[Medicolegal aspects of primary and renal hyperparathyroidism]

BACKGROUND

Compared with malpractice claims in thyroid surgery, expert medico-legal reviews of surgery performed for hyperparathyroidism (HPT) that aim to prove or rebut surgical malpractice are rare. The aim of this analysis was to describe typical risk patterns for possible treatment errors and to generate recommendations for avoiding these treatment errors.

MATERIAL AND METHODS

A total of 12 surgical expert medico-legal reviews, which were carried out by order of 9 arbitration boards and 3 courts between 1997 and 2020 were evaluated.

RESULTS

If the indications for surgical treatment of hyperparathyroidism were present, the failure to identify a parathyroid adenoma or hyperplastic parathyroid glands was in the majority of cases not rated as a surgical treatment error, especially in atypical localizations. Unilateral recurrent laryngeal nerve palsy and postoperative bleeding cannot always be prevented, despite maximum diligence. In contrast, bilateral recurrent laryngeal nerve palsy can be prevented when intraoperative neuromonitoring is correctly applied. A lack of patient information regarding postoperatively persistent HPT, postoperative hypoparathyroidism following the removal of inconspicuous parathyroid glands and nonindicated lobectomy or total thyroidectomy, mostly performed under the assumption of an intrathyroid parathyroid adenoma, represented avoidable malpractice issues.

CONCLUSION

Advanced knowledge of the pathophysiology of the disease and the anatomy of the parathyroid glands as well as the establishment of intraoperative and perioperative standards can prospectively greatly reduce avoidable errors in the surgical treatment and postoperative care of HPT.

[Update of the S2k guidelines : Surgical treatment of benign thyroid diseases]

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

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

BACKGROUND AND AIMS

Previous guidelines addressing surgery of adrenal tumors required actualization in adaption of developments in the area. The present guideline aims to provide practical and qualified recommendations on an evidence-based level reviewing the prevalent literature for the surgical therapy of adrenal tumors referring to patients of all age groups in operative medicine who require adrenal surgery. It primarily addresses general and visceral surgeons but offers information for all medical doctors related to conservative, ambulatory or inpatient care, rehabilitation, and general practice as well as pediatrics. It extends to interested patients to improve the knowledge and participation in the decision-making process regarding indications and methods of management of adrenal tumors. Furthermore, it provides effective medical options for the surgical treatment of adrenal lesions and balances positive and negative effects. Specific clinical questions addressed refer to indication, diagnostic procedures, effective therapeutic alternatives to surgery, type and extent of surgery, and postoperative management and follow-up regime.

METHODS

A PubMed research using specific key words identified literature to be considered and was evaluated for evidence previous to a formal Delphi decision process that finalized consented recommendations in a multidisciplinary setting.

RESULTS

Overall, 12 general and 52 specific recommendations regarding surgery for adrenal tumors were generated and complementary comments provided.

CONCLUSION

Effective and balanced medical options for the surgical treatment of adrenal tumors are provided on evidence-base. Specific clinical questions regarding indication, diagnostic procedures, alternatives to and type as well as extent of surgery for adrenal tumors including postoperative management are addressed.