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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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Najah H, Donatini G, Van Slycke S, Bizard JP, Triponez F, Sebag F. Place of laryngoscopy and neuromonitoring in thyroid surgery. Recommendations of the AFCE (Association francophone de chirurgie endocrinienne) with the SFE (Société française d'endocrinologie) and the SFMN (Société française de médecine nucléaire). J Visc Surg 2023:S1878-7886(23)00069-3. [PMID: 37210345 DOI: 10.1016/j.jviscsurg.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Preoperative laryngoscopy is mandatory when there is a history of cervical or thoracic surgery, dysphonia, posteriorly developed thyroid carcinoma, or significant lymph node involvement in the central compartment. Postoperative laryngoscopy should be performed for any postoperative dysphonia, swallowing difficulties, respiratory symptoms, or loss of signal during neuromonitoring of the recurrent and/or vagus nerve. Neuromonitoring can be useful in thyroid surgery because it lowers the rate of transient recurrent palsy (RP), although no impact on permanent RP has been demonstrated. It facilitates location of the recurrent nerve. Continuous neuromonitoring of the vagus nerve can, in some situations, allow early detection of a signal drop during dissection near the recurrent nerve.
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Affiliation(s)
- Haythem Najah
- Department of Digestive and Endocrine Surgery, Haut Lévêque Hospital, University Hospital Center of Bordeaux, Bordeaux France.
| | - Gianluca Donatini
- Digestive and endocrine surgery department, University Hospital Center of Poitiers, Poitiers, France
| | - Sam Van Slycke
- Digestive and endocrine surgery department, OLV Alost, Alost, Belgium
| | | | - Frédéric Triponez
- Department of Thoracic and Endocrine Surgery, University Hospital of Genève and Faculty of Medicine, Genève, Switzerland
| | - Frédéric Sebag
- General and Endocrine Surgery Department, University Hospital of Marseille Conception, Marseille, France
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Intraoperative Neuromonitoring and Optical Magnification in the Prevention of Recurrent Laryngeal Nerve Injuries during Total Thyroidectomy. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58111560. [PMID: 36363517 PMCID: PMC9692813 DOI: 10.3390/medicina58111560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 10/18/2022] [Accepted: 10/26/2022] [Indexed: 11/07/2022]
Abstract
Background and Objectives: Recurrent laryngeal nerve (RLN) paralysis is a fearful complication during thyroidectomy. Intraoperative neuromonitoring (IONM) and optical magnification (OM) facilitate RLN identification and dissection. The purpose of our study was to evaluate the influence of the two techniques on the incidence of RLN paralysis and determine correlations regarding common outcomes in thyroid surgery. Materials and Methods: Two equally sized groups of 50 patients who underwent total thyroidectomies were examined. In the first group (OM), only surgical binocular loupes (2.5×−4.5×) were used during surgery, while in the second group (IONM), the intermittent NIM was applied. Results: Both the operative time and the length of hospitalization were shorter in the OM group than in the IONM group (median 80 versus 100 min and median 2 versus 4 days, respectively) (p < 0.05). The male patients were found to have a five-fold higher risk of developing transient dysphonia than the females (adjusted OR 5.19, 95% IC 0.99−27.18, p = 0.05). The OM group reported a four-fold higher risk of developing transient hypocalcemia than the IONM group (OR 3.78, adjusted OR 4.11, p = 0.01). Despite two cases of temporary bilateral RLN paralysis in the IONM group versus none in the OM group, no statistically significant difference was found (p > 0.05). No permanent RLN paralysis or hypoparathyroidism have been reported. Conclusions: Despite some limitations, our study is the first to compare the use of IONM with OM alone in the prevention of RLN injuries. The risk of recurrent complications remains comparable and both techniques can be considered valid instruments, especially if applied simultaneously by surgeons.
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Optimization of Intraoperative Neural Monitoring of the Recurrent Laryngeal Nerve in Thyroid Surgery. Medicina (B Aires) 2022; 58:medicina58040495. [PMID: 35454334 PMCID: PMC9028259 DOI: 10.3390/medicina58040495] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/18/2022] [Accepted: 03/25/2022] [Indexed: 11/17/2022] Open
Abstract
The application of intraoperative neural monitoring (IONM) has been widely accepted to improve surgical outcomes after thyroid surgery. The malfunction of an IONM system might interfere with surgical procedures. Thus, the development of anesthesia modalities aimed at ensuring functional neuromonitoring is essential. Two key issues should be taken into consideration for anesthetic management. Firstly, most patients undergo recurrent laryngeal nerve monitoring via surface electrodes embedded in an endotracheal tube. Thus, advanced video-assisted devices might optimize surface electrode positioning for improved neuromonitoring signaling accuracy. Secondly, neuromuscular blocking agents are routinely used during thyroid surgery. The ideal neuromuscular block should be deep enough for surgical relaxation at excision and recovered enough for an adequate signal f nerve stimulation. Proper neuromuscular block management could be achieved by titration doses of muscle relaxants and reversal agents.
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Çomçalı B, Saylam B, Özdemir BA. The effect of intraoperative neuromonitoring on the number of lymph nodes excised and recurrence when applied during neck dissection in cases of papillary thyroid cancer. Ann Surg Treat Res 2022; 102:83-89. [PMID: 35198511 PMCID: PMC8831088 DOI: 10.4174/astr.2022.102.2.83] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 11/11/2021] [Accepted: 12/03/2021] [Indexed: 11/30/2022] Open
Abstract
Purpose The aim of this study was to evaluate the effect of neuromonitoring on the number of lymph nodes (LNs) removed when applied during neck dissection. Methods A total of 166 patients receiving neck dissection due to papillary thyroid cancer were separated into 2 groups (monitoring group, n = 76; non-monitoring group, n = 90). Results The number of LNs dissected was observed to be statistically significantly higher in the monitoring group (P = 0.001), and the difference between the groups in the number of positive LNs was significant (P = 0.031). There was seen to be a negative relationship between the number of positive LNs dissected and recurrence (r = –0.404, P = 0.005). Conclusion Intraoperative neuromonitoring during neck dissection makes a positive contribution to the prevention of the development of recurrence by increasing the number of LNs excised and the number of metastatic LNs.
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Affiliation(s)
- Bülent Çomçalı
- Department of General Surgery, Ankara City Hospital, Ankara, Turkey
| | - Barış Saylam
- Department of General Surgery, Ankara City Hospital, Ankara, Turkey
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Wu CW, Randolph GW, Barczyński M, Schneider R, Chiang FY, Huang TY, Karcioglu AS, Konturek A, Frattini F, Weber F, Liu CH, Dralle H, Dionigi G. Training Courses in Laryngeal Nerve Monitoring in Thyroid and Parathyroid Surgery- The INMSG Consensus Statement. Front Endocrinol (Lausanne) 2021; 12:705346. [PMID: 34220726 PMCID: PMC8253252 DOI: 10.3389/fendo.2021.705346] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 05/26/2021] [Indexed: 01/04/2023] Open
Abstract
Intraoperative neural monitoring (IONM) is now an integral aspect of thyroid surgery in many centers. Interest in IONM and the number of institutions that perform monitored thyroidectomies have increased throughout the world in recent years. For surgeons considering the introduction of IONM in their practice, specific training in IONM devices and procedures can substantially shorten the learning curve. The International Neural Monitoring Study Group (INMSG) has been at the forefront of IONM technology and procedural adoption since the introduction of neural monitoring in thyroid and parathyroid surgery. The purpose of this document is to define the INMSG consensus on essential elements of IONM training courses. Specifically, this document describes the minimum training required for teaching practical application of IONM and consensus views on key issues that must be addressed for the safe and reliable introduction of IONM in surgical practice. The intent of this publication is to provide societies, course directors, teaching institutions, and national organizations with a practical reference for developing IONM training programs. With these guidelines, IONM will be implemented optimally, to the ultimate benefit of the thyroid and parathyroid surgical patients.
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Affiliation(s)
- Che-Wei Wu
- International Thyroid Surgery Center, Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Center for Liquid Biopsy and Cohort Research, and Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Gregory W. Randolph
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, MA, United States
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Marcin Barczyński
- Department of Endocrine Surgery, Third Chair of General Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Rick Schneider
- Department of Surgery, University Hospital Halle, Martin-Luther-University, Halle-Wittenberg, Germany
| | - Feng-Yu Chiang
- Department of Otolaryngology, E-Da Hospital, School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Tzu-Yen Huang
- International Thyroid Surgery Center, Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Center for Liquid Biopsy and Cohort Research, and Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Amanda Silver Karcioglu
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, NorthShore University HealthSystem, Evanston, IL, United States
| | - Aleksander Konturek
- Department of Endocrine Surgery, Third Chair of General Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Francesco Frattini
- Department of Surgery, Ospedale di Circolo, ASST Settelaghi, Varese, Italy
| | - Frank Weber
- Department of General, Visceral and Transplantation Surgery, University of Duisburg-Essen, Essen, Germany
| | - Cheng-Hsin Liu
- International Thyroid Surgery Center, Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Henning Dralle
- Department of General, Visceral and Transplantation Surgery, University of Duisburg-Essen, Essen, Germany
| | - Gianlorenzo Dionigi
- Department of Human Pathology in Adulthood and Childhood “G. Barresi”, University Hospital G. Martino, University of Messina, Messina, Italy
- *Correspondence: Gianlorenzo Dionigi,
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Wu CW, Huang TY, Randolph GW, Barczyński M, Schneider R, Chiang FY, Silver Karcioglu A, Wojtczak B, Frattini F, Gualniera P, Sun H, Weber F, Angelos P, Dralle H, Dionigi G. Informed Consent for Intraoperative Neural Monitoring in Thyroid and Parathyroid Surgery - Consensus Statement of the International Neural Monitoring Study Group. Front Endocrinol (Lausanne) 2021; 12:795281. [PMID: 34950109 PMCID: PMC8689131 DOI: 10.3389/fendo.2021.795281] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 11/08/2021] [Indexed: 11/13/2022] Open
Abstract
In the past decade, the use of intraoperative neural monitoring (IONM) in thyroid and parathyroid surgery has been widely accepted by surgeons as a useful technology for improving laryngeal nerve identification and voice outcomes, facilitating neurophysiological research, educating and training surgeons, and reducing surgical complications and malpractice litigation. Informing patients about IONM is not only good practice and helpful in promoting the efficient use of IONM resources but is indispensable for effective shared decision making between the patient and surgeon. The International Neural Monitoring Study Group (INMSG) feels complete discussion of IONM in the preoperative planning and patient consent process is important in all patients undergoing thyroid and parathyroid surgery. The purpose of this publication is to evaluate the impact of IONM on the informed consent process before thyroid and parathyroid surgery and to review the current INMSG consensus on evidence-based consent. The objective of this consensus statement, which outlines general and specific considerations as well as recommended criteria for informed consent for the use of IONM, is to assist surgeons and patients in the processes of informed consent and shared decision making before thyroid and parathyroid surgery.
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Affiliation(s)
- Che-Wei Wu
- Department of Otorhinolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Center for Liquid Biopsy and Cohort Research, and Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Tzu-Yen Huang
- Department of Otorhinolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Gregory W. Randolph
- Department of Otolaryngology, Harvard Medical School, Boston, MA, United States
| | - Marcin Barczyński
- Department of Endocrine Surgery, Third Chair of General Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Rick Schneider
- Department of Visceral, Vascular and Endocrine Surgery, University Hospital Halle, Martin-Luther-University, Halle-Wittenberg, Germany
| | - Feng-Yu Chiang
- Department of Otolaryngology, E-Da Hospital, School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | | | - Beata Wojtczak
- Department of General, Minimally Invasive and Endocrine Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Francesco Frattini
- Department of Surgery, Ospedale di Circolo, ASST, Settelaghi, Varese, Italy
| | - Patrizia Gualniera
- Forensics Division, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Hui Sun
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Frank Weber
- Department of General, Visceral and Transplantation Surgery, University of Duisburg-Essen, Essen, Germany
| | - Peter Angelos
- Department of Surgery and MacLean Center for Clinical Medical Ethics, The University of Chicago, Chicago, IL, United States
| | - Henning Dralle
- Department of General, Visceral and Transplantation Surgery, University of Duisburg-Essen, Essen, Germany
| | - Gianlorenzo Dionigi
- Division of Surgery, Istituto Auxologico Italiano IRCCS, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- *Correspondence: Gianlorenzo Dionigi,
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Pliakos I, Papavramidis TS. Do surgeons really know how to perform neuromonitoring in thyroid surgery? An awareness study. Gland Surg 2021; 10:201-206. [PMID: 33633976 DOI: 10.21037/gs-20-579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The aim of this questionnaire-based observational study is to examine the awareness of endocrine surgeons regarding the use of intraoperative neuromonitoring (IONM) techniques in thyroid surgeries. Methods A survey project based on a structured questionnaire was conducted during the 14th Spring Meeting of the Greek Society of Endocrine Surgeons (GSES). The questionnaire consisted of 14 items and was handed to all participants-by the key speaker-during the neuromonitoring session. Results In the 14th spring meeting of GSES there were 205 delegates present. Among them there were 35 residents and 6 medical students. The surgeons being potential responders were 119. In the session of IONM, there were 83 eligible surgeons present and the questionnaire was answered voluntarily by 59 of them (71.08%). The responders' group consisted of 26 members of the GSES and 33 non-members. Conclusions Most of the participants believed that there are many benefits in the use of IONM such as anatomically identifying the branches of the laryngeal nerve, monitoring their functionality or offering to patients' greater confidence to the surgery. Attention should be paid not to abandon the conventional techniques for identifying the laryngeal nerve, as IONM may not always be available. Evidence is needed to establish the proper indications for its application.
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Affiliation(s)
- Ioannis Pliakos
- 1 Propedeutic Department of Surgery, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Theodosios S Papavramidis
- 1 Propedeutic Department of Surgery, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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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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Lu IC, Wu SH, Wu CW. Neuromuscular blockade management for intraoperative neural monitoring. Kaohsiung J Med Sci 2019; 36:230-235. [PMID: 31713975 DOI: 10.1002/kjm2.12153] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Accepted: 10/17/2019] [Indexed: 12/17/2022] Open
Abstract
This article reviews the literature on development of neuromuscular blockade management in thyroid surgery with intraoperative neural monitoring (IONM) in the past decade. Neuromuscular blockade management includes the choice of neuromuscular blocking agents (NMBAs) and reversal of neuromuscular blockade by sugammadex. A series of animal study and clinical trials showed NMBAs effect on IONM in thyroid surgery. We summarized five NMBA regimens for IONM: (a) relaxant-free regimen, (b) depolarizing NMBA-succinylcholine, (c) titration of nondepolarizing NMBA, and (d) rocuronium combined with sugammadex. The proper management of neuromuscular blockade during IONM has greatly developed over the past decade. The misuse of NMBAs is associated with false IONM interpretations to surgeons. A detailed understanding of NMBAs and neuromuscular blockade management by sugammadex may optimize IONM quality in patients receiving monitored thyroid surgery.
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Affiliation(s)
- I-Cheng Lu
- Department of Anesthesiology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Anesthesiology, Kaohsiung Municipal Siaogang Hospital, Kaohsiung, Taiwan
| | - Sheng-Hua Wu
- Department of Anesthesiology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Anesthesiology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan
| | - Che-Wei Wu
- Department of Otorhinolaryngology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Otorhinolaryngology-Head and Neck Surgery, Kaohsiung Municipal Siaogang Hospital, Kaohsiung, Taiwan
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Leong DCW, Lo J, Ryan S, Nguyen H, Lisewski D. Intraoperative nerve monitoring in endocrine surgery: prevalence and reasons for its use in Australia and New Zealand. ANZ J Surg 2019; 90:867-871. [PMID: 31668000 DOI: 10.1111/ans.15536] [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: 04/15/2019] [Revised: 09/20/2019] [Accepted: 09/27/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Intraoperative nerve monitoring (IONM) has increasingly been used in thyroid surgery by general, endocrine and head and neck surgeons. The purpose of this paper was to explore the prevalence and reasons for the usage of IONM in endocrine surgery in Australia and New Zealand. METHODS A survey was sent to general surgeons registered with the Royal Australasian College of Surgeons involved in endocrine surgery and members of the Australian and New Zealand Endocrine Surgeons. Users were divided into surgeon type, area of work, hospital type and volume of surgery. These data were analysed with univariate and multivariate logistic regression models. RESULTS Significant differences in IONM usage levels were observed between endocrine and general surgeons, area of work and volume of surgery performed. Endocrine surgeons are significantly more likely to use IONM than general surgeons. Surgeons who work in tertiary hospitals are more likely to use IONM as compared to those working in district hospitals. Surgeons who perform less than 100 thyroidectomies were more likely to be users of IONM. CONCLUSION IONM is not routinely used in thyroid surgery in Australia and New Zealand. The main reasons for the use of IONM given in our study by routine users were to establish familiarity of equipment and medicolegal reasons. Selective users chose as the most common reasons, a documented pre-existing unilateral nerve paresis or a hostile surgical field. Non-users stated that there was conflicting evidence that it improves outcomes and increased costs.
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Affiliation(s)
- David Chee Weng Leong
- Department of Endocrine Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Johnny Lo
- Research School of Science, Edith Cowan University, Perth, Western Australia, Australia
| | - Simon Ryan
- Department of Endocrine Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Hieu Nguyen
- Department of Endocrine Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Dean Lisewski
- Department of Endocrine Surgery, Fiona Stanley Hospital, Perth, Western Australia, Australia
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Feng AL, Puram SV, Singer MC, Modi R, Kamani D, Randolph GW. Increased prevalence of neural monitoring during thyroidectomy: Global surgical survey. Laryngoscope 2019; 130:1097-1104. [PMID: 31361342 DOI: 10.1002/lary.28210] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 05/17/2019] [Accepted: 07/10/2019] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To investigate intraoperative nerve monitoring (IONM) use among thyroid surgeons. METHODS A 25-question survey was used to assess attitudes regarding IONM use. Surveys were sent to surgeons registered to the American Academy of Otolaryngology-Head and Neck Surgery, International Association of Endocrine Surgeons, and American Head and Neck Society. RESULTS Among 1,015 respondents, 83% reported using IONM (65.1% always using IONM and 18.1% reporting selective use). For selective users, a majority reported using IONM for reoperative cases (95.1%) and in cases with preoperative vocal cord paralysis (59.8%). When comparing location, there was a significant difference in IONM implementation (P < 0.001), with 70.4% of North American responders using it ubiquitously compared to 27.4% of non-North American responders. Preoperative laryngeal exam was performed more universally by North American surgeons and more selectively by non-North American surgeons (P < 0.001). Other attitudes toward their implementation and the postoperative laryngeal exam were similar. Surgeons ≤45 years of age and those with ≤15 years of practice used IONM more than their peers (P < 0.001). Thyroid surgery volume, fellowship training, and type of practice had no bearing on IONM use. CONCLUSION The prevalence of IONM in thyroid and parathyroid surgeries has increased significantly over the past decade, with 83% of surgeons using IONM in some or all cases. Although IONM use may be more ubiquitous in North America, attitudes toward its implementation and pre- and postoperative laryngeal exams are fairly uniform. IONM use is more prevalent among younger surgeons, whereas its use has no correlation with thyroid surgery volume or type of practice. LEVEL OF EVIDENCE 4 Laryngoscope, 130:1097-1104, 2020.
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Affiliation(s)
- Allen L Feng
- Department of Otolaryngology, Massachusetts Eye and Ear, Harvard Medical School Boston, Massachusetts, U.S.A
| | - Sidharth V Puram
- Department of Otolaryngology, Massachusetts Eye and Ear, Harvard Medical School Boston, Massachusetts, U.S.A
| | - Michael C Singer
- Division of Thyroid and Parathyroid Surgery, Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health System, Detroit, Michigan, U.S.A
| | - Rahul Modi
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology, Massachusetts Eye and Ear, Harvard Medical School Boston, Massachusetts, U.S.A
| | - Dipti Kamani
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology, Massachusetts Eye and Ear, Harvard Medical School Boston, Massachusetts, U.S.A
| | - Gregory W Randolph
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology, Massachusetts Eye and Ear, Harvard Medical School Boston, Massachusetts, U.S.A.,Division of Surgical Oncology, Department of Surgery, Massachusetts General Hospital, Harvard Medical School Boston, Massachusetts, U.S.A
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Chen Y, Huang L, Li Y, Tong L, Wang X, Hu K, Feng Z. [Sequential method for determining the maximum dose of mivacurium continuously infused for intraoperative neuromonitoring in thyroid surgery]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2018; 38:1472-1475. [PMID: 30613016 DOI: 10.12122/j.issn.1673-4254.2018.12.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To determine the maximum dose of continuously infused mivacurium for intraoperative neuromonitoring and observe its adverse effects in thyroid surgery. METHODS Twenty-eight patients undergoing thyroid surgery with intraoperative neuromonitoring received continuous infusion of mivacurium at the initial rate of 5.43 μg?kg-1?min-1, and the infusion rate for the next patient was adjusted based on the response of the previous patient according to the results of neurological monitoring. The depth of anesthesia was maintained with sevoflurane and remifentanil during the surgery. The LD50 and 95% CI of mivacurium were calculated using Brownlee's up-and-down sequential method. RESULTS The LD50 of continuously infused mivacurium was 8.94 μg?kg-1?min-1 (95% CI: 8.89- 8.99 μg?kg-1?min-1) during thyroid surgery, which did not affect neurological function monitoring. Transient chest skin redness occurred after induction in 9 patients (32.1%). None of the patients experienced intubation difficulties or showed intraoperative body motions during the surgery. CONCLUSIONS In patients undergoing thyroid surgery under anesthesia maintained by inhalation and intravenous infusion, the LD50 of mivacurium was 8.94 μg?kg-1?min-1 (95% CI: 8.89-8.99 μg?kg-1?min-1) for continuous infusion, which does not cause serious adverse effects during the operation.
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Affiliation(s)
- Yongjie Chen
- Anesthesia and Operation Center, General Hospital of PLA, Beijing 100853, China
| | - Lianjun Huang
- Anesthesia and Operation Center, General Hospital of PLA, Beijing 100853, China
| | - Yang Li
- Anesthesia and Operation Center, General Hospital of PLA, Beijing 100853, China
| | - Li Tong
- Anesthesia and Operation Center, General Hospital of PLA, Beijing 100853, China
| | - Xiaochen Wang
- Anesthesia and Operation Center, General Hospital of PLA, Beijing 100853, China
| | - Keshi Hu
- Anesthesia and Operation Center, General Hospital of PLA, Beijing 100853, China
| | - Zeguo Feng
- Anesthesia and Operation Center, General Hospital of PLA, Beijing 100853, China
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Wu CW, Sun H, Zhang G, Kim HY, Catalfamo A, Portinari M, Carcoforo P, Randolph GW, Chai YJ, Dionigi G. Staged Thyroidectomy: A Single Institution Perspective. Laryngoscope Investig Otolaryngol 2018; 3:326-332. [PMID: 30186966 DOI: 10.1002/lio2.171] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Revised: 04/11/2018] [Accepted: 04/30/2018] [Indexed: 11/10/2022] Open
Abstract
Background The increasing use of intraoperative neuromonitoring (IONM) in thyroid surgery has revealed the need to develop new strategies for cases in which a loss of signal (LOS) occurs on the first side of a planned total thyroidectomy. Objectives This study reviews the experience of the authors in using IONM for planned total thyroidectomy after LOS on the first thyroid lobe. The aims were to estimate the incidence of LOS on the first side of resection and to compare intraoperative strategies applied after this event. Materials and Methods Intermittent IONM was performed with stimulation of both the vagal nerve and the recurrent laryngeal nerve (RLN) (V1, R1, R2, V2). Patients underwent pre- and postoperative laryngoscopy. Before surgery, patients were informed that staged thyroidectomy might be required. Results This study analyzed 803 consecutive thyroid procedures. Of these, V2 LOS (<100 mcV) occurred after first lobe exeresis in 23 (2.8%) procedures. The surgical procedure was stopped in 20 cases (ie, staged thyroidectomy was performed). In three cases with malignancy and severe comorbidity (ASA score 3-4), total bilateral thyroidectomy was performed as planned. No cases of bilateral RLN palsy occurred. Postoperative laryngoscopy confirmed RLN palsy in 21 of the 23 cases. All true positive patients received speech therapy. Patients who had false positive LOS (n = 2) or malignancy (n = 8) and patients who were symptomatic (n = 7) received completion thyroidectomy within 6 months. One patient received radioactive iodine therapy for hyperthyroidism. Two patients received follow up. Conclusions Neuromonitoring changes the surgical decision-making process in a multidisciplinary manner. A shared decision-making process involving the patient, anesthesiologist, and endocrinologist is suggested. In the case of intraoperative LOS on the first-operated side in a planned total thyroidectomy, the thyroid surgeon essentially has three options for surgery on the contralateral side: 1) Perform staged thyroidectomy. This option is recommended in bilateral goiter, Graves' disease, or low-risk thyroid carcinoma (differentiated or medullary thyroid carcinoma). The aim is to avoid bilateral vocal cord palsy. Two-stage completion surgery is delayed until recovery of ipsilateral nerve function. 2) Perform subtotal resection on the contralateral side ventrally to the RLN plane at a safe distance from the nerve. The aim is to avoid further disease recurrence and revision surgery. 3) Perform total thyroidectomy as planned for advanced thyroid carcinoma (including undifferentiated thyroid carcinoma). The aim is to improve disease control through radioactive iodine therapy, radiation therapy, or target therapy immediately after surgery. Level of Evidence 4.
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Affiliation(s)
- Che-Wei Wu
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Municipal Hsiao-Kang Hospital Kaohsiung Medical University Kaohsiung Taiwan.,the College of Medicine Kaohsiung Medical University Kaohsiung Taiwan
| | - Hui Sun
- the Jilin Provincial Key Laboratory of Surgical Translational Medicine China Japan Union Hospital of Jilin University, Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine Changchun Jilin China
| | - Guang Zhang
- the Jilin Provincial Key Laboratory of Surgical Translational Medicine China Japan Union Hospital of Jilin University, Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine Changchun Jilin China
| | - Hoon Yub Kim
- the KUMC Thyroid Center Korea University Anam Hospital Seoul South Korea
| | - Antonina Catalfamo
- the Division for Endocrine Surgery, Department of Human Pathology in Adulthood and Childhood "G. Barresi" University Hospital G. Martino, University of Messina Messina Italy
| | - Mattia Portinari
- the Department of Surgery S. Anna University Hospital Ferrara Italy.,the Department of Morphology, Surgery, and Experimental Medicine University of Ferrara Ferrara Italy
| | - Paolo Carcoforo
- the Department of Surgery S. Anna University Hospital Ferrara Italy.,the Department of Morphology, Surgery, and Experimental Medicine University of Ferrara Ferrara Italy
| | - Gregory W Randolph
- the Department of Otolaryngology-Head and Neck Surgery Harvard Medical School Boston Massachusetts U.S.A.,the Division of Thyroid and Parathyroid Endocrine Surgery Massachusetts Eye and Ear Infirmary Boston Massachusetts U.S.A.,the Division of Surgical Oncology, Department of Surgery Massachusetts General Hospital Boston Massachusetts U.S.A
| | - Young Jun Chai
- Department of Surgery Seoul National University Seoul Metropolitan Government Boramae Medical Center Dongjak-gu Seoul South Korea
| | - Gianlorenzo Dionigi
- the Division for Endocrine Surgery, Department of Human Pathology in Adulthood and Childhood "G. Barresi" University Hospital G. Martino, University of Messina Messina Italy
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Isik A, Firat D, Yilmaz I, Peker K, Idiz O, Yilmaz B, Demiryilmaz I, Celebi F. A survey of current approaches to thyroid nodules and thyroid operations. Int J Surg 2018; 54:100-104. [PMID: 29709542 DOI: 10.1016/j.ijsu.2018.04.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Accepted: 04/19/2018] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Thyroid nodules are commonly seen. Our aim is to learn the behaviors and operational attitudes of surgeons approaching the thyroid nodules. In a literature search, our study is the first and only study performed merely on surgeons. MATERIALS- METODS This cross-sectional study was done between June 2014-January 2015. The questionnaire consists of 25 questions. Initially, general questions consisting of demographic findings were asked. In step 2, questions consisting of the index case and case variants were asked. Results were compared with American Thyroid Association, European Thyroid Association guidelines, and Australia survey results. In the last step, questions about thyroid operations were asked. RESULTS A total of 301 surgeons responded to the survey. The response rate was approximately 20%. Thirty nine were female and 262 were male. For the question that asks the diameter of the thyroid nodule that will require a thyroid fine needle aspiration biopsy (TFNAB), 47.5% of the surgeons will require a TFNAB for 1-2 cm solid nodules. 40.15% of the surgeons required a TFNAB regardless of size. 46.1% of the surgeons who required a TFNAB between 1 and 2 cm solid nodules also required scintigraphy at diagnosis of suppressed TSH case variant. CONCLUSION In this survey, we identified differences from up-to-date guidelines about approaching thyroid nodules and perioperative thyroid surgery. From our perspective, surgeons need updated training requirements. This can be done with updated seminars across the country. Thereby approaches may become standard and consequently patients may have qualified services.
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Affiliation(s)
- Arda Isik
- Magee Womens Hospital of UPMC, Breast Surgery Clinic, Pittsburgh, USA.
| | - Deniz Firat
- Erzincan University, Faculty of Medicine, General Surgery Clinic, Erzincan, Turkey
| | - Ismayil Yilmaz
- Erzincan University, Faculty of Medicine, General Surgery Clinic, Erzincan, Turkey
| | - Kemal Peker
- Erzincan University, Faculty of Medicine, General Surgery Clinic, Erzincan, Turkey
| | - Oguz Idiz
- Istanbul Teaching and Research Hospital, General Surgery Clinic, Istanbul, Turkey
| | - Bahri Yilmaz
- Duzce Ataturk State Hospital, General Surgery Clinic, Duzce, Turkey
| | - Ismail Demiryilmaz
- Erzincan University, Faculty of Medicine, General Surgery Clinic, Erzincan, Turkey
| | - Fehmi Celebi
- Erzincan University, Faculty of Medicine, General Surgery Clinic, Erzincan, Turkey
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Wojtczak B, Kaliszewski K, Sutkowski K, Głód M, Barczyński M. Evaluating the introduction of intraoperative neuromonitoring of the recurrent laryngeal nerve in thyroid and parathyroid surgery. Arch Med Sci 2018; 14:321-328. [PMID: 29593805 PMCID: PMC5868670 DOI: 10.5114/aoms.2016.63003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 12/07/2015] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Paresis of the recurrent laryngeal nerve (RLN) is a complication of thyroid surgery. Neuromonitoring as is gaining acceptance among surgeons. The aim of the study was to assess the number of technical problems in the initial phase of intraoperative neuromonitoring (IONM) use and the specificity, sensitivity, positive predictive value and negative predictive value of neuromonitoring. The number of cases of postoperative paresis (transient and permanent) was assessed. MATERIAL AND METHODS The prospective analysis included 101 thyroid operations with IONM (190 RLNs at risk of injury) in the period from January to April, 2012. Demographic data, rate of RLN identification, sensitivity, specificity and predictive value of the method, the duration of the procedurę and the percentage of RLN paresis were considered. RESULTS The RLN was identified in 92% of the cases. Technical problems were observed in 12.98%, of which 61% were due to incorrect positioning of the endotracheal tube electrodes in relation to the vocal cords. The sensitivity, specificity, negative and positive predictive value and the accuracy of the method were respectively 71%, 98%, 62.5%, 98.9% and 97%. Early nerve injury occurred in 3.7% of the cases; 2.6% were temporary paresis and 1.1% permanent. CONCLUSIONS During the initial stages of implementing IONM we experienced technical problems that required correction in every tenth patient. The positive predictive value was relatively low; nevertheless, good results in terms of the rate of accurate identification of the RLN as well as the low rate of RLN paresis support the use of this method.
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Affiliation(s)
- Beata Wojtczak
- Department and Clinic of General, Gastroenterological and Endocrine Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Krzysztof Kaliszewski
- Department and Clinic of General, Gastroenterological and Endocrine Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Krzysztof Sutkowski
- Department and Clinic of General, Gastroenterological and Endocrine Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Mateusz Głód
- Department and Clinic of General, Gastroenterological and Endocrine Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Marcin Barczyński
- Department of Endocrine Surgery, Third Chair of General Surgery, Jagiellonian University Medical College, Krakow, Poland
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Hvilsom GB, Londero SC, Hahn CH, Schytte S, Pedersen HB, Christiansen P, Kiss K, Larsen SR, Jespersen ML, Lelkaitis G, Godballe C. Anaplastic thyroid carcinoma in Denmark 1996-2012: A national prospective study of 219 patients. Cancer Epidemiol 2018; 53:65-71. [PMID: 29414634 DOI: 10.1016/j.canep.2018.01.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 01/17/2018] [Accepted: 01/18/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Anaplastic thyroid carcinoma (ATC) is the least common but most malignant thyroid cancer. We aimed to examine the characteristics as well as evaluate the incidence, prognostic factors, and if introduction of a fast track cancer program might influence survival in a cohort of ATC patients. METHODS A cohort study based on prospective data from the national Danish thyroid cancer database DATHYRCA and the national Danish Pathology Register including 219 patients diagnosed from 1996 to 2012, whom were followed until death or through September 2014. RESULTS We found the median age in the 7th decade, the majority of patients being women presenting with a growing mass at the neck, diagnosed with stage T4b disease. At diagnosis, 56% of the patients had lymph node metastasis and 38% distant metastasis. We observed one- and five-year survival of 20.7% and 11.0%, respectively. Both univariate and multivariate analyses showed age (above 73.6 years), respiratory impairment, T4b stage, and distant metastasis at diagnosis to be significant prognostic factors. Further, introduction of a national fast track cancer program increased survival nearly two-fold. CONCLUSION As new information, our study adds "respiratory impairment at diagnosis" and "introduction of a national fast track cancer program" to the list of already established prognostic indicators for ATC.
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Affiliation(s)
- Gitte Bjørn Hvilsom
- Odense University Hospital, Department of ENT, Head & Neck Surgery, Sdr Boulevard 29, 5000 Odense C, Denmark.
| | - Stefano Christian Londero
- Odense University Hospital, Department of ENT, Head & Neck Surgery, Sdr Boulevard 29, 5000 Odense C, Denmark; Aarhus University Hospital, Department of ENT Head & Neck Surgery, Nørrebrogade 44, 8000 Aarhus C, Denmark.
| | - Christoffer Holst Hahn
- Copenhagen University Hospital, Rigshospitalet, Department of ENT Head & Neck Surgery, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark.
| | - Sten Schytte
- Aarhus University Hospital, Department of ENT Head & Neck Surgery, Nørrebrogade 44, 8000 Aarhus C, Denmark.
| | - Henrik Baymler Pedersen
- Aalborg University Hospital, Syd, Department of ENT Head & Neck Surgery, Hobrovej 18-22, 9000 Aalborg, Denmark.
| | - Peer Christiansen
- Aarhus University Hospital, Department of Surgery, Tage-Hansens Gade 2, 8000 Aarhus C, Denmark.
| | - Katalin Kiss
- Copenhagen University Hospital, Rigshospitalet, Department of Pathology, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark.
| | - Stine Rosenkilde Larsen
- Odense University Hospital, Department of Pathology, Sdr Boulevard 29, 5000 Odense C, Denmark.
| | - Marie Louise Jespersen
- Aarhus University Hospital, Department of Pathology, Tage-Hansens Gade 2, 8000 Aarhus C, Denmark.
| | - Giedrius Lelkaitis
- Aalborg University Hospital, Nord, Department of Pathology, Ladegårdsgade 3, 9000 Aalborg, Denmark.
| | - Christian Godballe
- Odense University Hospital, Department of ENT, Head & Neck Surgery, Sdr Boulevard 29, 5000 Odense C, Denmark.
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Calò PG, Medas F, Conzo G, Podda F, Canu GL, Gambardella C, Pisano G, Erdas E, Nicolosi A. Intraoperative neuromonitoring in thyroid surgery: Is the two-staged thyroidectomy justified? Int J Surg 2018; 41 Suppl 1:S13-S20. [PMID: 28506407 DOI: 10.1016/j.ijsu.2017.02.001] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 02/02/2017] [Accepted: 02/05/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the diagnostic accuracy of intraoperative neuromonitoring (IONM) in predicting postoperative nerve function during thyroid surgery and its consequent ability to assist the surgeon in intraoperative decision making. MATERIALS AND METHODS A total of 2365 consecutive patients were submitted to thyroidectomy by the same surgical team. Group A included 1356 patients (2712 nerves at risk) in whom IONM was utilized, and Group B included 1009 patients (2018 nerves at risk) in whom IONM was not utilized. RESULTS In Group A, loss of signal (LOS) was observed in 37 patients; there were 29 true positive, 1317 true negative, 8 false positive, and 2 false negative cases. Accuracy was 99.3%, positive predictive value was 78.4%, negative predictive value was 99.8%, sensitivity was 93.6%, and specificity was 99.4%. A total of 29 (2.1%) cases of unilateral paralysis were observed, 23 (1.7%) of which were transient and 6 (0.4%) of which were permanent. Bilateral palsy was observed in two (0.1%) cases requiring a tracheostomy. In Group A, 31 (2.3%) injuries were observed, 25 (1.8%) of which were transient and 6 (0.4%) of which were permanent. In Group B, 26 (2.6%) unilateral paralysis cases were observed, 20 (2%) of which were transient and 6 (0.6%) of which were permanent; bilateral palsy was observed in 2 (0.2%) cases. In Group B, 28 (2.8%) injuries were observed, 21 (2.1%) of which were transient and 7 (0.7%) of which were permanent. Differences between the two groups were not statistically significant. CONCLUSIONS Our results show that IONM has a very high sensitivity and negative predictive value, but also good specificity and positive predictive value. For these reasons, in selected patients with LOS, the surgical strategy should be reconsidered. However, patients need to be informed preoperatively about potential strategy changes during the planned bilateral surgery. Future larger and multicenter studies are needed to confirm the benefits of this therapeutic strategy.
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Affiliation(s)
- Pietro Giorgio Calò
- Department of Surgical Sciences, University of Cagliari, Cittadella Universitaria, SS554, Bivio Sestu, 09042, Monserrato (CA), Italy.
| | - Fabio Medas
- Department of Surgical Sciences, University of Cagliari, Cittadella Universitaria, SS554, Bivio Sestu, 09042, Monserrato (CA), Italy.
| | - Giovanni Conzo
- Università degli Studi della Campania "Luigi Vanvitelli" - School of Medicine, Division of General Surgery and Surgical Oncology, Via Gen.G.Orsini 42, 80132, Naples, Italy.
| | - Francesco Podda
- Department of Surgical Sciences, University of Cagliari, Cittadella Universitaria, SS554, Bivio Sestu, 09042, Monserrato (CA), Italy.
| | - Gian Luigi Canu
- Department of Surgical Sciences, University of Cagliari, Cittadella Universitaria, SS554, Bivio Sestu, 09042, Monserrato (CA), Italy.
| | - Claudio Gambardella
- Università degli Studi della Campania "Luigi Vanvitelli" - School of Medicine, Division of General Surgery and Surgical Oncology, Via Gen.G.Orsini 42, 80132, Naples, Italy.
| | - Giuseppe Pisano
- Department of Surgical Sciences, University of Cagliari, Cittadella Universitaria, SS554, Bivio Sestu, 09042, Monserrato (CA), Italy.
| | - Enrico Erdas
- Department of Surgical Sciences, University of Cagliari, Cittadella Universitaria, SS554, Bivio Sestu, 09042, Monserrato (CA), Italy.
| | - Angelo Nicolosi
- Department of Surgical Sciences, University of Cagliari, Cittadella Universitaria, SS554, Bivio Sestu, 09042, Monserrato (CA), Italy.
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Demontis R, Pittau MR, Maturo A, Petruzzo P, Calò G. Medico legal aspects on neuromonitoring in thyroid surgery: informed consent on malpractice claims. G Chir 2017; 38:149-154. [PMID: 29205147 DOI: 10.11138/gchir/2017.38.3.149] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM The purpose of this paper is to provide a forensic profile framework of neuromonitoring in thyroid surgery, regarding the information given to the patient and its classification as part of professional liability in the event of recurrent injury. METHOD Evaluation and reflections on the required behaviour of the surgeon on providing details on the operation before the informed consent is given and to outline the possible legal implications regarding professional liability as a result of recurrent injury. In particular, if it is an obligation to inform the patient about using this method and if it is possible for the surgeon to freely choose whether to employ this method, which is still burdened by a certain percentage of error and for that reason it cannot be defined a "standard of care". RESULTS To recognize neuromonitoring the role of standard of care in surgery of the thyroid means attribute a role of method able to avoid the surgeon to cause iatrogenic damage to the laryngeal nerve. For the foregoing reasons that is not true, determining false positives and false negatives, and this can be a double edged sword for the surgeon. CONCLUSIONS Although the progress in the field of thyroid surgery made in the last decade, currently there is no scientific reassuring evidence to completely avoid the possibility of producing an iatrogenic lesion of the laryngeal nerve. Information given to the patient prior to surgery should respect the requirements of completeness, freedom and honesty in order to allow the patient to self-determination.
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Wang T, Kim HY, Wu CW, Rausei S, Sun H, Pergolizzi FP, Dionigi G. Analyzing cost-effectiveness of neural-monitoring in recurrent laryngeal nerve recovery course in thyroid surgery. Int J Surg 2017; 48:180-188. [PMID: 29030215 DOI: 10.1016/j.ijsu.2017.10.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 09/21/2017] [Accepted: 10/02/2017] [Indexed: 12/25/2022]
Abstract
PURPOSE The increasing use of intraoperative neural monitoring (IONM) of the recurrent laryngeal nerve (RLN) during thyroid surgery imposes an evaluation of cost-effectiveness. METHODS The analysis estimated the cost versus utility of different alternatives that simulate nerve injury course and the consequences for the following cohorts of patients: (1) no RLN injury, or vocal fold palsy (VCP) recovery within 1 month (2), 2 months (3), 6 months (4), and after 12 months (5). In the model applied, the average simulated cohort consisted of a young female patient, 40 years old, employed, daily voice user, who underwent elective, conventional total thyroidectomy via cervical incision using a standardized intermittent IONM technique, for an operable benign, bilateral, diffuse, multinodular, non-toxic, non-retrosternal goiter. RESULTS IONM was cost-ineffective when parameters such as the rates of transient vocal fold palsy (VCP) reached 38.5%. IONM was cost-effective if the rate of VCP was 33.6% at 1 month, 22.9% at 2 months, 9.8% at 6 months, and 3.8% at 12 months, independent of phono-surgery. The described scenario is cost-effective only in a high-volume setting. CONCLUSIONS This study used simulation economic modeling to assess clinical and cost-effectiveness utility of IONM implementation. In light of the limitations of a simulation-based study, we conclusively assumed that IONM is cost-effective for permeant RLN injuries.
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Affiliation(s)
- Tie Wang
- Jilin Provincial Key Laboratory of Surgical Translational Medicine, China-Japan Union Hospital of Jilin University, Division of Thyroid Surgery, Changchun City, Jilin Province, China
| | - Hoon Yub Kim
- Department of Surgery, Korea University College of Medicine, Seoul, Republic of Korea
| | - Che-Wei Wu
- Department of Otolaryngology, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan
| | | | - Hui Sun
- Jilin Provincial Key Laboratory of Surgical Translational Medicine, China-Japan Union Hospital of Jilin University, Division of Thyroid Surgery, Changchun City, Jilin Province, China.
| | - Francesca Pia Pergolizzi
- Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University Hospital G. Martino, University of Messina, Via C. Valeria 1, 98125, 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, Via C. Valeria 1, 98125, Messina, Italy.
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Schneider R, Machens A, Randolph GW, Kamani D, Lorenz K, Dralle H. Opportunities and challenges of intermittent and continuous intraoperative neural monitoring in thyroid surgery. Gland Surg 2017; 6:537-545. [PMID: 29142846 DOI: 10.21037/gs.2017.06.08] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The number of thyroid operations and there radically continues to rise in the western hemisphere, bringing prevention of recurrent laryngeal nerve (RLN) palsy to the fore. Overall, the incidence of RLN palsy is fairly low but continues to prompt litigation for malpractice. In an effort to diminish transient, and more importantly permanent, RLN palsy rates, intraoperative neuromonitoring (IONM) has been advocated as a risk minimization tool. Recent meta-analyses of studies, many of which were limited by poor study design and the sole use of intermittent nerve stimulation, were unable to demonstrate superiority of IONM over mere anatomic RLN dissection. This is where continuous IONM (CIONM) comes into play: this technology enables the surgeon to (I) identify impending nerve injury as it unfolds; (II) release distressed nerves by reversing causative surgical maneuvers; and (III) verify functional nerve recovery after intraoperative loss of the electromyographic signal. Despite this superiority, CIONM is not devoid of methodological limitations, which need to be accounted for. This review summarizes the current key achievements of IONM; outlines opportunities for improvement regarding clinical implementation; and suggests areas of future research in this rapidly evolving field.
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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 W Randolph
- Division of Thyroid and Parathyroid Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Dipti Kamani
- Division of Thyroid and Parathyroid Surgery, Harvard Medical School, Boston, Massachusetts, 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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Cannizzaro MA, Lo Bianco S, Picardo MC, Provenzano D, Buffone A. How to avoid and to manage post-operative complications in thyroid surgery. Updates Surg 2017. [DOI: 10.1007/s13304-017-0475-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Dionigi G, Kim HY, Wu CW, Lavazza M, Materazzi G, Lombardi CP, Anuwong A, Tufano RP. Neuromonitoring in endoscopic and robotic thyroidectomy. Updates Surg 2017; 69:171-179. [DOI: 10.1007/s13304-017-0442-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 04/01/2017] [Indexed: 12/01/2022]
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Calò PG, Lombardi CP, Podda F, Sessa L, Santini L, Conzo G. Role of prophylactic central neck dissection in clinically node-negative differentiated thyroid cancer: assessment of the risk of regional recurrence. Updates Surg 2017; 69:241-248. [PMID: 28409443 DOI: 10.1007/s13304-017-0438-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 04/01/2017] [Indexed: 12/12/2022]
Abstract
Prophylactic central neck dissection in clinically node-negative patients remains controversial. The aim of this multicenter retrospective study was to determine the rate of metastases in the central neck in clinically node-negative differentiated thyroid cancer patients, to examine the morbidity, and to assess the risk of regional recurrence in patients treated with total thyroidectomy with concomitant bilateral or ipsilateral central neck dissection compared with those undergoing total thyroidectomy alone. 258 consecutive clinically node-negative patients were divided into three groups according to the procedures performed: total thyroidectomy only (group A), total thyroidectomy with concomitant ipsilateral central neck dissection (group B), and total thyroidectomy combined with bilateral central neck dissection (group C). Mean operative time and postoperative stay were shorter in Group A (p < 0.01). The incidence of postoperative transient hypoparathyroidism was lower in Group A (p = 0.03), whereas no differences in the incidence of permanent hypoparathyroidism and nerve palsy were present. Postoperative radioactive iodine administration was higher in group B and particularly C (p = 0.03) compared with group A. There were no statistically significant differences in terms of regional recurrence. Differentiated thyroid cancer has a high rate of central lymph node metastasis even in clinically node-negative patients; in the present study there was no statistically significant difference in the rates of locoregional recurrence between the three modalities of treatment. Total thyroidectomy appears to be an adequate treatment for clinically node-negative differentiated thyroid cancer. Prophylactic central neck dissection might be considered for differentiated thyroid cancer patients with large tumor size or extrathyroidal extension.
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Affiliation(s)
- Pietro Giorgio Calò
- Department of Surgical Sciences, University of Cagliari, S.S. 554, Bivio Sestu, Monserrato, 09042, Cagliari, Italy.
| | - Celestino Pio Lombardi
- Division of Endocrine Surgery, Università Cattolica del Sacro Cuore, "Agostino Gemelli" School of Medicine, Rome, Italy
| | - Francesco Podda
- Department of Surgical Sciences, University of Cagliari, S.S. 554, Bivio Sestu, Monserrato, 09042, Cagliari, Italy
| | - Luca Sessa
- Division of Endocrine Surgery, Università Cattolica del Sacro Cuore, "Agostino Gemelli" School of Medicine, Rome, Italy
| | - Luigi Santini
- Division of General Surgery and Surgical Oncology, School of Medicine, Università degli Studi della Campania "Luigi Vanvitelli", Napoli, Italy
| | - Giovanni Conzo
- Division of General Surgery and Surgical Oncology, School of Medicine, Università degli Studi della Campania "Luigi Vanvitelli", Napoli, Italy
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Phrenic nerve stimulation during neck dissection for advanced thyroid cancer involving level IV: is it worth doing it? Updates Surg 2017; 69:83-87. [PMID: 28194664 DOI: 10.1007/s13304-016-0411-y] [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: 03/24/2016] [Accepted: 11/27/2016] [Indexed: 10/20/2022]
Abstract
During thyroidectomy and neck dissection surgery for advanced or recurrent metastatic thyroid cancer under intraoperative monitoring, we used the available technology to assess the feasibility of such an intervention to monitor those patients with phrenic nerves at risk. A retrospective review of patients operated on from January 2009 to December 2015 by a single surgeon (CSD) was conducted. Patients who had neck and mediastinal dissection, with or without total thyroidectomy, due to advanced or recurrent metastatic disease to the neck were selected. The procedures were done under intraoperative nerve monitoring using nerve monitoring systems (NIM 2.0 or 3.0; Medtronic, Jacksonville, FL, USA). A total of 19 patients were included in the study, with a mean age of 57.6 years ± 16.3 and a male/female ratio of 10:9. Overall, all patients had an intact phrenic nerve at the conclusion of the surgery. One patient had an aggressive tumor that precluded sacrifice of the left recurrent laryngeal nerve and ipsilateral thoracic duct. The procedure was complicated by a temporary impairment of the diaphragm contraction with intraoperative nerve monitoring as well as a chyle fistula. This was due to the manipulation of the tissue surrounding the phrenic nerve. Intraoperative nerve monitoring of the phrenic nerve offers the surgeon a "potential" method of ensuring phrenic nerve integrity in cases of advanced thyroid cancers with gross level IV metastatic disease. Further prospective studies are needed to assess the risks of this intervention and evaluate the method of recording diaphragm contraction movement.
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Chiappa C, Rovera F, Rausei S, Del Ferraro S, Fachinetti A, Lavazza M, Marchionini V, Arlant V, Tanda ML, Piantanida E, Kim HY, Anuwong A, Dionigi G. Breast cancer and thyroid diseases: analysis of 867 consecutive cases. J Endocrinol Invest 2017; 40:179-184. [PMID: 27624298 DOI: 10.1007/s40618-016-0543-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 08/31/2016] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The aim of this study was to evaluate the association of breast cancer with thyroid diseases. Many authors have already studied the possible relationship between these two diseases, but the results are nowadays conflicting. MATERIALS AND METHODS Our study examining 867 patients with breast cancer (862 women and 5 men, average age = 61 years old) of whom 141 also had thyroid disease evaluated the recurrence of thyroid diseases and their association with different types of breast cancer. Statistical analyses were performed using SPSS software for Windows; we used nonparametric tests (Chi-square and Mann-Whitney), and the level of significance was set at p < 0.05. RESULTS We found a significant association between breast cancer diagnosed after menopause and thyroid disease (p < 0.003). Moreover, we analyzed the role of thyroid autoimmunity identifying an association between chronic autoimmune thyroiditis and breast cancer diagnosed before menopause (p < 0.05). Regarding receptor profile of breast carcinoma, we have found an increased expression of estrogen receptors in patients with autoimmune thyroiditis compared to patients with any other thyroid diseases (p < 0.03). Contrariwise, we do not have found any difference between the group with every thyroid disease and the group without thyroid disease (p < 1.00). We did not find other statistically significant associations with breast cancer's parameters like family history, tumor size, lymph node metastasis, distant metastasis, cancer clinical and pathological stage, differentiation grade and expression of Ki67, p53 and Her2 in the two main groups with or without thyroid disease. Likewise, we did not found other statistically significant association between hypothyroidism or hyperthyroidism and breast cancer.
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MESH Headings
- Biomarkers, Tumor/metabolism
- Breast Neoplasms/etiology
- Breast Neoplasms/metabolism
- Breast Neoplasms/pathology
- Carcinoma, Ductal, Breast/etiology
- Carcinoma, Ductal, Breast/metabolism
- Carcinoma, Ductal, Breast/secondary
- Carcinoma, Lobular/etiology
- Carcinoma, Lobular/metabolism
- Carcinoma, Lobular/secondary
- Female
- Follow-Up Studies
- Humans
- Lymphatic Metastasis
- Male
- Middle Aged
- Neoplasm Grading
- Prognosis
- Receptors, Estrogen/metabolism
- Receptors, Progesterone/metabolism
- Thyroid Diseases/complications
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Affiliation(s)
- C Chiappa
- Senology Research Center - 1st Division of Surgery, Department of Surgical and Morphological Sciences, University of Insubria, Varese, Italy.
| | - F Rovera
- Senology Research Center - 1st Division of Surgery, Department of Surgical and Morphological Sciences, University of Insubria, Varese, Italy
| | - S Rausei
- Senology Research Center - 1st Division of Surgery, Department of Surgical and Morphological Sciences, University of Insubria, Varese, Italy
| | - S Del Ferraro
- Senology Research Center - 1st Division of Surgery, Department of Surgical and Morphological Sciences, University of Insubria, Varese, Italy
| | - A Fachinetti
- Senology Research Center - 1st Division of Surgery, Department of Surgical and Morphological Sciences, University of Insubria, Varese, Italy
| | - M Lavazza
- Senology Research Center - 1st Division of Surgery, Department of Surgical and Morphological Sciences, University of Insubria, Varese, Italy
| | - V Marchionini
- Senology Research Center - 1st Division of Surgery, Department of Surgical and Morphological Sciences, University of Insubria, Varese, Italy
| | - V Arlant
- Senology Research Center - 1st Division of Surgery, Department of Surgical and Morphological Sciences, University of Insubria, Varese, Italy
| | - M L Tanda
- Endocrine Unit, Ospedale di Circolo - University of Insubria, Varese, Italy
| | - E Piantanida
- Endocrine Unit, Ospedale di Circolo - University of Insubria, Varese, Italy
| | - H Y Kim
- KUMC Thyroid Center, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - A Anuwong
- Department of Surgery, Police General Hospital, Faculty of Medicine, Siam University, Pathumwan, Bangkok, Thailand
| | - G Dionigi
- Senology Research Center - 1st Division of Surgery, Department of Surgical and Morphological Sciences, University of Insubria, Varese, Italy
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Filetti S, Ladenson PW, Biffoni M, D'Ambrosio MG, Giacomelli L, Lopatriello S. The true cost of thyroid surgery determined by a micro-costing approach. Endocrine 2017; 55:519-529. [PMID: 27172916 DOI: 10.1007/s12020-016-0980-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 05/02/2016] [Indexed: 10/21/2022]
Abstract
Whether the amount of the current DRG tariff for thyroid surgery covers its actual cost has been questioned. We estimated a reliable cost of thyroid surgery for a large Italian hospital. A micro-costing approach is used with data from the University Hospital "Umberto I," a large facility that conducts a high volume of thyroidectomy surgical procedures in the Lazio region. The direct costs of surgery and hospitalization for a total and a hemi-thyroidectomy were €4956 and €4673, respectively. When compared to the DRG tariff of €3340, total thyroidectomy was €1616 (48 %) more per procedure and hemi-thyroidectomy was €1333 (40 %) more per procedure. This DRG shortfall is calculated to generate an annual procedure-specific deficit of approximately €1.38 million for this hospital. Furthermore, when the costs associated with pre-surgical work-up, post-surgical follow-up, and complications management through 12 months are incorporated, the estimated costs of total and hemi-thyroidectomy rose to €5812 and €5277, respectively. The true cost of thyroid surgery in Italy is significantly higher than what has been reported in the literature or reimbursed by the DRG tariff.
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Affiliation(s)
- Sebastiano Filetti
- Departments of Internal Medicine and Medical Specialties, "Sapienza" University of Roma, Viale del Policlinico 155, 00161, Rome, Italy.
| | - Paul W Ladenson
- Departments of Medicine, Pathology, Oncology, and Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Marco Biffoni
- Department of Surgical Sciences, "Sapienza" University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Maria Giuseppina D'Ambrosio
- Ufficio Programmazione, AFC Programmazione, Governo Economico e Valutazione, Azienda Policlinico Umberto I, Roma, Viale del Policlinico 155, 00161, Rome, Italy
| | - Laura Giacomelli
- Department of Surgical Sciences, "Sapienza" University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
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Intraoperative localization of the parathyroid glands with indocyanine green and Firefly(R) technology during BABA robotic thyroidectomy. Surg Endosc 2016; 31:3020-3027. [PMID: 27864717 DOI: 10.1007/s00464-016-5330-y] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Accepted: 10/31/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND It is unclear whether near-infrared (NIR) light-induced indocyanine green (ICG) fluorescence can effectively identify, and thus permit the preservation of, parathyroid glands in bilateral axillo-breast approach (BABA) robotic thyroidectomy. This case-control study with a prospectively recruited consecutive series and a retrospectively selected control group assessed the usefulness of ICG with Firefly(R) technology to identify the parathyroid glands intraoperatively during BABA robotic thyroidectomy. METHODS All consecutive patients (N = 22) who were scheduled to undergo BABA robotic thyroidectomy for papillary thyroid carcinoma in December 2013-August 2015 and met the study eligibility criteria were recruited prospectively. ICG fluorescence was used with the Firefly system (NIR illuminator: 805 nm; filter: 825 nm) integrated in the da Vinci Si robot system to identify the lower parathyroid glands. Parathyroid hormone levels were recorded on postoperative days 0, 1, 2, and 14. Propensity score matching was used to identify an age-, gender-, tumor size-, and operation type-matched group of control patients who underwent BABA robotic thyroidectomy without the Firefly system. The two groups were compared in terms of parathyroid-related outcomes. RESULTS ICG fluorescence-mediated identification of the parathyroid and thyroid glands required on average (range) 203 ± 89 (125-331) and 207 ± 112 (130-356) s, respectively. The mean (range) fluorescence duration in these glands was 20.8 ± 6.0 (16.6-35.8) and 20.1 ± 7.3 (15.5-33.8) min, respectively. The ICG group had a significantly lower rate of incidental parathyroidectomy than the control group (0 vs. 15.9%, P = 0.048). CONCLUSIONS ICG with NIR light may feasibly and safely identify the parathyroid glands in BABA robotic thyroidectomy.
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Polistena A, Di Lorenzo P, Sanguinetti A, Buccelli C, Conzo G, Conti A, Niola M, Avenia N. Medicolegal implications of surgical errors and complications in neck surgery: A review based on the Italian current legislation. Open Med (Wars) 2016; 11:298-306. [PMID: 28352812 PMCID: PMC5329845 DOI: 10.1515/med-2016-0058] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Accepted: 07/07/2016] [Indexed: 11/15/2022] Open
Abstract
Aim of the present paper is the review of the principal complications associated to endocrine neck surgery considering how expertise, full adoption of guidelines, appropriate technology and proper informed consent may limit the medicolegal claims at the light of the incoming new regulation of the medical professional legal responsibility. A literature search, using the Medline/PubMed database for full-length papers, was used. Postoperative recurrent laryngeal nerve (RLN) palsy and hypoparathy-roidism remain the principal causes of surgical malpractice claims . In the procedure of neck lymphadenctomy intra-operative haemorrhage, thoracic duct injury, injuries to loco-regional nerves can be observed and can be source of claims. After many years of increased medicolegal litigations, the Italian government is proposing a drastic change in the regulations of supposed medical malpractice in order to guarantee the patient's right to a safe treatment and in the meantime to defend clinicians from often unmotivated and prejudicial legal cases. Surgical errors and complications in neck surgery are a relevant clinical issue. Only the combination of surgical and clinical expertise, application of guidelines, appropriate technology and a routinely use of specific informed consent can contain potential medicolegal implications.
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Affiliation(s)
- Andrea Polistena
- University of Perugia, Medical School, Endocrine Surgery Unit, S. Maria University Hospital, Terni, Italy
| | - Pierpaolo Di Lorenzo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Alessandro Sanguinetti
- University of Perugia, Medical School, Endocrine Surgery Unit, S. Maria University Hospital, Terni, Italy
| | - Claudio Buccelli
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Giovanni Conzo
- Department of Anesthesiological, Surgical and Emergency Sciences, Second University of Naples, Naples, Italy
| | - Adelaide Conti
- Department of Surgery, Radiology and Public Health, Public Health and Humanities Section, University of Brescia - Centre of Bioethics Research, Brescia, Italy
| | - Massimo Niola
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Nicola Avenia
- University of Perugia, Medical School, Endocrine Surgery Unit, S. Maria University Hospital, Terni, Italy
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Chen TY, Kumar A. Usefulness of video laryngoscopy before thyroid surgery to improve nerve monitoring: a technical note. Clin Otolaryngol 2016; 43:404-406. [PMID: 27429049 DOI: 10.1111/coa.12706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2016] [Indexed: 11/26/2022]
Affiliation(s)
- T-Y Chen
- Department of Otolaryngology Head and Neck Surgery, Palmerston North Hospital, Palmerston North, New Zealand
| | - A Kumar
- Department of Otolaryngology Head and Neck Surgery, Palmerston North Hospital, Palmerston North, New Zealand
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31
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Interpretation of intraoperative recurrent laryngeal nerve monitoring signals: The importance of a correct standardization. Int J Surg 2016; 28 Suppl 1:S54-8. [DOI: 10.1016/j.ijsu.2015.12.039] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Barczyński M, Randolph GW, Cernea C. International survey on the identification and neural monitoring of the EBSLN during thyroidectomy. Laryngoscope 2015; 126:285-91. [DOI: 10.1002/lary.25548] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Revised: 06/30/2015] [Accepted: 07/09/2015] [Indexed: 11/07/2022]
Affiliation(s)
- Marcin Barczyński
- Department of Endocrine Surgery; Third Chair of General Surgery, Jagiellonian University Medical College; Kraków Poland
| | - Gregory W. Randolph
- Department of Otology and Laryngology; Division of Thyroid and Parathyroid Surgery; Massachusetts Eye and Ear Infirmary; Department of Surgery; Division of Surgical Oncology; Massachusetts General Hospital, Harvard Medical School; Boston Massachusetts U.S.A
| | - Claudio Cernea
- Department of Head and Neck Surgery; University of Sao Paulo Medical School; Sao Paulo Brazil
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Universal Use of Intraoperative Nerve Monitoring by Recently Fellowship-Trained Thyroid Surgeons is Common, Associated with Higher Surgical Volume, and Impacts Intraoperative Decision-Making. World J Surg 2015; 40:337-43. [DOI: 10.1007/s00268-015-3238-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Kim HY, Tufano RP, Randolph G, Barczyński M, Wu CW, Chiang FY, Liu X, Masuoka H, Miyauchi A, Park SY, Kwak HY, Lee HY, Dionigi G. Impact of positional changes in neural monitoring endotracheal tube on amplitude and latency of electromyographic response in monitored thyroid surgery: Results from the Porcine Experiment. Head Neck 2015; 38 Suppl 1:E1004-8. [PMID: 26040955 DOI: 10.1002/hed.24145] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 04/14/2015] [Accepted: 05/31/2015] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND The purpose of this study was to evaluate electromyography (EMG) amplitude and latency changes during tube dislocation in monitored thyroid surgery, which may be observed without recurrent laryngeal nerve injury. METHODS Duroc-Landrace piglets were intubated with the TriVantage EMG tube. We measured EMG changes during both upward and downward tube dislocation (10-20 mm) and rotation (45-90°) with continuous neuromonitoring. RESULTS The EMG amplitude varied significantly with induced endotracheal tube rotation and depth changes. However, the EMG latency was relatively unaffected by such tube dislocation, just a transient artifactual latency change was observed in the situation of extreme amplitude variation. CONCLUSION Amplitude changes without latency changes may be due to changes in tube position alone during surgery, but could still reflect a neurophysiologic event; amplitude changes during neuropraxic injury merit additional investigation. Thus, the combined event (concordant amplitude decrease and latency increase) serves as an appropriate adverse EMG event correlating with impending neural injury. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1004-E1008, 2016.
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Affiliation(s)
- Hoon Yub Kim
- Department of Surgery, KUMC Thyroid Center, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Ralph P Tufano
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Gregory Randolph
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Laryngology and Otology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts
| | - Marcin Barczyński
- Department of General Surgery, Jagiellonian University, Medical College, Krakow, Poland
| | - Che-Wei Wu
- Institute of Clinical Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Feng-Yu Chiang
- Institute of Clinical Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Xiaoli Liu
- Jilin Provincial Key Laboratory of Surgical Translational Medicine, Japan Union Hospital of Jilin University, Division of Thyroid Surgery, Changchun City, Jilin Province, China
| | - Hiroo Masuoka
- Department of Surgery, Kuma Hospital, Center for Excellence in Thyroid Care, Kobe, Japan
| | - Akira Miyauchi
- Department of Anesthesiology, Korea University College of Medicine, Seoul, Korea
| | - Soo Young Park
- Department of Anesthesiology, Korea University College of Medicine, Seoul, Korea
| | - Hee Yong Kwak
- Department of Surgery, KUMC Thyroid Center, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Hye Yoon Lee
- Department of Surgery, KUMC Thyroid Center, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Gianlorenzo Dionigi
- First Division of Surgery, Research Center for Endocrine Surgery, Department of Surgical Sciences and Human Morphology, University of Insubria (Como-Varese), Varese, Italy
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