Recurrent Laryngeal Nerve Palsy Rate Research Articles

O19 OUTCOMES OF IVOR LEWIS VERSUS MCKEOWN OESOPHAGECTOMY FOR CANCER: A PROPENSITY SCORE MATCHED ANALYSIS OF THE NETHERLANDS CANCER REGISTRY

Abstract Aim The aim this study was to investigate possible differences in outcomes between Ivor-Lewis (IL) versus McKeown esophagectomy (MK) in a population based cohort. Background It is unknown whether IL or MK should be preferred in patients with potentially curable locoregionally oesophageal or gastro-oesophageal junction (GEJ) cancer. Methods Oesophageal and GEJ cancer patients without distant metastases who underwent a transthoracic oesophagectomy between 2015 and 2017 were selected from the Netherlands Cancer Registry. Patient and tumour characteristics, and treatment outcomes were analysed and compared between IL and MK after propensity score matching (PSM). Patients were matched based on sex, age, tumour morphology and topography, comorbidities, neoadjuvant treatment, cT and cN stage, ASA-score and hospital volume. Postoperative complications and survival were compared between both groups using Chi-Square and multivariable Cox regression analyses. In the multivariable Cox regression analyses we corrected for infectious complications (wound complications and pneumonia) and anastomotic leakage to investigate its effect on survival. Results Off all 1764 included patients (1201 IL patients and 563 MK patients), 948 patients remained after matching. Significantly more lymph nodes were yielded after IL compared to MK (P=0.02). Surgical radicality did not differ between both groups (P=0.25). The complication rate was significantly lower in the IL group regarding anastomotic leakage (17% vs. 28%, P<0.0007) and recurrent laryngeal nerve palsy (2% vs. 6%, P<0.001). Cardiac complications were seen more frequently in patients who underwent IL (17% vs. 11%, P<0.02). No differences were observed in 30 day and 90 day mortality. Kaplan-Meier showed a better survival for IL (63%) compared to MK (58%) (log-rank p=0.07). When correcting for anastomotic leakage and infectious complications the difference in survival remained (HR=0.84, 95% CI 0.69 – 1.03). Similar results regarding postoperative complications and survival were observed in the unmatched cohort. Conclusion Patients who underwent an IL have better outcomes in terms of anastomotic leakage and recurrent laryngeal nerve palsy rate and overall survival compared to MK. The difference in survival appears not to be related to the differences in infectious complications. Based on these results, IL appears to be the treatment of choice in patients in whom both oncological resections are appropriate.

O76 MICROANATOMY BASED STANDARDIZATION OF LEFT UPPER MEDIASTINAL LYMPH NODE DISSECTION IN THORACOSCOPIC ESOPHAGECTOMY IN THE PRONE POSITION

Abstract Aim The purpose of this study is to establish and evaluate our new standardized procedure in left UMLND Background & Methods Although thoracoscopic esophagectomy in the prone position (TEPP) has become a standard surgery for esophageal cancer, upper mediastinal lymph node dissection (UMLND) in left side has been still an issue in TEPP. We have recently developed the standardization of left UMLND in TEPP based on the microanatomy of membranes and layers. Patients were divided into 1 of 2 groups: a pre-standardization group (n = 100) and a post-standardization group (n = 100). Eventually, 83 paired cases were matched using propensity score matching. We perform left UMLND while paying attention to the visceral sheath, vascular sheath and the fusion layer between them using magnified view. Results The thoracoscopic operative time was significantly shorter (P < 0.001) in the post-standardization group [n = 83; 209.0 (176.0 - 235.0) min] than in the pre-standardization group [n = 83; 235.5 (202.8 - 264.5) min]. No significant differences were found in the number of mediastinal lymph nodes dissected or intraoperative blood loss between the 2 groups. There was a tendency for the total postoperative morbidity to decrease in the post-standardization group. Furthermore, recurrent laryngeal nerve (RLN) palsy rate has significantly decreased in the post-standardization group (18.1% to 8.7%, P = 0.015). Conclusion The microanatomy-based standardization contributes the safe and efficient left UMLND.

Transition from video-assisted thoracoscopic to robotic esophagectomy: a single surgeon's experience.

Lymph node dissection (LND) along the left recurrent laryngeal nerve (RLN) is a technically challenging part of esophageal cancer surgery, especially after chemoradiotherapy (CRT). Robotic surgery holds promise to increase its safety and feasibility. The aim of this study was to describe a single thoracoscopic surgeon's experience related to the transition from video-assisted esophagectomy (VATE) to robotic esophagectomy (RE)-with a special focus on the safety of left RLN LND. Patients who underwent minimally invasive esophagectomy and RLN dissection following CRT were dichotomized according to the use of robotic surgery (robotic esophagectomy [RE] versus video-assisted thoracoscopic esophagectomy [VATE]). The following parameters were determined: (1) number of dissected nodes, (2) rates of RLN palsy, (3) rates of perioperative complications, and (4) learning curve. Learning curve analysis was performed using the 10-patient moving average (MA) for operation times and with the cumulative sum (CUSUM) method for left RLN LND (target failure rate: 15%). The RE and VATE groups consisted of 39 and 67 patients, respectively. The intraoperative identification of the left RLN was more common in the RE group (97.4%) than in the VATE group (68.7%; P<0.001). Postoperative left RLN palsy was significantly more frequent in the VATE group (26.9%) than in the RE group (10.3%; P=0.042), with a higher rate of pneumonia in the former (16.4% versus 2.6%; P=0.03). The MA chart revealed a downward trend followed by a flattening of the RE operation time at operation number 17 and 29, respectively. CUSUM analysis showed that the left RLN palsy rate decreased to the target rate after 12 operations. We conclude that at least 12 cases are required for a surgeon with prior experience in VATE to safely accomplish left RLN LND through a robotic approach.

Total endoscopic thyroidectomy versus conventional open thyroidectomy in thyroid cancer: a systematic review and meta-analysis.

BackgroundDespite the considerable experience gained thus far using endoscopic technologies, the role of total endoscopic thyroidectomy (ET) for papillary thyroid cancer (PTC) remains controversial. We conducted a systematic review and meta-analysis to investigate the safety and effectiveness of total ET compared with conventional open thyroidectomy (OT) in PTC.MethodsA systematic search was conducted using the PubMed, Embase and Cochrane Library electronic databases up to March 2018. The quality of included studies was evaluated using the Newcastle–Ottawa Scale. Review Manager software version 5.3 was used for the meta-analysis.ResultsTwelve studies including 2,672 patients were ultimately included in the systematic review and meta-analysis. ET was associated with longer operative time (P<0.00001), drainage time (P<0.00001) and hospital stay (P=0.03), higher transient recurrent laryngeal nerve (RLN) palsy rate (P=0.004) and a greater amount of drainage fluid (P<0.0001) compared with OT. Furthermore, no significant differences were detected between ET and OT in terms of retrieved lymph nodes (P=0.17), blood loss (P=0.22), transient hypocalcemia (P=0.84), permanent hypocalcemia (P=0.58), permanent RLN palsy (P=0.14), hematoma or bleeding (P=0.15) and seroma (P=0.54). In addition, the rates of tumor recurrence were comparable (P=0.18), whereas the proportions of stimulated thyroglobulin levels <1 ng/mL measured after completion of thyroidectomy and radioactive iodine therapy were less (P=0.02) in the ET than in the OT group.ConclusionET is not superior to OT in terms of operation and drainage time, amount of drainage fluid, hospital stay or transient RLN palsy, but is comparable to OT in terms of retrieved lymph nodes and permanent complications. Despite the similar tumor recurrence rates between the two approaches, the level of surgical completeness in ET may not be as good as that for OT.

PS01.237: SAFETY OF RECURRENT LARYNGEAL NERVE NODAL DISSECTION IN PATIENTS WITH ESOPHAGEAL CANCER WHO HAD UNDERGONE CHEMORADIOTHERAPY

Abstract Background Lymph node dissection (LND) along the recurrent laryngeal nerve (RLN) is a challenging surgical procedure that carries a high risk of morbidity, especially in patients who had undergone chemoradiotherapy (CRT). Here, we retrospectively examined the feasibility and safety of thoracoscopic RLN LND in patients with esophageal cancer who had been previously treated with CRT. Methods Patients with esophageal cancer who had undergone thoracoscopic esophagectomy with RLN LND were divided into two groups according to prior treatment with CRT or not (CRT group versus upfront surgery [US] group, respectively). Intergroup comparisons were made in terms of 1) number of dissected nodes, 2) rates of RLN palsy, and 3) rates of perioperative complications. The learning curve for the RLN LND procedure was investigated with the cumulative sum (CUSUM) method. Results A total of 103 patients with esophageal cancer were included in the study (CRT group: n = 65; US group: n = 38). No conversion to open thoracotomy was required in either group. Moreover, intraoperative blood loss and the need for blood transfusions were similar. The technical challenges of RLN LND after CRT were more evident when performed in the left side. Accordingly, complete skeletonization of the left RLN was achieved only for 66.2% of patients in the CRT group, a percentage significantly lower than that obtained in the US group (86.8%; P = 0.022). Similarly, the rate of postoperative RLN palsy in the left side was significantly higher in the CRT group than in the US group (32.6% vs. 9.1%, respectively, P = 0.015), albeit not resulting in higher pneumonia rates. CUSUM analysis revealed a steep learning curve for left RLN LND performed in patients who had undergone CRT. Significant fluctuations in RLN palsy rates were observed over time, suggesting that proficiency did not improve linearly with increasing surgical experience. Conclusion To our knowledge, this is the first study to specifically investigate the feasibility and safety of thoracoscopic RLN LND in patients with esophageal cancer who had undergone CRT. Our data indicate that RLN LND is feasible even after CRT, although the technical challenges to be faced are greater than in CRT-naïve patients. Disclosure All authors have declared no conflicts of interest.

RA03.07: LEARNING CURVE FOR ROBOTIC AND VIDEO-ASSISTED THORACOSCOPIC ESOPHAGECTOMY: A MULTIDIMENSIONAL ANALYSIS

Abstract Background Lymph node dissection (LND) along the left recurrent laryngeal nerve (RLN) is a technically challenging part of esophageal cancer surgery, especially after chemoradiotherapy (CRT). Robotic surgery holds promise to increase its safety and feasibility. Methods Patients who underwent minimally invasive esophagectomy and RLN dissection following CRT were dichotomized according to the use of robotic surgery (robotic esophagectomy [RE] versus video-assisted thoracoscopic esophagectomy [VATE]). Comparisons were made in terms of 1) number of dissected nodes, 2) rates of RLN palsy, 3) rates of perioperative complications, and 4) learning curves. Analysis of learning curves was performed with the cumulative sum (CUSUM) method (target failure rate for left RLN palsy: 15%). Results The RE and VATE groups consisted of 39 and 67 patients, respectively. The intraoperative identification of the left RLN was more common in the RE group (97.4%) than in the VATE group (68.7%, P &lt; 0.001). Postoperative left RLN palsy was significantly more frequent in the VATE group (26.9%) than in the RE group (10.3%, P = 0.042), with a higher rate of pneumonia in the former (16.4% versus 2.6%, P = 0.03). CUSUM analysis revealed a longer learning curve when left RLN LND was performed through VATE. Left RLN palsy rates did not decrease below the target rate with the use of VATE, whereas RE allowed achieving the predefined target rate after 12 operations. Conclusion In the current study, we compared for the first time the learning curves of traditional and robotic surgery for RLN LND (which can be considered as one of the most technically challenging parts of esophageal cancer surgery). Our goal was to determine the minimum number of treated cases required to achieve an acceptable technical competency. Our data indicate that RE significantly facilitated a complex procedure like left RLN LND, resulting in a shorter learning curve compared with VATE. Notably, the left RLN was more easily identifiable with the use of RE, which in turn resulted in lower post-procedural left nerve palsy rates. Although MA analysis revealed that robotic surgery was initially more time-consuming than VATE, RE procedural times improved rapidly and became shorter than those of VATE after treatment of 26 cases. Disclosure All authors have declared no conflicts of interest.

PS01.138: EXPERIENCE FROM 102 PATIENTS WITH CONTINUOUS INTRAOPERATIVE VAGUS NERVE STIMULATION DURING MINIMALLY INVASIVE ESOPHAGECTOMY

Abstract Background The incidence of recurrent laryngeal nerve (RLN) injury after esophagectomy can be as high as 60–70% especially when lymphadenectomy is performed along bilateral RLN. Vocal cord paralysis is associated with increased pulmonary complication rate, longer hospital stay, and impaired quality-of-life. The authors have modified the Continuous Intraoperative Nerve Monitoring (CIONM) method for minimally invasive esophagectomy. This study reviews our experience in the first 102 patients. Methods From May 2014 to January 2018, patients who underwent thoracoscopic esophagectomy were recruited. CIONM and intermittent nerve stimulation were routinely used during left RLN lymphadenectomy. For right RLN dissection, only intermittent nerve stimulation was used because of much lower chance of nerve injury. Routine direct laryngoscopy was performed on postoperative day one to assess the vocal cord status. Patients with RLN palsy are referred to otorhinolaryngologist for assessment and treatment. Surgical outcome, especially RLN palsy and recovery rates were documented. Results 102 patients were recruited and 73 patients had more than one year follow up. Twenty-two patients had RLN palsy (21.6%); right side in 3, left side in 18, and bilateral in one. Thirty-eight patients (37%) had only unilateral or no RLN dissection performed. This was because of R2 resection negating the benefits of RLN dissection (15.6%), poor pulmonary exposure (9.8%), other technical difficulties (7.8%), preoperative vocal cord palsy (2%), intraoperative complications (1%) and uncertain contralateral nerve integrity (1%). For those 90 patients with successful CIONM, 20 RLN palsy (22.2%), 10 of whom underwent injection thyroplasty within 2–80 days. Thyroplasty was not performed in 12 patients as they had good compensation from the contralateral cord (58.3%), early recovery within 2 weeks (16.7%) tracheostomized status (16.7%) or refusal (8.3%). Thirteen patients (59%) recovered within 2–72 weeks (Median 6 weeks). For the 73 patients with more than 1 year follow up, only 4 has residual vocal cord paralysis, making a genuine cord palsy rate of 5.5%. Conclusion Lymphadenectomy along bilateral RLN is technically demanding. CIONM is a sensitive tool to guide surgeons for safer dissection. Proper patient selection, postoperative assessment and treatment protocol can reduce the morbidity of RLN injury. Majority of the vocal cord paralysis is temporary Disclosure All authors have declared no conflicts of interest.

Does the recurrent laryngeal nerve recover function after initial dysfunction in patients undergoing thyroidectomy?

ObjectiveTotal thyroidectomy with or without central compartment dissection is the treatment of choice for thyroid carcinoma. Extensive dissection along the recurrent laryngeal nerve (RLN) can lead to vocal cord fixity and hoarseness even without nerve sacrifice. Recovery rates after surgery for thyroid cancers have not been well documented. The aim of the study is to analyze the incidence of vocal cord palsy (VCP) and its recovery rates in patients operated for thyroid cancers. Methodology: We performed a retrospective study on prospectively collected data in 152 thyroidectomy patients with 254 RLNs at risk. All patients underwent a laryngoscopic examination to document vocal cord function in the immediate postoperative period and on subsequent follow‐up. Incidence of VCP, recovery rates, univariate and multivariate analysis to identify risk factors for permanent VCP were calculated using binary logistic regression.ResultsIn our study, 28% patients underwent redo surgeries and 74% patients had dissection of the central compartment. The immediate postoperative RLN palsy rate was 11.2%, with a palsy rate of 9% and 16.2% in the per primum and redo surgery cohorts. On follow‐up, there was complete recovery of VCP in 66.7% of these nerves. The incidence of permanent RLN palsy was 3.9%. The mean time to recovery was 9.6 months.ConclusionVocal cord dysfunction recovered in most patients in this high‐risk cohort. There was a significant recovery even in the redo surgery group and a policy of watchful waiting is recommended in the absence of severe symptoms.Level of EvidenceIII

Completion Thyroidectomy: Safer than Thought

Background: The aim of this study was to find out whether a substantial difference in terms of complication rates exists between primary and completion thyroidectomies following initial bilateral subtotal thyroidectomy in the light of current literature and our series. Patients and Methods: Total number of 696 patients who received completion thyroidectomy (Group 1, n = 289) and total thyroidectomy for differentiated thyroid cancer (Group 2, n = 407) and their data were reviewed and postoperative complications were compared between the groups and with the literature. Results: Transient and permanent hypocalcaemia rates were 20% and 5.8% in Group 1 and 10.5% and 5.1% for Group 2 respectively. Unilateral transient, bilateral transient and unilateral permanent recurrent laryngeal nerve palsy rates were 6.2%, 1.3% and 4.4% for patients in Group 1 whereas same complications were seen in 4.6%, 0.7% and 3.6% of patients in Group 2. When groups were compared for complications; temporary hypocalcaemia, unilateral temporary nerve palsy, and minor wound infection rates were statistically higher in Group 1, with no significant difference in permanent complications. Conclusion: When complication rates of re-operation after bilateral subtotal thyroidectomy and primary total thyroidectomy for differentiated thyroid cancer were compared in an unbiased fashion, completion thyroidectomy was shown to be as safe as a primary operation with regard to permanent complications.

Lymph node dissection along the recurrent laryngeal nerves in patients with oesophageal cancer who had undergone chemoradiotherapy: is it safe?

Upper mediastinal lymph node dissection (LND)-especially along the recurrent laryngeal nerve (RN)-is the most challenging part of oesophageal cancer surgery. We investigated whether thoracoscopic RN LND may be safely performed in patients with oesophageal cancer who had undergone chemoradiotherapy (CRT). Patients with oesophageal cancer who had undergone thoracoscopic RN LND (n = 103) were divided into 2 groups according to whether they had prior treatment with CRT or not [the CRT group (n = 65) vs the upfront surgery group (n = 38), respectively]. All patients were operated on by a single surgeon. Intergroup comparisons were made in terms of (i) the number of dissected nodes, (ii) rates of RN palsy and (iii) rates of perioperative complications. The learning curve for the RN LND procedure was investigated using the cumulative sum method. RN LND after CRT was more technically challenging when performed in the left side. Complete skeletonization of the left RN was achieved only in 66.2% of patients in the CRT group (vs 86.8% in the upfront surgery group; P = 0.022). The rate of postoperative left side RN palsy was significantly higher in the CRT group (26.6%) than in the upfront surgery group (7.9%, P = 0.022), albeit resulting in neither higher pneumonia rates nor longer hospital stays. The cumulative sum analysis revealed a steep learning curve for left RN LND in the CRT group. Unfortunately, an acceptable proficiency (left RN palsy rate: 15%) was not achievable even after treatment in 65 cases. Thoracoscopic RN LND is safe but poses significant challenges in CRT-treated patients.

Bilateral patterns and motor function of the extralaryngeal branching of the recurrent laryngeal nerve.

To evaluate the bilateral patterns and motor function of the extralaryngeal branches (ELB) of the recurrent laryngeal nerve(RLN). This study included 500 consecutive patients who underwent total thyroidectomy. Intraoperative nerve monitoring (IONM) was used in 230 patients. Demographic data, indications for surgery, the bilateral patterns of ELB of the RLN, electromyographic activity of the ELB, distance between the branching point to the entrance into the larynx, and the rate of postoperative morbidity were analyzed. The overall rate of ELB was 27.6% (276/1000). A single trunk of the RLN on both sides was found in 269 (54%) patients, whereas ELB on both sides was observed in 45 (9%) patients. The rates of ELB on the left and right sides were 26.6 and 28.6%, respectively. Of the 89 branched nerves which were dissected using IONM, an evoked motor response was present in 100% of the anterior branches and 5.6% of the posterior branches. The mean branching distance of the RLN was significantly greater in female patients than in male patients on the left side (p = 0.031). The patterns of ELB showed no significant difference in male and female patients. The rates of postoperative transient and permanent hypoparathyroidism and unilateral RLN palsy were 21.6 and 2.8%, and 3.2 and 0.8%, respectively. The rate of RLN palsy was higher in branched nerves compared to those with a single trunk (0.75 vs 0.3%; p = 0.2). Unilateral ELB of the RLN might be observed in approximately 1/4 of the patients, while bilateral branching is rare. A few number of posterior branches of the RLN can have motor function. The RLN's with ELB might have a higher risk of injury compared to those with a single trunk.

Does intraoperative neuromonitoring of recurrent nerves have an impact on the postoperative palsy rate? Results of a prospective multicenter study

The impact of intraoperative neuromonitoring on recurrent laryngeal nerve palsy remains debated. Our aim was to evaluate the potential protective effect of intraoperative neuromonitoring on recurrent laryngeal nerve during total thyroidectomy. This was a prospective, multicenter French national study. The use of intraoperative neuromonitoring was left at the surgeons' choice. Postoperative laryngoscopy was performed systematically at day 1 to 2 after operation and at 6 months in case of postoperative recurrent laryngeal nerve palsy. Univariate and multivariate analyses and propensity score (sensitivity analysis) were performed to compare recurrent laryngeal nerve palsy rates between patients operated with or without intraoperative neuromonitoring. Among 1,328 patients included (females 79.9%, median age 51.2 years, median body mass index 25.6 kg/m2), 807 (60.8%) underwent intraoperative neuromonitoring. Postoperative abnormal vocal cord mobility was diagnosed in 131 patients (9.92%), including 69 (8.6%) and 62 (12.1%) in the intraoperative neuromonitoring and nonintraoperative neuromonitoring groups, respectively. Intraoperative neuromonitoring was associated with a lesser rate of recurrent laryngeal nerve palsy in univariate analysis (odds ratio = 0.68, 95% confidence interval, 0.47; 0.98, P = .04) but not in multivariate analysis (oddsratio = 0.74, 95% confidence interval, 0.47; 1.17, P = .19), or when using a propensity score (odds ratio = 0.76, 95% confidence interval, 0.53; 1.07, P = .11). There was no difference in the rates of definitive recurrent laryngeal nerve palsy (0.8% and 1.3% in intraoperative neuromonitoring and non-intraoperative neuromonitoring groups respectively, P = .39). The sensitivity, specificity, and positive and negative predictive values of intraoperative neuromonitoring for detecting abnormal postoperative vocal cord mobility were 29%, 98%, 61%, and 94%, respectively. The use of intraoperative neuromonitoring does not decrease postoperative recurrent laryngeal nerve palsy rate. Due to its high specificity, however, intraoperative neuromonitoring is useful to predict normal vocal cord mobility. From the CHU de Nantes,a Clinique de Chirurgie Digestive et Endocrinienne, Nantes, France; CHU Lille, Université de Lille,b Chirurgie Générale et Endocrinienne, Lille, France; CHU Nancy-Hôpital de Brabois,c Service de Chirurgie Digestive, Hépato-Biliaire, et Endocrinienne, Nancy, France; CHU Angers,d Chirurgie Digestive et Endocrinienne, Angers, France; CHU de Toulouse-Hôpital Larrey,e Chirurgie Thoracique, Pôle Voies Respiratoires, Toulouse; CHU Saint-Etienne-Hôpital Nord,f ORL et Chirurgie Cervico-Faciale et Plastique, Saint-Etienne, France; CHU de Limoges-Hôpital Dupuytren,g Chirurgie Digestive, Générale et Endocrinienne, Limoges, France; CHU de Besançon-Hôpital Jean Minjoz,h Chirurgie Digestive, Besançon, France; Centre Hospitalier du Mans,i Service ORL et Chirurgie Cervico-Faciale, Le Mans, France; Centre Hospitalier Lyon-Sud,j Chirurgie Générale, Endocrinienne, Digestive et Thoracique, Pierre Bénite, France; AP-HM-Hôpital de La Conception,k Chirurgie Générale, Marseille, France; CHU de Rennes-Hôpital Pontchaillou,l Service ORL et Chirurgie Maxillo-Faciale, Rennes, France; CHU de Caen,m ORL et Chirurgie Cervico-Faciale, Caen, France; CHU d'Angers,n ORL et Chirurgie Cervico-Faciale, Angers, France; CHU de Nantes,o Service ORL, Nantes, France; AP HP URCEco île-de-France,p hôpital de l'Hôtel-Dieu, Paris, France; DRCI, département Promotion,q Nantes, France.

Opportunities and challenges of intermittent and continuous intraoperative neural monitoring in thyroid surgery.

The number of thyroid operations and there radically continues to rise in the western hemisphere, bringing prevention of recurrent laryngeal nerve (RLN) palsy to the fore. Overall, the incidence of RLN palsy is fairly low but continues to prompt litigation for malpractice. In an effort to diminish transient, and more importantly permanent, RLN palsy rates, intraoperative neuromonitoring (IONM) has been advocated as a risk minimization tool. Recent meta-analyses of studies, many of which were limited by poor study design and the sole use of intermittent nerve stimulation, were unable to demonstrate superiority of IONM over mere anatomic RLN dissection. This is where continuous IONM (CIONM) comes into play: this technology enables the surgeon to (I) identify impending nerve injury as it unfolds; (II) release distressed nerves by reversing causative surgical maneuvers; and (III) verify functional nerve recovery after intraoperative loss of the electromyographic signal. Despite this superiority, CIONM is not devoid of methodological limitations, which need to be accounted for. This review summarizes the current key achievements of IONM; outlines opportunities for improvement regarding clinical implementation; and suggests areas of future research in this rapidly evolving field.

Are total thyroidectomy and loboisthmectomy effective and safe in benign thyroid diseases? An analysis of 420 patients

Objective. Ideal thyroid surgery is still a debated issue due to preoperative pathology and varying rates of postoperative incidental carcinoma and complications. In our clinic loboisthmectomy and bilateral total thyroidectomy are the treatment of choice in benign nodular thyroid diseases. The objective of this study was to analyse effectiveness and safety of bilateral total thyroidectomy and loboisthmectomy for treating benign thyroid diseases. Methods. Patient charts of the subjects that have undergone thyroid surgery due to benign thyroid diseases between 2009-2015 were evaluated retrospectively. We extracted data including number of patients, type of surgery, preoperative and postoperative pathologies and postoperative complications from departments medical records. Results. Four hundred and twenty patients including 98 (23.3%) male and 322 (76.7%) females aged between 14-80 years (mean; 47.3 ± 12.5) were included into the study. Bilateral total thyroidectomy was performed in 348 (82.9%) patients and loboisthmectomy was performed in 72 (17.1%). Mean duration of follow-up was 41 (range: 15-70) months. Incidental thyroid carcinoma rate was 24.5% (n = 103) in postoperative pathological examination. Temporary and permanent hypocalcemia was seen in 53 (15.2%) patients and 8 (2.3%), respectively. Permanent and transient recurrent laryngeal nerve palsy rate were 2.6% and 2.1%, respectively. Postoperative hematoma was observed in 7 (1.7%) patients. Conclusions. Incidental thyroid carcinoma is frequent in patients who had surgical operation for benign thyroid diseases. When revision surgeries and additional complications due to revision surgery in the remaining cases are kept in mind, bilateral total thyroidectomy or loboisthmectomy at the minimum can be considered as the ideal surgical approach for benign thyroid diseases.

Lymph Node Evaluation in Robot-Assisted Versus Video-Assisted Thoracoscopic Esophagectomy for Esophageal Squamous Cell Carcinoma: A Propensity-Matched Analysis.

Radical lymph node dissection (LND) along the bilateral recurrent laryngeal nerve (RLN) is a surgically challenging procedure with a high rate of morbidity. Here, we assessed in a retrospective manner the adequacy of LND along the RLN performed with robot-assisted thoracoscopic esophagectomy (RATE) versus video-assisted thoracoscopic esophagectomy (VATE) in patients with esophageal squamous cell carcinoma (ESCC). This was a single-center, retrospective, propensity-matched study. ESCC patients who underwent McKeown esophagectomy and bilateral RLN LND with a minimally invasive approach were divided into two groups according to the use of robot-assisted surgery or not (RATE vs VATE, respectively). Using propensity score matching, 34 balanced matched pairs were identified. The number of dissected nodes as well as the rates of RLN palsy and perioperative complications served as the main outcome measures. No conversion to open thoracotomy occurred in either group. Intraoperative blood loss and the need of blood transfusions did not show significant intergroup differences. The mean number of dissected nodes was similar in the two study groups, the only exception being the left RLN area. Specifically, the mean number of nodes removed from this region was 5.32 in the RATE group and 3.38 in patients who received VATE (p=0.007). Notably, the RATE and VATE groups did not differ significantly with regard to rates of both RLN palsy (20.6 vs 29.4%, respectively, p=0.401) and pulmonary complications (5.9 vs 17.6%, respectively, p=0.259). Compared with VATE, RATE resulted in a higher lymph node yield along the left RLN without increasing morbidity.

A meta-analysis of intraoperative neuromonitoring of recurrent laryngeal nerve palsy during thyroid reoperations.

The rate of recurrent laryngeal nerve (RLN) palsy, a common complication of thyroid surgery, is especially high in thyroid reoperations. The present meta-analysis assesses whether intraoperative neuromonitoring (IONM) reduces the prevalence of RLN palsy in thyroid reoperations. A systematic literature search was conducted in the PubMed, SCIE and Wan Fang databases for studies published up to 31 August 2016. All data were analysed using STATA (version 11) software. Publication bias was assessed using Begg's funnel plot and Egger's test, and sensitivity analysis was performed. Nine studies including 2436 at-risk nerves met the inclusion criteria. The results were presented as pooled relative risks (RRs) with 95% confidence intervals (CI). The overall RLN palsy rate was significantly lower in reoperations conducted with IONM than in those conducted without IONM (RR=0.434, 95% CI=0.206-0.916, P=.029). High heterogeneity was found (I2 =70.2%, P=.001). The rates of transient RLN palsy with and without IONM did not differ significantly (RR=0.607, 95% CI=0.270-1.366, P=.227). The heterogeneity was high (I2 =67.4%, P=.005). However, IONM was significantly associated with a reduction in permanent RLN palsy (RR=0.426, 95% CI=0.196-0.925, P=.031). No significant heterogeneity was found (I2 =13.7%, P=.325). Funnel plots for overall and transient RLN palsy showed a possible publication bias. Intraoperative neuromonitoring (IONM) is associated with a reduction in overall and permanent RLN palsy in thyroid reoperations. However, given the limited sample size and heterogeneity in this meta-analysis, further studies are required to confirm our preliminary findings.

Continuous intraoperative neuromonitoring in minimally invasive video assisted thyroid surgery: first experience

Background: Visual identification of the recurrent laryngeal nerve (RLN) is mandatory in thyroid surgery independent of the approach. Intermittent intraoperative neuromonitoring (ioNM) is broadly in open and minimally invasive thyroid surgery. However, the use of continuous intraoperative neuromonitoring (C-ioNM) has yet not been described for minimally invasive video-assisted thyroidectomy (MIVAT). The correct placement of the vagal electrode and the problem of its dislocation represent the limiting factor due to the narrow space. We describe the technique for correct electrode positioning and report on our first experiences with the C-ioNM in MIVAT. Methods: C-ioNM was used in 9 patients eligible for MIVAT. To avoid dislocation of the electrode due to traction or interference with the electrode-wires during dissection both the wires and the electrode were pulled through an additional skin incision. MIVAT was then performed using a 5 mm 30° optical device and special instruments according to the original description from Miccoli. Video assisted hemithyroidectomy was performed in 3 patients, while 6 patients underwent total thyroidectomy. Results: Video-assisted application of the vagal electrode and positioning of the wires via an additional access was feasible in all patients without complications. In 6 cases, the electrode-wires were pulled through an additional skin incision on the dominating side lateral to the sternocleidomastoid muscle. In two patients the wires were pulled through an additional incision in the midline below the surgical approach. In one patient the wires were diverted directly through the primary incision. A significant intermittent decrease of the electromyographic (EMG) amplitude was observed in one patient. However, postoperative RLN palsy rate was zero. Conclusions: C-ioNM in MIVAT is feasible. An additional skin incision is helpful to avoid electrode dislocation. Traction of the thyroid lobe during thyroid lobe mobilization does not seem to affect RLN function. However, more data has to be collected to definitely estimate the significance of C-ioNM in MIVAT.

Morbidity of central compartment clearance: Comparison of lesser versus complete clearance in patients with thyroid cancer.

Extent of central compartment neck dissection (CCND) in thyroid cancers has been a debate because of associated morbidity. There have been attempts to reduce the extent of surgery in an attempt to decrease morbidity. We analyzed the morbidity of CCND from our prospectively maintained surgical morbidity database. CCND was divided into bilateral complete clearance (BCC) and less than complete clearance (LCC). LCC was performed for clinicoradiologically node negative patients. Rates of hypocalcemia and recurrent laryngeal nerve (RLN) palsy rates were compared for LCC versus BCC. We also classified procedures performed in the central neck according to the extent of dissection. Of 153 evaluable patients, BCC was performed in 43.8% and LCC in 56.2%. Rate of postoperative hypocalcemia was 40.2% in BCC group versus 17.4% in LCC group. We had an overall RLN palsy rate of 7.4%. There was no significant difference in RLN palsy rates between the groups. Lesser extent of dissection in central compartment reduces postoperative hypocalcemia but has no influence on RLN palsy rates.

Short-term outcomes and one surgeon's learning curve for thoracoscopic esophagectomy performed with the patient in the prone position.

Thoracoscopic esophagectomy with the patient in the prone position (TEP) is now being performed as minimally invasive esophagectomy for esophageal cancer. This study examines the short-term outcomes and the learning curve associated with TEP. One surgeon ("Surgeon A") performed TEP on 100 consecutive patients assigned to three periods based on treatment order. Each group consisted of 33 or 34 patients. The outcomes of the three groups were compared to define the influence of surgeon expertise. Outcomes improved as Surgeon A gained experience in performing this operation, as evidenced by reduced thoracic operative times between periods 1 and 2, and then between periods 2 and 3 (p=0.0033 and p=0.0326, respectively); an increased number of retrieved chest nodes between periods 1 and 2 (p=0.0070); and a decline in recurrent laryngeal nerve (RLN) palsy between periods 2 and 3 (p=0.0450). Period 2 was the pivotal period for each learning curve. An individual surgeon's learning curve over the course of 100 TEP procedures had three outcomes: a shortened operative time, a higher number of retrieved chest nodes, and a decreased rate of RLN palsy. Approximately 30-60 cases were needed to reach a plateau in the TEP procedure and a reduction in the morbidity rate.

Intraoperative Neuromonitoring in Thyroid Surgery: A Systematic Review.

This study aimed to assess the efficacy of intraoperative neurophysiologic monitoring (IONM) in preventing recurrent laryngeal nerve palsy (RLNP) during thyroid surgery. When IONM results in false positives, it seeks to evaluate contributing factors. A systematic review was conducted gauging the predictive power of neuromonitoring in determining RLN function intraoperatively, its reductions of temporary and permanent RLNP rates, and surgeons' response to the technology. MEDLINE, EMBASE, and PubMed were searched for RLN monitoring in thyroid surgery following a set of inclusion/exclusion criteria. Seventeen studies comparing thyroid surgery with and without IONM were reviewed, including 30,926 patients. Selected studies were pooled to gage the predictive power. Mean specificity of IONM in identifying functional nerves was 90.24% among 7366 nerves at risk (NAR). However, mean positive predictive power (PPP) was low, and both specificity and PPP varied substantially when stratified by risk levels. Among the pooled studies focusing on IONM efficacy-there were 44,575 NAR, of which (57.98%) were operated on with IONM and 18,732 (42.02%) without (control). The rates of overall RLNP per NAR were 3.18 and 3.83% for the IONM group and control, respectively. There is no statistically significant difference between IONM and control, a conclusion supported by qualitative analysis from many individual studies. IONM is not recommended as the standard of care for thyroidectomies. Low PPP of IONM and complications associated with IONM-assisted thyroidectomies may be attributed to either the absence of a standardized negative-signal cutoff value or injury from intubation.