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Hyperthermal liquid, spray, and smog may be potential risk factors for recurrent laryngeal nerve thermal injury during thyroid surgeries

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Abstract

Purpose

The hyperthermal liquid, spray and smog caused by energy-based surgical devices (EBDs) may be the potential risk factors for recurrent laryngeal nerve (RLN) thermal injury, but not been reported previously. We aim to demonstrated it both in thyroid surgeries and animal experiments.

Methods

321 thyroid patients and 32 rats were divided into two groups respectively. A type of endoscopic gauze was implemented in the protected group to prevent nerve from thermal risks. Electromyography and laryngoscope were recorded to determine nerve’s conductive ability. Microstructural morphological damage to nerves and muscles were evaluated by light and electron microscopy in the animal experiments.

Results

After thyroid surgeries, the incidence of transient vocal cord (VC) palsy was decreased in the protected group (1.4%) compared with the conventional group (4.7%) (P = 0.037). In animal experiments, the average nerve conductive velocity was significantly decreased in the conventional group (5.8 ± 2.1 vs. 25.5 ± 4.7 m/s, P < 0.01). Typical acute morphological thermal changes of edema, coagulation and homogenization in nerve tissues were recorded by light microscopy in the conventional group. Four weeks later, the average weight of gastrocnemius muscles in the injured limb was significantly decreased (1.3 ± 0.2 vs. 2.2 ± 0.2 g, P < 0.01), while no significant difference was noted in the protected group (2.0 ± 0.3 vs. 2.3 ± 0.4 g, P = 0.61).

Conclusions

Hyperthermal liquid, spray or smog may represent risk factors contributing to RLN thermal injury caused by EBDs. Damage to the nerve’s conductive ability and morphological changes in nerves and muscles likely represent typical responses to thermal injury. Implementation of endoscopic gauze may be a promising method to protect the RLN from thermal damage especially in endoscopic thyroid surgeries.

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Data availability

The data and material of this study are transparent, can be asked from the corresponding author.

Code availability

The software applicated in this study is standard, can be bought from the market.

References

  1. K.A. Kern, Medicolegal analysis of errors in diagnosis and treatment of surgical endocrine disease. Surgery. 114(6), 1167–73 (1993). discussion 1173-1164

    CAS  PubMed  Google Scholar 

  2. F.Y. Chiang, L.F. Wang, Y.F. Huang, K.W. Lee, W.R. Kuo, Recurrent laryngeal nerve palsy after thyroidectomy with routine identification of the recurrent laryngeal nerve. Surgery. 137(3), 342–7 (2005). https://doi.org/10.1016/j.surg.2004.09.008

    Article  PubMed  Google Scholar 

  3. C.W. Wu, F.Y. Chiang, G.W. Randolph, G. Dionigi, H.Y. Kim, Y.C. Lin, T.Y. Huang, C.I. Lin, P.C. Hun, D. Kamani, P.Y. Chang, I.C. Lu, Transcutaneous recording during intraoperative neuromonitoring in thyroid surgery. Thyroid. 28(11), 1500–7 (2018). https://doi.org/10.1089/thy.2017.0679

    Article  PubMed  Google Scholar 

  4. Y. Wang, X. Yu, P. Wang, C. Miao, Q. Xie, H. Yan, Q. Zhao, M. Zhang, C. Xiang, Implementation of intraoperative neuromonitoring for transoral endoscopic thyroid surgery: a preliminary report. J Laparoendosc Adv Surg Technol A. 26(12), 965–71 (2016). https://doi.org/10.1089/lap.2016.0291

    Article  Google Scholar 

  5. X. Yang, J. Cao, Y. Yan, F. Liu, T. Li, L. Han, C. Ye, S. Zheng, S. Wang, Y. Ye, K. Jiang, Comparison of the safety of electrotome, Harmonic scalpel, and LigaSure for management of thyroid surgery. Head Neck. 39(6), 1078–85 (2017). https://doi.org/10.1002/hed.24701

    Article  PubMed  Google Scholar 

  6. G. Dionigi, F.Y. Chiang, H.Y. Kim, G.W. Randolph, A. Mangano, P.Y. Chang, I.C. Lu, Y.C. Lin, H.C. Chen, C.W. Wu, Safety of LigaSure in recurrent laryngeal nerve dissection-porcine model using continuous monitoring. Laryngoscope. 127(7), 1724–9 (2017). https://doi.org/10.1002/lary.26271

    Article  PubMed  Google Scholar 

  7. K.V. Chavez, E.M. Barajas, F. Soroa, A. Gamboa-Dominguez, S. Ordonez, J.P. Pantoja, M. Sierra, D. Velazquez-Fernandez, M.F. Herrera, Safety assessment of the use of ultrasonic energy in the proximity of the recurrent laryngeal nerve in a porcine model. Am J Surg. 215(1), 186–90 (2018). https://doi.org/10.1016/j.amjsurg.2017.04.013

    Article  PubMed  Google Scholar 

  8. G. Dionigi, Energy based devices and recurrent laryngeal nerve injury: the need for safer instruments. Langenbecks Arch Surg. 394(3), 579–80 (2009). https://doi.org/10.1007/s00423-008-0454-8. author reply 581–576

    Article  PubMed  Google Scholar 

  9. C.W. Wu, G. Dionigi, H. Sun, X. Liu, H.Y. Kim, P.J. Hsiao, K.B. Tsai, H.C. Chen, H.Y. Chen, P.Y. Chang, I.C. Lu, F.Y. Chiang, Intraoperative neuromonitoring for the early detection and prevention of RLN traction injury in thyroid surgery: a porcine model. Surgery. 155(2), 329–39 (2014). https://doi.org/10.1016/j.surg.2013.08.015

    Article  PubMed  Google Scholar 

  10. Y.C. Lin, G. Dionigi, G.W. Randolph, I.C. Lu, P.Y. Chang, S.Y. Tsai, H.Y. Kim, H.Y. Lee, R.P. Tufano, H. Sun, X. Liu, F.Y. Chiang, C.W. Wu, Electrophysiologic monitoring correlates of recurrent laryngeal nerve heat thermal injury in a porcine model. Laryngoscope. 125(8), E283–E90 (2015). https://doi.org/10.1002/lary.25362

    Article  PubMed  Google Scholar 

  11. C.W. Wu, X. Liu, M. Barczynski, H.Y. Kim, G. Dionigi, H. Sun, F.Y. Chiang, D. Kamani, G.W. Randolph, Optimal stimulation during monitored thyroid surgery: EMG response characteristics in a porcine model. Laryngoscope. 127(4), 998–1005 (2017). https://doi.org/10.1002/lary.26141

    Article  PubMed  Google Scholar 

  12. X. Liu, D. Zhang, G. Zhang, L. Zhao, L. Zhou, Y. Fu, S. Li, Y. Zhao, C. Li, C.W. Wu, F.Y. Chiang, G. Dionigi, H. Sun, Laryngeal nerve morbidity in 1.273 central node dissections for thyroid cancer. Surg Oncol. 27(2), A21–A25 (2018). https://doi.org/10.1016/j.suronc.2018.01.003

    Article  PubMed  Google Scholar 

  13. H. Yan, Y. Wang, P. Wang, Q. Xie, Q. Zhao, “Scarless” (in the neck) endoscopic thyroidectomy (SET) with ipsilateral levels II, III, and IV dissection via breast approach for papillary thyroid carcinoma: a preliminary report. Surg Endosc. 29(8), 2158–63 (2015). https://doi.org/10.1007/s00464-014-3911-1

    Article  PubMed  Google Scholar 

  14. H. Sun, H. Zheng, X. Wang, Q. Zeng, P. Wang, Y. Wang, Comparison of transoral endoscopic thyroidectomy vestibular approach, total endoscopic thyroidectomy via areola approach, and conventional open thyroidectomy: a retrospective analysis of safety, trauma, and feasibility of central neck dissection in the treatment of papillary thyroid carcinoma. Surg Endosc. 34(1), 268–74 (2020). https://doi.org/10.1007/s00464-019-06762-6

    Article  PubMed  Google Scholar 

  15. Z. Li, P. Wang, Y. Wang, S. Xu, L. Cao, R. Que, F. Zhou, Endoscopic lateral neck dissection via breast approach for papillary thyroid carcinoma: a preliminary report. Surg Endosc. 25(3), 890–6 (2011). https://doi.org/10.1007/s00464-010-1292-7

    Article  PubMed  Google Scholar 

  16. Q. Xie, P. Wang, H. Yan, Y. Wang, Feasibility and effectiveness of intraoperative nerve monitoring in total endoscopic thyroidectomy for thyroid cancer. J Laparoendosc Adv Surg Technol A. 26(2), 109–15 (2016). https://doi.org/10.1089/lap.2015.0401

    Article  Google Scholar 

  17. F.Y. Chiang, I.C. Lu, W.R. Kuo, K.W. Lee, N.C. Chang, C.W. Wu, The mechanism of recurrent laryngeal nerve injury during thyroid surgery-the application of intraoperative neuromonitoring. Surgery. 143(6), 743–9 (2008). https://doi.org/10.1016/j.surg.2008.02.006

    Article  PubMed  Google Scholar 

  18. B.H. Lang, T.W. Shek, A.O. Chan, C.Y. Lo, K.Y. Wan, Significance of size of persistent/recurrent central nodal disease on surgical morbidity and response to therapy in reoperative neck dissection for papillary thyroid carcinoma. Thyroid. 27(1), 67–73 (2017). https://doi.org/10.1089/thy.2016.0337

    Article  CAS  PubMed  Google Scholar 

  19. P.A. Sutton, S. Awad, A.C. Perkins, D.N. Lobo, Comparison of lateral thermal spread using monopolar and bipolar diathermy, the Harmonic Scalpel and the Ligasure. Br J Surg. 97(3), 428–33 (2010). https://doi.org/10.1002/bjs.6901

    Article  CAS  PubMed  Google Scholar 

  20. A.J. Rosko, R.A. Kupfer, S.S. Oh, C.T. Haring, E.L. Feldman, N.D. Hogikyan, Immunohistologic analysis of spontaneous recurrent laryngeal nerve reinnervation in a rat model. Laryngoscope. 128(3), E117–E122 (2018). https://doi.org/10.1002/lary.27004

    Article  CAS  PubMed  Google Scholar 

  21. R.A. Kupfer, M.O. Old, S.S. Oh, E.L. Feldman, N.D. Hogikyan, Spontaneous laryngeal reinnervation following chronic recurrent laryngeal nerve injury. Laryngoscope. 123(9), 2216–27 (2013). https://doi.org/10.1002/lary.24049

    Article  PubMed  Google Scholar 

  22. A.M. Park, N.K. Bhatt, R.C. Paniello, Paclitaxel inhibits post-traumatic recurrent laryngeal nerve regeneration into the posterior cricoarytenoid muscle in a canine model. Laryngoscope. 127(3), 651–5 (2017). https://doi.org/10.1002/lary.26058

    Article  CAS  PubMed  Google Scholar 

  23. G. Foerster, A.H. Mueller, Laryngeal EMG: preferential damage of the posterior cricoarytenoid muscle branches especially in iatrogenic recurrent laryngeal nerve lesions. Laryngoscope. 128(5), 1152–6 (2018). https://doi.org/10.1002/lary.26862

    Article  PubMed  Google Scholar 

  24. M.J. Ban, E.H.E. Chang, D.Y. Lee, J.H. Park, C. Lee, D.H. Kim, J.H. Kim, Y.W. Koh, Analysis of neuromonitoring signal loss during retroauricular versus conventional thyroidectomy. Laryngoscope. 129(9), 2199–204 (2019). https://doi.org/10.1002/lary.27749

    Article  PubMed  Google Scholar 

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Acknowledgements

This study was supported by the Public Welfare Projects of Zhejiang Province (LGH18H160002).

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Authors and Affiliations

  1. Department of Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, China

    Xing Yu, Weihua Gong & Yong Wang

  2. College of Medicine, Zhejiang University, Hangzhou, 310058, China

    Chang Liu

  3. Department of Otorhinolaryngology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, China

    Maoxiao Yan

Authors
  1. Xing Yu
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  2. Chang Liu
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  3. Maoxiao Yan
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  4. Weihua Gong
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  5. Yong Wang
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Contributions

All authors participated in the design, execution, and interpretation of the study. YW, WHG, XY, and CL conceived and designed the study. XY and CL performed the majority of experiments and analyzed data. MXY contributed to the analyses and interpretation of the study. XY and CL wrote the manuscript. YW and WHG approved the final, submitted manuscript.

Corresponding authors

Correspondence to Weihua Gong or Yong Wang.

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The authors declare that they have no conflict of interest.

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All procedures performed in studies involving human participants and animals were in accordance with the ethical standards of the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Informed consent to publication was obtained from all individual participants included in this study.

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These authors contributed equally: Xing Yu, Chang Liu

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Yu, X., Liu, C., Yan, M. et al. Hyperthermal liquid, spray, and smog may be potential risk factors for recurrent laryngeal nerve thermal injury during thyroid surgeries. Endocrine 72, 198–207 (2021). https://doi.org/10.1007/s12020-020-02451-w

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  • DOI: https://doi.org/10.1007/s12020-020-02451-w

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