Recurrent Laryngeal Nerve Paresis Research Articles

475. MINIMALLY INVASIVE IVOR -LEWIS ESOPHAGECTOMY - ANALYSIS OF PERIOPERATIVE ONCOLOGICAL AND SHORT TERM OUTCOMES

Abstract Background Trans thoracic Ivor-Lewis esophagectomy is the widely adopted procedure for gastroesophageal junction adenocarcinoma. Minimally invasive esophagectomy has been shown to be superior in comparison to the traditional open approach in terms of pulmonary complications and lymph node yield. We present our experience of minimally invasive Ivor-Lewis esophagectomy in this review. Methods A retrospective review of the patients who underwent minimally invasive Ivor-Lewis esophagectomy at a single center between September 2009 and April 2023 was performed. The perioperative and short term outcomes were analyzed. Results A total of 195 patients [147 males (75.38%)] underwent minimally invasive Ivor-Lewis esophagectomy during the study period. The median (range) age was 62 (48-77) years. The median operative time was 435 (310-530) minutes. The median estimated blood loss was 125 (80-250) ml. R0 resection was achieved in all the patients. The median lymph node yield, ICU stay and overall hospital stay were 22 (12-30), 3.5 (2-12) days and 10 (7-33) days respectively. Pulmonary complications were the most common seen in 24 (12.31%) patients. Anastomotic leak was noted in 5 (2.56%), chyle leak in 2 (1.02%), recurrent laryngeal nerve paresis in 12 (6.15%) patients. Anastomotic stricture was noted in 22 (11.28%) patients who were managed with endoscopic dilatation. Thirty day mortality was observed in 4 (2.05%) patients. Conclusion Minimally invasive Ivor-Lewis esophagectomy is associated with good perioperative oncological and short term outcomes when performed in a specialist esophageal center

Hemithyroidectomy, does the indication influence the outcome?

PurposeHemithyroidectomies are mainly performed for two indications, either therapeutically to relieve compression symptoms or diagnostically for suspicious nodule(s). In case of the latter, one could consider the approach to be rather extensive since the majority of patients have no symptoms and will have benign disease. The aim of this study is to investigate the complication rates of diagnostic hemithyroidectomy and to compare it with the complication rates of compressive symptoms hemithyroidectomy.MethodsData from patients who had undergone hemithyroidectomy either for compression symptoms or for excluding malignancy were extracted from a well-established Scandinavian quality register (SQRTPA). The following complications were analyzed: bleedings, wound infections, and paresis of the recurrent laryngeal nerve (RLN). Risk factors for these complications were examined by univariable and multivariable logistic regression.ResultsA total of 9677 patients were included, 3871 (40%) underwent surgery to exclude malignancy and 5806 (60%) due to compression symptoms. In the multivariable analysis, the totally excised thyroid weight was an independent risk factor for bleeding. Permanent (6–12 months after the operation) RLN paresis were less common in the excluding malignancy group (p = 0.03).ConclusionA range of factors interfere and contribute to bleeding, wound infections, and RLN paresis after hemithyroidectomy. In this observational study based on a Scandinavian quality register, the indication “excluding malignancy” for hemithyroidectomy is associated with less permanent RLN paresis than the indication “compression symptoms.” Thus, patients undergoing diagnostic hemithyroidectomy can be reassured that this procedure is a safe surgical procedure and does not entail an unjustified risk.

257. UPDATE OF THE INTRODUCTION OF MINIMALLY INVASIVE TRANSCERVICAL ESOPHAGECTOMY (MICE), CLINICAL OUTCOMES OF THE LEARNING CURVE COHORT

Abstract Background Surgical resection remains the cornerstone of curative treatment for patients with esophageal cancer. Transthoracic minimally invasive esophagectomies have reduced the occurrence of pulmonary complications, however it is still associated with significant morbidity. The Minimally Invasive transCervical Esophagectomy (MICE) is a novel surgical technique. To date this technique is not routinely performed in Western esophageal cancer patients. We aim to assess the safety and efficacy of the MICE procedure in Dutch patients with esophageal carcinoma. An update of the clinical outcomes of the learning curve cohort. Methods The MICE is a recently developed surgical technique in Japan. The procedure combines a laparoscopic transhiatal and single-port transcervical mediastinal dissection and aims to ensure a radical oncological resection with a reduction of pulmonary complications because a thoracotomy/scopy is avoided. Potential drawbacks may be an increased incidence of recurrent laryngeal nerve paresis (RLNP) and learning associated morbidity. A prospective pilot study was performed including consecutive patients undergoing MICE for esophageal cancer. Results Results will be updated up to August 2023, probably around 70 cases. A total of 50 patients were included in this study in Januari 2023 (male/female ratio 16:4, median age 71 years (IQR 52–85). Median operation time and blood loss was 350 minutes (IQR 326–360) and 100 mL (IQR 50–175). Conversion occurred in five patients (12%). Anastomotic leakage occurred in four patients (10%, 3 ECCG grade 1 and 1 ECCG grade 3). Pneumonia, pleural effusion and chyle leakage occurred in two (5%), five 12%) and two (5%) patients. Recurrent laryngeal nerve paralysis was seen in 22 patients (55%), at least 16 (73%) of which were only temporary. Median length-of-stay was 9 days (IQR 7–10). Conclusion MICE is a novel minimally invasive surgical technique which seems safe and effective to perform in Dutch patients with esophageal carcinoma. As expected, a higher incidence of RLNP was seen, but often only temporarily. Long-term safety and effectiveness will be prospectively evaluated in a larger population.

255. EARLY COST-EFFECTIVENESS MODELLING STUDY COMPARING MINIMALLY INVASIVE TRANSCERVICAL ESOPHAGECTOMY (MICE) AND TRANSTHORACIC MINIMALLY INVASIVE ESOPHAGECTOMY (TMIE) IN OESOPHAGEAL CANCER PATIENTS

Abstract Introduction Minimally Invasive transCervical Esophagectomy (MICE) is a novel transcervical approach to esophagectomy with the possible advantage of decreased pulmonary complications. MICE is in an early stage of introduction in patients which are treated with the McKeown procedure in regular practice. The aim of this study was to provide insight in the potential cost-effectiveness of MICE and its sensitivity to different complications. Methods A decision tree modelled the postoperative outcomes of recurrent laryngeal nerve paresis, anastomotic leakage, pulmonary complications and 30-day mortality. Subsequently, we developed a Markov state transition model to calculate the effects of these input parameters on health outcomes (QALYs) and costs. The results were analysed with a sensitivity analysis and a scenario analysis of a clinical trial of a similar procedure. Results Preventing complications seemed to be effective in reducing hospital costs, but resulted in a limited improvement of health outcomes. Improving 30-day survival demonstrated to have a larger effect on health outcomes. A scenario analysis of data from a clinical trial studying similar procedures resulted in a cost reduction of €2974 and an increase of 0.016 QALYs per patient. Conclusion Reduced healthcare costs and improved health outcomes from reducing complications and 30-day mortality could offset the increased cost of MICE and lead to a cost-effective innovation. We advise close monitoring of short and long term survival outcomes in future studies.

The aortic uncrossing procedure

ObjectiveCross-sectional imaging allows identification of rare patients with a vascular ring and circumflex aorta. The key diagnostic feature is crossing of the transverse aortic arch from right to left posterior to the trachea and superior to the carina in a patient with a right aortic arch. We evaluated our patients who received an aortic uncrossing procedure. MethodsWe reviewed all patients who underwent aortic uncrossing from 2002 to 2022. All patients received preoperative computed tomography imaging and bronchoscopy. ResultsEleven patients ranging in age from 1.5 to 10 years (median 4 years) underwent aortic uncrossing. Two patients had prior left ligamentum division, and 3 patients had prior left aortic arch division. All had significant clinical symptoms. Eight patients had deep hypothermic circulatory arrest (mean 34 minutes), and 3 patients had antegrade cerebral perfusion (median, 28 minutes). Patch material was not used for aortic augmentation, and no patient underwent a posterior tracheopexy or rotational esophagoplasty. Postoperative length of stay ranged from 4 to 31 days (median, 5 days). One patient required a temporary tracheostomy for bilateral recurrent laryngeal nerve paresis, which recovered. One patient required an aortic extension graft to alleviate esophageal compression from an unusual ectatic esophageal course. All patients had relief of airway symptoms and dysphagia. ConclusionsIn properly selected patients with a right aortic arch and circumflex aorta, aortic uncrossing is a safe and effective therapy to treat airway and esophageal compression. The procedure can be conducted with deep hypothermic circulatory arrest or antegrade cerebral perfusion. Careful attention to the location of the esophagus and recurrent laryngeal nerves is required.

A Narrative Review of Preventive Central Lymph Node Dissection in Patients With Papillary Thyroid Cancer -A Necessity or an Excess.

ObjectiveThis review article summarises the latest evidence for preventive central lymph node dissection in patients with papillary thyroid cancer taking into account the possible complications and risk of recurrence.BackgroundPapillary thyroid cancer is the most frequent histological variant of malignant neoplasms of the thyroid gland. It accounts for about 80-85% of all cases of thyroid cancer. Despite good postoperative results and an excellent survival rate in comparison with many other malignant diseases, tumor metastases to the cervical lymph nodes are frequent. Most researchers agree that the presence of obvious metastases in the lymph nodes requires careful lymph node dissection. It was suggested to perform preventive routine lymphadenectomy in all patients with malignant thyroid diseases referred to surgery.MethodsIt was performed the literature review using the “papillary thyroid cancer”, “central lymph node dissection”, “hypocalcemia”, “recurrent laryngeal nerve paresis”, “metastasis”, “cancer recurrence” along with the MESH terms. The reference list of the articles was carefully reviewed as a potential source of information. The search was based on Medline, Scopus, Google Scholar, eLibrary engines. Selected publications were analyzed and their synthesis was used to write the review and analyse the role of preventive central lymph node dissection in patients with papillary thyroid cancer.ConclusionsThe necessity of preventive central lymph node dissection in patients with differentiated papillary thyroid carcinoma is still controversial. There is much evidence that it increases the frequency of transient hypocalcemia. Due to the fact that this complication is temporary, its significance in clinical practice is debatable. It can also be assumed that an extant of surgery in the neck area is associated with an increased risk of recurrent laryngeal nerve injury. However, most studies indicate that this injury is associated more with thyroidectomy itself than with lymph node dissection. Recurrent laryngeal nerve dysfunction is also a temporary complication in the vast majority of cases. At the same time, a large amount of data shows that central lymph node dissection reduces the risk of thyroid cancer recurrence in two times.

Recurrent laryngeal nerve paresis in benign thyroid surgery with and without intraoperative nerve monitoring.

Recurrent laryngeal nerve (RLN) paresis is a rare but serious complication in thyroid surgery. Intermittent intraoperative nerve monitoring (IONM) was thought to prevent paresis of the RLN, but until today data are not conclusive. Our objective was to confirm the hypothesis that IONM can reduce paresis of RLN compared to nerve visualization alone. Therefore, we examined one of the largest cohorts ever evaluated of a tertiary referral center for endocrine surgery undergoing thyroid surgery for benign thyroid disease. Overall, 2097 patients who underwent thyroid surgery for benign thyroid disease in 2016 and 2017 were evaluated. RLN was identified by IONM or visualization only. Preoperative and postoperative laryngoscopic examination was used to evaluate RLN paresis. Patients' characteristics and perioperative data were extracted retrospectively. Overall, 1963 patients (2720 nerves at risk [NAR]) were included in this study: 378 surgeries with IONM (560 NAR) and 1585 without IONM (2160 NAR). Transient and permanent RLN pareses were found in 13 (3.4%; NAR=2.3%) and one (0.3%; NAR=0.2%) nerve treated with IONM vs. 37 (2.3%; NAR=1.7%) and five (0.3%; NAR=0.2%) nerves without IONM (P=0.507; NAR P=0.654), respectively. Using intermittent IONM, our retrospective study could not demonstrate a significant decrease of RLN pareses in patients undergoing thyroid surgery for benign thyroid disease. This is probably explained by the very low overall number of RLN pareses in our department. Nevertheless, because of patients' safety to avoid any bilateral RLN pareses, we recommend IONM in bilateral resections.

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

Influence of Recurrent Laryngeal Nerve Transient Unilateral Palsy on Objective Voice Parameters and on Voice Handicap Index after Total Thyroidectomy (Including Thyroid Carcinoma).

Introduction: Total thyroidectomy (TT) is one of the most common surgical endocrine surgeries. Voice impairment after TT can occur not only in patients with recurrent laryngeal nerve (RLN) transient paralysis, but also in cases of normal vocal cord mobility. Aim: To compare voice limits using a speech range profile (SRP) in patients before and 14 days after TT and to investigate the influence of the early results of voice quality after TT on the personal lives of patients. We focused on the perception of voice change before and shortly after TT. Materials and methods: A retrospective study, in the period 2018–2020, included 65 patients aged 22–75 years. We compared two groups of patients: group I (n = 45) (without RLN paresis) and group II (n = 20) (with early transient postoperative RLN paresis). Patients underwent video flexible laryngocopy, SRP, and Voice Handicap Index-30 (VHI-30). Results: In group I, the mean values of Fmax (maximum frequency) and Imax (maximum intensity) decreased in women (both p = 0.001), and VHI-30 increased (p = 0.001). In group II after TT in women, the mean Fmax and Imax values decreased (p = 0.005 and p = 0.034), and the frequency range of the voice was reduced from 5 to 2 semitones. The dynamic range of the voice was reduced by 3.4 dB in women and 5.1 dB in men.VHI-30 increased (p = 0.001). Conclusion: The study documented a worsening of the mean values of SRP, VHI-30, and voice parameters of patients in group II. Voice disorders also occurred in group I without RLN paresis. Non-paretic causes can also contribute to voice damage after TT. SRP and VHI-30 are suitable tools for comparing voice status in two groups of patients, including those with dysphonia. Our data support the claim that the diagnosis of a thyroid cancer does not necessarily imply a higher postoperative risk of impaired voice quality for the patient.

Remote access endoscopic parathyroidectomy: a study of 17 cases from Central India

<p><strong>Background: </strong>It has been debated that "remote access endoscopic parathyroidectomy" requires extensive dissection, thereby, increasing the risk of complications. Hence, the aim of this study is to assess the feasibility and safety of remote access endoscopic parathyroidectomy via the unilateral axilla-breast approach (ABA) and transoral vestibular approach (TOEPVA). </p><p><strong>Method: </strong>The study includes 17 patients with primary hyperparathyroidism undergoing endoscopic parathyroidectomy from January 2016 to December 2020. Of these, 11 patients underwent parathyroidectomy via unilateral ABA and 6 had TOEPVA. Preoperatively, ultrasonography of neck, sestamibi scan and CT scan neck were done to localise the diseased gland. Post operatively, Serum calcium and parathyroid hormone levels were monitored.</p><p><strong>Results</strong>: The mean age of patients was 35.6±10.5 years. Except one, all the patients were females. The mean operative time of the unilateral ABA and TOEPVA group was 93.67±28.64 minutes and 138.6±31 minutes respectively. Except for three patients, in all the patients, the parathormone levels normalised. One patient had hungry bone syndrome postoperatively. The mean hospital stay of the unilateral ABA and TOEPVA group was 3±1.5 days and 4±3.09 days respectively. One patient had post-operative transient recurrent laryngeal nerve paresis. Seroma and surgical emphysema were seen in two patients each. </p><p><strong>Conclusions</strong>: Remote Access Endoscopic parathyroidectomy may be considered safe in treatment of parathyroid tumours. Precise preoperative localisation is mandatory. In addition to a magnified view and a better illumination, the potential advantages of endoscopic techniques are better cosmetic results, decreased hospital stay and better patient comfort.</p>

Neuromonitoring of recurrent laryngeal nerves in thyroid surgery comparative study of visualisation and electrophysiology methods.

Úvod: Poranění zvratného nervu je jedna znejzávažnějších komplikací chirurgie štítné žlázy, chirurgie příštítných tělísek achirurgie krčních obratlů. Vliteratuře se popisuje poranění zevní větve hrtanových nervů jako méně časté. Tato komplikace je natolik vážná, že může vést kinvalidizaci hlasových profesionálů (učitelů, herců, zpěváků, profesionálních řečníků amanažerů). Současná klinická praxe je spojena se zvýšeným úsilím operoperační ochranu funkce zvratných nervů využíváním elektrofyziologické monitorace funkce inervace hrtanu asoučasné vizualizace zvratných nervů. Metody: Design studie je prospektivní observační. Ze souboru 100 po sobě jdoucích operací byly chirurgy náhodně vytvořeny dvě skupiny: Skupina A- spoužitím neuromonitoringu (IONM) askupina B - identifikace avizualizace zvratného nervu (NLR) bez IONM. Jeden tým chirurgů byl složen zexperta (více než 1000 provedených operací) azačínajícího chirurga (méně než 100 operací) adruhý ze dvou zkušených chirurgů (jeden více než 150 operací adruhý více než 500 operací). Každý tým byl zapojen do operací několikrát vtýdnu. Porovnání bylo provedeno statistickými metodami apomocí indexu poranění zvratného nervu (recurrent nerve injury - IRI). Cílem studie je porovnat incidenci parézy zvratných nervů při využití neuromonitorace (IONM) avyužití peroperační vizualizace anatomicky neporaněného nervu dvěma týmy chirurgů. Výsledky: Bylo analyzováno 100 operací, respektive 50 operací ve skupině Aa50 ve skupině B. Skupina Azahrnovala 43 totálních thyreoidektomií a7 hemithyreoidektomií abyly zjištěny dvě dočasné jednostranné parézy. Skupina Aměla IRI=1,075. Skupina B zahrnovala 48 totálních thyreoidektomií a2 hemithyreoidektomie. Vtéto skupině byly zjištěna také dvě jednostranné dočasné parézy zvratného nervu. Skupina B měla IRI=1,02. Uvedené hodnoty IRI tak charakterizují asymetrické soubory, itato drobná asymetrie je ve výsledku hodnoty patrna. Celková incidence poranění zvratných nervů vcelém souboru operovaných sledovaného roku, ve kterém byl výběr pacientů dle metodiky této práce, byla 1,3%. Vsouboru bylo 16 dočasných a4 permanentní parézy zvratného nervu ve všech případech na jedné straně. Vesledovaném období nebyla zjištěna ani jediná oboustranná paréza trvalá ani dočasná. Index IRI pro operace štítné žlázy vuvedeném období byl 2,26. Tento soubor byl srovnáván se soubory skupiny Aaskupiny B avýsledky nevykazují statisticky významné rozdíly na hladině významnosti 1% (p=0,01). Závěr: Studie neprokázala statisticky významné rozdíly incidence poranění zvratného nervu (trvalá jednostranná paréza) vzávislosti na chirurgické technice bez využití IONM asvyužitím IONM prováděných chirurgem srozdílnou zkušeností vchirurgii štítné žlázy. Studie prokázala, že IONM může pomoci vyrovnat handicap uzačínajících améně zkušených chirurgů aomezit incidenci morbidity zvratného nervu vchirurgii štítné žlázy.

Lymph Node Dissection Morbidity in Thyroid Cancer: An Integrative Review.

Cervical lymphadenectomy is a common procedure for thyroid cancer. Some of the complications are congruent with the complications of thyroid surgery, in particular recurrent laryngeal nerve paresis and hypoparathyroidism as well as bleeding and wound infection. Specific complications of lateral cervical lymph node dissection are injuries to the accessory, phrenic and hypoglossal nerves, and the cervical plexus trunk and injuries, the salivary glands, and the lymphatic system, especially the ductus thoracicus. Most of these complications are very rare with an incidence of <1%. Profound anatomical knowledge and a careful dissection technique make a decisive contribution to minimizing complications.

Costs Associated With Lobectomy for Lung Cancer: An Analysis Merging STS and Medicare Data

Costs related to care of patients who undergo lobectomy for lung cancer may vary depending on patient, disease, and treating facility characteristics. We aimed to identify underlying case mix factors that contribute to variability of 90-day costs of lobectomy for early-stage lung cancer. The Society of Thoracic Surgeons General Thoracic Surgery Database was queried for lobectomy for clinical stage I lung cancer (2008-2013). Demographics, clinical outcomes, and 90-day episode-of-care costs across all care settings were analyzed for patients successfully linked to Medicare data. Hospital costs were estimated from charges using cost-to-charge ratios. Comprehensive regression models were created to identify impact of preoperative patient factors and hospital characteristics on costs, and to delineate additive costs due to perioperative outcomes and complications. The mean 90-day cost for lobectomy was $45,080 ± $38,239. Variables associated with significant additive costs were age greater than or equal to 75 years, American Society of Anesthesiologists classification III or IV, forced expiratory volume in 1 second less than 80% predicted, body mass index less than 18.5 or greater than 35, current or past smoker, cerebrovascular disease, chronic kidney disease, impaired functional status, open thoracotomy, prolonged operative time, government hospitals, metropolitan setting, and geographic location. Patients with 1 or more postoperative complication resulted in an overall mean added cost of $27,259. Added costs increased with the number of complications; isolated recurrent laryngeal nerve paresis ($3,911) and respiratory failure ($35,011) were associated with the least and most additive cost, respectively. Lobectomy is associated with substantial variability of episode-of-care costs. Variability is driven by patient demographic and clinical factors, hospital characteristics, and the occurrence and severity of complications.

HEALTH-RELATED QUALITY OF LIFE IN A PATIENT FOLLOWING ANEURYSMOTOMY OF RARE MEGA-GIANT ANEURYSM OF THE COMMON CAROTID ARTERY

In the subject literature there are only a few articles devoted to the Health-Related Quality of Life (HRQoL) of patients with large ex- tracranial aneurysms of the carotid artery segment. There are no reports on the quality of life of patients with rare Mega-Giant Carotid Artery Aneurysms (MGCAA) manifesting themselves as chronically large and growing neck tumors. The aim of the research was an evaluation of the health related quality of life (HRQL) of a patient following aneurysmotomy of Mega-Giant Carotid Artery Aneurysms (MGCAA). An 82-year-old patient was referred to the Department of Vascular Surgery at the John Paul II Hospital in Krakow, due to the presence of a megagiant, painful tumor covering the entire left side of the neck. A physical examination and angio-CT confirmed the pres- ence of a pulsating tumor, which extended vertically from the level of the angle of the mandible to the clavicle, and horizontally from the trachea to the cervical spine. An aneurysmotomy and recon- struction of LICA with cerebral protection using a shunt catheter was performed. The patient was awakened from anesthesia and extubated shortly after the procedure, without any Central Nervous System neurological defects. The surgery was complicated by left recurrent laryngeal nerve paresis and aphonia without dyspnoea, which was only partially resolved around 3 months after the oper- ation itself. The postoperative period was uncomplicated. Health related Quality of Life (HRQoL) was studied using the 36-Item Short Form Health Survey (SF-36) to study both the clinical symp-toms and how these symptoms would be reduced in a year follow up after the aneurysmotomy. Despite the increasing availability of endovascular options and techniques, open surgical repair of ICA aneurysms, especially Mega- Giant Carotid Artery Aneurysms (MGCAA), using cerebral protection (shunts), remains a basic option, providing an opportunity to avoid major intraoperative and postoperative complications. The aneurysmotomy, despite laryngeal nerve paresis and aphonia without dyspnoea, improves the patient’s health-related quality of life.

Aortic uncrossing and tracheobronchopexy corrects tracheal compression and tracheobronchomalacia associated with circumflex aortic arch

ObjectiveAortic uncrossing is an effective procedure for relieving the external airway compression from a circumflex aortic arch by transferring the aortic arch to the same side as the descending aorta. However, patients frequently have residual tracheobronchomalacia (TBM), which may result in persistent postoperative symptoms. We review a series of patients who underwent an aortic uncrossing and concomitant tracheobronchopexy to correct the airway compression and residual TBM. MethodsRetrospective review of all patients who underwent aortic uncrossing and concomitant tracheobronchopexy at a single institution between September 2016 and March 2019. Preoperative evaluation included computed tomography angiography and rigid 3-phase dynamic bronchoscopy. ResultsEight patients who ranged in age from 4 months to 15 years with significant respiratory symptoms underwent an aortic uncrossing procedure with concomitant tracheobronchial procedures. Mild hypothermic cardiopulmonary bypass (mean time, 105.6 ± 39.4 min) and regional perfusion (mean time, 44 ± 10 min) were used without circulatory arrest. Intraoperative bronchoscopy demonstrated no patients had residual TBM. There were no postoperative mortalities, neurologic complications, chylothoraces, coarctations, or obstructed aortic arches. Two patients required tracheostomy and gastrostomy for bilateral recurrent laryngeal nerve paresis (patients 2 and 3). One patient with bronchial stenosis after concomitant slide bronchoplasty required stenting. At a median follow-up of 22 months (range, 5-34 months), all patients were alive without evidence of significant respiratory symptoms. ConclusionsThe aortic uncrossing procedure can be performed safely in pediatric patients of all ages without circulatory arrest. Concomitant procedures addressing associated TBM can significantly improve respiratory symptoms.

Clinicopathological study of thyroid swelling and its management

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; There is high prevalence of thyroid lesions in India. In this study, an attempt is made to find out the clinical spectrum of thyroid swellings in central India, diagnostic accuracy of fine needle aspiration cytology (FNAC), appropriate surgical management and to compare it with postoperative histopathological diagnosis so as to determine its role in surgical management.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; In this prospective study, 100 subjects presenting to ENT OPD of GMC, Nagpur during the period from September 2017 to August 2019 with thyroid swelling who were fit to undergo surgery and willing to participate in the study were selected. After detailed evaluation and routine investigations, thyroid function test (TFT), FNAC, ultrasonography (USG) neck, all the subjects underwent required thyroidectomy. The postoperative histopathological examination (HPE) report was correlated with cytological report. &lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; In 100 subjects, majority of subjects were from 4th decade (32%) with female: male ratio=6.14:1. FNAC findings were colloid goiter (61%), nodular goiter (19%), follicular neoplasm (10%), and papillary carcinoma (9%). On HPE, colloid goitre (57%) was most common non-neoplastic lesion and papillary carcinoma (65.21 %) was most common malignant lesion. Hemithyroidectomy (70%) was most common procedure done. Transient hypocalcemia (5%), recurrent laryngeal nerve (RLN) paresis (2%) were the postoperative complications encountered. Sensitivity, specificity, accuracy, positive and negative predictive values of FNAC to diagnose malignancy were 55.6%, 100%, 91%, 100% and 90% respectively.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; FNAC is an easy, rapid, reliable, cost-effective, minimally invasive and readily repeatable technique for diagnosis of thyroid swellings. The common false negative diagnosis is seen in follicular pattern cases, cystic papillary thyroid carcinoma (PTC) and papillary microcarcinoma. &lt;/p&gt;

Outcomes of hemithyroidectomy under local with general anesthesia: A tertiary center experience

Context: The prevalence of thyroid neoplasm is high in the developing countries and therefore an increasing rate of thyroid surgery. Aims: We aimed to compare the outcomes of patients undergoing hemithyroidectomy under local anesthesia (LA) with general anesthesia (GA). Settings and Design: This was a prospective, comparative study. Methods: The study was conducted for a period of 22 months in 30 patients, undergoing hemithyroidectomy under LA and GA. Patients in both the groups were assessed for duration, postoperative pain, satisfaction, postoperative complications, and cost. Statistical Analysis Used: Analysis of the data was done using the Statistical Package for the Social Sciences 16 software (IBM, New York, US). Unpaired t-test was used to test the difference of mean and Fisher's exact test was used to test the association between the two groups. P < 0.05 was taken as statistically significant. Results: The mean operative time was less in Group A (LA) than Group B (GA) (79.2 min vs. 83.6 min) (P = 0.88). The mean postoperative pain score (using the Numerical Rating Scale) was high in Group A (3.4) than Group B (2.8) (P = 0.42). There was no statistical significant difference regarding satisfaction with anesthesia. One patient in each group developed recurrent laryngeal nerve (RLN) paresis, whereas two patients in Group B developed RLN paralysis. The mean cost was less in Group A (P < 0.001). Conclusions: Hemithyroidectomy under LA can be performed safely in a selected group of patients, expecting similar operative, clinical results and patient satisfaction.

Minimally invasivethyroidectomy: A cosmetic alternative to standard thyroidectomy

Background: We report on minimally invasive thyroidectomy (MIT) through a 2–4cm incision hypothesize similar clinical results to standard open thyroidectomy. Methods: Between January 2019 and March 2020, 61 MIT were evaluated for clinical outcomes, and patient satisfaction on a 1–10 scale. Results: The 61 study patients underwent MIT procedure. The final diagnoses were benign nodular goitre (63%), and papillary thyroid carcinoma (37%). Five patients had temporary recurrent laryngeal nerve paresis and four patients had temporary hypocalcemia. Conclusion: In selected patients, MIT through a 1,5–3cm incision assistance is a safe alternative to standard open thyroidectomy in the hands of an experienced surgeon. The clinical results are equivalent and patient satisfaction is significantly improved.

The laryngeal twitch response - Can it avoid unnecessary two-stage thyroidectomy? - A retrospective cohort study.

The objective of this study was to determine if the laryngeal twitch response, when compared to neuromonitoring, can predict postoperative vocal cord function and can thus be used in case of technical failure of the EMG-recording electrode. A total of 640 nerves at risk were included in this study based on a prospective protocol. The laryngeal twitch response and the EMG-records were compared with the results of the postoperative laryngoscopy. Of the 640 nerves at risk, 582 showed a normal postoperative vocal cord function. A recurrent laryngeal nerve paralysis (no vocal fold movement) was observed in 39 cases and recurrent laryngeal nerve paresis (reduced vocal cord movement) was diagnosed in 19 cases. The overall negative predictive value (NPV) in final vagus nerve stimulation (V2) was 95.0% for the EMG-records and 94.8% for the laryngeal twitch response. When pareses were excluded, the NPV was 96.8% and 96.6% respectively. The positive predictive value (PPV) of vagus nerve stimulation lies between 51.4% and 57.1% excluding the pareses. It rises to values between 60.0% and 65.1% if they are included. The laryngeal twitch response and the EMG-records show similar results, and the NPV is good in both. Thus, in case of technical failure or displacement of the EMG-recording electrode, the laryngeal twitch can be used in decision-making for or against a two-stage thyroidectomy.

Completion thyroidectomy: A risky undertaking?

BackgroundCompletion thyroidectomy (cT) is sometimes necessary after thyroid lobectomy (TL), and it remains controversial whether 2-stage thyroidectomy adds operative risk. This study compares complication rates for TL, total thyroidectomy (TT), and cT. MethodsUsing a cohort design, we reviewed 100 consecutive cases each of TL, TT, and cT. Complications examined included reoperation for hematoma, temporary/permanent recurrent laryngeal nerve (RLN) dysfunction, and hypoparathyroidism. ResultsTwo patients had reoperation for hematoma, both in the TT cohort (p = 0.33). No patients in any cohort had permanent hypoparathyroidism or RLN injury, but transient RLN paresis occurred in three (3%) TL, two (2%) TT, and no (0%) cT patients (p = 0.38). Transient hypoparathyroidism occurred in 3% following TT versus 0% after cT (p = 0.12). Overall complication rate was higher after TT (7%) compared to TL (3%) and cT (0%, p = 0.02). ConclusionsAt a high-volume center, the observed complication rates were equivalently low for TL, TT, and cT. SummaryCompletion thyroidectomy is occasionally needed after lobectomy, but its procedure-specific risks are not well characterized. In a cohort study at a high-volume center, operative outcomes for patients undergoing thyroid lobectomy, total thyroidectomy, and completion thyroidectomy were compared and equivalently low complication rates were observed for all 3 procedures.