title: Phrenic nerve stimulation during neck dissection for advanced thyroid cancer involving level IV: is it worth doing it?
abstract: During thyroidectomy and neck dissection surgery for advanced or recurrent metastatic thyroid cancer under intraoperative monitoring, we used the available technology to assess the feasibility of such an intervention to monitor those patients with phrenic nerves at risk. A retrospective review of patients operated on from January 2009 to December 2015 by a single surgeon (CSD) was conducted. Patients who had neck and mediastinal dissection, with or without total thyroidectomy, due to advanced or recurrent metastatic disease to the neck were selected. The procedures were done under intraoperative nerve monitoring using nerve monitoring systems (NIM 2.0 or 3.0; Medtronic, Jacksonville, FL, USA). A total of 19 patients were included in the study, with a mean age of 57.6 years ± 16.3 and a male/female ratio of 10:9. Overall, all patients had an intact phrenic nerve at the conclusion of the surgery. One patient had an aggressive tumor that precluded sacrifice of the left recurrent laryngeal nerve and ipsilateral thoracic duct. The procedure was complicated by a temporary impairment of the diaphragm contraction with intraoperative nerve monitoring as well as a chyle fistula. This was due to the manipulation of the tissue surrounding the phrenic nerve. Intraoperative nerve monitoring of the phrenic nerve offers the surgeon a "potential" method of ensuring phrenic nerve integrity in cases of advanced thyroid cancers with gross level IV metastatic disease. Further prospective studies are needed to assess the risks of this intervention and evaluate the method of recording diaphragm contraction movement.
authors.affiliation: Head and Neck Surgeon, Hospital Pablo Tobon Uribe, Medellín, Colombia. casiduque@hotmail.com.
authors.forename: Carlos S
authors.initials: CS
authors.lastname: Duque
authors.affiliation: Endocrine Surgeon, Hospital Pablo Tobon Uribe, Instituto de Cancerologia, Clinicas Las Americas, Medellín, Colombia.
authors.forename: Juan P
authors.initials: JP
authors.lastname: Dueñas
authors.affiliation: Otolaryngologist, Clinica SOMA, Medellín, Colombia.
authors.forename: Marcela
authors.initials: M
authors.lastname: Marulanda
authors.affiliation: Otolaryngologist, Hospital Militar, Medellin, Colombia.
authors.forename: Diana
authors.initials: D
authors.lastname: Pérez
authors.affiliation: Otolaryngologist, Hospital Pablo Tobon Uribe, Medellín, Colombia.
authors.forename: Andres
authors.initials: A
authors.lastname: Londoňo
authors.affiliation: Department of Otorhinolaryngology, Pediatric Otolaryngology, Head and Neck Surgery, University of Texas Medical School at Houston, Houston, TX, USA.
authors.forename: Soham
authors.initials: S
authors.lastname: Roy
authors.affiliation: Department of Otolaryngology, Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
authors.forename: Mai Al
authors.initials: MA
authors.lastname: Khadem
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative / Q000379:methods*; D037981:Neck Dissection; D010791:Phrenic Nerve / Q000502:physiology*; D013964:Thyroid Neoplasms / Q000601:surgery*; D013965:Thyroidectomy
keywords: Diaphragm muscle paralysis; Nerve monitoring; Phrenic nerve; Vagus nerve