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

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

How radical is total parathyroidectomy in patients with renal hyperparathyroidism?

PURPOSE: Total parathyroidectomy (tPTX) in patients with renal hyperparathyroidism (RHPT) aims at the complete removal of all hyperfunctioning parathyroid tissue. Whenever parathyroidectomy is termed "total," undetectable postoperative parathyroid hormone (PTH) levels within the first postoperative week are expected. The aim of this study was to evaluate if tPTX is technically possible using a radical surgical procedure. METHODS: In 109 consecutive patients with RHPT (on hemodialysis: n = 50; after kidney grafting n = 59), removal of all visible parathyroid tissue, bilateral thymectomy, bilateral central neck dissection (level VI), and immediate autotransplantation (AT) was performed. Intact PTH (iPTH) levels were measured in the first postoperative week. PTX was classified "total" when iPTH dropped below 10 pg/ml, "subtotal" between 10 and 65 pg/ml, and "insufficient" where levels stayed above 65 pg/ml. RESULTS: According to the postoperative PTH value, tPTX was achieved in 80 of 109 (73.4%) patients (hemodialysis n = 27, normal kidney function: n = 43, restricted: n = 10). PTX was "subtotal" in 25 patients (22.9%), 19 on hemodialysis, 2 had normal, and 4 had restricted kidney graft function. PTX turned out to be insufficient in four patients (3.7%); all of them were on hemodialysis. Insufficient PTX was not observed in kidney-grafted patients. Postoperative temporary laryngeal nerve morbidity was 1.8% (no permanent paresis). CONCLUSIONS: Although applying a very radical concept in patients with RHPT, PTX was "total" in only 73.4%. Persistence of disease was avoided in 91.7%, and low morbidity was documented. In conclusion, it seems difficult to remove all parathyroid tissue from the neck which has to be considered when choosing the surgical procedure.