Publications by authors named "Peter E Goretzki"

47 Publications

Insulinoma in pregnancy (a case presentation and systematic review of the literature).

Rare Tumors 2021 7;13:2036361320986647. Epub 2021 Feb 7.

Department of Surgery, Campus Charité Mitte|Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin.

Insulinomas are rare, benign and functional tumors that coincidentally may become overt during pregnancy or in the post-partum period. As the general symptoms of a pregnancy might cover the clinical presentation, diagnosing remains challenging. We present one additional case of a post-partum insulinoma, combined with a systematic review of the literature to sum up relevant details in diagnosis and treatment. A systematic request of Pubmed/Medline was conducted using the following terms: "insulinoma AND pregnancy" and "insulinoma" for a second request of ClinicalTrials.gov. All publications concerning pregnant or post-partum women with insulinoma were included. Thirty-six cases could be identified for analysis. Each publication was reviewed for demographic, diagnostic and therapeutic data. The most frequent clinical signs were unconsciousness and neurological symptoms. 64.9% were diagnosed during early pregnancy and 35.1% post-partum. 91.9% underwent surgery with a third resected during pregnancy without severe influence on fetal or maternal outcome. Three patients died of metastatic disease or misdiagnosing, two of them miscarried. Insulinoma in pregnancy is rare but should be considered in case of unclear hyperinsulinemic hypoglycemia. Surgery can be performed during the second trimester or post-partum with promising outcome.
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http://dx.doi.org/10.1177/2036361320986647DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7874339PMC
February 2021

A rare case of a patient with a high grade neuroendocrine tumor developing neutropenic sepsis after receiving PRRT combined with Capecitabine or Temozolomide: A case report.

Mol Clin Oncol 2021 Jan 27;14(1):20. Epub 2020 Nov 27.

Department of Hepatology and Gastroenterology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin 13353, Germany.

Neuroendocrine tumors (NET) are rare and demonstrate variable clinical behavior depending on the degree of tumor differentiation. Patients with poorly differentiated tumors (NET G3) have a poor prognosis. Systemic treatment with cytotoxic chemotherapy is considered to be the treatment of choice. In patients that are refractory or intolerant to first-line therapy, experts recommend peptide receptor radionuclide therapy (PRRT) in tumors that express somatostatin receptors. Recently, combinations of PRRT and chemotherapy were tested in patients with NET. Available data have reported promising tumor control rates and an excellent toxicity profile in cases where PRRT had been administered with capecitabine/temozolomide, even when administered as salvage therapy. The current study reported an exceptional case of advanced NET G3 with severe toxicity upon receiving PRRT in combination with capecitabine/temozolomide as third line therapy. The patient developed a life-threatening neutropenic fever, fungal pneumonia and necrotizing mastitis 23 days after the first cycle of therapy was administered. However, the treatment led to a significant reduction in tumor size. A total of 5 months after treatment initiation, the patient was alive and in excellent clinical condition with sustained tumor response. In summary, the current study presented a rare case of high grade NET exhibiting an almost complete response to PRRT in combination capecitabine/temozolomide, despite facing unexpected severe toxicity.
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http://dx.doi.org/10.3892/mco.2020.2182DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7725216PMC
January 2021

Influence of Parathyroidectomy on Kidney Graft Function in Secondary and Tertiary Hyperparathyroidism.

Transplant Proc 2020 Dec 11;52(10):3134-3143. Epub 2020 May 11.

Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany. Electronic address:

Background: Timing of parathyroidectomy (PTX) remains controversial in candidates for kidney transplant with concomitant renal hyperparathyroidism (HPT). The aim of this retrospective study was to identify the influence of early vs late posttransplant PTX compared to pretransplant PTX on renal graft function and morbidity.

Methods: This single-center cohort study includes 57 patients with renal HPT and kidney transplantation treated between 2007 and 2017. Ninety-six patients had surgery for renal HPT between 2007 and 2017 as a consecutive sample. Group 1 (n = 30; tertiary HPT), group 2 (n = 66; secondary HPT). Of group 1, 4 patients were excluded for PTX before and after kidney transplantation. In group 2, 20 patients were excluded since they had not undergone kidney transplantation during follow-up. Twelve patients were excluded because of short follow-up (kidney transplantation in 2018), and 3 patients were excluded because of transplant failure within 90 days. Twenty-six patients underwent posttransplant PTX (10 patients within 12 months after transplant), and 31 patients had undergone PTX prior to kidney transplantation. Graft function, serum calcium concentrations, parathyroid hormone (PTH) levels, postoperative morbidity, and 90-day mortality were recorded.

Results: Median age was 53.1 years in group 1 and 49.1 years in group 2. Most patients were male (53.8% in group 1; 54.8% in group 2). Median preoperative PTH levels were significantly different with 331.6 pg/mL in group 1 and 667.5 pg/mL in group 2 (P = .003). Creatinine levels changed little from 1.4 mg/dL (range, 0.8-2.5) to 1.7 mg/dL (range, 0.7-7.3) in group 1, and no difference was seen between early or late PTX after transplantation. In group 2, creatinine levels were 8.5 mg/dL (range, 4.6-11.7) before PTX and 8.7 mg/dL (range, 5.1-11.9) after PTX. We saw no correlation between postoperative PTH and kidney function. Thirty-five patients with postoperative PTH < 15 pg/mL displayed a mean postoperative creatinine of 5.5 mg/dL (range, 4.3-6.8), similar to other patients. Both the 30-day and 90-day mortality rates were zero.

Conclusions: PTX had no negative effect on graft function, whether performed before or after (early or late) kidney transplantation. Surgical cure of renal HPT should be performed as soon as possible to prevent secondary complications and can also be safely carried out early after transplantation.
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http://dx.doi.org/10.1016/j.transproceed.2020.03.024DOI Listing
December 2020

Long-term outcome of surgical resection in patients with gastroenteropancreatic neuroendocrine neoplasia: results from a German nation-wide multi-centric registry.

Langenbecks Arch Surg 2020 Mar 5;405(2):145-154. Epub 2020 May 5.

Department of General, Visceral and Transplant Surgery, Section of Endocrine Surgery, Charite, University Medicine Berlin, Berlin, Germany.

Background: Neuroendocrine neoplasia (NEN) are rare and heterogenous tumours. Few data exist on the impact of surgical therapy.

Materials And Methods: This is a retrospective analysis of prospectively collected data of gastroenteropancreatic NEN in the German NET-Registry (1999-2012). It focuses on patients without distant metastases (limited disease, LD, stage I-IIIB).

Results: Data of 2239 patients with NEN were recorded. Median age was 59 years, the gender ratio was 1:1.3 (f:m). A total of 986 patients (44%) had LD, and the 5-year survival rate (5 years) was 77% for all and 90% for patients with LD. A total of 1635 patients (73%) received a surgical therapy (1st to 6th line); the 5 and 10 ysr were 83/65% after and 59/35% without surgery for all patients (p < .001). The resection margins in the LD patients were 76%, 16%, and 3% for R0, R1 and R2, respectively. The 10 ysr was 84%, 59% and 42% for R0, R1 and R2 resections, respectively (p = .021 R0/R1, p < .001 R0/R2). The R0 resection rate was 75% for G1/G2 NET and 67% for G3 NEC.

Conclusion: The rate of complete tumour resection (R0) in LD is independent of tumour grading, and R0 resection is the key determinant of long-term survival, as demonstrated by the 10 ysr. of 84%. All NEN patients with limited disease should be considered for operation, if possible, as the best 10-year survival is shown after an R0 resection.
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http://dx.doi.org/10.1007/s00423-020-01868-1DOI Listing
March 2020

The Impact of Gender on Diagnosis and Treatment in Endocrine Surgery.

Authors:
Peter E Goretzki

Visc Med 2020 Feb 14;36(1). Epub 2020 Jan 14.

Department of General, Visceral and Transplant Surgery, Charité - University Medicine Berlin, Berlin, Germany.

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http://dx.doi.org/10.1159/000505502DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7036585PMC
February 2020

Early Postoperative Fasting Serum Glucose Levels are Useful in Depicting Future Diabetes Mellitus in Patients with Curative Insulinoma Surgery.

Exp Clin Endocrinol Diabetes 2020 Mar 30;128(3):158-163. Epub 2019 Apr 30.

Insulinoma and GEP Tumor Center Neuss-Düsseldorf, Lukaskrankenhaus Neuss, Neuss, Germany.

Background: Hyperglycemia has been reported in some patients after curative insulinoma resection but no systematic investigation of glucose metabolism has been shown in a larger cohort of these patients. Therefore, it is still unknown, whether long lasting hyperinsulinism in insulinoma patients induces insulin resistance, which may jeopardize the postoperative health status of these patients.

Methods: Early postoperative fasting serum glucose levels were measured in all insulinoma patients after curative tumor resection during the first 48 h, being operated between 2011 and 2018, retrospectively.

Results: Of 77 (100%) patients with benign, spontaneous occuring insulinoma 51 (66.2%) patients were operated on by tumor enucleation. In 15 (19.5%) patients a left pancreatic resection was performed and in 11 (14.3%) patients the pancreatic head or the middle console of pancreatic corpus were excised. In 32 (41.6%) cases the highest fasting postoperative glucose levels were measured between 140-200 mg/dl. In 16 (20.8%) patients the glucose serum levels reached values above 200 mg/dl and in 4 (5.2%) patients short term substitution with insulin was indicated. Only one (1.3%) of these patients developed diabetes mellitus with the need of ongoing insulin treatment. Major postoperative complications were registered in 31 of all 77 patients (40.3%) and in 9 of 16 patients (56.3%) with postoperative glucose levels above 200 mg/dl. This difference was not statistically significant.

Conclusions: Early postoperative (first 48 h) fasting serum glucose levels in insulinoma patients showed significant hyperglycemia above 200 mg/dl in only few patients (20.8%) and chronic postoperative Diabetes mellitus developed in only one of 77 patients (<2%). Therefore, recovery of glucose metabolism after insulinoma resection is fast and medical intervention is not mandatory in most of these patients.
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http://dx.doi.org/10.1055/a-0892-4157DOI Listing
March 2020

Stellenwert des Neuromonitorings in der Schilddrüsenchirurgie.

Zentralbl Chir 2018 10 24;143(5):451-454. Epub 2018 Oct 24.

Chirurgische Klinik, Campus Charité Mitte | Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin.

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http://dx.doi.org/10.1055/a-0623-8137DOI Listing
October 2018

International neuromonitoring study group guidelines 2018: Part II: Optimal recurrent laryngeal nerve management for invasive thyroid cancer-incorporation of surgical, laryngeal, and neural electrophysiologic data.

Laryngoscope 2018 10 6;128 Suppl 3:S18-S27. Epub 2018 Oct 6.

Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, U.S.A.

The purpose of this publication was to inform surgeons as to the modern state-of-the-art evidence-based guidelines for management of the recurrent laryngeal nerve invaded by malignancy through blending the domains of 1) surgical intraoperative information, 2) preoperative glottic function, and 3) intraoperative real-time electrophysiologic information. These guidelines generated by the International Neural Monitoring Study Group (INMSG) are envisioned to assist the clinical decision-making process involved in recurrent laryngeal nerve management during thyroid surgery by incorporating the important information domains of not only gross surgical findings but also intraoperative recurrent laryngeal nerve functional status and preoperative laryngoscopy findings. These guidelines are presented mainly through algorithmic workflow diagrams for convenience and the ease of application. These guidelines are published in conjunction with the INMSG Guidelines Part I: Staging Bilateral Thyroid Surgery With Monitoring Loss of Signal. Level of Evidence: 5 Laryngoscope, 128:S18-S27, 2018.
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http://dx.doi.org/10.1002/lary.27360DOI Listing
October 2018

International neural monitoring study group guideline 2018 part I: Staging bilateral thyroid surgery with monitoring loss of signal.

Laryngoscope 2018 10 5;128 Suppl 3:S1-S17. Epub 2018 Oct 5.

Mount Sinai Hospital, Department of Otolaryngology, Toronto, Ontario, Canada.

This publication offers modern, state-of-the-art International Neural Monitoring Study Group (INMSG) guidelines based on a detailed review of the recent monitoring literature. The guidelines outline evidence-based definitions of adverse electrophysiologic events, especially loss of signal, and their incorporation in surgical strategy. These recommendations are designed to reduce technique variations, enhance the quality of neural monitoring, and assist surgeons in the clinical decision-making process involved in surgical management of recurrent laryngeal nerve. The guidelines are published in conjunction with the INMSG Guidelines Part II, Optimal Recurrent Laryngeal Nerve Management for Invasive Thyroid Cancer-Incorporation of Surgical, Laryngeal, and Neural Electrophysiologic Data. Laryngoscope, 128:S1-S17, 2018.
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http://dx.doi.org/10.1002/lary.27359DOI Listing
October 2018

Curative and palliative surgery in patients with neuroendocrine tumors of the gastro-entero-pancreatic (GEP) tract.

Rev Endocr Metab Disord 2018 06;19(2):169-178

Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany.

The incidence of neuroendocrine tumors (NET) increases with age. Lately, the diagnosis of NET was mainly caused by early detection of small NET (<1 cm) in the rectum and stomach, which are depicted by chance during routine and prophylactic endoscopy. Also in patients with large and metastatic pancreatic and intestinal tumors thorough pathologic investigation with use of different immunohistologic markers discovers more neuroendocrine tumors with low differentiation grade (G2-G3) and more neuroendocrine carcinomas (NEC), nowadays, than in former times. While gastric and rectal NET are discovered as small (<1 cm in diameter) and mainly highly differentiated tumors, demonstrating lymph node metastases in less than 10% of the patients, the majority of pancreatic and small bowel NET have already metastasized at the time of diagnosis. This is of clinical importance, since tumor stage and differentiation grade not only influence prognosis but also surgical procedure and may define whether a combination of surgery with systemic biologic therapy, chemotherapy or local cytoreductive procedures may be used. The indication for surgery and the preferred surgical procedure will have to consider personal risk factors of each patient (i.e. general health, additional illnesses, etc.) and tumor specific factors (i.e. tumor stage, grade of differentiation, functional activity, mass and variety of loco regional as well as distant metastases etc.). Together they define, whether radical curative or only palliative surgery can be applied. Altogether surgery is the only cure for locally advanced NET and helps to increase quality of life and overall survival in many patients with metastatic neuroendocrine tumors. The question of cure versus palliative therapy sometimes only can be answered with time, however. Many different aspects and various questions concerning the indication and extent of surgery and the best therapeutic procedure are still unanswered. Therefore, a close multidisciplinary cooperation of colleagues involved in biochemical and localization diagnostics and those active in various treatment areas is warranted to search for the optimal strategy in each individual patient. How far genetic screening impacts survival remains to be seen. Since surgeons do have a central role in the treatment of NET patients, they have to understand the need for integration into such an interdisciplinary team.
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http://dx.doi.org/10.1007/s11154-018-9469-9DOI Listing
June 2018

Indications for the Surgical Management of Benign Goiter in Adults.

Dtsch Arztebl Int 2018 01;115(1-02):1-7

Department of Visceral, Thoracic and Vascular Surgery, University Hospital of Giessen and Marburg; Marburg; Department of Nuclear Medicine, University Hospital of Giessen and Marburg; Marburg; German Society for General and Visceral Surgery, Berlin; Department of General and Visceral Surgery, Sana Klinikum Offenbach; Offenbach; Department of General, Visceral and Vascular Surgery, University Hospital of Würzburg; Würzburg; Department of General, Visceral and Endocrine Surgery, Lukaskrankenhaus Neuss; Neuss.

Background: Thyroidectomy is still three to six times more common in Germany than in the USA, Great Britain, and the Scandinavian countries. Thus, the question is often asked whether thyroidectomy in Germany is being performed for the correct indications.

Methods: This review is based on studies and guidelines containing information on the indications for surgery in benign goiter and Graves' disease; these publications were retrieved by a systematic literature search in the Medline and Cochrane Library databases (1990-2016). The indications recommended here were determined by vote by the German Society for General and Visceral Surgery (Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie, DGAV).

Results: On the basis of the available evidence (levels 2-4), and in the absence of prospective studies, the indications for surgery in goiter include a well-founded suspicion of malignancy, local compressive symptoms, and, rarely, cosmesis. In hyperthyroid goiter and Graves' disease, surgery is a potential alternative to radio - iodine therapy, particularly if the volume of the thyroid gland exceeds 80 mL, in patients with advanced or active orbitopathy, and in female patients who are, or plan to be, pregnant. Large, asymptomatic, euthyroid nodular goiter without any suspicion of malignancy and scintigraphically "cold" nodules without any other evidence of malignancy are not indications for surgery. Thyroid operations of higher levels of difficulty (e.g., recurrent goiter, retrosternal extension, Graves' disease) should be carried out in institutions with special expertise in thyroid surgery.

Conclusion: The decision to operate should be made on an interdisciplinary basis and in conformity with the relevant guidelines after all of the appropriate diagnostic studies have been performed. The radicality of any proposed surgical procedure should be weighed against its potential complications.
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http://dx.doi.org/10.3238/arztebl.2018.0001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5778395PMC
January 2018

Measurement of Basal Serum Calcitonin for the Diagnosis of Medullary Thyroid Cancer.

Horm Metab Res 2018 01 23;50(1):23-28. Epub 2017 Nov 23.

Division for Specific Endocrinology, Medical Faculty, University Hospital Duesseldorf, Duesseldorf, Germany.

Calcitonin (CT), a tumor marker for medullary thyroid cancer (MTC), can be stimulated with pentagastrin or calcium. Because of the unavailability of pentagastrin, basal CT measurement is frequently used for the preoperative diagnosis of MTC. The aim of the study was to define basal serum calcitonin (bCT) cut-off thresholds for diagnosing MTC. Within a retrospective analysis, 114 patients (51 males) were included fulfilling the criteria of an increased preoperative bCT level (>10 pg/ml) and the criteria of an available postoperative histology analysis. Based on a ROC plot analysis, the cut-off values for the diagnosis of MTC vs. non-malignancy (C cell hyperplasia and goiter) were identified. The most precise bCT thresholds for the identification of MTC were ≥46 pg/ml for males (sensitivity: 93.6%, specificity: 95.0%, PPV: 97%, NPV: 90%) and ≥35 pg/ml for females (sensitivity: 87.3%, specificity: 87.5%, PPV: 98%, NPV: 50%). Using these cut-offs, only 6% of male patients were not identified of having MTC, whereas 5% were false positive (having instead C cell hyperplasia). In females, the discrepancy was higher since 13% of female MTC patients were false negative by using the cut-off of ≥35 pg/ml, and 13% had false positive results (suffering from C cell hyperplasia). Gender-specific bCT cut-offs for the identification of MTC vs. C cell hyperplasia and non-malignancy were defined, which can be used in clinical routine. In female patients, however, the accuracy is much lower compared to males.
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http://dx.doi.org/10.1055/s-0043-122237DOI Listing
January 2018

Evaluation of malignant parathyroid tumours in two European cohorts of patients with sporadic primary hyperparathyroidism.

Langenbecks Arch Surg 2016 Nov 11;401(7):943-951. Epub 2015 Dec 11.

Department of Surgery, Lukas Hospital, Neuss, Germany.

Purpose: Parathyroid carcinoma (PC) is remarkable for its rare occurrence and challenging diagnostics. PC accounts for 0.1-5 % cases of primary hyperparathyroidism (PHPT). The differentiation from benign tumours is difficult even by morphological criteria. To address these issues, we assessed the PC frequency in two separate European PHPT cohorts and evaluated the demographic, clinical, morphological and molecular background.

Methods: A retrospective study was carried out, using continuously maintained database (2005-2014) of PHPT patients from two tertiary referral university hospitals in Europe. The demographic, clinical data and frequency of PC among surgically treated PHPT was detected. Immunohistochemistry (IHC) was performed to detect parafibromin, representing protein product of HRPT2 gene and proliferation marker Ki-67.

Results: Both PHPT cohorts were characterised by close mean age values (58.6 and 58.0 years) and female predominance. The frequency of PC differed significantly between the cohorts: 2.1 vs. 0.3 %; p = 0.004. PC was characterised by invariable complete loss of parafibromin contrasting with parathyroid adenomas. The proliferation fraction was similar in both PC cohorts (10.6 and 11.0 %). PC showed significantly higher proliferation fraction than typical parathyroid adenomas (1.6 %), atypical adenomas (1.6 %) or adenomas featuring focal loss of parafibromin (2.2 %).

Conclusions: PC frequency can range significantly between the two European cohorts. The differences can be attributable to selection bias of patients referred for surgery and are not caused by discordant definition of malignant parathyroid histology. Diffuse loss of parafibromin and increased proliferation fraction by Ki-67 are valuable adjuncts in PC diagnostics due to significant differences with various clinical and morphological subtypes of adenoma.
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http://dx.doi.org/10.1007/s00423-015-1361-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5086340PMC
November 2016

Total Parathyroidectomy With Routine Thymectomy and Autotransplantation Versus Total Parathyroidectomy Alone for Secondary Hyperparathyroidism: Results of a Nonconfirmatory Multicenter Prospective Randomized Controlled Pilot Trial.

Ann Surg 2016 Nov;264(5):745-753

*Department for General, Visceral, and Vascular Surgery, Agaplesion Evangelisches Krankenhaus Mittelhessen, Giessen, Germany †Department for Visceral, Thoracic, and Vascular Surgery, University Hospital of Giessen and Marburg, Marburg, Germany ‡Department for General, Visceral, and Transplantation Surgery, University Heidelberg, Heidelberg, Germany §Institute of Medical Biometry and Informatics, University Heidelberg, Heidelberg, Germany ¶Department for General and Visceral Surgery, Marienhospital Osnabrück, Osnabrück, Germany ||Department for General, Visceral, Vascular, and Thoracic Surgery, Universitätsmedizin Berlin, Charité Campus Mitte, Berlin, Germany **Department of Surgery, Lukaskrankenhaus Neuss, Neuss, Germany ††Department of Surgery, University Medical Center Regensburg, Regensburg, Germany ‡‡Department of Visceral, Thoracic, and Vascular Surgery, Carl Gustav Carus University Hospital, Dresden, Germany.

Objective: This randomized controlled multicenter pilot trial was conducted to find robust estimates for the rates of recurrence of 2 surgical strategies for secondary hyperparathyroidism (SHPT) within 36 months of follow-up.

Background: SHPT is a frequent consequence of chronic renal failure. Total parathyroidectomy with autotransplantation (TPTX+AT) and subtotal parathyroidectomy (SPTX) are the standard surgical procedures. Total parathyroidectomy alone (TPTX) might be a good alternative, as morbidity and recurrence rates are low according to small-scale retrospective studies.

Methods: The trial was performed as a nonconfirmatory randomized controlled pilot trial with 100 patients on long-term dialysis with otherwise uncontrollable SHPT to generate data on the rate of recurrent disease within a 3-year follow-up period after TPTX or TPTX+AT. Parathyroid hormone (PTH) and calcium levels, recurrent or persistent hyperparathyroidism, parathyroid reoperations, morbidity, and mortality were evaluated during a 3-year follow-up.

Results: A total of 52 patients underwent TPTX and 48 TPTX+AT. Patient characteristics, preoperative baseline data, duration of surgery (02:29 vs 02:47 hrs, P = 0.17) and mean hospital stay (10 ± 7.1 vs 8 ± 3.7 days, P = 0.11) did not differ significantly. Persistent SHPT developed in 1 TPTX and 2 TPTX+AT patients. None of the TPTX patients required delayed parathyroid AT to treat permanent hypoparathyroidism. Serum-calcium values were similar (2.1 ± 0.3 vs 2.1 ± 0.2, P = 0.95) whereas PTH rose by time in the TPTX+AT group and was significantly higher at the end of follow-up when compared with the TPTX group (31.7 ± 43.6 vs 98.2 ± 156.8, P = 0.02). Recurrent SHPT developed in 4 TPTX+AT and none of the TPTX patients.

Conclusions: TPTX+AT and TPTX seem to be safe and equally effective for the treatment of otherwise uncontrollable SHPT. TPTX seems to suppress PTH more effectively and showed no recurrences after 3 years. The hypothesis that TPTX is superior to TPTX+AT referring to the rate of recurrent SHPT has to be tested in a large-scale confirmatory trial. Nevertheless, TPTX seems to be a feasible alternative therapeutic option for the surgical treatment of SHPT.
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http://dx.doi.org/10.1097/SLA.0000000000001875DOI Listing
November 2016

Resection of Ileoinguinal and Ileohypogastric Nerves Combined with Gluing in Modified Lichtenstein Repair.

Surg Technol Int 2015 May;26:143-8

Department of Colorectal and Hernia Surgery, Lukaskrankenhaus Neuss GmbH, Academic Teaching Hospital of Heinrich Heine University, Düsseldorf, Germany.

We conducted a cohort trial to investigate the relevance of resection of the ilioinguinal and iliohypogastric nerves in combination with mesh fixation with BioGlue™ (CryoLife® Inc., Kennsaw, Georgia) in modified Lichtenstein repair to the development of chronic pain and hernia recurrence.1 In all, 430 patients underwent Lichtenstein repair. In 247 patients the mesh was fixed by means of glue, and in 183 patients it was fixed with conventional sutures. In all cases the inguinal nerves N. ilioinguinalis and N. iliohypogastricus were located and resected after identification to prevent nerve reaction to the mesh. The pain intensity was measured with a numeric analogous scale (NAS) 24 hours after surgery. All complications were recorded with a follow-up of up to 5 years. There was a significantly lower pain intensity level in the gluing group compared with the suture group 24 hours after surgery (0.016 t test). The level was 3.8±2.4 in bilateral hernia and 3.3±2.1 in unilateral hernia in the gluing group. It was 4.7±3.3 in unilateral and 3.7±2.2 in bilateral hernia in the suture group. The cut-suture time was lower in the gluing group. There were no severe pain syndromes (NAS≥4) in the gluing group and only 1.1% in the suture group. There was a higher incidence of non-bacterial wound infections in the gluing group (3.6%) than in the suture group (1.1%). The rate of recurrence after 5 years amounted to 2.0% in the gluing group and 2.2% in the suture group. The technique of using BioGlue™ for mesh fixation combined with systematic nerve dissection reduces acute and chronic postoperative pain after modified Lichtenstein repair. Only 2 of 430 patients suffered from severe chronic pain. Combined gluing and systematic resection of the inguinal nerves is more comfortable than standard Lichtenstein repair.
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May 2015

Encapsulated cells expressing a chemotherapeutic activating enzyme allow the targeting of subtoxic chemotherapy and are safe and efficacious: data from two clinical trials in pancreatic cancer.

Pharmaceutics 2014 Aug 11;6(3):447-66. Epub 2014 Aug 11.

Austrianova Singapore Pte Ltd, Centros, Biopolis, Singapore.

Despite progress in the treatment of pancreatic cancer, there is still a need for improved therapies. In this manuscript, we report clinical experience with a new therapy for the treatment of pancreatic cancer involving the implantation of encapsulated cells over-expressing a cytochrome P450 enzyme followed by subsequent low-dose ifosfamide administrations as a means to target activated ifosfamide to the tumor. The safety and efficacy of the angiographic instillation of encapsulated allogeneic cells overexpressing cytochrome P450 in combination with low-dose systemic ifosfamide administration has now been evaluated in 27 patients in total. These patients were successfully treated in four centers by three different interventional radiologists, arguing strongly that the treatment can be successfully used in different centers. The safety of the intra-arterial delivery of the capsules and the lack of evidence that the patients developed an inflammatory or immune response to the encapsulated cells or encapsulation material was shown in all 27 patients. The ifosfamide dose of 1 g/m2/day used in the first trial was well tolerated by all patients. In contrast, the ifosfamide dose of 2 g/m2/day used in the second trial was poorly tolerated in most patients. Since the median survival in the first trial was 40 weeks and only 33 weeks in the second trial, this strongly suggests that there is no survival benefit to increasing the dose of ifosfamide, and indeed, a lower dose is beneficial for quality of life and the lack of side effects. This is supported by the one-year survival rate in the first trial being 38%, whilst that in the second trial was only 23%. However, taking the data from both trials together, a total of nine of the 27 patients were alive after one year, and two of these nine patients were alive for two years or more.
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http://dx.doi.org/10.3390/pharmaceutics6030447DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4190529PMC
August 2014

Postoperative vocal cord dysfunction despite normal intraoperative neuromonitoring: an unexpected complication with the risk of bilateral palsy.

World J Surg 2014 Oct;38(10):2597-602

Department of General, Visceral, Endocrine, Thoracic, and Vascular Surgery, Lukaskrankenhaus GmbH Neuss, 84 Preussenstrasse, 41464, Neuss, Germany,

Background: Intraoperative neuromonitoring (IONM) has become standard practice in thyroid surgery for many surgeons. It reduces the risk of vocal cord palsy in high-risk patients and has led to two-stage operations to prevent bilateral palsies. The specificity of detecting nerve injuries is not 100 %, leading to patients with vocal cord dysfunction (VCD) despite regular neuromonitoring (false-negative IONM). We aimed to evaluate possible risk factors for this phenomenon and its importance regarding bilateral palsies.

Methods: We performed a retrospective analysis of all patients with false-negative IONM.

Results: A total of 2152 patients (3426 nerves at risk) underwent surgery for benign disease between January 2008 and October 2010. Sensitivity for predicting VCD was 85.4 % and specificity 99.0 %. The positive predictive value was 68.0 % and the negative predictive value 99.6 %. We were not able to identify risk factors for false-negative IONM. We found four patients with delayed occurrence of VCD after regular IONM (1-8 weeks). We registered two patients with bilateral VCD after false negative IONM on the first side of bilateral resections (2/7) and four patients with bilateral palsy after correct IONM (4/1256). The relative risk for bilateral VCD between patients with false-negative IONM on the primary resection side and patients with correct IONM was 89.7.

Conclusions: Although seldom, false-negative IONM is of clinical importance as it bears a high risk of bilateral VCD if it occurs on the first side of a bilateral resection. It can also have a latent occurrence after surgery.
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http://dx.doi.org/10.1007/s00268-014-2591-2DOI Listing
October 2014

Functional long-term results after rectal cancer surgery--technique of the athermal mesorectal excision.

Int J Colorectal Dis 2014 Mar 5;29(3):285-92. Epub 2013 Dec 5.

Department of General Surgery, Städtisches Klinikum, Lukaskrankenhaus Neuss, Neuss, Germany,

Purpose: The total mesorectal excision (TME), embedded in a multimodal therapeutic concept, is accepted as the standard therapy of the advanced adenocarcinoma of the middle and lower thirds. The thermal damages of the autonomous nerves in the little pelvis caused by dissection devices remains a large problem. For our patients, we use water-jet dissection (WJD)-aided TME with the intention to minimise the rate of bladder and sexual function disorders.

Methods: From October 2001 until June 2010, we recorded 125 patients with an adenocarcinoma of the middle and lower third of the rectum. Ninety deep anterior rectum resections and 35 abdominoperineal rectum extirpations by WJD were performed. Of the patients, 27.2 % received neoadjuvant radiochemotherapy. Bladder and sexual function disorders were assessed by International Prostate Symptom Score and International Index of Erectile Function.

Results: The median follow-up period was 46 (2-117) months. Considering a local recurrence rate of 9.6 %, the tumour-specific 5-year survival of the entire collective was 75.4 %. Long-term bladder function disorders showed in 6.0 % (4/64) and sexual function disorders in 25.0 % (9/36) of the male patients in the course of time.

Conclusion: The specific advantage of the WJD technique is not only the facilitated dissection between the mesorectal fascia and the surrounding nervous structures in the little pelvis but also a completely athermal TME. The rate of bladder and sexual function disorders is an excellent result compared to that of international centres. Due to the size of the patient collective and the retrospective character of the study, further studies are necessary to validate the presented results.
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http://dx.doi.org/10.1007/s00384-013-1805-7DOI Listing
March 2014

Is the covering of the resection margin after distal pancreatectomy advantageous?

Eur J Med Res 2013 Sep 28;18:33. Epub 2013 Sep 28.

Department of Visceral and Endocrine Surgery, Lukaskrankenhaus Neuss, Preussenstr, 84, Neuss, 41464, Germany.

Background: In recent years, many advances in pancreatic surgery have been achieved. Nevertheless, the rate of pancreatic fistula following pancreatic tail resection does not differ between various techniques, still reaching up to 30% in prospective multicentric studies. Taking into account contradictory results concerning the usefulness of covering resection margins after distal pancreatectomy, we sought to perform a systematic, retrospective analysis of patients that underwent distal pancreatectomy at our center.

Methods: We retrospectively analysed the data of 74 patients that underwent distal pancreatectomy between 2001 and 2011 at the community hospital in Neuss. Demographic factors, indications, postoperative complications, surgical or interventional revisions, and length of hospital stay were registered to compare the outcome of patients undergoing distal pancreatectomy with coverage of the resection margins vs. patients undergoing distal pancreatectomy without coverage of the resection margins. Differences between groups were calculated using Fisher's exact and Mann-Whitney U test.

Results: Main indications for pancreatic surgery were insulinoma (n=18, 24%), ductal adenocarcinoma (n=9, 12%), non-single-insulinoma-pancreatogenic-hypoglycemia-syndrome (NSIPHS) (n=8, 11%), and pancreatic cysts with pancreatitis (n=8, 11%). In 39 of 74 (53%) patients no postoperative complications were noted. In detail we found that 23/42 (55%) patients with coverage vs. 16/32 (50%) without coverage of the resection margins had no postoperative complications. The most common complications were pancreatic fistulas in eleven patients (15%), and postoperative bleeding in nine patients (12%). Pancreatic fistulas occurred in patients without coverage of the resection margins in 7/32 (22%) vs. 4/42 (1011%) with coverage are of the resection margins, yet without reaching statistical significance. Postoperative bleeding ensued with equal frequency in both groups (12% with coverage versus 13% without coverage of the resection margins). The reoperation rate was 8%. The hospital stay for patients without coverage was 13 days (5-60) vs. 17 days (8-60) for patients with coverage.

Conclusions: The results show no significant difference in the fistula rate after covering of the resection margin after distal pancreatectomy, which contributes to the picture of an unsolved problem.
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http://dx.doi.org/10.1186/2047-783X-18-33DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3849835PMC
September 2013

Hedgehog-signaling is upregulated in non-producing human adrenal adenomas and antagonism of hedgehog-signaling inhibits proliferation of NCI-H295R cells and an immortalized primary human adrenal cell line.

J Steroid Biochem Mol Biol 2014 Jan 21;139:7-15. Epub 2013 Sep 21.

Department of Endocrinology and Diabetology, Medical Faculty, University of Dusseldorf, D-40225 Duesseldorf, Germany; Department of Oto-Rhino-Laryngology, Head and Neck Surgery, Medical Faculty, University of Dusseldorf, D-40225 Duesseldorf, Germany.

Hedgehog (Hh)-signaling pathway is important in embryonic development. Activation of Hh-signaling is associated with tumorigenesis. Recent studies demonstrate that Hh-signaling is involved in the development of the adrenal gland in mice and is important in regulating adrenal proliferation. We studied the expression of Sonic hedgehog (SHH), Smoothened (SMO), Patched1 (PTCH1) and GLI family zinc finger 1 (GLI1) in human adrenal and in adrenocortical tumors using immunohistochemistry and semi-quantitative reverse transcriptase-polymerase chain reaction. Modulation of GLI1 and SMO messenger ribonucleic acid (mRNA) expression was investigated with forskolin. The role of Hh-signaling was studied in NCI-H295R cells and in an immortalized primary cell line using the Hh-agonist smoothened agonist (SAG) and the Hh-antagonist cyclopamine. The Hh-pathway components SHH, GLI1, PTCH1 and SMO were detectable in all adrenal glands. While in cortisol-producing adenomas (CPA), Hh-signaling expression levels were comparable to that in normal adrenal cortex, a much higher mRNA expression of GLI1, SMO and SHH was observed in non-producing adenomas (NPA). Interestingly, stimulation of cultured adrenal cells with forskolin led to a decrease in expression of GLI1 and SMO mRNAs. Antagonism of Hh-signaling resulted in a lower proliferation rate of adrenocortical cells, while Hh-agonism had no significant effect on adrenal cell proliferation. Our data show Hh-signaling activity in adult adrenal glands. Activation of the PKA pathway results in lower expression of Hh-signaling proteins. This might explain the lower expression of the Hh components GLI1 and SMO in CPA in comparison to the higher expression in NPA. Hh-signaling might be involved in the tumorigenesis of NPA.
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http://dx.doi.org/10.1016/j.jsbmb.2013.09.007DOI Listing
January 2014

German Association of Endocrine Surgeons practice guideline for the surgical management of malignant thyroid tumors.

Langenbecks Arch Surg 2013 Mar 3;398(3):347-75. Epub 2013 Mar 3.

Department of General, Visceral and Vascular Surgery, Martin Luther University Halle-Wittenberg, Ernst-Grube-Straße 40, 06097, Halle, Saale, Germany.

Introduction: Over the past years, the incidence of thyroid cancer has surged not only in Germany but also in other countries of the Western hemisphere. This surge was first and foremost due to an increase of prognostically favorable ("low risk") papillary thyroid microcarcinomas, for which limited surgical procedures are often sufficient without loss of oncological benefit. These developments called for an update of the previous practice guideline to detail the surgical treatment options that are available for the various disease entities and tumor stages.

Methods: The present German Association of Endocrine Surgeons practice guideline was developed on the basis of clinical evidence considering current national and international treatment recommendations through a formal expert consensus process in collaboration with the German Societies of General and Visceral Surgery, Endocrinology, Nuclear Medicine, Pathology, Radiooncology, Oncological Hematology, and a German thyroid cancer patient support organization.

Results: The practice guideline for the surgical management of malignant thyroid tumors includes recommendations regarding preoperative workup; classification of locoregional nodes and terminology of surgical procedures; frequency, clinical, and histopathological features of occult and clinically apparent papillary, follicular, poorly differentiated, undifferentiated, and sporadic and hereditary medullary thyroid cancers, thyroid lymphoma and thyroid metastases from primaries outside the thyroid gland; extent of thyroidectomy; extent of lymph node dissection; aerodigestive tract resection; postoperative follow-up and surgery for recurrence and distant metastases.

Conclusion: These evidence-based recommendations for surgical therapy reflect various "treatment corridors" that are best discussed within multidisciplinary teams and the patient considering tumor type, stage, progression, and inherent surgical risk.
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http://dx.doi.org/10.1007/s00423-013-1057-6DOI Listing
March 2013

IONM-guided goiter surgery leading to two-stage thyroidectomy--indication and results.

Langenbecks Arch Surg 2013 Mar 23;398(3):411-8. Epub 2012 Nov 23.

Department of General Surgery, Endocrine Surgery, Abdominal Surgery, Thorax Surgery, Vascular Surgery, Colorectal and Hernia Surgery, Lukaskrankenhaus GmbH, Preußenstraße 84, 41464 Neuss, Germany.

Purpose: Intraoperative neuromonitoring (IONM) in thyroid surgery allows for changing the operative strategy during bilateral procedures to avoid bilateral recurrent laryngeal nerve palsy (RLNP). While this strategy is comprehendible for the surgeon, the question remains, whether it is always necessary.

Methods: Two thousand five hundred forty-six patients underwent surgery with IONM between January 2008 and October 2010 (4,012 nerves at risk). We performed a retrospective review of all patients after thyroid surgery. In 98 cases, signal loss occurred on the primary side. Of these patients, 64 required bilateral surgery. We proceeded with the contralateral surgery in 24 cases. Forty operations were ended unilaterally. The second operation was performed on 18 patients in total, 16 after confirmation of primarily intact (n = 8) or recovered vocal cord function (n = 8) and twice under persisting dysfunction. Patient satisfaction was evaluated using a five-point scale.

Results: We have shown a significant difference (p = 0.017) in the rate of bilateral RLNP when signal loss on the primary side resulted in termination of the procedure compared to continuation. Our evaluation of patient satisfaction did not show a significant difference when comparing the two-stage operation to other procedures.

Conclusions: We have shown a significant difference in the rate of bilateral RLNP when comparing termination and continuation of a bilateral procedure after primary IONM signal loss. We strongly recommend a two-stage thyroidectomy after signal loss on the primary side of resection in benign bilateral goiter surgery.
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http://dx.doi.org/10.1007/s00423-012-1032-7DOI Listing
March 2013

Cinacalcet effects on the perioperative course of patients with secondary hyperparathyroidism.

Langenbecks Arch Surg 2013 Jan 25;398(1):131-8. Epub 2012 Sep 25.

Department of Visceral and Endocrine Surgery, Lukaskrankenhaus Neuss, Preussenstr. 84, 41464 Neuss, Germany.

Purpose: Since its registration in 2004, the calcimimetic agent cinacalcet has been established as an alternative treatment for secondary hyperparathyroidism (SHPT). Working by allosteric activation of the calcium-sensing receptor, cinacalcet can lower parathyroid hormone (PTH) and calcium (Ca) in patients with SHPT. The influence of calcimimetics on the perioperative course has been unclear so far.

Methods: We retrospectively analyzed the data of patients with primary operation for SHPT between 2004 and 2011, comparing the perioperative course of patients with and without preoperative cinacalcet treatment.

Results: Fifty-six patients had cinacalcet therapy, and 54 patients had no calcimimetic medication prior to surgery. Gender, age, hemodialysis, and medical treatment were similar in both groups. Also, PTH levels were similar preoperatively and postoperatively (preoperative, 1,249 ± 676 vs. 1,196 ± 601 pg/ml; postoperative, 86 ± 220 vs. 62 ± 91 pg/ml). Patients with cinacalcet preoperatively had significant lower Ca levels preoperatively (2.49 ± 0.25 vs. 2.61 ± 0.24 mmol/l) and postoperatively (1.75 ± 0.37 vs. 1.86 ± 0.35 mmol/l) and had a higher rate of oral Ca substitution postoperatively (93 vs. 74 %). The risk for postoperative persistent disease was slightly higher in these patients compared to those without preoperative cinacalcet therapy (5 vs. 0 %, not significant).

Conclusions: In our experience, cinacalcet did not alter the perioperative course in SHPT patients.
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http://dx.doi.org/10.1007/s00423-012-1005-xDOI Listing
January 2013

Evaluation of Biocompatibility of Alloplastic Materials: Development of a Tissue Culture In Vitro Test System.

Surg Technol Int 2011 Dec;21:21-7

Department of Urology, Lukas Hospital, Neuss, Germany, Oncologist, West German Cancer Center, University of Essen, Essen, Germany.

Optimized biocompatibility is a major requirement for alloplastic materials currently applied in surgical approaches for hernia, incontinence, and prolapse situations. Tissue ingrowth/adherence and formation of connective tissue seem to have important influence in mesh incorporation at the implant site. In an in vitro approach we randomly investigated 7 different mesh types currently used in surgeries with various indications with regard to their adherence performance. Using a tissue culture approach, meshes were incubated with tissue representative of fibroblasts, muscle cells, and endothelial cells originating from 10 different patients. After 6 weeks, the meshes were assessed microscopically and a ranking of their adherence performance was established. Tissue culture was successful in 100% of the probes. We did not remark on interindividual differences concerning the growth and adherence performance after incubation with the different meshes in the investigated 10 patients. The ranking was consistent in all patients. In this test system, PVDF Dynamesh® (FEG Textiltechnik, Aachen, Germany) was the mesh with the best growth-in score. The test system was feasible and reproducible. Pore size seems to be a predictor of adherence performance. The test system may be a helpful tool for further investigations, and the predictive value should be assessed in further in vitro and in vivo experiments.
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December 2011

German Association of Endocrine Surgeons practice guidelines for the surgical treatment of benign thyroid disease.

Langenbecks Arch Surg 2011 Jun 22;396(5):639-49. Epub 2011 Mar 22.

Section of Endocrine Surgery, Clinic of General and Abdominal Surgery, University Medical Center, Gutenberg University-Mainz, Langenbeckstr. 1, 55101, Mainz, Germany.

Introduction: Benign thyroid disorders are among the most common diseases in Germany, affecting around 15 million people and leading to more than 100,000 thyroid surgeries per year. Since the first German guidelines for the surgical treatment of benign goiter were published in 1998, abundant new information has become available, significantly shifting surgical strategy towards more radical interventions. Additionally, minimally invasive techniques have been developed and gained wide usage. These circumstances demanded a revision of the guidelines.

Methods: Based on a review of relevant recent guidelines from other groups and additional literature, unpublished data, and clinical experience, the German Association of Endocrine Surgeons formulated new recommendations on the surgical treatment of benign thyroid diseases. These guidelines were developed through a formal expert consensus process and in collaboration with the German societies of Nuclear Medicine, Endocrinology, Pathology, and Phoniatrics & Pedaudiology as well as two patient organizations. Consensus was achieved through several moderated conferences of surgical experts and representatives of the collaborating medical societies and patient organizations.

Results: The revised guidelines for the surgical treatment of benign thyroid diseases include recommendations regarding the preoperative assessment necessary to determine when surgery is indicated. Recommendations regarding the extent of resection, surgical techniques, and perioperative management are also given in order to optimize patient outcomes.

Conclusions: Evidence-based recommendations for the surgical treatment of benign thyroid diseases have been created to aid the surgeon and to support optimal patient care, based on current knowledge. These recommendations comply with the Association of the Scientific Medical Societies in Germany requirements for S2k guidelines.
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http://dx.doi.org/10.1007/s00423-011-0774-yDOI Listing
June 2011

Water-jet dissection in rectal cancer surgery: surgical and oncological outcomes.

Surg Technol Int 2010 Oct;20:115-23

Department of General Surgery, Abdominal Surgery, Thorax and Vascular Surgery, Coloproctology, and Hernia Surgery, Städtisches Klinikum, Lukaskrankenhaus, Neuss, Germany.

Unlabelled: These days the treatment of rectal cancer remains an encounter for various medical disciplines. A key position in the whole concept of therapy is still taken by surgery itself. To facilitate the advantages of the total mesorectal excision (TME) we used the water-jet dissector (WJD) in our surgical routine. Our object was to analyze perioperative data as well as oncological long-term results following WJD-assisted rectal resection.

Materials And Methods: A total of 226 patients underwent surgery for rectal cancer in our center between October 2001 and June 2009. A retrospective review was performed of all WJD-assisted rectal resections during this time. One hundred and five patients with adenocarcinoma of the lower and middle rectum were operated on by 7 surgeons according to the concept of TME. Seventy-six patients underwent a low anterior resection, 29 patients an abdominoperineal resection. Twenty-eight patients received preoperative radiochemotherapy. The median follow-up period amounted to 35 (2-96) months. Survival rates were calculated using the Kaplan-Meier method.

Results: Anastomotic leakage occurred in 5.7%, wound healing disturbance (including perineal wound infections) in 29.5%, intra-abdominal infections in 7.6% and urinary tract infections in 7.6%. Postoperative bladder dysfunction (requiring catheterization) occurred in 1.9%. Postoperative 30-day mortality was 0%, 60-day mortality 1%. The rate of local recurrence (including three patients who refused postoperative radiochemotherapy) was 8.5%. Cancer-specific survival at 5 years was 74% and differed significantly by stage.

Conclusions: The particular advance of the WJD is the facile development of the embryological plane between the mesorectal fascia and the surrounding pelvic nerves. Without harming one of them, maximum radicality and excellent autonomic nerve preservation can be achieved. The WJD is a technique with acceptable postoperative morbidity and low mortality. Local control and survival are comparable to other surgical centers in international literature.
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October 2010

The impact of intraoperative neuromonitoring (IONM) on surgical strategy in bilateral thyroid diseases: is it worth the effort?

World J Surg 2010 Jun;34(6):1274-84

Surgical Department 1, Insulinoma GEP Tumor Center Neuss-Düsseldorf, Lukaskrankenhaus Neuss, Preussenstr. 84, 41456, Neuss, Germany.

Background: Intraoperative nerve monitoring (IONM) of the recurrent laryngeal nerve and the vagal nerve can detect nonfunctioning nerves (recurrent laryngeal nerve palsy, RLNP) that are visibly intact. The use of IONM is questionable, however, as we still lack evidence that it reduces the rate of postoperative nerve injuries. Since negative IONM results after thyroid dissection of the first side could change our surgical strategy and thus could prevent patients from bilateral RLNP, we questioned whether IONM results are reliable enough to base changes in surgical strategy and whether this has any effect on surgical outcome.

Methods: We retrospectively analyzed the data of 1333 consecutive patients with suggested benign bilateral thyroid disease who had been operated on under a defined protocol, including the use of a specific IONM technique (tube electrodes and stimulation of the vagal nerve and the inferior recurrent nerve before and after thyroid resection), between January 1, 2006 and December 31, 2008.

Results: In four patients the IONM system did not work, two nerves had not been found, and in eight patients the tube had to be readjusted. Of five permanent nerve injuries, four were visible during surgery and one was suspected. Sensitivity of IONM in detecting temporary nerve injuries of macroscopically normal-appearing nerves was 93%. Specificity was 75-83% at first side of dissection and 55-67% at the second side, with an overall specificity of 77%. In 11 of 13 patients (85%) with known nerve injury (preexisting or visible) and in 20 of 36 patients (56%) with negative IONM stimulation at the first side of dissection, the surgical strategy was changed (specific surgeon or restricted resection) with no postoperative bilateral RLNP. This was in contrast to 3 of 18 (17%) bilateral RLNP (p < 0.05), when surgeons were not aware of a preexisting or highly likely nerve injury at the first side of thyroid dissection.

Conclusions: Failed IONM stimulation of the vagal or recurrent laryngeal nerve after resection of the first thyroid lobe is specific enough to reconsider the surgical strategy in patients with bilateral thyroid disease to surely prevent bilateral RLNP.
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http://dx.doi.org/10.1007/s00268-009-0353-3DOI Listing
June 2010