Effect of the COVID-19 pandemic on surgery for indeterminate thyroid nodules (THYCOVID): a retrospective, international, multicentre, cross-sectional study.

BACKGROUND: Since its outbreak in early 2020, the COVID-19 pandemic has diverted resources from non-urgent and elective procedures, leading to diagnosis and treatment delays, with an increased number of neoplasms at advanced stages worldwide. The aims of this study were to quantify the reduction in surgical activity for indeterminate thyroid nodules during the COVID-19 pandemic; and to evaluate whether delays in surgery led to an increased occurrence of aggressive tumours. METHODS: In this retrospective, international, cross-sectional study, centres were invited to participate in June 22, 2022; each centre joining the study was asked to provide data from medical records on all surgical thyroidectomies consecutively performed from Jan 1, 2019, to Dec 31, 2021. Patients with indeterminate thyroid nodules were divided into three groups according to when they underwent surgery: from Jan 1, 2019, to Feb 29, 2020 (global prepandemic phase), from March 1, 2020, to May 31, 2021 (pandemic escalation phase), and from June 1 to Dec 31, 2021 (pandemic decrease phase). The main outcomes were, for each phase, the number of surgeries for indeterminate thyroid nodules, and in patients with a postoperative diagnosis of thyroid cancers, the occurrence of tumours larger than 10 mm, extrathyroidal extension, lymph node metastases, vascular invasion, distant metastases, and tumours at high risk of structural disease recurrence. Univariate analysis was used to compare the probability of aggressive thyroid features between the first and third study phases. The study was registered on ClinicalTrials.gov, NCT05178186. FINDINGS: Data from 157 centres (n=49 countries) on 87 467 patients who underwent surgery for benign and malignant thyroid disease were collected, of whom 22 974 patients (18 052 [78·6%] female patients and 4922 [21·4%] male patients) received surgery for indeterminate thyroid nodules. We observed a significant reduction in surgery for indeterminate thyroid nodules during the pandemic escalation phase (median monthly surgeries per centre, 1·4 [IQR 0·6-3·4]) compared with the prepandemic phase (2·0 [0·9-3·7]; p<0·0001) and pandemic decrease phase (2·3 [1·0-5·0]; p<0·0001). Compared with the prepandemic phase, in the pandemic decrease phase we observed an increased occurrence of thyroid tumours larger than 10 mm (2554 [69·0%] of 3704 vs 1515 [71·5%] of 2119; OR 1·1 [95% CI 1·0-1·3]; p=0·042), lymph node metastases (343 [9·3%] vs 264 [12·5%]; OR 1·4 [1·2-1·7]; p=0·0001), and tumours at high risk of structural disease recurrence (203 [5·7%] of 3584 vs 155 [7·7%] of 2006; OR 1·4 [1·1-1·7]; p=0·0039). INTERPRETATION: Our study suggests that the reduction in surgical activity for indeterminate thyroid nodules during the COVID-19 pandemic period could have led to an increased occurrence of aggressive thyroid tumours. However, other compelling hypotheses, including increased selection of patients with aggressive malignancies during this period, should be considered. We suggest that surgery for indeterminate thyroid nodules should no longer be postponed even in future instances of pandemic escalation. FUNDING: None.

Surgeon and patient-specific factors influencing the decision for minimally invasive or open surgery in acute bowel obstruction: a retrospective single-center analysis.

PURPOSE: Despite continuous improvement in minimally invasive surgery (MIS) and growing evidence for its superiority in procedures in various organ systems, a routinely application in patients with acute bowel obstruction (ABO) cannot be seen to date. Besides very general explanations for this attitude, not much is known about the decision process in a particular patient. This retrospective study aims at investigating surgeon- and patient-specific factors for or against MIS in acute bowel obstruction. METHODS: A retrospective analysis of all patients undergoing either MIS or open surgery (OS) for ABO at a single center between 2009 and 2017 was performed. All available preoperative parameters were included in the analysis and subdivided into patient- (age, gender, BMI, previous abdominal procedures, inflammatory process, ASA score, bowel dilatation) and surgeon-specific (time of patient admission, senior surgeon performed the procedure or taught the case, availability of a surgical resident or junior doctor as assisting surgeon) factors. Statistical analysis was performed to reveal their influence on the surgeon's decision for or against MIS. RESULTS: Of 106 patients requiring surgical intervention, 57 were treated by OS (53.77%) and 49 by MIS (46.23%). Patients with a higher ASA score (ASA III) and a bowel width of ≥ 3.8 cm in preoperative radiologic imaging were more likely to undergo OS (p < 0.01). Also, a late admission time to the hospital (x̄ = 14.78 h) was associated with OS (p = 0.01). Concerning previous abdominal surgical interventions, patients with prior appendectomy rather were assigned to MIS (p < 0.01) whereas those with prior colectomy to OS (p < 0.01). CONCLUSIONS: The choice of procedure in patients with bowel obstruction is a highly individualized decision. Whereas scientifically proven parameters, such as high age and BMI, had no influence on the decision process, impaired general health condition (ASA score), high bowel width, previous surgical intervention, and a late admission time influenced the decision process towards open surgery. TRIAL REGISTRATION: Retrospectively registered with the German Clinical Trials Register: DRKS00021600.

Flexible single port access in transoral endoscopic thyroidectomy vestibular approach.

Background: Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is regarded the only no-scar technique which combines minimized surgical trauma with all advantages of endoscopy such as enhanced view, fluorescent parathyroid imaging (FPI) and optimum cosmesis. Addressing TOETVA specific local risk profiles like mental nerve injury, the potential of skin lesions or difficult specimen retrieval we modified the three trocar based TOETVA towards a soft single port platform. Methods: Single port-TOETVA (SP-TOETVA) was established and retrospectively analysed in five patients using a soft handmade single port housing multiple trocar valves. Standard laparoscopic instruments, one articulating instrument and a vessel-sealing device were utilized. CO2 insufflation was maintained at 6-8 mmHg. Results: In all patients SP-TOETVA was completed successfully. Hemigland and total thyroid volumes ranged from 5-40 and 55 mL, respectively. Neither additional trocars nor conversion to open was required. Operation time yielded 102-214 min. Neuromonitoring and FPI were applied. The soft wound protection foil served for convenient specimen harvest. No intra- or postoperative complication occurred. In particular, no functional impairment on mental nerve was seen. Conclusions: SP-TOETVA with the soft and flexible handmade single port system is feasible and ensures wound protection. It allows for easy instrument application and benefits of minimally invasive surgery without the specific risk of lateral vestibular incisions.

The Shift from Multiport to Single Port Increases the Amount of Bleeding in Laparoscopic Major Hepatectomy.

BACKGROUND: Bleeding is a negative outcome predictor in liver surgery. Reduction in the abdominal wall trauma in major hepatectomy is challenging but might offer possible benefits for the patient. This study was conducted to assess hemostasis techniques in single-port major hepatectomies (SP-MajH) as compared to multiport major hepatectomies (MP-MajH). METHODS: The non-randomized study comprised 34 SP-MajH in selected patients; 14 MP-MajH served as the control group. Intraoperative blood loss and number of blood units transfused served as the primary endpoints. Secondary endpoints were complications and oncologic five-year outcome. RESULTS: All resections were completed without converting to open surgery. Time for hepatectomy did not differ between SP-MajH and MP-MajH. Blood loss and number of patients with blood loss > 25 mL were significantly larger in MP-MajH (p = 0.001). In contrast, bleeding control was more difficult in SP-MajH, resulting in more transfusions (p = 0.008). One intestinal laceration (SP-MajH) accounted for the only intraoperative complication; 90-day mortality was zero. Postoperative complications were noted in total in 20.6% and 21.4% of patients for SP-MajH and MP-MajH, respectively. No incisional hernia occurred. During a median oncologic follow-up at 61 and 56 months (SP-MajH and MP-MajH), no local tumor recurrence was observed. CONCLUSIONS: SP-MajH requires sophisticated techniques to ensure operative safety. Substantial blood loss requiring transfusion is more likely to occur in SP-MajH than in MP-MajH.