ОСОБЕННОСТИ АНЕСТЕЗИОЛОГИЧЕСКОГО ПОСОБИЯ ПРИ ПРОВЕДЕНИИ ОПЕРАЦИЙ С НЕЙРОМОНИТОРИНГОМ ВОЗВРАТНЫХ ГОРТАННЫХ НЕРВОВ В ТИРЕОИДНОЙ ХИРУРГИИ

The literature review describes the specifics of anesthesia when performing surgeries on the thyroid and parathyroid glands with neuromonitoring of recurrent laryngeal nerves. This technique has been described, the rationale of its use and role of the anesthesiologist in the provision of full functioning of neuromonitoring have been investigated. The article describes the anesthesia techniques (choice of neuromuscular relaxant, hypnotic and analgesic agents), method of endotracheal tube insertion, electrode positioning, causes of potential failures and ways of their management. В обзоре литературы рассмотрены особенности анестезии при проведении операций на щитовидных и паращитовидных железах с использованием нейромониторинга возвратных гортанных нервов. Приведено описание метода, изучены актуальность его применения и роль анестезиолога в обеспечении полноценного функционирования нейромониторинга. Освещены методики анестезии (выбор миорелаксантов, гипнотиков и анальгетиков), техника установки эндотрахеальной трубки, позиционирования электрода, причины возможных неудач и способы их исправления.

SPECIFIC FEATURES OF ANESTHETIC SUPPORT IN THYROID SURGERY WITH NEUROMONITORING OF RECURRENT LARYNGEAL NERVES

The literature review describes the specifics of anesthesia when performing surgeries on the thyroid and parathyroid glands with neuromonitoring of recurrent laryngeal nerves. This technique has been described, the rationale of its use and role of the anesthesiologist in the provision of full functioning of neuromonitoring have been investigated. The article describes the anesthesia techniques (choice of neuromuscular relaxant, hypnotic and analgesic agents), method of endotracheal tube insertion, electrode positioning, causes of potential failures and ways of their management

Minimally invasive surgery of primary hyperparathyroidism

Results of various surgical techniques application in primary hyperparathyroidism patients were studied. Bilateral neck exploration, unilateral neck exploration, selective parathyroidectomy (conventional and videoassisted) were used in 297 patients with primary hyperparathyroidism. Results of the study showed high efficacy of selective parathyroidectomy with some benefits in comparison with bilateral neck exploration (reduced postoperative pain, better cosmetic result, diminished hospital stay etc.)

Intraoperative neuromonitoring in thyroid and parathyroid surgery: indications and method

Intraoperative neuromonitoring finds widespread application in thyroid and parathyroid surgery, as a preventive method against laryngeal nerves injuries. Today it is possible to monitor the laryngeal nerve function in real time during an operation. In this article based on experience of 1065 thyroid and parathyroid operations with intraoperative neuromonitoring, we describe in details the procedure of intraoperative neuromonitoring of laryngeal nerves: features of anaesthesia, endotracheal tube position, algorythm of trouble shooting in case of loss of electromyographical sygnal. Besides that, there is an explanation of electromyographical indices, such as: signal amplitude, latency, threshold, LOS (loss of signal); there are main literature sources on this problem

Fine Needle Aspiration Biopsy of Thyroid Nodules: Diagnostic Value, Technical Aspects, Analysis of Results

The goal of the study was to determine diagnostic value of fine needle aspiration biopsy (FNAB) in detection of malignant thyroid tumors based on retrospective analyses of 40696 FNAB of patients with thyroid nodules. Results. Comparison of the results of FNAB with postoperative histological examination data from 3004 patients revealed that the rate of false positive cytopathological results was 1.2% and the rate of false negative results was 1.8%. The sensitivity reached 99.67%. The specificity of FNAB when taking into account follicular lesions dropped to 16.29%, while leaving follicular lesions - 94.29%. Cytological results of 49609 FNAB of patients with thyroid nodules according to Bethesda system were arranged as follows: noninformative results - 8%, benign nodules - 81.9% (colloid nodules - 71.6%, autoimmune thyroiditis - 10.2%, subacute thyroiditis and others - 0.02%), follicular lesions - 7.2% (follicular neoplasm - 7.1%, follicular lesion of indeterminate value - 0.1%), suspicious for malignancy - 0.02%, malignant tumor - 3%, among the latter papillary carcinoma - 93%. Malignant tumors, according to postoperative histological examination, were detected among the group with cytological diagnosis “follicular neoplasm” in 16.3% of cases. After performing FNAB of regional lymph nodes with suspicious ultrasound signs the metastases of papillary carcinoma were revealed in 24.6% of cases. Application of FNAB in clinical practice at our Center to all patients with thyroid nodules of 1 cm in size and larger resulted in increment of thyroid operations for oncological indications from 12.5% in 2004 to 53% in 2012. Conclusion. FNAB under ultrasound control is the most informative differential method for thyroid diseases, permitting to reveal primary and metastatic thyroid lesions. FNAB allow to evade nonobligatory diagnostic operations in many patients

Is it advisable to perform preoperativelaryngoscopy in all patients due to undergo the thyroid and parathyroid surgery?Analysis of 5172 preoperative laryngoscopies

Given the yearly growth of thyroid and parathyroid surgery, diagnosis of such serious complications as paresis of the larynx is still relevant today. Endoscopic laryngoscopy is the main method of controlling laryngeal function. The timely detection of violations of this function in the postoperative period allows for patients to be sent to specialists quickly for treatment. Nonetheless, the role of laryngoscopies in the preoperative period has not been precisely recognized. The main contentious issue has become the need to perform preoperative laryngoscopies on all patients due to undergo operations on the thyroid or parathyroid glands.For this paper, we analyzed 5172 consecutive endoscopic laryngoscopies. The role of preoperative laryngoscopy when planning surgery on the thyroid or parathyroid glands was determined. Aim: to evaluate the feasibility of performing routine laryngoscopies on patients due to undergo surgery for diseases of the thyroid and parathyroid glands. Materials and Methods.  This paper presents an analysis of the results of preoperative laryngoscopy on 5172 patients who underwent surgical procedures on the thyroid and parathyroid glands. Results.  Preoperative one-sided paresis of the larynx was detected in 12 (0.23%) of the 5172 patients. Patients did not exhibit bilateral paresis of the larynx. Conclusions.  Preoperative paresis of the larynx is rare, and performing routine endoscopic laryngoscopies on all patients due to undergo thyroid or parathyroid gland operations is not appropriate

Modified quick parathyroid hormone test in surgery of primary hyperparathyroidism

Aim. The aim of the current study was the improvement of intraoperative quick parathyroid hormone (PTH) test, enabling to receive the results in a shorter period of time and to reduce the cost of the test, comparing with the existing methods. Methods. 404 consecutive patients with primary hyperparathyroidism (PHPT) were included in the study. All patients were subjected to selective parathyroidectomy – by traditional or videoassisted technique. We performed two parathyroid tests – traditional and modified – in each patient. Blood was taken a) before skin incision, b) before cutting the parathyroid adenoma vessels and c) in 10 minutes after cutting the parathyroid adenoma vessels. We used immunochemiluminescent analyzer DiaSorin Liaison. Modified test for parathyroid hormone differed in the duration of reagents incubation – two times shorter than in traditional method, resulting in immune reaction break before plateau occurrence. The statistical analysis of the results was performed using Microsoft Excel 2010. Results. With 50% cut-off level for PTH level fall (between the maximal level – before operation or before cutting parathyroid adenoma vessels – and the level in 10 minutes after cutting the adenoma vessels), the sensitivity, specificity, positive predictive value and negative predictive value for modified test reached 92.73%, 60.00%, 97.81% and 30.00%, accordingly, comparing with 95.84%, 55.00%, 97.62% and 40.74% for conventional method. Cut-off level change to 40% improved the results of modified test application, and increased its sensitivity and negative predictive value (97.14%; 50.00%; 97.40%; 47.62%). Conclusions. 2 times reduction of incubation time with cut-off level change to 40% allowed to cut the duration of intraoperative test for parathyroid hormone by half, and to improve diagnostic accuracy of the test, and at the same time to preserve low cost of the test

Loss of signal during intraoperative neuromonitoring of laryngeal nerves as a predictor of postoperative larynx paresis: Analysis of 1065 consequetive thyroid and parathyroid operations. Surgeons' algorythm (tactics)

During thyroid and parathyroid operations performed with laryngeal nerves neuromonitoring, a segmental or global loss of signal may occur. The most frequent cause of loss of signal – is tension of thyroid gland tissue and at the same time tension of the laryngeal nerves. There is no consensus if this complication arises regarding surgeon’s actions. Aim. Evaluation of predictive value of loss of signal during IONM regarding larynx paresis in postoperative period, and algorithm suggestion in case of loss of signal develops. Materials and methods. 1065 patients were operated on thyroid and parathyroid glands with neuromonitoring of laryngeal nerves. Neuromonitore C2 (Inomed, Emmendingen, Germany) was used. We evaluated frequency of loss of signal, described types of loss of signal, showed sensitivity and specificity of loss of signal and development of postoperative larynx paresis. Results. Loss of signal developed in 32 (1,9%) patients. More frequently loss of signal was detected at left side (p=0,01, χ2 = 4,2 OR=2,9). Sensitivity (Se)  of loss of signal and postoperative larynx paresis development reached 59,2%, specificity – 99,7% (Sp), positive predicitive value (PPV) – 91,4%, negative predictive value (NPV) – 97,8%. There are no statistically reliable differences in recovery periods of larynx function depending on type of loss of signal (segmental or global) (p=0,5). Conclusions. In most cases loss of electromyographical signal indicates injury of laryngeal nerves during operation on thyroid and parathyroid glands. When there is loss of signal in case of bilateral thyroid gland disease it is reasonable to make a decision to stop operation to prevent development of bilateral larynx paresis