Division of Endocrine Surgery, Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong Special Administrative Region.
Division of Endocrine Surgery, Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong Special Administrative Region.
Int J Surg. 2017 Feb;38:21-30. doi: 10.1016/j.ijsu.2016.12.039. Epub 2016 Dec 26.
Use of intra-operative neuro-monitoring (IONM) during high-risk thyroidectomy has been suggested to decrease the rate of recurrent laryngeal nerve (RLN) palsy. However, current evidences were mixed and there was no large-scale study concluding its benefit. We evaluated the role of IONM in reducing RLN palsy during high-risk thyroidectomy and identified which high-risk subgroup would be most benefited.
A systemic review was performed to identify studies comparing the use of IONM and visual identification of RLN alone (VA) during high-risk thyroidectomy, namely re-operation, thyroidectomy for malignancy, thyrotoxicosis or retrosternal goitre. Rate of RLN palsy was presented in terms of number of nerve-at-risk (NAR). Meta-analysis on overall high-risk thyroidectomy and subgroups were performed using fixed or random-effects model.
Ten articles were eligible for final analysis. There were 4460 NARs in VA group and 6155 NARs in IONM group. Comparing to VA, IONM had lower rate of overall [4.5% vs. 2.5%, Odd ratio (OR): 1.40, 95% confidence interval (CI): 1.12-1.79, p = 0.003] and temporary [3.9% vs. 2.4%; OR: 1.47, 95% CI: 1.07-2.00, p = 0.016] RLN palsy in overall high-risk thyroidectomies. On subgroup analysis, although numbers of NARs were less than minimal numbers required for a statistical powered study (2.1%-72.7%), use of IONM decreased the rate of overall RLN palsy during re-operation (7.6% vs. 4.5%, OR: 1.32, p = 0.021) and temporary RLN palsy during thyroidectomy for malignancy (3.1% vs. 1.6%, OR: 1.90, p = 0.026). Use of IONM tended to have a lower rate of overall RLN palsy during thyroidectomy for malignancy than VA alone. (3.5% vs. 2.1%, p = 0.050).
Selective use of IONM during high-risk thyroidectomy decreased the rate of overall RLN palsy. IONM should be applied during re-operative thyroidectomy and thyroidectomy for malignancy.
术中神经监测（IONM）在高危甲状腺切除术中的应用被认为可以降低喉返神经（RLN）麻痹的发生率。然而，目前的证据存在分歧，并且没有大规模的研究得出其有益的结论。我们评估了 IONM 在降低高危甲状腺切除术中 RLN 麻痹中的作用，并确定了哪些高危亚组将受益最大。
系统回顾旨在确定比较术中神经监测和单独使用 RLN 视觉识别（VA）在高危甲状腺切除术（即再次手术、甲状腺癌切除术、甲状腺功能亢进或胸骨后甲状腺肿）中的应用的研究。RLN 麻痹的发生率以神经风险（NAR）数量表示。使用固定或随机效应模型对整体高危甲状腺切除术和亚组进行荟萃分析。
最终有 10 篇文章符合分析要求。VA 组有 4460 个 NAR，IONM 组有 6155 个 NAR。与 VA 相比，IONM 降低了整体[4.5%比 2.5%，比值比（OR）：1.40，95%置信区间（CI）：1.12-1.79，p=0.003]和暂时性[3.9%比 2.4%；OR：1.47，95%CI：1.07-2.00，p=0.016] RLN 麻痹的发生率。在亚组分析中，尽管 NAR 数量少于进行统计学有效研究所需的最小数量（2.1%-72.7%），但 IONM 降低了再次手术时整体 RLN 麻痹的发生率（7.6%比 4.5%，OR：1.32，p=0.021）和恶性肿瘤甲状腺切除术时暂时性 RLN 麻痹的发生率（3.1%比 1.6%，OR：1.90，p=0.026）。IONM 在恶性肿瘤甲状腺切除术时降低整体 RLN 麻痹的发生率的趋势优于 VA 单独使用（3.5%比 2.1%，p=0.050）。
高危甲状腺切除术中选择性使用 IONM 可降低整体 RLN 麻痹的发生率。IONM 应在再次手术和恶性肿瘤甲状腺切除术期间使用。
