Utility of intraoperative nerve monitoring in thyroid surgery: 20-year experience with 1418 cases

Ultrasound Visualization of the Recurrent Laryngeal Nerve: A Prospective Clinical Validation Study

BACKGROUND

This study aimed to optimize a lateral transthyroid approach by using high-resolution ultrasonography (HRUS) for recurrent laryngeal nerve (RLN) visualization.

PATIENTS AND METHODS

In this prospective study of 85 patients undergoing thyroidectomy, the RLN was visualized preoperatively by using a lateral transthyroid approach via HRUS. The inferior thyroid artery, thyroid nodule, and cricoid cartilage were used as landmarks. RLN visibility was graded from poor to excellent. The accuracy of the preoperative localization of the RLN was determined by intraoperative HRUS, neuromonitoring, and surgical findings.

RESULTS

RLN visualization and localization were verified intraoperatively by ultrasound-guided stimulation via a neuromonitoring probe in eight patients with extended incisions owing to the need for neck dissection. A total of 110 RLNs were present in 85 patients, and the locations of 103 RLNs detected by preoperative ultrasound were confirmed intraoperatively, with an accuracy rate of 93.6%. All detected RLNs were well visualized at the inferior thyroid artery and thyroid nodule levels. The RLN was visible in 83.5% of cases at the cricoid cartilage level. The maximum short-axis diameter and cross-sectional area of the RLN at all three levels were significantly larger in males than in females (p < 0.05). In total, ten RLNs were bifurcated and two showed tumor invasions. These findings were confirmed intraoperatively.

CONCLUSIONS

Effective RLN visualization can be achieved using a lateral transthyroid approach via HRUS. The precise localization, prediction of anatomic variation, and invasion of RLN provide significant advantages in the individualized treatment, surgical planning, and nerve protection of patients with thyroid lesions.

Does the Use of Intraoperative Neuromonitoring during Thyroid and Parathyroid Surgery Reduce the Incidence of Recurrent Laryngeal Nerve Injuries? A Systematic Review and Meta-Analysis

Injury to the recurrent laryngeal nerve (RLN) can be a devastating complication of thyroid and parathyroid surgery. Intraoperative neuromonitoring (IONM) has been proposed as a method to reduce the number of RLN injuries but the data are inconsistent. We performed a meta-analysis to critically assess the data. After applying inclusion and exclusion criteria, 60 studies, including five randomized trials and eight non-randomized prospective trials, were included. A meta-analysis of all studies demonstrated an odds ratio (OR) of 0.66 (95% CI [0.56, 0.79], p < 0.00001) favoring IONM compared to the visual identification of the RLN in limiting permanent RLN injuries. A meta-analysis of studies employing contemporaneous controls and routine postoperative laryngoscopy to diagnose RLN injuries (considered to be the most reliable design) demonstrated an OR of 0.69 (95% CI [0.56, 0.84], p = 0.0003), favoring IONM. Strong consideration should be given to employing IONM when performing thyroid and parathyroid surgery.

OUP accepted manuscript

The substernal goitre is defined as a goitre for which >50% of the mass is located below the superior orifice of the thorax, surgical resection remains the reference treatment, the approach used is the cervicotomy, which often allows to extract the mediastinal portion of the plunging goitre, and we report a rare case of a huge cancerous plunging goitre whose complete resection required the enlargement of the cervicotomy in right hemi-clamshell, for the carcinological, vascular and recurrent control.

Use of intraoperative neural monitoring for prognostication of recovery of vocal mobility and reduction of permanent vocal paralysis after thyroidectomy

INTRODUCTION

The benefits of intraoperative neural monitoring (IONM) of recurrent laryngeal nerve (RLN) on post-thyroidectomy vocal cord palsy (VCP) rates are contentious. We wished to study impact of IONM on permanent VCP after thyroidectomy.

METHODS

Retrospective review of prospective series of 1011 (1539 nerves-at-risk) patients undergoing thyroidectomy without (418, group 1) and with (583, group 2) IONM.

RESULTS

There were three recognized nerve injuries in group 1, vs one in group 2 (P = .3). There were no differences in overall VCP rates. However, patients in group 2 with immediate postoperative VCP had higher likelihood of full recovery than patients in group 1 (55 of 56 vs 23 of 29 patients, P = .01), and lower incidence of total permanent VCP (2 of 917 vs 9 of 647 patients, P = .01).

CONCLUSION

Among patients with immediate postoperative VCP after thyroidectomy, IONM is associated with a higher likelihood of regaining normal vocal function. This may be related to better identification of RLN branching in IONM cases.

Post-thyroidectomy emergency room visits and readmissions: Assessment from the Collaborative Endocrine Surgery Quality Improvement Program (CESQIP)

BACKGROUND

This study analyzed independent factors associated with post-thyroidectomy Emergency Room (ER) visits and Hospital Readmissions (HR).

METHODS

This is a retrospective review from the CESQIP registry of 8381 thyroidectomy patients by 173 surgeons at 46 institutions. A total of 7142 ER visits and 7265 HR were analyzed. Multivariable logistic regression analysis was performed to determine the risk factors for an ER visit or HR.

RESULTS

Within 30-days of surgery, rates of all ER visits were 3.4% (n = 250) and all HR were 2.3% (n = 170). Hypocalcemia was the reason for 21.9% of ER encounters and 36.4% of HR. BMI >40 kg/m² was a risk factor for both ER visit (OR1.86) and HR (OR1.94). Surgical duration >3 h (OR2.63), and transection of recurrent laryngeal nerve (OR4.58) were risk factors for HR.

CONCLUSIONS

Strategies to decrease hypocalcemia and improve perioperative care of patients with BMI >40 kg/m² may improve post-thyroidectomy outcome.