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Open Access Cionm in Intrathoracic Goiter

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Open Access Cionm in Intrathoracic Goiter Abstracts – DGCH Annual Congress 2018 – Berlin, April 17–20 • DOI 10.1515/iss-2018-3001 s1 Innov Surg Sci 2018; 3, (Suppl 1): s1–s231 Open Access cIONM in intrathoracic goiter – different decision of sternotomy (Abstract ID: 52) N. Sehnke1, K. Schwarz1, P. E. Goretzki1 1Städtische Kliniken Neuss - Lukaskrankenhaus Background: In about 1-15% of thyroidectomies, the goiter is intrathoracic with higher rates of complications and a somewhat different management. In the literature sternotomy should only be performed in cases of previous cervical thyroidectomy, invasive carcinoma and truly intrathoracic location. Materials and methods: We retrospectively analyzed 160 patients (269 nerves at risk) with thyroid surgery for intrathoracic goiter between 2001 - 06/2017. Intrathoracic goiter was defined when the retrosternal part exceeded 50% of the whole goiter. There were 83 women (52%) and 77 men (48%) with a median age of 63 years (range 34 to 98 years). 32 patients (20%) presented with a recurrent goiter. cIONM was used in 26 patients (16,2%). Results: A cervical approach was used in 126 patients (75%). 38 patients required median sternotomy and in two patients a lateral thoracotomy was performed (25%). In our collective most recurrent intrathoracic goiters were in the posterior left mediastinum. Indication for sternotomy was the complicated nerve course on the right side, whereas the size of the tumor on the left side was the reason for sternotomy. The preoperative decision for sternotomy was only in one case in the group of cIONM, whereas without cIONM in 60% of operations. Postoperative complications in these 160 patients were 16 transient hypocalcaemias, 10 transient and 3 permanent recurrent nerve palsies and 3 patients with collar secondary bleeding. There was no increasing complication rate in recurrent intrathoracic goiters. There was no significant difference between both groups. Conclusion: cIONM doesn’t reduce the rate of sternotomy actually, but it changed the operation strategy of sternotomy. It reduced the preoperative decision of sternotomy in case of intrathoracic goiter. © The Author(s) 2018, published by De Gruyter. This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 License. Abstracts – DGCH Annual Congress 2018 – Berlin, April 17–20 • DOI 10.1515/iss-2018-3001 s2 Innov Surg Sci 2018; 3, (Suppl 1): s1–s231 Duodenal and ampullary neuroendocrine neoplasms (Abstract ID: 160) A. Nießen1, S. Schimmack1, U. Hinz1, M. W. Büchler1, O. Strobel1 1Universitätsklinikum Heidelberg Background: Neuroendocrine neoplasms of the gastroenteropancreatic system (GEP-NEN) are a heterogeneous entity of increasing incidence. Duodenal NEN (dNEN) are extremely rare and account for about 4% of all GEP-NEN. Clinical management of dNEN remains controversial. In this study we aimed to assess the outcome of surgical management, with a focus on small-sized and well differentiated (G1) dNEN. Materials and methods: We conducted a retrospective study on all patients undergoing surgery for dNEN at our institution between 2002 and 2017. Clinicopathologic features, perioperative outcome and survival were analyzed. Results: A total of 27 patients were identified. Out of 25 patients presenting with their primary tumor, 22 patients (88%) underwent formal oncological resection whilst 3 patients (12%) received local resection. One (3.7%) patient presented with recurrent disease after endoscopic resection and one with diffuse metastatic disease. Surgical 90-day mortality was 1 of 27 (3.7%). The 5-year overall survival rate was 71% in the entire cohort, 74% in patients undergoing resection for primary pNEN, 79% for patients undergoing formal oncological resection, 100% after formal resection for pN0 and 73% for pN1 tumors. Out of 22 patients undergoing formal lymphadenectomy, 17 (77%) patients had lymph node metastasis (pN1). The rate of metastases correlated with the size of the tumor. Of patients presenting with tumors <1cm, 1-2cm, >2cm, 2 of 5 (40%) patients, 9 of 11 (82%) patients, and 6 of 6 (100%) patients had metastases (pN1 or pM1), respectively. Furthermore, 8 of 13 (62%) patients with G1 dNEN had lymph node metastases and 2 of 13 (15%) had liver metastases. Conclusion: Our data show that even well differentiated and small dNEN have a considerable risk of metastases. These data challenge the concept of surveillance or of local resection even for small and/or well differentiated dNEN. Abstracts – DGCH Annual Congress 2018 – Berlin, April 17–20 • DOI 10.1515/iss-2018-3001 s3 Innov Surg Sci 2018; 3, (Suppl 1): s1–s231 CRP promotes proliferation and metastasis in pancreatic neuroendocrine neoplasms (Abstract ID: 220) S. Schimmack1, Y. Yang1, M. Herbst1, F. Bergmann1, T. Hackert1, K. Felix1, O. Strobel1 1Universitätsklinikum Heidelberg Background: Elevated pre-operative C-reactive protein (CRP) serum values have been reported to be associated with poor overall survival for patients with pancreatic neuroendocrine neoplasms (pNEN). The aim of this study was firstly to prove this statement and secondly to investigate mechanisms connecting CRP and malignant behavior in pNEN, since reasons for this phenomenon are unclear. Materials and methods: Patients who underwent pancreatic resections for pNEN between 10/2001 and 03/2016 were identified from a prospective database. Clinicopathological parameters such as serum CRP and tumor grading as well as overall (OS) survival (DFS) were analyzed. The human pNEN-cell-line BON1 as well as tumor tissue (n = 14) and 76 pNEN patient sera were analyzed using Western blot, ELISA of cell line supernatant and patient serum, invasion assays, PCR and immunocytochemistry upon exposure to pro-inflammatory mediators including IL-6 and CRP. Results: Pre-operative serum CRP of 411 pNEN patients was analyzed. 5-year OS of patients with CRP <5 mg/l was 83.4%, between 6 and 19 mg/l was 77.4% and above 19 mg/l 31.3% (p<0.001). Although CRP was significantly associated with grade (mean CRP; G1: 5 mg/l, G2: 7.6 mg/l, G3: 22.3, p<0.001), significant differences in 5-year survival were also seen within G2 pNET, (n=157; CRP <5: 82.8%, 5- 19: 75.7%, >19: 29.2%, p<0.001). In BON1 cells, inflammation (exposure to IL-6) up-regulated CRP expression and secretion. CRP stimulation of BON1 cells increased IL-6 secretion. Both CRP and IL-6 promoted proliferation and invasion of BON1 cells. This was accompanied by activation/phosphorylation of the ERK, AKT, and/or STAT3 pathways. Although known CRP receptors - such as CD16, CD32 and CD64 - were not detected on BON1 cells, internalization of CRP was shown. In patients, increased pre-operative CRP-levels (>=5 mg/L) were associated with significantly higher serum levels of IL-6 and G-CSF, as well as with increased CRP-expression and ERK/AKT/STAT3-phosphorylation in pNEN tissue. Conclusion: Pre-operative serum CRP is associated with unfavorable outcome in pNEN. Possible molecular reason may be CRP and IL-6 promoting ERK/AKT/STAT pathways activation as well as proliferation and invasion in pNEN, thus linking systemic inflammation and poor prognosis. Abstracts – DGCH Annual Congress 2018 – Berlin, April 17–20 • DOI 10.1515/iss-2018-3001 s4 Innov Surg Sci 2018; 3, (Suppl 1): s1–s231 Synchronous antithyroid drug induced agranulocytosis and Fournier´s gangrene (Abstract ID: 309) D. Kauff1, J. I. Staubitz1, T. J. Musholt1, H. Lang1 1Universitätsmedizin Mainz Background: Antihyroid drugs (ATD) such as thioimidazoles (methimazole = thiamazole, carbimazole) and propylthiouracil are commonly used for the treatment of hyperthyroidism. A life-threatening adverse reaction is agranulocytosis with an incidence of 0.1% to 0.5%. There are very few cases in literature showing that the intake of ATDs finally led to sepsis with accompanying tissue necrosis. Materials and methods: We present an unusual case of severe symptomatic agranulocytosis with sudden development of Fournier´s gangrene in a patient, who was treated with ATDs for hyperthyroidism due to Graves´ disease. Results: A 69-year-old female was referred to our hospital with fever and a sore throat. For 6 weeks she was treated with methimazole. Laboratory examinations revealed an agranulocytosis (leucocytes 0,5*109/l (normally 4-10*109/l), granulocytes 0.2%, lymphocytes 81.3%). The bone marrow aspirate showed markedly reduced mature form of granulocytes. In peripheral blood cultures pseudomonas aeruginosa was isolated. A perianal and perineal inflammation became visible and worsened within hours, spreading to the right gluteal region involving the genital, suprapubic and bilateral inguinal region. This case of Fournier´s gangrene required intensive medical care and multiple surgeries. Conclusion: Albeit being a rare case, the history of this patient emphasizes the importance of being aware of the adverse effects ATDs can provoke and underlines the necessity of a structured clinical management if they do occur. To our knowledge, this is the first report on synchronous antihyroid drug induced agranulocytosis and Fournier´s gangrene. Abstracts – DGCH Annual Congress 2018 – Berlin, April 17–20 • DOI 10.1515/iss-2018-3001 s5 Innov Surg Sci 2018; 3, (Suppl 1): s1–s231 Transoral Endoscopic Thyroid Surgery: Tips and Tricks from First Clinical Series (Abstract ID: 439) R. Zorron1, C. Bures1, A. Brandl1, V. Müller1, J. Pratschke1, M. Mogl1 1Charité - Universitätsmedizin Berlin Background: Promising new endoscopic transoral approaches to the anterior neck (TOETVA) have been described with good results and few complications, and the first access is key. A new device is proposed to allow the safe entrance of trocars in the subplatysmal space. This study describes the key steps in performing transoral thyroidectomy in clinical series. Materials and methods: The study shows the technique performed for unilateral thyroidectomies. The technical steps consisted of a 10 mm incision made at the center of the oral vestibule, followed by subplatysmal hydrodissection. The blunt dissector stick was inserted creating a space below the platysma to the anterior neck and the strap muscles. The blunt dissector is a metallic stick with an olive at the end and promotes progressive gain in subplatysmal space enlarging the operative field.
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