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Munk PCB, Merkelbach ME, Lamadé W. The weepy cry - short neural signal bursts in intraoperative neuromonitoring. Langenbecks Arch Surg 2024; 409:102. [PMID: 38514480 PMCID: PMC10957688 DOI: 10.1007/s00423-024-03240-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 01/18/2024] [Indexed: 03/23/2024]
Abstract
PURPOSE This study aimed to establish an in-vitro alternative to existing in-vivo systems to analyze nerve dysfunction using continuous neuromonitoring (C-IONM). METHODS Three hundred sixty-three recurrent laryngeal nerves (RLN) (N(pigs) = 304, N(cattle) = 59) from food industry cadavers were exposed by microsurgical dissection following euthanasia. After rinsing with Ringer's lactate, they were tempered at 22 °C. Signal evaluation using C-IONM was performed for 10 min at 2 min intervals, and traction forces of up to 2N were applied for a median time of 60 s. Based on their post-traumatic electrophysiological response, RLNs were classified into four groups: Group A: Amplitude ≥ 100%, Group B: loss of function (LOS) 0-25%, Group C: ≥ 25-50%, and Group D: > 50%. RESULTS A viable in-vitro neuromonitoring system was established. The median post-traumatic amplitudes were 112%, 88%, 59%, and 9% in groups A, B, C, and D, respectively. A time-dependent further dynamic LOS was observed during the 10 min after cessation of strain. Surprisingly, following initial post-traumatic hyperconductivity, complete LOS occurred in up to 20% of the nerves in group A. The critical threshold for triggering LOS was 2N in all four groups, resulting in immediate paralysis of up to 51.4% of the nerves studied. CONCLUSION Consistent with in-vivo studies, RLN exhibit significant intrinsic electrophysiological variability in response to tensile forces. Moreover, nerve damage progresses even after the complete cessation of strain. Up to 20% of nerves with transiently increased post-traumatic amplitudes above 100% developed complete LOS, which we termed the "weepy cry." This time-delayed response must be considered during the interpretation of C-IONM signals.
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Affiliation(s)
| | - Mick E Merkelbach
- Ruprecht-Karls-Universität Heidelberg, Heidelberg, Germany
- BG Klinikum Murnau, Murnau, Germany
| | - Wolfram Lamadé
- Ruprecht-Karls-Universität Heidelberg, Heidelberg, Germany
- Helios Klinikum Pforzheim, Pforzheim, Germany
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Ali T, Abid Imam H, Maqsood B, Jawed I, Khan I, Haque MA. Artificial intelligence-powered intraoperative nerve monitoring: a visionary method to reduce facial nerve palsy in parotid surgery: an editorial. Ann Med Surg (Lond) 2024; 86:635-637. [PMID: 38333244 PMCID: PMC10849301 DOI: 10.1097/ms9.0000000000001612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 12/02/2023] [Indexed: 02/10/2024] Open
Affiliation(s)
- Tooba Ali
- Dow University of Health Sciences, Mission Road, Karachi, Pakistan
| | - Hibah Abid Imam
- Dow University of Health Sciences, Mission Road, Karachi, Pakistan
| | - Biya Maqsood
- Dow University of Health Sciences, Mission Road, Karachi, Pakistan
| | - Ifra Jawed
- Dow University of Health Sciences, Mission Road, Karachi, Pakistan
| | - Iman Khan
- Dow University of Health Sciences, Mission Road, Karachi, Pakistan
| | - Md Ariful Haque
- Department of Public Health, Atish Dipankar University of Science and Technology
- Voice of Doctors Research School, Dhaka, Bangladesh
- Department of Orthopedic Surgery, Yan’an Hospital Affiliated to Kunming Medical University, Kunming, Yunnan, China
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Liu X, Zhang X, Shang X, Wang H, Hou W, Sun Z. The TOFr of 0.75 to 0.85 is the optimal timing for IONM during thyroid surgery: a prospective observational cohort study. BMC Anesthesiol 2023; 23:286. [PMID: 37612707 PMCID: PMC10464378 DOI: 10.1186/s12871-023-02224-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 07/28/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUD Recurrent laryngeal nerve (RLN) injury is one of the serious complications of thyroid tumour surgery, surgical treatment of thyroid cancer requires careful consideration of the RLN and its impact on glottis function. There has been no unified standard for precise neuromuscular block monitoring to guide the monitoring of RLN in thyroid surgery. This study aimed to investigate the correlation between Train-of-four stabilization ratio (TOFr) and neural signal values of intraoperative neurophysiological monitoring (INOM) during thyroid operation, and further to determine the optimal timing for INOM during thyroid operation. METHODS Patients scheduled for thyroid tumour resection with INOM and RLN monitoring from April 2018 to July 2018 in our center were recruited. Electromyography (EMG) signals and corresponding TOFr were collected. All nerve stimulation data were included in group VR. Vagus nerve stimulation data were included in Subgroup V. RLN stimulation data were included in Subgroup R. The timing of recording was as follows: Vagus nerve EMG amplitude after opening the lateral space between the thyroid and carotid sheath and before the initiation of thyroid dissection, RLN EMG amplitude at first recognition, RLN EMG amplitude after complete thyroid dissection (Repeat three times), and Vagus nerve EMG amplitude after resection of the thyroid (Repeat three times). Correlation analysis of continuous variables was described by a scatter diagram. Pearson correlation analysis or Spearman correlation analysis was used for the two groups of variables. RESULTS Finally, 134 vagus nerve signals and 143 RLN signals were analysed after matching with TOFr. The EMG amplitude in the VR group and subgroups after nerve stimulation was positively correlated with TOFr (p < 0.05). In the VR, V and R group, the incidence of EMG ≥ 500 µV in the 0.75 < TOFr ≤ 0.85 interval was significantly higher than the 0 < TOFr ≤ 0.75 interval (P = 0.002, P = 0.013 and P = 0.029), and has no statistical difference compared to 0.85 < TOFr ≤ 0.95 interval (P > 0.05). CONCLUSIONS The EMG signals of the RLN and vagus nerve stimulation during thyroid surgery were positively correlated with TOFr. TOFr > 0.75 could reflect more than 50% of the effective nerve electrophysiological signals, 0.75 < TOFr ≤ 0.85 interval was the optimal timing for IONM during thyroid surgery. TRIAL REGISTRATION Chinese Clinical Trial Registry (ChiCTR1800015797) Registered on 20/04/2018. https://www.chictr.org.cn .
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Affiliation(s)
- Xi Liu
- Department of Anesthesiology and Intensive Care Unit, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Department of Anaesthesiology, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Xue Zhang
- Department of Anesthesiology and Intensive Care Unit, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Xue Shang
- Department of Anesthesiology and Intensive Care Unit, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Huihui Wang
- Department of Anesthesiology and Intensive Care Unit, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.
| | - Wenting Hou
- Department of Anesthesiology and Intensive Care Unit, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.
| | - Zhirong Sun
- Department of Anesthesiology and Intensive Care Unit, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.
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Fassari A, Gurrado A, Iossa A, Micalizzi A, Polistena A, Sibio S, Crocetti D, Bononi M, Testini M, Avenia N, Cavallaro G. Definition of learning curve for thyroidectomy: systematic review on the different approaches. Gland Surg 2023; 12:989-1006. [PMID: 37727342 PMCID: PMC10506114 DOI: 10.21037/gs-22-730] [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] [Received: 12/16/2022] [Accepted: 05/29/2023] [Indexed: 09/21/2023]
Abstract
Background Thyroidectomy is one of the most common surgical procedures carried out worldwide and it has evolved in recent years with alternative approaches. With the advent of minimally invasive techniques, the learning curve (LC) concept has become a fundamental "dogma". Methods A literature search, according to the PRISMA guidelines, was performed via PubMed (MEDLINE), Scopus, Cochrane Library, EMBASE, and Web of Science. Only studies assessing the learning process to thyroidectomy (including hemi- and total thyroidectomy), reporting a minimum of 30 procedures and describing clearly the minimum number of performances required to achieve proficiency and the main evaluation items used to establish it, were included. Conventional, endoscopic and robotic approaches were separately analyzed. Only English-language studies were considered. Results Forty-five relevant studies were selected for the analysis [respectively 16 concerning robotic thyroidectomy (RT), 22 endoscopic thyroidectomy (ET), 6 mini-invasive video assisted thyroidectomy (MIVAT), 1 conventional thyroidectomy (CT)]. The number of procedures required for a single surgeon to achieve competence and the parameters used to define surgical proficiency were fully investigated for each individual technique. Conclusions Our research shows how the current literature lacks an objective definition of the LC concept. The heterogeneity of analysis methodologies and parameters evaluated, the various surgical techniques and training background of single surgeons, make it impossible to draw univocal results. Future studies should consider confounding factors and establish criteria that should be consensually recognized in the assessment of surgical performances and skills.
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Affiliation(s)
- Alessia Fassari
- General Surgery Unit, Luxembourg Hospital Center, Luxembourg, Luxembourg
| | - 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
| | - Alessandra Micalizzi
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University, Rome, Italy
| | | | - Simone Sibio
- Department of Surgery, Sapienza University, Rome, Italy
| | | | - Marco Bononi
- Department of Surgery, Sapienza University, Rome, Italy
| | - Mario Testini
- Department of Precision and Regenerative Medicine and Ionian Area, Aldo Moro University, Bari, Italy
| | - Nicola Avenia
- Department of Surgery, University of Perugia, Perugia, Italy
| | - Giuseppe Cavallaro
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University, Rome, Italy
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Xu W, Teng C, Ding G, Zhao N. Hypoparathyroidism Risk After Total Endoscopic Thyroidectomy for Papillary Thyroid Cancer: A Comparison of the Transoral Vestibular and Breast Approaches. Cancer Manag Res 2022; 14:2485-2492. [PMID: 35996659 PMCID: PMC9391930 DOI: 10.2147/cmar.s380024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 08/09/2022] [Indexed: 11/23/2022] Open
Abstract
Background This study aimed to compare the risk of hypoparathyroidism between the transoral vestibular approach (TOVA) and the breast approach (BA) in patients undergoing total endoscopic thyroidectomy (TET) for papillary thyroid carcinoma (PTC). Methods The medical records of 121 PTC patients (all women) who underwent total TET from January 2015 to January 2021 were retrospectively analyzed. Patients were grouped according to surgical approach (BA or TOVA). Clinical status and concentrations of parathyroid hormone (PTH) and calcium were monitored in the perioperative period and 1, 6, and 12 months after surgery. Results The BA and TOVA groups comprised 101 and 20 patients, respectively. Clinicopathologic and characteristics and surgical data were comparable between the groups. Incidence of transient hypoparathyroidism was significantly lower in the TOVA group than the BA group (10% vs 63.4%; p <0.01). Incidence of permanent hypoparathyroidism was comparable (5% vs 6.9%). Two days after TET, mean PTH concentration was significantly higher and incidence of abnormal PTH was significantly lower in the TOVA group. The incidence of abnormal calcium concentration 2 days after surgery was significantly lower in the TOVA group. One month after surgery, the mean calcium concentration was significantly higher in the TOVA group. Univariate and multivariate Cox regression analysis suggested that patients who underwent TOVA had a lower risk of transient hypoparathyroidism (hazard ratio 0.05, 95% confidence interval, 0.01–0.23; p<0.01). No clinicopathological factors examined were significantly associated with permanent hypoparathyroidism. Conclusion In patients undergoing TET for PTC, the incidence of transient hypoparathyroidism may be lower with the TOVA than the BA. Surgeons should be aware of the relatively high risk of transient hypoparathyroidism when performing the BA.
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Affiliation(s)
- Wei Xu
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Changsheng Teng
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Guoqian Ding
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Ning Zhao
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
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Tarallo M, Crocetti D, Gurrado A, Iorio O, Iossa A, Caruso D, Bononi M, Stabilini C, Bracale U, Chiappini A, Testini M, Avenia N, Polistena A, Cavallaro G. Achieving the learning curve in total thyroidectomy: a prospective evaluation on resident's training by CUSUM and KPSS analysis. Ann R Coll Surg Engl 2022; 104:414-420. [PMID: 35175830 PMCID: PMC9157995 DOI: 10.1308/rcsann.2021.0318] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Total thyroidectomy (TT) is one of the most common procedures among general and endocrine surgeons worldwide. The conventional approach by neck incision is still the most frequently used, despite the growth of mini-invasive approaches. Controversies exist about the optimal learning curve for resident surgeons approaching this procedure. The aim of this study was to compare TT performed by experienced surgeons and residents in two academic hospitals, to define the correct shape of the specific learning curve. METHODS Between January 2016 and December 2018 patients undergoing TT in two academic departments were prospectively enrolled. In each department patients were divided into four groups: a reference group (A), consisting of 50 consecutive patients operated on by a senior surgeon, and three other groups (B, C, D) of 50 patients each where thyroidectomy was carried out by three different general surgery residents in their last 3 years of residency, respectively. Data were analysed by CUSUM and KPSS tests in order to compare operative time (OT) and its stabilisation during the learning curve. RESULTS Data from CUSUM test reported that residents could perform TT with OT similar to the senior surgeon after approximately 25-30 procedures, while the KPSS test showed that residents became more stable after 30 procedures, with no increase in perioperative complications. CONCLUSIONS This prospective study shows how a specific training in thyroid surgery can be reliable thanks to experienced tutors, and confirmed that the effect of dedicated and programmed training may result in positive outcomes for patients requiring thyroidectomy.
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Affiliation(s)
| | | | | | - O Iorio
- A. Spaziani Hospital, Frosinone (FR), Italy
| | - A Iossa
- Sapienza University, Rome, Italy
| | - D Caruso
- Sapienza University, Rome, Italy
| | - M Bononi
- Sapienza University, Rome, Italy
| | | | - U Bracale
- Federico II University Hospital, Naples, Italy
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Davey MG, Cleere EF, Lowery AJ, Kerin MJ. Intraoperative recurrent laryngeal nerve monitoring versus visualisation alone - A systematic review and meta-analysis of randomized controlled trials. Am J Surg 2022; 224:836-841. [DOI: 10.1016/j.amjsurg.2022.03.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 03/01/2022] [Accepted: 03/23/2022] [Indexed: 02/08/2023]
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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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Choi HW, Ji YB, Kim E, Kim KN, Tae K. Success rate and learning curve of intraoperative neural monitoring of the external branch of the superior laryngeal nerve in thyroidectomy. Head Neck 2021; 43:3946-3954. [PMID: 34632669 DOI: 10.1002/hed.26895] [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: 05/30/2021] [Revised: 09/14/2021] [Accepted: 09/21/2021] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND This study aimed to evaluate the success rate and learning curve of intraoperative neural monitoring (IONM) of the external branch of the superior laryngeal nerve (EBSLN) in thyroidectomy. METHODS We studied 130 consecutive patients (200 nerves at risk [NARs]) who had undergone conventional thyroidectomy with IONM of the recurrent laryngeal nerve (RLN) and EBSLN from January 2017 to March 2020. The learning curve was defined as the number of NARs required to achieve an effective and reliable neuromonitoring rate. RESULTS IONM of the EBSLN was successful in 136/200 (68%) NARs. The cutoff point of the learning curve was 45 NARs (28 patients). The neural identification rate of EBSLN was significantly higher in the post-learning 155 NARs group than the pre-learning group (82.6% vs. 17.8%, p < 0.001). CONCLUSIONS Approximately 45 NAR neuromonitoring attempts were required to reach a significant increase in the EBSLN identification rate and overcome the learning curve.
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Affiliation(s)
- Hae Won Choi
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Yong Bae Ji
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Eugene Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Kyu Nam Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Kyung Tae
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, Hanyang University, Seoul, Republic of Korea
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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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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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Kong DK, Kong AM, Chai RL. Comparison of a Handheld Device vs Endotracheal Tube-Based Neuromonitoring for Recurrent Laryngeal Nerve Stimulation. Otolaryngol Head Neck Surg 2021; 166:260-266. [PMID: 34030499 DOI: 10.1177/01945998211013753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To measure the effect of thyroidectomy difficulty on intraoperative neuromonitoring false loss of signal (LOS) and to compare intraoperative endotracheal tube-based neuromonitoring (ETNM) and Checkpoint palpation-based direct stimulation (pDS) signals with postoperative laryngoscopy. We hypothesized that pDS has higher a positive predictive value for postdissection confirmation of recurrent laryngeal nerve function than ETNM and that this difference is accentuated with increasing thyroidectomy difficulty. STUDY DESIGN Prospective single-arm cross-sectional study comparing ETNM and pDS for patients undergoing hemi-, total, or completion thyroidectomy from July 2018 to March 2020. SETTING Single-surgeon series at a tertiary care hospital. METHODS Percentage concordance and positive and negative predictive values were measured. Each thyroidectomy was assigned a validated thyroidectomy difficulty score, and recorded recurrent laryngeal nerve signals were compared with postoperative vocal fold mobility. RESULTS Percentage concordance was 90.09%. Positive and negative predictive values were 0.19 (95% CI, 0.09-0.31) and 1.0 for ETNM and 0.59 (95% CI, 0.35-0.82) and 1.0 for pDS. The difference in positive predictive value was significant (0.40 [95% CI, 0.33-0.47], P < .001). False LOS rates for ETNM and pDS were 13.19% versus 3.30% (9.89% [95% CI, 1.80%-18.62%], P = .0155), 44.11% versus 0% (44.11% [95% CI, 25.80%-60.54%], P < .001), and 73.33% versus 13.33% (60% [95% CI, 24.76%-78.46%], P = .001) for the second through fourth thyroidectomy difficulty score quartiles, respectively. False LOS with ETNM was linearly correlated with increasing difficulty (R2 = 0.97). CONCLUSION ETNM was subject to high rates of postdissection false LOS that increased with thyroidectomy difficulty score. pDS is a reliable alternative that has higher positive predictive value than ETNM, particularly in more challenging cases such as those with posteriorly fixed thyroid cancers and fibrotic glands. EVIDENCE LEVEL 2.
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Affiliation(s)
- Derek Kai Kong
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Raymond L Chai
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Influence of rocuronium on achieving optimal vagal stimulation during intraoperative nerve monitoring in thyroid surgery. Asian J Surg 2020; 44:527-530. [PMID: 33262046 DOI: 10.1016/j.asjsur.2020.11.009] [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: 08/13/2020] [Revised: 10/06/2020] [Accepted: 11/18/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND In the present study we determine the feasibility of intraoperative neuromonitoring following the administration of a nondepolarizing neuromuscular blocking agent during thyroid operations, as well as the influence of rocuronium on the achievement of optimal vagal stimulation during intraoperative neuromonitoring in thyroid surgery. We further investigate whether accelerometry is a reliable approach to obtaining an ipsilateral vagus signal prior to recurrent laryngeal nerve dissection. METHODS Included in the study were 61 thyroidectomized patients whose demographic data, indications, type of surgery, vagus, and recurrent nerve values before and after resection were obtained. We created five groups of patients based on the twitch values recorded during ipsilateral vagus stimulation prior to the recurrent laryngeal nerve dissection: (1) <10%, (2) 11-25%, (3) 26-50%, (4) 51-75% and (5) >75%. RESULTS The average electromyography amplitudes of the vagus nerve prior to the determination of the recurrent laryngeal nerve for each group were 552 μV, 463 μV, 543 μV, 513 μV and 551 μV, respectively. No difference between the groups was observed in this regard (p > 0.05). CONCLUSION It can be expected that as soon as the effects of neuromuscular blockers on the peripheral muscles begin to abate, it will be possible to obtain the ipsilateral vagus signal prior to recurrent laryngeal nerve dissection at the desired levels. It can be concluded from this study that accelerometry using the pollicis muscle is an unreliable tool for the interpretation of the proper electromyography signals of the vagus nerve prior to the determination of the recurrent laryngeal nerve.
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Cossa A, Castagnola G, Romeo G, Bellucci M, Nigri G, Bellotti C. Utility of intraoperative neuromonitoring in detecting recurrent nerve's anatomical anomalies during thyroidectomy. Endocrine 2020; 70:194-197. [PMID: 32430794 DOI: 10.1007/s12020-020-02345-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Accepted: 05/07/2020] [Indexed: 10/24/2022]
Abstract
Anatomical variations such as a non-recurrent laryngeal nerve (NRLN) are very rare (reported rates within 0.6-1% to the right side and only four cases to the left side) but they can lead to serious risk of nerve lesion during thyroidectomy. It is known that to prevent inferior laryngeal nerve lesions, it is mandatory to obtain a correct and wide exposure of the nerve during all kind of thyroid surgeries but in case of laryngeal nerve position anomalies, it is hard to achieve a safe nerve identification. Continuous intraoperative neuromonitoring (C-IONM) technology can detect the presence of NRLN. In this study we present seven cases of NRLN incidentally found during our last 10-year experience, in a total of 1074 procedures, including total thyroidectomy and lobectomy. Three out of seven cases were identified with the help of C-IONM. On the other hand, the other four cases of non-recurrent laryngeal nerve were identified during an extensive dissection of the thyroid lodge. We registered no nerve palsy in the group of patients who underwent surgery with the help of C-IONM, while we had two nerve palsies (out of four cases) in the group of patients without the help of C-IONM. In our experience we also registered a reduction of surgery time when we used the C-IONM. In our opinion C-IONM is a safe method to discover anatomical anomalies such as a non-recurrent laryngeal nerve and may help to reduce nerve palsy rate.
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Affiliation(s)
- Alessandra Cossa
- Facolta di Farmacia e Medicina, Universita degli Studi di Roma La Sapienza, Roma, RM, Italy.
| | - Giorgio Castagnola
- Facolta di Farmacia e Medicina, Universita degli Studi di Roma La Sapienza, Roma, RM, Italy
| | - Gherardo Romeo
- Facolta di Farmacia e Medicina, Universita degli Studi di Roma La Sapienza, Roma, RM, Italy
| | - Marco Bellucci
- Facolta di Farmacia e Medicina, Universita degli Studi di Roma La Sapienza, Roma, RM, Italy
| | - Giuseppe Nigri
- Facolta di Farmacia e Medicina, Universita degli Studi di Roma La Sapienza, Roma, RM, Italy
| | - Carlo Bellotti
- Facolta di Farmacia e Medicina, Universita degli Studi di Roma La Sapienza, Roma, RM, Italy
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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: 236] [Impact Index Per Article: 59.0] [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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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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Recurrent laryngeal nerve injury assessment by intraoperative laryngeal ultrasonography: a prospective diagnostic test accuracy study. Wideochir Inne Tech Maloinwazyjne 2018; 14:38-45. [PMID: 30766627 PMCID: PMC6372865 DOI: 10.5114/wiitm.2018.80066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Accepted: 11/08/2018] [Indexed: 12/31/2022] Open
Abstract
Introduction Recurrent laryngeal nerve injury is one of the major complications related to thyroid surgery. Intraoperative recurrent laryngeal nerve functional status monitoring is becoming a standard part of thyroid surgery. However, the current methods for intraoperative nerve functional status assessment are associated with a demand for specialized devices and increased costs. Aim To assess the validity of a new method – intraoperative laryngeal ultrasonography – for prediction of recurrent laryngeal nerve injury. Material and methods This prospective diagnostic test accuracy study included 112 patients undergoing thyroid surgery in Vilnius University Hospital Santaros Clinics. Neurostimulation combined with laryngeal ultrasonography and laryngeal palpation was performed intraoperatively to evaluate recurrent laryngeal nerve functional status. Recurrent laryngeal nerve injury was confirmed by laryngoscopy, which was performed on the first postoperative day and considered to be the gold standard method. Results Data on 112 consecutive patients and 200 nerves at risk were collected. The temporary vocal cord palsy rate was 5.4% per patient and 3% per nerve at risk. No permanent palsy or bilateral injury cases were registered in the study cohort. Laryngeal ultrasound sensitivity counted per nerve at risk was 83.3%, specificity 97.2%, accuracy 96.4%, positive predictive value 62.5% and negative predictive value 99%. Conclusions Laryngeal ultrasonography is a feasible new technique for accurate intraoperative recurrent laryngeal nerve injury evaluation.
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Cheng X, Feng H, Chen L, Jin Z, Shao T, Wang Y, Liang J, Sun H, Yang W, Zhao R, Shen B, Kuang J, Yan J, Qiu W. Intraoperative carbon nanoparticles mapping in secondary total thyroidectomy for recurrent thyroid nodules: Results of a 8-criterion case-match study (case control study). Int J Surg 2018; 60:210-215. [PMID: 30472362 DOI: 10.1016/j.ijsu.2018.11.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Revised: 11/08/2018] [Accepted: 11/14/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND The extent of total thyroidectomy in the management of multinodular goiter remains unclear. Compared to primary thyroidectomy, secondary total thyroidectomy is more difficult to perform and carries a significantly higher risk of postoperative complications such as recurrent laryngeal nerve (RLN) palsy or hypoparathyroidism. In this study, we aimed to evaluate the efficacy and safety of intraoperative carbon nanoparticle (CN) mapping in patients undergoing secondary total thyroidectomy. METHODS We performed a case-matched analysis of a prospectively maintained database using 8 specific criteria to compare perioperative outcomes after primary total thyroidectomy to those after secondary total thyroidectomy with intraoperative CN mapping. The criteria included age, sex, operative procedure, RLN/parathyroid glands (PGs) exploration, preoperative vocal cord calcium abnormalities, and pathological results. Thirty-five patients underwent secondary total thyroidectomy with intraoperative CN mapping due to recurrent thyroid nodules or development of nodules suspicious for malignancy after subtotal thyroidectomy. Fifty exact matches for all 8 criteria were identified from the database in our previous study, which included records of 3078 primary thyroidectomies without CNs. Perioperative outcomes, surgical technique, and complications were analyzed. RESULTS The RLNs were successfully identified in all 35 patients. Among three patients that experienced slight hoarseness, one had an RLN end-to-end anastomosis with subsequent improvement in the during the 12-month follow-up period. Two patients experienced changes in vocal tone, but recovered after several months. Two patients underwent parathyroid auto-transplantations, and subsequently presented with transient hypocalcaemia. Their symptoms gradually remitted within one year. Except for mean operation time, there were no statistically significant differences in complications between the primary total thyroidectomies and the secondary total thyroidectomy with CNs. CONCLUSIONS Intraoperative CN mapping, expert knowledge of the jugular anatomy, and standardized resection procedures can minimize the incidence of complications such as RLN palsy and hypoparathyroidism after secondary total thyroidectomy.
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Affiliation(s)
- Xi Cheng
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China; Department of General Surgery, Ruijin North Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 201801, China
| | - Haoran Feng
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Lingxie Chen
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Zhijian Jin
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Tanglei Shao
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Yue Wang
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Juyong Liang
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Hanxin Sun
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Weiping Yang
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Ren Zhao
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China; Department of General Surgery, Ruijin North Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 201801, China
| | - Baiyong Shen
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Jie Kuang
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.
| | - Jiqi Yan
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.
| | - Weihua Qiu
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.
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A Review of Methods for the Preservation of Laryngeal Nerves During Thyroidectomy. MEDICAL BULLETIN OF SISLI ETFAL HOSPITAL 2018; 52:79-91. [PMID: 32595378 PMCID: PMC7315061 DOI: 10.14744/semb.2018.37928] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 06/11/2018] [Indexed: 11/20/2022]
Abstract
The recurrent laryngeal nerve (RLN) provides motor innervation to the abductor and adductor muscles of the vocal cord, whereas the external branch of the superior laryngeal nerve (EBSLN) provides motor innervation to the cricothyroid muscle, which is the tensor muscle of the vocal cord. Both the RLN and the EBSLN are anatomically close to the thyroid and are therefore at risk of injury during thyroidectomy. These 2 laryngeal nerves must be carefully preserved during surgery to ensure that the function of the vocal cord is not impaired. Currently, complete exposure of the RLN during thyroidectomy is accepted as the gold standard method for the preservation of RLN. Sufficient knowledge of surgical anatomy, clinical experience, and meticulous surgical techniques are key factors in the identification and safe dissection of the RLN. During a thyroidectomy, the RLN can be identified using four different approaches, depending on the type of thyroid growth and choice of the surgeon: There are lateral, inferior, superior, and medial approaches. The lateral approach is the most commonly used technique in primary thyroid surgery. The RLN is usually found by dissection around the inferior thyroid artery at the level of the middle lobe of the thyroid. RLN is generally found at the site of its entry into the neck region devoid of scar formation when the inferior approach is used especially in cases with secondary surgery. The superior approach is recommended for patients with an huge goiter or large substernal goiter. In this approach, the upper pole of the thyroid is first released and then pulled forward and laterally, and the RLN is exposed on the nerve’s entry point (NEP), into the larynx, under the cricopharyngeus muscle. The medial approach is preferred for patients with substernally or retropharyngeally enlarged goiters. In this approach, the isthmus is first dissected and divided, and then the isthmus and the medial part of the lobe are dissected away from the trachea to reveal the anterolateral part of the trachea. The fibers between the lateral aspect of the second or third tracheal rings and the thyroid, and the fibers of the Berry ligament are gradually dissected cranially, to allow RLN to enter into the field of view lateral to the trachea. The preservation of the anatomical integrity of the RLN does not indicate that its functional integrity is also preserved. IONM is a tool for the functional assessment of RLN, and so this method is an addition to visually identifying RLN, which is the gold standard. IONM significantly contributes to visual identification of the RLN, determination of its anatomical variations, intraoperative recognition of RLN injury, prevention of bilateral vocal cord paralysis, and detection and preservation of electrical activity in the nerve in patients with preoperative vocal cord paralysis. Although there is no standardized method for the preservation of the EBSLN, 3 methods have been defined during the release of the upper pole of the thyroid. These methods involve dividing the branches of the superior thyroidal artery one by one on the capsule without visually identifying the EBSLN, searching and visually identifying the EBSLN before the dissection of the upper pole vessels, or detecting the EBSLN and dissecting the upper pole under the guidance of IONM. IONM also significantly contributes to the detection and confirmation of the EBSLN and dissection and preservation of the upper pole of the thyroid gland.
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Wojtczak B, Kaliszewski K, Sutkowski K, Bolanowski M, Barczyński M. A functional assessment of anatomical variants of the recurrent laryngeal nerve during thyroidectomies using neuromonitoring. Endocrine 2018; 59:82-89. [PMID: 29119329 PMCID: PMC5765187 DOI: 10.1007/s12020-017-1466-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 10/26/2017] [Indexed: 11/29/2022]
Abstract
PURPOSE The aim of the study was to assess the usefulness of intraoperative neuromonitoring (IONM) in identifying anatomical variants of the recurrent laryngeal nerve (RLN) during thyroidectomies, with emphasis on the nerve's relationship to the inferior thyroid artery (ITA), Zuckerkandl's tubercle, nonrecurrent laryngeal nerves (NRLNs), and extralaryngeal bifurcation. METHODS A total of 128 subjects undergoing surgery for thyroid disorders were enrolled in the study, and the course and anatomical variants of RLN were assessed with IONM application. RESULTS The standard relationship between RLN and ITA was that the artery and nerve intersect (100%). The right RLN was below the ITA in 76.67% of the patients, and the left RNL was below it in 75.81%. There were no statistically significant differences in the relationship between RLN and ITA on the two sides; and gender did not significantly influence the relationship between the RLN and ITA on either side. In one patient a nonrecurrent inferior laryngeal nerve was present on the right side (0.83%). RLN bifurcation was observed in 33.33% of the patients on the right and in 19.35% on the left side; the difference between sides was statistically significant (p < 0.05). Posterior tubercle (Zuckerkandl's tubercle) was observed on the right in 83% of the subjects and on the left in 69%. The age, thyroid volume and body mass index (BMI) did not influence the size of the tumor. CONCLUSIONS The utilization of IONM of the RLN in thyroid surgery adds a new dimension to the standard of visual nerve identification allowing for functional nerve testing at the most vulnerable area of the dissection: at the level of Berry's ligament, posterior tubercle (Zuckerkandl's tubercle) and crossing of the RLN with the inferior thyroid artery.
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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
| | - Marek Bolanowski
- Department of Endocrinology, Diabetes and Isotope Therapy, 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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Wojtczak B, Sutkowski K, Kaliszewski K, Barczyński M, Bolanowski M. Thyroid reoperation using intraoperative neuromonitoring. Endocrine 2017; 58:458-466. [PMID: 29052179 PMCID: PMC5693961 DOI: 10.1007/s12020-017-1443-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 09/25/2017] [Indexed: 12/03/2022]
Abstract
PURPOSE Thyroid reoperations are at a high risk of recurrent laryngeal nerve (RLN) injury. The aim of the study was to investigate whether the use of intraoperative neuromonitoring (IONM) can aid in the RLN identification and minimize the risk of its injury, in comparison with visual RLN identification. METHODS This was a retrospective cohort study of patients who underwent thyroid reoperations with and without the use of IONM. Primary endpoint was the RLN identification rate; secondary: the prevalence of RLN injury, the frequency of total thyroidectomies, and the course of the RLN. RESULTS The study involved 61 patients undergoing thyroid reoperation among whom 24 were operated on with visual RLN identification only, while 37 procedures used IONM. In the non-monitored reoperations, 44.4% of the RLN were visually identified, as opposed to 91.6% in the IONM group (p < 0.001). Transient paresis occurred in three nerves with visualization (6.6%), and in one in IONM group 1.6% (p = 0.185). Permanent paresis occurred in the group with visualization (6.6%), as opposed to none with neuromonitoring. The extent of resection in both groups was significantly different (p = 0.043). Total, near-total thyroidectomies, Dunhill operations and subtotal thyroidectomies were performed in 71, 17, 4, and 8% in the visualization group, and in 94, 0, 3, and 3%, respectively, in the IONM group. A non-anatomical RLN course was observed in 80% of the reoperations with IONM. CONCLUSIONS Thyroid reoperation should be performed using IONM, because it allows for a significantly improved RLN identification rate and a significantly more radical resection.
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Affiliation(s)
- Beata Wojtczak
- 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
| | - Krzysztof Kaliszewski
- 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
| | - Marek Bolanowski
- Department of Endocrinology, Diabetes and Isotope Therapy, Wroclaw Medical University, Wroclaw, Poland
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Henry BM, Graves MJ, Vikse J, Sanna B, Pękala PA, Walocha JA, Barczyński M, Tomaszewski KA. The current state of intermittent intraoperative neural monitoring for prevention of recurrent laryngeal nerve injury during thyroidectomy: a PRISMA-compliant systematic review of overlapping meta-analyses. Langenbecks Arch Surg 2017; 402:663-673. [PMID: 28378238 DOI: 10.1007/s00423-017-1580-y/figures/2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 03/26/2017] [Indexed: 05/26/2023]
Abstract
PURPOSE Recurrent laryngeal nerve (RLN) injury is one of the most common and detrimental complications following thyroidectomy. Intermittent intraoperative nerve monitoring (I-IONM) has been proposed to reduce prevalence of RLN injury following thyroidectomy and has gained increasing acceptance in recent years. METHODS A comprehensive database search was performed, and data from eligible meta-analyses meeting the inclusion criteria were extracted. Transient, permanent, and overall RLN injuries were the primary outcome measures. Quality assessment via AMSTAR, heterogeneity appraisal, and selection of best evidence was performed via a Jadad algorithm. RESULTS Eight meta-analyses met the inclusion criteria. Meta-analyses included between 6 and 23 original studies each. Via utilization of the Jadad algorithm, the selection of best evidence resulted in choosing of Pisanu et al. (Surg Res 188:152-161, 2014). Five out of eight meta-analyses demonstrated non-significant (p > 0.05) RLN injury reduction with the use of I-IONM versus nerve visualization alone. CONCLUSIONS To date, I-IONM has not achieved a significant level of RLN injury reduction as shown by the meta-analysis conducted by Pisanu et al. (Surg Res 188:152-161, 2014). However, most recent developments of IONM technology including continuous vagal IONM and concept of staged thyroidectomy in case of loss of signal on the first side in order to prevent bilateral RLN injury may provide additional benefits which were out of the scope of this study and need to be assessed in further prospective multicenter trials.
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Affiliation(s)
- Brandon Michael Henry
- International Evidence-Based Anatomy Working Group, 12 Kopernika St, 31-034, Krakow, Poland.
- Department of Anatomy, Jagiellonian University Medical College, 12 Kopernika St, 31-034, Krakow, Poland.
| | - Matthew J Graves
- International Evidence-Based Anatomy Working Group, 12 Kopernika St, 31-034, Krakow, Poland
- Department of Anatomy, Jagiellonian University Medical College, 12 Kopernika St, 31-034, Krakow, Poland
| | - Jens Vikse
- International Evidence-Based Anatomy Working Group, 12 Kopernika St, 31-034, Krakow, Poland
- Department of Anatomy, Jagiellonian University Medical College, 12 Kopernika St, 31-034, Krakow, Poland
- Division of Medicine, Stavanger University Hospital, Gerd-Ragna Bloch Thorsens gate 8, 4011, Stavanger, Norway
| | - Beatrice Sanna
- Faculty of Medicine and Surgery, University of Cagliari, S.S. 554, Bivio Sestu, 09042, Monserrato, CA, Sardinia, Italy
| | - Przemysław A Pękala
- International Evidence-Based Anatomy Working Group, 12 Kopernika St, 31-034, Krakow, Poland
- Department of Anatomy, Jagiellonian University Medical College, 12 Kopernika St, 31-034, Krakow, Poland
| | - Jerzy A Walocha
- International Evidence-Based Anatomy Working Group, 12 Kopernika St, 31-034, Krakow, Poland
- Department of Anatomy, Jagiellonian University Medical College, 12 Kopernika St, 31-034, Krakow, Poland
| | - Marcin Barczyński
- Department of Endocrine Surgery, Third Chair of General Surgery, Jagiellonian University Medical College, 35-37 Pradnicka St, 31-202, Krakow, Poland
| | - Krzysztof A Tomaszewski
- International Evidence-Based Anatomy Working Group, 12 Kopernika St, 31-034, Krakow, Poland
- Department of Anatomy, Jagiellonian University Medical College, 12 Kopernika St, 31-034, Krakow, Poland
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The current state of intermittent intraoperative neural monitoring for prevention of recurrent laryngeal nerve injury during thyroidectomy: a PRISMA-compliant systematic review of overlapping meta-analyses. Langenbecks Arch Surg 2017; 402:663-673. [PMID: 28378238 PMCID: PMC5437188 DOI: 10.1007/s00423-017-1580-y] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 03/26/2017] [Indexed: 12/23/2022]
Abstract
Purpose Recurrent laryngeal nerve (RLN) injury is one of the most common and detrimental complications following thyroidectomy. Intermittent intraoperative nerve monitoring (I-IONM) has been proposed to reduce prevalence of RLN injury following thyroidectomy and has gained increasing acceptance in recent years. Methods A comprehensive database search was performed, and data from eligible meta-analyses meeting the inclusion criteria were extracted. Transient, permanent, and overall RLN injuries were the primary outcome measures. Quality assessment via AMSTAR, heterogeneity appraisal, and selection of best evidence was performed via a Jadad algorithm. Results Eight meta-analyses met the inclusion criteria. Meta-analyses included between 6 and 23 original studies each. Via utilization of the Jadad algorithm, the selection of best evidence resulted in choosing of Pisanu et al. (Surg Res 188:152–161, 2014). Five out of eight meta-analyses demonstrated non-significant (p > 0.05) RLN injury reduction with the use of I-IONM versus nerve visualization alone. Conclusions To date, I-IONM has not achieved a significant level of RLN injury reduction as shown by the meta-analysis conducted by Pisanu et al. (Surg Res 188:152–161, 2014). However, most recent developments of IONM technology including continuous vagal IONM and concept of staged thyroidectomy in case of loss of signal on the first side in order to prevent bilateral RLN injury may provide additional benefits which were out of the scope of this study and need to be assessed in further prospective multicenter trials. Electronic supplementary material The online version of this article (doi:10.1007/s00423-017-1580-y) contains supplementary material, which is available to authorized users.
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Uludag M, Aygun N, Kartal K, Citgez B, Besler E, Yetkin G, Kaya C, Ozsahin H, Mihmanli M, Isgor A. Contribution of intraoperative neural monitoring to preservation of the external branch of the superior laryngeal nerve: a randomized prospective clinical trial. Langenbecks Arch Surg 2016; 402:965-976. [PMID: 28035477 DOI: 10.1007/s00423-016-1544-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 12/16/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the effect of intraoperative neuromonitoring (IONM) on the injury rate of the external branch of the superior laryngeal nerve (EBSLN) during thyroidectomy. METHODS A total of 133 consenting patients (98 female, 35 male; mean age, 45.6 ± 11.7 years) undergoing thyroidectomy were randomly assigned to 2 groups. In group 1 (n = 65 patients, 105 nerves), superior thyroid pole dissection was performed with no attempt to identify the EBSLN; in group 2 (n = 68 patients, 106 nerves), IONM was used to identify the EBSLN during surgery. EBSLN function was evaluated by intraoperative electromyography of the cricothyroid muscle. The EBSLN Voice Impairment Index-5 (VII-5) was conducted preoperatively and at 1, 3, and 6 months postoperatively. The primary outcome was the prevalence of EBSLN injury. The secondary outcomes were the identification rate of the EBSLN using IONM and changes in postoperative voice performance. RESULTS EBSLN injury was detected in eight (12.3%) patients and nine (8.6%) nerves in group 1 and in one (1.5%) patient and one (0.9%) nerve in group 2 (patients, p = 0.015; nerves, p = 0.010). IONM contributed significantly to visual (p < 0.001) and functional (p < 0.001) nerve identification in group 2. The VII-5 indicated more voice changes in group 1 than 2 at 1, 3, and 6 months postoperatively (p = 0.012, p = 0.015, and p = 0.02, respectively). CONCLUSION IONM contributes to visual and functional identification of the EBSLN and decreases the rate of EBSLN injury during superior pole dissection. Routine use of IONM to identify the EBSLN will minimize the risk of injury during thyroidectomy.
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Affiliation(s)
- Mehmet Uludag
- General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey.
| | - Nurcihan Aygun
- General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Kinyas Kartal
- General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Bulent Citgez
- General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Evren Besler
- General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Gurkan Yetkin
- General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Cemal Kaya
- General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Hamdi Ozsahin
- General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Mihmanli
- General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Adnan Isgor
- General Surgery, Bahcesehir University Medical Faculty, Istanbul, Turkey
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Wojtczak B, Barczyński M. Intermittent neural monitoring of the recurrent laryngeal nerve in surgery for recurrent goiter. Gland Surg 2016; 5:481-489. [PMID: 27867862 DOI: 10.21037/gs.2016.09.07] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Reoperative thyroid surgery is still challenging even for skilled surgeons, and is associated with a higher incidence of complications, such as hypoparathyroidism and recurrent laryngeal nerve (RLN) palsy. Displacement of the RLN, scar tissue from previous neck surgery and difficulty in maintaining good hemostasis are risk factors in reoperations. The prevalence of RLN injury in reoperative thyroid surgery ranges as high as 12.5% for transient injury and up to 3.8% for permanent injury. Bilateral paresis can also occur during reoperations, and is a dangerous complication influencing the quality of life, sometimes requiring tracheostomy. RLN identification is the gold standard during thyroidectomy, and the use of intraoperative neuromonitoring (IONM) can be a valuable adjunct to visual identification. This technique can be used to identify the RLN and the external branch of the superior laryngeal nerve (EBSLN), both of which are standardized procedures. The aim of this review was to evaluate the use of intermittent neural monitoring of the RLN in surgery for recurrent goiter, and to assess the prevalence of RLN injury while using IONM reported in the current literature.
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Affiliation(s)
- Beata Wojtczak
- 1st Department and Clinic of General, Gastroenterological and Endocrine Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Marcin Barczyński
- Department of Endocrine Surgery, 3rd Chair of General Surgery, Jagiellonian University Medical College, Krakow, Poland
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