Bernhard J. Lammers

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

PurposeIntraoperative 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.MethodsTwo 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.ResultsWe 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.ConclusionsWe 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.

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

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.

A Need for Catching up in Testing Meshes

At the present time, any categorical recommendation for mesh-based hernia repair can be made only subject to certain caveats (1). Unanswered questions on the biocompatibility of meshes remain, and this on the background of possible physical reactions to foreign bodies, which make later procedures, such as lymphadenectomy, vascular reconstruction, or radical prostatovesiculectomy, difficult or even altogether impossible. Hydrocele, varicocele, spermatic cord irritations, ilioinguinal pain syndromes after mesh implantations are not rare. And why would they be, in view of the occasionally catastrophic results after using the same alloplastic materials in prolapse surgery in women (2).

Hormone replacement after thyroid and parathyroid surgery: Importance of postoperative hypocalcemia.

In his review the author describes the hormone replacement therapy after thyroid surgery, as well as the therapeutic options in hypocalcemia following thyroid or parathyroid surgery. Important issues in this context are not mentioned. The different medicinal options are described in detail, but their practical implementation and the consequences for the affected patients are not explained. Whereas permanent hypocalcemia is rare, even transient hypothyroidism occuring in 10–25% is a serious complication. Further to the demanded intraoperative exposure of all 4 parathyroid glands, also their immediate autotransplantation in the strap muscles in case of visible or expected ischemia to prevent permanent hypoparathyroidism has to be mentioned. Clinically manifest hypocalcemia puts a severe strain on patients and may affect their quality of life substantially. For this reason it is important to explain to patients with postoperative hypocalcemia—even if this is considered transient—in detail the symptoms and prognosis and provide them and the general practitioners practical guidelines. In our hospital, we determine serum calcium and parathyroid hormone before and after surgery in all thyroid and parathyroid patients. In case of postoperative hypoparathyroidism (<15 pg/mL) we substitute even in patients without symptoms 3×1,000 mg calcium/d plus 2×0.5 µg 1.25-dihydroxy-cholecalciferol/d for at least 2–3 weeks, since these patients are usually discharged after 2 days. The substitution treatment is eventually completed after examinations by the general practitioner or endocrinologist. In case of reoperations of the parathyroid glands or multiple gland disease, the facility of cryopreservation of parathyroid tissue for possible later reimplantation should be available.

Importance of Postoperative Hypocalcemia

In his review the author describes the hormone replacement therapy after thyroid surgery, as well as the therapeutic options in hypocalcemia following thyroid or parathyroid surgery. Important issues in this context are not mentioned. The different medicinal options are described in detail, but their practical implementation and the consequences for the affected patients are not explained. Whereas permanent hypocalcemia is rare, even transient hypothyroidism occuring in 10–25% is a serious complication. Further to the demanded intraoperative exposure of all 4 parathyroid glands, also their immediate autotransplantation in the strap muscles in case of visible or expected ischemia to prevent permanent hypoparathyroidism has to be mentioned. Clinically manifest hypocalcemia puts a severe strain on patients and may affect their quality of life substantially. For this reason it is important to explain to patients with postoperative hypocalcemia—even if this is considered transient—in detail the symptoms and prognosis and provide them and the general practitioners practical guidelines. In our hospital, we determine serum calcium and parathyroid hormone before and after surgery in all thyroid and parathyroid patients. In case of postoperative hypoparathyroidism (<15 pg/mL) we substitute even in patients without symptoms 3×1,000 mg calcium/d plus 2×0.5 µg 1.25-dihydroxy-cholecalciferol/d for at least 2–3 weeks, since these patients are usually discharged after 2 days. The substitution treatment is eventually completed after examinations by the general practitioner or endocrinologist. In case of reoperations of the parathyroid glands or multiple gland disease, the facility of cryopreservation of parathyroid tissue for possible later reimplantation should be available.

Correspondence (letter to the editor): Importance of Postoperative Hypocalcemia

In his review the author describes the hormone replacement therapy after thyroid surgery, as well as the therapeutic options in hypocalcemia following thyroid or parathyroid surgery. Important issues in this context are not mentioned. The different medicinal options are described in detail, but their practical implementation and the consequences for the affected patients are not explained. Whereas permanent hypocalcemia is rare, even transient hypothyroidism occuring in 10–25% is a serious complication. Further to the demanded intraoperative exposure of all 4 parathyroid glands, also their immediate autotransplantation in the strap muscles in case of visible or expected ischemia to prevent permanent hypoparathyroidism has to be mentioned. Clinically manifest hypocalcemia puts a severe strain on patients and may affect their quality of life substantially. For this reason it is important to explain to patients with postoperative hypocalcemia—even if this is considered transient—in detail the symptoms and prognosis and provide them and the general practitioners practical guidelines. In our hospital, we determine serum calcium and parathyroid hormone before and after surgery in all thyroid and parathyroid patients. In case of postoperative hypoparathyroidism (<15 pg/mL) we substitute even in patients without symptoms 3×1,000 mg calcium/d plus 2×0.5 µg 1.25-dihydroxy-cholecalciferol/d for at least 2–3 weeks, since these patients are usually discharged after 2 days. The substitution treatment is eventually completed after examinations by the general practitioner or endocrinologist. In case of reoperations of the parathyroid glands or multiple gland disease, the facility of cryopreservation of parathyroid tissue for possible later reimplantation should be available.

Correspondence (letter to the editor): Substantial Deficiencies

The article has some serious methodological flaws. Preoperative data about quality of life and sexuality are lacking in 72.9% of patients, and for the 2 year observation period after surgery, data are available for merely 18% of subjects. This seriously limits the evidence of the study, which can be classified neither as a prospective nor as a retrospective study. The questionnaires do not do justice to impaired sexual functioning in both sexes. The Female Sexual Function Index (FSI) and the international Index of Erectile Function (IIEF) would have provided more adequate tools. Impaired innervation in women can be diagnosed on the basis of vaginal sensitivity, temperature perception, vibratory sensation, ability to experience vaginal orgasm, and lubrication (1). Erectile dysfunction in men that has been persistently present for more than 2 years is a known problem and should be mentioned preoperatively. An early solution to the problem as well as advice are required. The authors’ assumption, that adjuvant radiotherapy does not affect ED, cannot be answered methodologically because observation periods of more than 2 years are required to assess the situation (2). However, the assessment of bladder voiding disorder that is commonly associated with FSD by means of postoperative measurements of residual urine and micturition protocol is clinically justified (3). We evaluated 58 men with rectal carcinoma while investigating a similar clinical question. The patients were treated according to their tumor stage with deep anterior rectal and mesorectal resection (AR) or abdominoperineal extirpation of the rectum(APR) by using the water jet short needle knife (flush knife) technique. The mean period of aftercare was 35 months. The effect on sexuality and bladder voiding function was evaluated by using validated questionnaires (International Prostate Symptom Score [IPSS], [IIEF-5]). Impaired bladder voiding function necessitating therapy was not observed when the flush knife technique was used, independently of the surgical approach. ED requiring treatment occurred in 9 of 58 patients (15%) postoperatively. Using the flush knife technique in the context of rectal surgery enables neuroprotection of structures relevant to patients’ sexuality, in addition to incurring a lower degree of blood loss.

E-PTFE-IPOM versus Polypropylene-Onlay — Ergebnisse einer prospektiv, randomisierten Studie bei Narbenhernien

Introduction: The use of alloplastic material in the repair of incisional hernias is established nowadays. However, investigations of different procedures and implants are not available. Material and methods: The efficiency of three operative procedures and two different alloplastic materials (e-PTFE-intraperitoneal-Onlay-mesh, Mycro-Mesh-plus, and polypropylene-Onlay, Prolene-Mesh) was investigated in a prospective randomised trial. Randomisation was performed when the tension for adapting the fascia margins was less than 70 N. Results: Since July 1997 71 patients with 72 incisional hernias could be included. In 28 patients e-PTFE-IPOM and in 31 a polypropylene-Onlay was used. The results of the two randomised groups are given in Table 1. Open image in new window Table 1. Complications: seroma (S), wound infection (WI), prosthesis infection (PI), prosthesis explanation (EXPL) and recurrence (REC) In 12 cases areplacement of the abdominal wall was necessary because the tension for adapting was > 70 N. In the group with abdominal wall replacement we observed four prosthetic infections, a removal of the prosthesis was not necessary. In two cases recurrence occurred. Conclusion: Both procedures (e-PTFE-IPOM and PP-Onlay) show good long-term results with recurrence rates oflower than 10%, which was 2/12 in the high-risk group. In only one of six cases with prosthetic infection a removal of the implant was necessary. Thus both procedures are comparably useful in treating reinforcement of abdominal wall hernias.