Tsang Raymond K, Law Simon
World J Surg. 2016 Jan;40(1):137-41. doi: 10.1007/s00268-015-3265-4.
Esophagectomy has risk of recurrent laryngeal nerve (RLN) injury. Conventional nerve monitoring has been used to help identify and protect the RLN. A new concept of continuous intraoperative nerve monitoring (CIONM) by stimulation of the ipsilateral vagus nerve has been used in thyroidectomy. The current report describes adapting the CIONM method for use in video-assisted thoracoscopic (VATS) esophagectomy.
The nerve monitor employed is NIM 3.0 with automatic periodic stimulation (Medtronics Inc., USA). Patient is intubated with NIM contact-reinforced EMG endotracheal tube (Medtronics Inc., USA). The operation starts with a left lower neck incision, and the stimulating electrode is secured around the left vagus nerve. The patient is then turned to the left lateral position for VATS esophagectomy. CIONM of the left RLN is achieved by regular stimulation of the left vagus nerve, and intact nerve conduction is detected by the electromyography (EMG) of the left vocalis muscle. The alarm is set to activate when EMG amplitude reduces by 50% or latency prolongs by 10%.
Initial experience of ten cases showed that a mean time of 35 min was required to complete the electrode insertion in the neck. There was one event in which there was more than 50% reduction of EMG amplitude that persisted but the patient had no vocal cord paralysis after operation. In another patient, the EMG reduced by 75% and persisted. The patient had temporary vocal cord paralysis.
CIONM is feasible during VATS esophagectomy and can alert the surgeon of imminent injury to the RLNs, thereby preventing permanent injury.
食管切除术存在喉返神经（RLN）损伤的风险。传统的神经监测已被用于帮助识别和保护喉返神经。通过刺激同侧迷走神经进行术中连续神经监测（CIONM）这一新概念已应用于甲状腺切除术。本报告描述了将CIONM方法应用于电视辅助胸腔镜（VATS）食管切除术。
所使用的神经监测仪为带有自动周期性刺激功能的NIM 3.0（美国美敦力公司）。患者使用NIM接触增强型肌电图气管内导管（美国美敦力公司）进行插管。手术从左颈部下切口开始，刺激电极固定在左迷走神经周围。然后患者转为左侧卧位进行VATS食管切除术。通过定期刺激左迷走神经实现对左喉返神经的CIONM，并通过左声带肌的肌电图（EMG）检测完整的神经传导。当EMG振幅降低50%或潜伏期延长10%时，警报被设置为激活。
10例患者的初步经验表明，在颈部完成电极插入平均需要35分钟。有1例事件中，EMG振幅降低超过50%且持续存在，但患者术后未出现声带麻痹。在另一例患者中，EMG降低了75%且持续存在。该患者出现了暂时性声带麻痹。
CIONM在VATS食管切除术中是可行的，并且可以提醒外科医生喉返神经即将受到损伤，从而防止永久性损伤。
