Department of Head & Neck Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China; Cancer Research Institute, Fudan University Shanghai Cancer Center, Shanghai, 200032, China.
Department of Head & Neck Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China.
Int J Surg. 2017 Mar;39:104-113. doi: 10.1016/j.ijsu.2017.01.086. Epub 2017 Jan 25.
Intraoperative neuromonitoring (IONM) has been a commonly used technology during thyroid surgery aimed at reducing the incidence of recurrent laryngeal nerve palsy (RLNP), which is a severe complication and leads to significant impacts on a patient's life. In order to give a comprehensive assessment for potential benefits and disadvantage of IONM, this meta-analysis and systematic review discusses RLNP rate, predictive power, continuous intraoperative neuromonitoring (CIONM), and emphasises application during thyroid cancer surgeries.
A literature search was performed in the following electronic databases: PubMed, Embase, and the Cochrane library from January 1, 2004 to July 30, 2016. After applying inclusion and exclusion criteria, 24 studies, including four prospective randomised trials, were selected. Heterogeneity of studies was checked by the Cochran Q test. Publication bias was assessed by funnel plots with Egger's linear regression test of asymmetry. Odds ratio (OR) was calculated by random effects model.
Overall, 9203 patients and 17,203 nerves at risk (NAR) were included. Incidence of overall, transient, and persistent RLNP in IONM group were, respectively, 3.15%, 1.82%, and 0.67%, whereas for the ID group, they were 4.37%, 2.58%, and 1.07%. The summary OR of overall, transient, and persistent RLNP compared using IONM and ID were, respectively, 0.81 (95%CI 0.66-0.99), 0.76 (95%CI 0.61-0.94), and 0.78 (95%CI 0.55-1.09).
The presented data showed benefits of reducing RLNP rate by using IONM, but without statistical significance for persistent RLNP rate. For patients with thyroid cancer who undergo total thyroidectomy, using IONM may improve the outcome by reducing amount of residual thyroid tissue. However, no benefits were found for thyroid reoperation; visual identification and careful dissection remain standard for this challenging procedure. In addition, the relative low positive predictive power indicated intermittent intraoperative neuromonitoring (IIONM) may not be reliable; but CIONM was showed to be a more promising method, with prudent approach.
术中神经监测（IONM）已成为甲状腺手术中常用的技术，旨在降低喉返神经麻痹（RLNP）的发生率，RLNP 是一种严重的并发症，会对患者的生活产生重大影响。为了全面评估 IONM 的潜在益处和缺点，本荟萃分析和系统评价讨论了 RLNP 发生率、预测能力、连续术中神经监测（CIONM），并强调了在甲状腺癌手术中的应用。
我们在以下电子数据库中进行了文献检索：PubMed、Embase 和 Cochrane 图书馆，检索时间为 2004 年 1 月 1 日至 2016 年 7 月 30 日。应用纳入和排除标准后，选择了 24 项研究，其中包括四项前瞻性随机试验。通过 Cochran Q 检验检查研究的异质性。通过漏斗图和 Egger 线性回归检验不对称性评估发表偏倚。采用随机效应模型计算比值比（OR）。
总体而言，纳入了 9203 名患者和 17203 条风险神经（NAR）。IONM 组的总体、短暂和持续性 RLNP 发生率分别为 3.15%、1.82%和 0.67%，而 ID 组分别为 4.37%、2.58%和 1.07%。与 ID 相比，IONM 组的总体、短暂和持续性 RLNP 的汇总 OR 分别为 0.81（95%CI 0.66-0.99）、0.76（95%CI 0.61-0.94）和 0.78（95%CI 0.55-1.09）。
目前的数据显示，使用 IONM 可降低 RLNP 发生率，但持续性 RLNP 发生率无统计学意义。对于接受全甲状腺切除术的甲状腺癌患者，使用 IONM 可通过减少残留甲状腺组织来改善结果。然而，在甲状腺再手术中未发现益处；对于这一具有挑战性的手术，仍需通过肉眼识别和仔细解剖。此外，相对较低的阳性预测能力表明间歇性术中神经监测（IIONM）可能不可靠；但 CIONM 是一种更有前途的方法，需要谨慎的方法。
