Keep it simple: a crosshair on the screen during proctored laparoscopic surgeries

INTRODUCTION

Inside the operating room, experts use verbal instructions to guide surgical novices through laparoscopic procedures. In this study, we evaluated the use of a crosshair attached to the video monitor, as a hands-free pointing tool to simplify instructions during operation.

METHODS

Ten surgical novices performed two elective laparoscopic cholecystectomies within a week of each other, randomized such that one was performed with and the other without using the crosshair. Directly after operation, questionnaires were completed by the novices and the consultant surgeons. Measures including the comprehensibility of instructions, subjective feeling of safety during preparation, time delays due to different instruction options, and disruptive influence while instructors used the crosshair. Differences in operative performance were evaluated based on the global operative assessment of laparoscopic skills (GOALS) scores.

RESULTS

When the crosshair was used, surgical novices had a better understanding of which anatomical structure should be shown (p = 0.028). Operating time (p = 0.222) and feeling of confidence during preparation did not differ with versus without crosshair use (p = 0.081). All participants stated that the crosshair did not negatively affect the field of vision. In terms of the median GOALS score, the operative performance was improved when the crosshair was used compared with verbal instructions only (median 15, IQR (11; 21) vs. median 12, IQR (5; 19), p < 0.001).

CONCLUSION

The crosshair is a simple, inexpensive, and widely available method to improve communication between instructors and novices in everyday training.

Real-world EUROCRINE® registry data challenge the reliability of Bethesda cytopathology for thyroid surgery indication

Objectives

Fine-needle aspiration cytology (FNAC) is recommended by international guidelines for the preoperative evaluation of suspicious thyroid nodules >1 cm. Despite robust evidence from endocrine centers demonstrating the key role of FNAC results for the indication of surgery, the method is not routinely used in European clinics. The database EUROCRINE^®, which was introduced in 2015 with the scope of registering operations of the endocrine system, allows for a large-scale analysis of the current service reality in Europe concerning FNAC use and associated accuracy.

Methods

Operations performed to "exclude malignancy", registered from January 2015 to December 2018 in EUROCRINE^®, were analyzed. Parameters of accuracy were calculated for FNAC. FNAC results were considered "test positive" in the case of Bethesda category IV, V, and VI, since these categories usually prompt surgical interventions in European centers for thyroid surgery. Bethesda category II and III were considered "test negative".

Results

Of 8,791 operations, 5,780 had preoperative FNAC (65.7%). The overall malignancy rate was 28.3% (2,488/8,791). Malignancy rates were 68.8% for Bethesda VI, 69.9% for Bethesda V, 32.6% for Bethesda IV, 28.2% for III, 20.2% for Bethesda II, and 24.5% for Bethesda I. After exclusion of papillary microcarcinomas (PTMCs), the sensitivity of FNAC was 71.7% and specificity 43.5%, the positive predictive value was 29.1% and the negative predictive value 82.7%.

Conclusions

Although the indication to "exclude malignancy" was the predominant reason that prompted thyroid resection in the present cohort, FNAC was only used in about 65.7% of cases. When performed, FNAC was associated with unexpectedly low accuracy. Interestingly, in Bethesda II, 20.2% of malignant entities were present (13.3% after the exclusion of PTMCs).

[EUROCRINE®: adrenal surgery 2015-2019- surprising initial results]

Hintergrund

Seit 2015 erfolgt in Europa mithilfe des EUROCRINE®-Registers eine systematische Dokumentation endokrin-chirurgischer Operationen. Ziel dieser ersten Auswertung war eine Darstellung der Versorgungsrealität für Nebenniereneingriffe in einem homogenen Versorgungsumfeld, entsprechend des deutschsprachigen Raums – bzw. des Präsenzgebiets der Chirurgischen Arbeitsgemeinschaft Endokrinologie (CAEK) der Deutschen Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV) – einschließlich einer Analyse der Adhärenz zu geltenden Therapieempfehlungen.

Methodik

Es erfolgte eine deskriptive Analyse der präoperativen Diagnostik, der angewandten Operationstechniken sowie der zugrunde liegenden histologischen Entitäten der zwischen den Jahren 2015 und 2019 über EUROCRINE® in Deutschland, Österreich und der Schweiz dokumentierten Nebennierenoperationen.

Ergebnisse

In den insgesamt 21 teilnehmenden Kliniken des deutschsprachigen EUROCRINE®-Gebiets wurden 658 Operationen an Nebennieren durchgeführt. In 90 % erfolgten unilaterale, in 3 % bilaterale Adrenalektomien und in 7 % andere Resektionsverfahren. Die in 41 % der Operationen dokumentierte histologische Hauptdiagnose war das adrenokortikale Adenom. In 15 % lagen maligne Befunde zugrunde (einschließlich 6 % Nebennierenrindenkarzinome (ACC) und 8 % Nebennierenmetastasen). 23 % der Operationen erfolgten bei Phäochromozytomen. Diese wurden zu 82 % minimal-invasiv operiert, Nebennierenrindenkarzinome lediglich zu 28 % und Nebennierenmetastasen zu 66 %.

Schlussfolgerung

Überraschenderweise wurden nach Nebennierenadenomen und Phäochromozytomen an dritthäufigster Stelle Nebennierenmetastasen unterschiedlicher Primärtumoren reseziert. 28 % der ACC waren für minimal-invasive Techniken vorgesehen, wobei 20 % dieser Fälle eine Konversion zur offenen Operation erforderten. Die aktuelle Analyse deckte Diskrepanzen zwischen Versorgungsrealität und Leitlinienempfehlungen auf, aus denen sich zahlreiche Fragestellungen ergeben, welche nun in ein überarbeitetes EUROCRINE®-Modul zur Dokumentation von Nebennierenoperationen einfließen werden.

Targeted use of intraoperative frozen-section analysis lowers the frequency of completion thyroidectomy

BACKGROUND

The impact of intraoperative frozen section (iFS) analysis on the frequency of completion thyroidectomy for the management of thyroid carcinoma is controversial. Although specialized endocrine centres have published their respective results, there are insufficient data from primary and secondary healthcare levels. The aim of this study was to analyse the utility of iFS analysis.

METHODS

In the Prospective Evaluation Study Thyroid Surgery (PETS) 2 study, 22 011 operations for benign and malignant thyroid disease were registered prospectively in 68 European hospitals from 1 July 2010 to 31 December 2012. Group 1 consisted of 569 patients from University Medical Centre (UMC) Mainz, and group 2 comprised 21 442 patients from other PETS 2 participating hospitals. UMC Mainz exercised targeted but liberal use of iFS analysis for suspected malignant nodules. iFS analysis was compared with standard histological examination regarding the correct distinction between benign and malignant disease. The percentage of completion thyroidectomies was assessed for the participating hospitals.

RESULTS

iFS analysis was performed in 35.70 per cent of patients in group 1 versus 21.80 per cent of those in group 2 (risk ratio (RR) 1.6, 95 per cent c.i. 1.5 to 1.8; P < 0.001). Sensitivity of iFS analysis was 75.0 per cent in group 1 versus 63.50 per cent in group 2 (RR 1.2, 1.2 to 1.3; P = 0.040). Completion surgery was necessary in 8.10 per cent of patients in group 1 versus 20.8 per cent of those in group 2 (RR 0.4, 0.2 to 0.7; P = 0.001).

CONCLUSION

iFS analysis is a useful tool in determining the appropriate surgical management of thyroid disease. Targeted use of iFS was associated with a significantly higher sensitivity for the detection of malignancy, and with a significantly reduced necessity for completion surgery.

Integrative Concepts for Liver Surgery

BACKGROUND

Surgery is the standard treatment for primary tumors and metastases. Due to improvements in surgical outcomes as well as the efficacy of systemic treatments, the role of surgery has changed in recent years.

SUMMARY

Liver surgery has become safe and efficient, with resectability being increased by multimodality concepts as well as staged liver resections and orthotopic liver transplantation. These concepts may be applied to primary liver tumors but also to selected patients with liver metastases from various diseases. In addition, even debulking surgery may be indicated for selected patients with endocrine metastases. While patient selection for liver resections was limited to clinical parameters in the past, histological and molecular characteristics have become increasingly important. Moreover, the response to regional or systemic chemotherapy has been demonstrated to be strong for a beneficial course of the disease even in advanced diseases.

KEY-MESSAGES

Due to the variety of available treatment options, optimal patient selection is crucial. Besides liver surgery, staged concepts as well as liver transplantation are curative tools for many patients.

Effect of intraoperative nerve monitoring on postoperative vocal cord palsy rates after thyroidectomy: European multicentre registry-based study

Background

Intraoperative nerve monitoring (IONM) of the recurrent laryngeal nerve (RLN) predicts the risk of vocal cord palsy (VCP). IONM can be used to adapt the surgical strategy in order to prevent bilateral VCP and associated morbidity. Controversial results have been reported in the literature for the effect of IONM on rates of VCP, and large multicentre studies are required for elucidation.

Methods

Patients undergoing first‐time thyroidectomy for benign thyroid disease between May 2015 and January 2019, documented prospectively in the European registry EUROCRINE®, were included in a cohort study. The influence of IONM and other factors on the development of postoperative VCP was analysed using multivariable regression analysis.

Results

Of 4598 operations from 82 hospitals, 3542 (77·0 per cent) were performed in female patients. IONM was used in 4182 (91·0 per cent) of 4598 operations, independent of hospital volume. Postoperative VCP was diagnosed in 50 (1·1 per cent) of the 4598 patients. The use of IONM was associated with a lower risk of postoperative VCP in multivariable analysis (odds ratio (OR) 0·34, 95 per cent c.i. 0·16 to 0·73). Damage to the RLN noted during surgery (OR 24·77, 12·91 to 48·07) and thyroiditis (OR 2·03, 1·10 to 3·76) were associated with an increased risk of VCP. Higher hospital volume correlated with a lower rate of VCP (OR 0·05, 0·01 to 0·13).

Conclusion

Use of IONM was associated with a low rate of postoperative VCP.

Rating of camera navigation skills in colorectal surgery

PURPOSE

In advanced minimally invasive surgery the laparoscopic camera navigation (LCN) quality can influence the flow of the operation. This study aimed to investigate the applicability of a scoring system for LCN (SALAS score) in colorectal surgery and whether an adequate scoring can be achieved using a specified sequence of the operation.

METHODS

The score was assessed by four blinded raters using synchronized video and voice recordings of 20 randomly selected laparoscopic colorectal surgeries (group A: assessment of the entire operation; group B: assessment of the 2nd and 3rd quartile). Experience in LCN was defined as at least 100 assistances in complex laparoscopic procedures.

RESULTS

The surgical teams consisted of three residents, three fellows, and two attendings forming 15 different teams. The ratio between experienced and inexperienced camera assistants was balanced (n = 11 vs. n = 9). Regarding the total SALAS score, the four raters discriminated between experienced and inexperienced camera assistants, regardless of their group assignment (group A, p < 0.05; group B, p < 0.05). The score's interrater variability and reliability were proven with an intraclass correlation coefficient of 0.88. No statistically relevant correlation was achieved between operation time and SALAS score.

CONCLUSION

This study presents the first intraoperative, objective, and structured assessment of LCN in colorectal surgery. We could demonstrate that the SALAS score is a reliable tool for the assessment of LCN even when only the middle part (50%) of the procedure is analyzed. Construct validity was proven by discriminating between experienced and inexperienced camera assistants.

[Differentiated surgical therapy for neuroendocrine tumours (NET) of the stomach]

Neuroendocrine tumours (NET) of the stomach have increasingly entered into the focus of attention recently by endocrinologists as well as by surgeons on account of new findings on their biological background and their clinical relevance. The discriminating pathogenesis and the basically different biological behaviours of neuroendocrine tumours of the stomach require a differentiated therapeutical treatment for the different sub-types. The differential diagnostic clarification of the basic pathomechanism is therefore of decisive importance. As a consequence of the rarity of this entity, any treatment should be performed in corresponding centres. An interdisciplinary therapy planning, e. g., in the context of specialised inter-disciplinary conferences, such as an interdisciplinary board for endocrine and neuroendocrine tumours, is essential for an optimised management of these tumours. Important aspects of future research should - besides the genetic and molecular biological backgrounds - be the additional and potentially apparent factors for hypergastrinaemia, which induce a dysplastic and perhaps malignant transformation of the hyperplastic changes. Neuroendocrine tumours of the stomach remain a special challenge within the clinical daily routine - not only in the correct classification but also in the optimal surgical therapy.