Loss of neuromonitoring signal during bilateral thyroidectomy: no systematic change in operative strategy according to a survey of the French Association of Endocrine Surgeons (AFCE)

Khamsy, Lilly; Constanthin, Paul; Sadowski, Samira M.; Triponez, Frédéric

doi:10.1186/s12893-015-0082-5

Cited by 9 publications

(11 citation statements)

References 23 publications

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“…There are only few studies supporting the decrease in RLN palsy (transient) when using IONM compared to visual recognition alone, while the sample, for permanent palsy, was small to achieve a statistically significant result despite the decreased trend that it has also shown (8,17). Other large national studies (i.e., Scandinavian) showed contradictory results on the subject (21,22). Therefore, it is not yet safe to come to a clear conclusion.…”

Section: Introductionmentioning

confidence: 96%

Two-stage thyroidectomy in the era of intraoperative neuromonitoring

Christoforides¹,

Papandrikos²,

Polyzois³

et al. 2017

Gland Surg.

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Background: The use of intraoperative neuromonitoring (IONM) provides surgeons with real time information about recurrent laryngeal nerves (RLN) functional integrity. Hence, allowing them to modify the initially scheduled bilateral procedure, to a two-stage thyroidectomy in cases of loss of signal (LOS) on the first side of resection resulting in minimization of bilateral RLN injury. The purpose of our study was to present our results since the implementation of the above mentioned process in both malignant and benign thyroid disease. Methods: We conducted a retrospective, observational cohort study of prospectively collected data from all patients who underwent a scheduled total thyroidectomy with or without neck dissection in our Department over the last 4 years [2013-2016]. From the 1,138 patients who received surgical treatment during that period, 284 were excluded since they did not meet the criteria. Exclusion criteria involved previous neck operation, parathyroid surgery, pre-existing vocal cord palsy (VCP) and unilateral surgery. A total of 854 patients were eligible for our study. All patients were subjected to pre-and postoperative indirect laryngoscopy by the same experienced ENT specialist team and all the surgeries were performed by the same experienced team. The whole procedure followed the International Neural Monitoring Study Group's (INMSG) Guideline Statement. Results: We experienced 70 cases (70/854, 8.2%) with postoperative VCP. Two of them (0.23%) had permanent VCP and the rest of those patients (7.97%) experienced transient VCP. Twenty-three (2.7%) patients were candidates for staged thyroidectomy after LOS on the first side of resection, including ten patients with papillary or medullary thyroid carcinoma and one with toxic multinodular goiter (MNG). Of those patients, 22 incidents of VCP (95.7%) have recovered within two months and one of them persisted for more than six months (permanent VCP). We did not experience any permanent bilateral RLN palsy after the implementation of the staged procedure. Conclusions: Staged thyroidectomy seems a very attractive and promising procedure for both patient and surgeon, since it nearly eliminates one of the most fearful complications in thyroid surgery. We suggest staged thyroidectomy in all cases with first side of resection signal loss, even in malignancies, since the benefits are much more than the disabilities in a patient's morbidity and quality of life.

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Section: Introductionmentioning

confidence: 96%

Two-stage thyroidectomy in the era of intraoperative neuromonitoring

Christoforides¹,

Papandrikos²,

Polyzois³

et al. 2017

Gland Surg.

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“…An enquiry among German endocrine and thyroid surgeons revealed that over 85 per cent of the surgical departments surveyed would be willing to discontinue surgery in the event of initial loss of signal. In contrast, a recent survey among French endocrine surgeons reported that only a minority would be in favour of staging a total thyroidectomy.…”

Section: Discussionmentioning

confidence: 82%

Contralateral surgery in patients scheduled for total thyroidectomy with initial loss or absence of signal during neural monitoring

Sitges‐Serra

Gallego-Otaegui

Fontané

et al. 2019

British Journal of Surgery

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Background: Staged total thyroidectomy has been advised to prevent bilateral recurrent laryngeal nerve paralysis when loss of the signal from neural monitoring is observed after dissection of the initial thyroid lobe. This is supported by expert opinion but hard evidence is lacking. A lost signal can return during surgery or, even if it persists, its positive predictive value is only in the range 60-70 per cent. The aim of the present study was to investigate the clinical outcome of patients in whom total thyroidectomy was performed following loss of signal after dissection of the first thyroid lobe. Methods:This was a prospective observational study of adult patients scheduled for neural monitoring during total thyroidectomy. The prevalence of first-side absence or loss of signal was recorded. The contralateral thyroid lobe was approached routinely. The vagus and recurrent laryngeal nerves on the first side were retested during and at the end of the contralateral procedure.Results: Some 462 patients were included. Loss (32 patients) or initial absence (8) of signal at dissection of the first thyroid lobe was noted in 40 patients (8⋅7 per cent). Total thyroidectomy was completed in 29 patients, and a change of surgical strategy adopted in 11 patients with benign disease. At retesting, 15 of 37 initially silent nerves recovered electromyographic signal after a mean(s.d.) interval of 30(14) min. Postoperative vocal cord palsy/paresis was demonstrated in 24 of 40 patients. One patient developed a bilateral paresis that could be managed conservatively. Conclusion:After an absence or loss of signal of the recurrent laryngeal nerve following dissection of the first thyroid lobe, contralateral thyroidectomy can be performed safely, avoiding the expense, psychological burden and potential complications of a second procedure.

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“…The prompt relief of symptoms and the best alleviation obtained in case of endocrine ophthalmopathy are also worth to be counted among its advantages. Although lifelong thyroxine replacement treatment should be applied to patients following total thyroidectomy, the complication ratio seem to be almost equal with those seen in nontotal procedures (4,5). Furthemore, in case of repeat surgery for recurrent disease, especially when the operation is performed by an inexperienced surgeon, the complication rates reach up to 20-25 % (3).…”

Section: Discussionmentioning

confidence: 99%

“…Meticulous hemostasis can be achieved with harmonic sealing instrument, since improper hemostasis is known to increase the risk of RLNI (4). Despite the lack of evidence to support an advantage of IONM over the standard anatomic dissection of RLN, surgeons have adopted it in increasing ratios (5,11,12).…”

Section: Discussionmentioning

confidence: 99%

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Recurrent laryngeal nerve injury (RLNI) in total thyroidectomy with intraoperative nerve monitoring (IONM) and harmonic sealing instrument: A retrospective analysis and treatment results

Yuksekdag¹,

Topcu²,

Deveci³

et al. 2019

Eastern J Med

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The aim of the current study was to reveal the incidence of RLNI in our patients with total thyroidectomy and to evaluate their clinical outcomes. Charts of 260 patients who underwent total thyroidectomy between 2014 and 2018 were interrogated retrospectively. Standard IONM and harmonic seal were used in all. Patients with suspect of RLNI were further evaluated. Demographics, etiologic disease and the overall treatment results were presented. A total of 12 patients with RLNI (4.6 %) were presented. Nine (75 %) were women and 3 (25 %) were men. Mean age was 51 years (range, 32-67). RLNI was unilateral in 8 patients (3 %; 50 % in right RLN and 50 % in left RLN) and bilateral in four (1.5 %). All were started corticosteroid and follow-up period was 26 months (range, 9-52). Mean hospital stay was 4 days (range, 2-14). Histopathological evaluations revealed papillary carcinoma (n=7, 58 %), multinodular goitre with thyroiditis (n=4, 34 %) and multinodular goitre with parathyroid adenoma (n=1, 8 %). In a patient with bilateral RLNI (0.3 %), tracheostomy was done on postoperative day 2, and closed on postoperative month 4. Thyroplasty and suture lateralization were applied to other bilateral RLNI cases. In 5 patients with unilateral RLNI and one with bilateral palsy, vocal cords became normal in first 6 months (transient palsy, 2.3 %). Careful surgical dissection with harmonic and IONM employed in total thyroidectomy are both reliable methods. In case of inevitable RLNI, a close follow-up and cooperation are mandatory to have optimal results.

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Loss of neuromonitoring signal during bilateral thyroidectomy: no systematic change in operative strategy according to a survey of the French Association of Endocrine Surgeons (AFCE)

Cited by 9 publications

References 23 publications

Two-stage thyroidectomy in the era of intraoperative neuromonitoring

Two-stage thyroidectomy in the era of intraoperative neuromonitoring

Contralateral surgery in patients scheduled for total thyroidectomy with initial loss or absence of signal during neural monitoring

Recurrent laryngeal nerve injury (RLNI) in total thyroidectomy with intraoperative nerve monitoring (IONM) and harmonic sealing instrument: A retrospective analysis and treatment results

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