Clinical Value of Intraoperative Neuromonitoring of the Recurrent Laryngeal Nerves in Improving Outcomes of Surgery for Well-Differentiated Thyroid Cancer

• Authors: Marcin Barczyński , Aleksander Konturek , Małgorzata Stopa , Alicja Hubalewska-Dydejczyk , Piotr Richter , Wojciech Nowak
• Languages of publication: EN

Abstracts

EN

The recurrent laryngeal nerve (RLN) is particularly prone to injury during thyroidectomy in case of extralaryngeal bifurcation being present in approximately one-third of patients near the inferior thyroid artery or ligament of Berry. Meticulous surgical dissection in this area may be additionally facilitated by the use of intraoperative neuromonitoring (IONM) to assure safe and complete removal of thyroid tissue.The aim of the study was to verify the hypothesis that meticulous surgical technique of tissue dissection in the area of the posterior surface of the thyroid capsule and adjacent RLN may be additionally facilitated by intraoperative neuromonitoring (IONM), and may contribute to increasing the safety and radicalness of total thyroidectomy in patients with well-differentiated thyroid cancer.Material and methods. The outcomes of total thyroidectomy with level VI lymph node clearance for well-differentiated thyroid cancer (WDTC; pT1-3, N0-1, Mx) were retrospectively compared between 151 patients undergoing surgery with IONM (01/2005-06/2009) and 151 patients undergoing surgery without IONM (2003-2004). RLN morbidity (calculated for nerves at risk) was assessed by videolaryngoscopy or indirect laryngoscopy (mandatory before and after surgery and at 12-month follow-up). The anatomical course of the extralaryngeal segment of RLNs were analyzed in detail in each operation. Thyroid iodine uptake (131I) was measured during endogenous TSH stimulation test a week before radioiodine therapy.Results. Among patients operated with vs. without IONM, the early RLN injury rate was 3% vs. 6.7% (p=0.02), including 2% vs. 5% (p=0.04) of temporary nerve lesions, and 1% vs. 1.7% of permanent nerve events (p=0.31), respectively. Extralaryngeal RLN bifurcation was identified in 42 (27.8%) vs. 25 (16.6%) of patients operated with vs. without IONM, respectively (p=0.001). Mean I-131 uptake following total thyroidectomy with vs. without IONM was 0.67 ± 0.39% vs. 1.59 ± 0.69% (p<0.001). 131I uptake lower than 1% was found in 106 (70.2%) vs. 38 (25.2%) patients operated with vs. without IONM, respectively (p<0.001).Conclusions. Most patients with WDTC who undergo total thyroidectomy have a small amount of residual thyroid tissue. The use of IONM may improve the outcomes of surgery among these patients by both increasing the completeness of total thyroidectomy and significantly reducing the prevalence of temporary RLN injury. The possible mechanism of this improvement is the aid in dissection at the level of the Berry's ligament offered by IONM which enhances the surgeon's ability to identify a branched RLN, and allows for reduction of traction injury and neuropraxia of the anterior branch of bifid nerves.

Keywords

EN

thyroid cancer; recurrent laryngeal nerve; intraoperative neuromonitoring

• Publisher: De Gruyter Open
• Journal: Polish Journal of Surgery
• Year: 2011
• Volume: 83
• Issue: 4
• Pages: 196-203

Dates

published

1 - 4 - 2011

online

7 - 6 - 2011

Contributors

author

Marcin Barczyński

• 3rd Chair and Department of General Surgery, Collegium Medicum Jagiellonian, University in Cracow

author

Aleksander Konturek

• 3rd Chair and Department of General Surgery, Collegium Medicum Jagiellonian, University in Cracow

author

Małgorzata Stopa

• 3rd Chair and Department of General Surgery, Collegium Medicum Jagiellonian, University in Cracow

author

Alicja Hubalewska-Dydejczyk

• Chair and Department of Endocrinology, Collegium Medicum Jagiellonian University in Cracow

author

Piotr Richter

• 3rd Chair and Department of General Surgery, Collegium Medicum Jagiellonian, University in Cracow

author

Wojciech Nowak

• 3rd Chair and Department of General Surgery, Collegium Medicum Jagiellonian, University in Cracow

References

• Cooper DS, Doherty GM, Haugen BR et al.: Revised American Thyroid Association Management Guidelines for Patients with Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid 2009; 19: 1167-1214[Crossref][PubMed][WoS]
• Barczyński M, Konturek A, Hubalewska-Dydejczyk A et al.: Five-year follow-up of a randomized clinical trial of total thyroidectomy versus Dunhill operation versus bilateral subtotal thyroidectomy for multinodular nontoxic goiter. World J Surg 2010; 34: 1203-13.[WoS]
• Salvatori M, Raffaelli M, Castaldi P et al.: Evaluation of the surgical completeness after total thyroidectomy for differentiated thyroid carcinoma. Eur J Surg Oncol 2007; 33: 648-54.[WoS]
• Lahey FH: Routine dissection and demonstration of recurrent laryngeal nerves in subtotal thyroidectomy. Surg Gynecol Obstet 1938; 66: 775-77.
• Riddel VH: Injury to recurrent laryngeal nerves during thyroidctomy - a comparison between the results of identification and non-identification in 1022 nerves exposed to risk. Lancet 1956; 29: 638-41.
• Hermann M, Alk G, Roka R et al.: Laryngeal recurrent nerve injury in surgery for benign thyroid disease: effect of the nerve dissection and impact of individual surgeon in more than 27,000 nerves at risk. Ann Surg 2002; 235: 261-68.
• Steurer M, Passler C, Denk DM et al.: Advantages of recurrent laryngeal nerve identification in thyroidectomy and parathyroidectomy and the importance of preoperative and postoperative laryngoscopic examination in more than 1000 nerves at risk. Laryngoscope 2002; 112: 124-33.
• Randolph GW: The importance of pre- and postoperative laryngeal examination for thyroid surgery. Thyroid 2010; 20: 453-58.[WoS][Crossref][PubMed]
• Sancho JJ, Pascual-Damieta M, Pereira JA et al.: Risk factors for transient vocal cord palsy after thyroidectomy. Br J Surg 2008; 95: 961-67.
• Barczyński M, Konturek A, Cichoń S: Randomized clinical trial of visualization versus neuromonitoring of recurrent laryngeal nerves during thyroidectomy. Br J Surg 2009; 96: 240-46.
• Serpell JW: New operative surgical concept of two fascial layers enveloping the recurrent laryngeal nerve. Ann Surg Oncol 2010; 17: 1628-36.[WoS]
• Serpell JW, Yeung MJ, Grodski S: The motor fibers of the recurrent laryngeal nerve are located in the anterior extralaryngeal branch. Ann Surg 2009; 249: 648-52.[WoS]
• Barczyński M, Nowak W, Sancho JJ et al.: The motor fibers of the recurrent laryngeal nerves are located in the anterior extralaryngeal branch. Ann Surg 2010; 251: 773-74.
• Randolph GW, Dralle H with the International Intraoperative Monitoring Study Group. Electrophysiologic recurrent laryngeal nerve monitoring during thyroid and parathyroid surgery - International standards guideline statement. Laryngoscope 2011; 121(S1): S1-S16.[WoS]
• Jarząb B, Sporny S, Lange D i wsp.: Diagnostyka i leczenie raka tarczycy - rekomendacje polskie. Endokrnol Pol 2010; 61: 518-68.
• Dralle H, Sekulla C, Lorenz K et al with the German IONM Study Group. Intraoperative monitoring of the recurrent laryngeal nerve in thyroid surgery. World J Surg. 2008; 32: 1358-66.[Crossref][WoS]
• Chiang FY, Lu IC, Kuo WR: The mechanism of recurrent laryngeal nerve injury during thyroid surgery - the application of intraoperative neuromonitoring. Surgery 2008; 143: 743-49.[WoS]
• Snyder SK, Hendricks JC: Intraoperative neurophysiology testing of the recurrent laryngeal nerve: Plaudits and pitfalls. Surgery 2005; 138: 1183-92.
• Barczyński M, Konturek A, Cichoń S: Value of intraoperative neuromonitoring in surgery for thyroid cancer in identification and prognosis of function of the recurrent laryngeal nerves. Endokrynol Pol 2006; 57: 343-46.
• 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 206; 140: 866-73.
• Snyder SK, Lairmore TC, Hendricks JC et al.: Elucidating mechanisms of recurrent laryngeal nerve injury during thyroidectomy and parathyroidectomy. J Am Coll Surg 2008; 206: 123-30.
• Kruse E, Olthoff A, Schiel R: Functional anatomy of the recurrent and superior laryngeal nerve. Langenbecks Arch Surg 2006; 391: 4-8.
• Angelos P: Recurrent laryngeal nerve monitoring: state of the art, ethical and legal issues. Surg Clin North Am 2009; 89: 1157-69.[WoS]
• Horne SK, Gal TJ, Brennan JA: Prevalence and patterns of intraoperative nerve monitoring for thyroidectomy. Otolaryngol Head Neck Surg 2007; 136: 952-56.[WoS]
• Sturgeon C, Sturgeon T, Angelos P: Neuromonitoring in thyroid surgery: attitudes, usage patterns, and predictors of use among endocrine surgeons. World J Surg 2009; 33: 417-25.[WoS]
• Dadan J, Łukaszewicz J, Safiejko K i wsp.: Ocena przydatności śródoperacyjnej lokalizacji nerwów krtaniowych wstecznych z zastosowaniem neuromonitoringu w chirurgicznym leczeniu wola. Acta Clinica et Morphologica 2008; 11: 8-14.

Identifiers

DOI

10.2478/v10035-011-0030-8