[Surgery of euthyroid nodular goiter: special considerations in surgery of recurrent struma]. / Chirurgie der euthyreoten Knotenstruma: Besonderheiten bei der Operation der Rezidivstruma.

Indications for surgery need individual risk-analysis. Operative strategy is more conservative with unilateral procedures, more radical with total lobectomy. The crucial risk is recurrent laryngeal nerve paralysis (r.l.n.p.). In 434 operations with 647 nerves at risk (1985-2001) we classified the anatomical situation of the nerve prospectively: X: not identified, A: not in scar and B: within scar (B1, B2 and B3 dorsally, laterally or ventrally). The risk of r.l.n.p. increased from types A to type B to X, and from B1 to B3. Up to now, intraoperative neuromonitoring did not reduce this risk, additionally.

[Acute abdominal pain--standardized findings as diagnostic support. Results of a prospective multicenter intervention study and testing of a computer-assisted diagnosis system]. / Akuter Bauchschmerz--standardisierte Befundung als Diagnoseunterstützung. Ergebnisse einer prospektiven multizentrischen Interventionsstudie und Testung eines computerunterstützten Diagnosesystems.

Despite powerful diagnostic tools (e.g. ultrasound, special laboratory investigations), the diagnosis of acute abdominal pain is still a considerable problem. Several studies in the UK have shown that the diagnostic accuracy can be improved by structured and standardized history taking and clinical examination and by computer-aided diagnosis. In the framework of a concerted action of the European Community we have conducted a prospective multicenter interventional trial comparing two consecutive phases: a) a baseline phase in clinical routine without additional intervention, b) a test phase with structured and standardized history and clinical examination (questionnaire, documentation programme). In addition, a computer-aided diagnostic system developed in the UK was applied to the cases in the test phase. Outcome criteria were the diagnostic accuracy of the initial and the final examiner, the perforated appendix rate, the negative appendectomy rate, the negative laparotomy rate and the rates of diagnostic errors with missing indication to operation and of delayed urgent operations. No differences could be found between the phases with respect to the outcome criteria. In the baseline phase (test phase) diagnostic accuracy was 59% (59%), diagnostic accuracy after investigation (senior examiner) was 77% (78%), perforated appendix rate was 11% (16%), negative appendectomy rate was 13% (15%), negative laparotomy rate was 7% (8%), the rate of missed urgent indications to operation was 1.1% (1.9%) and the rate of delayed urgent operations was 3.4% (2.4%). Major differences between the centers were recorded. Computer-aided diagnosis resulted in a diagnostic accuracy of 51%. The introduction of structured and standardized history taking and clinical examination has not brought any improvement of the good results in clinical routine. It is doubtful, whether existing systems of computer-aided diagnosis are able to significantly decrease the still remaining error rate of 20%.

[What is the place of "selective thyroid gland resection" in surgery of benign nodular struma]. / Welchen Platz hat die "selektive Schilddrüsenresektion" in der Chirurgie der benignen Knotenstrumen.

Remnants after "classic" Subtotal Thyroidectomy are of constant size in constant position. "Selective" thyroidectomy intends to remove all nodules, but to save normal tissue--irrespective of their localization. From July 1985 to Dec. 1989 in 48.5% of 1124 thyroid lobes sel. surgery was performed, in 27.8% subtotal, in 23.8% total lobectomy. Primary postop. recurrent lar. palsy occurred in 1.3% after sel., 1.0% after subt. and 2.7% after total lobectomy. 90% of primary r.l.n.p.'s were transient--after sel. lobectomy only one persistend (0.2%). Hypocalcemia: 0.7% after sel., 1.4% after subt. thyroidectomy. Besides better quality and quantity of remnants selective thyroidectomy is supported by low rate of complications.

[Reintervention in C-cell carcinoma]. / Reintervention beim C-Zell-Karzinom.

Cervical re-exploration in persistent medullary thyroid cancer usually fails to normalize serum calcitonin levels, which is the most sensitive criterion of tumour-free status (2 out of 21 patients in our re-exploration series). Positive lymph nodes - even at an early tumour stage - seem much more important (postoperative normal serum calcitonin: 86% in the occult tumour group, 71% in patients with palpable primary tumour and negative lymph nodes, as opposed to only 18% with a palpable cervical mass and positive lymph nodes). However, local re-exploration in case of persistent medullary thyroid cancer seems to offer a possible curative chance for the control of recurrence, especially after inadequate primary surgery. In cases without visible distant metastases a marked reduction in serum calcitonin level may be expected (21% of the preoperative level for stages N1 and N2 and 16% for stage N3 on average). In patients with elevated calcitonin levels after stimulation as sole indicator of persistent tumour the indication for reoperation should be handled cautiously. Thus, in 3 out of 5 patients with occult medullary thyroid cancer diagnosed only on the basis of venous sampling who were subjected to multiple cervical re-explorations, distant metastases were subsequently found during follow-up.