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Yang J, Han Y, Min Y, Chen C, Chen J, Xiang K, Liao J, Feng Y, Hu D, Yin G. Prophylactic central neck dissection for cN0 papillary thyroid carcinoma: is there any difference between western countries and China? A systematic review and meta-analysis. Front Endocrinol (Lausanne) 2023; 14:1176512. [PMID: 37576962 PMCID: PMC10413573 DOI: 10.3389/fendo.2023.1176512] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 07/12/2023] [Indexed: 08/15/2023] Open
Abstract
Background Recommendations for the performance of prophylactic central neck dissection (pCND) in patients with clinically node-uninvolved (cN0) papillary thyroid carcinoma (PTC) are not the same. This meta-analysis set out to compare the effectiveness of pCND with total thyroidectomy (TT) in different countries and regions, mainly between western countries and China. Methods The electronic databases PubMed, EMBASE, and Cochrane Library were searched for studies published until August 2022. The incidence rate of cervical lymph node metastases (LNMs), locoregional recurrences (LRRs), and postoperative complications were pooled by a random-effects model. Subgroup analyses based on different countries and regions were performed. Results Eighteen studies involving 5,346 patients were analyzed. In the subgroup of western countries, patients undergoing pCND with TT had a significantly lower LRR rate [69/1,804, 3.82% vs. 139/2,541, 5.47%; odds ratio (OR) = 0.56; 95% CI 0.37-0.85] and a higher rate of temporary hypoparathyroidism (HPT) (316/1,279, 24.71% vs. 194/1,467, 13.22%; OR = 2.23; 95% CI 1.61-3.08) than that of the TT alone group, while no statistically significant difference was found in the rate of permanent HPT and temporary and permanent recurrent laryngeal nerve (RLN) injury. In the Chinese subgroup, the pCND with TT group had a significantly higher incidence rate of both temporary HPT (87/374, 23.26% vs. 36/324, 11.11%; OR = 2.24; 95% CI 1.32-3.81) and permanent HPT (21/374, 5.61% vs. 4/324, 1.23%; OR = 3.58; 95% CI = 1.24-10.37) than that of the TT alone group, while no significant difference was detected in the rate of LRR and temporary and permanent RLN injury. Conclusion Compared with the TT alone for cN0 PTC patients, pCND with TT had a significantly lower LRR rate while having a higher temporary HPT rate in Europe, America, and Australia; however, it showed no significant difference in decreasing LRR rate while having a significantly raised rate of temporary and permanent HPT in China. More population-based results are required to advocate precision medicine in PTC. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022358546.
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Affiliation(s)
- Jiaxin Yang
- Department of Breast and Thyroid Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yuling Han
- Department of Breast and Thyroid Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yu Min
- Department of Biotherapy and National Clinical Research Center for Geriatrics, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Cheng Chen
- Department of Breast and Thyroid Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jialin Chen
- Department of Breast and Thyroid Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ke Xiang
- Department of Breast and Thyroid Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jiahu Liao
- Department of Breast and Thyroid Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yang Feng
- Department of Breast and Thyroid Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Daixing Hu
- Department of Breast and Thyroid Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Guobing Yin
- Department of Breast and Thyroid Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Mathieson T, Jimaja W, Triponez F, Licker M, Karenovics W, Makovac P, Muradbegovic M, Belfontali V, Bédat B, Demarchi MS. Safety of continuous intraoperative vagus nerve neuromonitoring during thyroid surgery. BJS Open 2023; 7:zrad039. [PMID: 37289251 PMCID: PMC10249491 DOI: 10.1093/bjsopen/zrad039] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 02/02/2023] [Accepted: 03/08/2023] [Indexed: 06/09/2023] Open
Abstract
BACKGROUND Continuous intraoperative neuromonitoring has successfully demonstrated to predict impending damage to the recurrent laryngeal nerve, by detecting changes in electromyographic recordings. Despite the apparent benefits associated with continuous intraoperative neuromonitoring, its safety is still a debate. The aim of this study was to investigate the electrophysiological impact of continuous intraoperative neuromonitoring on the vagus nerve. METHODS In this prospective study, the amplitude of the electromyographic wave of the vagus nerve-recurrent laryngeal nerve axis was measured both proximally and distally to the stimulation electrode placed upon the vagus nerve. Electromyographic signal amplitudes were collected at three distinct events during the operation: during the dissection of the vagus nerve, before application of the continuous stimulation electrode onto the vagus nerve and after its removal. RESULTS In total, 169 vagus nerves were analysed, among 108 included patients undergoing continuous intraoperative neuromonitoring-enhanced endocrine neck surgeries. Electrode application resulted in a significant overall decrease in measured proximo-distal amplitudes of -10.94 µV (95 per cent c.i. -17.06 to -4.82 µV) (P < 0.005), corresponding to a mean(s.d.) decrease of -1.4(5.4) per cent. Before the removal of the electrode, the measured proximo-distal difference in amplitudes was -18.58 µV (95 per cent c.i. -28.31 to -8.86 µV) (P < 0.005), corresponding to a mean(s.d.) decrease of -2.50(9.59) per cent. Seven nerves suffered a loss of amplitude greater than 20 per cent of the baseline measurement. CONCLUSION In addition to supporting claims that continuous intraoperative neuromonitoring exposes the vagus nerve to injury, this study shows a mild electrophysiological impact of continuous intraoperative neuromonitoring electrode placement on the vagus nerve-recurrent laryngeal nerve axis. However, the small observed differences are negligible and were not associated with a clinically relevant outcome, making continuous intraoperative neuromonitoring a safe adjunct in selected thyroid surgeries.
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Affiliation(s)
- Timothy Mathieson
- Department of Thoracic and Endocrine Surgery and Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Wedali Jimaja
- Department of Thoracic and Endocrine Surgery and Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Frédéric Triponez
- Department of Thoracic and Endocrine Surgery and Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Marc Licker
- Department of Anaesthesiology and Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Wolfram Karenovics
- Department of Thoracic and Endocrine Surgery and Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Petra Makovac
- Department of Thoracic and Endocrine Surgery and Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Mirza Muradbegovic
- Department of Thoracic and Endocrine Surgery and Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Valentina Belfontali
- Department of Thoracic and Endocrine Surgery and Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Benoît Bédat
- Department of Thoracic and Endocrine Surgery and Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Marco Stefano Demarchi
- Department of Thoracic and Endocrine Surgery and Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
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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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Matsushima K, Kohno M, Ichimasu N, Tanaka Y, Nakajima N, Yoshino M. Intraoperative continuous vagus nerve monitoring with repetitive direct stimulation in surgery for jugular foramen tumors. J Neurosurg 2021; 135:1036-1043. [PMID: 33607614 DOI: 10.3171/2020.8.jns202680] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 08/18/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Surgery for tumors around the jugular foramen has significant risks of dysphagia and vocal cord palsy due to possible damage to the lower cranial nerve functions. For its treatment, long-term tumor control by maximum resection while avoiding permanent neurological damage is required. To accomplish this challenging goal, the authors developed an intraoperative continuous vagus nerve monitoring system and herein report their experience with this novel neuromonitoring method. METHODS Fifty consecutive patients with tumors around the jugular foramen (34 jugular foramen schwannomas, 11 meningiomas, 3 hypoglossal schwannomas, and 2 others) who underwent microsurgical resection under continuous vagus nerve monitoring within an 11-year period were retrospectively investigated. Evoked vagus nerve electromyograms were continuously monitored by direct 1-Hz stimulation to the nerve throughout the microsurgical procedure. RESULTS The average resection rate was 96.2%, and no additional surgery was required in any of the patients during the follow-up period (average 65.0 months). Extubation immediately after surgery and oral feeding within 10 days postoperatively were each achieved in 49 patients (98.0%). In 7 patients (14.0%), dysphagia and/or hoarseness were mildly worsened postoperatively at the latest follow-up, but tracheostomy or gastrostomy was not required in any of them. Amplitude preservation ratios on intraoperative vagus nerve electromyograms were significantly smaller in patients with postoperative worsening of dysphagia and/or hoarseness (cutoff value 63%, sensitivity 86%, specificity 79%). CONCLUSIONS Intraoperative continuous vagus nerve monitoring enables real-time and quantitative assessment of vagus nerve function and is important for avoiding permanent vagus nerve palsy, while helping to achieve sufficient resection of tumors around the jugular foramen.
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Affiliation(s)
- Ken Matsushima
- 1Department of Neurosurgery, Tokyo Medical University; and
| | - Michihiro Kohno
- 1Department of Neurosurgery, Tokyo Medical University; and
- 2Department of Neurosurgery, Tokyo Metropolitan Police Hospital, Tokyo, Japan
| | - Norio Ichimasu
- 1Department of Neurosurgery, Tokyo Medical University; and
| | - Yujiro Tanaka
- 1Department of Neurosurgery, Tokyo Medical University; and
| | | | - Masanori Yoshino
- 2Department of Neurosurgery, Tokyo Metropolitan Police Hospital, Tokyo, Japan
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Oh MY, Lee JM, Lee MH, Choi HS, Kim J, Hwang KT, Chai YJ. Application of patch stimulator for intraoperative neuromonitoring during thyroid surgery: maximizing surgeon's convenience. Gland Surg 2021; 10:2378-2385. [PMID: 34527549 DOI: 10.21037/gs-21-327] [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: 06/01/2021] [Accepted: 07/22/2021] [Indexed: 02/02/2023]
Abstract
Background Intraoperative neuromonitoring (IONM) is frequently used in thyroid surgery to reduce recurrent laryngeal nerve (RLN) injury by providing the surgeon with real-time feedback on nerve stimulation during dissection. We applied a disposable adhesive patch electrode to a dissecting instrument to transfer electrical stimulation to the dissecting instrument for IONM during thyroid surgery. This study aimed to evaluate the feasibility of using the patch stimulator approach for IONM during thyroid surgery. Methods We reviewed the medical records of patients who underwent thyroidectomy using both conventional stimulator and adhesive patch stimulator for IONM. The electromyography (EMG) amplitudes of the vagal and the RLNs before (V1, R1) and after thyroid resection (V2, R2) were alternatively checked with each type of stimulator at the same location of each nerve. Results Fifteen consecutive patients (4 males, 11 females) were included in this analysis, and a total of 38 nerves (19 vagus nerves and 19 RLNs) were evaluated. No statistically significant differences were seen in the mean amplitudes evoked by the patch stimulator and the conventional probe stimulator for the V1 signal (825.5±394.6 vs. 821.8±360.9 µV, P=0.954), R1 signal (1,044.8±471.2 vs. 1,039.2±507.4 µV, P=0.898), R2 signal (1,037.8±495.0 vs. 938.2±415.8 µV, P=0.948), or V2 signal (812.5±391.9 vs. 787.3±355.7 µV, P=0.975). Conclusions The patch stimulator was safely and effectively used for IONM during thyroid surgery and provided similar nerve monitoring responses as the conventional stimulator. This approach may be used to enhance the surgeon's convenience during thyroid surgery.
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Affiliation(s)
- Moon Young Oh
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jung-Man Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Korea.,Department of Anesthesiology and Pain Medicine, Seoul Metropolitan Government - Seoul National University Boramae Medical Center, Seoul, Korea
| | - Myung-Ho Lee
- Department of Surgery, Seoul Metropolitan Government - Seoul National University Boramae Medical Center, Seoul, Korea
| | - Hyun Suk Choi
- Department of Nursing, Seoul Metropolitan Government - Seoul National University Boramae Medical Center, Seoul, Korea
| | - Jongjin Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.,Department of Surgery, Seoul Metropolitan Government - Seoul National University Boramae Medical Center, Seoul, Korea
| | - Ki-Tae Hwang
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.,Department of Surgery, Seoul Metropolitan Government - Seoul National University Boramae Medical Center, Seoul, Korea
| | - Young Jun Chai
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.,Department of Surgery, Seoul Metropolitan Government - Seoul National University Boramae Medical Center, Seoul, Korea.,Transdisciplinary Department of Medicine & Advanced Technology, Seoul National University Hospital, Seoul, Korea
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6
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Ku D, Hui M, Cheung P, Chow O, Smith M, Riffat F, Sritharan N, Kamani D, Randolph G. Meta-analysis on continuous nerve monitoring in thyroidectomies. Head Neck 2021; 43:3966-3978. [PMID: 34342380 DOI: 10.1002/hed.26828] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 06/15/2021] [Accepted: 07/22/2021] [Indexed: 11/05/2022] Open
Abstract
In the last decade, the introduction of continuous intraoperative recurrent laryngeal nerve (RLN) monitoring (C-IONM) has enabled the operator to verify the functional integrity of the vagus nerve-recurrent laryngeal nerve (VN-RLN) axis in real-time. We aim to present the current evidence on C-IONM utility for thyroid surgery by conducting the first meta-analysis on this technique. A systematic review of literature was conducted by two independent reviewers via Ovid in the Medline, EMBASE, and Cochrane reviews databases. The search was limited to human subject research in peer-reviewed articles of all languages published between Jan 1946 and April 2020. Medical subject headings (MeSH) terms utilized were thyroid surgery, thyroidectomies, recurrent laryngeal nerve, vagal nerve, monitor, and stimulation. Thirty-eight papers were identified from Ovid, another six papers were identified by hand-search. A random effect meta-analysis was performed with assessment of heterogeneity using the I2 value. A total of 23 papers that investigated the use of continuous vagal nerve monitoring during thyroid surgery were identified. The proportion of nerves at risk (NAR) with temporary RLN paralysis postoperation was 2.26% (95% CI: 1.6-2.9, I2 = 37). The proportion of NAR with permanent RLN palsy postoperation was 0.05% (95% CI: 0.08-0.2, I2 = 0). In this meta-analysis, there is one case of temporary vagal nerve paralysis secondary to VN electrode dislodgement, and a case of hemodynamic instability manifested in bradycardia and hypotension in the initial phase of surgery shortly after calibration. C-IONM is a safe and effective means by which RLN paralyses in thyroid surgery can be reduced.
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Affiliation(s)
- Dominic Ku
- Department of Otolaryngology - Head & Neck Surgery, Westmead Hospital, Sydney, New South Wales, Australia
| | - Michelle Hui
- Department of Otolaryngology - Head & Neck Surgery, Westmead Hospital, Sydney, New South Wales, Australia
| | - Phylannie Cheung
- Department of Otolaryngology - Head & Neck Surgery, Westmead Hospital, Sydney, New South Wales, Australia
| | - Oliver Chow
- Department of Otolaryngology - Head & Neck Surgery, Westmead Hospital, Sydney, New South Wales, Australia
| | - Mark Smith
- Department of Otolaryngology - Head & Neck Surgery, Westmead Hospital, Sydney, New South Wales, Australia.,Department of Otolaryngology - Head & Neck Surgery, Nepean Hospital, Sydney, New South Wales, Australia
| | - Faruque Riffat
- Department of Otolaryngology - Head & Neck Surgery, Westmead Hospital, Sydney, New South Wales, Australia.,Department of Otolaryngology - Head & Neck Surgery, Nepean Hospital, Sydney, New South Wales, Australia
| | - Niranjan Sritharan
- Department of Otolaryngology - Head & Neck Surgery, Westmead Hospital, Sydney, New South Wales, Australia.,Department of Otolaryngology - Head & Neck Surgery, Nepean Hospital, Sydney, New South Wales, Australia
| | - Dipti Kamani
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Gregory Randolph
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA.,Division of Surgical Oncology, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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7
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Schneider R, Machens A, Sekulla C, Lorenz K, Elwerr M, Dralle H. Superiority of continuous over intermittent intraoperative nerve monitoring in preventing vocal cord palsy. Br J Surg 2021; 108:566-573. [PMID: 34043775 DOI: 10.1002/bjs.11901] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 04/20/2020] [Accepted: 06/14/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Continuous intraoperative nerve stimulation (IONM) with uninterrupted monitoring is likely better than intermittent IONM in preventing vocal cord palsy after thyroid surgery. METHODS This was a comparative study of intermittent versus continuous IONM in patients with benign and malignant thyroid disease treated at a tertiary centre over 10 years. Early postoperative and permanent vocal cord palsy rates were estimated. Multivariable logistic regression analysis was used to quantify the contributions of clinical and histopathological variables to early postoperative and permanent vocal cord palsy. RESULTS A total of 6029 patients were included, of whom 3139 underwent continuous and 2890 intermittent IONM. Based on nerves at risk (5208 versus 5024 nerves), continuous IONM had a 1·7-fold lower early postoperative vocal cord palsy rate than intermittent monitoring (1·5 versus 2·5 per cent). This translated into a 30-fold lower permanent vocal cord palsy rate (0·02 versus 0·6 per cent). In multivariable logistic regression analysis, continuous IONM independently reduced early postoperative vocal cord palsy 1·8-fold (odds ratio (OR) 0·56) and permanent vocal cord palsy 29·4-fold (OR 0·034) compared with intermittent IONM. One permanent vocal cord palsy per 75·0 early vocal cord palsies was observed with continuous IONM, compared with one per 4·2 after intermittent IONM. Early postoperative vocal cord palsies were 17·9-fold less likely to become permanent with continuous than intermittent IONM. CONCLUSION Continuous IONM is superior to intermittent IONM in preventing vocal cord palsy.
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Affiliation(s)
- R Schneider
- Department of Visceral, Vascular and Endocrine Surgery, University Hospital, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - A Machens
- Department of Visceral, Vascular and Endocrine Surgery, University Hospital, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - C Sekulla
- Department of Visceral, Vascular and Endocrine Surgery, University Hospital, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - K Lorenz
- Department of Visceral, Vascular and Endocrine Surgery, University Hospital, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - M Elwerr
- Department of Visceral, Vascular and Endocrine Surgery, University Hospital, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - H Dralle
- Department of Visceral, Vascular and Endocrine Surgery, University Hospital, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany.,Department of General, Visceral and Transplantation Surgery, Section of Endocrine Surgery, University of Duisburg-Essen, Essen, Germany
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8
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Tensile strength analysis of automatic periodic stimulation for continuous intraoperative neural monitoring in a piglet model. Sci Rep 2021; 11:5898. [PMID: 33723308 PMCID: PMC7960733 DOI: 10.1038/s41598-021-84988-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 02/18/2021] [Indexed: 11/17/2022] Open
Abstract
Continuous intraoperative neural monitoring (C-IONM) during thyroid surgery is a useful tool for preventing recurrent laryngeal nerve (RLN) injury. The present study aims to analyze the tensile strength tolerance of C-IONM electrodes on the vagal nerve (VN). A C-IONM wire was enclosed in a hand-held tensile testing system. The probe displacement on the VN was continuously monitored by positioning a second probe far-up/proximally in a piglet model, and an automatic periodic stimulation (APS) accessory was used. The 3-mm and 2-mm APS accessory has a mean tensile strength of 20.6 ± 10 N (range, 14.6–24.4 N) and 11.25 ± 8 N (range, 8.4–15.6 N), respectively (P = 0.002). There was no difference between bilateral VNs. The mean amplitude before and during electrode displacement was 1.835 ± 102 μV and 1.795 ± 169 μV, respectively (P = 0.45). The mean percentage of amplitude decrease on the electromyography (EMG) was 6.9 ± 2.5%, and the mean percentage of latency increase was 1.9 ± 1.5%. No significant amplitude reduction or loss of signal (LOS) was observed after > 50 probe dislocations. C-IONM probe dislocation does not cause any LOS or significant EMG alterations on the VN.
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9
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Stankovic P, Wittlinger J, Georgiew R, Dominas N, Hoch S, Wilhelm T. Continuous intraoperative neuromonitoring (cIONM) in head and neck surgery-a review. HNO 2020; 68:86-92. [PMID: 32219490 PMCID: PMC7403167 DOI: 10.1007/s00106-020-00824-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Although the history of intraoperative neuromonitoring (IONM) dates back to the 19th century, the method did not evolve further than the mere differentiation of nerves until recently. Only the development of continuous IONM (cIONM) has allowed for non-stop analysis of excitation amplitude and latency during surgical procedures, which is nowadays integrated into the software of almost all commercially available neuromonitoring devices. The objective of cIONM is real-time monitoring of nerve status in order to recognize and prevent impending nerve injury and predict postoperative nerve function. Despite some drawbacks such as false-positive/negative alarms, technical artefacts, and rare adverse effects, cIONM remains a good instrument which is still under development. Active (acIONM) and passive (pcIONM) methods of cIONM are described in literature. The main fields of cIONM implementation are currently thyroid surgery (in which the vagal nerve is continuously stimulated) and surgery to the cerebellopontine angle (in which the facial nerve is either continuously stimulated or the discharge signal of the nerve is analyzed via pcIONM). In the latter surgery, continuous monitoring of the cochlear nerve is also established.
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Affiliation(s)
- P Stankovic
- Department of Otolaryngology, Head/Neck & Facial Plastic Surgery, Sana Kliniken Leipziger Land, Rudolf-Virchow-Straße 2, 04552, Borna, Germany
| | - J Wittlinger
- Department of Otolaryngology, Head and Neck Surgery, Martin Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - R Georgiew
- Department of Otolaryngology, Head/Neck & Facial Plastic Surgery, Sana Kliniken Leipziger Land, Rudolf-Virchow-Straße 2, 04552, Borna, Germany
| | - N Dominas
- Department of Otolaryngology, Philipps-University Marburg, Marburg, Germany
| | - S Hoch
- Department of Otolaryngology, Philipps-University Marburg, Marburg, Germany
| | - T Wilhelm
- Department of Otolaryngology, Head/Neck & Facial Plastic Surgery, Sana Kliniken Leipziger Land, Rudolf-Virchow-Straße 2, 04552, Borna, Germany. .,Medical Faculty, Philipps-University Marburg, Marburg, Germany.
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10
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What is the impact of continuous neuromonitoring on the incidence of injury to the recurrent laryngeal nerve during total thyroidectomy? Surgery 2020; 169:63-69. [PMID: 32409167 DOI: 10.1016/j.surg.2020.03.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 03/17/2020] [Accepted: 03/24/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Continuous intraoperative neuromonitoring may facilitate reversal of intraoperative injurious operative maneuvers in comparison with intermittent intraoperative neuromonitoring. The aim of this study was to evaluate the impact of the routine use of continuous intraoperative neuromonitoring on intraoperative injuries to the recurrent laryngeal nerve. METHOD This study was a prospective case series with retrospective analysis of consecutive patients undergoing total thyroidectomy from August 2013 to August 2019. During this period, intermittent intraoperative neuromonitoring (before Mar 2016) and continuous intraoperative neuromonitoring (after Mar 2016) were used in all patients. RESULTS We reviewed the outcomes of 603 patients (466 female patients) comprising 236 who underwent intermittent intraoperative neuromonitoring and 367 who underwent continuous intraoperative neuromonitoring. Intraoperative adverse electromyography events (>50% decrease in amplitude between VN1 and VN2) were observed in 87 patients (14.5%) and were less frequent in the continuous intraoperative neuromonitoring group (10.6 vs 20.3%, P = .001). Intraoperative loss of signal (electromyography events with VN2 ≤100μV) were observed in 35 patients (5.8%) without any difference between the 2 groups of patients (5.2 vs 6.8%, P = .415). Postoperative recurrent laryngeal nerve palsies were observed in 36 patients (5.9%) without any difference between the 2 groups of patients (4.9 vs 7.6%, P = .168). CONCLUSION The routine use of continuous intraoperative neuromonitoring improves the rate of intraoperative adverse electromyography events but does not impact significantly the rates of loss of signal and recurrent laryngeal nerve palsy.
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The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults. Ann Surg 2020; 271:e21-e93. [PMID: 32079830 DOI: 10.1097/sla.0000000000003580] [Citation(s) in RCA: 238] [Impact Index Per Article: 59.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To develop evidence-based recommendations for safe, effective, and appropriate thyroidectomy. BACKGROUND Surgical management of thyroid disease has evolved considerably over several decades leading to variability in rendered care. Over 100,000 thyroid operations are performed annually in the US. METHODS The medical literature from 1/1/1985 to 11/9/2018 was reviewed by a panel of 19 experts in thyroid disorders representing multiple disciplines. The authors used the best available evidence to construct surgical management recommendations. Levels of evidence were determined using the American College of Physicians grading system, and management recommendations were discussed to consensus. Members of the American Association of Endocrine Surgeons reviewed and commented on preliminary drafts of the content. RESULTS These clinical guidelines analyze the indications for thyroidectomy as well as its definitions, technique, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Fine Needle Aspiration Biopsy Diagnosis, Molecular Testing, Indications, Extent and Outcomes of Surgery, Preoperative Care, Initial Thyroidectomy, Perioperative Tissue Diagnosis, Nodal Dissection, Concurrent Parathyroidectomy, Hyperthyroid Conditions, Goiter, Adjuncts and Approaches to Thyroidectomy, Laryngology, Familial Thyroid Cancer, Postoperative Care and Complications, Cancer Management, and Reoperation. CONCLUSIONS Evidence-based guidelines were created to assist clinicians in the optimal surgical management of thyroid disease.
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Sinclair CF, Téllez MJ, Ulkatan S. Continuous Laryngeal Adductor Reflex Versus Intermittent Nerve Monitoring in Neck Endocrine Surgery. Laryngoscope 2020; 131:230-236. [PMID: 32364626 DOI: 10.1002/lary.28710] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 04/01/2020] [Accepted: 04/10/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Intraoperative neuromonitoring (IONM) techniques aim to identify and potentially prevent nerve injury during surgeries. Prior studies into the efficacy of recurrent laryngeal nerve (RLN) IONM convey mixed results, with some claiming equivalence between IONM and no monitoring at all. The goal of the current study was to compare continuous RLN monitoring using the laryngeal adductor reflex (LAR) to intermittent RLN monitoring (intermittent IONM) to determine whether continuous monitoring reduces the incidence of intraoperative RLN injury during neck endocrine surgeries. METHODS In this observational, historical case-control study, a historical cohort of patients monitored with intermittent-IONM (group 1, n = 130) were compared to prospectively collected data from consecutive nerves-at-risk monitored continuously with the LAR (LAR-CIONM, group 2, n = 205), at a single center by a single surgeon. The test benefit ratio and relative risk reduction (RRR) for LAR-CIONM over intermittent IONM were calculated. RESULTS For group 1, nine nerves at risk exhibited intraoperative LOS with transient postoperative vocal fold (VF) hypomobility (n = 2) or immobility (VFI, n = 7). For group 2, two nerves at risk (0.98%) had sudden intraoperative LAR LOS following bipolar cautery, resulting in postoperative transient VFI (P = .004). In each group, there was one case of permanent postoperative VFI. The test benefit rate ratio for LAR-CIONM demonstrated a dramatic effect at 5.23, with an RRR of 81.0%. CONCLUSION LAR-CIONM significantly decreased rates of postoperative transient VF paralysis and paresis over intermittent IONM alone (P = .004). Surgeons should be aware of the benefits and limitations of intermittent IONM versus CIONM. Intermittent IONM, although useful in nerve mapping and intraoperative decision making, has minimal benefit for the prevention of nerve injury, whereas CIONM can potentially reduce nerve injury rates and improve patient outcomes. LEVEL OF EVIDENCE 3 Laryngoscope, 131:230-236, 2021.
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Affiliation(s)
- Catherine F Sinclair
- Department of Otolaryngology Head and Neck Surgery, Mount Sinai West Hospital, New York, NY, USA
| | - Maria J Téllez
- Department of Intraoperative Neurophysiology, Mount Sinai West Hospital, New York, NY, USA
| | - Sedat Ulkatan
- Department of Intraoperative Neurophysiology, Mount Sinai West Hospital, New York, NY, USA
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Ninomiya Y, Oguma J, Ozawa S, Koyanagi K, Kazuno A, Yamamoto M, Yatabe K. Thoracoscopic esophagectomy with left recurrent laryngeal nerve monitoring for thoracic esophageal cancer in a patient with a right aortic arch: a case report. Surg Case Rep 2020; 6:62. [PMID: 32232599 PMCID: PMC7105558 DOI: 10.1186/s40792-020-00819-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 03/13/2020] [Indexed: 11/10/2022] Open
Abstract
Background Surgery for cases of thoracic esophageal cancer with a right aortic arch is rare, and the anatomic abnormalities in such patients necessitate a different surgical approach. Since the position of the recurrent laryngeal nerve often differs from the usual in these cases, the lymph node dissection around the recurrent laryngeal nerve, which is an important step in surgery for thoracic esophageal cancer, requires careful attention. There are some reports on the usefulness of intraoperative recurrent laryngeal nerve monitoring during esophageal cancer surgery. Herein, we report a case of successful thoracoscopic esophagectomy for esophageal cancer in a patient with a right aortic arch using intraoperative recurrent laryngeal nerve monitoring. Case presentation A 70-year-old man was diagnosed as having esophageal cancer (Ut, type 0-IIc, T1b/MtLt, type 0-IIc, T1b, N2, M0, cStage II) and was treated by neoadjuvant chemoradiotherapy followed by radical surgery. Preoperative CT examination revealed a right aortic arch, and based on the findings of 3D-CT, we classified the right aortic arch as type IIIB1 (Edwards classification), which is the most frequent type of right aortic arch. We performed thoracoscopic esophagectomy via a left thoracic approach with the patient placed in the prone position, cervical esophagogastric conduit reconstruction via the retrosternal route, and three-field lymph node dissection. Although Kommerell’s diverticulum could be easily confirmed, the descending aorta took a meandering course, making it difficult for the esophagus to be mobilized and detached and therefore also to identify the ductus arteriosus and left recurrent laryngeal nerve. Intraoperative recurrent laryngeal nerve monitoring using NIM-RESPONSE® 3.0 (Medtronic Japan, Tokyo, Japan) allowed the position of the left recurrent laryngeal nerve to be accurately determined, and upper mediastinal lymph node dissection and mobilization of the upper thoracic esophagus were performed safely. Postoperatively, the patient showed no evidence of recurrent laryngeal nerve palsy, but needed conservative treatment for anastomotic leakage. The patient was discharged 46 days after the surgery. Conclusion It was suggested that intraoperative recurrent laryngeal nerve monitoring is useful in esophageal cancer with a right aortic arch undergoing surgery, in whom anatomic abnormalities of the recurrent laryngeal nerve can be expected.
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Affiliation(s)
- Yamato Ninomiya
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Junya Oguma
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan.,Department of Esophageal Surgery, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Soji Ozawa
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan.
| | - Kazuo Koyanagi
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Akihito Kazuno
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Miho Yamamoto
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Kentaro Yatabe
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
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[Continuous intraoperative neuromonitoring (cIONM) in head and neck surgery-a review. German version]. HNO 2020; 68:801-809. [PMID: 32157335 PMCID: PMC7591407 DOI: 10.1007/s00106-020-00823-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Obwohl die Geschichte des intraoperativen Neuromonitorings (IONM) bereits in das 19. Jahrhundert zurückdatiert werden kann, hat sich diese Methode bis vor Kurzem nicht von der reinen Differenzierung des Nervs weiterentwickelt. Erst das kontinuierliche IONM (cIONM) ermöglichte die durchgehende Analyse der Reizamplituden und -latenzen, welche mittlerweile ebenfalls in die Software gängiger Monitoringsysteme integriert wurde. Zielsetzung des cIONM ist ein Real-Time-Monitoring des Nervenstatus während des Eingriffs, um so drohende Nervenverletzung erkennen und verhindern zu können und die postoperative Funktion des Nervs vorhersehbar zu erhalten. Trotz einiger Nachteile wie falsch-positiver oder -negativer Alarme, technischer Artefakte und seltener Nebenwirkungen bleibt das cIONM ein gutes Hilfsmittel, das noch weiterentwickelt wird. In der Literatur sind sowohl aktive (acIONM) als auch passive (pcIONM) Reiz- und Ableitmethoden des cIONM beschrieben. Derzeit gängige Anwendungsgebiete des cIONM umfassen die Schilddrüsenchirurgie mit der kontinuierlichen Stimulation des N. vagus sowie die Chirurgie des Kleinhirnbrückenwinkels (KHBW) mit dem Monitoring des N. facialis; hierbei werden neben kontinuierlicher Stimulation auch die Entladungsmuster des Nervs analysiert. Des Weiteren ist in die Chirurgie des KHBW das kontinuierliche Monitoring des Hörnervs etabliert.
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Yu Q, Liu K, Zhang S, Li H, Xie C, Wu Y, Jiang H, Dai W. Application of Continuous and Intermittent Intraoperative Nerve Monitoring in Thyroid Surgery. J Surg Res 2019; 243:325-331. [DOI: 10.1016/j.jss.2019.05.054] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 04/19/2019] [Accepted: 05/30/2019] [Indexed: 01/25/2023]
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Liu F, Yu X, Liu Z, Qiao Z, Dou J, Cheng Z, Han Z, Yu J, Liang P. Comparison of ultrasound-guided percutaneous microwave ablation and parathyroidectomy for primary hyperparathyroidism. Int J Hyperthermia 2019; 36:835-840. [PMID: 31452422 DOI: 10.1080/02656736.2019.1645365] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Fangyi Liu
- Department of Interventional Ultrasound, Chinese PLA General Hospital, Beijing, China
| | - Xiaoling Yu
- Department of Interventional Ultrasound, Chinese PLA General Hospital, Beijing, China
| | - Zhoulu Liu
- Department of General Surgery, Chinese PLA General Hospital, Beijing, China
| | - Zhi Qiao
- Department of General Surgery, Chinese PLA General Hospital, Beijing, China
| | - Jianping Dou
- Department of Interventional Ultrasound, Chinese PLA General Hospital, Beijing, China
| | - Zhigang Cheng
- Department of Interventional Ultrasound, Chinese PLA General Hospital, Beijing, China
| | - Zhiyu Han
- Department of Interventional Ultrasound, Chinese PLA General Hospital, Beijing, China
| | - Jie Yu
- Department of Interventional Ultrasound, Chinese PLA General Hospital, Beijing, China
| | - Ping Liang
- Department of Interventional Ultrasound, Chinese PLA General Hospital, Beijing, China
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Schneider R, Machens A, Randolph G, Kamani D, Lorenz K, Dralle H. Impact of continuous intraoperative vagus stimulation on intraoperative decision making in favor of or against bilateral surgery in benign goiter. Best Pract Res Clin Endocrinol Metab 2019; 33:101285. [PMID: 31221571 DOI: 10.1016/j.beem.2019.06.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The advent of continuous vagus stimulation (CVS), eliminating lag time between nerve preparation with potential trauma and stimulation, has transformed the intraoperative surgical strategy in thyroid surgery. Continuous intraoperative nerve monitoring empowers the surgeon to be optimally aware of traction-related injury to the recurrent laryngeal nerve (RLN). Electromyographic precursor lesions, called combined events, prompt surgeons to cease harmful surgical maneuvers and release the nerve before damage to the nerve is established. Complete RLN recovery, defined as restitution of the nerve amplitude to ≥50% of baseline, assures the surgeon that it is safe to pursue completion surgery of the contralateral side in one procedure. If this restitution is incomplete or absent (<50% of amplitude baseline) immediate vocal cord paralysis is likely and it is advisable to delay completion surgery until the nerve has fully recovered. This review summarizes the tremendous progress made in this dynamic field, delineating the extent to which CVS has changed the landscape: tailoring intraoperative decision making to determine the safest course of action for patients with benign goiter.
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Affiliation(s)
- Rick Schneider
- Department of Visceral, Vascular and Endocrine Surgery, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany.
| | - Andreas Machens
- Department of Visceral, Vascular and Endocrine Surgery, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Gregory Randolph
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA; Division of Surgical Oncology, Endocrine Surgery Service, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Dipti Kamani
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
| | - Kerstin Lorenz
- 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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Limitations of Continuous Neural Monitoring in Thyroid Surgery. MEDICAL BULLETIN OF SISLI ETFAL HOSPITAL 2019; 53:81-83. [PMID: 32377063 PMCID: PMC7199830 DOI: 10.14744/semb.2019.85698] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 06/24/2019] [Indexed: 11/20/2022]
Abstract
Continuous intraoperative neuromonitoring is currently the gold standard technique available to prevent recurrent laryngeal nerve injuries. It significantly reduces the complication rate compared with intermittent intraoperative neuromonitoring, and represents significant progress in thyroid surgery, particularly in cases of more difficult dissections. There are, however, some technological and interpretative limits related to the lack of standardization of continuous intraoperative neuromonitoring and the prolonged length of time employed in the surgical positioning of the probe, despite various proposed approaches to the vagal nerve. Nonetheless, this method can be considered a safe and modern approach to thyroid surgery that reduces post-surgical complications and provides useful information.
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Chen L, Wu YH, Lee CH, Chen HA, Loh EW, Tam KW. Prophylactic Central Neck Dissection for Papillary Thyroid Carcinoma with Clinically Uninvolved Central Neck Lymph Nodes: A Systematic Review and Meta-analysis. World J Surg 2018; 42:2846-2857. [PMID: 29488066 DOI: 10.1007/s00268-018-4547-4] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Central neck dissection and total thyroidectomy are standard treatments for patients with papillary thyroid carcinoma (PTC) with clinically involved central nodes. However, prophylactic central neck dissection (pCND) in patients with clinically uninvolved cN0 has been beneficial in some studies but ineffective in others. We conducted a meta-analysis to evaluate the efficacy and safety of pCND in patients with central neck lymph nodes cN0 PTC. METHODS The PubMed, EMBASE, Cochrane Library, and Scopus databases and the ClinicalTrials.gov registry were electronically searched for studies published until September 2017. The meta-analysis was conducted to calculate the pooled effect size by using random-effects model. Treatment efficacies were measured by determining locoregional recurrence (LRR). Secondary outcomes included transient recurrent laryngeal nerve (RLN) injury, permanent RLN injury, transient hypocalcemia, and permanent hypocalcemia. RESULTS Twenty-three retrospective and prospective cohort studies involving 18,376 patients were reviewed. Patients who underwent pCND had significantly lower LRR (odds ratio [OR] 0.65; 95% confidence interval [CI] 0.48-0.88) but significantly higher incidence rates of transient RLN injury (OR 2.03; 95% CI 1.32-3.13), transient hypocalcemia (OR 2.23; 95% CI 1.84-2.70), and permanent hypocalcemia (OR 2.22; 95% CI 1.58-3.13) than that of no pCND group. CONCLUSION Compared with no pCND, pCND significantly reduces LRR but is accompanied by numerous adverse effects. The clinical decision should be made after the shared decision-making process of clinicians and patients.
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Affiliation(s)
- Lawrence Chen
- Lake Erie College of Osteopathic Medicine, Bradenton, FL, USA
| | - Yi-Hsiu Wu
- Division of General Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Chia-Hwa Lee
- School of Medical Laboratory Science and Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan.,Comprehensive Cancer Center of Taipei Medical University, Taipei, Taiwan.,Department of Laboratory Medicine, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | - Hsin-An Chen
- Division of General Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - El-Wui Loh
- Center for Evidence-Based Health Care, Shuang Ho Hospital, Taipei Medical University 291, Zhongzheng Road, Zhonghe District, New Taipei City, 23561, Taiwan
| | - Ka-Wai Tam
- Division of General Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan. .,Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan. .,Center for Evidence-Based Health Care, Shuang Ho Hospital, Taipei Medical University 291, Zhongzheng Road, Zhonghe District, New Taipei City, 23561, Taiwan. .,Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan.
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Sun H, Wu CW, Catalfamo A, Fabiano V, Dionigi G. Limits of continuous neural monitoring in thyroid surgery. Updates Surg 2018; 71:187-188. [DOI: 10.1007/s13304-018-0593-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 09/01/2018] [Indexed: 11/29/2022]
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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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Sun H, Zanghì GN, Freni F, Dionigi G. Continuous and intermitted nerve monitoring in thyroid surgery: two complementary devices. Gland Surg 2018; 7:S80-S81. [PMID: 30175069 DOI: 10.21037/gs.2018.02.02] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Hui Sun
- Division of Thyroid Surgery, Jilin Provincial Key Laboratory of Surgical Translational Medicine, China-Japan Union Hospital of Jilin University, Changchun 130033, China
| | - Guido Nicola Zanghì
- Department of Surgery, Policlinico Vittorio Emanuele University Hospital - General Surgery and Oncology Unit, University of Catania, Catania, Sicily, Italy
| | - Francesco Freni
- Division ENT Surgery, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University Hospital G. Martino, University of Messina, Messina, Italy
| | - Gianlorenzo Dionigi
- Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University Hospital G. Martino, University of Messina, Messina, Italy
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Sidhu S. Modification of the Surgical Strategy for the Dissection of the Recurrent Laryngeal Nerve Using Continuous Intraoperative Nerve Monitoring. World J Surg 2017; 42:451-452. [PMID: 29204668 DOI: 10.1007/s00268-017-4379-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Stan Sidhu
- Endocrine Surgical Unit, University of Sydney, St Leonards, Australia.
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