Chinese guidelines on intraoperative neuromonitoring in thyroid and parathyroid surgery (2023 edition)
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ABSTRACT:
SUBMITTER: Sun H
PROVIDER: S-EPMC10493630 | biostudies-literature | 2023 Aug
REPOSITORIES: biostudies-literature
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Project description:BackgroundContinuous intraoperative neuromonitoring has successfully demonstrated to predict impending damage to the recurrent laryngeal nerve, by detecting changes in electromyographic recordings. Despite the apparent benefits associated with continuous intraoperative neuromonitoring, its safety is still a debate. The aim of this study was to investigate the electrophysiological impact of continuous intraoperative neuromonitoring on the vagus nerve.MethodsIn this prospective study, the amplitude of the electromyographic wave of the vagus nerve-recurrent laryngeal nerve axis was measured both proximally and distally to the stimulation electrode placed upon the vagus nerve. Electromyographic signal amplitudes were collected at three distinct events during the operation: during the dissection of the vagus nerve, before application of the continuous stimulation electrode onto the vagus nerve and after its removal.ResultsIn total, 169 vagus nerves were analysed, among 108 included patients undergoing continuous intraoperative neuromonitoring-enhanced endocrine neck surgeries. Electrode application resulted in a significant overall decrease in measured proximo-distal amplitudes of -10.94 µV (95 per cent c.i. -17.06 to -4.82 µV) (P < 0.005), corresponding to a mean(s.d.) decrease of -1.4(5.4) per cent. Before the removal of the electrode, the measured proximo-distal difference in amplitudes was -18.58 µV (95 per cent c.i. -28.31 to -8.86 µV) (P < 0.005), corresponding to a mean(s.d.) decrease of -2.50(9.59) per cent. Seven nerves suffered a loss of amplitude greater than 20 per cent of the baseline measurement.ConclusionIn addition to supporting claims that continuous intraoperative neuromonitoring exposes the vagus nerve to injury, this study shows a mild electrophysiological impact of continuous intraoperative neuromonitoring electrode placement on the vagus nerve-recurrent laryngeal nerve axis. However, the small observed differences are negligible and were not associated with a clinically relevant outcome, making continuous intraoperative neuromonitoring a safe adjunct in selected thyroid surgeries.
| S-EPMC10249491 | biostudies-literature
Project description:Objective:Stimulator-attached dissecting instruments are useful for intraoperative nerve monitoring during thyroidectomy. The aim of this study was to evaluate the feasibility of an attachable ring stimulator (ARS) by comparing the electromyography (EMG) amplitudes evoked by an ARS and a conventional stimulator. Methods:Medical records of fourteen patients who underwent thyroidectomy using intraoperative neuromonitoring between June and August 2019 were retrospectively reviewed. The amplitudes of V1, R1, R2, and V2 signals were checked using both the ARS and a conventional stimulator, at the same point. Results:Both stimulators were tested on 20 recurrent laryngeal nerves (RLNs) and 20 vagus nerves (VNs). In all the nerves, the amplitudes of V1, R1, R2, and V2 were greater than 500??V. The mean amplitudes of V1, R1, R2, and V2 checked with the ARS were 1175, 1432, 1598, and 1279??V, respectively. The mean amplitudes of V1, R1, R2, and V2 checked with the conventional stimulator were 1140, 1425, 1557, and 1217??V, respectively. Difference between amplitudes evoked by the two stimulators for V1, R1, R2, and V2 was 77, 110, 102, and 99??V, respectively. There was no statistical difference in the amplitudes between the two groups for V1, R1, R2, and V2. Conclusion:The ARS transferred electric stimulation as effectively as the conventional stimulator. It is an effective tool for repeated stimulation and facilitates continuous feedback regarding the functional integrity of nerves during thyroid surgery.
| S-EPMC7204267 | biostudies-literature
Project description: Not available
| S-EPMC7808084 | biostudies-literature
Project description:BackgroundThe advantage of intraoperative neuromonitoring (IONM) has been widely accepted in thyroid/parathyroid surgery. However, there are discrepancies of amplitudes on recurrent laryngeal nerve (RLN) palsy and vocal cord paralysis (VCP) because of amplitude variations among individuals. Accordingly, the universal usefulness of quantitative amplitude value per se among patients were assessed.Study designIONM using a 4-step method (Vagus nerve (V1)-RLN (R1)-R2-V2) was applied to 777 RLNs (510 patients). Forty-nine RLNs were excluded because of either loss of signal without preoperative VCP or combined RLN resection. The remaining 728 RLNs were evaluated. The optimal cut-offs of amplitudes or ratios of amplitude decrease on VCP were determined and evaluated. An independent recent cohort (177 RLNs) was analyzed for validation.ResultsQuantitative amplitudes of V2 or R2, and V2/V1 or R2/R1 ratio predicted VCP. The V2 of 117-216 μV predicted VCP with high (>80 %) sensitivity and specificity. Interestingly, the AUC of ROC curve of V2 was the highest, and a cut-off 124 μV of V2 most excellently predicted VCP with the highest sensitivity, specificity, and both positive and negative predictive values. In dissociative analyses, a V2 cut-off 124 μV still excellently predicted VCP in all ranges of initial V1 ≥ 100 μV. In a validation cohort, the V2 of 126-205 μV (cut-off 197 μV) predicted VCP with both high (>80 %) sensitivity and specificity.ConclusionsA quantitative V2 amplitude can predict postoperative VCP among individuals as a simple and a second option, that may be especially useful in some circumstances with unavoidable insufficient initial exposure of vagus nerve.
| S-EPMC11773083 | biostudies-literature
Project description:BackgroundSkin electrodes have been reported to be a useful alternative recording method for intraoperative neuromonitoring (IONM) and show typical electromyography (EMG) waveforms while overcoming the shortcomings of the EMG endotracheal tube. However, the skin electrodes showed relatively lower evoked amplitudes than other recording methods. In this study, we analyzed normative EMG data using skin electrodes and factors that affect the evoked amplitude of thyroid IONM.MethodsIn total, 167 patients [242 nerves at risk (NAR)] who underwent thyroidectomy under IONM with adhesive skin electrodes were analyzed. A pair of skin electrodes was attached to the lateral border of the lamina of the thyroid cartilage. Evoked EMG data, including mean amplitude and latency, obtained after stimulation of the recurrent laryngeal nerve (RLN) and vagus nerve (VN), were collected and analyzed.ResultsThe mean amplitudes of RLN and VN recorded via skin electrodes were 255.48±96.53 and 236.15±69.72 μV, respectively. The mean latency of the right and left RLN was 3.22±0.03 and 3.49±0.08 mS, respectively. The mean latency of the right and left VN was 5.37±0.80 and 7.57±0.10 mS, respectively. The mean amplitude was significantly lower in the obesity, male, and total thyroidectomy (TT) groups. As body mass index (BMI) and age increased, the amplitude of EMG tended to decrease significantly.ConclusionsThe evoked amplitude recorded with the skin electrodes was relatively low. A larger surgical extent, obesity, male sex, and age >55 years showed significantly lower evoked amplitudes.
| S-EPMC11002475 | biostudies-literature
Project description:PurposeThe use of nondepolarizing neuromuscular blocking agents (NMBAs) may affect intraoperative neuromonitoring (IONM) during anesthesia used during thyroid and parathyroid surgery.MethodsThe use of sugammadex was evaluated in a prospective clinical study during thyroid surgery. Between July 2018 and January 2019, 129 patients were prospectively randomized to either the sugammadex group (group B) or the control group (group A). Group A patients underwent standardized IONM during thyroidectomy, while group B patients used an NMBA-reversal protocol comprised of rocuronium (0.6 mg/kg) in anesthesia induction and sugammadex (2 mg/kg) after first vagal stimulation (V0). A peripheral nerve stimulator was used to monitor the neuromuscular transmission.ResultsIn our clinical study, it took 26.07 ± 3.26 and 50.0 ± 8.46 minutes to reach 100% recovery of laryngeal electromyography at injection of the sugammadex group (2 mg/kg) and the control group, respectively (P < 0.001). The train-of-four ratio recovered from 0 to >0.9 within 4 minutes after administering 2 mg/kg of sugammadex at the beginning of resection. Surgery time was significantly shorter in group B than in group A (P < 0.001). Transient recurrent laryngeal nerve (RLN) paralysis was detected in 4 patients from group A and in 3 patients from group B (P = 0.681). There was no permanent RLN paralysis in the 2 groups.ConclusionOur clinical study showed that sugammadex effectively and rapidly improved the inhibition of neuromuscular function induced by rocuronium. The implementation of the nondepolarizing neuromuscular block recovery protocol may lead to tracheal intubation as well as favorable conditions for IONM in thyroid surgery.
| S-EPMC6893217 | biostudies-literature
Project description:BACKGROUND:Hypoparathyroidism, the most common complication after thyroid surgery, leads to hypocalcaemia and significant medical problems. An RCT was undertaken to determine whether intraoperative parathyroid gland angiography with indocyanine green (ICG) could predict postoperative hypoparathyroidism, and obviate the need for systematic blood tests and oral calcium supplementation. METHODS:Between September 2014 and February 2016, patients who had at least one well perfused parathyroid gland on ICG angiography were randomized to receive standard follow-up (measurement of calcium and parathyroid hormone (PTH) on postoperative day (POD) 1 and systematic supplementation with calcium and vitamin D; control group) or no supplementation and no blood test on POD 1 (intervention group). In all patients, calcium and PTH levels were measured 10-15 days after thyroidectomy. The primary endpoint was hypocalcaemia on POD 10-15. RESULTS:A total of 196 patients underwent ICG angiography during thyroid surgery, of whom 146 had at least one well perfused parathyroid gland on ICG angiography and were randomized. None of these patients presented with hypoparathyroidism, including those who did not receive calcium supplementation. The intervention group was statistically non-inferior to the control group (exact 95 per cent c.i. of the difference in proportion of patients with hypocalcaemia -0·053 to 0·053; P = 0·012). Eleven of the 50 excluded patients, in whom no well perfused parathyroid gland could be identified by angiography, presented with hypoparathyroidism on POD 1, and six on POD 10-15, which was significantly different from the findings in randomized patients (P = 0·007). CONCLUSION:ICG angiography reliably predicts the vascularization of the parathyroid glands and obviates the need for postoperative measurement of calcium and PTH, and supplementation with calcium in patients with at least one well perfused parathyroid gland. Registration number: NCT02249780 (http://www.clinicaltrials.gov).
| S-EPMC6084300 | biostudies-literature
Project description: Not available
| S-EPMC6353246 | biostudies-literature
Project description:BackgroundThis study assessed the feasibility of near-infrared fluorescence imaging with indocyanine green (ICG) to identify the parathyroid glands (PGs) intraoperatively and to assess their perfusion after thyroid resection.MethodsPatients undergoing elective thyroidectomy were enrolled in this prospective study. An intravenous bolus of 7.5 mg ICG was administered twice: the first bolus to identify the PGs before resection of the thyroid and the second to assess vascularization of the PGs after resection.ResultsA total of 30 operations in 26 patients were included. In 17 surgeries (56.7%), fluorescence imaging was of added value, especially to confirm the presence of a suspected PG. No intraoperative or postoperative complications occurred because of the use of ICG.ConclusionNear-infrared fluorescence imaging with the use of ICG for intraoperative identification of the PGs and the assessment of its vascularization is feasible and safe and can provide more certainty about the location of the PGs.
| S-EPMC6590433 | biostudies-literature
Project description:ObjectiveStress hormone levels such as cortisol and epinephrine increase with general anesthesia (GA) and surgery. Parathyroid hormone (PTH) has been shown to increase with GA in those undergoing parathyroidectomy (PT) with abnormal parathyroid function, but there are conflicting reports of it in those with normal parathyroid function. In this study, we aim to determine the effects of anesthetic and surgical stress on those with abnormal parathyroid function undergoing PTs as well as those with normal parathyroid function undergoing unilateral/total thyroidectomies (UTs/TTs).Study designProspective study.SettingSingle tertiary academic center.MethodsPatients undergoing TT, UT, and PT were studied. PTH was measured consecutively during the preoperative, postanesthetic induction before incision, intraoperative, and postoperative periods.ResultsOne hundred sixty patients were included, with 77 and 31 undergoing TT and UT, respectively, and 52 undergoing PT. Mean PTH levels were significantly higher following induction and intubation across all groups (TT: 139.2 vs 65.1 pg/mL, 113.8% increase; UT: 130.4 vs 57.1 pg/mL, 128.4% increase; PT: 219.6 vs 163.7 pg/mL, 34.1% increase) and remained elevated until excision (TT: 131.8 pg/mL; UT: 124.9 pg/mL; PT: 228.7 pg/mL). Following UT, mean PTH declined to preoperative levels by 1 hour postexcision. Compared to thyroidectomy groups, PTH in the PT group showed more variable responses to anesthesia induction.ConclusionPTH consistently increases in response to anesthetic and surgical stress in adults undergoing UT and TT with normal preoperative parathyroid function. In contrast, those with hyperparathyroidism demonstrated variable changes.
| S-EPMC11739895 | biostudies-literature