Is the use of intraoperative nerve monitoring an effective method to reduce the rate of permanent recurrent laryngeal nerve paralysis?

Year 2018, , 22 - 25, 02.03.2018

Doğan Yıldırım Turgut Dönmez , Mikail Çakır , Okan Murat Aktürk , Adnan Hut , Ahmet Kocakuşak , Erdinç Çekiç Leyla Zeynep Tigrel Turgay Yıldız

https://doi.org/10.25000/acem.383033

Abstract

Aim: Recurrent laryngeal nerve (RLN) paralysis is a common complication of thyroid surgery. In recent years, intraoperative nerve monitoring (IONM) has been used to reduce the risk of RLN paralysis. The purpose of this study was to assess the role of IONM in reducing RLN paralysis.

Methods: A retrospective clinical study was conducted between January 2015 and January 2017 in a two-center-clinical trial at Lutfiye Nuri Burat State and Haseki Teaching and Research Hospitals. Patients who underwent thyroidectomy using IONM (Group A, n=100) or direct visual technique (Group B, n=232) were included. Patients' files were reviewed for age, body mass index, gender, American Society of Anesthesiologists score, calcium levels, complications, duration of operation and follow-up. Postoperative complications were regarded as the main outcomes.

Results: A total of 332 patients (52 male, 280 female) with a mean age of 46.4±12.9 years were enrolled. 30.1% of the patients were in Group A (IONM). Bilateral and unilateral thyroidectomies were performed in 70.8% and 29.2% of the operations, respectively. Operative time was shorter in Group A (76.9±12.0 minutes vs 97.7±27.6 minutes, p <0.001). There was no significant difference between the two groups in terms of preoperative and postoperative calcium levels (p=0.407).There was no statistically significant difference in early RLN paralysis rates between the two groups (for Group A and Group B, 10 (10%) and 34 (14%), respectively) (p=0.251) While it was not present in Group A, permanent RLN paralysis was found in 10 patients in Group B (4.3%) (p = 0.035).

Conclusion: The use of IONM may be useful in reducing the rate of permanent RLN paralysis.

Keywords

Thyroidectomy, recurrent laryngeal, nerve monitoring

İntraoperatif sinir monitorizasyonu kalıcı rekürren laringeal sinir paralizi oranının azaltılmasında etkili bir yöntem midir?

Abstract

Amaç: Rekürren laringeal sinir (RLN) paralizisi tiroid ameliyatının bilinen bir komplikasyonudur. RLN paralizisi riskini azaltmak için son yıllarda intraoperative sinir monitorizasyonu (İONM) yöntemi kullanılmaktadır. Bu çalışmanın amacı İONM kullanılmasının RLN paralizisinin azaltılmasındaki potansiyel rolünü değerlendirmektir.

Yöntemler: Ocak 2015-Ocak 2017 tarihleri arasında çift merkezli, retrospektif klinik bir çalışmada Lütfiye Nuri Burat Devlet Hastanesi ve Haseki Eğitim ve Araştırma hastanesinde yapılan tiroidektomi ameliyatları incelendi. Hastalar İONM kullanılarak yapılan troidektomi (Grup A, n=100) ve direkt görsel teknik kullanılarak yapılan troidektomi (Grup B, n=232) olarak çalışmaya dahil edildi. Hastaların dosyaları incelenerek yaş, vücut kitle indeksi, cinsiyet, ASA skoru, kalsiyum seviyeleri, komplikasyonlar, ameliyat süreleri, takip süreleri incelendi. Postoperatif komplikasyonlar esas çıktı olarak belirlendi.

Bulgular: Çalışmaya tiroid operasyonu yapılan yaş ortalamaları 46,4±12,9 yıl olan 52 erkek, 280 kadın toplam 332 hasta dahil edildi. Hastaların %30,1’i İONM kullanılan, %69,9’u kullanılmayan grupta idi. Operasyonların %70,8’i çift taraflı, %29,2’si tek taraflıydı. İONM grubunda ameliyat süreleri diğer gruptan daha kısa idi (76,9±12,0 dakika ve 97,7±27,6 dakika, p<0.001). Preoperatif ve postoperatif kalsiyum seviyeleri açısından iki grup arasında anlamlı bir fark saptanmadı (p=0.407). İki grup arasında erken dönem RLN paralizisi oranlarında istatistiksel olarak anlamlı fark saptanmadı (Grup A için 10 (%10) ve Grup B için 34 (%14) (p=0.251). İONM grubunda kalıcı RLN paralizi saptanmazken, direkt görsel teknikte istatistiksel olarak anlamlı fark oluşturan kalıcı RLN paralizi 10 hastada (% 4,3) tespit edildi (p=0,035). 

Sonuç: İONM kullanımı, direkt görsel teknikle karşılaştırıldığında geçici paralizi oranlarında fark olmasa da, kalıcı RLN paralizi oranını azaltmada faydalı olabilir.

Keywords

Tiroidektomi, rekürren laringeal, sinir monitorizasyonu

References

• 1. Henry BM, Graves MJ, Vikse J, Sanna B, Pękala PA, Walocha JA, et al. The current state of intermittent intraoperative neural monitoring for prevention of recurrent laryngeal nerve injury during thyroidectomy: a PRISMA-compliant systematic review of overlapping meta-analyses. Langenbecks Arch Surg. 2017;402:663-73.
• 2. Ahn HS, Kim HJ, Welch HG. Korea's thyroid-cancer epidemic:screening and overdiagnosis. N Engl J Med. 2014;371:1765-7.
• 3. Lo CY, Kwok KF, Yuen PW. A prospective evaluation of recurrent laryngeal nerve paralysis during thyroidectomy. Arch Surg. 2000;135:204-7.
• 4. Dionigi G, Chiang FY, Rausei S, Wu CW, Boni L, Lee KW, et al. Surgical anatomy and neurophysiology of the vagus nerve (VN) for standardised intraoperative neuromonitoring (IONM) of the inferior laryngeal nerve (ILN) during thyroidectomy. Langenbecks Arch Surg. 2010;395:893-9.
• 5. Chiang FY, Lee KW, Chen HC, Chen HY, Lu IC, Kuo WR, et al. Standardization of intraoperative neuromonitoring of recurrent laryngeal nerve in thyroid operation. World J Surg. 2010;34:223-9.
• 6. Duclos A, Lifante JC, Ducarroz S, Soardo P, Colin C, Peix JL Influence of intraoperative neuromonitoring on surgeons’ technique during thyroidectomy. World J Surg. 2011;35:773-8.
• 7. Sarı S, Erbil Y, Sümer A, Agcaoglu O, Bayraktar A, Issever H, et al. Evaluation of recurrent laryngeal nerve monitoring in thyroid surgery. Int J Surg. 2010;8:474-8.
• 8. Filho JG, Kowalski LP. Surgical complications after thyroid surgery performed in a cancer hospital. Otolaryngol Head Neck Surg. 2005;132:490-4.
• 9. Cirocchi R, Boselli C, Guarino S, Sanguinetti A, Trastulli S, Desiderio J, et al. Total thyroidectomy with ultrasonic dissector for cancer: multicentric experience. World J Surg Oncol. 2012;10:70.
• 10. Hermann M, Alk G, Roka R, Glaser K, Freissmuth M. Laryngeal recurrent nerve injury in surgery for benign thyroid diseases: effect of nerve dissection and impact of individual surgeon in more than 27,000 nerves at risk. Ann Surg. 2002;235:261-8.
• 11. Sosa JA, Bowman HM, Tielsch JM, Powe NR, Gordon TA, Udelsman R. The importance of surgeon experience for clinical and economic outcomes from thyroidectomy. Ann Surg. 1998;228:320-30.
• 12. Rios-Zambudio A, Rodriguez J, Riquelme J, Soria T, Canteras M, Parrilla P. Prospective study of postoperative complications after total thyroidectomy for multinodular goiters by surgeons with experience in endocrine surgery. Ann Surg. 2004;240:18-25.
• 13. Lahey RF. Routine dissection and demonstration of the recurrent laryngeal nerve in subtotal thyroidectomy. Surg Gynecol Obstet. 1938;66:775-7.
• 14. Chan WF, Lo CY. Pitfalls of intraoperative neuromonitoring for predicting postoperative recurrent laryngeal nerve function during thyroidectomy. World J Surg. 2006;30:806-12.
• 15. Hermann M, Hellebart C, Freissmuth M. Neuromonitoring in thyroid surgery: prospective evaluation of intraoperative electrophysiological responses for the prediction of recurrent laryngeal nerve injury. Ann Surg. 2004;240:9-17.
• 16. Thomusch O, Sekulla C, Machens A, Neumann HJ, Timmermann W, Dralle H. Validity of intra-operative neuromonitoring signals in thyroid surgery. Langenbecks Arch Surg. 2004;389:499-503.
• 17. Angelos P. Recurrent laryngeal nerve monitoring: state of the art, ethical and legal issues. Surg Clin North Am. 2009;89:1157-69.
• 18. Dralle H, Sekulla C, Haerting J, Timmermann W, Neumann HJ, Kruse E, et al. Risk factors of paralysis and functional outcome after recurrent laryngeal nerve monitoring in thyroid surgery. Surgery. 2004;136:1310-22.
• 19. Stevens K, Stojadinovic A, Helou LB, Solomon NP, Howard RS, Shriver CD, et al. The impact of recurrent laryngeal neuromonitoring on multi‐dimensional voice outcomes following thyroid surgery. J Surgical Oncol. 2012;105:4-9.
• 20. Chan WF, Lang BHH, Lo CY. The role of intraoperative neuromonitoring of recurrent laryngeal nerve during thyroidectomy: a comparative study on 1000 nerves at risk. Surgery. 2006;140:866-73.
• 21. Dionigi G, Boni L, Rovera F, Bacuzzi A, Dionigi R. Neuromonitoring and video-assisted thyroidectomy: a prospective, randomized case-control evaluation. Surg Endosc. 2009;23:996-1003.
• 22. Calo PG, Medas F, Erdas E, Pittau MR, Demontis R, Pisano G, et al. Role of intraoperative neuromonitoring of recurrent laryngeal nerves in the outcomes of surgery for thyroid cancer. Int J Surg. 2014;12:S213-7.
• 23. Yang S, Zhou L, Lu Z, Ma B, Ji Q, Wang Y. Systematic review with meta-analysis of intraoperative neuromonitoring during thyroidectomy. Int J Surg. 2017;39:104-13.
• 24. Wong KP, Mak KL, Wong CKH, Lang BHH. Systematic review and meta-analysis on intra-operative neuro-monitoring in high-risk thyroidectomy. Int J Surg. 2017;38:21-30.
• 25. Zheng S, Xu Z, Wei Y, Zeng M, He J. Effect of intraoperative neuromonitoring on recurrent laryngeal nerve palsy rates after thyroid surgery—a meta-analysis. J Formos Med Assoc. 2013;112:463-72.
• 26. Pisanu A, Porceddu G, Podda M, Cois A, Uccheddu A. Systematic review with meta-analysis of studies comparing intraoperative neuromonitoring of recurrent laryngeal nerves versus visualization alone during thyroidectomy. J Surg Res. 2014;188:152-61.
• 27. Sanabria A, Ramirez A, Kowalski LP, Silver CE, Shaha AR, Owen RP, et al. Neuromonitoring in thyroidectomy: a meta-analysis of effectiveness from randomized controlled trials. Eur Arch Otorhinolaryngol. 2013;270:2175-89.
• 28. Musholt TJ, Clerici T, Dralle H, Frilling A, Goretzki PE, Hermann MM. German Association of Endocrine Surgeons practice guidelines for the surgical treatment of benign thyroid disease. Langenbecks Arch Surg. 2011;396:639-49.