Is sharpest scalpel more important than a good surgeon?

Comparison of ultrasound-guided microwave ablation, laser ablation,

Dear Sirs, we read with great interest the paper by Quian et al. entitled "Comparison of ultrasound-guided microwave ablation, laser ablation, and radiofrequency ablation for the treatment of elderly patients with benign thyroid nodules: A meta-analysis" (Qian et al., 2024).The study is aimed at identifying a potential difference in volume reduction rate (VRR) among different ablative modalities, namely radiofrequency ablation (RFA), laser ablation (LA) and microwave ablation (MWA).Authors conclude that "LA was superior to RFA and MWA in reducing the volume of benign thyroid nodules in 6 months of follow-up", also reporting a significant P < 005 for all comparisons in the abstract.However, this conclusion is not supported by any of the study reported, and the conclusions drawn by the authorsy can be seriously misleading for readers.As reported by the same authors in the results of their study, in the three studies comparing LA and RFA no significant difference was found between the two technologies s in VRR.Also, the two studies comparing RFA and MWA did not show any statistically significant difference in VRR.Finally, the only study reported about comparison of LA and MWA also did not show a statistically significant difference in VRR between the two, if not for the subgroup of patients with nodules >13 ml (Shi et al., 2019).So, drawing the conclusion that LA is superior to RFA and MWA cannot be supported by the results of this study.
Image-guided thermal ablations are increasingly successfully used in the treatment of benign and malignant thyroid diseases (Papini et al., 2019;Mauri et al., 2021;Mauri et al., 2019).Different technologies have been used for the percutaneous treatment of thyroid disease, including LA, RFA and MWA.Different experiences have been reported with the use of those techniques, some also trying to compare different technologies.However, no strong evidence of better results of one technology over the other has never been reported, as several other factors can affect the result, including nodule composition and volume, and operator experience with a specific technology (Pacella et al., 2017).Furthermore, the sometime obsessive search of the demonstration of superiority of one technology over the other too often seems to be related to an industry-based interest, while several other factors even much more relevant, like the operator experience, are often neglected.How many studies are nowadays investigating for example the sharpness of a blade in any kind of open surgery, in comparison on studies on surgeon case volume and expertise?In other word, how much the result of a surgical treatment is due to the used surgical materials, and how much on the proper operation technique and operator experience?
In the paper by Quian et al., some other points need to be addressed.First, authors report to have investigated a population of "elderly" patients, setting the threshold of old age at 50 years.Regardless the questionable age threshold, no one of the mentioned studies applied that criteria for patient's selection, and considering the standard deviation reported about the mean age of the patients, for sure several patients had an age < 50 years.Than, authors report including 7 randomized controlled trials (RCTs), while none of the included studies was an RCT.Particularly, one included study compared ablation with surgery, and seems not to provide any information about comparison among ablation techniques (Che et al., 2015).Finally, conversely from what reported in the results section, not two but only one included study compared LA and MWA (Shi et al., 2019).
In conclusion, it is author opinion that the results of the study by Qian et al. should be carefully evaluated before using them to conclude that one technology is superior to another.Several further studies are needed to better address if one technology can provide any benefit over the others, and particularly it would be advisable to evaluate the different technologies in the context of prospective randomized studies, where ablations are performed by the same operators, with same experience, operation setting end operative technique.

Declaration of competing interest
The authors have no competing interests to declare.