life-threatening postoperative complication of these procedures. OBJECTIVE The aim of this study is to evaluate the clinical value and safety of performing a planned sigmoidoscopy and biopsy for detection of colonic ischemia in patients undergoing elective aortic surgery. We also aim to develop prediction scores which could identify patients at risk for colonic ischemia and facilitate their timely treatment. METHODS The trial is designed as a prospective study. The decision for aortic surgery and eligibility for these procedures will be ascertained according to current guidelines. Afterward, screening of the patient for the remaining inclusion and exclusion criteria will occur. If eligibility for study inclusion is confirmed, the patient will be informed about the aims of the study and all study-specific procedures (sigmoidoscopy and biopsy) and asked to provide informed consent. RESULTS The primary end point is the proportion of patients diagnosed endoscopically with subclinical and clinically relevant colonic ischemia among all patients undergoing aortic surgery. Patient recruitment started on June 2021. The final patient is expected to be treated by the end of June 2023. Institutional Review Board review has been completed at the University of Halle (Saale; reference #052-2021). CONCLUSIONS this shows that sigmoidoscopy can be performed safely and is effective for the timely diagnosis of colonic ischemia in these patients, this could result in its routine implementation in both elective and emergency settings. TRIAL REGISTRATION German Clinical Trials Register DRKS00025587; https://www.drks.de/drks_web/navigate.do?navigationId =trial.HTML&TRIAL_ID=DRKS00025587. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/39071.
Collapse
Affiliation(s)
| | - Ulrich Ronellenfitsch
- Department of Visceral, Vascular and Endocrine Surgery, Universitätsklinikum Halle, Halle, Germany
| | - Jumber Partsakhashvili
- Department of Visceral, Vascular and Endocrine Surgery, Universitätsklinikum Halle, Halle, Germany
| | - Endres John
- Department of Visceral, Vascular and Endocrine Surgery, Universitätsklinikum Halle, Halle, Germany
| | - Carsten Sekulla
- Department of Visceral, Vascular and Endocrine Surgery, Universitätsklinikum Halle, Halle, Germany
| | - Sebastian Krug
- Department of Gastroenterology, Universitätsklinikum Halle, Halle, Germany
| | - Jonas Rosendahl
- Department of Gastroenterology, Universitätsklinikum Halle, Halle, Germany
| | - Patrick Michl
- Department of Gastroenterology, Universitätsklinikum Halle, Halle, Germany
| | - Jörg Ukkat
- Department of Visceral, Vascular and Endocrine Surgery, Universitätsklinikum Halle, Halle, Germany
| | - Jörg Kleeff
- Department of Visceral, Vascular and Endocrine Surgery, Universitätsklinikum Halle, Halle, Germany
| |
Collapse
|
2
|
Rebelo A, Mammadov M, Partsakhashvili J, Sekulla C, Ronellenfitsch U, Kleeff J, John E, Ukkat J. Acute and chronic mesenteric ischemia: single center analysis of open, endovascular, and hybrid surgery. BMC Surg 2022; 22:56. [PMID: 35152898 PMCID: PMC8842922 DOI: 10.1186/s12893-022-01511-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 02/07/2022] [Indexed: 01/16/2023] Open
Abstract
Abstract
Background
The aim of the study was to analyse the outcome of open surgical, endovascular, and hybrid interventions in the treatment of acute (AMI) and chronic (CMI) mesenteric ischemia.
Methods
Retrospective review of a cohort of mesenteric ischemia patients at a single tertiary referral center from 2015 to 2021. Primary end point was postoperative in-hospital mortality. Secondary end points were the number of bowel resections, duration of the procedure, length of postoperative intensive care treatment, length of hospital stay, revision surgery (number and type), and the nature and severity of postoperative complications according to Dindo-Clavien.
Results
A total of 64 patients, 20 with CMI and 44 with AMI, underwent open, hybrid or endovascular surgery. Bowel resection was performed in 45.5% of the patients with AMI (29.5% small intestine, 2.3% colon and 13.6% both). There was no in-hospital mortality in the CMI cohort as compared to 29.5% in the AMI cohort (p = 0.03), with no differences regarding endovascular and open surgery (29.6 vs 29.4%). Severe postoperative morbidity (Dindo-Clavien ≥ 3) was also significantly more frequent in the AMI group when compared to the CMI group (20 vs 77.3%, p < 0.001). ASA classification and intensive care stay were identified as factors associated with mortality in AMI patients.
Conclusions
Morbidity and in-hospital mortality are low in CMI patients, but substantial in AMI patients. Early diagnosis and open or endovascular treatment may be decisive for the outcome of these patients.
Collapse
|
3
|
Schneider R, Machens A, Sekulla C, Lorenz K, Elwerr M, Dralle H. Superiority of continuous over intermittent intraoperative nerve monitoring in preventing vocal cord palsy. Br J Surg 2021; 108:566-573. [PMID: 34043775 DOI: 10.1002/bjs.11901] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 04/20/2020] [Accepted: 06/14/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Continuous intraoperative nerve stimulation (IONM) with uninterrupted monitoring is likely better than intermittent IONM in preventing vocal cord palsy after thyroid surgery. METHODS This was a comparative study of intermittent versus continuous IONM in patients with benign and malignant thyroid disease treated at a tertiary centre over 10 years. Early postoperative and permanent vocal cord palsy rates were estimated. Multivariable logistic regression analysis was used to quantify the contributions of clinical and histopathological variables to early postoperative and permanent vocal cord palsy. RESULTS A total of 6029 patients were included, of whom 3139 underwent continuous and 2890 intermittent IONM. Based on nerves at risk (5208 versus 5024 nerves), continuous IONM had a 1·7-fold lower early postoperative vocal cord palsy rate than intermittent monitoring (1·5 versus 2·5 per cent). This translated into a 30-fold lower permanent vocal cord palsy rate (0·02 versus 0·6 per cent). In multivariable logistic regression analysis, continuous IONM independently reduced early postoperative vocal cord palsy 1·8-fold (odds ratio (OR) 0·56) and permanent vocal cord palsy 29·4-fold (OR 0·034) compared with intermittent IONM. One permanent vocal cord palsy per 75·0 early vocal cord palsies was observed with continuous IONM, compared with one per 4·2 after intermittent IONM. Early postoperative vocal cord palsies were 17·9-fold less likely to become permanent with continuous than intermittent IONM. CONCLUSION Continuous IONM is superior to intermittent IONM in preventing vocal cord palsy.
Collapse
Affiliation(s)
- R Schneider
- Department of Visceral, Vascular and Endocrine Surgery, University Hospital, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - A Machens
- Department of Visceral, Vascular and Endocrine Surgery, University Hospital, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - C Sekulla
- Department of Visceral, Vascular and Endocrine Surgery, University Hospital, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - K Lorenz
- Department of Visceral, Vascular and Endocrine Surgery, University Hospital, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - M Elwerr
- Department of Visceral, Vascular and Endocrine Surgery, University Hospital, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - H Dralle
- Department of Visceral, Vascular and Endocrine Surgery, University Hospital, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany.,Department of General, Visceral and Transplantation Surgery, Section of Endocrine Surgery, University of Duisburg-Essen, Essen, Germany
| |
Collapse
|
4
|
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
|
5
|
Trojanowicz B, Sekulla C, Dralle H, Hoang-Vu C. Expression of ARE-binding proteins AUF1 and HuR in follicular adenoma and carcinoma of thyroid gland. Neoplasma 2019; 63:371-7. [PMID: 26925783 DOI: 10.4149/305_150819n450] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Both adenylate-uridylate rich elements binding proteins AUF1 and HuR may participate in thyroid carcinoma progression. In this study we investigated the expression of both factors on a protein level with a special focus on follicular adenoma and follicular thyroid carcinoma. By employment of immunofluorescence and western blot on 68 thyroid tissues including 7 goiter, 16 follicular adenoma (4 adenomatous hyperplasia), 19 follicular thyroid carcinomas, 13 papillary thyroid carcinomas and 14 undifferentiated thyroid carcinomas we investigated protein expression of AUF1 and HuR. In addition to previous results we demonstrated that AUF1 and HuR are significantly up-regulated in carcinoma tissues as compared with follicular adenoma or goiter tissues. Furthermore, by evaluation of AUF1 or HuR expression, or combination of both proteins on total tissue lysates, we were able to demonstrate a significant difference between follicular adenoma and follicular thyroid carcinoma. Overexpression of AUF1 and HuR is a common finding observed in thyroid malignancy. Analysis of the tissues obtained by surgical resection as demonstrated in this study is comparable to a fine needle aspiration and in combination with AUF1/HuR immuno-analysis may support the conventional immunohistological investigations. The promising results of this study were performed on relatively small collective, but justify future development of a quick thyroid diagnostic test on larger cohort of the patients, especially for thyroid samples which are inadequate for histological examinations.
Collapse
|
6
|
Schneider R, Randolph G, Dionigi G, Barczynski M, Chiang FY, Wu CW, Musholt T, Uludag M, Makay Ö, Sezer A, Teksöz S, Weber T, Sekulla C, Lorenz K, Özdemir M, Machens A, Dralle H. Prediction of Postoperative Vocal Fold Function After Intraoperative Recovery of Loss of Signal. Laryngoscope 2018; 129:525-531. [DOI: 10.1002/lary.27327] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 05/09/2018] [Accepted: 05/16/2018] [Indexed: 11/10/2022]
Affiliation(s)
- Rick Schneider
- Department of Visceral, Vascular, and Endocrine Surgery; University Hospital of Martin Luther University; Halle (Saale) Germany
| | - Gregory Randolph
- Division of Thyroid and Parathyroid Surgery; Harvard Medical School; Boston Massachusetts U.S.A
| | - Gianlorenzo Dionigi
- Department of Human Pathology in Adulthood and Childhood “G. Barresi”; University Hospital “G. Martino,” University of Messina; Messina Italy
| | - Marcin Barczynski
- Department of Endocrine Surgery, Third Chair of General Surgery; Jagiellonian University Medical College, Faculty of Medicine; Kraków Poland
| | - Feng-Yu Chiang
- Department of Otolaryngology-Head and Neck Surgery; Kaohsiung Medical University; Kaohsiung Taiwan
| | - Che-Wei Wu
- Department of Otolaryngology-Head and Neck Surgery; Kaohsiung Medical University; Kaohsiung Taiwan
| | - Thomas Musholt
- Endocrine Surgery Section, Clinic of General, Visceral and Transplantation Surgery; University Medical Center; Mainz Germany
| | - Mehmet Uludag
- Department of General Surgery, Sisli Hamidiye Etfal Medical Practice and Research Center; University of Health Sciences; Istanbul Turkey
| | - Özer Makay
- Department of General Surgery; Ege University; Izmir Turkey
| | - Atakan Sezer
- Department of General Surgery; Trakya University; Edirne Turkey
| | - Serkan Teksöz
- Department of General Surgery; Cerrahpasa Medical Faculty; Istanbul Turkey
| | - Theresia Weber
- Department of Endocrine Surgery; Catholic Hospital; Mainz Germany
| | - Carsten Sekulla
- Department of Visceral, Vascular, and Endocrine Surgery; University Hospital of Martin Luther University; Halle (Saale) Germany
| | - Kerstin Lorenz
- Department of Visceral, Vascular, and Endocrine Surgery; University Hospital of Martin Luther University; Halle (Saale) Germany
| | - Murat Özdemir
- Department of General Surgery; Ege University; Izmir Turkey
| | - Andreas Machens
- Department of Visceral, Vascular, and Endocrine Surgery; University Hospital of Martin Luther University; Halle (Saale) Germany
| | - Henning Dralle
- Department of General, Visceral, and Transplantation Surgery, Section of Endocrine Surgery; University of Duisburg-Essen; Essen Germany
| |
Collapse
|
7
|
Thomusch O, Sekulla C, Billmann F, Seifert G, Dralle H, Lorenz K. Risk profile analysis and complications after surgery for autoimmune thyroid disease. Br J Surg 2018; 105:677-685. [PMID: 29579336 DOI: 10.1002/bjs.10770] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 07/04/2017] [Accepted: 10/25/2017] [Indexed: 12/27/2022]
Abstract
BACKGROUND Surgical approaches to autoimmune thyroid disease are currently hampered by concerns over postoperative complications. Risk profiles and incidences of postoperative complications have not been investigated systematically, and studies with sufficient power to show valid data have not been performed. METHODS A prospective multicentre European study was conducted between July 2010 and December 2012. Questionnaires were used to collect data prospectively on patients who had surgery for autoimmune thyroid disease and the findings were compared with those of patients undergoing surgery for multinodular goitre. Logistic regression analysis was used to evaluate risk factors for thyroid surgery-specific complications, transient and permanent recurrent laryngeal nerve (RLN) palsy and hypoparathyroidism. RESULTS Data were available for 22 011 patients, of whom 18 955 were eligible for analysis (2488 who had surgery for autoimmune thyroid disease and 16 467 for multinodular goitre). Surgery for multinodular goitre and that for autoimmune thyroid disease did not differ significantly with regard to general complications. With regard to thyroid surgery-specific complications, the rate of temporary and permanent vocal cord palsy ranged from 2·7 to 6·7 per cent (P = 0·623) and from 0·0 to 1·4 per cent (P = 0·600) respectively, whereas the range for temporary and permanent hypoparathyroidism was 12·9 to 20·0 per cent (P < 0·001) and 0·0 to 7·0 per cent (P < 0·001) respectively. In logistic regression analysis of transient and permanent vocal cord palsy, autoimmune thyroid disease was not an independent risk factor. Autoimmune thyroid disease, extent of thyroid resection, number of identified parathyroid glands and no autotransplantation were identified as independent risk factors for both transient and permanent hypoparathyroidism. CONCLUSION Surgery for autoimmune thyroid disease is safe in comparison with surgery for multinodular goitre in terms of general complications and RLN palsy. To avoid the increased risk of postoperative hypoparathyroidism, special attention needs to be paid to the parathyroid glands.
Collapse
Affiliation(s)
- O Thomusch
- Department of General and Visceral Surgery, Albert Ludwig University of Freiburg, Freiburg, Germany
| | - C Sekulla
- Department of General, Vascular and Visceral Surgery, Martin Luther University of Halle-Wittenberg, Halle an der Saale, Germany
| | - F Billmann
- Department of General, Visceral and Transplantation Surgery, University Hospital of Heidelberg, Heidelberg, Germany
| | - G Seifert
- Department of General and Visceral Surgery, Albert Ludwig University of Freiburg, Freiburg, Germany
| | - H Dralle
- Department of General, Vascular and Visceral Surgery, Martin Luther University of Halle-Wittenberg, Halle an der Saale, Germany
| | - K Lorenz
- Department of General, Vascular and Visceral Surgery, Martin Luther University of Halle-Wittenberg, Halle an der Saale, Germany
| |
Collapse
|
8
|
Schneider R, Machens A, Sekulla C, Lorenz K, Weber F, Dralle H. Twenty-year experience of paediatric thyroid surgery using intraoperative nerve monitoring. Br J Surg 2018. [PMID: 29532905 DOI: 10.1002/bjs.10792] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND There are few data on intermittent and continuous intraoperative nerve monitoring (IONM) during thyroidectomy in children. METHODS All children aged 18 years or younger who had standard thyroid operations using intermittent or continuous IONM between January 1998 and December 2016 were included in the study. The impact of age and type of IONM on basal amplitude, latency and complications after thyroidectomy were assessed. RESULTS A total of 504 children were included in the study. With continuous IONM, median basal amplitude and latency increased significantly with age, more on the left side (from 199 to 870 μV, and from 3·88 to 5·75 ms) than on the right (from 340 to 778 μV, and from 2·63 to 3·50 ms). Compared with intermittent IONM with needle electrode, continuous IONM with tube electrode resulted in an increase in median basal amplitude in children aged 13-18 years on both sides (from 675 to 778 μV on the right and from 450 to 870 μV on the left), and a decrease in median latency in all children older than 3 years: in children aged 4-6 years, from 4·20 to 3·00 ms on the right and from 6·10 to 4·63 ms on the left; in children aged 7-12 years, from 4·60 to 3·50 ms and from 6·00 to 5·25 ms respectively; and in children aged 13-18 years, from 4·60 to 3·50 ms and from 6·40 to 5·75 ms. Overall, wound infection, but not bleeding/haematoma or vocal fold palsy, affected younger children more: 3 per cent of children aged 3 years or less; 2 per cent of children aged 4-6 years; and 0 per cent of children aged over 6 years (P = 0·031). With continuous IONM, no wound infection, bleeding/haematoma or permanent vocal fold palsy was noted in any age group. CONCLUSION Continuous IONM measures nerve electrophysiology more accurately than intermittent IONM during thyroidectomy in children.
Collapse
Affiliation(s)
- R Schneider
- Department of General, Visceral and Vascular Surgery, University Hospital, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - A Machens
- Department of General, Visceral and Vascular Surgery, University Hospital, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - C Sekulla
- Department of General, Visceral and Vascular Surgery, University Hospital, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - K Lorenz
- Department of General, Visceral and Vascular Surgery, University Hospital, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - F Weber
- Department of General, Visceral and Transplantation Surgery, Section of Endocrine Surgery, University of Duisburg-Essen, Essen, Germany
| | - H Dralle
- Department of General, Visceral and Vascular Surgery, University Hospital, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany.,Department of General, Visceral and Transplantation Surgery, Section of Endocrine Surgery, University of Duisburg-Essen, Essen, Germany
| |
Collapse
|
9
|
Schneider R, Lorenz K, Sekulla C, Machens A, Nguyen-Thanh P, Dralle H. [Surgical strategy during intended total thyroidectomy after loss of EMG signal on the first side of resection]. Chirurg 2015; 86:154-63. [PMID: 24823999 DOI: 10.1007/s00104-014-2751-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Unambiguous identification of the recurrent laryngeal nerve with detection of nerve dysfunction giving rise to postoperative vocal cord palsy (VCP) is the principal objective of intraoperative neuromonitoring (IONM) in thyroid surgery. Because intraoperative loss of the electromyographic (EMG) signal (LOS) does not result in VCP in one third of patients, controversy surrounds the issue of whether a change in strategy is needed in planned total thyroidectomy after LOS on the first side of resection. PATIENTS AND METHODS This was a retrospective institutional study of 1,049 consecutive patients (2,086 nerves at risk) with intended bilateral thyroid surgery who were operated on between April 2010 and July 2012 with the use of IONM. The rates of temporary and permanent VCP were analyzed on the basis of the IONM results of the first side of resection and the extent of contralateral resection for completion: resection without LOS (group 1); resection with LOS and contralateral thyroidectomy (group 2); resection with LOS and contralateral subtotal resection (group 3); resection with LOS without any contralateral resection (group 4). RESULTS LOS on the first side of resection was noted in 27 patients (2.6 %). All VCPs were unilateral. The rates of temporary and permanent VCP were 2.5 and 0.4 %, respectively, overall; specifically: group 1: 0.5 and 0 %; group 2: 64 and 9.1 %; group 3: 100 and 50 %; group 4: 83 and 8.3 %, respectively. CONCLUSION Because an abnormal intraoperative electromyogram carries an 80 % risk for early postoperative VCP, the initial plan of bilateral surgery needs to be critically reviewed after LOS has occurred on the first side of resection, taking into account the underlying thyroid disease of the patient and surgeon expertise. Since more than 80 % of affected nerves will fully recover after the operation, staged completion thyroidectomy is recommended.
Collapse
Affiliation(s)
- R Schneider
- Universitätsklinik und Poliklinik für Allgemein-, Viszeral- und Gefäßchirurgie, Martin-Luther-Universität, Ernst-Grube-Str. 40, 06120, Halle/Saale, Deutschland,
| | | | | | | | | | | |
Collapse
|
10
|
Schneider R, Randolph G, Dionigi G, Barczyński M, Chiang FY, Triponez F, Vamvakidis K, Brauckhoff K, Musholt TJ, Almquist M, Innaro N, Jimenez-Garcia A, Kraimps JL, Miyauchi A, Wojtczak B, Donatini G, Lombardi D, Müller U, Pezzullo L, Ratia T, Van Slycke S, Nguyen Thanh P, Lorenz K, Sekulla C, Machens A, Dralle H. Prospective study of vocal fold function after loss of the neuromonitoring signal in thyroid surgery: The International Neural Monitoring Study Group's POLT study. Laryngoscope 2015; 126:1260-6. [PMID: 26667156 DOI: 10.1002/lary.25807] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [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: 11/03/2015] [Indexed: 11/09/2022]
Abstract
OBJECTIVES/HYPOTHESIS Intraoperative neuromonitoring identifies recurrent laryngeal nerve (RLN) injury and gives prognostic information regarding postoperative glottic function. Loss of the neuromonitoring signal (LOS) signifies segmental type 1 or global type 2 RLN injury. This study aimed at identifying risk factors for RLN injury and determining vocal fold (VF) function initially and 6 months after definitive LOS. STUDY DESIGN Prospective study encompassing 21 hospitals from 13 countries. METHODS Included in this study were patients with persistent intraoperative LOS. RESULTS At first postoperative laryngoscopy, early VF palsy was present in 94 of all 115 patients with LOS (81.7%): in 53 of 56 patients (94.6%) with type 1 injury and 41 of 59 patients (69.5%) with type 2 injury. In LOS type 1, women outnumbered men >5-fold. Traction produced LOS type 1 in 38 of 56 patients (67.9%) and LOS type 2 in 54 of 59 patients (91.5%). Course of the RLN posterior and/or anterior to the inferior thyroid artery, extralaryngeal branching, or tuberculum of Zuckerkandl did not increase VF palsy rates. Permanent VF palsy rates were also lower (P = .661) after LOS type 2 than after LOS type 1: 6.8% (four of 59 patients) versus 10.7% (six of 56 patients). Intraoperative administration of steroids did not diminish postoperative VF palsy rates. CONCLUSIONS LOS type 1 entails more severe nerve damage than LOS type 2, affecting women disproportionately. Both LOS types, being primarily associated with traction injury, are unaffected by variant neck anatomy in expert hands and unresponsive to steroids. LEVEL OF EVIDENCE 2b Laryngoscope, 126:1260-1266, 2016.
Collapse
Affiliation(s)
- Rick Schneider
- Department of General, Visceral, and Vascular Surgery, University Hospital of Martin Luther University, Halle (Saale), Germany
| | - Gregory Randolph
- Division of Thyroid and Parathyroid Surgery, Harvard Medical School, Boston, Massachusetts, U.S.A
| | | | - Marcin Barczyński
- Department of Endocrine Surgery, 3rd Chair of General Surgery, Jagiellonian University, Krakow, Poland
| | - Feng-Yu Chiang
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University, Kaohsiung City, Taiwan
| | - Frédéric Triponez
- Thoracic and Endocrine Surgery, University Hospitals of Geneva, Geneva, Switzerland
| | | | - Katrin Brauckhoff
- Department of Surgery, Haukeland University Hospital, Bergen, Norway
| | - Thomas J Musholt
- Endocrine Surgery Section, Clinic of General, Visceral, and Transplantation Surgery, University Medical Center, Mainz, Germany
| | - Martin Almquist
- Department of Surgery, Lund University Hospital, Lund, Sweden
| | - Nadia Innaro
- Department of General Surgery, University of Catanzaro, Catanzaro, Italy
| | | | - Jean-Louis Kraimps
- Department of Endocrine Surgery, University Hospital of Poitiers, Poitiers, France
| | | | - Beata Wojtczak
- Department of General, Gastroenterological and Endocrine Surgery, Medical University Wrocław, Wrocław, Poland
| | - Gianluca Donatini
- Department of Endocrine Surgery, University Hospital of Poitiers, Poitiers, France
| | - Davide Lombardi
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Brescia, Brescia, Italy
| | - Uwe Müller
- Department of General, Viszeral and Thoracic Surgery, Bundeswehr Hospital, Berlin, Germany
| | - Luciano Pezzullo
- Thyroid and Parathyroid Surgery Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori, Fondazione G. Pascale, Naples, Italy
| | - Tomas Ratia
- Department of General Surgery, "Principe de Asturias" University Hospital, Madrid, Spain
| | - Sam Van Slycke
- Department of General and Endocrine Surgery, OLV Clinic Aalst, Aalst, Belgium
| | - Phuong Nguyen Thanh
- Department of General, Visceral, and Vascular Surgery, University Hospital of Martin Luther University, Halle (Saale), Germany
| | - Kerstin Lorenz
- Department of General, Visceral, and Vascular Surgery, University Hospital of Martin Luther University, Halle (Saale), Germany
| | - Carsten Sekulla
- Department of General, Visceral, and Vascular Surgery, University Hospital of Martin Luther University, Halle (Saale), Germany
| | - Andreas Machens
- Department of General, Visceral, and Vascular Surgery, University Hospital of Martin Luther University, Halle (Saale), Germany
| | - Henning Dralle
- Department of General, Visceral, and Vascular Surgery, University Hospital of Martin Luther University, Halle (Saale), Germany
| |
Collapse
|
11
|
Schneider R, Sekulla C, Machens A, Lorenz K, Nguyen Thanh P, Dralle H. Postoperative vocal fold palsy in patients undergoing thyroid surgery with continuous or intermittent nerve monitoring. Br J Surg 2015; 102:1380-7. [DOI: 10.1002/bjs.9889] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 03/24/2015] [Accepted: 06/02/2015] [Indexed: 11/11/2022]
Abstract
Abstract
Background
Continuous monitoring of electromyographic (EMG) amplitudes of the vocal muscles detects impending injury of the recurrent laryngeal nerve (RLN) during thyroid operations earlier than intermittent EMG monitoring. This may alert the surgeon to stop a manoeuvre causing stretching or pressure on the RLN, with better recovery of nerve function.
Methods
Patients with intact preoperative RLN function who underwent thyroid surgery for benign disease between January 2011 and September 2014 under continuous intraoperative nerve monitoring (CIONM) or intermittent intraoperative nerve monitoring (IIONM) were included in this observational study conducted at a tertiary surgical centre. For CIONM, combined EMG events indicative of imminent nerve injury were defined as an EMG amplitude decrease of 50 per cent or more and a latency increase of 10 per cent relative to baseline values. The rates of early and permanent palsy for the two groups of patients were compared.
Results
There were 1526 patients, 788 of whom (1314 nerves at risk) underwent thyroid surgery using CIONM and 738 (965 nerves at risk) had IIONM. With the use of CIONM, 63 (82 per cent) of 77 combined events were reversible during the operation. No permanent vocal fold palsy occurred with CIONM, whereas four unilateral permanent vocal fold palsies (0·4 per cent) were diagnosed after IIONM (P = 0·019).
Conclusion
Operation with CIONM resulted in fewer permanent vocal fold palsies compared with IIONM after thyroid surgery in patients with benign disease.
Collapse
Affiliation(s)
- R Schneider
- Department of General, Visceral and Vascular Surgery, Martin Luther University Halle-Wittenberg, Ernst-Grube-Strasse 40, D-06120, Halle (Saale), Germany
| | - C Sekulla
- Department of General, Visceral and Vascular Surgery, Martin Luther University Halle-Wittenberg, Ernst-Grube-Strasse 40, D-06120, Halle (Saale), Germany
| | - A Machens
- Department of General, Visceral and Vascular Surgery, Martin Luther University Halle-Wittenberg, Ernst-Grube-Strasse 40, D-06120, Halle (Saale), Germany
| | - K Lorenz
- Department of General, Visceral and Vascular Surgery, Martin Luther University Halle-Wittenberg, Ernst-Grube-Strasse 40, D-06120, Halle (Saale), Germany
| | - P Nguyen Thanh
- Department of General, Visceral and Vascular Surgery, Martin Luther University Halle-Wittenberg, Ernst-Grube-Strasse 40, D-06120, Halle (Saale), Germany
| | - H Dralle
- Department of General, Visceral and Vascular Surgery, Martin Luther University Halle-Wittenberg, Ernst-Grube-Strasse 40, D-06120, Halle (Saale), Germany
| |
Collapse
|
12
|
Schneider R, Sekulla C, Machens A, Lorenz K, Thanh PN, Dralle H. Dynamics of loss and recovery of the nerve monitoring signal during thyroidectomy predict early postoperative vocal fold function. Head Neck 2015; 38 Suppl 1:E1144-51. [DOI: 10.1002/hed.24175] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Revised: 03/29/2015] [Accepted: 06/13/2015] [Indexed: 12/27/2022] Open
Affiliation(s)
- Rick Schneider
- Department of General; Visceral, and Vascular Surgery, Martin Luther University Halle-Wittenberg; Halle (Saale) Germany
| | - Carsten Sekulla
- Department of General; Visceral, and Vascular Surgery, Martin Luther University Halle-Wittenberg; Halle (Saale) Germany
| | - Andreas Machens
- Department of General; Visceral, and Vascular Surgery, Martin Luther University Halle-Wittenberg; Halle (Saale) Germany
| | - Kerstin Lorenz
- Department of General; Visceral, and Vascular Surgery, Martin Luther University Halle-Wittenberg; Halle (Saale) Germany
| | - Phuong Nguyen Thanh
- Department of General; Visceral, and Vascular Surgery, Martin Luther University Halle-Wittenberg; Halle (Saale) Germany
| | - Henning Dralle
- Department of General; Visceral, and Vascular Surgery, Martin Luther University Halle-Wittenberg; Halle (Saale) Germany
| |
Collapse
|
13
|
Kachel P, Trojanowicz B, Sekulla C, Prenzel H, Dralle H, Hoang-Vu C. Phosphorylation of pyruvate kinase M2 and lactate dehydrogenase A by fibroblast growth factor receptor 1 in benign and malignant thyroid tissue. BMC Cancer 2015; 15:140. [PMID: 25880801 PMCID: PMC4393606 DOI: 10.1186/s12885-015-1135-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Accepted: 02/24/2015] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Lactate dehydrogenase A (LDHA) and Pyruvate Kinase M2 (PKM2) are important enzymes of glycolysis. Both of them can be phosphorylated and therefore regulated by Fibroblast growth factor receptor 1 (FGFR1). While phosphorylation of LDHA at tyrosine10 leads to tetramerization and activation, phosphorylation of PKM2 at tyrosine105 promotes dimerization and inactivation. Dimeric PKM2 is found in the nucleus and regulates gene transcription. Up-regulation and phosphorylation of LDHA and PKM2 contribute to faster proliferation under hypoxic conditions and promote the Warburg effect. METHODS Using western blot and SYBR Green Real time PCR we investigated 77 thyroid tissues including 19 goiter tissues, 11 follicular adenomas, 16 follicular carcinomas, 15 papillary thyroid carcinomas, and 16 undifferentiated thyroid carcinomas for total expression of PKM2, LDHA and FGFR1. Additionally, phosphorylation status of PKM2 and LDHA was analysed. Inhibition of FGFR was performed on FTC133 cells with SU-5402 and Dovitinib. RESULTS All examined thyroid cancer subtypes overexpressed PKM2 as compared to goiter. LDHA was overexpressed in follicular and papillary thyroid cancer as compared to goiter. Elevated phosphorylation of LDHA and PKM2 was detectable in all analysed cancer subtypes. The highest relative phosphorylation levels of PKM2 and LDHA compared to overall expression were found in undifferentiated thyroid cancer. Inhibition of FGFR led to significantly decreased phosphorylation levels of PKM2 and LDHA. CONCLUSIONS Our data shows that overexpression and increased phosphorylation of PKM2 and LHDA is a common finding in thyroid malignancies. Phospho-PKM2 and Phospho-LDHA could be valuable tumour markers for thyroglobulin negative thyroid cancer.
Collapse
Affiliation(s)
- Paul Kachel
- Department of General, Visceral and Vascular Surgery, Faculty of Medicine, Martin-Luther-University of Halle-Wittenberg, Halle/Saale, Germany.
| | - Bogusz Trojanowicz
- Department of Internal Medicine II, Faculty of Medicine, Martin-Luther-University of Halle-Wittenberg, Halle/Saale, Germany.
| | - Carsten Sekulla
- Department of General, Visceral and Vascular Surgery, Faculty of Medicine, Martin-Luther-University of Halle-Wittenberg, Halle/Saale, Germany.
| | - Hanna Prenzel
- Department of General, Visceral and Vascular Surgery, Faculty of Medicine, Martin-Luther-University of Halle-Wittenberg, Halle/Saale, Germany.
| | - Henning Dralle
- Department of General, Visceral and Vascular Surgery, Faculty of Medicine, Martin-Luther-University of Halle-Wittenberg, Halle/Saale, Germany.
| | - Cuong Hoang-Vu
- Department of General, Visceral and Vascular Surgery, Faculty of Medicine, Martin-Luther-University of Halle-Wittenberg, Halle/Saale, Germany.
| |
Collapse
|
14
|
|
15
|
Brauckhoff M, Machens A, Sekulla C, Lorenz K, Dralle H. Reply to letter: "Limits of neuromonitoring in thyroid surgery": vagus nerve stimulation for diagnosis of a nonrecurrent laryngeal nerve. Ann Surg 2013; 258:e3. [PMID: 23728283 DOI: 10.1097/sla.0b013e3182984995] [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: 11/25/2022]
|
16
|
Machens A, Lorenz K, Sekulla C, Höppner W, Frank-Raue K, Raue F, Dralle H. Molecular epidemiology of multiple endocrine neoplasia 2: implications for RET screening in the new millenium. Eur J Endocrinol 2013; 168:307-14. [PMID: 23211574 DOI: 10.1530/eje-12-0919] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Twenty years ago, the groundbreaking discovery that rearranged during transfection (RET) mutations underlie multiple endocrine neoplasia 2 (MEN2) and familial medullary thyroid cancer (FMTC) ushered in the era of personalized medicine. MEN2-associated signs, taking time to manifest, can be subtle. This study sought to clarify to what extent conventional estimates of 1:200 000-500 000 underestimate the incidence of RET mutations in the population. DESIGN Included in this retrospective investigation were 333 RET carriers born between 1951 and 2000 and operated on at the largest German surgical referral center (286 carriers) or elsewhere (47 carriers). METHODS To estimate the incidence of RET mutations, the number of RET carriers born in Germany in five decades (1951-1960, 1961-1970, 1971-1980, 1981-1990, and 1991-2000) was divided by the corresponding number of German live births. RESULTS Owing to improved diagnosis and capture of FMTC and MEN2 patients, minimum incidence estimates increased over time: overall from 5.0 (1951-1960) to 9.9 (1991-2000) per million live births and year (P=0.008), and by American Thyroid Association/ATA class from 1.7 to 3.7 for ATA class C (P=0.008); from 1.8 to 2.7 for ATA class A (P=0.017); from 1.5 to 2.2 for ATA class B (P=0.20); and from 0 to 1.4 for ATA class D mutations per million live births and year (P=0.008). Based on 1991-2000 incidence estimates the prevalence in Germany is ∼1:80 000 inhabitants. CONCLUSIONS The molecular minimum incidence estimate of ≈1:100 000 was two- to fivefold greater than conventional estimates of 1:200 000-500 000.
Collapse
Affiliation(s)
- Andreas Machens
- Department of General, Visceral and Vascular Surgery, Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Straße 40, D-06097 Halle (Saale), Germany.
| | | | | | | | | | | | | |
Collapse
|
17
|
Schneider R, Randolph GW, Sekulla C, Phelan E, Thanh PN, Bucher M, Machens A, Dralle H, Lorenz K. Continuous intraoperative vagus nerve stimulation for identification of imminent recurrent laryngeal nerve injury. Head Neck 2012; 35:1591-8. [PMID: 23169450 DOI: 10.1002/hed.23187] [Citation(s) in RCA: 131] [Impact Index Per Article: 10.9] [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: 09/12/2012] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Conventional intraoperative nerve monitoring, predicated on intermittent stimulation, can predict recurrent laryngeal nerve (RLN) palsy only after the damage has been done. METHODS Fifty-two patients (52 nerves at risk) who underwent continuous intraoperative nerve monitoring (CIONM) for thyroid surgery via vagus nerve stimulation had their electromyographic (EMG) tracings recorded and correlated with surgical maneuvers and postoperative RLN function. RESULTS There was 1 imminent loss of signal (LOS) with intraoperative signal recovery and there were 4 losses of signal with corresponding unilateral transient RLN palsy. When EMG amplitude decreased >50% and EMG latency increased >10%, LOS and postoperative RLN palsy were noted in 4 of 8 patients (50%) who had multiple combined events. In 9 of 13 patients (70%) who developed adverse EMG changes, modification of the causative surgical maneuver resulted in recovery of those EMG changes and aversion of impending RLN palsy. CONCLUSION CIONM reliably signaled impending nerve injury, enabling immediate corrective action.
Collapse
Affiliation(s)
- Rick Schneider
- Department of General, Visceral, and Vascular Surgery, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Schneider R, Ukkat J, Nguyen-Thanh P, Lorenz K, Plontke S, Behrmann C, Sekulla C, Dralle H. [Endocrine surgery for neck paraganglioma: operation, radiation therapy or wait and scan?]. Chirurg 2012; 83:1060-7. [PMID: 22802215 DOI: 10.1007/s00104-012-2326-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Head and neck paraganglioma (HNP) represent rare endocrine tumors. Therapy is decided on genetic findings, tumor characteristics (e.g. tumor size, localization and dignity), age of patient and symptoms. In terms of local control radiation therapy is as equally effective as surgery but surgical morbidity rates secondary to cranial nerve injuries remain high. PATIENTS Based on 6 patients with 11 solitary (4 patients) and multiple (2 patients) HNP (8 carotid body tumors, 1 vagal, 1 jugular and 1 jugulotympanic paraganglioma) the specific characteristics of the need for surgery as well as correct choice of treatment in cases of sporadic succinate dehydrogenase (SDH) negative and hereditary SDH positive HNP will be exemplarily demonstrated. RESULTS A total of 6 carotid body tumors (four sporadic, two hereditary) were resected in 4 patients, five as primary surgery and one as a revision procedure. In one case a preoperative embolization was performed 24 h before surgery. Malignancy could not be proven in any patient. The 30-day mortality was zero. In the patient with bilateral hereditary carotid body tumors, unilateral local recurrent disease occurred. After resection of the recurrent tumor permanent unilateral paralysis of the laryngeal nerve, glossopharyngeal nerve and hypoglossal nerve occurred. All patients were followed-up postoperatively for a mean of 64 months (range 23-78 months) with a local tumor control rate of 100%. The overall survival rate after 5 years was 100%. CONCLUSIONS Given a very strict indication with awareness of surgical risks selective surgery has a key position with low postoperative morbidity in the treatment of HNPs. We prefer surgery for small unilateral paraganglioma, malignant or functioning tumors.
Collapse
Affiliation(s)
- R Schneider
- Universitätsklinik und Poliklinik für Allgemein-, Viszeral- und Gefässchirurgie, Martin-Luther-Universität, Ernst-Grube-Str. 40, 06120, Halle/Saale, Deutschland.
| | | | | | | | | | | | | | | |
Collapse
|
19
|
Dralle H, Sekulla C, Lorenz K, Thanh PN, Schneider R, Machens A. Loss of the nerve monitoring signal during bilateral thyroid surgery. Br J Surg 2012; 99:1089-95. [DOI: 10.1002/bjs.8831] [Citation(s) in RCA: 110] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2012] [Indexed: 11/10/2022]
Abstract
Abstract
Background
This study aimed to assess current use of recurrent laryngeal nerve monitoring (RLNM) for bilateral thyroid surgery in Germany. It explored the willingness of surgeons to change strategy after loss of signal (LOS) on the first side of resection.
Methods
Surgical departments in Germany equipped with nerve monitors were asked to complete a structured questionnaire, specifying the number of thyroidectomies done in 2010, and the frequencies of RLNM, vagal stimulation, and electromyographic (EMG) recording before and after thyroidectomy. They were also asked about the surgical plan for bilateral goitre after LOS on the first side of resection.
Results
Based on manufacturers' sales data, 1119 (89·1 per cent) of 1256 surgical departments in Germany were equipped with nerve monitors in 2010. A total of 595 departments (53·2 per cent), accounting for approximately 75 per cent of all thyroidectomies in Germany during that year, returned a completed questionnaire. RLNM was used in 91·7–93·5 per cent of thyroidectomies, with the addition of routine vagal stimulation in 49·3 per cent before, and 73·8 per cent after resection. EMG responses to vagal stimulation were recorded in 54·8 per cent before, and 72·5 per cent after resection. Some 93·5 per cent of surgeons changed the resection plan for the other side in bilateral thyroid surgery after LOS had occurred on the first side.
Conclusion
RLNM is now the standard of care during thyroidectomy in Germany. After LOS on the first side of resection in bilateral goitre, more than 90 per cent of respondents declared their willingness to change the resection plan for the contralateral side to avoid the risk of bilateral recurrent laryngeal nerve palsy.
Collapse
Affiliation(s)
- H Dralle
- Department of General, Visceral and Vascular Surgery, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - C Sekulla
- Department of General, Visceral and Vascular Surgery, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - K Lorenz
- Department of General, Visceral and Vascular Surgery, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - P Nguyen Thanh
- Department of General, Visceral and Vascular Surgery, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - R Schneider
- Department of General, Visceral and Vascular Surgery, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - A Machens
- Department of General, Visceral and Vascular Surgery, Martin Luther University Halle-Wittenberg, Halle, Germany
| |
Collapse
|
20
|
Abstract
Conservative management of renal hyperparathyroidism has changed recently. Innovative substances, especially the advent of calcimimetics, have influenced the therapeutic concept. Consequently, a decline in surgical frequency for renal hyperparathyroidism has been reported. In this context it is now mandatory to evaluate the role of surgery, the surgical strategy and procedures for renal hyperparathyroidism anew. Based on a review of the literature the current position of surgical indications and care for renal hyperparathyroidism as well as possible influences of innovative medical treatment are highlighted. In summary, the timing and indications for surgery have been influenced, however, surgery still remains the only permanently effective treatment option for renal hyperparathyroidism.
Collapse
Affiliation(s)
- K Lorenz
- Martin-Luther Universität Halle-Wittenberg, Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Halle / Saale, Deutschland
| | - C Sekulla
- Martin-Luther Universität Halle-Wittenberg, Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Halle / Saale, Deutschland
| | - H Dralle
- Martin-Luther Universität Halle-Wittenberg, Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Halle / Saale, Deutschland
| |
Collapse
|
21
|
Brauckhoff M, Machens A, Thanh PN, Lorenz K, Schmeil A, Stratmann M, Sekulla C, Brauckhoff K, Dralle H. Impact of extent of resection for thyroid cancer invading the aerodigestive tract on surgical morbidity, local recurrence, and cancer-specific survival. Surgery 2010; 148:1257-66. [DOI: 10.1016/j.surg.2010.09.011] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2010] [Accepted: 09/14/2010] [Indexed: 11/29/2022]
|
22
|
Trocchi P, Kluttig A, Sekulla C, Dralle H, Stang A. Chirurgische Versorgung von Patienten mit malignen Schilddrüsentumoren (ICD-10: C73). Eine deutschlandweite Analyse von Krankenhaus- und Krebsregisterdaten. Gesundheitswesen 2010. [DOI: 10.1055/s-0030-1266695] [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: 10/19/2022]
|
23
|
Trojanowicz B, Sekulla C, Lorenz K, Köhrle J, Finke R, Dralle H, Hoang-Vu C. Proteomic approach reveals novel targets for retinoic acid-mediated therapy of thyroid carcinoma. Mol Cell Endocrinol 2010; 325:110-7. [PMID: 20538039 DOI: 10.1016/j.mce.2010.05.022] [Citation(s) in RCA: 21] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2010] [Revised: 05/31/2010] [Accepted: 05/31/2010] [Indexed: 11/20/2022]
Abstract
Our previous studies demonstrated that retinoic acid (RA)-induced reduction of both, the key glycolytic enzyme ENO1 and proliferation-promoting c-Myc, resulted in decreased vitality and invasiveness of the follicular thyroid carcinoma cell lines FTC-133 and FTC-238. By employing two-dimensional electrophoresis and mass spectrometry, we identified proteins affected by RA treatment. In addition to previously reported decrease in ENO1 expression, we found that RA led to significantly reduced levels of glyceraldehyde-3-phosphate dehydrogenase (GAPDH), pyruvate kinase isoenzymes M1/M2 (PKM1/M2), peptidyl-prolyl cis-trans isomerase A (PPIA), transketolase (TKT), annexin A2 (ANXA2), glutathione S-transferase P (GSTP1) and peroxiredoxin 2 (PRDX2) as compared to untreated control. The same proteins investigated on thyroid tissues were found to be significantly up-regulated in follicular, papillary and undifferentiated thyroid carcinomas when compared with goiter and adenoma tissues. These findings identify new target proteins for RA-mediated anti-tumor and re-differentiation therapies and provide novel insights into treatments for thyroid carcinoma.
Collapse
Affiliation(s)
- Bogusz Trojanowicz
- Universitätsklinik und Poliklinik für Allgemein-, Viszeral- und Gefässchirurgie, Martin-Luther Universität, 06097 Halle, Germany
| | | | | | | | | | | | | |
Collapse
|
24
|
Machens A, Hoffmann F, Sekulla C, Dralle H. Importance of gender-specific calcitonin thresholds in screening for occult sporadic medullary thyroid cancer. Endocr Relat Cancer 2009; 16:1291-8. [PMID: 19726541 DOI: 10.1677/erc-09-0136] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Men and women differ in thyroidal C-cell mass and calcitonin secretion. This difference may have implications for the definition of calcitonin thresholds to distinguish sporadic C-cell hyperplasia from occult medullary thyroid cancer. This retrospective study examined the hypothesis that gender-specific calcitonin thresholds predict occult medullary thyroid cancer more accurately among patients with increased basal calcitonin levels than unisex thresholds. A total of 100 consecutive patients were evaluated with occult sporadic C-cell disease no larger than 10 mm who were referred for increased basal calcitonin levels and underwent pentagastrin stimulation preoperatively at this institution. Altogether, gender-specific calcitonin thresholds predicted medullary thyroid cancer better than unisex thresholds. At lower (<or=50 pg/ml basally; <or=500 pg/ml after stimulation), but not higher, calcitonin serum levels, women revealed medullary thyroid cancer four to eight times more often than men. Most discriminatory between C-cell hyperplasia and medullary thyroid cancer was a basal calcitonin threshold of 15 pg/ml (corrected 20 pg/ml) for women and 80 pg/ml (corrected 100 pg/ml) for men, based on the greatest accuracy at the lowest possible calcitonin level. The respective gender-specific stimulated peak calcitonin thresholds were 80 pg/ml (corrected 100 pg/ml) and 500 pg/ml. Corresponding positive predictive values for medullary thyroid cancer at these calcitonin thresholds were 89 and 90% for women, as opposed to 100% for men. To increase the positive predictive value for women to 100%, the respective calcitonin thresholds would have to be raised to 40 pg/ml (corrected 50 pg/ml) and 250 pg/ml. These findings indicate that gender-specific calcitonin thresholds predict sporadic occult medullary thyroid cancer better than unisex thresholds.
Collapse
Affiliation(s)
- Andreas Machens
- Department of General, Visceral and Vascular Surgery, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany.
| | | | | | | |
Collapse
|
25
|
Abstract
AUF1/heterogeneous nuclear ribonucleoprotein D is an adenylate-uridylate-rich elements (AREs) -binding protein, which regulates the mRNA stability of many genes related to growth regulation, such as proto-oncogenes, growth factors, cytokines, and cell cycle-regulatory genes. Several studies demonstrated AUF1 involvement in the processes of apoptosis, tumorigenesis, and development by its interactions with ARE-bearing mRNAs. We report here that AUF1 may be involved in thyroid carcinoma progression. Investigations on thyroid tissues revealed that cytoplasmic expression of AUF1 in malignant tissues was increased when compared with benign thyroid tissues. In thyroid carcinoma cell lines, AUF1 was mostly detectable in the nucleus; however, in dividing cells, its increased production was also observed in the cytoplasm. We found AUF1 in complexes with ARE-bearing mRNAs, previously described to be crucial for proliferation and cell cycle of thyroid carcinoma. Total or exon-selective knockdown of AUF1 led to growth inhibition accompanied by induction of cell cycle inhibitors and decreased levels of cell cycle promoters. Our data demonstrate the existence of a complex network between AUF1 and mRNAs encoding proteins related to cell proliferation. AUF1 may control the balance between stabilizing and destabilizing effects, both of which are exerted on cell cycle machinery in thyroid carcinoma. Although we cannot exclude participation of other factors, thyroid carcinoma may recruit cytoplasmic AUF1 to disturb the stability of mRNAs encoding cyclin-dependent kinase inhibitors, leading to uncontrolled growth and progression of tumor cells. Thus, AUF1 may be considered as a new, additional marker for thyroid carcinoma.
Collapse
Affiliation(s)
- Bogusz Trojanowicz
- AG Experimentelle and Chirurgische Onkologie, Universitätsklinik und Poliklinik für Allgemein-, Viszeral- und Gefässchirurgie, Martin-Luther Universität, Magdeburger Strasse 18, 06097 Halle/S, Germany
| | | | | | | | | | | | | |
Collapse
|
26
|
Trojanowicz B, Winkler A, Hammje K, Chen Z, Sekulla C, Glanz D, Schmutzler C, Mentrup B, Hombach-Klonisch S, Klonisch T, Finke R, Köhrle J, Dralle H, Hoang-Vu C. Retinoic acid-mediated down-regulation of ENO1/MBP-1 gene products caused decreased invasiveness of the follicular thyroid carcinoma cell lines. J Mol Endocrinol 2009; 42:249-60. [PMID: 19060179 DOI: 10.1677/jme-08-0118] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Retinoic acid (RA) acts as an anti-proliferative and redifferentiation agent in the therapy of thyroid carcinoma. Our previous studies demonstrated that pretreatment of follicular thyroid carcinoma cell lines FTC-133 and FTC-238 resulted in decreased in vitro proliferation rates and reduced tumor cell growth of xenotransplants. In addition to the previous results, we found that RA led to decreased vitality and invasiveness of FTC-133 and FTC-238 cells as they reacted with reduction of intracellular ATP levels and number of migrated cells respectively. However, the molecular mechanisms by which RA mediates these effects are not well understood. Two-dimensional (2D) screening of the proteins related to ATP metabolism and western blot analysis revealed alpha-enolase (ENO1) to be down-regulated in FTC-133 and FTC-238 cells after RA treatment. 2D gel detection and mass spectrometric analysis revealed that ENO1 existed as three separate protein spots of distinct pIs (ENO1-A1-A3). Comparative 2D difference gel electrophoresis analysis of fluorescently labeled protein samples of RA-treated and untreated FTC-133 demonstrated a selective down-regulation of ENO1-A1 which we identified as a phosphoprotein. RA caused the dephosphorylation of ENO1-A1. Both, RA-mediated and specific knock-down of ENO1/MBP-1 resulted in the reduction of MYC oncoprotein, and simultaneously decreased proliferation rates of FTC-133 and FTC-238 cell lines. In summary, the RA-mediated down-regulation of the ENO1 gene products and MYC oncoprotein provides a novel molecular mechanism facilitating the anti-proliferative effect of RA in human thyroid carcinoma cells and suggests new pathways for supportive RA therapies.
Collapse
Affiliation(s)
- Bogusz Trojanowicz
- AG Experimentelle & Chirurgische Onkologie, Universitätsklinik und Poliklinik für Allgemein-, Viszeral- und Gefässchirurgie, Martin-Luther Universität, Halle/S., Germany
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Brauckhoff M, Machens A, Hess S, Lorenz K, Gimm O, Brauckhoff K, Sekulla C, Dralle H. Premonitory symptoms preceding metastatic medullary thyroid cancer in MEN 2B: An exploratory analysis. Surgery 2008; 144:1044-50; discussion 1050-3. [PMID: 19041016 DOI: 10.1016/j.surg.2008.08.028] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2008] [Accepted: 08/15/2008] [Indexed: 11/25/2022]
Abstract
BACKGROUND More than 90% of M918T carriers with multiple endocrine neoplasia type 2B (MEN 2B) harbor de novo mutations in the REarranged during Transfection (RET) protooncogene. DNA-based screening for RET germline mutations is rarely useful for early diagnosis, which thus is contingent on the clinical ascertainment of MEN 2B-specific symptoms as soon as they emerge. Little information exists about the presence of these symptoms in infancy. METHODS Detailed information was gathered regarding the development of MEN 2B-associated symptoms from the parents of 25 M918T RET carriers and 50 age- and sex-matched controls with the use of a disease-specific questionnaire. RESULTS Until the end of the study, at a median age of 16.2 (range, 0.5-34.9 years), all 25 M918T RET carriers had developed medullary thyroid cancer. By that time, 96%, 91%, 71%, 75%, and 28% of carriers displayed oral manifestations, ocular abnormalities, intestinal symptoms, musculoskeletal malformations, and pheochromocytoma, respectively. During the first year of life, fewer than 20% of carriers were found to express the typical MEN 2B phenotype, whereas 86% and 61% of these children, but none of the controls, were noted for their inability to cry tears and for constipation. CONCLUSION Because the classic MEN 2B phenotype is rare during the first year of life, more emphasis should be placed on the more subtle features of the syndrome. Additional studies are needed to validate the usefulness of the symptoms "inability to cry" and "constipation" for earlier diagnosis of MEN 2B.
Collapse
Affiliation(s)
- Michael Brauckhoff
- Department of General, Visceral and Vascular Surgery, Martin-Luther-University, Halle-Wittenberg, Germany.
| | | | | | | | | | | | | | | |
Collapse
|
28
|
Brauckhoff M, Stock K, Stock S, Lorenz K, Sekulla C, Brauckhoff K, Thanh PN, Gimm O, Spielmann RP, Dralle H. Limitations of intraoperative adrenal remnant volume measurement in patients undergoing subtotal adrenalectomy. World J Surg 2008; 32:863-72. [PMID: 18224482 DOI: 10.1007/s00268-007-9402-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [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: 11/26/2022]
Abstract
BACKGROUND Recent studies have shown that a minimum of approximately one-third of one normal adrenal gland is required for sufficient adrenocortical stress capacity. Correlation between intraoperative measurement, determination of remnant size by computed tomography (CT), and adrenocortical stress capacity has not been examined so far. METHODS Twenty-two patients with familial pheochromocytoma (n=13), sporadic pheochromocytoma (n=3), and adrenocortical tumors (n=6) who underwent unilateral or bilateral subtotal adrenalectomy (STAE, 28 adrenal remnants) were prospectively studied. Patients were examined in a multi-slice CT to determine residual adrenal tissue and by ACTH test 4 days and 3 months postoperatively. RESULTS There was a slight significant correlation between intraoperative and CT calculated volumes (r=0.77; p<0.001). However, volumes assessed by CT were almost doubled compared with intraoperative determination (p<0.001). Although recovery of adrenal function could be observed, no significant changes of remnant volumes could be detected within 3 months. In patients with familial pheochromocytoma, there was a significant correlation between residual adrenal volume and stimulated cortisol levels (P<0.001). A distinct minimum of adrenal volume for intact adrenocortical stress capacity could not be exactly determined; however, in one patient with only 10% residual adrenal tissue intact stress capacity was found. CONCLUSIONS Residual adrenal tissue of approximately 10-15% offers intact stress capacity. However, an exact determination of the size of an adrenal remnant after STAE has limitations. CT gives larger volumes compared with intraoperative determination. For calculation of a volume-function correlation of residual adrenal tissue, in clinical practice, the determination of relative adrenal residual volume is acceptable.
Collapse
Affiliation(s)
- Michael Brauckhoff
- Department of General, Visceral, and Vascular Surgery, Martin-Luther-University of Halle-Wittenberg, Ernst-Grube-Strasse 40, 06097 Halle/Saale, Germany.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Trojanowicz B, Brodauf L, Sekulla C, Chen Z, Bialek J, Radestock Y, Hombach-Klonisch S, Finke R, Dralle H, Hoang-Vu C. Stability of mRNA and carcinogenesis: The role of AUF1 in thyroid carcinoma progression. Exp Clin Endocrinol Diabetes 2007. [DOI: 10.1055/s-2007-972359] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
30
|
Lorenz K, Ukkat J, Sekulla C, Gimm O, Brauckhoff M, Dralle H. Total parathyroidectomy without autotransplantation for renal hyperparathyroidism: experience with a qPTH-controlled protocol. World J Surg 2006; 30:743-51. [PMID: 16680589 DOI: 10.1007/s00268-005-0379-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [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: 11/25/2022]
Abstract
BACKGROUND Controversy regarding the optimal surgical treatment for secondary hyperparathyroidism (sHPT) continues. Subtotal parathyroidectomy (PTX) with a small remnant and total parathyroidectomy with autotransplantation prevail, although impaired by considerable recurrence rates. Concerns about postoperative management and long-term supplementation prevent broader acceptance of total parathyroidectomy without autotransplantation. MATERIALS AND METHODS The standardized surgical procedure with intraoperative PTH assessment (qPTH) included cervical thymectomy, histological proof of four parathyroid specimens and obligatory cryopreservation of parathyroid tissue in all 23 patients undergoing total PTX without autotransplantation. Whenever qPTH did not normalize, complete cervical exploration of ectopic sites was performed. Another 64 patients with subtotal PTX for sHPT served as comparison for the postoperative course. RESULTS There were 13 primary and 10 completion (5 persistent, 5 recurrent sHPT) total PTX with 14 concurrent thyroid resections performed. Mean preoperative PTH was 1.351 pg/ml (12-72 pg/ml) and serum calcium was 2.5 mmol/l (2.25-2.5 mmol/l). PTH showed intraoperative normalization in 15 patients and a 50% PTH reduction from preoperative values in all. Postoperative course was not significantly different from the subtotal PTX group and showed PTH within the normal range for 5 patients (4 < 35 pg/ml), 7 with PTH < 12 pg/ml, and 4 without measurable PTH. In 4 patients PTH did not normalize postoperatively. Serum calcium levels were below normal in all patients: < 2.25 mmol/l in 9, < 2.00 mmol/l in 7, and <1.8 mmol/l in 6 patients. Only 1 patient required intermittent early postoperative i.v. calcium supplementation, 6 patients received oral calcium and vitamin D supplement for low calcium levels, but no severe hypocalcemic symptoms were encountered. Mean postoperative hospital stay was 5 days. No recurrent laryngeal nerve palsies were encountered. Complications were two cervical bleedings following postoperative hemodialysis requiring evacuation. CONCLUSIONS Total PTX without autotransplantation proves to be an equally safe and successful procedure for sHPT as subtotal PTX or total PTX with autotransplantation. Measurable PTH after total PTX as demonstrated in this study, supports the idea of uncontrollable isolated cell nests that are inevitably prone to stimulated growth with time. Therefore, total PTX is superior with regard to prevention of recurrence. Adequate supplementation with calcium and vitamin D, often necessary after subtotal PTX to suppress inadequate PTH and protect from recurrence, will prevent severe hypocalcemia and with the modern aluminium-diminishing dialysis regimen, development of adynamic bone disease appears less likely than feared. If necessary, cryopreserved parathyroid tissue can be autotransplanted on demand.
Collapse
Affiliation(s)
- Kerstin Lorenz
- Department of General, Visceral and Vascular Surgery, Martin-Luther University of Halle-Wittenberg, Klinikum Kröllwitz, Ernst-Grube-Strasse 40, 06097, Halle, Germany.
| | | | | | | | | | | |
Collapse
|
31
|
Gimm O, Heyn V, Krause U, Sekulla C, Ukkat J, Dralle H. Prognostic Significance of Disseminated Tumor Cells in the Connective Tissue of Patients with Medullary Thyroid Carcinoma. World J Surg 2006; 30:847-52. [PMID: 16680599 DOI: 10.1007/s00268-005-0367-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [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: 11/28/2022]
Abstract
INTRODUCTION Disseminated tumor cells in the connective tissue (CT-DTCs) do not have any connection to a primary tumor or the lymph nodes. They are identified quite often in patients with medullary thyroid carcinoma (MTC), but nothing is known regarding their prognostic significance. METHODS Among 450 patients with MTC, 69 (15%) were identified as having CT-DTCs. A case-control group of patients without CT-DTCs was selected. The two groups were matched concerning TNM classification, age, heredity, and sex. Because many patients with CT-DTCs had extrathyroidal tumor extension (pT4 category), distant metastases (M1 category), or both, only 35 matched pairs could be identified. The TNM classification in both groups was as follows: pT1, n = 8; pT2, n = 15; pT3, n = 4; pT4, n = 8; pN0, n = 4; pN1, n = 31; M0, n = 30; M1, n = 5. The mean age was 46.8 +/- 17.0 years in the CT-DTC group and 44.4 +/- 15.0 years in the case-control group (NS). RESULTS In both groups, 23 patients had sporadic MTC, and 12 patients had hereditary MTC. Neither mean basal preoperative nor postoperative calcitonin levels differed significantly between the two groups. In contrast, none of the patients with CT-DTCs was biochemically cured (normal calcitonin level after pentagastrin stimulation) compared to eight patients without CT-DTCs (P < 0.005). The two groups did not differ concerning other parameters (basal calcitonin level > 3000 pg/ml, more than 10 lymph node metastases, more than two involved locoregional lymph node compartments, mediastinal lymph node metastases) that have been reported to correlate with the lack of or almost (< 10%) lack of biochemical cure. CONCLUSIONS In patients with MTC, disseminated tumor cells in the connective tissue correlate with advanced tumor stages and appear to be of prognostic significance.
Collapse
Affiliation(s)
- Oliver Gimm
- Department of General, Visceral, and Vascular Surgery, Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Strasse 40, 06097, Halle/Saale, Germany.
| | | | | | | | | | | |
Collapse
|
32
|
Trojanowicz B, Winkler A, Hammje K, Chen Z, Sekulla C, Glanz D, Schmutzler C, Mentrup B, Hombach-Klonisch S, Klonisch T, Finke R, Köhrle J, Dralle H, Hoang-Vu C. Retinoic acid actions are connected with downregulation of ENO1 gene products in the follicular thyroid carcinoma cell line FTC-133. Exp Clin Endocrinol Diabetes 2006. [DOI: 10.1055/s-2006-932950] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
33
|
Abstract
BACKGROUND Thyroid surgery is done in Germany in a considerable numbers of operations (about 110,000 per year). To perform thyroid operations by so called "generalists" or "specialists" have been discussed intensively, however, this issue have not been analyzed in detail. METHODS Study material comprised 16,500 consecutive thyroid operations with 30,000 operated sites that have been prospectively documented in the German Thyroid Multicenter Study performed 1998 through 2001. Quality of surgery were analyzed by calculating the inverse relationship between volume and outcome (complication rate). RESULTS To achieve complication rates (permanent unilateral recurrent laryngeal nerve paralysis and hypocalcemia) of < 1 % (primary surgery) or < 3 % (redo surgery) the minimum number of thyroid operations of lower level of experience (e. g. benign nodular goiter) per year was n=30. The minimum number of operations with higher level of experience was significantly lower (n=3-12) due to the higher level of experience of operating surgeons. In contrast to the rates of postoperative hypocalcemia the rates of postoperative recurrent laryngeal nerve paralysis was clearly related to the number of thyroid operations performed. CONCLUSIONS The high number of thyroid operations in Germany with about 20 % of operations of high level experience are requiring surgical curricula and hospital structures that offer as well generalists as specialists to treat the broad spectrum of thyroid diseases accordingly. To lower the complication rate especially of difficult thyroid operations the level of specialization in Germany have to be increased.
Collapse
Affiliation(s)
- H Dralle
- Klinik für Allgemein-, Viszeral-und Gefässchirurgie, Martin-Luther-Universität Halle-Wittenberg, Klinikum Kröllwitz, Halle.
| | | |
Collapse
|
34
|
Lorenz K, Brauckhoff M, Behrmann C, Sekulla C, Ukkat J, Brauckhoff K, Gimm O, Dralle H. Selective arterial chemoembolization for hepatic metastases from medullary thyroid carcinoma. Surgery 2005; 138:986-93; discussion 993. [PMID: 16360382 DOI: 10.1016/j.surg.2005.09.020] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2005] [Revised: 09/15/2005] [Accepted: 09/22/2005] [Indexed: 11/16/2022]
Abstract
BACKGROUND Hepatic metastases from medullary thyroid carcinoma (MTC) may impair quality of life by hypercalcitonemia-associated diarrhea and pain. In this prospective study, the effect of selective arterial chemoembolization (SACE) was evaluated. METHODS Eleven patients with hepatic metastases from MTC received 1 to 9 courses of SACE using epirubicine. Symptomatic, biochemical, and morphologic responses on SACE were recorded. RESULTS Symptomatic response was observed in all symptomatic patients. However, biochemical and radiologic response occurred only in 6 patients. Liver function was not affected by SACE. One patient with unexpected concurrent pheochromocytoma metastases died after the first course. Development of side effects in the course was observed in 8 patients but were only World Health Organization grade 1. Patients' satisfaction with SACE was excellent. Long-term follow-up found 7 patients alive (1-72 months). Three patients died with tumor 6, 12, and 24 months after SACE, respectively. CONCLUSION SACE provided good symptom palliation for the majority of patients with hepatic metastases from MTC. However, transient remission or stabilization of hepatic metastases resulted in only 60%. Further studies using a randomized protocol are required.
Collapse
Affiliation(s)
- Kerstin Lorenz
- Department of General, Visceral and Vascular Surgery, Martin-Luther University of Halle-Wittenberg, Germany.
| | | | | | | | | | | | | | | |
Collapse
|
35
|
Dralle H, Sekulla C, Haerting J, Timmermann W, Neumann HJ, Kruse E, Grond S, Mühlig HP, Richter C, Voss J, Thomusch O, Lippert H, Gastinger I, Brauckhoff M, Gimm O. Risk factors of paralysis and functional outcome after recurrent laryngeal nerve monitoring in thyroid surgery. Surgery 2005; 136:1310-22. [PMID: 15657592 DOI: 10.1016/j.surg.2004.07.018] [Citation(s) in RCA: 382] [Impact Index Per Article: 20.1] [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: 01/09/2023]
Abstract
BACKGROUND Recurrent laryngeal nerve monitoring (RLNM) has been suspected to reduce postoperative RLN paralysis (RLNP). However, functional outcome of RLNM in comparison with no nerve identification and visual nerve identification only has not been analyzed. METHODS Analysis of 16,448 consecutive multi-institutional operations resulted in 29,998 nerves at risk. Three groups of different RLN treatment were compared: group 1, no RLN identification; group 2, visual RLN identification; and group 3, visual RLN identification and electromyographic monitoring. RLNM was performed with a bipolar needle electrode that was placed through the cricothyroid ligament into the vocal muscle. RESULTS Risk factors for permanent RLNP were recurrent benign and malignant goiter (odds ratios, [ORs]), 4.7, and 6.7, respectively), primary surgery in thyroid malignancy (OR, 2.0), lobectomy (OR, 1.8), no nerve identification (OR, 1.4), low or medium volume hospital (OR, 1.3), and low volume surgeons (OR, 1.2). CONCLUSIONS Based on these data, visual nerve identification was identified to be the gold standard of RLN treatment in thyroid surgery. RLNM is a promising tool for nerve identification and protection in extended thyroid resection procedures. However, because of the overall low frequency of RLNP, no statistical difference compared with visual nerve identification only was reached in the setting of this study.
Collapse
Affiliation(s)
- Henning Dralle
- Department of General, Visceral and Vascular Surgery, Klinikum Kröllwitz, University of Halle, Ernst-Grube-Strasse 40, D-06097 Halle, Germany
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
36
|
Trojanowicz B, Winkler A, Hammje K, Chen Z, Sekulla C, Glanz D, Schmutzler C, Mentrup B, Hombach-Klonisch S, Klonisch T, Finke R, Köhrle J, Dralle H, Hoang-Vu C. Influence of retinoic acid on post-translational modifications of a-enolase in the human follicular thyroid carcinoma cell line FTC-133. Exp Clin Endocrinol Diabetes 2005. [DOI: 10.1055/s-2005-862998] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
37
|
Dralle H, Machens A, Brauckhoff M, Ukkat J, Sekulla C, Nguyen-Thanh P, Lorenz K, Gimm O. Chirurgie der Schilddr�senkarzinome. Onkologe 2005. [DOI: 10.1007/s00761-004-0809-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
38
|
Brauckhoff M, Gimm O, Weiss CL, Ukkat J, Sekulla C, Brauckhoff K, Thanh PN, Dralle H. Multiple endocrine neoplasia 2B syndrome due to codon 918 mutation: clinical manifestation and course in early and late onset disease. World J Surg 2004; 28:1305-11. [PMID: 15517484 DOI: 10.1007/s00268-004-7637-4] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.3] [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: 10/26/2022]
Abstract
More than 50% of patients with typical MEN-2B have a de novo M918T germline mutation of the RET protooncogene. However, even in typical MEN-2B, extrathyroidal manifestations of MEN-2B can be found to be differently expressed. We analyzed the clinical manifestation and course in 21 patients harboring a de novo RET M918T mutation. Mean age at MEN-2B diagnosis was 14.2 years (range: 1-31 years). All patients had medullary thyroid carcinoma (MTC). At the time of syndrome diagnosis, oral manifestations (bumpy lips, ganglioneuroma), ocular manifestations (corneal fibers, conjunctivitis sicca), intestinal dysfunctions, musculoskeletal manifestations, and pheochromocytoma were found in 86%, 90%, 74%, 79%, and 19% of the patients, respectively. At the time of follow-up examination, the symptoms were found at higher frequency. Severe intestinal manifestation was predominantly found in patients with prepubertal onset (< or = 12 years) of MTC (n = 4/10) compared with patients with late onset (> 12 years) of MTC (n = 0/11) (40% versus 0%; p = 0.019). Although biochemical cure was found only in four patients with early onset of MTC, the long-term prognosis for patients with early onset of MTC was poorer than for patients presenting with late onset of MTC (p = 0.005). During mean follow-up of 55.8 months (range: 3-161 months), seven patients (33%) died from MTC. In conclusion, whereas most typical MEN-2B symptoms were found to be age-related, severe intestinal manifestation was found to be predominantly expressed in patients with early onset of MTC. Furthermore, in patients with early onset of MTC who could not be biochemically cured, the long-term prognosis was found to be worse than that of non-cured patients with late onset of MTC, suggesting an additional pathological process in the younger subgroup reinforcing the very high transforming in vitro activity of the M918T RET mutation.
Collapse
Affiliation(s)
- Michael Brauckhoff
- Department of General, Visceral and Vascular Surgery, Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Strasse 40, D-0609 Halle/Saale, Germany.
| | | | | | | | | | | | | | | |
Collapse
|
39
|
Dralle H, Kruse E, Hamelmann WH, Grond S, Neumann HJ, Sekulla C, Richter C, Thomusch O, Mühlig HP, Voss J, Timmermann W. [Not all vocal cord failure following thyroid surgery is recurrent paresis due to damage during operation. Statement of the German Interdisciplinary Study Group on Intraoperative Neuromonitoring of Thyroid Surgery concerning recurring paresis due to intubation]. Chirurg 2004; 75:810-22. [PMID: 15146278 DOI: 10.1007/s00104-004-0857-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [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: 11/25/2022]
Abstract
Since the phoniatrician H. Bauer described the first case of recurrent laryngeal nerve palsy most likely caused by intubation some 45 years ago, several case reports have been published. However, systematic analyses regarding the frequency of recurrent laryngeal nerve palsies due to intubation are scarce, and none of them has used the proper methods to demonstrate clearly that such a mechanism exists. Currently available data justify the assumption that not every recurrent laryngeal nerve palsy following thyroid surgery is due to the operation itself and that the damage caused by intubation, however, may only account for a minority of these cases. The differential diagnosis of postoperative recurrent laryngeal nerve palsy requires the use of specific tools which go beyond simple laryngoscopy and include stroboscopy as well as intra- and extralaryngeal electromyography. A partial palsy of recurrent laryngeal nerve due to intubation would be associated with severe dysphonia or aphonia, not with dyspnea because of the typical intermediate position of the paralyzed vocal folds with a normal electromyographic function of the cricothyroid muscle. The use of these methods to identify the nature of postoperative recurrent laryngeal nerve palsy is recommended in cases of regular intraoperative neuromonitoring but postoperatively impaired function of the vocal cords.
Collapse
Affiliation(s)
- H Dralle
- Universitätsklinik für Allgemein-, Viszeral- und Gefässchirurgie, Martin-Luther-Universität Halle-Wittenberg, Halle/Saale.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
40
|
Timmermann W, Hamelmann WH, Thomusch O, Sekulla C, Grond S, Neumann HJ, Kruse E, Mühlig HP, Richter C, Voss J, Dralle H. Zuverl�ssigkeit und Konsequenzen des intraoperativen Neuromonitorings in der Schilddr�senchirurgie. Chirurg 2004; 75:916-22. [PMID: 15168032 DOI: 10.1007/s00104-004-0858-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [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: 10/26/2022]
Abstract
Intraoperative neuromonitoring (IONM) has yielded an increasing effect on thyroid surgery. During IONM, the recurrent laryngeal nerve is stimulated electrically and an acoustically transformed electromyographic signal is derived via either a needle electrode placed in the vocalis muscle or an electrode adjusted to the intubation tube. The IONM is used for identifying and predicting the function of the recurrent laryngeal nerve. Especially under difficult anatomic conditions, IONM has proven a valuable tool for identification of recurrent laryngeal nerves. This can lead to decreased occurrence of nerve palsy rates, as shown in numerous studies. The reliability of the IONM signal (defined as the correlation between intraoperative signal interpretation and postoperative vocal cord function) is reflected by a specificity as high as 98.2%, as shown by German multicenter studies. Thus, normal vocal cord function could be demonstrated postoperatively in over 98.2% of patients with intraoperatively unchanged neuromonitoring signals. If the neuromonitoring signal changed during operation, 39% of the patients suffered from transient vocal cord immobility and 12% had permanent loss of vocal cord function.
Collapse
Affiliation(s)
- W Timmermann
- Universitätsklinik für Chirurgie, Würzburg, Germany
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
41
|
Dralle H, Sekulla C. [Morbidity after subtotal and total thyroidectomy in patients with Graves' disease: the basis for decision-making regarding surgical indication and extent of resection]. Z Arztl Fortbild Qualitatssich 2004; 98 Suppl 5:45-53. [PMID: 15255313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
Compared to radioiodine therapy the surgical treatment of Graves' disease aims to combine high therapeutic efficacy with low morbidity. According to the literature the risk for complications concerning recurrent laryngeal nerve paralysis and hypocalcaemia is lower after subtotal (0.6% and 0.9% respectively) than after total thyroidectomy (1.1% and 1.7% respectively). In contrast, the rate of persistent or recurrent thyrotoxicosis (3.2% and zero respectively) and the rate of worsening or newly developing endocrine ophthalmopathy is higher after subtotal resection than after total thyroidectomy (8% and 2% respectively). On the basis of these data, total thyroidectomy performed by an experienced surgeon is recommended in the case of complicated Graves' disease and in special situations (e.g. pregnancy and breastfeeding, suspected or proven concomitant thyroid malignancy, severe side effects of antithyroid drug treatment). Subtotal thyroidectomy should be reserved for patients with low activity of Graves' goitre, where radioiodine treatment has a similar effect but without the risks associated with surgery.
Collapse
Affiliation(s)
- Henning Dralle
- Klinik für Allgemein-, Viszeral- und Geässchirurgie, Martin-Luther-Universität Halle-Wittenberg, Klinikum Kröllwitz, Halle Saale.
| | | |
Collapse
|
42
|
Abstract
Outpatient or short-stay thyroid and parathyroid surgery is still uncommon in Germany. Although a substantial number of these operations are performed with low morbidity, nearly zero mortality, and short operation time, some potentially lethal complications, especially postoperative hemorrhage, are strong arguments against liberal shortening of hospital stay. Symptomatic hematomas after thyroid and parathyroid surgery are observed in about 1-2% of cases. They frequently occur during the first 8 h after operation (40%). However, two thirds of these major complications occur later, about 20% of them more than 24 h postoperatively. Therefore, an outpatient procedure cannot be generally recommended. Short-stay (<23 h, overnight) thyroid and parathyroid surgery may be attractive, but this concept requires clear release-criteria and professional outpatient structures. Compared to general anesthesia, local and regional anesthesia did not emerge as helpful to shorten hospital stay. Also, prophylactic calcium supplementation is not recommended to enhance early hospital discharge after bilateral thyroid or parathyroid surgery.
Collapse
Affiliation(s)
- H Dralle
- Klinik für Allgemein-,Viszeral- und Gefässchirurgie, Martin-Luther-Universität Halle-Wittenberg, Halle (Saale).
| | | | | | | | | |
Collapse
|
43
|
Thomusch O, Sekulla C, Machens A, Neumann HJ, Timmermann W, Dralle H. Validity of intra-operative neuromonitoring signals in thyroid surgery. Langenbecks Arch Surg 2004; 389:499-503. [PMID: 14722777 DOI: 10.1007/s00423-003-0444-9] [Citation(s) in RCA: 122] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2003] [Accepted: 10/29/2003] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although intra-operative neuromonitoring (IONM) is widely used in thyroid surgery, the validity of the received IONM signals are still unknown. METHOD Prospective collection of data forms in 29 hospitals from 8,534 patients with 15,403 nerves at risk, who underwent surgery for benign and malignant goitre disorders between August 1999 and January 2001. IONM was performed by indirect stimulation via the vagal nerve and by direct recurrent laryngeal nerve (RLN) stimulation in 12,486 cases. IONM signals were compared with early (<14 days) and late (6 months) postoperative vocal cord function findings. RESULTS The transient and permanent RLN palsy rate was 2.8% and 0.7%, respectively. Monitoring of the RLN function was significantly more reliable via the indirect IONM stimulation route than via the direct IONM stimulation route (specificity P<0.05). IONM by indirect stimulation via the vagal nerve reliably excluded postoperative, permanent, vocal cord palsy (specificity 97.6%, negative predictive value 99.6%). However, a changed IONM was insufficient to predict permanent RLN palsy (sensitivity 45.9%, positive predictive value 11.6%). IONM was not associated with increased general morbidity. CONCLUSIONS For intra-operative neuromonitoring, indirect stimulation of the RLN is superior to direct stimulation. An intact acoustic IONM signal is highly predictive of intact postoperative RLN function. When the IONM signal is abnormal or absent, a one-stage extensive thyroid resection should be performed only if the surgeon is absolutely convinced that the first RLN is not harmed or a total thyroidectomy is mandatory.
Collapse
Affiliation(s)
- Oliver Thomusch
- Department of General, Visceral and Vascular Surgery, Martin Luther University of Halle-Wittenberg, Halle, Germany.
| | | | | | | | | | | |
Collapse
|
44
|
Thomusch O, Sekulla C, Dralle H. [Is primary total thyroidectomy justified in benign multinodular goiter? Results of a prospective quality assurance study of 45 hospitals offering different levels of care]. Chirurg 2003; 74:437-43. [PMID: 12748792 DOI: 10.1007/s00104-002-0605-3] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.1] [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: 10/26/2022]
Abstract
INTRODUCTION After subtotal resection of multinodular goiter, rates of up to 40% are reported for recurrent goiter in the long-term follow-up. Because of the increased morbidity of surgery for recurrent goiter, this study evaluated the preconditions that would justify total thyroidectomy as part of the primary therapy concept for benign multinodular goiter. MATERIAL AND METHODS The Quality Assurance Study of Benign and Malignant Goiter covering the period from 1 January to 31 December 1998 assessed 5195 patients treated for benign goiter by primary bilateral resection. With respect to the extent of resection three groups were analyzed: bilateral subtotal resection (ST+ST, n=4580), subtotal resection with contralateral lobectomy (ST+HT, n=527), and total thyroidectomy (TT, n=88). RESULTS The age of the patients was significantly higher (60.3 years) in the TT group than in the ST+ST (52.5 years) and ST+HT (55.6 years) groups. ASA classification grades III and IV were significantly more frequent in the TT group. The postoperative morbidity increased with the extent of resection. The rate of permanent recurrent laryngeal nerve (RLN) palsy was 0.8% for ST+ST, 1.4% for ST+HT, and 2.3% for TT and of permanent hypoparathyroidism 1.5% for ST+ST, 2.8% for ST+HT, and 12.5% for TT. Multivariate analysis showed that the extent of resection significantly increased the risk of RLN palsy (transient RR 0.5, permanent RR 0.4) and hypoparathyroidism (transient RR 0.2,permanent RR 0.08). The surgeon's experience (RR 0.6) and identification of the RLN (RR 0.5) reduced the risk of permanent RLN palsy. Additionally, the development of permanent hypoparathyroidism was reduced if at least two parathyroid glands (RR 0.4) were identified. CONCLUSION Total thyroidectomy is associated with an increased rate of RLN palsies and hypoparathyroidism in comparison to less extensive thyroid surgery. In the hands of well-trained surgeons using an appropriate intraoperative technique, primary thyroidectomy is justified if the patient has an increased risk of recurrent goiter. Due to the increased postoperative morbidity after total thyroidectomy, subtotal thyroid resection based on the morphologic changes in the thyroid gland is still recommended as the standard treatment regimen for multinodular goiter.
Collapse
Affiliation(s)
- O Thomusch
- Klinik für Allgemein-,Viszeral- und Gefässchirurgie,Martin-Luther-Universität Halle-Wittenberg.
| | | | | |
Collapse
|
45
|
Thomusch O, Machens A, Sekulla C, Ukkat J, Brauckhoff M, Dralle H. The impact of surgical technique on postoperative hypoparathyroidism in bilateral thyroid surgery: a multivariate analysis of 5846 consecutive patients. Surgery 2003; 133:180-5. [PMID: 12605179 DOI: 10.1067/msy.2003.61] [Citation(s) in RCA: 274] [Impact Index Per Article: 13.0] [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: 11/22/2022]
Abstract
BACKGROUND Limited information exists about risk factors for postoperative hypoparathyroidism after bilateral thyroid surgery. METHODS Between January 1 and December 31, 1998, bilateral thyroid surgery was performed on 5846 patients for benign and malignant thyroid disease. Data were prospectively collected by questionnaires from 45 hospitals. A logistic regression model was used to determine independent risk factors. RESULTS The overall incidence of transient and permanent hypoparathyroidism was 7.3% and 1.5%, respectively. On logistic regression analysis, total thyroidectomy (odds ratio [OR], 4.7), female gender (OR, 1.9), Graves' disease (OR, 1.9), recurrent goiter (OR, 1.7), and bilateral central ligation of the inferior thyroid artery (OR, 1.7) constituted independent risk factors for transient hypoparathyroidism. When the multivariate analysis was confined to permanent hypoparathyroidism, total thyroidectomy (OR, 11.4), bilateral central (OR, 5.0) and peripheral (OR, 2.0) ligation of the inferior thyroid artery, identification and preservation of no or only a single parathyroid gland (OR, 4.1), and Graves' disease (OR, 2.4) emerged as independent risk factors. CONCLUSIONS Extent of resection and surgical technique had a greater impact on the rates of permanent postoperative hypoparathyroidism than thyroid pathologic condition. In bilateral thyroid surgery, peripheral ligation of the inferior thyroid artery at the thyroid capsule should be favored over central ligation, and at least 2 parathyroid glands should be identified and preserved. High-risk procedures, such as total thyroidectomy and Graves' disease, require special surgical training and expertise.
Collapse
Affiliation(s)
- Oliver Thomusch
- Department of General Surgery, Albert-Ludwigs University Freiburg, Hugstetter Strasse 55, D-79106 Freiburg, Germany
| | | | | | | | | | | |
Collapse
|
46
|
Thomusch O, Sekulla C, Dralle H. Thyroid surgery with intraoperative neuromonitoring of the recurrent laryngeal nerve: a prospective multicentre study in Germany with 7617 patients. Br J Surg 2002. [DOI: 10.1046/j.1365-2168.2000.01601-48.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Abstract
Background
Injury to the recurrent laryngeal nerve (RLN) is a frequently noted and serious complication in thyroid surgery. Several studies have established that identification of the RLN may reduce the incidence of RLN palsy. To date, no prospective study has evaluated whether the RLN palsy rate can be further reduced by intraoperative neuromonitoring of the RLN.
Methods
Between 1 January and 31 December 1998, surgery for benign and malignant goitre was performed on 7607 patients in 45 hospitals. Data were collected prospectively by questionnaire. RLN function was evaluated before and after operation in all patients. RLN palsy was defined as permanent when there was no evidence of recovery within 6 months after surgery. The RLN palsy rate was adjusted to nerves at risk in the three groups ‘no identification of the RLN’, ‘intraoperative identification of the RLN without neuromonitoring’ and ‘identification of the RLN with neuromonitoring’. Statistical analysis was by χ2 test.
Results
Mean patient age was 51·8 years; 72·7 per cent were women. Some 7256 patients were treated for benign goitre (multinodular goitre 74·0 per cent, uninodular goitre 16·6 per cent, recurrent goitre 6·1 per cent, Graves' disease 3·3 per cent, Hashimoto and De Quervain thyroiditis less than 0·1 per cent) and 351 patients for thyroid carcinoma, with a negative selection of recurrent goitre and thyroid carcinoma for the two groups with intraoperative RLN identification (P < 0·0001). With respect to the extent of resection, in cases of lobectomy the rate of permanent RLN palsy was 1·5 per cent with intraoperative neuromonitoring which was significantly lower than rate with intraoperative RLN identification without neuromonitoring (2·6 per cent) or no RLN identification (6·3 per cent) (P < 0·0001). Detailed analysis of the complete spectrum of extent of resection and indications for surgery showed a positive trend for intraoperative neuromonitoring in comparison to the group with RLN identification without the use of neuromonitoring, but this trend was not statistically significant because of the small number of permanent RLN palsies.
Conclusion
Intraoperative neuromonitoring of the RLN has a beneficial effect for high-risk patients with recurrent goitre and thyroid carcinoma in whom the RLN is at greatest risk in cases of lobectomy or total thyroidectomy.
Collapse
Affiliation(s)
- O Thomusch
- Department of General Surgery, Martin-Luther-University Halle-Wittenburg, Halle, Germany
| | - C Sekulla
- Department of General Surgery, Martin-Luther-University Halle-Wittenburg, Halle, Germany
| | - H Dralle
- Department of General Surgery, Martin-Luther-University Halle-Wittenburg, Halle, Germany
| |
Collapse
|
47
|
Abstract
Surgery has been the treatment of choice for many disorders of the thyroid gland, both benign and malignant, for many decades. However, surgery has not been invariable but has continued to change in accordance with research results. In benign cases, surgery has generally evolved to be as organ preserving as possible. In several instances, however, a more radical extent of resection seems justified in order to ensure that the risk of recurrence is as low as possible. For instance, total thyroidectomy may be beneficial in patients with endemic multinodular goitre or young patients with Graves' disease and accompanying cold nodules or high levels of autoantibodies. Several tools, e.g. magnifying glasses, bipolar coagulation forceps and neuromonitoring, are available to identify and preserve the recurrent laryngeal nerve and the parathyroid glands, hence keeping the morbidity at a low level. Most recently, minimally invasive surgery has been successfully used in treating both benign and malignant disorders of the thyroid gland. In the case of malignant disorders, minimally invasive surgery may become an attractive alternative to open surgery if a limited surgical extent is justified, e.g. in patients with micro-PTC (papillary thyroid carcinoma, diameter less than 1 cm). Whether a limited surgical approach is also justified in other cases, e.g. in any patient with intrathyroidal PTC or patients with micro-FTC (follicular thyroid carcinoma), remains to be shown and is the subject of ongoing investigations. One of the most intriguing recent discoveries is the identification of genotype-phenotype correlations in patients with hereditary medullary thyroid carcinoma. In these patients, the timing and extent of surgery may depend not only on the patient's age and serum levels of the tumour marker calcitonin but also on the specific germline RET proto-oncogene mutation. Surgery will certainly continue to play an important role in the treatment of thyroid diseases and may be increasingly based on individual findings instead of general recommendations.
Collapse
Affiliation(s)
- O Gimm
- Universität- und Poliklinik für Allgemein-, Viszeral- und Gefässchirurgie, Ernst-Grube-Strasse 40, 06097 Halle, Germany.
| | | | | | | | | |
Collapse
|
48
|
Thomusch O, Gerstenkorn C, Sekulla C, Heischkel L, Dralle H. Bilateral En Bloc Resection of the Thyroid without Division of the Isthmus: A Technical Alternative to Conventional Subtotal Resection in Multinodular Goitre. Eur Surg 2002. [DOI: 10.1046/j.1563-2563.2002.t01-1-02026.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
49
|
Abstract
BACKGROUND Recurrent laryngeal nerve (RLN) palsy is one of the most serious complications in thyroid surgery. No prospective studies are available that evaluate if the additional use of intraoperative neuromonitoring reduces the rate of RLN palsy. METHODS Between January 1 and December 31, 1998, surgery for histologically benign goiter with intraoperative identification with and without additional intraoperative RLN neuromonitoring was performed on 4,382 patients in 45 hospitals. Data were collected prospectively by questionnaire. RESULTS The rate of transient and permanent RLN palsy based on nerves at risk were 1.4% and 0.4% with intraoperative neuromonitoring. These rates were significantly lower (P <0.05) compared with intraoperative visual RLN identification without intraoperative neuromonitoring which resulted in rates of 2.1% and 0.8%, respectively. A multivariate logistic regression analysis confirmed that the use of intraoperative neuromonitoring decreases the rate of postoperative transient (P <0.008) and permanent (P <0.004) RLN palsies as an independent factor by 0.58 and 0.30, respectively. CONCLUSIONS Intraoperative neuromonitoring of the RLN in thyroid surgery is recommended because of significantly lower rates of transient and permanent RLN palsy rates in comparison with conventional RLN identification.
Collapse
Affiliation(s)
- Oliver Thomusch
- Department of General Surgery, Martin-Luther University Halle, Wittenberg, Germany.
| | | | | | | | | |
Collapse
|
50
|
Timmermann W, Dralle H, Hamelmann W, Thomusch O, Sekulla C, Meyer T, Timm S, Thiede A. [Does intraoperative nerve monitoring reduce the rate of recurrent nerve palsies during thyroid surgery?]. Zentralbl Chir 2002; 127:395-9. [PMID: 12058296 DOI: 10.1055/s-2002-31979] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [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: 10/16/2022]
Abstract
Two different aspects of the influence of neuromonitoring on the possible reduction of post-operative recurrent laryngeal nerve palsies require critical examination: the nerve identification and the monitoring of it's functions. Due to the additional information from the EMG signals, neuromonitoring is the best method for identifying the nerves as compared to visual identification alone. There are still no randomized studies available that compare the visual and electrophysiological recurrent laryngeal nerve detection in thyroid operations with respect to the postoperative nerve palsies. Nevertheless, comparisons with historical collectives show that a constant low nerve-palsy-rate was achieved with electrophysiological detection in comparison to visual detection. The rate of nerve identification is normally very high and amounts to 99 % in our own patients. The data obtained during the "Quality assurance of benign and malignant Goiter" study show that in hemithyreoidectomy and subtotal resection, lower nerve-palsy-rates are achieved with neuromonitoring as compared to solely visual detection. Following subtotal resection, this discrepancy becomes even statistically significant. While monitoring the nerve functions with the presently used neuromonitoring technique, it is possible to observe the EMG-signal remaining constant or decreasing in volume. Assuming that a constant neuromonitoring signal represents a normal vocal cord, our evaluation shows that there is a small percentage of false negative and positive results. Looking at the permanent recurrent nerve palsy rates, this method has a specificity of 98 %, a sensitivity of 100 %, a positive prognostic value of 10 %, and a negative prognostic value of 100 %. Although an altered neuromonitoring signal can be taken as a clear indication of eventual nerve damage, an absolutely reliable statement about the postoperative vocal cord function is presently not possible with intraoperative neuromonitoring.
Collapse
Affiliation(s)
- W Timmermann
- Chirurgische Universitätsklinik Würzburg, Grmany.
| | | | | | | | | | | | | | | |
Collapse
|