Thoracic and Endocrine Surgery, University Hospitals of Geneva, Geneva, Switzerland.
Thyroid. 2013 Mar;23(3):329-33. doi: 10.1089/thy.2012.0368.
One of the worst complications in thyroid surgery is bilateral recurrent laryngeal nerve paralysis, which can lead to transient or definitive tracheotomy.
We implemented a strict standard operative procedure beginning in January 2010 and modified our operative procedure. In all patients undergoing bilateral operation, we begin with the largest side or with the cancerous/suspicious side without dissecting the contralateral side. If the intraoperative neuromonitoring (IONM) signal is lost after stimulation of the vagus nerve at the end of the first side, we stop the procedure after the unilateral lobectomy, even if the recurrent nerve is anatomically intact and regardless of malignancy. If the IONM signal is lost, serial laryngoscopies are performed until recovery or definitive recurrent laryngeal nerve palsy is demonstrated. We report here our results in patients with loss of the IONM signal after lobectomy and discuss the medical implications for benign and malignant thyroid conditions.
Since January 2010, the operation has been stopped at the first side in 9 out of 220 planned bilateral thyroidectomies. There were five benign thyroid conditions and four thyroid cancers, including three papillary thyroid cancers and one bilateral medullary thyroid cancer in a patient with multiple endocrine neoplasia 2a. In two patients, it was a false-positive IONM loss. One of these two patients had the other lobe removed at day 3. In seven patients the laryngoscopy demonstrated total or partial laryngeal nerve palsy at day 1, but the recurrent nerve function recovered fully in all patients between 1 and 4 months postoperatively. All cancer patients were operated on the other side within 3 days to 3 months; one patient with a benign condition is being followed conservatively. One of the eight re-operated patients had transient recurrent nerve palsy postoperatively.
In our opinion, the systematic use of IONM and the change in operative strategy will lead to an almost 0% rate of bilateral laryngeal nerve palsy, at least in benign thyroid conditions. A loss of signal after the first side should prompt a halt in the procedure, even in cases of malignancies.
甲状腺手术中最严重的并发症之一是双侧喉返神经麻痹，这可能导致暂时性或永久性气管切开。
我们自 2010 年 1 月开始实施严格的标准手术程序，并修改了手术程序。在所有接受双侧手术的患者中，我们首先处理最大的一侧或有癌症/可疑的一侧，而不解剖对侧。如果在第一侧结束时刺激迷走神经后术中神经监测（IONM）信号丢失，我们将在单侧叶切除术后停止手术，即使喉返神经解剖完整且无论是否为恶性肿瘤。如果 IONM 信号丢失，将进行连续喉镜检查，直到恢复或明确出现喉返神经麻痹。我们在此报告我们在 IONM 信号丢失后行 lobectomy 的患者的结果，并讨论良性和恶性甲状腺疾病的医学意义。
自 2010 年 1 月以来，在 220 例计划双侧甲状腺切除术中有 9 例在第一侧停止手术。其中有 5 例为良性甲状腺疾病，4 例为甲状腺癌，包括 3 例甲状腺乳头状癌和 1 例多发性内分泌瘤 2a 患者的双侧髓样甲状腺癌。在 2 例患者中，IONM 信号丢失为假阳性。这 2 例患者中的 1 例在第 3 天切除了另一侧。7 例患者在第 1 天行喉镜检查显示完全或部分喉返神经麻痹，但所有患者在术后 1 至 4 个月内完全恢复了喉返神经功能。所有癌症患者均在 3 天至 3 个月内对另一侧进行手术；1 例良性疾病患者正在保守治疗中。8 例再次手术的患者中有 1 例术后出现暂时性喉返神经麻痹。
我们认为，系统使用 IONM 和改变手术策略将导致双侧喉返神经麻痹率几乎为 0%，至少在良性甲状腺疾病中是这样。第一侧手术后信号丢失应促使手术停止，即使是恶性肿瘤。
