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Barczyński M, Konturek A. Clinical validation of NerveTrend versus conventional i-IONM mode of NIM Vital in prevention of recurrent laryngeal nerve events during bilateral thyroid surgery: A randomized controlled trial. Head Neck 2024; 46:492-502. [PMID: 38095022 DOI: 10.1002/hed.27601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 12/04/2023] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND The aim of this study was to test the hypothesis that use of NerveTrend™ mode of intermittent neuromonitoring (i-IONM) during thyroidectomy may identify and prevent impending recurrent laryngeal nerve (RLN) injury. METHODS A randomized clinical trial. The primary outcome was prevalence of RLN injury on postoperative day 1. In NerveTrend™ group the i-IONM stimulator was used for trending of amplitude and latency changes from initial vagal electromyographic baseline to tailor surgical strategy. RESULTS Some 264 patients were randomized into the intervention versus the control group, 132 patients each. RLN injury was found on postoperative day 1 in 5/264 (1.89%) nerves at risk (NAR) versus 12/258 (4.65%) NAR whereas staged thyroidectomy was used in 0/132 (0.00%) versus 6/132 (4.54%) patients (p = 0.067 and p = 0.029, respectively). CONCLUSION The use of NerveTrend™ mode resulted in tendency towards reduced RLN injury on postoperative day 1 and significant decrease of need for a staged thyroidectomy.
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Affiliation(s)
- Marcin Barczyński
- Department of Endocrine Surgery, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Aleksander Konturek
- Department of Endocrine Surgery, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland
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Wu CW, Randolph GW, Barczyński M, Schneider R, Chiang FY, Huang TY, Karcioglu AS, Konturek A, Frattini F, Weber F, Liu CH, Dralle H, Dionigi G. Training Courses in Laryngeal Nerve Monitoring in Thyroid and Parathyroid Surgery- The INMSG Consensus Statement. Front Endocrinol (Lausanne) 2021; 12:705346. [PMID: 34220726 PMCID: PMC8253252 DOI: 10.3389/fendo.2021.705346] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 05/26/2021] [Indexed: 01/04/2023] Open
Abstract
Intraoperative neural monitoring (IONM) is now an integral aspect of thyroid surgery in many centers. Interest in IONM and the number of institutions that perform monitored thyroidectomies have increased throughout the world in recent years. For surgeons considering the introduction of IONM in their practice, specific training in IONM devices and procedures can substantially shorten the learning curve. The International Neural Monitoring Study Group (INMSG) has been at the forefront of IONM technology and procedural adoption since the introduction of neural monitoring in thyroid and parathyroid surgery. The purpose of this document is to define the INMSG consensus on essential elements of IONM training courses. Specifically, this document describes the minimum training required for teaching practical application of IONM and consensus views on key issues that must be addressed for the safe and reliable introduction of IONM in surgical practice. The intent of this publication is to provide societies, course directors, teaching institutions, and national organizations with a practical reference for developing IONM training programs. With these guidelines, IONM will be implemented optimally, to the ultimate benefit of the thyroid and parathyroid surgical patients.
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Affiliation(s)
- Che-Wei Wu
- International Thyroid Surgery Center, Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Center for Liquid Biopsy and Cohort Research, and Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Gregory W. Randolph
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, MA, United States
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Marcin Barczyński
- Department of Endocrine Surgery, Third Chair of General Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Rick Schneider
- Department of Surgery, University Hospital Halle, Martin-Luther-University, Halle-Wittenberg, Germany
| | - Feng-Yu Chiang
- Department of Otolaryngology, E-Da Hospital, School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Tzu-Yen Huang
- International Thyroid Surgery Center, Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Center for Liquid Biopsy and Cohort Research, and Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Amanda Silver Karcioglu
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, NorthShore University HealthSystem, Evanston, IL, United States
| | - Aleksander Konturek
- Department of Endocrine Surgery, Third Chair of General Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Francesco Frattini
- Department of Surgery, Ospedale di Circolo, ASST Settelaghi, Varese, Italy
| | - Frank Weber
- Department of General, Visceral and Transplantation Surgery, University of Duisburg-Essen, Essen, Germany
| | - Cheng-Hsin Liu
- International Thyroid Surgery Center, Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Henning Dralle
- Department of General, Visceral and Transplantation Surgery, University of Duisburg-Essen, Essen, Germany
| | - Gianlorenzo Dionigi
- Department of Human Pathology in Adulthood and Childhood “G. Barresi”, University Hospital G. Martino, University of Messina, Messina, Italy
- *Correspondence: Gianlorenzo Dionigi,
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Abt NB, Puram SV, Kamani D, Modi R, Randolph GW. Neuromonitored Thyroid Surgery: Optimal Stimulation Based on Intraoperative EMG Response Features. Laryngoscope 2020; 130:E970-E975. [DOI: 10.1002/lary.28613] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 02/10/2020] [Accepted: 02/19/2020] [Indexed: 11/05/2022]
Affiliation(s)
- Nicholas B. Abt
- Department of Otolaryngology Massachusetts Eye and Ear Infirmary Boston Massachusetts U.S.A
| | - Sidharth V. Puram
- Department of Otolaryngology‐Head and Neck Surgery and Department of Genetics Washington University School of Medicine St. Louis Missouri U.S.A
| | - Dipti Kamani
- Department of Otolaryngology Massachusetts Eye and Ear Infirmary Boston Massachusetts U.S.A
| | - Rahul Modi
- Department of Otolaryngology Massachusetts Eye and Ear Infirmary Boston Massachusetts U.S.A
| | - Gregory W. Randolph
- Department of Otolaryngology Massachusetts Eye and Ear Infirmary Boston Massachusetts U.S.A
- Division of Surgical Oncology, Department of Surgery Massachusetts General Hospital, Harvard Medical School Boston Massachusetts U.S.A
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Turkmen HI, Karsligil ME. Advanced computing solutions for analysis of laryngeal disorders. Med Biol Eng Comput 2019; 57:2535-2552. [DOI: 10.1007/s11517-019-02031-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 08/13/2019] [Indexed: 11/29/2022]
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Schneider R, Randolph GW, Dionigi G, Wu CW, Barczynski M, Chiang FY, Al-Quaryshi Z, Angelos P, Brauckhoff K, Cernea CR, Chaplin J, Cheetham J, Davies L, Goretzki PE, Hartl D, Kamani D, Kandil E, Kyriazidis N, Liddy W, Orloff L, Scharpf J, Serpell J, Shin JJ, Sinclair CF, Singer MC, Snyder SK, Tolley NS, Van Slycke S, Volpi E, Witterick I, Wong RJ, Woodson G, Zafereo M, Dralle H. International neural monitoring study group guideline 2018 part I: Staging bilateral thyroid surgery with monitoring loss of signal. Laryngoscope 2018; 128 Suppl 3:S1-S17. [DOI: 10.1002/lary.27359] [Citation(s) in RCA: 123] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2018] [Indexed: 11/09/2022]
Affiliation(s)
- Rick Schneider
- Martin Luther University Halle-Wittenberg; Department of General, Visceral, and Vascular Surgery; Halle Germany
| | - Gregory W. Randolph
- Division of Thyroid and Parathyroid Surgery, Department of Otolaryngology; Massachusetts Eye and Ear Harvard Medical School; Boston Massachusetts
- Division of Surgical Oncology, Endocrine Surgery Service, Department of Surgery; Massachusetts General Hospital, Harvard Medical School; Boston Massachusetts
| | - Gianlorenzo Dionigi
- Division for Endocrine Surgery, at the Department of Human Pathology in Adulthood and Childhood “G. Barresi,” University Hospital G. Martino; University of Messina; Italy
| | - Che-Wei Wu
- Kaohsiung Medical University Hospital, Kaohsiung Medical University; Otolaryngology-Head and Neck Surgery; Kaohsiung Taiwan
| | - Marcin Barczynski
- Jagiellonian University, Department of Endocrine Surgery, Third Chair of General Surgery; Krakow Poland
| | - Feng-Yu Chiang
- Kaohsiung Medical University Hospital, Kaohsiung Medical University; Otolaryngology-Head and Neck Surgery; Kaohsiung Taiwan
| | - Zaid Al-Quaryshi
- University of Iowa Hospitals and Clinics, Otolaryngology; Iowa City Iowa
| | - Peter Angelos
- University of Chicago; Division of Endocrine Surgery, Department of Surgery; Chicago Illinois
| | - Katrin Brauckhoff
- Haukeland Universitetssjukehus; Department of Breast and Endocrine Surgery; Bergen Norway
| | - Claudio R. Cernea
- University of Sao Paulo Medical School; Department of Head and Neck Surgery; Sao Paulo SP Brazil
| | | | - Jonathan Cheetham
- Cornell University, Clinical Sciences, College of Veterinary Medicine; Ithaca New York
| | - Louise Davies
- VA Outcomes Group at the Veterans Affairs Medical Center; Norwich Vermont
| | - Peter E. Goretzki
- Stadtische Kliniken Neuss Lukaskrankenhaus GmbH; Neuss Nordrhein-Westfalen Germany
| | - Dana Hartl
- Institut Gustave Roussy, Otolaryngology Head & Neck Surgery; Villejuif France
| | - Dipti Kamani
- Division of Thyroid and Parathyroid Surgery, Department of Otolaryngology; Massachusetts Eye and Ear Harvard Medical School; Boston Massachusetts
| | - Emad Kandil
- Department of Surgery; Tulane University School of Medicine; New Orleans Louisiana
| | - Natalia Kyriazidis
- State University of New York Upstate Medical University; Otolaryngology; Syracuse New York
| | - Whitney Liddy
- Northwestern University Feinberg School of Medicine Department of Psychiatry and Behavioral Sciences, Otolaryngology; Chicago Illinois
| | - Lisa Orloff
- Stanford University School of Medicine, Otolaryngology, Division of Head and Neck Surgery; Stanford California
| | | | - Jonathan Serpell
- Alfred Hospital; Melbourne Victoria Australia
- Monash University School of Languages Literatures Cultures and Linguistics; Clayton Victoria Australia
| | | | | | - Michael C. Singer
- Henry Ford Hospital, Otolaryngology-Head & Neck Surgery; Detroit Michigan
| | - Samuel K. Snyder
- University of Texas Rio Grande Valley School of Medicine; Department of General Surgery; Edinburg Texas
| | - Neil S. Tolley
- St. Mary's Hospital, Imperial College Hospitals NHS Trust, St. Mary's Hospital; London United Kingdom
| | | | - Erivelto Volpi
- Hospital das Clinicas-University of Sao Paulo Medical School; Sao Paulo Brazil
| | - Ian Witterick
- Mount Sinai Hospital; Department of Otolaryngology; Toronto Ontario Canada
| | - Richard J. Wong
- Memorial Sloan-Kettering Cancer Center, Department of Surgery, Head and Neck Service; New York New York
| | | | - Mark Zafereo
- MD Anderson Cancer Center, Head and Neck Surgery; Houston Texas U.S.A
| | - Henning Dralle
- Allgemeinchirurgie, Uniklinik Halle; Halle/Saale Germany
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Brauckhoff K, Svendsen ØS, Stangeland L, Biermann M, Aas T, Husby PJA. Injury mechanisms and electromyographic changes after injury of the recurrent laryngeal nerve: Experiments in a porcine model. Head Neck 2017; 40:274-282. [DOI: 10.1002/hed.24940] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 05/19/2017] [Accepted: 07/28/2017] [Indexed: 11/12/2022] Open
Affiliation(s)
- Katrin Brauckhoff
- Department of Breast and Endocrine Surgery; Haukeland University Hospital; Bergen Norway
| | - Øyvind S. Svendsen
- Department of Anesthesia and Intensive Care; Haukeland University Hospital; Bergen Norway
| | - Lodve Stangeland
- Department of Clinical Science; University of Bergen; Bergen Norway
| | - Martin Biermann
- Department of Radiology; Haukeland University Hospital; Bergen Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
| | - Turid Aas
- Department of Breast and Endocrine Surgery; Haukeland University Hospital; Bergen Norway
| | - Paul J. A. Husby
- Department of Anesthesia and Intensive Care; Haukeland University Hospital; Bergen Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
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Dionigi G, Kim HY, Wu CW, Lavazza M, Materazzi G, Lombardi CP, Anuwong A, Tufano RP. Neuromonitoring in endoscopic and robotic thyroidectomy. Updates Surg 2017; 69:171-179. [DOI: 10.1007/s13304-017-0442-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 04/01/2017] [Indexed: 12/01/2022]
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Dionigi G, Wu CW, Kim HY, Rausei S, Boni L, Chiang FY. Severity of Recurrent Laryngeal Nerve Injuries in Thyroid Surgery. World J Surg 2017; 40:1373-81. [PMID: 26817650 DOI: 10.1007/s00268-016-3415-3] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Few studies in the literature have reported recovery data for different types of recurrent laryngeal nerve injuries (RLNIs). This study is the first attempt to classify RLNIs and rank them by severity. METHODS This prospective clinical study analyzed 281 RLNIs in which a true loss of signal was identified by intraoperative neuromonitoring (IONM), and vocal cord palsy (VCP) was confirmed by a postoperative laryngoscope. For each injury type, the prevalence of VCP, the time of VCP recovery, and physical changes on nerves were analyzed. Additionally, different RLNI types were experimentally induced in a porcine model to compare morphological change. RESULTS The overall VCP rate in at-risk patients/nerves was 8.9/4.6 %, respectively. The distribution of RLNI types, in order of frequency, was traction (71 %), thermal (17 %), compression (4.2 %), clamping (3.4 %), ligature entrapment (1.6 %), suction (1.4 %), and nerve transection (1.4 %). Complete recovery from VCP was documented in 91 % of RLNIs. Recovery time was significantly faster in the traction group compared to the other groups (p < 0.001). The rates of temporary and permanent VCP were 98.6 and 1.4 % for traction lesion, 72 and 28 % for thermal injury, 100 and 0 % for compression injury, 50 and 50 % for clamping injury, 100 and 0 % for ligature entrapment, 100 and 0 % for suction injury, and 0 and 100 % for nerve transection, respectively. Physical changes were noted in 14 % of RLNIs in which 56 % of VCP was permanent. However, among the remaining 86 % IONM-detectable RLNIs without physical changes, only 1.2 % of VCP was permanent. A porcine model of traction lesion showed only distorted outer nerve structure, whereas the thermal lesion showed severe damage in the inner endoneurium. CONCLUSIONS Different RNLIs induce different morphological alterations and have different recovery outcomes. Permanent VCP is rare in lesions that are visually undetectable but detectable by IONM. By enabling early detection of RLNI and prediction of outcome, IONM can help clinicians plan intra- and postoperative treatment.
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Affiliation(s)
- Gianlorenzo Dionigi
- 1st Division of General Surgery, Department of Surgical Sciences and Human Morphology, Research Center for Endocrine Surgery, University of Insubria (Varese-Como), via Guicciardini 9, 21100, Varese, Italy
| | - Che-Wei Wu
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, 100TzYou 1st Road, Kaohsiung City, 807, Taiwan.
| | - Hoon Yub Kim
- Division of Breast and Endocrine Surgery, Department of Surgery, Minimally Invasive Surgery and Robotic Surgery Center, Korea University Hospital, Korea University College of Medicine, 73, Inchon-ro, Seongbuk-gu, Seoul, 136-705, Korea
| | - Stefano Rausei
- 1st Division of General Surgery, Department of Surgical Sciences and Human Morphology, Research Center for Endocrine Surgery, University of Insubria (Varese-Como), via Guicciardini 9, 21100, Varese, Italy
| | - Luigi Boni
- 1st Division of General Surgery, Department of Surgical Sciences and Human Morphology, Research Center for Endocrine Surgery, University of Insubria (Varese-Como), via Guicciardini 9, 21100, Varese, Italy
| | - Feng-Yu Chiang
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, 100TzYou 1st Road, Kaohsiung City, 807, Taiwan
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Barber SR, Liddy W, Kyriazidis N, Cinquepalmi M, Lin BM, Modi R, Patricio S, Kamani D, Belotti C, Mahamad S, Lawson B, Randolph GW. Changes in electromyographic amplitudes but not latencies occur with endotracheal tube malpositioning during intraoperative monitoring for thyroid surgery: Implications for guidelines. Laryngoscope 2016; 127:2182-2188. [DOI: 10.1002/lary.26392] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 08/26/2016] [Accepted: 09/22/2016] [Indexed: 12/18/2022]
Affiliation(s)
- Samuel R. Barber
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
| | - Whitney Liddy
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
- Department of Otology and Laryngology; Harvard Medical School; Boston Massachusetts U.S.A
| | - Natalia Kyriazidis
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
| | - Matteo Cinquepalmi
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
- Operative Unit Surgery of Thyroid and Parathyroid; Sapienza University of Rome, Sant'Andrea Hospital; Rome Italy
| | - Brian M. Lin
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
- Department of Otology and Laryngology; Harvard Medical School; Boston Massachusetts U.S.A
| | - Rahul Modi
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
| | - Stephanie Patricio
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
| | - Dipti Kamani
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
- Department of Otology and Laryngology; Harvard Medical School; Boston Massachusetts U.S.A
| | - Carlo Belotti
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
- Operative Unit Surgery of Thyroid and Parathyroid; Sapienza University of Rome, Sant'Andrea Hospital; Rome Italy
| | - Sadhana Mahamad
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
| | - Bradley Lawson
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
- Department of Otology and Laryngology; Harvard Medical School; Boston Massachusetts U.S.A
| | - Gregory W. Randolph
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
- Department of Otology and Laryngology; Harvard Medical School; Boston Massachusetts U.S.A
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Dionigi G, Wu CW, Kim HY, Liu X, Liu R, Randolph GW, Anuwong A. Safety of energy based devices for hemostasis in thyroid surgery. Gland Surg 2016; 5:490-494. [PMID: 27867863 DOI: 10.21037/gs.2016.09.01] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Energy based devices (EBD) have been developed, implemented and increasingly applied in thyroid surgery because they can provide a combined dissection and haemostatic effect. In particular, advantages of EBD have been described in terms of efficacious haemostasis, reduction of procedure-associated time, reduced incision length, less operative blood loss and transfusion need, decreased postoperative drain, pain and hospital stay. In addition, EBD are essential for endoscopic procedures. On the contrary, a potential drawback is the increased health care costs. This paper reviews relevant medical literature published on the safety of new devices for achieving hemostasis and dissection around the recurrent laryngeal nerve (RLN).
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Affiliation(s)
- Gianlorenzo Dionigi
- 1st Division of Surgery, Research Center for Endocrine Surgery, Department of Surgical Sciences and Human Morphology, University of Insubria (Como-Varese), Varese, Italy
| | - Che-Wei Wu
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hoon-Yub Kim
- Department of Surgery, KUMC Thyroid Center, Korea University Hospital, Korea University College of Medicine, Seoul, Korea
| | - Xiaoli Liu
- Division of Thyroid Surgery, Jilin Provincial Key Laboratory of Surgical Translational Medicine, China-Japan Union Hospital of Jilin University, Changchun 130031, China
| | - Renbin Liu
- Division of Thyroid and Breast Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Gregory W Randolph
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Laryngology and Otology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, USA
| | - Angkoon Anuwong
- Minimally Invasive and Endocrine Surgery Division, Department of Surgery, Police General Hospital, Bangkok, Thailand
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Wu CW, Randolph GW, Lu IC, Chang PY, Chen YT, Hun PC, Lin YC, Dionigi G, Chiang FY. Intraoperative neural monitoring in thyroid surgery: lessons learned from animal studies. Gland Surg 2016; 5:473-480. [PMID: 27867861 PMCID: PMC5106378 DOI: 10.21037/gs.2016.09.06] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Accepted: 09/09/2016] [Indexed: 12/31/2022]
Abstract
Recurrent laryngeal nerve (RLN) injury remains a significant morbidity associated with thyroid and parathyroid surgery. In the past decade, surgeons have increasingly used intraoperative neural monitoring (IONM) as an adjunct technique for localizing and identifying the RLN, detecting RLN injury, and predicting the outcome of vocal cord function. In recent years, many animal studies have investigated common pitfalls and new applications of IONM. For example, the use of IONM technology in animal models has proven valuable in studies of the electrophysiology of RLN injury. The advent of animal studies has substantially improved understanding of IONM technology. Lessons learned from animal studies have immediate clinical applications in establishing reliable strategies for preventing intraoperative RLN injury. This article gives an overview of the research progress on IONM-relevant animal models.
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Affiliation(s)
- Che-Wei Wu
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Gregory W. Randolph
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Laryngology and Otology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, USA
| | - I-Cheng Lu
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Pi-Ying Chang
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yi-Ting Chen
- Department of Pathology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Pao-Chu Hun
- Laboratory Animal Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yi-Chu Lin
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Gianlorenzo Dionigi
- 1 Division of Surgery, Research Center for Endocrine Surgery, Department of Surgical Sciences and Human Morphology, University of Insubria (Como-Varese), Varese, Italy
| | - Feng-Yu Chiang
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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12
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Li T, Zhou G, Yang Y, Gao ZD, Guo P, Shen ZL, Yang XD, Xie QW, Ye YJ, Jiang KW, Wang S. Identifying a Safe Range of Stimulation Current for Intraoperative Neuromonitoring of the Recurrent Laryngeal Nerve: Results from a Canine Model. Chin Med J (Engl) 2016; 129:1830-4. [PMID: 27453233 PMCID: PMC4976572 DOI: 10.4103/0366-6999.186636] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background: Intraoperative neuromonitoring (IONM) of the recurrent laryngeal nerve (RLN) has been widely applied during thyroid surgery. However, the safe range of stimulation intensity for IONM remains undetermined. Methods: Total thyroidectomies were performed on twenty dogs, and their RLNs were stimulated with a current of 5–20 mA (step-wise in 5 mA increments) for 1 min. The evoked electromyography (EMG) of vocal muscles before and after supramaximal stimulation were recorded and compared. Acute microstructural morphological changes in the RLNs were observed immediately postoperatively under an electron microscope. Results: The average stimulating threshold for RLNs stimulated with 15 mA and 20 mA showed no significant changes compared to the unstimulated RLNs (15 mA group: 0.320 ± 0.123 mA vs. 0.315 ± 0.097 mA, P = 0.847; 20 mA group: 0.305 ± 0.101 mA vs. 0.300 ± 0.103 mA, P = 0.758). Similar outcomes were shown in average evoked EMG amplitude (15 mA group: 1,026 ± 268 μV vs. 1,021 ± 273 μV, P = 0.834; 20 mA group: 1,162 ± 275 μV vs. 1,200 ± 258 μV, P = 0.148). However, obvious acute microstructural morphological changes were observed in the nerves that were stimulated with 20 mA. Conclusions: A stimulation intensity less than 15 mA might be safe for IONM of the RLN.
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Affiliation(s)
- Tao Li
- Department of Gastrointestinal Surgery, Surgical Oncology Laboratory, Peking University People's Hospital, Peking University, Beijing 100044, China
| | - Gang Zhou
- Department of Gastrointestinal Surgery, Surgical Oncology Laboratory, Peking University People's Hospital, Peking University, Beijing 100044, China
| | - Yang Yang
- Department of Gastrointestinal Surgery, Surgical Oncology Laboratory, Peking University People's Hospital, Peking University, Beijing 100044, China
| | - Zhi-Dong Gao
- Department of Gastrointestinal Surgery, Surgical Oncology Laboratory, Peking University People's Hospital, Peking University, Beijing 100044, China
| | - Peng Guo
- Department of Gastrointestinal Surgery, Surgical Oncology Laboratory, Peking University People's Hospital, Peking University, Beijing 100044, China
| | - Zhan-Long Shen
- Department of Gastrointestinal Surgery, Surgical Oncology Laboratory, Peking University People's Hospital, Peking University, Beijing 100044, China
| | - Xiao-Dong Yang
- Department of Gastrointestinal Surgery, Surgical Oncology Laboratory, Peking University People's Hospital, Peking University, Beijing 100044, China
| | - Qi-Wei Xie
- Department of Gastrointestinal Surgery, Surgical Oncology Laboratory, Peking University People's Hospital, Peking University, Beijing 100044, China
| | - Ying-Jiang Ye
- Department of Gastrointestinal Surgery, Surgical Oncology Laboratory, Peking University People's Hospital, Peking University, Beijing 100044, China
| | - Ke-Wei Jiang
- Department of Gastrointestinal Surgery, Surgical Oncology Laboratory, Peking University People's Hospital, Peking University, Beijing 100044, China
| | - Shan Wang
- Department of Gastrointestinal Surgery, Surgical Oncology Laboratory, Peking University People's Hospital, Peking University, Beijing 100044, China
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13
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Lamadé W, Béchu M, Lauzana E, Köhler P, Klein S, Tuncer T, Rashid NIH, Kahle E, Erdmann B, Meyding-Lamadé U. The weepy nerve-different sensitivity of left and right recurrent laryngeal nerves under tensile stress in a porcine model. Langenbecks Arch Surg 2016; 401:983-990. [PMID: 27209314 DOI: 10.1007/s00423-016-1439-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 04/19/2016] [Indexed: 01/23/2023]
Abstract
PURPOSE Recurrent laryngeal nerve palsy in thyroid surgery is still a threatening complication. Our aim was to analyze the impact of prolonged tensile stress on the recurrent laryngeal nerve (RLN) in an animal model using continuous intraoperative neuromonitoring (C-IONM). METHODS Constant tensile stress was applied to left and right RLNs in 20 pigs (40 RLN). In a pilot study, five animals were subjected to a tensile force of 0.34 ± 0.07 N for 10 min and changes in amplitude were documented using C-IONM. In the main study, a force of 1.2 N was applied until the signal amplitude was reduced by 85 %, in 15 pigs. Nerve conductivity was analyzed by threshold current measurements. RESULTS Good correlation was found between stress and amplitude decrease in the pilot study as well as between signal decrease and duration of trauma in the main study. Great variations were found inter- and intra-individually. These variations were most prominent at 85 % signal reduction (median 36 min, range 0.3-171 min). There was no side specificity (left 0.3-171 min, right 0.3-168 min, respectively, p = 0.19). However, in each individual animal, there was a sensitive (0.3-98.9 min) and less sensitive nerve (26.8-171 min). These differences became highly significant at 85 % of signal reduction (p = 0.008), where the vulnerability is 1.4 to 146.4 times higher on one side (mean 4.3). CONCLUSIONS Our study demonstrates the presence of a sensitive RLN that was 4.3 times more vulnerable than the contralateral nerve (range 1.4-146.4 times, p = 0.008). Thus, the right and the left nerves cannot be assumed to be of equal sensitivity to trauma. In our data, the more sensitive nerve does not occur predominantly on one side and was named the "weepy nerve."
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Affiliation(s)
- Wolfram Lamadé
- Allgemein- und Viszeralchirurgie, HELIOS Spital Überlingen, Härlenweg 1, Überlingen, Germany.
| | - Maren Béchu
- Allgemein- und Viszeralchirurgie, HELIOS Spital Überlingen, Härlenweg 1, Überlingen, Germany.,Klinik für Neurologie, Krankenhaus Nordwest, Frankfurt am Main, Germany
| | - Ester Lauzana
- Allgemein- und Viszeralchirurgie, HELIOS Spital Überlingen, Härlenweg 1, Überlingen, Germany
| | - Peter Köhler
- Friedrich-Loeffler-Institut, Bundesforschungsinstitut für Tiergesundheit, Neustadt, Germany
| | - Sabine Klein
- Friedrich-Loeffler-Institut, Bundesforschungsinstitut für Tiergesundheit, Neustadt, Germany
| | - Tuncay Tuncer
- Allgemein- und Viszeralchirurgie, HELIOS Spital Überlingen, Härlenweg 1, Überlingen, Germany
| | | | - Erich Kahle
- Friedrich-Loeffler-Institut, Bundesforschungsinstitut für Tiergesundheit, Neustadt, Germany
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14
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Puram SV, Chow H, Wu CW, Heaton JT, Kamani D, Gorti G, Chiang FY, Dionigi G, Barczynski M, Schneider R, Dralle H, Lorenz K, Randolph GW. Posterior cricoarytenoid muscle electrophysiologic changes are predictive of vocal cord paralysis with recurrent laryngeal nerve compressive injury in a canine model. Laryngoscope 2016; 126:2744-2751. [PMID: 27113438 DOI: 10.1002/lary.25967] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 02/16/2016] [Indexed: 11/08/2022]
Abstract
OBJECTIVES/HYPOTHESIS Injury to the recurrent laryngeal nerve (RLN) is a dreaded complication of endocrine surgery. Intraoperative neural monitoring (IONM) has been increasingly utilized to assess the functional status of the RLN. Although the posterior cricoarytenoid muscle (PCA) is innervated by the RLN as the abductor of the larynx, PCA electromyography (EMG) is infrequently recorded during IONM and PCA activity after RLN compressive injury remains poorly characterized. STUDY DESIGN Single-subject prospective animal study. METHODS We employed a canine model to identify postcricoid EMG correlates of postoperative vocal cord paralysis (VCP). Postcricoid electrode recordings were obtained before and after compressive RLN injury associated with VCP. RESULTS Normative postcricoid recordings revealed mean amplitude of 1288 microvolt (μV) and latency of 8.2 millisecond (ms) with maximum (1 milliamp [mA]) vagal stimulation, and mean amplitude of 1807 μV and latency of 3.5 ms with maximum (1 mA) RLN stimulation. Following injury that was associated with VCP, there was 62.1% decrement in postcricoid EMG amplitude with maximum vagal stimulation and 80% decrement with maximum RLN stimulation. Threshold stimulation of the vagus increased by 23%, and there was a corresponding 42% decrease in amplitude. For RLN stimulation, latency increased by 17.3% following injury, whereas threshold stimulation increased by 61% with 35.5% decrement in EMG amplitude. Thus, if RLN amplitude decreases by ≥ 80%, with absolute amplitude of ≤ 300 μV or less and latency increase of ≥ 10%, RLN injury is likely associated with VCP. CONCLUSION Our results predict postoperative VCP based on postcricoid electromyographic IONM and may guide surgical decision making. LEVEL OF EVIDENCE NA Laryngoscope, 126:2744-2751, 2016.
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Affiliation(s)
- Sidharth V Puram
- Division of Thyroid and Parathyroid Surgery, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary and Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Harold Chow
- Division of Thyroid and Parathyroid Surgery, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary and Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Che-Wei Wu
- Division of Thyroid and Parathyroid Surgery, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary and Harvard Medical School, Boston, Massachusetts, U.S.A.,Department of Otorhinolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital; Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - James T Heaton
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Dipti Kamani
- Division of Thyroid and Parathyroid Surgery, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary and Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Gautham Gorti
- Division of Thyroid and Parathyroid Surgery, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary and Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Feng Yu Chiang
- Department of Otorhinolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital; Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Gianlorenzo Dionigi
- Department of Surgical Sciences and Human Morphology, Division of Surgery, University of Insubria-School of Medicine, Varese, Italy
| | - Marcin Barczynski
- Department of Endocrine Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Rick Schneider
- Department of General, Visceral, and Vascular Surgery, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Henning Dralle
- Department of General, Visceral, and Vascular Surgery, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Kerstin Lorenz
- Department of General, Visceral, and Vascular Surgery, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Gregory W Randolph
- Division of Thyroid and Parathyroid Surgery, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary and Harvard Medical School, Boston, Massachusetts, U.S.A.,Division of Surgical Oncology, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, U.S.A
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