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Saxe A, Idris M, Gemechu J. Does the Use of Intraoperative Neuromonitoring during Thyroid and Parathyroid Surgery Reduce the Incidence of Recurrent Laryngeal Nerve Injuries? A Systematic Review and Meta-Analysis. Diagnostics (Basel) 2024; 14:860. [PMID: 38732275 PMCID: PMC11083343 DOI: 10.3390/diagnostics14090860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Revised: 04/07/2024] [Accepted: 04/11/2024] [Indexed: 05/13/2024] Open
Abstract
Injury to the recurrent laryngeal nerve (RLN) can be a devastating complication of thyroid and parathyroid surgery. Intraoperative neuromonitoring (IONM) has been proposed as a method to reduce the number of RLN injuries but the data are inconsistent. We performed a meta-analysis to critically assess the data. After applying inclusion and exclusion criteria, 60 studies, including five randomized trials and eight non-randomized prospective trials, were included. A meta-analysis of all studies demonstrated an odds ratio (OR) of 0.66 (95% CI [0.56, 0.79], p < 0.00001) favoring IONM compared to the visual identification of the RLN in limiting permanent RLN injuries. A meta-analysis of studies employing contemporaneous controls and routine postoperative laryngoscopy to diagnose RLN injuries (considered to be the most reliable design) demonstrated an OR of 0.69 (95% CI [0.56, 0.84], p = 0.0003), favoring IONM. Strong consideration should be given to employing IONM when performing thyroid and parathyroid surgery.
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Affiliation(s)
- Andrew Saxe
- Department of Foundational Medical Studies, Oakland University William Beaumont School of Medicine, Rochester, MI 48309, USA; (M.I.); (J.G.)
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Fassari A, Micalizzi A, Lelli G, Gurrado A, Polistena A, Iossa A, De Angelis F, Martini L, Tamagnini GT, Testini M, Cavallaro G. Impact of Intermittent Intraoperative Neuromonitoring (IONM) on the Learning Curve for Total Thyroidectomy by Residents in General Surgery. Surg Innov 2024:15533506241248974. [PMID: 38632109 DOI: 10.1177/15533506241248974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
INTRODUCTION Recurrent laryngeal nerve (RNL) identification constitutes the standard in thyroidectomy. Intraoperative nerve monitoring (IONM) has been introduced as a complementary tool for RLN functionality evaluation. The aim of this study is to establish how routine use of IONM can affect the learning curve (LC) in thyroidectomy. METHODS Patients undergoing total thyroidectomy performed by surgery residents in their learning curve course in 2 academic hospitals, were divided into 2 groups: Group A, including 150 thyroidectomies performed without IONM by 3 different residents, and Group B, including 150 procedures with routine use of intermittent IONM, by other 3 different residents. LC was measured by comparing operative time (OT), its stabilization during the development of the LC, perioperative complication rate. RESULTS As previously demonstrated, the LC was achieved after 30 procedures, in both groups, with no differences due to the use of IONM. Similarly, there were no significant differences among the 2 groups, and between subgroups independently matched, for both OT and complications, even when comparing RLN palsy. Direct nerve visualization and IONM assessment rates were comparable in all groups, and no bilateral RLN palsy (transient or permanent) were reported. No case of interrupted procedure to unilateral lobectomy, due to evidence of RLN injury, was reported. CONCLUSIONS The study demonstrates that the use of IONM thyroid surgery, despite requiring a specific training with experienced surgeons, does not particularly affect the learning curve of residents approaching this kind of surgery, and for this reason its routine use should be encouraged even for trainees.
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Affiliation(s)
- Alessia Fassari
- General Surgery Unit, Luxembourg Hospital Center, Luxembourg
| | - Alessandra Micalizzi
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University, Rome, Italy
| | - Giulio Lelli
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University, Rome, Italy
| | - Angela Gurrado
- Department of Precision and Regenerative Medicine and Ionian Area, Aldo Moro University, Bari, Italy
| | | | - Angelo Iossa
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University, Rome, Italy
| | - Francesco De Angelis
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University, Rome, Italy
| | - Lorenzo Martini
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University, Rome, Italy
| | | | - Mario Testini
- Department of Precision and Regenerative Medicine and Ionian Area, Aldo Moro University, Bari, Italy
| | - Giuseppe Cavallaro
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University, Rome, Italy
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Cozzi AT, Ottavi A, Lozza P, Maccari A, Borloni R, Nitro L, Felisati EG, Alliata A, Martino B, Cacioppo G, Fuccillo M, Rosso C, Pipolo C, Felisati G, De Pasquale L, Saibene AM. Intraoperative Neuromonitoring Does Not Reduce the Risk of Temporary and Definitive Recurrent Laryngeal Nerve Damage during Thyroid Surgery: A Systematic Review and Meta-Analysis of Endoscopic Findings from 73,325 Nerves at Risk. J Pers Med 2023; 13:1429. [PMID: 37888040 PMCID: PMC10607766 DOI: 10.3390/jpm13101429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 09/19/2023] [Accepted: 09/22/2023] [Indexed: 10/28/2023] Open
Abstract
BACKGROUND While intraoperative neuromonitoring (IONM) helps the early identification of recurrent laryngeal nerve (RLN) damage, IONM's role in RLN damage prevention is not defined, given the lack of large studies on the subject. METHODS In a PRISMA-compliant framework, all original thyroid surgery prospective studies providing early postoperative endoscopic data for all patients were pooled in a random-effects meta-analysis. We compared the temporary (and definitive where available) RLN damage rates according to IONM use and IONM type (intermittent, I-IONM, or continuous, C-IONM). RESULTS We identified 2358 temporary and 257 definitive RLN injuries in, respectively, 73,325 and 66,476 nerves at risk. The pooled temporary and definitive RLN injury rates were, respectively, 3.15% and 0.422% considering all procedures, 3.29% and 0.409% in cases using IONM, and 3.16% and 0.463 in cases not using IONM. I-IONM and C-IONM, respectively, showed a pooled temporary RLN injury rate of 2.48% and 2.913% and a pooled definitive injury rate of 0.395% and 0.4%. All pooled rates had largely overlapping 95% confidence intervals. CONCLUSIONS Our data suggest that IONM does not affect the temporary or definitive RLN injury rate following thyroidectomy, though its use can be advised in selected cases and for bilateral palsy prevention.
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Affiliation(s)
- Anna Teresa Cozzi
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy; (A.T.C.); (A.O.); (P.L.); (A.M.); (R.B.); (L.N.); (E.G.F.); (A.A.); (B.M.); (G.C.); (M.F.); (C.R.); (C.P.); (G.F.)
| | - Alice Ottavi
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy; (A.T.C.); (A.O.); (P.L.); (A.M.); (R.B.); (L.N.); (E.G.F.); (A.A.); (B.M.); (G.C.); (M.F.); (C.R.); (C.P.); (G.F.)
| | - Paolo Lozza
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy; (A.T.C.); (A.O.); (P.L.); (A.M.); (R.B.); (L.N.); (E.G.F.); (A.A.); (B.M.); (G.C.); (M.F.); (C.R.); (C.P.); (G.F.)
| | - Alberto Maccari
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy; (A.T.C.); (A.O.); (P.L.); (A.M.); (R.B.); (L.N.); (E.G.F.); (A.A.); (B.M.); (G.C.); (M.F.); (C.R.); (C.P.); (G.F.)
| | - Roberto Borloni
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy; (A.T.C.); (A.O.); (P.L.); (A.M.); (R.B.); (L.N.); (E.G.F.); (A.A.); (B.M.); (G.C.); (M.F.); (C.R.); (C.P.); (G.F.)
| | - Letizia Nitro
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy; (A.T.C.); (A.O.); (P.L.); (A.M.); (R.B.); (L.N.); (E.G.F.); (A.A.); (B.M.); (G.C.); (M.F.); (C.R.); (C.P.); (G.F.)
| | - Elena Giulia Felisati
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy; (A.T.C.); (A.O.); (P.L.); (A.M.); (R.B.); (L.N.); (E.G.F.); (A.A.); (B.M.); (G.C.); (M.F.); (C.R.); (C.P.); (G.F.)
| | - Andrea Alliata
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy; (A.T.C.); (A.O.); (P.L.); (A.M.); (R.B.); (L.N.); (E.G.F.); (A.A.); (B.M.); (G.C.); (M.F.); (C.R.); (C.P.); (G.F.)
| | - Barbara Martino
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy; (A.T.C.); (A.O.); (P.L.); (A.M.); (R.B.); (L.N.); (E.G.F.); (A.A.); (B.M.); (G.C.); (M.F.); (C.R.); (C.P.); (G.F.)
| | - Giancarlo Cacioppo
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy; (A.T.C.); (A.O.); (P.L.); (A.M.); (R.B.); (L.N.); (E.G.F.); (A.A.); (B.M.); (G.C.); (M.F.); (C.R.); (C.P.); (G.F.)
| | - Manuela Fuccillo
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy; (A.T.C.); (A.O.); (P.L.); (A.M.); (R.B.); (L.N.); (E.G.F.); (A.A.); (B.M.); (G.C.); (M.F.); (C.R.); (C.P.); (G.F.)
| | - Cecilia Rosso
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy; (A.T.C.); (A.O.); (P.L.); (A.M.); (R.B.); (L.N.); (E.G.F.); (A.A.); (B.M.); (G.C.); (M.F.); (C.R.); (C.P.); (G.F.)
| | - Carlotta Pipolo
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy; (A.T.C.); (A.O.); (P.L.); (A.M.); (R.B.); (L.N.); (E.G.F.); (A.A.); (B.M.); (G.C.); (M.F.); (C.R.); (C.P.); (G.F.)
| | - Giovanni Felisati
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy; (A.T.C.); (A.O.); (P.L.); (A.M.); (R.B.); (L.N.); (E.G.F.); (A.A.); (B.M.); (G.C.); (M.F.); (C.R.); (C.P.); (G.F.)
| | - Loredana De Pasquale
- Thyroid and Parathyroid Surgery Unit, ASST Santi Paolo e Carlo, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy;
| | - Alberto Maria Saibene
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health Sciences, Università Degli Studi di Milano, 20142 Milan, Italy; (A.T.C.); (A.O.); (P.L.); (A.M.); (R.B.); (L.N.); (E.G.F.); (A.A.); (B.M.); (G.C.); (M.F.); (C.R.); (C.P.); (G.F.)
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Wilhelm A, Conroy PC, Calthorpe L, Frye W, Sosa JA, Roman S. Routine use of intraoperative nerve monitoring is associated with a reduced risk of vocal cord dysfunction after thyroid cancer surgery. BMC Surg 2023; 23:215. [PMID: 37533002 PMCID: PMC10399064 DOI: 10.1186/s12893-023-02122-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 07/24/2023] [Indexed: 08/04/2023] Open
Abstract
BACKGROUND The aim of this study was to investigate the associations between individual surgeon's intraoperative nerve monitoring (IONM) practice and factors associated with vocal cord (VC) dysfunction in patients with thyroid cancer undergoing thyroidectomy. METHODS Using Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) 2014-21 data, multivariable logistic regression analyses investigated variables associated with short- and long-term VC-dysfunction, associations of routine use of IONM with postoperative outcomes, and patient characteristics associated with IONM use. RESULTS Among 5,446 patients (76.7% female, mean age 49 years), 68.5% had surgery by surgeons using IONM in ≥ 90% of cases (63% of surgeons, n = 73). Post-operative VC-dysfunction was diagnosed by laryngoscopy in 3.0% of patients in the short-term and 2.7% in the long-term. When surgeons routinely used IONM, the incidence of VC-dysfunction was 2.4% in the short-term and 2.2% in the long-term, compared to 4.4% and 3.7%, respectively, when surgeons did not routinely use IONM (p < 0.01). After adjustment, routine use of IONM was independently associated with reduced risk of short- (OR 0.48, p < 0.01) and long-term (OR 0.52, p < 0.01) VC-dysfunction, a lower risk of postoperative hypoparathyroidism in the short- (OR 0.67, p < 0.01) and long-term (OR 0.54, p < 0.01), and higher likelihood of same-day discharge (OR 2.03, p < 0.01). Extrathyroidal tumor extension and N1-stage were factors associated with postoperative VC-dysfunction in the short- (OR 3.12, p < 0.01; OR 1.92, p = 0.01, respectively) and long-term (OR 3.11, p < 0.01; OR 2.32, p < 0.01, respectively). CONCLUSION Routine use of IONM was independently associated with a lower risk of endocrine surgery-specific complications and greater likelihood of same-day discharge.
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Affiliation(s)
- Alexander Wilhelm
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
- Department of Surgery, Clarunis - St. Clara Hospital and University Hospital Basel, Basel, Switzerland
| | - Patricia C Conroy
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Lucia Calthorpe
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Willow Frye
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Julie Ann Sosa
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Sanziana Roman
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA.
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ÜSTÜN M, TUNCER K, AKPINAR G, SAĞLAM B, GÜLER N, MAKAY Ö. The role of intraoperative neuromonitoring in thyroid surgery training. EGE TIP DERGISI 2023. [DOI: 10.19161/etd.1262399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023] Open
Abstract
Aim: Intraoperative nerve monitoring (IONM) during thyroid surgery has been widely accepted as an additive improvement to the gold standard of visually identifying the RLN. This study aims to evaluate the role of IONM application in thyroid surgery education during general surgery residency.
Materials and Methods: Patients who underwent total thyroidectomy between January 2012 and December 2019 were included in the study. The patients were divided into 2 groups according to the use of IONM (Group 1: With IONM, Group 2: Without IONM). These groups were also divided into subgroups as assistants and experts among themselves.
Results: This study involved 256 patients. There were 116 patients in group 1, and 140 patients in group 2. Histologic analysis results revealed that IONM was used more frequently in patients with a
malignancy (p=0.015). The median operative time was significantly longer when IONM was used, with an operative time of 130 minutes for group 1 and 120 minutes for group 2 (p=0.015). When Group 1B and Group 2B were compared among themselves, the median operation time in Group 1B was 130 minutes, and the median operation time in Group 2B was 125 minutes (p=0.026). In the comparison between Groups 1B and 2B, it was detected that the rate of use of IONM was higher in malignancies
(p=0.025).
Conclusion: According to our results, the use of IONM did not reduce the incidence of RLN paralysis in thyroidectomy performed by specialists and residents.
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Affiliation(s)
- Mehmet ÜSTÜN
- Izmir University of Health Sciences Tepecik Training and Research Hospital, Department of General Surgery, Izmir, Türkiye
| | - Korhan TUNCER
- Izmir University of Health Sciences Tepecik Training and Research Hospital, Department of General Surgery, Izmir, Türkiye
| | - Göksever AKPINAR
- Izmir University of Health Sciences Tepecik Training and Research Hospital, Department of General Surgery, Izmir, Türkiye
| | - Buğra SAĞLAM
- Izmir University of Health Sciences Tepecik Training and Research Hospital, Department of General Surgery, Izmir, Türkiye
| | - Necdet GÜLER
- Izmir University of Health Sciences Tepecik Training and Research Hospital, Department of General Surgery, Izmir, Türkiye
| | - Özer MAKAY
- Ege University, Faculty of Medicine, Department of General Surgery, Izmir, Türkiye
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Intraoperative Neuromonitoring and Optical Magnification in the Prevention of Recurrent Laryngeal Nerve Injuries during Total Thyroidectomy. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58111560. [PMID: 36363517 PMCID: PMC9692813 DOI: 10.3390/medicina58111560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 10/18/2022] [Accepted: 10/26/2022] [Indexed: 11/07/2022]
Abstract
Background and Objectives: Recurrent laryngeal nerve (RLN) paralysis is a fearful complication during thyroidectomy. Intraoperative neuromonitoring (IONM) and optical magnification (OM) facilitate RLN identification and dissection. The purpose of our study was to evaluate the influence of the two techniques on the incidence of RLN paralysis and determine correlations regarding common outcomes in thyroid surgery. Materials and Methods: Two equally sized groups of 50 patients who underwent total thyroidectomies were examined. In the first group (OM), only surgical binocular loupes (2.5×−4.5×) were used during surgery, while in the second group (IONM), the intermittent NIM was applied. Results: Both the operative time and the length of hospitalization were shorter in the OM group than in the IONM group (median 80 versus 100 min and median 2 versus 4 days, respectively) (p < 0.05). The male patients were found to have a five-fold higher risk of developing transient dysphonia than the females (adjusted OR 5.19, 95% IC 0.99−27.18, p = 0.05). The OM group reported a four-fold higher risk of developing transient hypocalcemia than the IONM group (OR 3.78, adjusted OR 4.11, p = 0.01). Despite two cases of temporary bilateral RLN paralysis in the IONM group versus none in the OM group, no statistically significant difference was found (p > 0.05). No permanent RLN paralysis or hypoparathyroidism have been reported. Conclusions: Despite some limitations, our study is the first to compare the use of IONM with OM alone in the prevention of RLN injuries. The risk of recurrent complications remains comparable and both techniques can be considered valid instruments, especially if applied simultaneously by surgeons.
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Kuo EJ, Lee JA. To stim, or not to stim, that is the question. Am J Surg 2022; 224:834-835. [DOI: 10.1016/j.amjsurg.2022.05.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 05/18/2022] [Indexed: 11/29/2022]
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Laryngeal Nerves and Voice Change in Thyroid Surgery. Indian J Surg Oncol 2022; 13:99-108. [PMID: 35462660 PMCID: PMC8986921 DOI: 10.1007/s13193-021-01318-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 04/07/2021] [Indexed: 10/21/2022] Open
Abstract
The low incidence of injury to the recurrent laryngeal nerve (RLN) and external branch of the superior laryngeal nerve (EBSLN) quoted in the literature is derived from expert series. The exact incidence of nerve injury of a thyroid surgeon will be revealed only if pre-operative and post-operative laryngoscopy is becoming routine practice. It is found that the injury rates are increased with routine post-operative laryngoscopy. Subjective voice change occurred in one third of patients all whom had normal vocal cord motion. Therefore, it is important to take written informed consent for voice change in addition to identification of both nerves and documenting it.
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Seeing Is Not Believing: Intraoperative Nerve Monitoring (IONM) in the Thyroid Surgery. Indian J Surg Oncol 2022; 13:121-132. [PMID: 35462673 PMCID: PMC8986933 DOI: 10.1007/s13193-021-01348-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 05/12/2021] [Indexed: 10/21/2022] Open
Abstract
Ensuring the integrity of the recurrent laryngeal nerve (RLN), the external branch of superior laryngeal nerve (EBSLN) and preservation of normal voice are the prime 'functional' goals of thyroid surgery. More in-depth knowledge of neuronal mechanisms has revealed that anatomical integrity does not always translate into functional integrity. Despite meticulous dissection, neural injuries are not always predictable or visually evident. Intraoperative nerve monitoring (IONM) is designed to aid in nerve identification and early detection of functional impairment. With the evolution of technique, intermittent monitoring has given way to continuous-IONM. Over the years, IONM gathered both support and flak. Despite numerous randomised studies, systematic reviews, and meta-analyses, there still prevails a state of clinical equipoise concerning the utility of IONM and its cost-effectiveness. This article inspects the true usefulness of IONM, elaborates on the optimal way to practice it, and presents a critical literature review.
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Pei M, Zhu S, Zhang C, Wang G, Hu M. The value of intraoperative nerve monitoring against recurrent laryngeal nerve injury in thyroid reoperations. Medicine (Baltimore) 2021; 100:e28233. [PMID: 34941090 PMCID: PMC8702291 DOI: 10.1097/md.0000000000028233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 11/24/2021] [Indexed: 01/05/2023] Open
Abstract
Reoperative thyroidectomy is challenging for surgeons because of the higher incidence of recurrent laryngeal nerve (RLN) palsy. RLN identification is the gold standard during thyroidectomy; however, it is sometimes difficult to perform thyroid reoperations. In recent years, intraoperative nerve monitoring (IONM) has gained increased acceptance, and the use of IONM can be a valuable adjunct to visual identification. The aim of this study was to evaluate the value of IONM during thyroid reoperation.A total of 109 patients who met our criteria at the Affiliated Hospital of Hangzhou Normal University from January 2010 to June 2020 were retrospectively analyzed and divided into the IONM group and the visualization-alone group (VA group) according to whether neuromonitoring was used during the operation. The patients' characteristics, perioperative data, and intraoperative information including the RLN identification, time of RLNs confirmation, operative time, intraoperative blood loss, and the rate of RLN injury were collected.Sixty-five procedures (94 RLNs at risk) were performed in the IONM group, whereas 44 (65 RLNs at risk) were in the VA group. The rate of RLN identification was 96.8% in the IONM group and 75.4% in the VA group (P < .05). The incidence of RLN injury was 5.3% in the IONM group and 13.8% in the VA group (P > .05). The incidence of surgeon-related RLN injury rate was 0% in the IONM group compared to 7.7% in the VA group (P < .05), but the tumor-related or scar-related RLN injury rate between the 2 groups were not significantly different (4.3% vs 3.1%, 1.1% vs 3.1%, P > .05).IONM in thyroid reoperation was helpful in improving the RLN identification rate and reducing the surgeon-related RLN injury rate, but was ineffective in reducing the tumor-related and scar-related RLN injury rate. In the future, multicenter prospective studies with large sample sizes may be needed to further assess the role of IONM in thyroid reoperations.
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Affiliation(s)
- Maowei Pei
- Department of General Surgery, The Zhejiang Hospital, Zhejiang, China
| | - Siqi Zhu
- Department of Thyroid and Breast Surgery, The Affiliated Hospital of Hangzhou Normal University, Hangzhou, China
| | - Chunjie Zhang
- Department of General Surgery, The Zhejiang Hospital, Zhejiang, China
| | - Guoliang Wang
- Department of General Surgery, The Zhejiang Hospital, Zhejiang, China
| | - Mingrong Hu
- Department of Thyroid and Breast Surgery, The Affiliated Hospital of Hangzhou Normal University, Hangzhou, China
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Sinclair CF, Buczek E, Cottril E, Angelos P, Barczynski M, Ho AS, Makarin V, Musholt T, Scharpf J, Schneider R, Stack BC, Tellez MJ, Tolley N, Woodson G, Wu CW, Randolph G. Clarifying optimal outcome measures in intermittent and continuous laryngeal neuromonitoring. Head Neck 2021; 44:460-471. [PMID: 34850992 DOI: 10.1002/hed.26946] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 11/15/2021] [Accepted: 11/18/2021] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Intraoperative neuromonitoring (IONM) techniques have evolved over the past decade into intermittent IONM (I-IONM) and continuous IONM (C-IONM) modes of application. Despite many prior publications on both types of IONM, there remains uncertainty about what outcomes should be measured for each form of IONM. The primary objective of this paper is to define categories of benefit for I-IONM/C-IONM and to clarify and standardize their reporting outcomes. METHODS Expert review consensus statement utilizing modified Delphi methodology. RESULTS I-IONM provides diagnosis, classification, and prevention of nerve injury through accurate and early nerve identification. C-IONM provides real-time information on nerve functional integrity and thus may prevent some types of nerve injury but cannot assist in nerve localization. Sudden mechanisms of nerve injury cannot be predicted or prevented by either technique. CONCLUSIONS I-IONM and C-IONM are complementary techniques. Future studies evaluating the utility of IONM should focus on outcomes that are appropriate to the type of IONM being utilized.
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Affiliation(s)
- Catherine F Sinclair
- Department of Otolaryngology Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Erin Buczek
- Department of Otolaryngology Head and Neck Surgery, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Elizabeth Cottril
- Department of Otolaryngology Head and Neck Surgery, Jefferson University, Philadelphia, Pennsylvania, USA
| | - Peter Angelos
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Marcin Barczynski
- Department of Endocrine Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Allen S Ho
- Department of Otolaryngology Head and Neck Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Viktor Makarin
- Saint Petersburg State University Hospital, Saint Petersburg, Russian Federation
| | - Thomas Musholt
- Department of Endocrine Surgery, Gutenberg University Mainz, Mainz, Germany
| | - Joseph Scharpf
- Department of Otolaryngology Head and Neck Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Rick Schneider
- Department of Visceral, Vascular and Endocrine Surgery, Martin Luther University of Halle-Wittenberg, Halle, Germany
| | - Brendan C Stack
- Department of Otolaryngology Head and Neck Surgery, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Maria J Tellez
- Department of Neurosurgery, Mount Sinai Hospital, New York, New York, USA
| | - Neil Tolley
- Department of Otolaryngology Head and Neck Surgery, Imperial College Healthcare NHS Trust, London, UK
| | - Gayle Woodson
- Department of Otolaryngology Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Che Wei Wu
- Department of Otorhinolaryngology-Head and Neck Surgery, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Greg Randolph
- Department of Otolaryngology Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
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12
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Gibson MM, Chen AY. Intermittent Neuromonitoring of the Recurrent Laryngeal and Vagus Nerves: the Ins and Outs. CURRENT OTORHINOLARYNGOLOGY REPORTS 2021. [DOI: 10.1007/s40136-021-00351-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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13
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Scharpf J, Liu JC, Sinclair C, Singer M, Liddy W, Orloff L, Steward D, Bonilla Velez J, Randolph GW. Critical Review and Consensus Statement for Neural Monitoring in Otolaryngologic Head, Neck, and Endocrine Surgery. Otolaryngol Head Neck Surg 2021; 166:233-248. [PMID: 34000898 DOI: 10.1177/01945998211011062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Enhancing patient outcomes in an array of surgical procedures in the head and neck requires the maintenance of complex regional functions through the protection of cranial nerve integrity. This review and consensus statement cover the scope of cranial nerve monitoring of all cranial nerves that are of practical importance in head, neck, and endocrine surgery except for cranial nerves VII and VIII within the temporal bone. Complete and applied understanding of neurophysiologic principles facilitates the surgeon's ability to monitor the at-risk nerve. METHODS The American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) identified the need for a consensus statement on cranial nerve monitoring. An AAO-HNS task force was created through soliciting experts on the subject. Relevant domains were identified, including residency education, neurophysiology, application, and various techniques for monitoring pertinent cranial nerves. A document was generated to incorporate and consolidate these domains. The panel used a modified Delphi method for consensus generation. RESULTS Consensus was achieved in the domains of education needs and anesthesia considerations, as well as setup, troubleshooting, and documentation. Specific cranial nerve monitoring was evaluated and reached consensus for all cranial nerves in statement 4 with the exception of the spinal accessory nerve. Although the spinal accessory nerve's value can never be marginalized, the task force did not feel that the existing literature was as robust to support a recommendation of routine monitoring of this nerve. In contrast, there is robust supporting literature cited and consensus for routine monitoring in certain procedures, such as thyroid surgery, to optimize patient outcomes. CONCLUSIONS The AAO-HNS Cranial Nerve Monitoring Task Force has provided a state-of-the-art review in neural monitoring in otolaryngologic head, neck, and endocrine surgery. The evidence-based review was complemented by consensus statements utilizing a modified Delphi method to prioritize key statements to enhance patient outcomes in an array of surgical procedures in the head and neck. A precise definition of what actually constitutes intraoperative nerve monitoring and its benefits have been provided.
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Affiliation(s)
- Joseph Scharpf
- Cleveland Clinic Foundation Head and Neck Institute, Cleveland, Ohio, USA
| | - Jeffrey C Liu
- Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania, USA
| | | | | | | | - Lisa Orloff
- Stanford University, Palo Alto, California, USA
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14
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Kuryga D, Wojskowicz P, Szymczuk J, Wojdyla A, Milewska AJ, Barczynski M, Dadan J, Rogowski M, Mysliwiec P. Training in intraoperative neuromonitoring of recurrent laryngeal nerves reduces the risk of their injury during thyroid surgery. Arch Med Sci 2021; 17:1294-1302. [PMID: 34522258 PMCID: PMC8425229 DOI: 10.5114/aoms.2019.85737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 08/24/2018] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Even though incidence of recurrent laryngeal nerve palsy (RLNP) is low, it affects importantly the quality of life of patients and remains one of main medicolegal litigation problems in surgery. Intraoperative neuromonitoring (IONM) has become widely accepted tool helping in recurrent laryngeal nerve identification, however no clear association of IONM with RLNP rate has been demonstrated. The aim of our study was to assess whether training in IONM influences rates of RNLP after thyroid surgery as an independent factor. MATERIAL AND METHODS We analysed retrospectively 1235 patients who underwent thyroidectomy at the 1st Department of General and Endocrine Surgery, Medical University of Bialystok. Possible risk factors for RLNP were evaluated: application or not of IONM, the extent of surgery or thyroid pathology in correlation with surgeons' experience in IONM (trained or untrained). RESULTS There were 2351 nerves at risk (NAR) and 39 RNLP were diagnosed after thyroid surgery (1.66%). Surgeons trained in IONM performed 52.2% of all operations (1200 NAR) with 7 RLNP (0.58%), whereas not-trained had 32 RLNP for 1151 NAR (2.8%; p < 0.001). After 182 thyroidectomies (357 NAR) guided by IONM (14.7%) 3 RLNP were observed (0.84%) vs. 36 palsies per 1994 NAR without IONM (1.81%; p = 0.189). The highest danger of RLNP was reported after reoperations and the lowest after subtotal thyroidectomies. We found no association between thyroid pathology and RLNP rate. CONCLUSIONS According to our study training in IONM decreases chances of RLNP especially during total or near total thyroidectomy.
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Affiliation(s)
- Dorota Kuryga
- Department of Otolaryngology, Medical University of Bialystok, Bialystok, Poland
| | - Piotr Wojskowicz
- 1 Department of General and Endocrinological Surgery, Medical University of Bialystok, Bialystok, Poland
| | - Jaroslaw Szymczuk
- 1 Department of General and Endocrinological Surgery, Medical University of Bialystok, Bialystok, Poland
| | - Anna Wojdyla
- Department of General and Minimally Invasive Surgery, Municipal Polyclinical Hospital, Olsztyn, Poland
| | - Anna J. Milewska
- Department of Statistics and Medical Informatics, Medical University of Bialystok, Bialystok, Poland
| | - Marcin Barczynski
- Department of Endocrine Surgery, Third Chair of General Surgery, Jagiellonian University, Medical College, Krakow, Poland
| | - Jacek Dadan
- 1 Department of General and Endocrinological Surgery, Medical University of Bialystok, Bialystok, Poland
| | - Marek Rogowski
- Department of Otolaryngology, Medical University of Bialystok, Bialystok, Poland
| | - Piotr Mysliwiec
- 1 Department of General and Endocrinological Surgery, Medical University of Bialystok, Bialystok, Poland
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15
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Choi S, Shin S, Lee W, Choi SM, Kang SW. Medicolegal lessons learned from thyroidectomy-related lawsuits: an analysis of judicial precedents in South Korea from 1998 to 2019. Gland Surg 2020; 9:1286-1297. [PMID: 33224803 DOI: 10.21037/gs-20-398] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background Thyroid cancer is one of the most common cancers in South Korea, and thyroidectomy is still frequently performed. As new diagnostic methods have led to a significant increase in the early detection of thyroid cancer worldwide, medical disputes related to thyroid surgery are also likely to increase. The purpose of this study was to investigate the causes of medical disputes related to thyroidectomy and to identify ways to prevent unnecessary disputes and malpractice. Methods We analyzed 35 judicial decisions involving thyroidectomy in South Korea from January 1998 to July 2019. Results The most common cause of lawsuits was "performance error during surgery" (n=19), especially "recurrent laryngeal nerve (RLN) injury" (n=7), of which five cases were ruled medical malpractice. For lawsuits involving misdiagnosis (n=14), five regarding fine needle aspiration cytology (FNAC) and frozen section examination were ruled malpractice. The most common malpractice related to informed consent was "lack of explanation about surgery complications" (n=10). Conclusions Surgeons should follow guidelines to protect themselves from diagnostic error dispute; performing FNAC more often might also prevent lawsuits. When the courts judge the surgeon's negligence in cases of RLN injuries, whether bilateral or unilateral, it is necessary to consider fully the surgeon's efforts to prevent RLN injuries. Providing information and building trust through sufficient patient-doctor communication is crucial.
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Affiliation(s)
- Sungkyoung Choi
- Division of Medical Law and Ethics, Department of Medical Humanities and Social Sciences, Yonsei University College of Medicine, Seoul, Korea
| | - Suhwan Shin
- Blue Urology Clinic, Seoul, Korea.,Department of Medical Law and Ethics, Graduate School, Yonsei University, Seoul, Korea
| | - Won Lee
- Department of Nursing, Chung-Ang University, Seoul, Korea
| | - Soon-Min Choi
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Sang-Wook Kang
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
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16
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Kartal K, Aygun N, Celayir MF, Besler E, Citgez B, Isgor A, Uludag M. Intraoperative Neuromonitoring in Thyroid Surgery: An Efficient Tool to Avoid Bilateral Vocal Cord Palsy. EAR, NOSE & THROAT JOURNAL 2020; 100:694S-699S. [PMID: 32067477 DOI: 10.1177/0145561320906325] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVES This study aimed to analyze the effects of intraoperative neuromonitoring (IONM) on the prevalence of vocal cord palsy (VCP) in thyroid surgery. METHODS Data from 493 patients (839 nerves at risk [NAR]) who underwent thyroid surgery between July 2014 and May 2016 were retrospectively evaluated. The patients were divided into 2 groups: Group 1 (G1) consisted of patients who underwent surgery without IONM, whereas group 2 (G2) consisted of patients who underwent surgery with IONM. The surgical techniques were identical, and experienced surgeons performed the procedures in both groups. Intraoperative neuromonitoring was performed in compliance with the International Neural Monitoring Guidelines. RESULTS In total, 211 patients (170 female, 41 male) with 360 NAR were included in G1, and 282 patients (220 female, 62 male) with 479 NAR were included in G2. The number of VCP per NAR in G1 and G2 was 33 (9.2%) and 27 (5.6%), respectively (P = .005). The number of transient VCP per NAR in G1 and G2 was 27 (7.5%) and 23 (4.8%; P = .230), respectively. The number of permanent VCP per NAR in G1 and G2 was 6 (1.7%) and 4 (0.8%; P = .341), respectively. Bilateral VCP was detected in 4 (2.7%) patients in G1, whereas there was no patient with bilateral VCP in G2 (P = .033). CONCLUSIONS Intraoperative neuromonitoring may decrease the incidence of total VCP and prevent the development of bilateral VCP, which has unfavorable results for both patients and health-care professionals.
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Affiliation(s)
- Kinyas Kartal
- Department of General Surgery, 52979Koc University Hospital, Istanbul, Turkey
| | - Nurcihan Aygun
- Department of General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Mustafa Fevzi Celayir
- Department of General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Evren Besler
- Department of General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Bulent Citgez
- Department of General Surgery, Health Sciences University, Sisli Hamidiye Etfal Health Practice and Research Center, Istanbul, Turkey
| | - Adnan Isgor
- Department of General Surgery, 52946Bahcesehir University School of Medicine, Istanbul, Turkey
| | - Mehmet Uludag
- Department of General Surgery, Health Sciences University, Sisli Hamidiye Etfal Health Practice and Research Center, Istanbul, Turkey
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17
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Schneider R, Machens A, Lorenz K, Dralle H. Intraoperative nerve monitoring in thyroid surgery-shifting current paradigms. Gland Surg 2020; 9:S120-S128. [PMID: 32175252 DOI: 10.21037/gs.2019.11.04] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Over the past two decades, intraoperative neural monitoring (IONM) has matured into a powerful risk minimization tool. Meta-analyses of studies, most of which were limited by poor study designs and the sole use of intermittent nerve stimulation, failed to demonstrate superiority of IONM over anatomic recurrent laryngeal nerve (RLN) dissection in the absence of IONM. With the advent of continuous IONM (CIONM), intraoperative nerve electromyographic tracings, registered almost in real time during the operation, accurately predict postoperative vocal fold function when International Neural Monitoring Study Group quality standards are adhered to. CIONM aids in avoiding permanent traction-related nerve injury by urging surgeons to reverse harmful surgical maneuvers. CIONM also forms an integral part in the surgical concept of staged thyroidectomy. Delaying completion surgery on the other side until nerve function has recovered mitigates the risk of bilateral vocal fold palsy. CIONM has greatly furthered our understanding of functional RLN injury, enabling conception of effective risk minimization strategies tailored to the individual patient. The review summarizes the advances of continuous IONM technology that caused a quantum leap in risk minimization for thyroid surgery, shifting current paradigms.
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Affiliation(s)
- Rick Schneider
- Medical Faculty, Department of Visceral, Vascular and Endocrine Surgery, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Andreas Machens
- Medical Faculty, Department of Visceral, Vascular and Endocrine Surgery, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Kerstin Lorenz
- Medical Faculty, Department of Visceral, Vascular and Endocrine Surgery, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Henning Dralle
- Department of General, Visceral and Transplantation Surgery, Section of Endocrine Surgery, University of Duisburg-Essen, Essen, Germany
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18
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Zhang D, Pino A, Caruso E, Dionigi G, Sun H. Neural monitoring in thyroid surgery is here to stay. Gland Surg 2020; 9:S43-S46. [PMID: 32055497 DOI: 10.21037/gs.2019.10.24] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The iatrogenic injury of the recurrent laryngeal nerve (RLN), more clinically significant than those affecting the external branch of the superior laryngeal nerve (EBSLN), constitute one of the most feared perioperative complications of thyroid surgery and parathyroid glands, in terms of impact in clinical and economic-social costs. Moreover, these events rank among the leading reasons for medicolegal litigation of surgeons because of its attendant reduction in quality of life. The average incidence of RLN paralysis, permanent and temporary, after thyroidectomy is high and stands between 2.3% and 9.8% respectively. Given the elements described above, it is essential for the surgeon to adhere to a carefully standardized intraoperative technique that minimizes the possibility of RLN injuries. Intraoperative neuromonitoring (IONM) was introduced to reduce RLN injuries and for this reason, it achieved considerable success among endocrine surgeons. However, even today it is considered an adjunct device to the direct identification of the RLN. In this perspective, IONM of RLN constitutes an important aid, since it represents a reliable tool for the evaluation of functional neural integrity. Despite the ever-increasing diffusion of the IONM, prospective randomized studies are needed for further validation. The purpose of this work is to analyze scientific evidence to show that IONM in thyroid surgery is here to stay.
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Affiliation(s)
- Daqi Zhang
- Division of Thyroid Surgery, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, China-Japan Union Hospital Of Jilin University, Changchun 130000, China
| | - Antonella Pino
- Division of Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood ''G. Barresi'', University Hospital G. Martino, University of Messina, Messina, Italy
| | - Ettore Caruso
- Division of Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood ''G. Barresi'', University Hospital G. Martino, University of Messina, Messina, Italy
| | - Gianlorenzo Dionigi
- Division of Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood ''G. Barresi'', University Hospital G. Martino, University of Messina, Messina, Italy
| | - Hui Sun
- Division of Thyroid Surgery, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, China-Japan Union Hospital Of Jilin University, Changchun 130000, China
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19
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Sanabria A, Kowalski LP, Nixon I, Angelos P, Shaha A, Owen RP, Suarez C, Rinaldo A, Ferlito A. Methodological Quality of Systematic Reviews of Intraoperative Neuromonitoring in Thyroidectomy: A Systematic Review. JAMA Otolaryngol Head Neck Surg 2019; 145:563-573. [PMID: 30973598 DOI: 10.1001/jamaoto.2019.0092] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Importance Systematic reviews and meta-analyses are considered the best evidence for clinical decision making. Many reviews of intraoperative neuromonitoring (IONM) in thyroidectomy have conflicting results, owing in large part to methodological quality. Objective To assess the methodological quality and the causes of heterogeneous results of systematic reviews that compare routine IONM vs visual identification of the recurrent laryngeal nerve (RLN) in patients undergoing thyroidectomy. Data Sources A systematic search was performed of MEDLINE (PubMed), Embase, the Cochrane Library, LILACS (Literatura Latino Americana e do Caribe em Ciências da Saúde), Web of Science, and Google from January 1, 1968, through June 30, 2018. Data were analyzed from July 17 to November 30, 2018. Study Selection Studies that mentioned performance of a systematic review/meta-analysis during the search period. Data Extraction and Synthesis Data including study characteristics, type of patients, numbers of nerves at risk, and temporary and definitive RLN paralysis by group were extracted. Data about methodological characteristics, type of statistical analysis and summary estimator, endorsement of systematic review/meta-analysis guidelines, heterogeneity, publication bias, funding, conflict of interest, and statistical analysis were also recorded. The methodological quality was measured with the AMSTAR2 (A Measurement Tool to Assess Systematic Reviews) tool by 2 independent evaluators. Main Outcomes and Measures Methodological quality. Results The search identified 13 systematic reviews that included patients who underwent open or minimally invasive thyroidectomy, second operations, and a mixture of low- and high-risk procedures. The mean compliance with the AMSTAR2 overall criteria was 53% (range, 11%-83%); with critical criteria, 71% (range, 50%-94%). The percentage of nerves at risk from RCTs was 4.8%. The mean (SD) crude rate of definitive RLN paralysis was 0.81% (0.22%; median, 0.75% [range, 0.53%-1.30%]) in the monitoring group and 1.14% (0.56%; median, 0.96% [range, 0.57%-2.56%]) in the control group. Conclusions and Relevance A substantial number of systematic reviews of IONM in thyroidectomy have conflicting results, but their mean methodological quality is critically low. Design of a systematic review should comply with methodological standards and recommendations to offer relevant and practical information for decision making.
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Affiliation(s)
- Alvaro Sanabria
- Department of Surgery, School of Medicine, Universidad de Antioquia, Fundación Colombiana de Cancerología-Clínica Vida, Medellin, Colombia
| | - Luiz P Kowalski
- Department of Head and Neck Surgery and Otorhinolaryngology, A.C. Camargo Cancer Center, Sao Paulo, Brazil
| | - Iain Nixon
- Ear, Nose and Throat Department, NHS Lothian, Edinburgh, United Kingdom
| | - Peter Angelos
- Department of Surgery and MacLean Center for Clinical Ethics, University of Chicago Medicine, Chicago, Illinois
| | - Ashok Shaha
- Head & Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Randall P Owen
- Division of Metabolic, Endocrine and Minimally Invasive Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Carlos Suarez
- Instituto de Investigacion Sanitaria del Principado de Asturias, University of Oviedo, Fundación de Investigación e Innovación Biosanitaria del Principado de Asturias, Oviedo, Spain
| | - Alessandra Rinaldo
- Ear, Nose, and Throat Section, University of Udine School of Medicine, Udine, Italy
| | - Alfio Ferlito
- Coordinator of the International Head and Neck Scientific Group, Padua, Italy
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20
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Chen Y, Huang L, Li Y, Tong L, Wang X, Hu K, Feng Z. [Sequential method for determining the maximum dose of mivacurium continuously infused for intraoperative neuromonitoring in thyroid surgery]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2018; 38:1472-1475. [PMID: 30613016 DOI: 10.12122/j.issn.1673-4254.2018.12.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To determine the maximum dose of continuously infused mivacurium for intraoperative neuromonitoring and observe its adverse effects in thyroid surgery. METHODS Twenty-eight patients undergoing thyroid surgery with intraoperative neuromonitoring received continuous infusion of mivacurium at the initial rate of 5.43 μg?kg-1?min-1, and the infusion rate for the next patient was adjusted based on the response of the previous patient according to the results of neurological monitoring. The depth of anesthesia was maintained with sevoflurane and remifentanil during the surgery. The LD50 and 95% CI of mivacurium were calculated using Brownlee's up-and-down sequential method. RESULTS The LD50 of continuously infused mivacurium was 8.94 μg?kg-1?min-1 (95% CI: 8.89- 8.99 μg?kg-1?min-1) during thyroid surgery, which did not affect neurological function monitoring. Transient chest skin redness occurred after induction in 9 patients (32.1%). None of the patients experienced intubation difficulties or showed intraoperative body motions during the surgery. CONCLUSIONS In patients undergoing thyroid surgery under anesthesia maintained by inhalation and intravenous infusion, the LD50 of mivacurium was 8.94 μg?kg-1?min-1 (95% CI: 8.89-8.99 μg?kg-1?min-1) for continuous infusion, which does not cause serious adverse effects during the operation.
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Affiliation(s)
- Yongjie Chen
- Anesthesia and Operation Center, General Hospital of PLA, Beijing 100853, China
| | - Lianjun Huang
- Anesthesia and Operation Center, General Hospital of PLA, Beijing 100853, China
| | - Yang Li
- Anesthesia and Operation Center, General Hospital of PLA, Beijing 100853, China
| | - Li Tong
- Anesthesia and Operation Center, General Hospital of PLA, Beijing 100853, China
| | - Xiaochen Wang
- Anesthesia and Operation Center, General Hospital of PLA, Beijing 100853, China
| | - Keshi Hu
- Anesthesia and Operation Center, General Hospital of PLA, Beijing 100853, China
| | - Zeguo Feng
- Anesthesia and Operation Center, General Hospital of PLA, Beijing 100853, China
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21
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Wu SY, Shen HY, Duh QY, Hsieh CB, Yu JC, Shih ML. Routine Intraoperative Neuromonitoring of the Recurrent Laryngeal Nerve to Facilitate Complete Resection and Ensure Safety in Thyroid Cancer Surgery. Am Surg 2018. [DOI: 10.1177/000313481808401232] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Routine use of intraoperative neuromonitoring (IONM) in thyroid cancer surgery is controversial. We aimed to investigate whether it improves the completeness of thyroidectomy and ensures safety. This retrospective study included 380 thyroid cancer patients who underwent thyroidectomy, by one surgeon, between July 2006 and November 2015. Patients were grouped according to the surgeon's adaptation of IONM, as follows: none (period 1; n = 92), early (period 2; n = 141), and late (period 3; n = 147). The operative time and rates of vocal cord palsy were determined. Surgical completeness was assessed by technetium-99m imaging of the thyroid remnant and serum thyroglobulin measurement before ablation. The rate of recurrent laryngeal nerve (RLN) palsy showed a decreasing trend over time. No permanent RLN palsies occurred in nerves not invaded by tumor after routine IONM was introduced. Technetium-99m uptake (periods 1–3, 0.62 vs 0.32 vs 0.20; P < 0.01) and thyroglobulin levels (periods 1 and 2, 37.93 vs 8.98 ng/mL, respectively; P = 0.034; period 3, 9.10 ng/mL) progressively decreased. The mean thyroglobulin level dropped significantly after introduction of routine IONM. We conclude that routine IONM during thyroid cancer surgery improves surgical completeness and might prevent permanent RLN palsy over time.
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Affiliation(s)
- Si-Yuan Wu
- Division of General Surgery, Departments of Surgery, National Defense Medical Center, Taipei, Taiwan, R.O.C
| | - Hung-Yuan Shen
- Nuclear Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, R.O.C
| | - Quan-Yang Duh
- Department of Surgery, University of California, San Francisco, California
| | - Chung-Bao Hsieh
- Division of General Surgery, Departments of Surgery, National Defense Medical Center, Taipei, Taiwan, R.O.C
| | - Jyh-Cherng Yu
- Division of General Surgery, Departments of Surgery, National Defense Medical Center, Taipei, Taiwan, R.O.C
| | - Ming-Lang Shih
- Division of General Surgery, Departments of Surgery, National Defense Medical Center, Taipei, Taiwan, R.O.C
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22
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Erçetin C, Şahbaz A, Acar S, Tutal F, Aksakal N, Sarı S, Erbil Y. Is intraoperative nerve monitoring useful for surgical training in thyroid surgery? Turk J Surg 2018; 35:259-264. [PMID: 32551421 DOI: 10.5578/turkjsurg.4281] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 10/24/2018] [Indexed: 11/15/2022]
Abstract
Objectives Parathyroid glands and recurrent laryngeal nerves (RLNs) are at risk during thyroid surgery. However, the identification of the nerves has reduced these risks. Intraoperative nerve monitoring (IONM) during thyroid surgery has gained widespread acceptance as an aid to the gold standard of visually identifying the RLN. The aim of the present study was to evaluate the effect of the identification of the RLN during thyroidectomy by using IONM. Material and Methods Seven hundred forty-eight patients were included in our prospectively designed study. Of these 748 patients, 1496 nerves at risk were studied. Group 1 consisted of 736 nerves that were identified using IONM, whereas Group 2 consisted of 760 visually identified nerves. Results In the non-IONM group, the rate of temporary nerve palsy was lower in patients operated by experienced surgeons than in patients operated by residents (p= 0.001). In the IONM group, RLN injury rates were similar between experienced surgeons and residents. Conclusion In spite of the fact that the duration of the operation was lower with IONM, the abbreviated duration may not appear to have clinical significance. The main advantage is for less experienced surgeons. IONM significantly decreases RLN palsy rates of the surgeons with limited experience in thyroid surgery.
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Affiliation(s)
- Candaş Erçetin
- Department of General Surgery, Health Sciences University, Bağcılar Training and Research Hospital, İstanbul, Turkey
| | - Alper Şahbaz
- Department of General Surgery, Health Sciences University, Bakırköy Dr. Sadi Konuk Training and Research Hospital, İstanbul, Turkey
| | - Sami Acar
- Department of General Surgery, Acıbadem Taksim Hospital, İstanbul, Turkey
| | - Fırat Tutal
- Department of General Surgery, Kolan International Hospital, İstanbul, Turkey
| | - Nihat Aksakal
- Department of General Surgery, İstanbul University Istanbul School of Medicine, İstanbul, Turkey
| | - Serkan Sarı
- Department of General Surgery, Health Sciences University, İstanbul Training and Research Hospital, İstanbul, Turkey
| | - Yeşim Erbil
- Department of General Surgery, İstanbul University İstanbul School of Medicine, İstanbul, Turkey
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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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Sinclair CF, Téllez MJ, Ulkatan S. Noninvasive, tube-based, continuous vagal nerve monitoring using the laryngeal adductor reflex: Feasibility study of 134 nerves at risk. Head Neck 2018; 40:2498-2506. [PMID: 30120890 DOI: 10.1002/hed.25377] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 05/27/2018] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Continuous vagal intraoperative neuromonitoring (IONM) currently requires placement of a vagal nerve electrode. Herein, we present data from 100 patients (134 nerves-at-risk) monitored continuously during neck endocrine surgeries using a noninvasive, new methodology that solely utilizes endotracheal tube electrodes to simultaneously stimulate laryngeal mucosa and record a laryngeal adductor reflex continuous IONM (LAR-C-IONM) response. METHODS The laryngeal adductor reflex (LAR) was elicited by electrical laryngeal mucosal stimulation on the side contralateral to the operative field using endotracheal tube electrodes. All patients completed preoperative and postoperative laryngeal and voice examinations. RESULTS One hundred patients (134 nerves-at-risk) were included. Significantly more nerves-at-risk with an LAR opening to closing amplitude decrement >60% or with absolute closing amplitude <100 μV had postoperative vocal fold paralysis (P < .001). The LAR-C-IONM was highly sensitive to recurrent laryngeal nerve (RLN) stretch or compression. CONCLUSION The LAR-C-IONM is a promising new way to perform continuous vagal monitoring that requires no equipment other than an electromyography (EMG) endotracheal tube and is undergoing further, large-scale evaluation.
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Affiliation(s)
- Catherine F Sinclair
- Department of Otolaryngology - Head and Neck Surgery, Mount Sinai West Hospital, New York, New York
| | - Maria J Téllez
- Department of Intraoperative Neurophysiology, Mount Sinai West Hospital, New York, New York
| | - Sedat Ulkatan
- Department of Intraoperative Neurophysiology, Mount Sinai West Hospital, New York, New York
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Protective Effects of Intraoperative Nerve Monitoring (IONM) for Recurrent Laryngeal Nerve Injury in Thyroidectomy: Meta-analysis. Sci Rep 2018; 8:7761. [PMID: 29773852 PMCID: PMC5958090 DOI: 10.1038/s41598-018-26219-5] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 05/04/2018] [Indexed: 12/13/2022] Open
Abstract
Recurrent laryngeal nerve (RLN) injury is an intractable complication of thyroidectomy. Intraoperative nerve monitoring (IONM) was designed to prevent RLN injury. However, the results concerning the protective effect of IONM on RLN injury are still controversial. We searched all eligible databases from 1980 to 2017. Meta-analysis was performed to evaluate the effect of IONM on RLN injury. Sensitivity analysis was also conducted to check the stability of our results. There were 34 studies included in the analysis. Overall analysis found a significant decrease in total injury (RR = 0.68, 95%CI: 0.55 to 0.83), transient injury (RR = 0.71, 95%CI: 0.57 to 0.88), and permanent injury (RD = −0.0026, 95%CI: −0.0039 to −0.0012) with IONM. Subgroup analysis found IONM played a preventive role of total, transient and permanent injury in patients undergoing bilateral thyroidectomy. IONM also reduced the incidence of total and transient injury for malignancy cases. Operations with IONM were associated with fewer total and transient RLN injuries in operation volume < 300 NARs per year and fewer total and permanent RLN injuries in operation volume ≥ 300 NARs per year. The application of IONM could reduce the RLN injury of thyroidectomy. Particularly, we recommend routine IONM for use in bilateral operations and malignancy operations.
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Wojtczak B, Kaliszewski K, Sutkowski K, Głód M, Barczyński M. Evaluating the introduction of intraoperative neuromonitoring of the recurrent laryngeal nerve in thyroid and parathyroid surgery. Arch Med Sci 2018; 14:321-328. [PMID: 29593805 PMCID: PMC5868670 DOI: 10.5114/aoms.2016.63003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 12/07/2015] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Paresis of the recurrent laryngeal nerve (RLN) is a complication of thyroid surgery. Neuromonitoring as is gaining acceptance among surgeons. The aim of the study was to assess the number of technical problems in the initial phase of intraoperative neuromonitoring (IONM) use and the specificity, sensitivity, positive predictive value and negative predictive value of neuromonitoring. The number of cases of postoperative paresis (transient and permanent) was assessed. MATERIAL AND METHODS The prospective analysis included 101 thyroid operations with IONM (190 RLNs at risk of injury) in the period from January to April, 2012. Demographic data, rate of RLN identification, sensitivity, specificity and predictive value of the method, the duration of the procedurę and the percentage of RLN paresis were considered. RESULTS The RLN was identified in 92% of the cases. Technical problems were observed in 12.98%, of which 61% were due to incorrect positioning of the endotracheal tube electrodes in relation to the vocal cords. The sensitivity, specificity, negative and positive predictive value and the accuracy of the method were respectively 71%, 98%, 62.5%, 98.9% and 97%. Early nerve injury occurred in 3.7% of the cases; 2.6% were temporary paresis and 1.1% permanent. CONCLUSIONS During the initial stages of implementing IONM we experienced technical problems that required correction in every tenth patient. The positive predictive value was relatively low; nevertheless, good results in terms of the rate of accurate identification of the RLN as well as the low rate of RLN paresis support the use of this method.
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Affiliation(s)
- Beata Wojtczak
- Department and Clinic of General, Gastroenterological and Endocrine Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Krzysztof Kaliszewski
- Department and Clinic of General, Gastroenterological and Endocrine Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Krzysztof Sutkowski
- Department and Clinic of General, Gastroenterological and Endocrine Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Mateusz Głód
- Department and Clinic of General, Gastroenterological and Endocrine Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Marcin Barczyński
- Department of Endocrine Surgery, Third Chair of General Surgery, Jagiellonian University Medical College, Krakow, Poland
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Wojtczak B, Sutkowski K, Kaliszewski K, Głód M, Barczyński M. Experience with intraoperative neuromonitoring of the recurrent laryngeal nerve improves surgical skills and outcomes of non-monitored thyroidectomy. Langenbecks Arch Surg 2017; 402:709-717. [PMID: 27209315 PMCID: PMC5437184 DOI: 10.1007/s00423-016-1449-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 05/11/2016] [Indexed: 01/03/2023]
Abstract
PURPOSE Intraoperative neuromonitoring (IONM) can serve as a tool to increase skills in recurrent laryngeal nerve (RLN) identification and complete removal of thyroid tissue. The aim of this study was to validate this hypothesis. METHODS This prospective study involved 632 patients (1161 RLNs at risk) who underwent thyroid surgery in 2011-2014. Although IONM was not used until 2012, this prospective study started on 1 January 2011. The three participating surgeons knew about the study before that date and that the rate of RLN identification would be carefully measured in total and near-total surgery. Solely, visual identification of the RLN was used throughout 2011. IONM was introduced as a training tool in 2012-2014 for the first 3 months of each year. In the remaining months, thyroid operations were performed without IONM. Outcomes of non-monitored thyroid operations were compared before (01-12/2011) vs. after (04-12/2012-2014) 3 months of exposure to IONM yearly (01-03/2012-2014). The rate of RLN identification was assessed in total and near-total thyroidectomies and in totally resected lobes in Dunhill's operation. The prevalence of RLN injury and the utilization of total thyroidectomy were evaluated. RESULTS In 2011, the rate of successful RLN visual identification in total and near-total thyroidectomies and in totally resected lobes in Dunhill's operation was 45.71 %. After the introduction of IONM in 2012-2014, in the procedures performed without IONM, the rate was 86.66, 90.81, and 91.3 %. The prevalence of RLN injury in 2011 was 6.8 %, while in the years following the introduction of IONM, it was 3.61, 2.65, and 1.45 %. Utilization of total thyroidectomy increased from 47.9 % in 2011 to 100 % in 2014. CONCLUSIONS Experience with IONM led to an increase in RLN identification (p < 0.0001), a decrease of RLN injury (p < 0.05), and an increase in the safe utilization of total thyroidectomy (p < 0.0001) in non-monitored thyroid operations. IONM is a valuable tool for surgical training.
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Affiliation(s)
- Beata Wojtczak
- Department and Clinic of General, Gastroenterological and Endocrine Surgery, Wroclaw Medical University, M.C. Sklodowskiej 66, 50-369, Wrocław, Poland.
| | - Krzysztof Sutkowski
- Department and Clinic of General, Gastroenterological and Endocrine Surgery, Wroclaw Medical University, M.C. Sklodowskiej 66, 50-369, Wrocław, Poland
| | - Krzysztof Kaliszewski
- Department and Clinic of General, Gastroenterological and Endocrine Surgery, Wroclaw Medical University, M.C. Sklodowskiej 66, 50-369, Wrocław, Poland
| | - Mateusz Głód
- Department and Clinic of General, Gastroenterological and Endocrine Surgery, Wroclaw Medical University, M.C. Sklodowskiej 66, 50-369, Wrocław, Poland
| | - Marcin Barczyński
- Department of Endocrine Surgery, Third Chair of General Surgery, Jagiellonian University Medical College, Kraków, Poland
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Ghani U, Assad S, Assad S. Role of Intraoperative Nerve Monitoring During Parathyroidectomy to Prevent Recurrent Laryngeal Nerve Injury. Cureus 2016; 8:e880. [PMID: 28003944 PMCID: PMC5161260 DOI: 10.7759/cureus.880] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Injury to the recurrent laryngeal nerve (RLN) is a well known, though less frequent, complication of parathyroid surgery. In recent years, the use of intraoperative nerve monitoring (IONM) has gained popularity amongst surgeons when operating on thyroid gland; however, its utilization in parathyroid surgery is not established. This trend continues to rise, despite multiple studies documenting no statistically significant difference that IONM decreases the incidence of RLN injury. Most surgeons use this technology as an adjunct to visualization alone for identification of RLN. The purpose of this review is to discuss the possible role of IONM in parathyroid surgery with regards to the accuracy, efficacy, and recent trends in the utilization of this technology. There is insufficient evidence that IONM reduces the risk of RLN injury in parathyroidectomy. Although IONM may decrease the likelihood of nerve injury by helping to identify and map the RLN during thyroidectomy, we did not find studies exclusive to parathyroid surgery to see if its use can be supported for parathyroidectomy. Despite this lack of evidence, we believe that IONM is a promising adjunct to visualization alone in detecting nerve structures during neck dissection, but more clinical trials are warranted to establish its role in preventing nerve injury in parathyroid surgery.
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Affiliation(s)
- Usman Ghani
- Department of Medicine, Shifa International Hospital, Islamabad, Pakistan
| | - Salman Assad
- Department of Medicine, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Shuja Assad
- Department of Urology, Nawaz Sharif Medical College, University of Gujrat
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Randolph GW, Kamani D. Intraoperative electrophysiologic monitoring of the recurrent laryngeal nerve during thyroid and parathyroid surgery: Experience with 1,381 nerves at risk. Laryngoscope 2016; 127:280-286. [PMID: 27389369 DOI: 10.1002/lary.26166] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2016] [Indexed: 11/06/2022]
Abstract
OBJECTIVES The electrophysiologic responses of 1,381 recurrent laryngeal nerves (RLN) during monitored neck surgery were recorded and reviewed. STUDY DESIGN Retrospective case series. METHODS With institutional review board approval, we reviewed thyroid and other neck surgeries performed with intraoperative nerve monitoring (IONM) between the years 1995 and 2006. This list yielded consecutively monitored 1,381 RLNs, with over 3,000 hours of monitoring experience. All patients underwent preoperative and postoperative laryngoscopy. In an initial subset of patients, both hook-wire and endotracheal tube (ETT) surface electrodes were utilized. Normative stimulation parameters; postoperative vocal cord function prognostication using monitoring data; and false-positive, false-negative, and passive electrophysiologic responses were evaluated RESULTS: Hook-wire electrodes and ETT surface electrodes were found to have good correlation in terms of amplitude (correlation coefficient, R = 0.89). Nerve stimulation of 1 to 2 mA resulted in an ipsilateral biphasic response, with 3.3 ms mean latency and 900 μV mean amplitude. Permanent and temporary RLN paralysis rates were 0% and 0.7%, respectively. Specificity of electromyography (EMG) loss of signal (LOS) postoperative vocal cord paralysis (VCP) detection was 99.9%, and sensitivity was 33%. Negative predictive value of EMG LOS at the end of surgery in the prediction of postoperative VCP was 99.6%, whereas its positive predictive value for VCP was 75%. CONCLUSION Intraoperative nerve monitoring of the RLN during thyroid and other neck surgeries can aid in the nerve mapping, nerve identification, and prognostication of postoperative vocal cord function, which in turn can influence the surgeon's decision to proceed to bilateral surgery. LEVEL OF EVIDENCE 4. Laryngoscope, 127:280-286, 2017.
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Affiliation(s)
- 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
| | - 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
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Snowdon DA, Hau R, Leggat SG, Taylor NF. Does clinical supervision of health professionals improve patient safety? A systematic review and meta-analysis. Int J Qual Health Care 2016; 28:447-55. [DOI: 10.1093/intqhc/mzw059] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2016] [Indexed: 12/20/2022] Open
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Wojtczak B, Kaliszewski K, Sutkowski K, Głód M, Barczyński M. The learning curve for intraoperative neuromonitoring of the recurrent laryngeal nerve in thyroid surgery. Langenbecks Arch Surg 2016; 402:701-708. [PMID: 27178203 PMCID: PMC5437179 DOI: 10.1007/s00423-016-1438-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 04/19/2016] [Indexed: 12/22/2022]
Abstract
Purpose Intraoperative neuromonitoring (IONM) of the recurrent laryngeal nerve (RLN) is often used in thyroid surgery. However, this procedure is complex and requires a learning period to master the technique. The aim of the study was to evaluate the learning curve for IONM. Methods A 3-year period (2012–2014) of working with IONM (NIM3.0, Medtronic) was prospectively analyzed with a special emphasis on comparing the initial implementation phase in 2012 (101 patients, 190 RLNs at risk) with subsequent years of IONM use in 2013 (70 patients, 124 RLNs at risk) and 2014 (65 patients, 120 RLNs at risk). Results The rate of successful IONM-assisted RLN identification increased gradually over the 3-year study period (92.11 % in 2012 vs. 95.16 % in 2013 vs. 99.16 % in 2014; p = 0.022), with a corresponding decrease in the rate of technical problems (12.87, 4.3, and 4.6 %, respectively; p = 0.039). The rate of RLN injuries tended to decrease over time: 3.68, 1.55, and 0.83 %, respectively (p = 0.220). Between 2012 and 2014, increases in the sensitivity (71.4 vs. 100 %), specificity (98 vs. 99 %), positive predictive value (62.5 vs. 75 %), negative predictive value (98 vs. 100 %), and overall accuracy of IONM (97.4 vs. 99.6 %) were observed (p = 0.049). Increasing experience with IONM resulted in more frequent utilization of total thyroidectomy (92 % in 2012 vs. 100 % in 2013–2014; p = 0.004). Conclusions There was a sharp decrease in the number of technical problems involving equipment setup from 2012 to 2014.
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Affiliation(s)
- Beata Wojtczak
- Department and Clinic of General, Gastroenterological and Endocrine Surgery, Wroclaw Medical University, Wroclaw, Poland.
| | - Krzysztof Kaliszewski
- Department and Clinic of General, Gastroenterological and Endocrine Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Krzysztof Sutkowski
- Department and Clinic of General, Gastroenterological and Endocrine Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Mateusz Głód
- Department and Clinic of General, Gastroenterological and Endocrine Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Marcin Barczyński
- Department of Endocrine Surgery, Third Chair of General Surgery, Jagiellonian University Medical College, Kraków, Poland
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Gurleyik E. Location of motor fibers within branches of the recurrent laryngeal nerve with extralaryngeal terminal bifurcation; Functional identification by intraoperative neuromonitoring. Surgery 2015; 158:1339-44. [PMID: 26054316 DOI: 10.1016/j.surg.2015.04.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 03/28/2015] [Accepted: 04/07/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Extralaryngeal terminal bifurcation (ETB) of the recurrent laryngeal nerve (RLN) is an anatomic variation that threatens the safety of thyroid operation. Therefore, it is important to identify motor function in nerve branches to preserve appropriate motor activity. Intraoperative neuromonitoring (IONM) is an accepted procedure to identify motor function of the RLN. METHODS We established the operative anatomy of RLNs with ETB in 47 patients. The main trunk, bifurcation point, and the branches were identified and exposed completely during thyroid operation. The location of motor fibers within nerve branches was investigated by identifying motor function via IONM. Wave amplitudes were recorded after electrophysiologic stimulation. RESULTS A total of 61 RLNs had ETBs with anterior and posterior branches. Bifurcation occurred early along the pre-arterial (proximal) segment in 13% of bifid RLNs. IONM showed motor function in all anterior branches. IONM identified motor activity in 4 (18%) posterior branches of 22 right, 3 (8%) posterior branches of 39 left, and 7 (12%) posterior branches of all 61 RLNs with ETB. The rate of recorded wave amplitudes of motor function in seven posterior branches was between 14 and 78% of those of corresponding anterior branches. CONCLUSION In the RLN, the anterior branch always and the posterior branch uncommonly contain motor fibers. Wave amplitude analysis showed that motor function in the posterior branch is weaker than that in the anterior branch. On the basis of the location of motor fibers in both branches, total exposure and preservation of anatomy and function of all branches of the RLN is mandatory for complication-free thyroid surgery. Electrophysiologic testing may be as an important adjunct to visualization of the nerve with anatomic variation.
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Affiliation(s)
- Emin Gurleyik
- Department of Surgery, Duzce University, Medical Faculty, Duzce, Turkey.
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Calò PG, Medas F, Erdas E, Pittau MR, Demontis R, Pisano G, Nicolosi A. Role of intraoperative neuromonitoring of recurrent laryngeal nerves in the outcomes of surgery for thyroid cancer. Int J Surg 2014; 12 Suppl 1:S213-7. [DOI: 10.1016/j.ijsu.2014.05.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2014] [Accepted: 05/03/2014] [Indexed: 11/16/2022]
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