Prophylactic Central Neck Dissection in Papillary Thyroid Carcinoma: All Risks, No Reward.

BACKGROUND: Central neck dissection (CND) remains a controversial intervention for papillary thyroid carcinoma (PTC) patients with clinically negative nodes (cN0) in the central compartment. Proponents state that CND in cN0 patients prevents locoregional recurrence, while opponents deem that the risks of complications outweigh any potential benefit. Thus, there remains conflicting results amongst studies assessing oncologic and surgical outcomes in cN0 PTC patients who undergo CND. To provide clarity to this controversy, we sought to evaluate the efficacy, safety, and oncologic impact of CND in cN0 PTC patients at our institution. MATERIALS AND METHODS: Six hundred and ninety-five patients with PTC who underwent thyroidectomy at our institution between 1998 and 2018 were identified using an institutional cancer registry and supplemental electronic medical record queries. Patients were stratified by whether or not they underwent CND; identified as CND(+) or CND(-), respectively. Patients were also stratified by whether or not they received adjuvant radioactive iodine (RAI) therapy. Patient demographics, pathologic results, as well as surgical and oncologic outcomes were reviewed. Standard statistical analyses were performed using ANOVA and/or t-test and chi-squared tests as appropriate. RESULTS: Among the 695 patients with PTC, 492 (70.8%) had clinically and radiographically node negative disease (cN0). The mean age was 50 ± 1 years old and 368 (74.8%) were female. Of those with cN0 PTC, 61 patients (12.4%) underwent CND. CND(+) patients were found to have higher preoperative thyroid stimulating hormone (TSH) values, 2.8 ± 0.8 versus 1.5 ± 0.2 mU/L (P = 0.028) compared to CND(-) patients. CND did not significantly decrease disease recurrence, development of distant metastatic disease (P = 0.105) or persistence of disease (P = 0.069) at time of mean follow-up of 38 ± 3 months compared to CND(-) patients. However, surgical morbidity rates were significantly higher in CND(+) patients; including transient hypocalcemia (36.1% versus 14.4%; P < 0.001), transient recurrent laryngeal nerve (RLN) injury (19.7% vers us 7.0%; P < 0.001), and permanent RLN injury (3.3% versus 0.7%; P < 0.001). CONCLUSIONS: The majority of patients at our institution with cN0 PTC did not undergo CND. This data suggests that CND was not associated with improvements in oncologic outcomes during the short-term follow-up period and led to increased postoperative morbidity. Therefore, we conclude that CND should not be routinely performed for patients with cN0 PTC.

A prospective study comparing prophylactic gastrostomy to nutritional counselling with a therapeutic feeding tube if required in head and neck cancer patients undergoing chemoradiotherapy in Thai real-world practice.

BACKGROUND: Concurrent chemoradiotherapy (CRT) is the standard treatment for head and neck (HN) cancer patients. Most patients experience malnutrition and weight loss during treatment because of mucositis and difficulty in swallowing. Prevention of malnutrition may allow more patients to complete their treatment. The present study aimed to examine whether prophylactic gastrostomy tube (PGT) could reduce treatment interruption, prevent malnutrition and maintain quality of life, especially in Thai patients who generally do not accept feeding tubes. METHODS: A prospective study was performed on HN cancer patients undergoing CRT at a tertiary hospital in Thailand (n = 95). Before starting CRT, all patients received nutritional assessment and were counselled about the risks and benefits of PGT. According to patient discretion, they chose to have a PGT (experimental group) or only nutritional counselling with a therapeutic feeding tube if required (control group). During CRT, weight, degree of mucositis, delayed chemotherapy and/or radiotherapy, and nutritional status were recorded. Quality of life (Functional Assessment of Cancer Therapy - Head and Neck Scale; FACT-H&N) was compared between two groups. RESULTS: There was no significant difference in the rates of delayed treatment. Mean weight loss was 3.1 and 4.8 kg in the experimental and control groups, respectively (P = 0.04). A higher proportion of patients in the control group experienced ≥10% weight loss (24% versus 4%; P = 0.03). In terms of quality of life, no significant difference in FACT-H&N score was found. CONCLUSIONS: The results of the present study suggest that PGT provided similar quality of life without a reduction in treatment interruption. However, patients with PGT had significantly less weight loss (P = 0.04) during CRT.

[Necessary and unnecessary treatment options for hemorrhoids]. / Nötige und unnötige Behandlungen beim Hämorrhoidalleiden: Der Patient bestimmt mit.

Up to one third of the general population suffers from symptoms caused by hemorrhoids. Conservative treatment comes first unless the patient presents with an acute hemorrhoidal prolapse or a thrombosis. A fiber enriched diet is the primary treatment option, recommended in the perioperative period as well as a long-term prophylaxis. A timely limited application of topical ointments or suppositories and/or flavonoids are further treatment options. When symptoms persist interventional procedures for grade I-II hemorrhoids, and surgery for grade III-IV hemorrhoids should be considered. Rubber band ligation is the interventional treatment of choice. A comparable efficacy using sclerosing or infrared therapy has not yet been demonstrated. We therefore do not recommend these treatment options for the cure of hemorrhoids. Self-treatment by anal insertion of bougies is of lowrisk and may be successful, particularly in the setting of an elevated sphincter pressure. Anal dilation, sphincterotomy, cryosurgery, bipolar diathermy, galvanic electrotherapy, and heat therapy should be regarded as obsolete given the poor or missing data reported for these methods. For a long time, the classic excisional hemorrhoidectomy was considered to be the gold standard as far as surgical procedures are concerned. Primary closure (Ferguson) seems to be superior compared to the "open" version (Milligan Morgan) with respect to postoperative pain and wound healing. The more recently proposed stapled hemorrhoidopexy (Longo) is particularly advisable for circular hemorrhoids. Compared to excisional hemorrhoidectomy the Longo-operation is associated with reduced postoperative pain, shorter operation time and hospital stay as well as a faster recovery, with the disadvantage though of a higher recurrence rate. Data from Hemorrhoidal Artery Ligation (HAL)-, if appropriate in combination with a Recto-Anal Repair (HAL/RAR)-, demonstrates a similar trend towards a better tolerance of the procedure at the expense of a higher recurrence rate. These relatively "new" procedures equally qualify for the treatment of grade III and IV hemorrhoids, and, in the case of stapled hemorrhoidopexy, may even be employed in the emergency situation of an acute anal prolapse. While under certain circumstances different treatment options are equivalent, there is a clear specificity with respect to the application of those procedures in other situations. The respective pros and cons need to be discussed separately with every patient. According to their own requirements a treatment strategy has to be defined according to their individual requirements.

[The general practitioner is amazed, the specialist is astonished - or put differently: unnecessary operations? - a fictive interview with a general practitioner]. / Der Hausarzt staunt, der Facharzt wundert sich darüber - oder anders gefragt: Unnötige Operationen? - Ein fiktives Interview mit einem Hausarzt.

From the sight of a General Practitioner time and again certain indications for some interventions on patients in hospitals are questionable. Enough evidence-based studies are of great importance, so that the individual evidence of the patient including the view of his General Practitioner can be put in first place when making decisions for interventions. In order to generate as much data with as little time and effort possible, structures for patient-centered care have to be created over the whole therapeutic chain (GPs, specialists, hospitals), where the necessary data can be gathered. In an interview GP Dr. med. H.U. Blunier speaks his mind, about how he is persistently pursuing his goal to develop patient paths across all institutions to finally close the therapy chain in terms of an integrated health care.