Efficacy of four different hemostatic agents in thyroid surgery in reducing the amount of post-operative fluid collection.

PURPOSES: Postoperative bleeding remains a life-threatening complication in thyroid surgery. The aim was to assess the efficacy of four different hemostatic agents, Collagen-Fibrinogen-Thrombin Patch (CFTP) in two sizes (3 × 2.5 cm and 9.5 × 4.8 cm), polysaccharide particles (1 g) and Cellulose Gauze (2.5 × 5 cm) on postoperative drainage volume (DV) compared to a control group. METHODS: We included from October 2007 until Mai 2011, 150 patients (30 per group) for this monocentric, retrospective case-controlled study. Patients were scheduled for a hemithyroidectomy or thyroidectomy. The primary endpoint was the postoperative DV within the first 24 h, secondary the incidence of adverse events. RESULTS: There were no difference in demographic parameters. The mean DV (± SD) was 51.15 (± 36.86) ml in the control, 50.65 (± 42.79) ml in small (3 × 2.5 cm), 25.38 (± 23.99) ml in large CFTP (9.5 × 4.8 cm), 53.11 (± 39.48) ml in the polysaccharide particles and 48.94 (± 30.59) ml in the cellulose gauze group. DV was significantly reduced with the large CFTP (p < 0.05) compared to all other groups. There were no adverse events. CONCLUSIONS: We were able to demonstrate a significant reduction in the DV for the large CFTP group compared to the other collectives. Although this as being associated with not inconsiderable costs and we would only recommend its use for high-risk patients only.

A cervical compartment syndrome impairs cerebral circulation in post-thyroidectomy hemorrhage: data from an animal model.

Background: Post thyroidectomy hemorrhage is a potentially life-threatening complication. As the mechanism leading to hypoxemic brain damage and death is still unknown, our aim was to examine the underlaying pathophysiology in an animal model. Methods: A series of experiments was performed in our established model for post thyroidectomy hemorrhage in 6 pigs. First, post thyroidectomy hemorrhage was simulated with an artificial increase of cervical compartment pressure. Second, spontaneous bleeding into the cervical compartment was initiated. Primary outcome measure is the correlation between cerebral oxygenation and cervical compartment pressure. Results: With an increase in cervical compartment pressure apnea could be detected in all experiments. A significant 24.2% (9.5-34.4%) decrease of cerebral oxygenation at time of apnea (47.0%; 38.0-65.0%) compared to baseline values (63.5%; 56.0-74.0%; P=0.043) occurred due increase of cervical compartment pressure concurrent with an impaired cerebral perfusion. Apnea occurred about 200 sec after a 10% decrease of cerebral oxygenation, but 35 sec before a 10% decrease of peripheral oxygenation. Spontaneous bleeding into the cervical compartment causes an increase of cervical compartment pressure reaching levels of the mean arterial blood pressure 56.0 (35.0-72.0) mmHg. Conclusions: Peripheral hypoxemia occurs with relevant delay in time after decrease of cerebral perfusion and cerebral hypoxemia, therefore cerebral hypoxemia seems to be causal for a central apnea. With this evidence of impaired cerebral perfusion and cerebral hypoxemia due to an increased cervical compartment pressure we can disprove the historic theory of tracheal collapse due to a compressive hematoma in post thyroidectomy hemorrhage. A cervical compartment syndrome seems to be causal, not only for brain hypoxemia but also an additional laryngo-pharyngeal mucosal edema.

Endoscopic cephalic access thyroid surgery (EndoCATS) using the retroauricular approach - a single centre retrospective data analysis.

BACKGROUND: Due to improvements in endoscopic as well as robotic technology, and a request for better cosmetic results, there was a significant increase in thyroid surgery using these methods during the past decade. METHODS: The aim of our study is to evaluate the perioperative short- and long-term outcome as well as the learning curve of EndoCATS and the Quality of Life (QoL). RESULTS: A total of 150 patients with 152 hemithyroidectomies who underwent endoscopic thyroid surgery by EndoCATS between 2010 and 2016 were enrolled in this study. The mean specimen volume was 15.04 g ± 7.89 g. The mean operation time was 132.79 ± 50.52 min. There is a significant reduction of the operation time after the 53th case. (p < 0.05) There was no acute rebleeding or permanent hypoparathyroidism. Permanent RLN palsy occurred in 3 nerves at risk (NAR) 1.97%. There were no cases of pneumothorax, postoperative infections or skin flap ischemia. 94.11% of the patients describe their state of general health as good as or better than before the surgery. CONCLUSIONS: EndoCATS is a safe and effective, but a demanding single port access procedure; therefore, extensive training is required. An advantage is the near ideal visualization of the RLN and the parathyroid glands as well as the ability to recover even large specimens without difficulties.

Quality of life and surgical outcome of ABBA versus EndoCATS endoscopic thyroid surgery: a single center experience.

BACKGROUND: Thyroid surgery is often performed, especially in young female patients. As patient satisfaction become more and more important, different extra-cervical "remote" approaches have evolved to avoid visible scars in the neck for better cosmetic outcome. The most common remote approaches are the transaxillary and retroauricular. Aim of this work is to compare Endoscopic Cephalic Access Thyroid Surgery (EndoCATS) and axillo-bilateral-breast approach (ABBA) to standard open procedures regarding perioperative outcome and in addition to control cohorts regarding quality of life (QoL) and patient satisfaction. METHODS: In a single center, 59 EndoCATS und 52 ABBA procedures were included out of a 2 years period and compared to 225 open procedures using propensity-score matching. For the endoscopic procedures, cosmetic outcome, patient satisfaction and QoL (SF-12 questionnaire) were examined in prospective follow-up. For QoL a German standard cohort and non-surgically patients with thyroid disease were used as controls. RESULT: The overall perioperative outcome was similar for all endoscopic compared to open thyroid surgeries. Surgical time was longer for endoscopic procedures. There were no cases of permanent hypoparathyroidism and no significant differences regarding temporary or permanent recurrent laryngeal nerve (RLN) palsies between open and ABBA or EndoCATS procedures (χ2; p = 0.893 and 0.840). For ABBA and EndoCATS, 89.6% and 94.2% of patients were satisfied with the surgical procedure. Regarding QoL, there was an overall significant difference in distribution for physical, but not for mental health between groups (p < 0.001 and 0.658). Both endoscopic groups performed slightly worse regarding physical health, but without significant difference between the individual groups in post hoc multiple comparison. CONCLUSION: Endoscopic thyroid surgery is safe with comparable perioperative outcome in experienced high-volume centers. Patient satisfaction and cosmetic results are excellent; QoL is impaired in surgical patients, as they perform slightly worse compared to German standard cohort and non-surgical patients.

Evaluation of a rapid-antigen test for COVID-19 in an asymptomatic collective : A prospective study.

BACKGROUND: Over the past year, there has been a significant increase in rapid antigen test (RAT) detection of SARS-CoV­2 COVID-19. Antigen detection is usually inferior to real-time reverse transcription polymerase chain reaction (RT-PCR) in terms of sensitivity and specificity. The aim of this study was to evaluate a RAT for specificity and sensitivity in an asymptomatic collective. METHODS: The study was carried out in January 2021 at a hospital located in a district with a 7-day index and an average of more than 100 cases per 100,000 inhabitants. COVID-19 patients are treated at this hospital. All employees with symptoms typical of COVID-19 were not allowed to go to work. We used RAT by Roche® (Roche Diagnostics GmbH, D-68305 Mannheim) and RT-PCR on our employees. The testing was done voluntarily. We performed RT-PCR and RAT using two swab tubes at the same time. RESULTS: We could correlate 919 RAT to 919 RT-PCR tests. 12 people tested positive in RAT. All 12 tests were validated by RT-PCR. There was not one incorrect positive result in RAT. In one person COVID-19 was not detected by RAT, but then positively identified with a RT-PCR. In the group of positive RAT, the mean cycle threshold (CT) value was 19.95. Our results showed a sensitivity of 92.3%, CI (confidence interval) [0.78; 1.00] and a specificity of 100.00% CI [1.0; 1.0]. CONCLUSION: RAT can be an important tool for screening for SARS-CoV­2 COVID-19 at the point of care. With low cost and resource needs, high specificity, and high specificity, RAT are performed best during the early stages of SARS-CoV­2 COVID-19, when the viral loads are high.

Anastomotic Leak: Toward an Understanding of Its Root Causes.

BACKGROUND: When an anastomotic leak is discussed at a typical surgical morbidity and mortality conference, it is often presented as a due to an error in surgical technique involving ischemia, tension, or device failure. Here we assert that without direct visual analysis of the leak site and its tissue histology, an ex post facto claim that an anastomotic leak is due to an error in surgical technique remains speculative. METHODS: The arguments and rationale used to conclude that an anastomotic leak is due to an error in surgical technique are critically reviewed and assessed for their validity. RESULTS: No case series or literature exists in which a root cause analysis has been carried out with visual and tissue level evidence to determine the root cause(s) of an anastomotic leak. CONCLUSIONS: At the individual case level, declaring that an anastomotic leak is due to an error in surgical technique without clear and compelling evidence either visually and/or at the tissue level to substantiate such a claim remains speculative.

Oral antibiotic bowel decontamination in open and laparoscopic sigmoid resections for diverticular disease.

PURPOSE: There is an ongoing debate on whether or not to use oral antibiotic bowel decontamination in colorectal surgery, despite the numerous different regimens in terms of antibiotic substances and duration of application. As we routinely use oral antibiotic bowel decontamination (selective decontamination of the digestive tract (SDD) regimen and SDD regimen plus vancomycin since 2016) in surgery for diverticular disease, our aim was to retrospectively analyze the perioperative outcome in two independent centers. METHODS: Data from two centers with a routine use of oral antibiotic bowel decontamination for up to 20 years of experience were analyzed for the perioperative outcome of 384 patients undergoing surgery for diverticular disease. RESULTS: Overall morbidity was 12.8%, overall mortality was 0.3%, the overall rate of anastomotic leakage (AL) was 1.0%, and surgical site infections (SSIs) were 5.5% and 7.8% of all infectious complications including urinary tract infections and pneumonia. No serious adverse events were related to use of oral antibiotic bowel decontamination. Most of the patients (93.8%) completed the perioperative regimen. Additional use of vancomycin to the SDD regimen did not show a further reduction of infectious complications, including SSI and AL. CONCLUSION: Oral antibiotic decontamination appears to be safe and effective with low rates of AL and infectious complications in surgery for diverticular disease.

Intraoperative Fascia Tension as an Alternative to Component Separation. A Prospective Observational Study.

Incisional hernias are common late complications of abdominal surgery, with a 1-year post-laparotomy incidence of about 20%. A giant hernia is often preceded by severe peritonitis of various causes. The Fasciotens® Abdomen device is used to stretch the fascia in a measurably controlled manner during surgery to achieve primary tension-free abdominal closure. This prospective observational study aims to clarify the extent to which this traction method can function as an alternative to component separation (CS) methods. Methods: We included data of 21 patients treated with intraoperative fascia stretching in seven specialized hernia centers between November 2019 and August 2020. Results: Intraoperatively-measured fascial distance averaged 17.3 cm (range 8.5-44 cm). After application of diagonal-anterior traction >10 kg for an average duration of 32.3 min (range 30-40 min), the fascial distance decreased by 9.8 cm (1-26 cm) to an average 7.5 cm (range 2-19 cm), which is a large effect (r = 0.62). The fascial length increase (average 9.8 cm) after applied traction was highly significant. All hernias were closed under moderate tension after the traction phase. In 19 patients, this closure was reinforced with mesh using a sublay technique. Conclusion: This method allows primary closure of complex (LOD) hernias and is potentially less prone to complications than component separation (CS) methods.

Long-term outcome and chronic pain in atraumatic fibrin glue versus staple fixation of extra light titanized meshes in laparoscopic inguinal hernia repair (TAPP): a single-center experience.

BACKGROUND: Inguinal hernia repair belongs to the most frequently performed surgical procedures. Endoscopic techniques like TAPP and TEP have become standard of care together with the conventional open techniques. Especially in endoscopic techniques, there is a confusing amount of different meshes and fixation techniques with impact on perioperative and long-term outcome. We present the first single-center data on the use of titanized extra lightweight meshes and fibrin glue fixation compared to staple fixation regarding long-term outcome, especially chronic pain. MATERIALS AND METHODS: A clinical trial with retrospective analysis of patient- and procedure-related data and questionnaire-based follow-up of TAPP procedures performed in 2012-2014 was conducted in a specialized hernia center. Standard TAPP technique was used with placement of TiMesh extra light (16 g/m2) and either fibrin glue or staple fixation. Procedure- and patient-related data are compared after propensity score matching regarding perioperative complications and long-term outcome. RESULTS: Of 612 TAPP procedures 372 procedures were included in analysis after propensity score matching. Fibrin glue was used in n = 279 and staple fixation in n = 93 cases. There were significant differences regarding duration of the surgical procedures (p = 0.001) and distribution of mesh size. No differences were noted regarding perioperative complications such as seroma or hematoma formation and need for re-laparoscopy. During a mean follow-up of 32.1 ± 20.6 month with a follow-up rate of 79%, there was no difference in long-term outcome, especially for rate of recurrence (p = 0.112) and development of chronic pain (p = 0.846). The overall rate of recurrence was 3.0% (n = 11), and in 2.4% (n = 9) patients complained of chronic pain. CONCLUSION: Inguinal hernia repair using extra lightweight titanized meshes and fibrin glue fixation is safe and feasible compared to staple fixation even in large and combined hernia defects, if mesh size is adjusted to size of hernia defect. The rate of chronic pain was extremely low at 2.4%.

New insights into the pathophysiology of postoperative hemorrhage in thyroid surgery: An experimental study in a porcine model.

BACKGROUND: Postoperative cervical hemorrhage is a rare but life-threatening complication that can cause severe morbidity. Different mechanisms leading to asphyxia have been described based only on clinical observation. METHODS: We performed a series of in vivo animal studies simulating post-thyroidectomy hemorrhage and its effect on respiratory drive. Three series of tests were carried out in 12 German domestic pigs under general anesthesia. The pigs were breathing spontaneously with secured airways. An additional series using functional magnetic resonance imaging of the pigs' brainstem was also conducted. RESULTS: The first experimental series carried out on 2 animals revealed an obvious difference between the effects of cervical hemorrhage and external bleeding with development of hemorrhagic shock. An experimental setting for the repeated simulation of cervical hemorrhage was established. A pressure-dependent mechanism was discovered that led to apnea in every animal despite the secured airway. In 8 of 10 animals, relief of cervical pressure led to complete respiratory recovery. The test was repeated up to 6 times per pig. Apnea was induced in 25 of 25 test procedures (100%) and was followed by respiratory recovery in 22 of 25 tests (88%). The threshold pressure at which the respiratory rate started to decrease was 47 ± 14 Torr when blood was used to increase the cervical compartment pressure. When silicone oil was used in a further experimental series, the threshold pressure was similar at 44 ± 21 Torr. The cervical compartment pressure needed to induce apnea was 74 ± 18 Torr using blood and 74 ± 39 Torr using silicone oil, both of which exceeded the mean arterial pressure by 28 Torr during apnea. Functional magnetic resonance imaging revealed a decrease in brainstem activity during phases of increased cervical compartment pressure, which suggests a possible role for cerebral vascular perfusion. CONCLUSION: Respiratory drive can be suppressed by increased pressure in the cervical compartment, possibly because of a pressure-dependent impairment in cerebral perfusion through a form of cervical compartment phenomenon or, less likely, a pressure-dependent reflex (nervous) mechanism.

Local antibiotic decontamination to prevent anastomotic leakage short-term outcome in rectal cancer surgery.

PURPOSE: Anastomotic leakage still presents an issue in rectal cancer surgery with rates of about 11%. As bacteria play a critical role, there is the concept of perioperative local decontamination to prevent anastomotic leakage. METHODS: To ascertain the effectiveness of this treatment, we performed a retrospective analysis on 206 rectal resections with primary anastomosis and routine use of a selective decontamination of the digestive tract (SDD) regimen for local decontamination. SDD medication was administered every 8 h from the day before surgery to the seventh postoperative day. All patients were treated according to the fast-track protocol without mechanical bowel preparation; instead, a laxative was used. RESULTS: Overall morbidity was 30%, overall mortality 0.5%. In our data, overall rate of anastomotic leakage (AL) was 5.8%, with 3.9% in anterior rectal resection and 6.5% in low anterior rectal resection group. In 75% of cases, anastomotic leakage was grade "C" and needed re-laparotomy. Surgical site infection rate was 19.9%. No serious adverse events were related to decontamination. CONCLUSION: Local antibiotic decontamination appears to be safe and effective to decrease the rate of anastomotic leakage in rectal cancer surgery. Further focus should be on perioperative management including bowel preparation and choice of antimicrobial agents for local decontamination.

Compartment Pressure Monitoring After Thyroid Surgery: A Possible Method to Detect a Rebleeding.

BACKGROUND: Postoperative rebleeding after thyroid surgery is a rare but a serious complication. The aim of this study was to ascertain the extent to which postoperative pressure could be used as detector for rebleeding after thyroid surgery. METHODS: Thirty-two patients with thyroidectomy or hemithyroidectomy were considered prospectively. In the course of surgery, a pressure microsensor (3PN Probe Spiegelberg) was implanted into the postoperative cavity and data were collected for special activities and stress situations over the first 48 h postoperatively. Additional endpoint was the influence of drains on the determined values. RESULTS: The overall mean pressure (MP) at rest on both postoperative days for all patients with and without drain was 0.36 ± 2.84 mmHg (range -6.7 to 6.7). The MP in all activity and stress situations on the first day was with 0.23 ± 3.71 mmHg, and on the second day, the MP was 1.33 ± 4.50. 92.13% of our values were below 7 mmHg. One patient had a hemorrhage. The pressure increases continuously up to 36 mmHg, before the patient was transferred to the operating theater. CONCLUSIONS: This is the first pilot study to consider continuous pressure measurement to be a potential tool for early detection of a postoperative rebleeding in thyroid surgery. In the strictest sense, postoperative intra-cervical pressure at rest ranges from subatmospheric to 7 mmHg. The elevation of pressure in case of a rebleeding up to 36 mmHg differs dramatically from normal postoperative pressure. The collected data will warrant further validation to be able to recommend threshold values for an early treatment decisions in rebleeding.

[Traumatic thyroid rupture: case report and review of the literature]. / Traumatische Schilddrüsenruptur: Fallbericht und Literaturübersicht.

BACKGROUND: Traumatic rupture of the thyroid gland is rare. A common approach does not exist. Surgical and nonsurgical management have been advocated. METHOD: This work summarizes the publications in PubMed including an own case. This study will analyse the accident mechanism, the underlying thyroid pathologies, possible pathogenetic mechanisms of airway obstruction and the therapeutic options. A present classification is revised in order to develop it into a treatment proposal. RESULTS: A total of 34 case reports were analysed. The first half had to be performed a surgery on, the other half was observed without surgical treatment. None of the patients died of his injury. 59% of the patients, that had to be performed a surgery on had thyroid pathology before rupture. 50% of all patients had a road accident as a cause for the rupture. CONCLUSION: The revised classification and treatment proposal developed here presents a clinically-viable approach.

Acute renal artery aneurysm rupture - a rare differential diagnosis of acute appendicitis.

A 50-year-old patient with symptoms of an acute appendicitis turns out to be suffering of a life threatening rupture of a renal artery aneurysm. We performed an emergency operation with the resection of this aneurysm. An imminent hemorrhagic shock made a targeted intensive medical therapy necessary.

Invisible scar endoscopic thyroid surgery by the dorsal approach: importance of the spinal accessory nerve.

PURPOSE: With about 100,000 surgeries per year in Germany, thyroid operations count among the most common procedures performed in general and endocrine visceral surgery. Twentieth century technological development gives the opportunity to perform thyroid surgery without leaving visible scar like conventional approaches do. This study is part of the work on the videoendoscopic retro-auricular access to the thyroid gland using the EndoCATS method by Schardey and Schopf. To avoid possible complications with the spinal accessory nerve (SAN), like irritation or injury of the nerve as happened during a feasibility study, a systematic study of the surgical anatomy at the nerve's entry to the posterior cervical triangle is performed especially in relation to the EndoCATS operation method. METHODS: Sixty-one neck regions in fifty-three specimens were examined at the anatomical institute of Munich to investigate the course of the SAN relative to the anatomic landmarks tip of mastoid bone, sternal notch, and posterior border of the sternocleidomastoid muscle together with the SAN's course variants at its entry to the posterior cervical triangle. The results were then statistically analyzed. RESULTS: From this analysis, we derived a simple method to predict the course of the SAN preoperatively and offer a new approach to protect the SAN during EndoCATS surgery. Additionally, we found a significant difference of the SAN's course between male and female specimens. CONCLUSION: The EndoCATS method can be a safe alternative to conventional thyroid surgery, but the SAN is at risk during the surgery procedure. Here we give feasible solutions to eliminate the SAN-problem performing EndoCATS thyroid surgery.

Invisible scar endoscopic dorsal approach thyroidectomy: a clinical feasibility study.

BACKGROUND: The aim of the present study was to test the safety and feasibility of the dorsal approach endoscopic thyroidectomy procedure in a prospective trial in humans, after the procedure had been developed ex vivo in human cadavers. METHODS: A total of 28 patients were enrolled for 30 unilateral procedures of thyroidectomy. Two cases were staged bilateral procedures. Patients presenting with suspicious cold nodules, hot nodules, or goiters were operated on under general anaesthesia. Skin incision is carried out on the scalp, behind the ear. Deep to the sternocleidomastoid muscle, but respecting the superficial cervical fascia, the preparation goes past the carotid triangle to reach the thyroid below the straight neck muscles. Postoperatively the patients underwent neurological assessment, vocal cord examination, clinical control for hemorrhage, and determination of serum levels of Ca(2+). RESULTS: Thirty unilateral procedures by the dorsal approach were carried out in 22 women and 6 men. There was 1 subtotal thyroidectomy and 29 total unilateral thyroidectomies with no conversions. There was one permanent recurrent laryngeal nerve (RLN) lesion and one postoperative hemorrhage. The size of the lobes removed ranged from 6 to 40 ml (mean: 18 ml). In four cases the specimen exceeded 38 ml. There was one multifocal papillary cancer requiring open surgical revision and lymphadenectomy. The other diagnoses were benign. All wounds healed by primary intention. Temporary impairment of cervical nerves was detected in six patients. It was possible to avoid access-related problems by improving the patient's positioning on the operating table, omitting straight instruments, and respecting the superficial fascia before entering the carotid triangle. CONCLUSIONS: Hemithyroidectomy by the dorsal approach is feasible. It is a single surgeon, single port, gasless unilateral endoscopic technique with the option to go bilateral.

Invisible scar endoscopic thyroidectomy by the dorsal approach: experimental development of a new technique with human cadavers and preliminary clinical results.

BACKGROUND: A unilateral gasless single-surgeon videoendoscopic thyroidectomy procedure using a dorsal cephalic approach from the scalp with the option for a bilateral approach was developed with human cadavers and a porcine model for access training. The final preclinical trials and the first three clinical cases are described in detail. METHODS: Preclinical evaluation and training for the procedure were conducted with fresh human cadavers. The procedure was defined precisely by a sequence of nodal points initiating surgical steps. A quality score was developed by issuing each important anatomic structure a specific organ value and a factor for positive identification, inability to identify a given anatomic structure, spare it (meaning omit causing a lesion) or injure the structure. The quality of each operation was expressed as a single number or quality score value, calculated by summing the points achieved for the individual anatomic structures. The results of the procedures were controlled by prospective video documentation and autopsy. After conclusion of the preclinical training, the operation was performed for patients. The reported patients are part of a feasibility study approved by the institutional review board of the University of Munich. RESULTS: Nodal points were helpful in preparation for the operation by mental training. During the procedure, they helped to guide the preparation in the neck, where the working space must first be created on the way to the target organ. The surgical quality score improved over the first three cases and reached the maximum score, which was reproducible every time after that. It showed that the dorsal approach from the scalp to the thyroid gland is easily achievable without complications. The technical challenge is exposure of the recurrent laryngeal nerve (RLN) and the parathyroid glands. There was no difference between the results achieved by the resident and the senior surgeon. Preclinical training was good preparation for hemithyroidectomy in patients. All cases could be managed without postoperative hemorrhage or impairment of the parathyroid or the RLN. CONCLUSIONS: Videoendoscopic thyroidectomy by the dorsal approach is feasible in both human cadavers and patients. It leaves no visible scars. Nodal points are helpful for executing a new operation. The surgical quality score is a complex and objective measure of ability to deal with the procedure. Further clinical studies are required for evaluation of this new procedure.