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Neuromonitoring in Thyroidectomy

Neuromonitoring in Thyroidectomy. Is neuromonitoring useful in preventing recurrent laryngeal nerve injury?. Wong Chun Lam United Christian Hospital Joint Hospital Surgical Grand Round 18 th July 2015. Introduction.

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Neuromonitoring in Thyroidectomy

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  1. Neuromonitoring in Thyroidectomy Is neuromonitoring useful in preventing recurrent laryngeal nerve injury? Wong Chun Lam United Christian Hospital Joint Hospital Surgical Grand Round 18th July 2015

  2. Introduction • Recurrent laryngeal nerve (RLN) injury – one of the most significant complications in thyroidectomy • Visual identification of RLN • Incidence of RLN palsy • Transient: 3% • Permanent: 1%

  3. Mode of RLN Injury • Traction / stretching • Thermal • Ischemia due to over-skeletonization • Direct Transection

  4. Neuromonitoring • Firstly described since 1960s • Continuous discussion on its role in reducing risk of RLN injury

  5. Methods of Neuromonitoring • Electromyography (EMG) • Needle electrodes inserted to effector muscle • Surface electrodes on endotracheal tube contacting with vocal cord

  6. Stimulating probe emits electric current when activited RLN stimulated and vocalis muscle activity registered by monitoring machine

  7. Use of Neuromonitoring • RLN mapping and identification • Aiding RLN dissection • Predicting post-operative vocal cord function • High negative predictive value (92-100%) • Helps operation planning in total thyroidectomy • Loss of signal upon stimulation of first side RLN  defers contralateral thyroidectomy as second operation after functional recovery of ipsilateral vocal cord

  8. Disadvantage of Neuromonitoring • Time in setup the monitoring system • Cost • Endotracheal tube: HKD 3,500 • Monitoring system: HKD 300,000 • Surgeon’s dependence on neuromonitoring

  9. Current Evidence

  10. Search Strategy • Literature search using Pubmed with keywords: thyroidectomy, recurrent laryngeal nerve, monitor • From 2005 till now • 10 comparative studies • 4 RCTs • 4 meta-analyses

  11. Randomized clinical trial of visualization versus neuromonitoring of recurrent laryngeal nerves during thyroidectomyM. Barczynski, A. Kontrurek, S. Cichon • 2000 nerves-at-risk • 3.9% reduction in risk of transient RLN palsy with neuromonitoring • No significant difference in risk of permanent RLN palsy

  12. Neuromonitoring and video-assisted thyroidectomy: a prospective, randomized case-control evaluationGianlorenzo Dionigi, Luigi Boni, Francesca Rovera, Alessandro Bacuzzi, Renzo Dionigi • 112 nerves-at-risk • No significant difference in risks of transient and permanent RLN palsy

  13. Evaluation of recurrent laryngeal nerve monitoring in thyroid surgerySerkan Sari, Yesim Erbil, Aziz Sumer, Orhan Agcaoglu, Adem Bayraktar, Halim Issever, Selcuk Ozarmagan • 409 nerves-at-risk • No significant difference in risks of transient and permanent RLN palsy

  14. Randomized Controlled Trial of Visualization versus Neuromonitoring of the External Branch of the Superior Laryngeal Nerve during ThyroidectomyMarcin Barczynski, Aleksander Konturek, Malgorzata Stopa, Agnieszka Honowska, Wojciech Nowak • 402 nerves-at-risk • No significant difference in risks of transient and permanent RLN palsy

  15. Recurrent Laryngeal Nerve Monitoring Versus Identification Alone on Post-Thyroidectomy True Vocal Fold Palsy: A Meta-AnalysisThomas S. Higgins, Reena Gupta, Amy S. Ketcham, Robert T. Sataloff, J. Trad Wadsworth, John T. Sinacori • Includes 1 RCT, 8 comparative studies and 34 single-arm case series • 64,699 nerves-at-risk Transient Permanent Odd Ratio: 1.07 (0.95 – 1.20) Odd Ratio: 0.99 (0.80 – 1.24) • No significant difference in risks of transient and permanent RLN palsy

  16. Neuromonitoring in thyroidectomy: a meta-analysis of effectiveness from randomized controlled trialsAlvaro Sanabria, Adonis Ramirez, LuizP. Kowalski, Carl E. Silver, Ashok R. Shaha, Randall P. Owen, Carlos Suarez, Avi Khafif, Alessandra Rinaldo, Alfio Ferlito • Includes 4 RCTs • 2,912 nerves-at-risk Transient Permanent Risk Difference: -0.01 (-0.02 – 0.00) Risk Difference: 0.00 (-0.01 – 0.00) • No significant difference in risks of transient and permanent RLN palsy

  17. Effect of intraoperative neuromonitoring on recurrent laryngeal nerve palsy rates after thyroid surgery – A meta-analysisShixing Zheng, Zhiwen Xu, Yuanyuan Wei, Manli Zeng, Jinnian He • Includes 2 RCTs and 12 comparative studies • 36,487 nerves-at-risk Transient Permanent Odd Ratio: 0.80 (0.65 – 0.99) Odd Ratio: 0.80 (0.62 – 1.03) • 0.15% reduction in risk of transient RLN palsy • No significant difference in risk of permanent RLN palsy

  18. Systematic review with meta-analysis of studies comparing intraoperative neuromonitoring of recurrent laryngeal nerves versus visualization alone during thyroidectomyAdolfo Pisanu, Giulia Porceddu, Mauro Podda, Alessandro Cois, Alessandro Uccheddu • Includes 3 RCTs and 17 comparative studies • 35,513 nerves-at-risk Transient Permanent Odd Ratio: 0.946 (0.817 – 1.063) Odd Ratio: 0.884 (0.687 – 1.136) • No significant difference in risks of transient and permanent RLN palsy

  19. “High Risks” Operations • Malignancies • Retrosternal goiter • Toxic goiter • Revision surgeries Recurrent Laryngeal Nerve Monitoring Versus Identification Alone on Post-Thyroidectomy True Vocal Fold Palsy: A Meta-analysis. The Laryngoscope 2011.

  20. Continuous Vagal Stimulation • Automatic periodic stimulation from electrode placing at vagus nerve • Reduction or loss of signal – RLN injury • Real time feedback of RLN function • Enables immediate corrective measures to prevent further injury (indirect trauma including traction, heat) • Increased vagal tone, but no significant change in haemodynamics

  21. Intermittent versus Continuous Monitoring • Laryngealneuromonitoring and neurostimulation versusneurostimulation alone in thyroid surgery: a randomizedclinical trial. Head Neck 2012;34:141. • 250 patients • No signficant difference in incidence of RLN palsy (2.6% in intermittent stiumulation; 2.7% on continuous stimulation)

  22. Conclusion • Current literature does not support use of neuromonitoring in preventing RLN injury in thyroidectomy, comparing with visual identification of RLN • ?use in “high risk” cases; definition varies between different opinions, no strong literature support

  23. Overall incidence of RLN palsy is low • Large sample size needed to show the statistical significance, if any • Cost-effectiveness • ~ 25 thyroidectomies with neuromonitoring costing HKD 87,500, to prevent 1 transient RLN palsy (taking 3.9% as risk reduction) • Visual identification of RLN, careful nerve dissection and meticulous surgical skills – gold standard for preventing vocal cord palsy in thyroidectomy

  24. Thank you

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