[Medicolegal aspects of primary and renal hyperparathyroidism]. / Medikolegale Aspekte der Chirurgie des primären und renalen Hyperparathyreoidismus.

BACKGROUND: Compared with malpractice claims in thyroid surgery, expert medico-legal reviews of surgery performed for hyperparathyroidism (HPT) that aim to prove or rebut surgical malpractice are rare. The aim of this analysis was to describe typical risk patterns for possible treatment errors and to generate recommendations for avoiding these treatment errors. MATERIAL AND METHODS: A total of 12 surgical expert medico-legal reviews, which were carried out by order of 9 arbitration boards and 3 courts between 1997 and 2020 were evaluated. RESULTS: If the indications for surgical treatment of hyperparathyroidism were present, the failure to identify a parathyroid adenoma or hyperplastic parathyroid glands was in the majority of cases not rated as a surgical treatment error, especially in atypical localizations. Unilateral recurrent laryngeal nerve palsy and postoperative bleeding cannot always be prevented, despite maximum diligence. In contrast, bilateral recurrent laryngeal nerve palsy can be prevented when intraoperative neuromonitoring is correctly applied. A lack of patient information regarding postoperatively persistent HPT, postoperative hypoparathyroidism following the removal of inconspicuous parathyroid glands and nonindicated lobectomy or total thyroidectomy, mostly performed under the assumption of an intrathyroid parathyroid adenoma, represented avoidable malpractice issues. CONCLUSION: Advanced knowledge of the pathophysiology of the disease and the anatomy of the parathyroid glands as well as the establishment of intraoperative and perioperative standards can prospectively greatly reduce avoidable errors in the surgical treatment and postoperative care of HPT.

Management of primary and renal hyperparathyroidism: guidelines from the German Association of Endocrine Surgeons (CAEK).

BACKGROUND AND AIMS: The purpose of this review is to provide updated recommendations for the surgical management of primary (pHPT) and renal (rHPT) hyperparathyroidism, formulating a new guideline of the German Association of Endocrine Surgeons (CAEK). METHODS: Evidence-based recommendations for the diagnosis and therapy of pHPT and rHPT were assessed by a multidisciplinary panel using PubMed for a comprehensive literature search together with a structured consensus dialogue (S2k guideline of the Association of the German Scientific Medical Societies, AWMF). RESULTS: During the last 20 years, a variety of new preoperative localization procedures, such as sestamibi-SPECT, 4D-CT, and various PET/CT procedures, were established for pHPT. High-resolution imaging, together with intraoperative parathyroid hormone (IOPTH) measurement, enabled focused or minimally invasive surgery to become the most favored surgical technique. Patients with pHPT and nonlocalizing imaging have a higher risk of multiglandular disease. Surgical therapy provides very high cure rates, with a clear relation to the surgeon's experience in parathyroid procedures. Reoperative parathyroidectomy, children with pHPT or familial forms, and parathyroid carcinoma are addressed and require special surgical expertise. A multidisciplinary team of experienced nephrologists, transplant, and endocrine surgeons should assess the diagnosis and treatment of renal HPT. CONCLUSION: Surgery is the only curative treatment for pHPT and should be considered for all patients with pHPT. For rHPT, a more selective approach is required, and parathyroidectomy is indicated only when conservative treatment options fail. In parathyroid carcinoma, the adequacy of local resection influences local disease control.

[Case volume and complications after thyroid gland surgery in Germany: an analysis of routine data from 48,387 AOK patients]. / Fallvolumen und Komplikationen nach Schilddrüsenoperationen in Deutschland: eine Routinedatenanalyse von 48.387 AOK-Patienten.

BACKGROUND: Many studies showed that hospital and surgeon volume have a significant influence on the complication rates of thyroid surgery. The present study investigates whether this relationship applies in subtotal as well as total lobe resections. Furthermore, it is still unclear which threshold for the hospital-related case volume can be determined, above which the risk of complications lies below the current national average. MATERIAL AND METHODS: The study was based on nationwide routine data for persons insured with the Local General Sickness Fund (AOK) who had undergone thyroid surgery in 2014-2016. Permanent vocal cord palsy, bleeding and wound infection needing revision were recorded using indicators. The effect of the case volume on the indicators and the case number threshold was determined using logistic regression. RESULTS: Permanent vocal cord palsy was observed in 1.3% and bleeding or wound infections needing revision in 1.6% and 0.3% of the cases. Compared to hospitals with >450 surgeries per year, the risk of permanent vocal cord palsy in hospitals with fewer than 201, 101 and 51 surgeries was significantly increased (OR [95% CI]: 1.5 [1.1-2.1]; 1.5 [1.1-2.1]; 1.8 [1.3-2.5]). The threshold needed to achieve a risk for permanent vocal cord palsy below the national average (1.3%) was 265 thyroid surgeries per year (95% CI: 110-420). For bleeding or wound infection in need of revision, no association between volume and outcome was found. CONCLUSION: The present study showed that the risk of postoperative permanent vocal cord palsy decreased with increasing case volume. The broad confidence interval of the threshold makes clear case volume recommendation difficult. In order that the risk for a postoperative permanent vocal cord palsy is not likely above the national average, the annual case volume should reach 110 thyroid interventions.

Surgical therapy of adrenal tumors: guidelines from the German Association of Endocrine Surgeons (CAEK).

BACKGROUND AND AIMS: Previous guidelines addressing surgery of adrenal tumors required actualization in adaption of developments in the area. The present guideline aims to provide practical and qualified recommendations on an evidence-based level reviewing the prevalent literature for the surgical therapy of adrenal tumors referring to patients of all age groups in operative medicine who require adrenal surgery. It primarily addresses general and visceral surgeons but offers information for all medical doctors related to conservative, ambulatory or inpatient care, rehabilitation, and general practice as well as pediatrics. It extends to interested patients to improve the knowledge and participation in the decision-making process regarding indications and methods of management of adrenal tumors. Furthermore, it provides effective medical options for the surgical treatment of adrenal lesions and balances positive and negative effects. Specific clinical questions addressed refer to indication, diagnostic procedures, effective therapeutic alternatives to surgery, type and extent of surgery, and postoperative management and follow-up regime. METHODS: A PubMed research using specific key words identified literature to be considered and was evaluated for evidence previous to a formal Delphi decision process that finalized consented recommendations in a multidisciplinary setting. RESULTS: Overall, 12 general and 52 specific recommendations regarding surgery for adrenal tumors were generated and complementary comments provided. CONCLUSION: Effective and balanced medical options for the surgical treatment of adrenal tumors are provided on evidence-base. Specific clinical questions regarding indication, diagnostic procedures, alternatives to and type as well as extent of surgery for adrenal tumors including postoperative management are addressed.

[Speech therapy after thyroid gland operations in Germany: analysis of routine data from 50,676 AOK patients]. / Logopädie nach Schilddrüsenoperationen in Deutschland: eine Routinedatenanalyse von 50.676 AOK-Patienten.

BACKGROUND: This study investigated the frequency of postoperative speech therapy in the context of vocal cord palsy after thyroid surgery based on nationwide routine data. Additionally, volume-outcome relationships were examined. MATERIAL AND METHODS: Nationwide routine data from insured patients of the Local Health Insurance Fund (AOK) who underwent thyroid surgery for a benign thyroid disease between 2013 and 2015 were analyzed. Postoperative speech therapy was determined based on prescription data. Transient and permanent vocal cord palsy were determined using indicators. The effect of hospital volumes (volume quintiles) on prescription of postoperative speech therapy was determined by multivariate logistic regression. RESULTS: A total of 50,676 thyroid gland operations were identified. The overall frequency of postoperative speech therapy prescription was 6.5%. In AOK patients with transient or permanent vocal cord palsy, the frequencies of postoperative speech therapy prescription were 56.1% and 75.2%, respectively. The prescription volume of the normal case (≥21 units of speech therapy) was exceeded in 0.7% of the AOK patients. In the two lowest case volume categories the risk of postoperative speech therapy exceeding the prescription volume of the normal case was significantly higher compared to the highest case volume hospitals (odds ratios: 1.2 and 1.8, respectively). CONCLUSION: This study presents the reality of healthcare with respect to the frequency of speech therapy prescription after thyroid gland surgery in Germany. In addition, it was determined that the risk of postoperative speech therapy prescription exceeding the volume of the normal case after thyroid gland operations decreases with increasing case volumes of hospitals.

[Update of the S2k guidelines : Surgical treatment of benign thyroid diseases]. / Aktualisierung der S2k-Leitlinie : Operative Therapie benigner Schilddrüsenerkrankungen.

Thyroid resections represent one of the most common operations with 76,140 interventions in the year 2016 in Germany (source Destatis). These are predominantly benign thyroid gland diseases. Recommendations for the operative treatment of benign thyroid diseases were last published by the CAEK in 2010 as S2k guidelines (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e.V. [AWMF] 003/002) against the background of increasingly more radical resection procedures. Hemithyroidectomy and thyroidectomy are routinely performed for benign thyroid disease in practice. The operation-specific risks show a clear increase with the extent of the resection. Therefore, weighing-up of the risk-indications ratio between unilateral lobectomy or thyroidectomy necessitates an independent evaluation of the indications for both sides. This principle in particular has been used to update the guidelines. In addition, the previously published recommendations of the CAEK for correct execution and consequences of intraoperative neuromonitoring were included into the guidelines, which in particular serve the aim to avoid bilateral recurrent laryngeal nerve paralysis. Moreover, the recommendations for the treatment of postoperative complications, such as hypoparathyroidism and postoperative infections were revised. The updated guidelines therefore represent the current state of the science as well as the resulting surgical practice.

[Complications after thyroid gland operations in Germany : A routine data analysis of 66,902 AOK patients]. / Komplikationen nach Schilddrüsenoperationen in Deutschland : Eine Routinedatenanalyse von 66.902 AOK-Patienten.

BACKGROUND: Routine data from hospitals in the public healthcare system allow the analysis of large patient datasets without generating additional documentation efforts for hospitals. This study reports the frequencies of postoperative complications after thyroid surgery based on routine nationwide data. Moreover, volume-outcome relationships were investigated. MATERIAL AND METHODS: Nationwide routine data from insured patients of the Local Health Insurance Fund (AOK) who underwent thyroid surgery between 2008 and 2010 were analyzed. Complications were determined based on indicators for permanent vocal cord palsy, re-bleeding with re-operations and wound infections with specific treatment. The effect of hospital volumes (volume quintiles) on the indicators was determined by multivariate logistic regression. RESULTS: A total of 66,902 thyroid gland operations were identified. The overall frequency of permanent vocal cord palsy was 1.5 %, re-bleeding 1.8 % and wound infections 0.4 %. In the four lowest case volume categories the risk of permanent vocal cord palsy was significantly higher compared to the highest case volume hospitals (odds ratio 1.5, 1.7, 1.7 and 2.2, respectively). CONCLUSION: This study represents the reality of healthcare for thyroid surgery in Germany. Additionally, it was determined that the risk for permanent vocal cord palsy after thyroid gland operations decreased with increasing case volumes of hospitals.

Follicular variant of papillary thyroid cancer in Alström syndrome.

Alström syndrome (AS) is an autosomal recessive disorder, characterized by cone-rod dystrophy, sensorineural hearing loss, obesity, hyperinsulinemia with insulin resistance, type 2 diabetes mellitus and progressive pulmonary, hepatic and renal dysfunction. AS is caused by mutations in the ALMS1 gene, located on the short arm of chromosome 2. We report a 35-year-old woman with known history of AS, who developed a follicular variant of papillary thyroid carcinoma. To our knowledge this is the first association of AS with thyroid malignancy, among the approximately 450 cases reported since the first description of the syndrome. We conclude that papillary thyroid carcinoma should be considered in the differential diagnosis of thyroid nodules in patients with AS.

[Intraoperative management of undetectable parathyroid adenoma]. / Intraoperatives Management beim nicht auffindbaren Nebenschilddrüsenadenom.

Despite new technologies and progress in parathyroid gland imaging, missed parathyroid adenomas are still a problem. In reoperations most adenomas were found in eutopic positions. Adenoma in atypical positions were mostly situated in the thymus or in the esophageal-tracheal groove. Positive parathyroid imaging can be helpful but does not necessarily result in a better success rate than conventional bilateral exploration by an experienced surgeon, which is > 95 %. The knowledge of anatomy and embryological development of parathyroid glands is most important. Intraoperative determination of parathyroid hormone levels can help localize the site of the adenoma. Thyroid resection should only be performed if preoperative or intraoperative ultrasound indicates a tumor in the thyroid gland. The most important factor for a successful parathyroid operation is an experienced surgeon.

Failed surgery in primary hyperparathyroidism - what has changed with time.

Advanced preoperative imaging of parathyroid adenomas and intraoperative parathyroid hormone determination optimized the results in the surgical treatment of primary hyperparathyroidism patients. We asked, whether reasons for failure have changed during the last 25 years.We retrospectively analyzed operations for persistent primary hyperparathyroidism in our department between 2001 and 2011 (n=67), and compared these results to our experience between 1986 and 2001 (n=80).From 2001 to 2011, 765 primary hyperparathyroidism patients were operated on at our department. All but 4 patients were cured (761/765, 99.5%). 67 operations were performed for persistent primary hyperparathyroidism. Main reasons for failure were a misdiagnosed sporadic multiple gland disease in our own patients (18/29, 62.1%), and an undetected solitary adenoma in patients referred to us after -initial operation in another hospital (22/38, 57.9%) (statistically significant). From 1986 to 2001 (1 105 primary hyperparathyroidism patients), main indications for re-operation due to persistent disease were an undiagnosed sporadic multiple gland disease in our own patients (15/24, 62.5%), and a missed solitary adenoma in patients being operated on primarily somewhere else (38/56, 67.9%) (statistically significant).Comparing our experience in 147 patients with persistent primary hyperparathyroidism being operated on between 2001-2011 and 1986-2001, not much has changed with the modern armamentarium of improved preoperative imaging or intraoperative biochemical control. Whereas sporadic multiple gland disease was the most common reason for unsuccessful surgery in experienced hands, other units mainly failed due to an undetected solitary adenoma. Re-operations for persistent primary hyperparathyroidism performed by us were successful in 93.8% (2001-2011) and 96.0% (1986-2001), respectively.

[Indications for parathyroidectomy in renal hyperparathyroidism: comments on the significance of new therapeutics]. / Indikation zur operativen Therapie des renalen Hyperparathyreoidismus: Stellungnahme zur Bedeutung neuer medikamentöser Therapieverfahren.

New therapeutics for the treatment of chronic kidney disease and secondary hyperparathyroidism, such as calcium and aluminium-free phosphate binders, calcimimetic agents and active vitamin D metabolites may decrease the need for parathyroidectomy. The calcimimetic cinacalcet does not induce a longer lasting regression of renal hyperparathyroidism and autonomous growing of parathyroids and the therapeutic effect is limited to the period of treatment. The classical indications for surgery, hypercalcemia, vascular calcification, severe osteopathy, drug-resistant hyperphosphatemia and calciphylaxis are still valid if patients do not respond to medical therapy under the condition that adynamic bone disease is excluded. Individual operative risk factors and improvement of quality of life are important supplementary factors for the indication for parathyroidectomy.

Diagnosis and treatment of small follicular thyroid carcinomas.

BACKGROUND: Follicular thyroid microcarcinomas (mFTCs) of 10 mm or less in size rarely manifest clinically and their clinical significance is controversial. This study assessed their characteristics and incidence, and analysed treatment modalities used for mFTC. METHODS: Members of the German Association of Endocrine Surgeons were asked to review patients with mFTC operated on between 1990 and 2005. RESULTS: Data for 90 patients from 26 institutions were reported. Histopathological slides were available for re-evaluation in 35 patients. Most initial diagnoses had to be revised because of incorrect size assessment or incorrect diagnosis (benign adenoma, papillary thyroid carcinoma (PTC), follicular variant of PTC). The diagnosis of mFTC was confirmed in only four patients. As a result of the incorrect histopathological diagnosis, unnecessary completion thyroidectomy and radioiodine ablation were performed in 17 and 20 patients respectively. The incidence of mFTC was calculated to be 0.12 per million population per year. CONCLUSION: mFTC is exceptionally rare. Such tumours are overdiagnosed, resulting in unnecessary treatment associated with avoidable morbidity. Histopathological re-evaluation by an experienced pathologist is recommended before embarking on further treatments when a diagnosis of mFTC is made.

Operative treatment of renal autonomous hyperparathyroidism: cause of persistent or recurrent disease in 304 patients.

BACKGROUND: Subtotal parathyroidectomy (SPTX) and total parathyroidectomy with autotransplantation (TPTX and AT) are standard procedures in the treatment of renal autonomous hyperparathyroidism. In contrast to primary hyperparathyroidism, the persistence/recurrence rate is reported of up to 12.0%. PATIENTS AND METHODS: Between 1986 and 2000 we operated on 304 patients with renal autonomous hyperparathyroidism including 14 patients who were admitted after a primary operation in an outside hospital. Mean observation period was 51.4+/-38.9 months. RESULTS: The overall persistence/recurrence rate in our patients was 9.0% (26/290). After SPTX, excluding patients with an incomplete operation, it was 3.7%, and after TPTX and AT it was 6.0%. Reasons for developing recurrent or persistent disease in these patients were removal of less than 3.5 glands ( n=12), hyperplastic autograft ( n=5), and supernumerary gland ( n=4). After the first reoperation 7 patients (26.9%) had persistent or recurrent disease. CONCLUSIONS: An incomplete primary operation caused by missed cervical glands was the major reason for persistent ( n=8) or recurrent ( n=4) disease after different operative strategies in renal autonomous hyperparathyroidism.

The actual role of classic bilateral cervicotomic approach for primary hyperparathyroidism in the era of minimally invasive surgery.

UNLABELLED: Recent advances in preoperative localisation of parathyroid adenomas and intraoperative prove of complete removal of hyperfunctioning parathyroid tissue have fostered less invasive operative procedures which directly target the diseased gland. Such strategies have partially replaced the previous gold standard procedure of bilateral neck exploration. We herein report on our own series of 1099 consecutive operations for primary hyperparathyroidism performed in a 16 year period and provide information and arguments for primary bilateral exploration in selected cases. 97.1% of patients were cured by the primary operation. From 1999 through 2001, 200 patients underwent bilateral neck exploration, whereas 63 unilateral operations were performed (33 patients were treated by minimally invasive video-assisted parathyroidectomy (MIVAP) and 30 by minimally invasive open parathyroidectomy (MIOP). In the remaining 200 patients minimally invasive unilateral parathyroid surgery was not feasible due to concomitant goiter (n = 102), lack of preoperative localisation (n = 30), previous thyroid surgery (n = 10), suspected multiglandular disease (n = 10), or other reasons (n = 8). In 40 patients the decision for bilateral neck exploration was made despite feasibility of a unilateral approach. CONCLUSION: Whereas unilateral exploration produced excellent cure rates in older patients, it is not recommended in patients with a high likelihood of multiglandular disease, presence of a large or multinodular goitre, high PTH levels, giant adenoma, unclear MIBI scans or an unreliable OPTH assay. Contrasting recent reports on a dramatic shift of technique towards minimally invasive procedures unilateral parathyroid surgery may not be preferably advisable in a majority of patients from countries with insufficient iodine supplementation.

Is there any consensus in diagnostic and operative strategy with respect to medullary thyroid cancer? A questionnaire answered by 73 endocrine surgical units.

BACKGROUND: The purpose of this investigation was to analyze the individual diagnostic and operative strategy in the treatment of medullary thyroid carcinoma (MTC) in international specialized centers and to assess whether standard procedures are carried out in practice everywhere. METHODS: A questionnaire concerning diagnosis and treatment of patients with primary, persistent, or recurrent sporadic or familial MTC was sent to 263 members of the International Association of Endocrine Surgeons. RESULTS: Primary treatment of MTC does not show significant differences for patients with sporadic or familial disease (Chi-square, n.s.), and standard procedures are performed in only 25-40% of patients. Computed tomography scan is the most common localization procedure in persistent or recurrent disease (52-72%), followed by scintigraphy (43-71%), ultrasonography (41-56%), and magnetic resonance imaging (31-49%). In case of negative localization studies, 68-86% of colleagues do not recommend reoperation. In symptomatic patients with stage-IV tumors, however, 84% of colleagues advocate reoperation to provide relief from the tumor burden. CONCLUSIONS: Even with experienced endocrine surgeons, a consensus to uni- and/or bilateral neck dissection in primary MTC is lacking. The majority of authors supports at least total thyroidectomy with central lymph-node dissection. In recurrent disease, there is a general tendency to reoperate in case of positive localization studies and in case of symptomatic disease.

Parathyroid carcinoma: problems in diagnosis and the need for radical surgery even in recurrent disease.

INTRODUCTION: From 1986 to 1999 we operated on 963 patients with primary hyperparathyroidism (pHPT). METHODS AND RESULTS: Parathyroid carcinoma was diagnosed clinically and histologically in four patients (0.4%). In two of these patients diagnosis of parathyroid cancer was delayed by misinterpretation of the histopathology leading to an autotransplantation of malignant parathyroid tissue in one case. In two patients multivisceral surgery was performed: beside thyroidectomy, neck dissection, tracheal wall resection and resection of the muscular layer of the oesophagus one patient received oesophagectomy and gastric transposition and one patient a lung wedge resection. Both patients had a temporary palliation of tumour-associated symptoms after multivisceral surgery. The first patient died 2 years after oesophagectomy and 12 years after primary diagnosis from local tumour recurrence and cachexia. The second patient is living with tumour recurrence presenting a serum calcium level of 4.2 mmol/l (normal range 2.0 to 2.5 mol/l) and multiple brown tumours 2 years after lung resection and 6 years after the primary diagnosis. CONCLUSIONS: We conclude that parathyroid carcinomas, being difficult to diagnose, warrant radical surgery, including multivisceral resection to prolong survival and reduce tumour and hypercalcaemia associated symptoms.