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Chen Y, Xu C, Mou Z, Hu Y, Yang C, Hu J, Chen X, Luo J, Zou L, Jiang H. Endoscopic Cryoablation Versus Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma. Eur Urol Oncol 2024:S2588-9311(24)00104-4. [PMID: 38693018 DOI: 10.1016/j.euo.2024.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 02/25/2024] [Accepted: 04/09/2024] [Indexed: 05/03/2024]
Abstract
BACKGROUND AND OBJECTIVE Cryoablation is a traditional antitumor therapy with good prospects for development. The efficacy of endoscopic management as a kidney-sparing surgery for high-risk upper tract urothelial carcinoma (UTUC) remains controversial. Our aim was to evaluate the impact of endoscopic cryoablation (ECA) versus radical nephroureterectomy (RNU) on survival outcomes, renal function, and complications. METHODS We retrospectively analyzed data for 116 patients with newly diagnosed high-risk UTUC who underwent either ECA (n = 13) or RNU (n = 103) from March 25, 2019 to December 8, 2021. Propensity score matching (1:4) using the nearest neighbor method was performed before analysis. The primary outcome was overall survival (OS). Secondary outcomes included progression-free survival (PFS), intravesical recurrence-free survival (RFS), the change in renal function, and treatment-emergent adverse events (TEAEs). KEY FINDINGS AND LIMITATIONS At median follow-up of 28.2 mo for the ECA group and 27.6 mo for the RNU group, 2-yr OS (82% vs 84%), PFS (73% vs 71%), and intravesical RFS (81% vs 83%) rates after matching did not significantly differ. A decline in renal function was observed after RNU, but not after ECA. Five (41.7%) patients in the ECA group reported six TEAEs, and 17 patients (35.4%) in the RNU group reported 20 TEAEs. CONCLUSIONS AND CLINICAL IMPLICATIONS In comparison to RNU, ECA for UTUC resulted in noninferior oncological outcomes and superior preservation of renal function. PATIENT SUMMARY Our study suggests that a treatment called endoscopic cryoablation for high-risk cancer in the upper urinary tract can help in preserving kidney function, with similar survival outcomes to those after more extensive surgery. This option can be considered for selected patients with a strong preference for kidney preservation.
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Affiliation(s)
- Yiling Chen
- Department of Urology, Huashan Hospital, Fudan University, Shanghai, China; Institute of Urology, Fudan University, Shanghai, China
| | - Chenyang Xu
- Department of Urology, Huashan Hospital, Fudan University, Shanghai, China; Institute of Urology, Fudan University, Shanghai, China
| | - Zezhong Mou
- Department of Urology, Huashan Hospital, Fudan University, Shanghai, China; Institute of Urology, Fudan University, Shanghai, China
| | - Yun Hu
- Department of Urology, Huashan Hospital, Fudan University, Shanghai, China; Institute of Urology, Fudan University, Shanghai, China
| | - Chen Yang
- Department of Urology, Huashan Hospital, Fudan University, Shanghai, China; Institute of Urology, Fudan University, Shanghai, China
| | - Jinzhong Hu
- Department of Urology, Huashan Hospital, Fudan University, Shanghai, China; Institute of Urology, Fudan University, Shanghai, China
| | - Xinan Chen
- Department of Urology, Huashan Hospital, Fudan University, Shanghai, China; Institute of Urology, Fudan University, Shanghai, China
| | - Jianfeng Luo
- Department of Biostatistics and Social Medicine, School of Public Health, Fudan University, Shanghai, China.
| | - Lujia Zou
- Department of Urology, Huashan Hospital, Fudan University, Shanghai, China; Institute of Urology, Fudan University, Shanghai, China.
| | - Haowen Jiang
- Department of Urology, Huashan Hospital, Fudan University, Shanghai, China; Institute of Urology, Fudan University, Shanghai, China; National Clinical Research Center for Aging and Medicine, Fudan University, Shanghai, China.
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Wang Z, Zhang Q, Gao J, Cao T, Zhang Y, Qu K. Investigating the optimal parathyroid autotransplantation strategy in transareolar endoscopic thyroidectomy: A retrospective cohort study. Asian J Surg 2024; 47:886-892. [PMID: 37879989 DOI: 10.1016/j.asjsur.2023.10.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 10/03/2023] [Accepted: 10/06/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND There is ongoing debate about whether intraoperative parathyroid autotransplantation effectively prevents permanent hypoparathyroidism after thyroidectomy. This study aims to examine its impact on postoperative parathyroid function and determine the best autotransplantation strategy. METHODS A retrospective analysis was conducted on 194 patients who underwent total thyroidectomy with central lymph node dissection (CLND) for papillary thyroid carcinoma (PTC). Patients were divided into four groups based on the number of parathyroid autotransplants during surgery: Group 1 (none, n = 43), Group 2 (1 transplant, n = 60), Group 3 (2 transplants, n = 67), and Group 4 (3 transplants, n = 24). Various clinical parameters were collected and compared among the groups. RESULTS Parathyroid autotransplantation was identified as a risk factor for temporary hypoparathyroidism (OR: 1.74; 95% CI: 1.27-2.39, P = 0.001) and a protective factor for permanent hypoparathyroidism (OR: 0.27; 95% CI: 0.14-0.55, P < 0.001). At 12 months postoperative, systemic parathyroid hormone (PTH) levels increased progressively from Groups 1 to 4, with significant differences observed only between Group 1 and Group 2 (P < 0.02). Difference values in systemic PTH levels between Month 1 and Day 1 postoperative increased progressively from Groups 1 to 4, with statistically significant differences observed between adjacent groups (P < 0.02). The number of dissected positive lymph nodes increased progressively across the four groups, showing statistical differences (P < 0.02). CONCLUSION Parathyroid autotransplantation can prevent permanent hypoparathyroidism. Additionally, we recommend preserving parathyroids in situ whenever possible. If autotransplantation is required, it should involve no more than two glands.
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Affiliation(s)
- Zesheng Wang
- Department of General Surgery, Gansu Provincial Central Hospital, Lanzhou, 730050, China; The First Clinical Medical College, Gansu University of Chinese Medicine, Lanzhou, 730000, China
| | - Qi Zhang
- Department of General Surgery, Gansu Provincial Central Hospital, Lanzhou, 730050, China
| | - Jinwei Gao
- Department of General Surgery, Gansu Provincial People's Hospital, Lanzhou, 730000, China
| | - Tingbao Cao
- Department of General Surgery, Gansu Provincial Central Hospital, Lanzhou, 730050, China
| | - Yupeng Zhang
- Department of General Surgery, Gansu Provincial Central Hospital, Lanzhou, 730050, China
| | - Kunpeng Qu
- Department of General Surgery, Gansu Provincial Central Hospital, Lanzhou, 730050, China.
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Lykke E, Christensen A, Juhl K, Feldt-Rasmussen U, Friberg Hitz M, Svenningsen Sjöstedt SM, Holst Hahn C, Kraik Svensson DM, Kanstrup Springborg K, Stage MG, Bjørn Hvilsom G, Hilsted LM, Dahl M, Lelkaitis G, Kjaer A, Homøe P, von Buchwald C. Effect of near infrared autofluorescence guided total thyroidectomy on postoperative hypoparathyroidism: a randomized clinical trial. Eur Arch Otorhinolaryngol 2023; 280:2593-2603. [PMID: 36853388 PMCID: PMC9971666 DOI: 10.1007/s00405-023-07867-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 01/30/2023] [Indexed: 03/01/2023]
Abstract
PURPOSE The purpose of this single-blinded, 2-centre, randomized controlled trial was to test if near-infrared (NIR) autofluorescence image guidance for parathyroid gland (PG) detection during total thyroidectomy can reduce the incidence of hypoparathyroidism in both malignant and benign cases. METHOD Patients admitted for primary or completion total thyroidectomy were randomized to either the NIR intervention group or the standard care NONIR (no near infrared) group. The primary endpoint was the rate of hypoparathyroidism at the 3-month follow-up, defined as hypocalcemia and inappropriately low parathyroid hormone levels and/or continuous treatment with active vitamin D. The secondary endpoint was the PG identification rate. RESULTS A total of 147 patients were included of whom 73 were allocated to NIR. Primary or completion thyroidectomy was conducted in 84 and 63 cases, respectively. A total of 130 completed 3 months follow-up. Postoperative hypoparathyroidism in the NIR group at 12 h, 1 month and 3 months was, respectively, 31.8, 14.1, 6.5% compared with 35.9, 18.9, 11.8% in the NONIR group (all p > 0.46). In the NIR group, the identification rate of PGs was 69.5% (146 of 210 PGs), and 9% (19 of 210 PGs) were identified only due to additional use of NIR. For 15 out of 69 patients (21.7%) additionally PGs was found. CONCLUSION Hypoparathyroidism was nominally less frequent in the NIR group, although not statistically significant. Further studies are needed to confirm if NIR may be a supportive PG identification tool to minimize the number of PG which would have been otherwise missed, especially during more complicated thyroid procedures. TRIAL REGISTRY ClinicalTrials.gov: NCT04193332. Registration date: 16.08.2019.
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Affiliation(s)
- Eva Lykke
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark.
| | - Anders Christensen
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Karina Juhl
- Department of Clinical Physiology, Nuclear Medicine and PET and Cluster for Molecular Imaging, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Ulla Feldt-Rasmussen
- Department of Endocrinology and Metabolism, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Clinical Sciences, Copenhagen University, Copenhagen, Denmark
| | - Mette Friberg Hitz
- National Research Center for Bone Health, Medical Department, Zealand University Hospital, Køge, Denmark
- Department of Clinical Medicine, Faculty of Health and Clinical Sciences, Copenhagen University, Copenhagen, Denmark
| | - Sannia Mia Svenningsen Sjöstedt
- Department of Clinical Physiology and Nuclear Medicine 260, Center of Functional and Diagnostic Imaging and Research, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Christoffer Holst Hahn
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Ditte Maria Kraik Svensson
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Karoline Kanstrup Springborg
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Mads Georg Stage
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Gitte Bjørn Hvilsom
- Department of Otorhinolaryngology and Maxillofacial Surgery, Zealand University Hospital, Køge, Denmark
- Department of Clinical Medicine, Faculty of Health and Clinical Sciences, Copenhagen University, Copenhagen, Denmark
| | - Linda Maria Hilsted
- Department of Clinical Biochemistry, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Morten Dahl
- Department of Clinical Biochemistry, Zealand University Hospital, Køge, Denmark
- Department of Clinical Medicine, Faculty of Health and Clinical Sciences, Copenhagen University, Copenhagen, Denmark
| | - Giedrius Lelkaitis
- Department of Pathology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Andreas Kjaer
- Department of Clinical Physiology, Nuclear Medicine and PET and Cluster for Molecular Imaging, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Clinical Sciences, Copenhagen University, Copenhagen, Denmark
| | - Preben Homøe
- Department of Otorhinolaryngology and Maxillofacial Surgery, Zealand University Hospital, Køge, Denmark
- Department of Clinical Medicine, Faculty of Health and Clinical Sciences, Copenhagen University, Copenhagen, Denmark
| | - Christian von Buchwald
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Clinical Sciences, Copenhagen University, Copenhagen, Denmark
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Pastoricchio M, Bernardi S, Bortul M, de Manzini N, Dobrinja C. Autofluorescence of parathyroid glands during endocrine surgery with minimally invasive technique. J Endocrinol Invest 2022; 45:1393-1403. [PMID: 35262861 DOI: 10.1007/s40618-022-01774-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 02/18/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Accidental injury to the parathyroid glands (PTGs) is common during thyroid and parathyroid surgery. To overcome the limitation of naked eye in identifying the PTGs, intraoperative autofluorescence imaging has been embraced by an increasing number of surgeons. The aim of our study was to describe the technique and assess its utility in clinical practice. METHODS Near-infrared (NIR) autofluorescence imaging was carried out during open parathyroid and thyroid surgery in 25 patients (NIR group), while other 26 patients underwent traditional PTG detection based on naked eye alone (NO-NIR group). Primary variables assessed for correlation between traditional approach and autofluorescence were number of PTGs identified and incidence of postoperative hypoparathyroidism (hypoPT). RESULTS 81.9% of PTGs were detected by means of fluorescence imaging and 74.5% with visual inspection alone, with an average of 2.72 PTGs visualized per patient using NIR imaging versus approximately 2.4 per patient using naked eye (p = 0.38). Considering only the more complex total thyroidectomies (TTs), the difference was almost statistically significant (p = 0.06). Although not statistically significant, the observed postoperative hypoPT rate was lower in the NIR group. CONCLUSION Despite the limitations and technical aspects still to be investigated, fluorescence seems to reduce this complication rate by improving the intraoperative detection of the PTGs.
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Affiliation(s)
- M Pastoricchio
- Division of General Surgery, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), Gorizia, Italy
| | - S Bernardi
- Department of Medical, Surgical, and Health Sciences, University of Trieste, Cattinara Teaching Hospital UCO Medicina Clinica, 34100, Trieste, Italy
| | - M Bortul
- Division of General Surgery, Department of Medical, Surgical, and Health Sciences, Cattinara Teaching Hospital, University of Trieste, Trieste, Italy
| | - N de Manzini
- Division of General Surgery, Department of Medical, Surgical, and Health Sciences, Cattinara Teaching Hospital, University of Trieste, Trieste, Italy
| | - C Dobrinja
- Division of General Surgery, Department of Medical, Surgical, and Health Sciences, Cattinara Teaching Hospital, University of Trieste, Trieste, Italy.
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Kördel C, Koman A, Bränström R, Stenman A. Seasonal variation in calcium treatment after thyroidectomy as surrogate for post-operative hypocalcemia: a retrospective register-based national cohort study. Thyroid Res 2022; 15:5. [PMID: 35305689 PMCID: PMC8933912 DOI: 10.1186/s13044-022-00123-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 03/08/2022] [Indexed: 11/10/2022] Open
Abstract
Background Hypocalcemia is one of the most common complications of thyroidectomy, and vitamin D deficiency has been found to be an independent risk factor. Sweden is located north of the 55th latitude, resulting in a significant seasonal variation in sun exposure, thereby large variation in the naturally occurring levels of vitamin D. This study aimed to determine if there is a correlation between season of surgery and post-thyroidectomy hypocalcemia. Methods We conducted a retrospective register-based observation study on patients who had undergone total thyroidectomy during 2008–2015. In total, 7125 patients operated in Swedish facilities were identified via the Scandinavian Quality Register for Thyroid, Parathyroid, and Adrenal Surgery (SQRTPA). Patients operated during February–April were included in the dark group and patients operated during August–October were included in the bright group. Further stratification was made on the indication for surgery. The primary outcome was post-operative calcium treatment due to hypocalcemia, defined as having received calcium orally or intravenously before discharge. Results The risk of receiving post-operative calcium treatment was significantly lower in the bright group (29.7%) compared to the dark group (35.1%), with a relative risk of 0.846 (P < 0.001). This correlation held true if the indication for surgery was goiter or thyrotoxicosis. For malignancy, there was no significant difference between the groups. Conclusion In this cohort, total thyroidectomy performed during August–October was associated with a lower rate of calcium treatment given post-operatively when compared to total thyroidectomy performed during February–April. This would indicate a decreased risk of post-operative hypocalcemia if surgery was carried out after the brighter season.
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Affiliation(s)
- Carl Kördel
- Department of Breast, Endocrine Tumors and Sarcoma, Karolinska University Hospital, Stockholm, Sweden and Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 76, Stockholm, Sweden
| | - Anna Koman
- Department of Breast, Endocrine Tumors and Sarcoma, Karolinska University Hospital, Stockholm, Sweden and Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 76, Stockholm, Sweden
| | - Robert Bränström
- Department of Breast, Endocrine Tumors and Sarcoma, Karolinska University Hospital, Stockholm, Sweden and Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 76, Stockholm, Sweden
| | - Adam Stenman
- Department of Breast, Endocrine Tumors and Sarcoma, Karolinska University Hospital, Stockholm, Sweden and Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 76, Stockholm, Sweden.
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Loncar I, Noltes ME, Dickhoff C, Engelsman AF, Schepers A, Vriens MR, Bouvy ND, Kruijff S, van Ginhoven TM. Persistent Postthyroidectomy Hypoparathyroidism in the Netherlands. JAMA Otolaryngol Head Neck Surg 2021; 147:959-965. [PMID: 34617977 DOI: 10.1001/jamaoto.2021.2475] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Hypoparathyroidism is one of the most common complications after total or completion thyroidectomy. The reported incidence rate of hypoparathyroidism in the literature is highly variable. Data that provide a better understanding of the magnitude of this postoperative complication are warranted and can provide a stepping stone for further collaborations that aim to reduce complication rates and establish uniform treatment protocols. Objective To evaluate the incidence of postoperative, persistent hypoparathyroidism after total or completion thyroidectomy in patients who were referred to university hospital centers and assess the association of different definitions with the incidence of hypoparathyroidism. Design, Setting, and Participants This retrospective multicenter cohort study conducted throughout 2016 in 7 Dutch university hospital centers included 200 patients who were undergoing a total or completion thyroidectomy. Data analysis was conducted in January 2021. Main Outcomes and Measures We report on the incidence of persistent hypoparathyroidism, defined as the need for active vitamin D with or without calcium supplementation longer than 1 year after surgery. Results A total of 200 patients (143 women [71.5%]; mean [IQR] age, 49.0 [37.0-62.0] years) were included and 30 patients (15.0%) developed persistent hypoparathyroidism. The incidence of persistent hypoparathyroidism varied between 14.5% (calcium and active vitamin D 1 year postsurgery) to 28.5% (calcium and/or active vitamin D 6 months postsurgery) depending on the definition used. Conclusions and Relevance In this cohort study, the risk of persistent hypoparathyroidism after total or completion thyroidectomy was 15% in patients who were referred to university hospital centers. The high rate of persistent hypoparathyroidism warrants efforts to reduce this complication rate. There is discrepancy in the definition and treatment of persistent hypoparathyroidism, and use of uniform evidence-based treatment guidelines enables comparison of interventions.
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Affiliation(s)
- Ivona Loncar
- Erasmus MC Cancer Institute, Department of Surgical Oncology and Gastrointestinal Surgery, Rotterdam, the Netherlands
| | - Milou E Noltes
- University of Groningen, University Medical Center Groningen, Department of Surgical Oncology, Groningen, the Netherlands.,University of Groningen, University Medical Center Groningen, Department of Nuclear Medicine and Molecular Imaging, Groningen, the Netherlands
| | - Chris Dickhoff
- Amsterdam UMC, location VUmc, Department of Surgery, Amsterdam, the Netherlands
| | - Anton F Engelsman
- Amsterdam UMC, location AMC, Department of Surgery, Amsterdam, the Netherlands
| | - Abbey Schepers
- Leiden University Medical Center, Department of Surgery, Leiden, the Netherlands
| | - Menno R Vriens
- University Medical Center Utrecht, Department of Surgery, Utrecht, the Netherlands
| | - Nicole D Bouvy
- Maastricht University Medical Center, Department of Surgery, Maastricht, the Netherlands
| | - Schelto Kruijff
- University of Groningen, University Medical Center Groningen, Department of Surgical Oncology, Groningen, the Netherlands
| | - Tessa M van Ginhoven
- Erasmus MC Cancer Institute, Department of Surgical Oncology and Gastrointestinal Surgery, Rotterdam, the Netherlands
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Jørgensen CU, Homøe P, Dahl M, Hitz MF. Postoperative Chronic Hypoparathyroidism and Quality of Life After Total Thyroidectomy. JBMR Plus 2021; 5:e10479. [PMID: 33869995 PMCID: PMC8046100 DOI: 10.1002/jbm4.10479] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 02/02/2021] [Accepted: 02/13/2021] [Indexed: 12/31/2022] Open
Abstract
Chronic hypoparathyroidism (HypoPT) is a common complication after total thyroidectomy and it impacts affected patients' quality of life (QoL). This study aimed to assess the QoL in patients with chronic HypoPT independently from their concurrent hypothyroidism and other comorbidities. For this purpose a follow‐up study was performed, including 14 patients who developed chronic HypoPT after total thyroidectomy and 28 age‐ and sex‐matched patients who had intact parathyroid function after total thyroidectomy. We used the RAND Short Form 36 Health Survey (SF‐36) to compare the QoL between patients with or without chronic HypoPT. Chronic HypoPT patients had lower QoL scores in all domains of the RAND‐SF‐36 questionnaire and significant impairment in six of eight domains after adjustment for relevant confounders. They were more often operated because of a toxic diagnosis (p = .01), often being Graves disease. Additionally adjusting for surgical indications resulted in three of eight domains being significant affected. Chronic HypoPT is associated with significantly impairment of QoL, independently of the concurrent disease of hypothyroidism, comorbidities, and prospective values of TSH and serum (se)‐ionized‐Ca++. There is a need for more focus and better treatment of patients experiencing chronic HypoPT after surgery. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Camilla Uhre Jørgensen
- Department of Otorhinolaryngology and Maxillofacial Surgery Zealand University Hospital (ZUH) Køge Denmark.,Department of Medical Endocrinology Zealand University Hospital (ZUH) Køge Denmark
| | - Preben Homøe
- Department of Otorhinolaryngology and Maxillofacial Surgery Zealand University Hospital (ZUH) Køge Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences University of Copenhagen Copenhagen Denmark
| | - Morten Dahl
- Department of Clinical Medicine, Faculty of Health and Medical Sciences University of Copenhagen Copenhagen Denmark.,Department of Clinical Biochemistry Zealand University Hospital (ZUH) Køge Denmark
| | - Mette Friberg Hitz
- Department of Medical Endocrinology Zealand University Hospital (ZUH) Køge Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences University of Copenhagen Copenhagen Denmark
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Karunakaran P, Abraham DT, Devadas G, Ramalingam S, Balu S, Hussain Z. The impact of operative duration and intraoperative fluid dynamics on postoperative hypocalcemia after total thyroidectomy: a prospective non-randomized study. Langenbecks Arch Surg 2020; 406:1211-1221. [PMID: 33174169 DOI: 10.1007/s00423-020-02013-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 10/11/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Postoperative hypocalcemia after total thyroidectomy (TT) still remains common. This prospective observation study examined the role of intraoperative time period (IOP) and intravenous fluids (IVF) in transient and permanent (> 6 months) hypocalcemia post-TT. SUBJECTS AND METHOD Consecutive patients (n = 328; age = median (IQR); 34 (15) years; M:F = 65:263) with benign or malignant thyroid disease undergoing TT were evaluated for IOP, intraoperative IVF, serum corrected calcium, intact parathormone (iPTH), and 25-hydroxyvitamin D (25OHD) levels at baseline, 48 h, and 6 months post-TT. RESULTS The incidence of symptomatic transient and permanent hypocalcemia post-TT was 33.5% and 7.9% respectively. In multivariate logistic regression analysis, the independent risk factors for transient hypocalcemia were IOP (odds ratio: 11.6), 48-h iPTH (4.8), IVF (2.9), hyperthyroidism (2.8), and percent calcium decline (1.07), while 25OHD deficiency increased the risk by 10.5 odds in subset with preoperative hypocalcemia. In receiver operating characteristic analysis, IOP, and IVF strongly predicted transient hypocalcemia with a threshold of 123 min and 1085 mL. Area under the curve, sensitivity, and specificity were 0.883 (95% CI: 0.838-0.928), 88.1%, and 74.4% and 0.883 (0.840-0.926; each P = 0.001), 84.4%, and 74.4% respectively. Serum 48-h calcium < 7.8 mg/dL was the only reliable predictor of permanent hypocalcemia. CONCLUSION Operative duration > 123 min and IVF > 1085 mL increased the risk of transient hypocalcemia post-TT manyfold but not permanent hypocalcemia. Routine intraoperative identification, preservation of viable in situ parathyroid glands, and laryngeal nerves increased IOP and rates of transient hypocalcemia but improved long-term outcome.
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Affiliation(s)
- Poongkodi Karunakaran
- The Tamilnadu Dr MGR Medical University, Chennai, 600032, India. .,Endocrine Surgery Unit, Government Mohan Kumaramangalam Medical College, Salem, 636030, India. .,Department of Endocrine Surgery, Madras Medical College, Chennai, Tamilnadu, 600003, India.
| | | | - Geetha Devadas
- Institute of Pathology, Madras Medical College, Chennai, 600003, India
| | - Srinivasan Ramalingam
- ICMR-National Institute for Research in Tuberculosis, Chetpet, Chennai, 600031, India
| | - Sudhapresanna Balu
- Department of Biochemistry, Government Stanley Medical College and Hospital, Chennai, 600001, India
| | - Zahir Hussain
- Department of Endocrine Surgery, Madras Medical College, Chennai, Tamilnadu, 600003, India
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9
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Karunakaran P, Abraham DT, Devadas G, Hussain Z, Kanakasabapathi R. The Effect of Hypomagnesemia on Refractory Hypocalcemia after Total Thyroidectomy: A Single-Center Prospective Cohort Study. Indian J Endocrinol Metab 2020; 24:518-524. [PMID: 33643868 PMCID: PMC7906105 DOI: 10.4103/ijem.ijem_681_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 10/30/2020] [Accepted: 12/05/2020] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Hypomagnesemia is known to impede hypocalcemia correction. This prospective observational study aimed to evaluate the impact of serum magnesium levels on the development of refractory hypocalcemia, which remains a concerning problem after total thyroidectomy (TT). SUBJECTS AND METHODS Consecutive subjects (n = 312; mean age = 38.4 [range: 13-83] years; M:F = 62:250) undergoing TT for benign or malignant thyroid diseases were evaluated for serum corrected-calcium (8.4-10.4 mg/dL), magnesium (1.7-2.4 mg/dL), intact parathormone (iPTH), and 25-hydroxycholecalciferol (25OHD) levels preoperatively, at 48-h and 6-month post-TT. RESULTS Postoperatively, 98 subjects (31.4%) exhibited transient hypocalcemia, 96 (30.8%) had hypomagnesemia, and 52 (16.7%) had refractory hypocalcemia. Preoperatively, 38 subjects (12.2%) had asymptomatic hypocalcemia and 77 (24.7%) had hypomagnesemia. In multivariate logistic regression analysis, independent risk factors of transient hypocalcemia were hyperthyroidism (odd's ratio [OR]: 5.6), 48-h iPTH (OR: 3.2), 48-h magnesium (OR: 2.7), preoperative 25OHD (OR: 0.96), and preoperative calcium (OR: 0.5; each P < 0.01). In receiver-operating characteristic analysis, percent calcium decline and 48-h magnesium reliably predicted transient hypocalcemia with a threshold of 10.5% and 1.9 mg/dL, respectively. Area under curve, sensitivity, and specificity were 0.822, 82.7%, and 72.9%; and 0.649 (each P < 0.001), 68.4%, and 63.1%, respectively. CONCLUSION Serum magnesium below 1.9 mg/dL had 2.7 times higher odds of developing transient hypocalcemia post-TT. Hypomagnesemia and percent calcium decline >10.5% within 48-h post-TT are associated with refractory hypocalcemia, which necessitates correction of both the deficiencies for prompt resolution of symptoms.
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Affiliation(s)
- Poongkodi Karunakaran
- Department of Endocrine Surgery, Madras Medical College, The Tamilnadu Dr MGR Medical University, Chennai, India
- Government Mohan Kumaramangalam Medical College, Salem, India
| | | | - Geetha Devadas
- Institute of Pathology, Madras Medical College, Chennai, India
| | - Zahir Hussain
- Department of Endocrine Surgery, Madras Medical College, Chennai, India
| | - Ramadevi Kanakasabapathi
- Institute of Biochemistry, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, India
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Palmhag D, Brydolf J, Zedenius J, Bränström R, Nilsson IL. A Single Parathyroid Hormone Measurement Two Hours after a Thyroidectomy Reliably Predicts Permanent Hypoparathyroidism. Scand J Surg 2020; 110:322-328. [PMID: 32268827 DOI: 10.1177/1457496920913666] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Hypoparathyroidism is the most common complication following thyroidectomy, and various algorithms for early detection have been suggested. The aim of this study was to evaluate the predictive value of measuring the parathyroid hormone level 2 h after thyroidectomy and whether determination of the perioperative decline in parathyroid hormone added diagnostic value. METHODS Patients subjected to thyroidectomy for benign thyroid disorders were analyzed in (1) a retrospective register-based study (366 consecutive patients treated during 2015-2016) and (2) a prospective observational study (39 patients treated during 2018). Optimal cut-off values for postoperative parathyroid hormone and perioperative decline (%) in parathyroid hormone were determined by receiver operating characteristics and area under the curve. Sensitivity, specificity, positive and negative predictive values were calculated using cross tabulation. RESULTS The prevalence of hypoparathyroidism the first day after thyroidectomy was higher among patients treated for hyperthyroidism (30% vs 20%; P = 0.03). The optimal cut-off level for postoperative parathyroid hormone was 1.1 pmol/L (area under the curve = 0.887, 95% confidence interval: 0.839-0.934; positive predictive value: 88%, negative predictive value: 93%) for the entire cohort. When the groups were analyzed separately, the optimal cut-off was 1.05 for the non-hyperfunctioning group and 1.55 pmol/L for the group with hyperthyroidism. Twelve months after thyroidectomy, 3% were defined as having permanent hypoparathyroidism. Measurement of parathyroid hormone decline added diagnostic value for one patient with preoperative parathyroid-hormone-elevation associated with vitamin D deficiency. CONCLUSION For patients with vitamin D sufficiency, the diagnostic accuracy of a single measurement of parathyroid hormone 2 h after thyroidectomy is an excellent indicator for predicting transient hypoparathyroidism.
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Affiliation(s)
- D Palmhag
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - J Brydolf
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - J Zedenius
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Breast, Endocrine Tumors and Sarcoma, Karolinska University Hospital, Stockholm, Sweden
| | - R Bränström
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Breast, Endocrine Tumors and Sarcoma, Karolinska University Hospital, Stockholm, Sweden
| | - I-L Nilsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Breast, Endocrine Tumors and Sarcoma, Karolinska University Hospital, Stockholm, Sweden
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Priya SR, Dravid C. Central Compartment Nodal Bulk: A Predictor of Permanent Postoperative Hypocalcaemia. Indian J Surg Oncol 2020; 11:92-100. [PMID: 32205978 PMCID: PMC7064669 DOI: 10.1007/s13193-019-01010-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 11/06/2019] [Indexed: 10/25/2022] Open
Abstract
Central compartment clearance (CCC) for Papillary thyroid cancers (PTC) is one of the factors causing postoperative hypocalcaemia. We aimed to examine determinants of this major sequela. 41 patients treated for PTCs between 2014 and 2016 were studied. Surgical details, tumour and nodal characteristics, incidence of transient, temporary and permanent hypocalcaemia were noted. Central clearance was done bilaterally in 24 (58.5%) cases, ipsilaterally in 17 (41.6%). Central nodes were involved in 26 (63.4%) cases, unilaterally in 15 (36.6%), bilaterally in 11 (26.8%). Transient hypocalcaemia developed in 10 (24.4%) cases, temporary hypocalcaemia in 6 (14.6%) cases, and permanent hypocalcaemia in 2 (4.9%) cases. 17 (41%) patients were symptomatic. 9 (21.9%) patients received intravenous calcium. The only factor consistently associated with development of hypocalcaemia of all patterns, was the presence of matted central compartment nodes (p = 0.021). Matted nodes also related to a longer length of stay (p = 0.04) and requirement of intravenous calcium (p = 0.000). Extent of CCC, nodal yield, nodal positivity, perinodal extension, number of parathyroids identified, gender or pT size were not significantly associated. Symptomatic patients did not necessarily become permanently hypocalcaemic (p = 0.8). Patients requiring intravenous calcium were more likely to take oral calcium after discharge (p = 0.002). Postoperative hypocalcaemia is more likely in cases with bulky involved central nodes where extensive clearance is done. In routine CCC, even if done bilaterally, preservation of parathyroid function is possible. Permanent hypocalcaemia after CCC need not be taken as inevitable.
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Affiliation(s)
- S. R. Priya
- Head Neck Unit, Delhi State Cancer Institute, Delhi, India
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Wang B, Zhu CR, Liu H, Wu J. The effectiveness of parathyroid gland autotransplantation in preserving parathyroid function during thyroid surgery for thyroid neoplasms: A meta-analysis. PLoS One 2019; 14:e0221173. [PMID: 31412080 PMCID: PMC6693848 DOI: 10.1371/journal.pone.0221173] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 07/31/2019] [Indexed: 12/13/2022] Open
Abstract
Objective We conducted this meta-analysis to assess the effectiveness of parathyroid gland autotransplantation in preserving parathyroid function during thyroid surgery for thyroid neoplasms. Methods We conducted a search by using PubMed, Embase, and the Cochrane Library electronic databases for studies that were published up to January 2019. The reference lists of the retrieved articles were also reviewed. Two authors independently assessed the methodological quality and extracted the data. A random-effects model was used to calculate the overall combined risk estimates. Publication bias was evaluated with a funnel plot using Egger’s and Begg’s tests. Results A total of 25 independent studies involving 10,531 participants were included in the meta-analysis. Compared with patients who did not undergo parathyroid gland autotransplantation, the overall pooled relative risks for patients who underwent parathyroid gland autotransplantation were 1.75 (95% CI: 1.51–2.02, p<0.001) for postoperative hypoparathyroidism, 1.72 (95% CI: 1.45–2.05, p<0.001) for protracted hypoparathyroidism, 1.06 (95% CI: 0.44–2.58, p = 0.894) and 0.71 (95% CI: 0.22–2.29, p = 0.561) for biochemical hypoparathyroidism and biochemical hypocalcemia at 6 months postoperatively, respectively, and 1.89 (95% CI: 1.33–2.69, p<0.001) and 0.22 (95% CI: 0.09–0.52, p = 0.001) for biochemical hypoparathyroidism and biochemical hypocalcemia at 12 months postoperatively, respectively. The pooled relative risks for patients who underwent one parathyroid gland autotransplantation and patients who underwent two or more parathyroid gland autotransplantations were 1.71 (95% CI: 1.25–2.35, p = 0.001) and 2.22 (95% CI: 1.43–3.45, p<0.001) for postoperative hypoparathyroidism, 1.09 (95% CI: 0.59–2.01, p = 0.781) and 0.55 (95% CI: 0.16–1.87, p = 0.341) for hypoparathyroidism at 6 months postoperatively compared with those of patients who did not undergo parathyroid gland autotransplantation. Conclusions Parathyroid gland autotransplantation is significantly associated with increased risk of postoperative and protracted hypoparathyroidism, and the number of autoplastic parathyroid glands is positively correlated with the incidence of postoperative hypoparathyroidism.
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Affiliation(s)
- Bin Wang
- Department of Thyroid and Breast Surgery, The Third People's Hospital of Chengdu, Chengdu, Sichuan, China
| | - Chun-Rong Zhu
- Sichuan Key Laboratory of Medical Imaging, Department of Radiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
- Department of Chemistry, School of Basic Medical Science, North Sichuan Medical College, Nanchong, China
| | - Hong Liu
- Department of Thyroid and Breast Surgery, The Third People's Hospital of Chengdu, Chengdu, Sichuan, China
| | - Jian Wu
- Department of Thyroid and Breast Surgery, The Third People's Hospital of Chengdu, Chengdu, Sichuan, China
- * E-mail:
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Calvo Espino P, Rivera Bautista JÁ, Artés Caselles M, Serrano González J, García Pavía A, García-Oria MJ, Caravaca-Fontán F, Lucena de la Poza JL, Sánchez Turrión V. Uso del valor de la hormona paratiroidea intacta en el primer día postoperatorio tras tiroidectomía total como predictor de hipoparatiroidismo permanente. ENDOCRINOL DIAB NUTR 2019; 66:195-201. [DOI: 10.1016/j.endinu.2018.08.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 08/01/2018] [Accepted: 08/03/2018] [Indexed: 11/26/2022]
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Mirian C, Grønhøj C, Jensen DH, Jakobsen KK, Karnov K, Jensen JS, Hahn CH, Klitmøller TA, Bentzen J, von Buchwald C. Trends in thyroid cancer: Retrospective analysis of incidence and survival in Denmark 1980–2014. Cancer Epidemiol 2018; 55:81-87. [DOI: 10.1016/j.canep.2018.05.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 05/01/2018] [Accepted: 05/21/2018] [Indexed: 01/08/2023]
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Falch C, Hornig J, Senne M, Braun M, Konigsrainer A, Kirschniak A, Muller S. Factors predicting hypocalcemia after total thyroidectomy - A retrospective cohort analysis. Int J Surg 2018; 55:46-50. [PMID: 29777882 DOI: 10.1016/j.ijsu.2018.05.014] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 03/20/2018] [Accepted: 05/10/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hypocalcemia after total thyroidectomy is the most frequent complication resulting in prolongation of hospitalisation. Therefore we aimed to analyse clinical risk factors predictive for hypocalcemia and its long term persistence after total thyroidectomy. METHODS Retrospective analysis of patients undergoing total thyroidectomy from 2005 until 2013. Outcome measures were initial postoperative hypocalcemia defined as serum calcium below 2.0 mmol/l after total thyroidectomy within 48 h and persistent hypocalcemia defined as serum calcium below 2.0 mmol/l above six months and/or the need for additional calcium and vitamin D supplementation. RESULTS Initial postoperative hypocalcemia was present in 160 of 702 patients (22.8%) with 91 patients (13%) developing symptoms. 48 patients (6.8%) had a persistent hypocalcemia above six months. Patients with an initial symptomatic postoperative hypocalcemia showed significantly more often a persistent hypocalcemia compared to asymptomatic patients with biochemical hypocalcemia (38 patients (41.8%) vs. 10 patients (14.5%), p < 0,001). In the binary logistic regression analysis, female gender (OR 2.4; CI95% 1.5-3.8), prolonged surgery time >189 min (OR 1.8; CI95% 1.2-2.6) and parathyroid reimplantation (OR 2.4; CI95% 1.2-4.7) were associated with initial hypocalcemia while only initial symptomatic hypocalcaemia was shown to be independently associated with persistent hypocalcemia (OR 40.9; CI95% 18.5-90.4). CONCLUSION Prolonged surgery time seems to correlate with initial postoperative hypocalcemia independently of the underlying disease and surgical expertise but does not affect the persistence of hypocalcemia. Initial symptomatic postoperative hypocalcemia after total thyroidectomy is associated with a high rate of persistent hypocalcemia.
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Affiliation(s)
- Claudius Falch
- Working Group for Surgical Technique and Training, Clinic for Visceral, General and Transplant Surgery, Tuebingen University Hospital, Germany
| | - Jan Hornig
- Working Group for Surgical Technique and Training, Clinic for Visceral, General and Transplant Surgery, Tuebingen University Hospital, Germany
| | - Moritz Senne
- Working Group for Surgical Technique and Training, Clinic for Visceral, General and Transplant Surgery, Tuebingen University Hospital, Germany
| | - Manuel Braun
- Working Group for Surgical Technique and Training, Clinic for Visceral, General and Transplant Surgery, Tuebingen University Hospital, Germany
| | - Alfred Konigsrainer
- Working Group for Surgical Technique and Training, Clinic for Visceral, General and Transplant Surgery, Tuebingen University Hospital, Germany
| | - Andreas Kirschniak
- Working Group for Surgical Technique and Training, Clinic for Visceral, General and Transplant Surgery, Tuebingen University Hospital, Germany
| | - Sven Muller
- Working Group for Surgical Technique and Training, Clinic for Visceral, General and Transplant Surgery, Tuebingen University Hospital, Germany.
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