[Thyroid surgery in Germany: where are complex surgical procedures performed?]

Endocrine surgery has become an established subspecialty of general and visceral surgery in many countries, supported by curriculum-based advanced and continuing training. In Germany, comparable structures have not yet been fully implemented, although a robust body of evidence demonstrates an inverse relationship between the experience of the surgeon and complication rates, particularly for complex procedures. The aim of this study was to analyze the treatment situation for complex endocrine surgical procedures in Germany with respect to the number of interventions and distribution of locations and to show potential discrepancies between evidence-based recommendations and treatment reality.

Using the in-house developed Geo::Surg modelling framework, which integrates publicly available hospital quality reports, high-resolution geographic information and nationwide German census data in a computer model, the distribution of hemithyroidectomy and thyroidectomy (OPS 5-061.* and 5‑063.*) across Germany from 2019-2023 was analyzed. Particular focus was placed on surgical cases of thyroid carcinoma (ICD-10 C73) and Graves' disease (ICD-10 E05.0) treated in German surgical departments, both of which are generally regarded as being highly complex. According to the European Society of Endocrine Surgeons (ESES), a high-volume thyroid surgeon was defined as performing at least 50 thyroid procedures per year.

Overall, the number of thyroid gland resections(hemithyroidectomy and thyroidectomy) performed in Germany declined by 5.1% between 2019-2023 to finally 50,947. Analogous to international trends, the proportion of total thyroidectomies was reduced in favor of hemithyroidectomies. Although in 2023 a total of 860 hospital sites performed (hemi)thyroidectomies, only 248 sites (28.8%) achieved the threshold of ≥ 50 procedures per year recommended in the current literature. Only 127 (14.8%) of the hospital sites reached the theoretical volume required for 2 high-volume thyroid surgeons (≥ 100 procedures). Of the at least 7470 thyroid cancer cases and 4173 Graves' disease cases coded by surgical departments in 2023, only 67.9% and 62.7%, respectively, were treated in centers performing more than 100 thyroid procedures annually.

Approximately one third each of surgical cases of thyroid carcinoma and Graves' disease in Germany are still treated at sites that possibly do not fulfil the expertise recommended in the current literature. Although these data do not enable direct conclusions regarding the actual quality of care at the individual hospital level, they underline the persistent need for further centralization of complex thyroid surgery in certified, high-volume centers as well as the establishment of a structured endocrine-surgical subspecialty training in Germany.