Postoperative Recurrent Laryngeal Nerve Palsy Research Articles

Association of perioperative oral swallowing function with post-esophagectomy outcomes and nutritional statuses in patients with esophageal cancer.

Dysphagia after esophagectomy is a serious complication; however, no method has been established to accurately assess swallowing function. We evaluated the association of swallowing function tests with patients' post-esophagectomy complications and nutritional statuses. We retrospectively reviewed the data of 95 patients with esophageal cancer who underwent esophagectomy between 2016 and 2021. We performed perioperative swallowing function tests, including the repetitive saliva swallowing test (RSST), maximum phonation time (MPT), and laryngeal elevation (LE). Patients with recurrent laryngeal nerve palsy (RLNP) and respiratory complications (RC) had significantly lower postoperative RSST scores than patients without them; the scores in patients with or without anastomotic leakage (AL) were similar. Postoperative MPT in patients with RLNP was shorter than that in patients without RLNP; however, it was similar to that in patients with or without AL and RC. LE was not associated with any complications. Patients with an RSST score ≤2 at 2weeks post-esophagectomy had significant weight loss at 1, 6, and 12months postoperatively compared with patients with an RSST score ≥3. The proportion of patients with severe weight loss (≥20% weight loss) within 1year of esophagectomy was significantly greater in patients with RSST scores ≤2 than in those with RSST scores ≥3. Multivariate analysis showed that an RSST score ≤2 was the only predictor of severe post-esophagectomy weight loss. RSST scoring is a simple tool for evaluating post-esophagectomy swallowing function. A lower RSST score is associated with postoperative RLNP, RC, and poor nutritional status.

Assessment of pre-extubating recurrent laryngeal nerve palsy using ultrasound in postoperative patients with esophageal cancer: a prospective observational study.

Ultrasound performed after extubation has been suggested to be useful for the diagnosis of recurrent laryngeal nerve (RLN) paralysis. However, the use of ultrasound for this purpose before extubation has not been examined. The aim of this study was to examine the versatility (interrater reliability) and usefulness of ultrasound for evaluating the movement of vocal cords before extubation. The subjects were 30 patients who underwent radical surgery for esophageal cancer from August 2020 to December 2021. An experienced examiner performed an ultrasound examination before and after elective extubation on the day after surgery to evaluate RLN paralysis and record videos. Bronchoscopy was then performed to make a definite diagnosis. Three anesthetists blinded to the diagnosis also evaluated the cases using the videos, and the versatility of the examination was determined using a kappa test. The diagnostic accuracies of the examiner and three anesthetists were 76.7%, 50.0%, 53.3%, and 46.7%, respectively, and the kappa coefficients for the examiner with the anesthetists were 0.310, 0.502, and 0.169, respectively. The sensitivity, specificity, positive predictive value and negative predictive value for diagnosis of RLN paralysis by the examiner using ultrasound before extubation were 0.57, 0.95, 0.80, and 0.87, respectively. These results indicate a lack of versatility of the ultrasound examination based on the low kappa coefficients. However, with an experienced examiner, ultrasound can serve as a non-invasive examination that can be performed before extubation with high accuracy and specificity for diagnosis of postoperative RLN paralysis.

Outcomes of Preoperative Medical Therapy for Thyroidectomy in Autoimmune Thyroid Disease

IntroductionThyroidectomy provides definitive treatment for autoimmune thyroid disease (AITD) often resulting in improved quality of life. Historically, patients with AITD undergoing thyroidectomy have increased rates of postoperative hypoparathyroidism and recurrent laryngeal nerve palsy. We investigated the outcomes of preoperative medications in patients with AITD undergoing thyroidectomy. MethodsWe performed a retrospective analysis of patients who underwent thyroidectomy for AITD at a single institution from 2015 to 2021. Surgical outcomes and perioperative laboratory values were analyzed by type of AITD and type of preoperative medical treatment: none, saturated solution of potassium iodide (SSKI), corticosteroids, or both SSKI and corticosteroids. ResultsA total of 123 patients underwent thyroidectomy for AITD and were included in analysis: 50 received no preoperative medications, 40 received SSKI, 20 received corticosteroids, and 13 received both. Seventy-six patients had Graves’ disease and 47 had Hashimoto’s thyroiditis. There were no significant differences in blood loss, operative time, wound complications, hematoma, or recurrent laryngeal nerve injury for patients treated with preoperative corticosteroids compared to those who were not. Patients who received corticosteroids and patients with Graves’ disease more commonly had at least one instance of hypocalcemia postoperatively (P < 0.01, P = 0.01), although only on postoperative day 1 was mean calcium < 8.5 mg/dL. There was no difference in rate of transient or permanent hypoparathyroidism. ConclusionsPatients who received corticosteroids preoperatively had no increased risk of complications. They did have mildly lower calcium levels in the early postoperative period, although no difference in hypoparathyroidism. Further exploration is warranted to investigate the impact of preoperative corticosteroids on operative difficulty, quality of life, and autoantibody clearance.

436. USEFULNESS OF INTRAOPERATIVE CONTINUOUS NERVE MONITORING IN TRANSMEDIASTINAL MINIMALLY INVASIVE ESOPHAGECTOMY

Abstract Introduction We have previously reported that continuous intraoperative nerve monitoring (CIONM) is useful in reducing postoperative left recurrent laryngeal nerve paralysis (RLNP) in transmediastinal esophagectomy (TME). In this study, we investigated the relationship between the paralysis risk types on CIONM and postoperative RLNP. Methods A total of 161 patients who underwent TME for esophageal malignancies and esophagogastric junctional cancer with CIONM between October 2017 and July 2022. The relationship between clinical background factors, changes in amplitude during surgery, and left RLNP (endoscopic vocal cord findings on postoperative day 7) was retrospectively investigated. Furthermore, the relationship between LOS types (segmental or diffuse) and left RLNP was examined. Results The median age was 70 years, with 127 male and 34 female patients. At the end of transcervical procedure, 46 patients had amplitude less than 100 μV (LOS: loss of signal) and 78 patients had amplitude ≤50% of baseline. Postoperatively, 76.1% of LOS cases and 46.2% of cases with amplitudes ≤50% of baseline had left RLNP. The amplitude reduction types (LOS, baseline≤50%), primary tumor in the cervical/upper thoracic/middle thoracic esophagus, and males were significantly associated with left RLNP (p &amp;lt; 0.001). When examined by LOS type, RLNP was more common in segmental LOS than in diffuse LOS. Conclusion The pattern of amplitude reduction on CIONM is useful in predicting postoperative left RLNP. We will continue to increase the number of cases and verify the further effectiveness of CIONM for TME.

Intraoperative Neuromonitoring for Thyroid Surgery in Children and Adolescents: A Single Center Experience.

Intraoperative neuromonitoring (IONM) of the recurrent laryngeal nerve (RLN) has been shown in adults to minimize nerve palsy after thyroid surgery, but only few studies on its efficacy in a pediatric population have been reported. We conducted a retrospective study on patients operated for thyroid lesions from 2016 to 2022. The analyzed population was divided in two groups: patients treated from 2016 to 2020, when the identification of the RLN was performed without IONM (Group A); and patients treated since 2021, when IONM was implemented in every surgical procedure on the thyroid (Group B). Intraoperative Neurophysiological Monitoring was performed by using corticobulbar motor-evoked potentials and continuous electromyography. Twentyfive children underwent thyroid resection, 19 (76%) of which due to thyroid carcinoma. Each patient's recurrent nerve was identified; IONM was used in 13 patients. In Group A, one temporary nerve palsy was identified postoperatively (8.3%), while in group B one nerve dysfunction occurred (7.7%). No statistically significant difference was found between the two groups in terms of post-operative RLN palsy. No surgical complication due to the use of IONM was reported. In children and teenagers, intraoperative neuromonitoring of the recurrent laryngeal nerve is a safe and accurate method, minimizing the risk of nerve damage.

A descriptive comparison of postoperative outcomes between hybrid mediastino-thoracoscopic approach and conventional thoracoscopic esophagectomy for esophageal cancer.

The purpose of this study was to compare the results of the hybrid mediastino-thoracoscopic approach with that of the conventional thoracoscopic approach and to identify the advantages and disadvantages of the hybrid approach. We retrospectively analyzed 172 patients who underwent thoracoscopic esophagectomy for esophageal cancer from July 2009 to June 2021, excluding salvage surgery. In the mediastinoscopic approach, the lymph nodes were dissected from a small incision in the left aspect of the neck to the aortic arch with supine double-lung ventilation. Thereafter, the middle-to-lower mediastinum and right superior mediastinum were dissected thoracoscopically in the prone position. The patients' demographics, surgical outcomes, postoperative complications, and postoperative recurrence patterns were compared between 51 patients in the hybrid approach and 121 patients in the conventional approach. The hybrid group had more elderly patients (71years vs. 67years; P = 0.010), more cardiovascular disease (33.3% vs. 16.7%; P = 0.021), lower rates of preoperative chemotherapy (49.0% vs. 69.4%; P = 0.015), and shorter right lung collapse time (196min vs. 264min; P < 0.001). Postoperative hoarseness was not different between the two groups (31.4% vs. 27.3%; P = 0.584), and there was a significant difference in the sternal-vertebral distance at the level of the sternal notch (41mm in the hybrid group vs. 48mm in the conventional group; P = 0.029). The sternal-vertebral distance of less than 45mm was an independent risk factor for postoperative hoarseness in the logistic analysis (odds ratio 3.636, 95% confidence interval 1.054-12.546; P = 0.041). The hybrid mediastino-thoracoscopic approach could be safely adapted to elderly or cardiopulmonary diseased patients; however, short sternal-vertebral distance might be a risk factor of postoperative recurrent laryngeal nerve palsy.

A modified tracheal transection approach for cervical esophageal lesion treatment: A report of 13 cases.

Surgical interventions for tumors in the cervical esophageal region are complicated and laryngeal function is frequently sacrificed. Therefore, we attempted the tracheal transection approach to resect the tumor while preserving laryngeal function. Three patients with papillary thyroid cancer (PTC), six with cervical esophageal cancer (CEC), and four with CEC mixed with thoracic esophageal cancer (TEC) were enrolled. The esophagus was exposed after the trachea was transected between the second and third tracheal rings. CEC/TEC: Resection of the esophagus or/and a portion of the hypopharynx with acceptable safety margins and repair with free jejunum or tubular stomach. PTC: Suture the small esophageal incision immediately after removing the tumor. The tracheal dissection was repaired with interrupted sutures throughout the entire layer after the esophageal lesion was resected. The status of the recurrent laryngeal nerve (RLN) determined whether a tracheotomy was necessary. All 13 patients had effective esophageal lesion excision, with six of them requiring intraoperative tracheotomy. Postoperative complications included a tracheoesophageal fistula (one case, 7.7%), postoperative RLN paralysis (two cases, 15.4%), and aspiration (three cases, 23.1%). Except for two patients with distant metastases, there was no recurrence in the remaining patients after 5-92 months of follow-up. The tracheal transection approach, as a new surgical technique, can retain laryngeal function while ensuring appropriate exposure and satisfactory surgical resection. Before surgery, the feasibility of this approach must be carefully assessed. The RLN should be protected during the procedure. The operation is both safe and effective, with a wide range of applications.

Continuous Recurrent Laryngeal Nerve Monitoring During Single-Port Mediastinoscopic Radical Esophagectomy for Esophageal Cancer

BackgroundAlthough single-port mediastinoscopic radical esophagectomy is ultimate minimally invasive surgery for esophageal cancer without thoracotomy or the thoracoscopic approach, the high incidence of recurrent laryngeal nerve (RLN) palsy remains a pivotal clinical issue. MethodsThis study included 41 patients who underwent single-port mediastinoscopic radical esophagectomy with mediastinal lymphadenectomy between September 2014 and March 2022. Among these, continuous nerve monitoring (CNM) for RLN was done in 25 patients (CNM group), while the remaining 16 patients underwent without CNM (non-CNM group). Clinical benefits of CNM for RLN were evaluated. ResultsThe overall incidence of postoperative RLN palsy was 14.6% (6/41). The CNM group showed a significantly lower incidence of postoperative RLN palsy as compared to the non-CNM group (P = 0.026: CNM vs. non-CRNM: 4.0% (1/25) vs. 31.2% (5/16)). The CNM group had a lower incidence of postoperative pneumoniae (CNM vs. non-CNM: 4.0% (1/25) vs. 18.8% (3/16)) and shorter days of postoperative hospital stay (CNM vs. non-CNM: 13 days vs. 41 days). Multivariate analysis revealed that the CNM use (odds ratio 0.07; 95% CI 0.05–0.98) was an independent factor avoiding postoperative RLN palsy. ConclusionThe CNM for RLN contributes to a remarkable reduction in the risk of postoperative RLN palsy and improvement in outcomes in single-port mediastinoscopic radical esophagectomy.

417. ROBOT-ASSISTED MINIMALLY INVASIVE ESOPHAGECTOMY WITH UPPER MEDIASTINAL LYMPHADENECTOMY

Abstract We started robot-assisted minimally invasive esophagectomy (RAMIE) in 2012 using da Vinci S. After the reimbursement in the national insurance system in 2018, RAMIE has been indicated as an institutional standard surgery simply depending on the da Vinci availability. Our early series of 45 RAMIEs showed significantly less postoperative morbidity (p = 0.03) mainly due to less pulmonary complication (p = 0.006) compared to conventional minimally invasive esophagectomy using propensity score matching (Ann Surg Oncol. 2020). This study aims to retrospectively evaluate the feasibility of RAMIE and to demonstrate our standardized RAMIE with updated data. Our surgical technique is as follows. A patient is placed in a prone position with both lung ventilation with 8-10 mmHg artificial pneumothorax. In the upper mediastinum, the thoracic duct is usually preserved unless there is tumor invasion. Then, the tracheoesophageal arteries flowing into the visceral sheath over the recurrent laryngeal nerve (RLN) are divided first and RLN is isolated laterally. Then, the lymphatic tissue is dissected from the trachea. This procedure is identical on both sides of RLN nodal dissection. By January 2022, 89 RAMIEs (S: 6 cases and Xi: 83 cases) were performed. Thoracic operation time was 348 min and console time was 296 min. Intraoperative blood loss was 80 g and the number of harvested thoracic nodes is 23. There was no conversion from RAMIE to MIE nor to open procedure. Overall severe postoperative morbidity (Clavien-Dindo Grade 3 or higher) was 17% (15/89) and clinically relevant postoperative recurrent laryngeal nerve palsy (Clavien-Dindo Grade 2 or higher) was 10% (9/89). There was no postoperative mortality. RAMIE was safe and feasible.

504. LONG-TERM PROGNOSIS AND CAUSES OF DEATH IN CLINICAL STAGE I ESOPHAGEAL CANCER PATIENTS AFTER ESOPHAGECTOMY

Abstract For patients with clinical stage (cStage) I esophageal cancer that were not indicated for endoscopic resection, esophagectomy was the standard treatment if surgery was desired. The long-term prognosis after surgical resection of cStage I esophageal cancer was 86.5% of the 5-year survival rate in the results of the JCOG0502 study. The aim of this study was to review the long-term survival the causes of death in cStage I esophageal cancer patients after esophagectomy. Between January 2004 to February 2021, 138 patients underwent radical esophagectomy for the treatment of cStage I esophageal cancer in our institution. These cases also included non-curative resection cases after endoscopic resection. The patient cohort contained 116 (84 %) males, and 22 (16 %) patients. The median age was 68.5 years (range, 49–82). We estimated long-term overall and cancer-specific cumulative mortality for these patients. In addition, we analyzed the deaths from other causes. The median follow-up period was 52 months. The 5-year survival rates and cancer-specific survival rate were 82.8% and 87.3%, respectively. There were two surgery-related deaths. Other-cause deaths were observed in 19 patients. The causes were other cancers in 7 patients, respiratory diseases (pneumonia, acute exacerbation of COPD) in 4 patients, heart failure in 1 patient, and unknown in 7 patients. The breakdown of other cancers was cervical esophageal cancer in 1 patient, hypopharyngeal cancer in 3 patients, lung cancer in 2 patients, and malignant lymphoma in 1 patient. Of the 4 patients who were caused by respiratory disease, 3 had recurrent laryngeal nerve palsy as postoperative complication. The long-term prognosis of cStage I esophageal cancer patients after esophagectomy in our institution was comparable to that of other clinical trials. Head and neck cancer and lung cancer accounted for the majority of deaths due to other causes. In addition, most of the cases caused by respiratory disease had postoperative recurrent laryngeal nerve palsy. It was considered that attention should be paid to aspiration even during outpatient follow-up.

The effectiveness of reducing endotracheal cuff pressure after retractor placement to decrease postoperative laryngeal dysfunction in anterior cervical surgery: a meta-analysis.

The authors sought to determine if a consensus could be reached regarding the effectiveness of endotracheal tube cuff pressure (ETTCP) reduction after retractor placement in reducing postoperative laryngeal dysfunction after anterior cervical fusion surgery. A literature search of MEDLINE (PubMed), EMBASE, Cochrane Central, Google Scholar, and Scopus databases was performed. Quantitative analysis was performed on data from articles comparing groups of patients with either reduced or unadjusted ETTCP after retractor placement in the context of anterior cervical surgery. The incidence and severity of postoperative recurrent laryngeal nerve palsy (RLNP), dysphagia, and dysphonia were compared at several postsurgical time points, ranging from 24 hours to 3 months. Heterogeneity was assessed using the chi-square test, I2 statistics, and inverted funnel plots. A random-effects model was used to provide a conservative estimate of the level of effect. Nine studies (7 randomized, 1 prospective, and 1 retrospective) were included in the analysis. A total of 1671 patients were included (1073 [64.2%] in the reduced ETTCP group and 598 [35.8%] in the unadjusted ETTCP group). In the reduced ETTCP group, the severity of dysphagia, measured by the Bazaz-Yoo system in 3 randomized studies at 24 hours and at 4-8 weeks, was significantly lower (24 hours [standardized mean difference: -1.83, p = 0.04] and 4-8 weeks [standardized mean difference: -0.40, p = 0.05]). At 24 hours, the odds of developing dysphonia were significantly lower (OR 0.51, p = 0.002). The odds of dysphagia (24 hours: OR 0.77, p = 0.24; 1 week: OR 0.70, p = 0.47; 12 weeks: OR 0.58, p = 0.20) were lower, although not significantly, in the reduced ETTCP group. The odds of a patient having RLNP were significantly lower at all time points (24 hours: OR 0.38, p = 0.01; 12 weeks: OR 0.26, p = 0.03) when 3 randomized and 2 observational studies were analyzed. A subgroup analysis using only randomized studies demonstrated a similar trend in odds of having RLNP, yet without statistical significance (24 hours: OR 0.79, p = 0.60). All other statistically significant findings persisted with removal of any observational data. Based on the current best available evidence, reduction of ETTCP after retractor placement in anterior cervical surgery may be a protective measure to decrease the severity of dysphagia and the odds of developing RLNP or dysphonia.

The Prevalence and Risk Factors of Postoperative Recurrent Laryngeal Nerve Palsy in Thyroidectomy

The Prevalence and Risk Factors of Postoperative Recurrent Laryngeal Nerve Palsy in Thyroidectomy

Intraoperative Measurement of Endotracheal Tube Cuff Pressure and Its Change During Surgery in Correlation With Recurrent Laryngeal Nerve Palsies, Hoarseness, and Dysphagia After Anterior Cervical Discectomy and Fusion: A Prospective Randomized Controlled Trial.

Prospective randomized controlled trial. Adjustment of endotracheal tube cuff pressure (ETCP) in anterior cervical discectomy and fusion (ACDF) may influence the incidence of complications such as recurrent laryngeal nerve palsy (RLNP), hoarseness, and dysphagia. The prospective randomized controlled trial was designed to investigate the influence of ETCP on the incidence of postoperative complications. All eligible patients underwent vocal cord examination before and after ACDF and were randomized into a control group (CG) and intervention group (IG). Endotracheal tube cuff pressure was passively monitored in CG, and in IG, it was maintained at 20mmHg. Outcomes were evaluated during hospitalization and during follow-up. A total of 98 patients were randomized, each group consisted of 49 patients. Statistical analysis showed that gender and age did not influence the incidence of complications. In CG, duration of retractor placement and extent of approach significantly impacted the occurrence of complications. The incidence of postoperative RLNP was 8.2% in IG and 12.2% in CG, hoarseness and dysphonia were present in 18.4% in IG and in 37.5% in CG, and dysphagia in 20.8% in IG and in 22.5% in CG. Hoarseness was significantly present more in CG (P = .018). Only one patient from CG presented with RLNP after 1year, the remaining nine patients spontaneously recovered. Unregulated ETCP can lead to a significantly higher incidence of hoarseness; however, its improvement rate is 100%. The early postoperative complication rate was higher in CG, and after one year, 1 patient had RLNP and 1 patient had dysphagia.

213 CLINICAL SIGNIFICANCE OF ROBOTIC ESOPHAGECTOMY FOR THORACIC ESOPHAGEAL CANCER

Abstract Nowadays many patients with esophageal cancer are treated with thoracoscopic esophagectomy (TE) with precise mediastinal lymphadenectomy as a minimally invasive esophagectomy (MIE) in Japan. These advanced endoscopic surgeries are believed to contribute to early postoperative recovery. More recently robotic esophagectomy (RE) appeared attractively. To date, however, there has been a very limited number of comparison studies to verify the benefits of RE for esophageal cancer, especially in Japan where squamous cell carcinoma is predominant. Methods We retrospectively compared the short-term outcomes between TE (n = 43) and RE (n = 19) which were performed in our institution between 2018 and 2020 to verify the clinical significance of RE. Preoperative background factors of the patients compared were almost identical between the two groups. Results The operative time was longer in the RE group than in the OE group, whereas blood loss was equivalent between the two groups. There was no significant differences in the number of dissected mediastinal lymph nodes between the TE and RE groups (33+/−15 vs 29+/−11). The incidence of postoperative recurrent laryngeal nerve palsy was markedly less in the RE group than the TE group (5.2% vs. 18.6%). Moreover, the incidence of postoperative pneumonia also tended to be less in the RE group than in the TE group (5.2% vs. 11.6%). There were no operative mortality in the two groups. Conclusion Our results suggest that RE is comparable with conventional TE in terms of short-term outcome after surgery, and beneficial to technically reduce the recurrent laryngeal nerve palsy as a promising MIE.

661 EFFICACY OF ROBOT ASSISTED MINIMALLY INVASIVE ESOPHAGECTOMY: PROPENSITY MATCHED ANALYSIS OF RAMIE IN COMPARISON WITH CONVENTIONAL MIE

Abstract Robot assisted minimally invasive esophagectomy (RAMIE) has been reported to be potential advantages in previous reports. Here we demonstrate the difference between these two minimally invasive procedures and investigated the surgical results of RAMIE in comparison with MIE using propensity matched-cohort. Methods We investigated 154 cases of thoracic esophagectomy conducted between 2020/1 to 2021/1. Among these cases, we analyzed 30 cases of RAMIE in comparison with 30 cases of matched-cohort which conducted conventional thoracoscopic esophagectomy (MIE) in the prone. Then we evaluated the surgical results between two groups. Results There were no differences in age (69.2 vs 69.1 yo), gender (M:F = 24:6 vs 24:6), cStage (Stage I,II,III,IV:6,3,14,7 vs 8,3,14,5), and preoperative chemotherapy (70% vs 66.7%) between RAMIE and matched-cohort MIE. There was statistically significant difference in total time of thoracic phase (233.1 vs 173.3 min; p &amp;lt; 0.01). There were no significant differences in postoperative events in RAMIE vs MIE (Clavien-Dindo Grade 1≧; Recurrent laryngeal nerve paralysis (RLNP) (16.7 vs 20.0%; p = 0.19). However, after the learning curve archived, seldom cases were diagnosed postoperative RLNP in RAMIE cases in comparison with MIE (p = 0.06). Conclusion We demonstrated the formalization of our procedure and surgical results of RAMIE. There were no significant differences in postoperative events between two groups. However RLNP was lower after the learning peak. Incidence of RLNP could be reduced in RAMIE.

Intraoperative nerve monitoring during esophagectomy reduces the risk of recurrent laryngeal nerve palsy.

Despite the risk of recurrent laryngeal nerve (RLN) palsy during esophagectomy, no established method of monitoring RLN injury is currently available. This study included 187 patients who underwent esophagectomy between 2011 and 2018. Among these, intraoperative nerve monitoring (IONM) was done in 142 patients (IONM group), while the remaining 45 patients underwent conventional surgery without IONM (control group). We investigated the incidence of postoperative complications with regard to the use of IONM. The overall incidence of postoperative RLN palsy was 28% (52/187). The IONM group showed a significantly lower incidence of postoperative RLN palsy as compared to that in the control group (p = 0.004). The overall incidence of postoperative pneumonia was 22% (41/187) in those with Clavien-Dindo (CD) classification beyond grade 2. There were no significant differences between the incidence of any grade of postoperative pneumonia and the use of IONM (p = 0.195 and 0.333; CD > 2 and > 3, respectively). Multivariate analysis demonstrated that tumors in the upper third [odds ratio (OR) 3.12; 95% confidence interval (CI) 1.04-9.29] and lack of IONM use (OR 2.51; 95% CI 1.17-5.38) were independent factors causing postoperative RLN palsy after esophagectomy. IONM helps to reduce the risk of postoperative RLN palsy after esophageal cancer surgery.

Robotic retroauricular thyroidectomy with additional axillary port: Early personal experiences.

ObjectiveThis study aimed to analyze the usefulness of an additional axillary port in robotic retroauricular thyroidectomy by comparing the perioperative data and postoperative function between the operations with and without an additional axillary port.Materials and methodsA retrospective review of the medical records of 11 patients who underwent robotic thyroid operations using a unilateral retroauricular approach with or without an additional axillary port between 2016 and 2021 was conducted. Patient demographics, operation time, drainage amount, hospital stay, complication, postoperative cosmetic satisfaction, and postoperative neck and shoulder pain were analyzed.ResultsAmong the 11 patients who underwent robotic retroauricular thyroidectomy, an additional axillary port was used in 6 patients and not used in 5 patients. The total operation time was significantly shorter in the axillary port group (174.5 ± 23 minutes) compared to the without the axillary port group (207.6 ± 20.1 minutes) (P = .033). The intraoperative estimated blood loss (P = .525), total amount of drainage (P = .172), and postoperative hospital stays (P = .092) were not different between the 2 groups. There was no postoperative recurrent laryngeal nerve palsy, hypoparathyroidism, hematoma, seroma in the two groups. There was no significant difference for either group in the pain score and cosmetic satisfaction at 2 weeks (P = .378, P = .650) and 6 weeks (P = .242, P = .546) postoperatively.ConclusionRobotic retroauricular thyroidectomy using an additional axillary port was a novel, safe, and feasible procedure. Dissection was easy due to the availability of the fourth robotic arm to retract the thyroid gland.Level of Evidence: 4.

The circumstances in which recurrent laryngeal nerve palsy occurs after surgery for benign thyroid disease: a retrospective study of 1026 patients

To evaluate the circumstances in which recurrent laryngeal nerve palsy occurs after thyroid surgery. This study assessed 1026 patients who underwent surgery for benign thyroid disease over a seven-year period in a retrospective, single-centre study. With a total of 1835 recurrent laryngeal nerves at risk, there were 38 cases (2.07 per cent) of transient recurrent laryngeal nerve palsy and 8 (0.44 per cent) of permanent recurrent laryngeal nerve palsy. No explanation was found for 10 of the 46 cases of recurrent laryngeal nerve palsy. Among the 38 other cases, the probable causes included poor identification of the recurrent laryngeal nerve during surgery, involuntary resection of the nerve and several other factors. Apart from accidental resection of the recurrent laryngeal nerve during thyroid surgery, the causes of post-operative recurrent laryngeal nerve palsy are often unclear and likely multifactorial. Poor identification of the recurrent laryngeal nerve during surgery is still the main cause of post-operative recurrent laryngeal nerve palsy, even when intra-operative neuromonitoring is used.

Neuromonitoring zvratného nervu během operace štítné žlázy – výsledky a zkušenosti

Paresis of the recurrent laryngeal nerve (RLN) is one of the serious complications of thyroid and parathyroid gland surgery. The intraoperative neural monitoring (IONM) enables to verify the functionality of RLN. The aim of this study is to compare the incidence of postoperative RLN palsy in patients who underwent surgery with and without the use of IONM RLN and to evaluate the positive and negative predictive values, sensitivity, specifi city and accuracy of the method. Methods: Retrospective analysis of thyroid gland surgeries performed within the period from 1. 7. 2016 to 1. 7. 2018. A total of 467 operations were performed (780 nerves exposed). One hundred and thirty procedures (215 nerves) were carried out without IONM (group A). In total, 337 procedures (565 nerves) were performed with IONM (group B). Results: In group A, unilateral postoperative RLN paresis occurred in 7 cases (3.26%); 6 of them were temporary (2.79%) and 1 was permanent (0.47%). In group B, unilateral postoperative RLN paresis occurred in 33 cases (5.84%); 32 of them were temporary (5.66%) and 1 was permanent (0.18%). The incidence of postoperative RLN paresis related to the use of IONM was not considered statistically signifi cant. (Chi-square test: P = 0.146; Fisher‘s exact test: P = 0.2015, P = 0.4715). The sensitivity, specifi city, positive predictive value, negative predictive value and accuracy were 78.79%, 99.25%, 86.67%, 98.69%, and 98.05%, respectively. There was no case of bilateral postoperative RLN paresis. Conclusion: There was no statistically significant diff erence in the incidence of postoperative RLN palsy in patients who underwent surgery with IONM compared to the group without IONM. The high negative predictive value, specifi city and accuracy indicate high reliability of the method. The IONM provides the surgeon with valuable information regarding the functional status of the nerve. This knowledge allows for changing the operative strategy during the procedure. Keywords: intraoperative neural monitoring – IONM – recurrent laryngeal nerve injury – recurrent laryngeal nerve – thyroid surgery

Energy Based Vessel Sealing Devices in Thyroid Surgery: A Systematic Review to Clarify the Relationship with Recurrent Laryngeal Nerve Injuries.

Background and objectives: The principal complications associated with thyroid surgery consist in postoperative recurrent laryngeal nerve (RLN) palsy, hypoparathyroidism, intra-operative and post-operative hemorrhage. In this paper, structured as a literature review, we describe the current knowledge and the technical improvements currently employed in the field of thyroid surgery, focusing on the contribution of energy based devices in relation with the reduction of the operating time and the odds of possible complication. Materials and methods: a relevant systematic literature search on Pubmed was carried out including works from 2004 through 2019, selecting studies providing information on the energy based devices employed in surgeries and statistic data concerning RNL (transient and permanent) injury and operative time. Results: Nineteen studies were reviewed, dealing with 4468 patients in total. The operative variables considered in this study are: employed device, number of patients, pathological conditions affecting the patients, surgical treatment, RNL injury percentage and the operating time, offering an insight on different patient conditions and their relative operative outcomes. A total of 1843 patients, accounting to the 41.2% of the total pool, underwent the traditional technique operation, while 2605 patients (58.3%) were treated employing the energy based devices techniques. Thyroidectomy performed by approaches different from traditional (for example robotic, MIVAT (Mini Invasive Video Assisted thyroidectomy)) were excluded from this study. Conclusions: The energy-based vessel sealing devices in study, represent a safe and efficient alternative to the traditional clamp-and-tie hand technique in the thyroidal surgery scenario, granting a reduction in operating time while not increasing RNL injury rates. According to this information, a preference for energy based devices techniques might be expressed, furthermore, a progressively higher usage rate for these devices is expected in the near future.