endokrin cerrahisi - 7 turkish congress of endocrine surgery 2015 · 2017-03-01 · endocrine...
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Greg Randolph
Harvard Medical School
7th Turkish Congress of
Endocrine Surgery 2015
SLN monitoring and Continuous Vagal monitoring
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Disclosure Elements
• Relevant Financial Disclosures
-- None
Name of Presenter Gregory W. Randolph
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Fenway
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Monitoring 2015
1- SLN-100% ID
2- CIONM -Prevention
3- IONM -Professional Voice
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RLN Neural Monitoring
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The Non Recurrent Laryngeal Nerve:
Anatomic and Electrophysiologic
algorithm for reliable identification
Dipti Kamani, Andre Potenza, Claudio Cernea,
Gregory Randolph
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EMPOWERING PHYSICIANS TO DELIVER THE BEST
PATIENT CARE
Statement 7.
INTRAOPERATIVE EMG MONITORING: The surgeon or their
designee may monitor laryngeal electromyography (EMG) during
thyroid surgery. Option based on one RCT and observational studies
with a balance of benefit versus harm
Action Statement Profile
• Aggregate Evidence Quality: Grade C
• Benefit: Added information regarding neurophysiologic status of the RLN (specifically
when the nerve is injured), potential improved accuracy in nerve identification,
avoiding transient/temporary nerve paresis in one RCT (number needed to treat 33)
• Risk, Harm, Cost: cost of endotracheal tube and probe, capital equipment costs,
education of key personnel including anesthesia, nursing, surgeon and technician,
misinterpretation (both false positive/false negative), may instill a false sense of
security in identifying nerve
• Benefit-Harm Assessment: Equilibrium
• Value Judgments: None
• Intentional Vagueness: None
• Role of Patient Preferences: None
• Exclusions: None
• Policy level: Option
• AAOHNS guidelines 2013:-special utility in
cases
1. bilateral thyroid surgery
2. revision thyroid surgery
3. surgery in the setting of existing RLN paralysis
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2014 American Thyroid Association Management Guidelines for Patients with
Thyroid Nodules and Differentiated Thyroid Cancer
The American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules and
Differentiated Thyroid Cancer
Bryan R. Haugen, M.D.1 (Chair)*, Erik K. Alexander, M.D.
2, Keith C. Bible, M.D.,
Ph.D.3, Gerard M. Doherty, M.D.
4, Susan J. Mandel, M.D., M.P.H.
5, Yuri E. Nikiforov, M.D.,
Ph.D.6, Furio Pacini, M.D.
7, Gregory W. Randolph, M.D.
8, Anna M. Sawka, M.D., Ph.D.
9,
Martin Schlumberger, M.D.10
, Kathryn Schuff, M.D.11
, Steven I. Sherman, M.D.12
, Julie Ann
Sosa, M.D.13
, David L. Steward, M.D.,14
R. Michael Tuttle, M.D.15
, and Leonard Wartofsky,
M.D.16
2015
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2015
• [B13] Intraoperative Voice and Parathyroid Management
• ■ RECOMMENDATION 41
• A) Visual identification of the recurrent laryngeal nerve (RLN) during dissection is required in all cases. Steps should also be taken to preserve the external branch of the superior laryngeal nerve (EBSLN) during dissection of the superior pole of the thyroid gland. (Strong recommendation, Moderate-quality evidence)
• B) Intraoperative neural stimulation (with or without monitoring) may be considered to facilitate nerve identification and confirm neural function. (Weak recommendation, Low-quality evidence)
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Monitoring 2015
1- SLN-100% ID
2- CIONM -Prevention
3- IONM -Professional Voice
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EMPOWERING PHYSICIANS TO DELIVER THE BEST
PATIENT CARE
Statement 6.
PROTECTION OF SUPERIOR LARYNGEAL NERVE: The surgeon
should take steps to preserve the external branch of the superior
laryngeal nerve(s) when performing thyroid surgery.
Recommendation based on preponderance of benefit over harm
Action Statement Profile
• Aggregate Evidence Quality: Grade C
• Benefit: Preserves vocal projection and high frequencies, may improve
airway in extreme circumstances
• Risk, Harm, Cost: May leave superior pole thyroid tissue
• Benefit-Harm Assessment: Preponderance of benefit
• Value Judgments: None
• Intentional Vagueness: The steps taken to preserve the nerve are
purposefully not specified in the statement to emphasize the important
issue is preserving the nerve, which may or may not be identifiable during
surgery. Therefore, it is the attention to the nerve that is important
• Role of Patient Preferences: None
• Exclusions: None
• Policy level: Recommendation
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Amelita Galli-Curci
• “the surprising voice is gone forever. The
sad specter of a ghost replaces the velvety
softness”
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Laryngeal head of the
sternothyroid muscle
SLN
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RLN and SLN – Statistical Analysis
782,2
269.9
0,0
200,0
400,0
600,0
800,0
1000,0
1200,0
1400,0
1600,0
Nerve
Amplitude of EMG response in
microvolts
RLN SLN
p<0.0001
SLN amplitude: 34% of ipsilateral RLN amplitude
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EBSLN and Cricothyroid muscle
twitch
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Monitoring 2015
1- SLN-100% ID
2- CIONM -Prevention
3- IONM -Professional Voice
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Why Continuous Vagal Nerve
Monitoring (CIONM) ?
1-Standard IONM- stim is intermittent
Stimulation-injury-stimulation
2-Passive traumatic (non-evoked) responses
are poorly related to nerve injury
Standard IONM has great utility but CIONM
brings the potential of preventing injury
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Mechanism of injury
Snyder 08 and Chiang 08
IONM mapping studies
75% RLN injuries are
stretch injury at LOB
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Vagal Electrode configuration
Closed
• Medtronic
• Saxophone
Open
• Inomed
• Langer
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Initial CIONM studies during
thyroidectomy-Safety
• Lamade 00,07, 11 Ulmer 08: saxophone and cuff <1mA,
stim ~ 1-1/2 hrs
• Schneider 09: 45 pts, Anchor < 1hr
• Jonas 10: V3 inomed 100 pts-LOS
• Ulmer 11: studied HRV-parasympathetic predominance
w/o cardiac arrthyrmia,hemodynamic instablity
• Dralle, Randolph 12
Safe-neural, cardiac, pulmonary
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CIONM EMG Injury Construct A
xis
AM
PL
ITU
DE
Axis TIME
Transection
Cautery
Compression
Stretch
LOS
Injury
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CIONM Electrode Image
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APS Electrode on Vagus Nerve
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Case 4- RLN Recovery Post Manipulation
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Case 37- Mild Combined Event
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Continuous Vagal IONM (CIONM):
Amplitude and latency changes :
1. Mild Combined Event (mCE)-
amplitude decrease of >50 – 70 % with a concordant
latency increase of 5-10%
2. Severe Combined Event (sCE)-
amplitude decrease of >70% with an concordant latency
increase of >10%
3. Loss of Signal (LOS) –
complete loss of recognizable RLN signal (amplitude <
100 µV) intraoperatively
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Continuous Vagal IONM (CIONM):
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Adverse but nascent EMG outcome
parameter: severe CE
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Continuous Vagal IONM (CIONM):
~72%
~17%
N=16
N=6 N=6 N=5
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LOS –an evolutionCIONM:
-amp, latency in isolation without utility
-severe Combined Events: p=0.001 -VCP
sens 67% spec 91% NPV 97% PPV 33%
reversible in >70%%
- LOS: p<0.001 –VCP
sens 83% spec 99% NPV 98% PPV 83%
reversible in <20%
sCE multiple sCE LOS VCP72% 17%
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Monitoring 2015
1- SLN-100% ID
2- CIONM -Prevention
3- IONM -Professional Voice
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Normal Singing Voice
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Thyroidectomy in the Professional Singer –Neural Monitored Surgical Outcomes
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• Methods– Prospective database
of 30 professional voice users undergoing thyroid surgery with IONM between August 2002 – March 2014
– Pre- and post-operative vocal cord function was normal in all patients
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• Methods– I.Surveys to collect pre & post-operative voice
instrument data• Voice Handicap Index (VHI)
• Singing Voice Handicap Index (SVHI)
• Evaluation of the Ability to Sing Easily (EASE)
– II. Additional questions formulated by our laryngologist team• Vocal parameters affected during ‘recovery phase’
• Time to return to performance
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• Results
– Average age 44.81 (range 17 – 76)
– 100 % return to performance
– Mean time of 2.26 months (range 0.5 – 8 months)
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• Results
– Vocal instrument mean scores showed no statistically significant difference in pre-operative to post-operative comparisons
VocalInstrument
Pre –Op Post -Op P-value
VHI 4.15 4.04 0.9301
SVHI 11.26 12.07 0.8297
EASE 6.19 6.00 0.9348
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• Conclusion
– Neural monitored thyroid surgery in professional voice users is safe
– Key elements are:
• Strict adherence to INMSG with respect to RLN & EBSLN
• pre and post-operative laryngeal assessment (in compliance with the AAO-HNS voice guidelines)
• specific intra-operative surgical techniques to maximize vocal integrity
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Monitoring 2015
1- SLN-100% ID
2- CIONM -Prevention
3- IONM -Professional Voice
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Invitations
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Surgery of the Thyroid and
Parathyroid Glands
Harvard Medical School, Boston
October 2016 [email protected]
617 –573- 4115
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September 17-19 2015
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3rd World Congress on Thyroid CancerJuly 27 – 30, 2017
Steering CommitteeGregory W. Randolph, MD, Harvard Medical School
Bryan McIver, MD, Moffitt Cancer Center
Ezra Cohen, MD, University of California San Diego
Jeremy Freeman, MD, University of Toronto
Bryan Haugen, MD, University of Colorado Health Sciences Center
Jatin P. Shah, MD, Memorial Sloan-Kettering Cancer Center
Ashok R. Shaha, MD, Memorial Sloan-Kettering Cancer Center
Steven I. Sherman, MD, UT MD Anderson Cancer Center
Ian J. Witterick, MD, University of Toronto
A global multi-disciplinary meeting of all specialists involved in the field of Thyroid Cancer and Thyroid Nodules.
The Westin Boston WaterfrontBoston, Massachusetts
www.thyroidworldcongress.com
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Thank you