Incidence of thyroidectomies is continuing to increase. Identifying factors associated with favorable outcomes can lead to cost savings.
To assess the association of surgeon volume with clinical ...outcomes and costs of thyroidectomy.
Cross-sectional analysis performed in October of 2014 of adult (≥ 18 years) inpatients in US community hospitals using the Nationwide Inpatient Sample for the years 2003 through 2009.
Thyroidectomy.
Complications, length of stay, and cost following thyroidectomy in relation to surgeon volume. Surgeon volumes were stratified into low (1-3 thyroidectomies per year), intermediate (4-29 thyroidectomies per year), and high (≥ 30 thyroidectomies per year).
A total of 77,863 patients were included. Procedures performed by low-volume surgeons were associated with a higher risk of postoperative complications compared with high-volume surgeons (15.8% vs 7.7%; OR, 1.55 95% CI, 1.19-2.03; P = .001). Mean (SD) hospital cost was significantly associated with surgeon volume (high volume, $6662.69 $409.31; intermediate volume, $6912.41 $137.20; low volume, $10,396.21 $345.17; P < .001). During the study period, if all operations performed by low-volume surgeons had been selectively referred to intermediate- or high-volume surgeons, savings of 11.2% or 12.2%, respectively, would have been incurred. On the basis of the cost growth rate, greater savings are forecasted for high-volume surgeons. With a conservative assumption of 150,000 thyroidectomies per year in the United States, referral of all patients to intermediate- or high-volume surgeons would produce savings of $2.08 billion or $3.11 billion, respectively, over a span of 14 years.
A surgeon's expertise (measured by surgical volume of procedures per year) is associated with favorable clinical as well as financial outcomes. Our model estimates that considerable cost savings are attainable if higher-volume surgeons perform thyroid procedures in the United States.
Objectives
The electrophysiologic responses of 1,381 recurrent laryngeal nerves (RLN) during monitored neck surgery were recorded and reviewed.
Study Design
Retrospective case series.
Methods
With ...institutional review board approval, we reviewed thyroid and other neck surgeries performed with intraoperative nerve monitoring (IONM) between the years 1995 and 2006. This list yielded consecutively monitored 1,381 RLNs, with over 3,000 hours of monitoring experience. All patients underwent preoperative and postoperative laryngoscopy. In an initial subset of patients, both hook‐wire and endotracheal tube (ETT) surface electrodes were utilized. Normative stimulation parameters; postoperative vocal cord function prognostication using monitoring data; and false‐positive, false‐negative, and passive electrophysiologic responses were evaluated
Results
Hook‐wire electrodes and ETT surface electrodes were found to have good correlation in terms of amplitude (correlation coefficient, R = 0.89). Nerve stimulation of 1 to 2 mA resulted in an ipsilateral biphasic response, with 3.3 ms mean latency and 900 μV mean amplitude. Permanent and temporary RLN paralysis rates were 0% and 0.7%, respectively. Specificity of electromyography (EMG) loss of signal (LOS) postoperative vocal cord paralysis (VCP) detection was 99.9%, and sensitivity was 33%. Negative predictive value of EMG LOS at the end of surgery in the prediction of postoperative VCP was 99.6%, whereas its positive predictive value for VCP was 75%.
Conclusion
Intraoperative nerve monitoring of the RLN during thyroid and other neck surgeries can aid in the nerve mapping, nerve identification, and prognostication of postoperative vocal cord function, which in turn can influence the surgeon's decision to proceed to bilateral surgery.
Level of Evidence
4. Laryngoscope, 127:280–286, 2017
Intraoperative neural monitoring (IONM) during thyroid and parathyroid surgery has gained widespread acceptance as an adjunct to the gold standard of visual nerve identification. Despite the ...increasing use of IONM, review of the literature and clinical experience confirms there is little uniformity in application of and results from nerve monitoring across different centers. We provide a review of the literature and cumulative experience of the multidisciplinary International Neural Monitoring Study Group with IONM spanning nearly 15 years. The study group focused its initial work on formulation of standards in IONM as it relates to important areas: 1) standards of equipment setup/endotracheal tube placement and 2) standards of loss of signal evaluation/intraoperative problem‐solving algorithm. The use of standardized methods and reporting will provide greater uniformity in application of IONM. In addition, this report clarifies the limitations of IONM and helps identify areas where additional research is necessary. This guideline is, at its forefront, quality driven; it is intended to improve the quality of neural monitoring, to translate the best available evidence into clinical practice to promote best practices. We hope this work will minimize inappropriate variations in monitoring rather than to dictate practice options. Laryngoscope, 121:S1–S16, 2011
Objectives/Hypothesis
Continuous intraoperative neuromonitoring (CIONM) of the vagus nerve was proposed to obtained frequent repetitive electromyography (EMG) data to recognize early change in ...intraoperative function of the recurrent laryngeal nerve. We examine our initial experience using this technology.
Study Design
Retrospective review.
Methods
Data for all patients who underwent neck surgery by a single surgeon at a North American institution over a 5‐year period were reviewed. CIONM was used in cases with possible higher risk of traction injury and according to surgeon preference. In these cases, stretch injury was established by warning alarm with threshold of ≥50% reduction in amplitude and/or ≥ 10% increase in latency. Preoperative and postoperative direct laryngoscopy was performed for all patients.
Results
A total of 879 endocrine neck surgeries were performed. CIONM was used to monitor 455 recurrent laryngeal nerves (RLNs) in 344 (39.1%) surgeries. An automatic periodic stimulation (APS) alarm detected impending nerve injury in 33 (9.6%) cases by 64.9% ± 12.7% decrease in amplitude and by 27.3% increase in latency in one case. A total loss of signal (LOS) was detected in 15 (4.36%) cases. The immediate release of causative retraction successfully preserved the nerves in all cases with impending injury; however, there was no improvement in the LOS cases. Other than the cases with LOS, postoperative laryngoscopy showed normal vocal cord function in all cases.
Conclusions
APS technology is safe, feasible, and helpful in approximately 10% of cases in our series, which developed nascent neurapraxia adverse EMG changes associated with intraoperative RLN stretch that could be reversed intraoperatively.
Level of Evidence
4. Laryngoscope, 128:2429–2432, 2018
Thyroid nodules are a common clinical problem, and differentiated thyroid cancer is becoming increasingly prevalent. Since the American Thyroid Association's (ATA's) guidelines for the management of ...these disorders were revised in 2009, significant scientific advances have occurred in the field. The aim of these guidelines is to inform clinicians, patients, researchers, and health policy makers on published evidence relating to the diagnosis and management of thyroid nodules and differentiated thyroid cancer.
The specific clinical questions addressed in these guidelines were based on prior versions of the guidelines, stakeholder input, and input of task force members. Task force panel members were educated on knowledge synthesis methods, including electronic database searching, review and selection of relevant citations, and critical appraisal of selected studies. Published English language articles on adults were eligible for inclusion. The American College of Physicians Guideline Grading System was used for critical appraisal of evidence and grading strength of recommendations for therapeutic interventions. We developed a similarly formatted system to appraise the quality of such studies and resultant recommendations. The guideline panel had complete editorial independence from the ATA. Competing interests of guideline task force members were regularly updated, managed, and communicated to the ATA and task force members.
The revised guidelines for the management of thyroid nodules include recommendations regarding initial evaluation, clinical and ultrasound criteria for fine-needle aspiration biopsy, interpretation of fine-needle aspiration biopsy results, use of molecular markers, and management of benign thyroid nodules. Recommendations regarding the initial management of thyroid cancer include those relating to screening for thyroid cancer, staging and risk assessment, surgical management, radioiodine remnant ablation and therapy, and thyrotropin suppression therapy using levothyroxine. Recommendations related to long-term management of differentiated thyroid cancer include those related to surveillance for recurrent disease using imaging and serum thyroglobulin, thyroid hormone therapy, management of recurrent and metastatic disease, consideration for clinical trials and targeted therapy, as well as directions for future research.
We have developed evidence-based recommendations to inform clinical decision-making in the management of thyroid nodules and differentiated thyroid cancer. They represent, in our opinion, contemporary optimal care for patients with these disorders.
Thyroidectomy may be performed for clinical indications that include malignancy, benign nodules or cysts, suspicious findings on fine needle aspiration biopsy, dysphagia from cervical esophageal ...compression, or dyspnea from airway compression. About 1 in 10 patients experience temporary laryngeal nerve injury after surgery, with longer lasting voice problems in up to 1 in 25. Reduced quality of life after thyroid surgery is multifactorial and may include the need for lifelong medication, thyroid suppression, radioactive scanning/treatment, temporary and permanent hypoparathyroidism, temporary or permanent dysphonia postoperatively, and dysphagia. This clinical practice guideline provides evidence-based recommendations for management of the patient's voice when undergoing thyroid surgery during the preoperative, intraoperative, and postoperative period.
The purpose of this guideline is to optimize voice outcomes for adult patients aged 18 years or older after thyroid surgery. The target audience is any clinician involved in managing such patients, which includes but may not be limited to otolaryngologists, general surgeons, endocrinologists, internists, speech-language pathologists, family physicians and other primary care providers, anesthesiologists, nurses, and others who manage patients with thyroid/voice issues. The guideline applies to any setting in which clinicians may interact with patients before, during, or after thyroid surgery. Children under age 18 years are specifically excluded from the target population; however, the panel understands that many of the findings may be applicable to this population. Also excluded are patients undergoing concurrent laryngectomy. Although this guideline is limited to thyroidectomy, some of the recommendations may extrapolate to parathyroidectomy as well.
The guideline development group made a strong recommendation that the surgeon should identify the recurrent laryngeal nerve(s) during thyroid surgery. The group made recommendations that the clinician or surgeon should (1) document assessment of the patient's voice once a decision has been made to proceed with thyroid surgery; (2) examine vocal fold mobility, or refer the patient to a clinician who can examine vocal fold mobility, if the patient's voice is impaired and a decision has been made to proceed with thyroid surgery; (3) examine vocal fold mobility, or refer the patient to a clinician who can examine vocal fold mobility, once a decision has been made to proceed with thyroid surgery if the patient's voice is normal and the patient has (a) thyroid cancer with suspected extrathyroidal extension, or (b) prior neck surgery that increases the risk of laryngeal nerve injury (carotid endarterectomy, anterior approach to the cervical spine, cervical esophagectomy, and prior thyroid or parathyroid surgery), or (c) both; (4) educate the patient about the potential impact of thyroid surgery on voice once a decision has been made to proceed with thyroid surgery; (5) inform the anesthesiologist of the results of abnormal preoperative laryngeal assessment in patients who have had laryngoscopy prior to thyroid surgery; (6) take steps to preserve the external branch of the surperior laryngeal nerve(s) when performing thyroid surgery; (7) document whether there has been a change in voice between 2 weeks and 2 months following thyroid surgery; (8) examine vocal fold mobility or refer the patient for examination of vocal fold mobility in patients with a change in voice following thyroid surgery; (9) refer a patient to an otolaryngologist when abnormal vocal fold mobility is identified after thyroid surgery; (10) counsel patients with voice change or abnormal vocal fold mobility after thyroid surgery on options for voice rehabilitation. The group made an option that the surgeon or his or her designee may monitor laryngeal electromyography during thyroid surgery. The group made no recommendation regarding the impact of a single intraoperative dose of intravenous corticosteroid on voice outcomes in patients undergoing thyroid surgery.
Finding and preserving normal parathyroid glands or localizing and removing diseased parathyroid glands are crucial steps to successful thyroid and parathyroid operations. Using near-infrared ...fluorescence detection to identify parathyroid glands during thyroid and parathyroid operations has lately gained widespread recognition, with 2 Food and Drug Administration–cleared devices currently in the market. We aim to update the endocrine surgery community on how near-infrared fluorescence detection can be most optimally used for rapid intraoperative parathyroid gland identification or preservation.
A literature review was performed using the key terms: “parathyroid,” “near infrared,” and “fluorescence” in relevant search engines. Based on the reviewed literature and expert surgeons’ opinions, recommendations were formulated for applying near-infrared fluorescence detection to identify or preserve parathyroid glands during cervical endocrine surgery.
The scope of near-infrared fluorescence detection can be broadly categorized into (1) using near-infrared auto-fluorescence to identify or locate both healthy and diseased parathyroid glands, and (2) using contrast-enhanced near-infrared fluorescence to evaluate parathyroid gland perfusion. The benefits and pitfalls for both near-infrared–based approaches are described herein.
Near-infrared fluorescence detection appears helpful for identification and likely preservation of parathyroid glands. We hope these recommendations will be valuable to the practicing endocrine surgeon as they consider incorporating these intraoperative adjuncts in their surgical practice.
Intraoperative neural monitoring (IONM) during thyroid surgery has gained widespread acceptance as an adjunct to the gold standard of visual identification of the recurrent laryngeal nerve (RLN). ...Contrary to routine dissection of the RLN, most surgeons tend to avoid rather than routinely expose and identify the external branch of the superior laryngeal nerve (EBSLN) during thyroidectomy or parathyroidectomy. IONM has the potential to be utilized for identification of the EBSLN and functional assessment of its integrity; therefore, IONM might contribute to voice preservation following thyroidectomy or parathyroidectomy. We reviewed the literature and the cumulative experience of the multidisciplinary International Neural Monitoring Study Group (INMSG) with IONM of the EBSLN. A systematic search of the MEDLINE database (from 1950 to the present) with predefined search terms (EBSLN, superior laryngeal nerve, stimulation, neuromonitoring, identification) was undertaken and supplemented by personal communication between members of the INMSG to identify relevant publications in the field. The hypothesis explored in this review is that the use of a standardized approach to the functional preservation of the EBSLN can be facilitated by application of IONM resulting in improved preservation of voice following thyroidectomy or parathyroidectomy. These guidelines are intended to improve the practice of neural monitoring of the EBSLN during thyroidectomy or parathyroidectomy and to optimize clinical utility of this technique based on available evidence and consensus of experts.
Level of Evidence
5 Laryngoscope, 123:S1–S14, 2013
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