Christoforides Christos, Papandrikos Ioannis, Polyzois Georgios, Roukounakis Nikolaos, Dionigi Gianlorenzo, Vamvakidis Kyriakos
Department of Endocrine Surgery, Central Clinic of Athens, Athens, Greece.
ENT Department, Central Clinic of Athens, Athens, Greece.
Gland Surg. 2017 Oct;6(5):453-463. doi: 10.21037/gs.2017.07.15.
The use of intraoperative neuromonitoring (IONM) provides surgeons with real time information about recurrent laryngeal nerves (RLN) functional integrity. Hence, allowing them to modify the initially scheduled bilateral procedure, to a two-stage thyroidectomy in cases of loss of signal (LOS) on the first side of resection resulting in minimization of bilateral RLN injury. The purpose of our study was to present our results since the implementation of the above mentioned process in both malignant and benign thyroid disease.
We conducted a retrospective, observational cohort study of prospectively collected data from all patients who underwent a scheduled total thyroidectomy with or without neck dissection in our Department over the last 4 years [2013-2016]. From the 1,138 patients who received surgical treatment during that period, 284 were excluded since they did not meet the criteria. Exclusion criteria involved previous neck operation, parathyroid surgery, pre-existing vocal cord palsy (VCP) and unilateral surgery. A total of 854 patients were eligible for our study. All patients were subjected to pre- and postoperative indirect laryngoscopy by the same experienced ENT specialist team and all the surgeries were performed by the same experienced team. The whole procedure followed the International Neural Monitoring Study Group's (INMSG) Guideline Statement.
We experienced 70 cases (70/854, 8.2%) with postoperative VCP. Two of them (0.23%) had permanent VCP and the rest of those patients (7.97%) experienced transient VCP. Twenty-three (2.7%) patients were candidates for staged thyroidectomy after LOS on the first side of resection, including ten patients with papillary or medullary thyroid carcinoma and one with toxic multinodular goiter (MNG). Of those patients, 22 incidents of VCP (95.7%) have recovered within two months and one of them persisted for more than six months (permanent VCP). We did not experience any permanent bilateral RLN palsy after the implementation of the staged procedure.
Staged thyroidectomy seems a very attractive and promising procedure for both patient and surgeon, since it nearly eliminates one of the most fearful complications in thyroid surgery. We suggest staged thyroidectomy in all cases with first side of resection signal loss, even in malignancies, since the benefits are much more than the disabilities in a patient's morbidity and quality of life.
术中神经监测（IONM）的应用为外科医生提供了有关喉返神经（RLN）功能完整性的实时信息。因此，在切除一侧出现信号丢失（LOS）的情况下，可使他们将最初计划的双侧手术改为两阶段甲状腺切除术，从而将双侧RLN损伤降至最低。我们研究的目的是展示自上述过程应用于恶性和良性甲状腺疾病以来的结果。
我们对过去4年[2013 - 2016年]在我们科室接受计划甲状腺全切除术（伴或不伴颈部淋巴结清扫）的所有患者前瞻性收集的数据进行了一项回顾性观察队列研究。在该期间接受手术治疗的1138例患者中，284例因不符合标准而被排除。排除标准包括既往颈部手术、甲状旁腺手术、既往存在声带麻痹（VCP）和单侧手术。共有854例患者符合我们的研究条件。所有患者均由同一经验丰富的耳鼻喉专科团队进行术前和术后间接喉镜检查，所有手术均由同一经验丰富的团队进行。整个过程遵循国际神经监测研究组（INMSG）的指南声明。
我们有70例（70/854，8.2%）患者术后出现VCP。其中2例（0.23%）发生永久性VCP，其余患者（7.97%）经历短暂性VCP。23例（2.7%）患者在切除一侧出现LOS后成为两阶段甲状腺切除术的候选者，包括10例乳头状或髓样甲状腺癌患者和1例毒性多结节性甲状腺肿（MNG）患者。在这些患者中，22例VCP事件（95.7%）在两个月内恢复，其中1例持续超过6个月（永久性VCP）。在实施两阶段手术之后，我们未出现任何永久性双侧RLN麻痹。
两阶段甲状腺切除术对患者和外科医生来说似乎都是一种非常有吸引力且有前景的手术方式，因为它几乎消除了甲状腺手术中最可怕的并发症之一。我们建议在所有切除一侧出现信号丢失的病例中采用两阶段甲状腺切除术，即使是恶性肿瘤患者，因为其益处远大于对患者发病率和生活质量造成的不利影响。
