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

Video-Assisted Thyroidectomy: Report On The Experience Of A Single Center In More Than Four Hundred Cases

Abstract Background. We report on our series of patients selected for video-assisted thyroidectomy (VAT) over a 7-years period and discuss about the results obtained. Methods. VAT is a gasless procedure performed under endoscopic vision through a single 1-5-2.0 cm skin incision, using a technique very similar to conventional surgery. Eligibility criteria were: thyroid nodules < 35 mm; thyroid volume <30ml; no previous conventional neck surgery. Small low risk papillary thyroid carcinomas (PTC) were considered eligible. Results. 473 VATs were attempted on 459 patients. Loco-regional anesthesia was used in 15 patients. Conversion was necessary 6 times (difficult dissection in 1 case, large nodule size in 3, gross lymph node metastases in 2). Thyroid lobectomy was successfully performed in 110 cases, total thyroidectomy in 343 and completion thyroidectomy in 14. In 66 patients with carcinoma central neck nodes were removed through the same access. Concomitant parathyroidectomy was performed in 14 patients. Pathology showed benign diseases in 277 cases, PTC in 175 and medullary microcarcinoma in 1. Postoperative complications included: 8 transient recurrent nerve palsies, 64 transient hypocalcemias, 3 definitive hypocalcemias, 1 post-operative haematoma and 2 wound infections. Postoperative pain was minimal and cosmetic result excellent. In patients with PTC no evidence of recurrent or residual disease was shown. Conclusions. Indications for VAT are still limited (20% of patients who require thyroidectomy). Nonetheless, in selected patients, it seems a valid option for thyroidectomy and it could be considered even preferable to conventional surgery because of its significant advantages, especially in terms of cosmetic result

Management of primary and renal hyperparathyroidism: guidelines from the German Association of Endocrine Surgeons (CAEK).

BACKGROUND AND AIMS The purpose of this review is to provide updated recommendations for the surgical management of primary (pHPT) and renal (rHPT) hyperparathyroidism, formulating a new guideline of the German Association of Endocrine Surgeons (CAEK). METHODS Evidence-based recommendations for the diagnosis and therapy of pHPT and rHPT were assessed by a multidisciplinary panel using PubMed for a comprehensive literature search together with a structured consensus dialogue (S2k guideline of the Association of the German Scientific Medical Societies, AWMF). RESULTS During the last 20 years, a variety of new preoperative localization procedures, such as sestamibi-SPECT, 4D-CT, and various PET/CT procedures, were established for pHPT. High-resolution imaging, together with intraoperative parathyroid hormone (IOPTH) measurement, enabled focused or minimally invasive surgery to become the most favored surgical technique. Patients with pHPT and nonlocalizing imaging have a higher risk of multiglandular disease. Surgical therapy provides very high cure rates, with a clear relation to the surgeon's experience in parathyroid procedures. Reoperative parathyroidectomy, children with pHPT or familial forms, and parathyroid carcinoma are addressed and require special surgical expertise. A multidisciplinary team of experienced nephrologists, transplant, and endocrine surgeons should assess the diagnosis and treatment of renal HPT. CONCLUSION Surgery is the only curative treatment for pHPT and should be considered for all patients with pHPT. For rHPT, a more selective approach is required, and parathyroidectomy is indicated only when conservative treatment options fail. In parathyroid carcinoma, the adequacy of local resection influences local disease control