Kontinuierliches, intraoperatives Neuromonitoring des N. laryngeus recurrens links über den Doppellumentubus - eine Feasibility-Studie
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Philipps-Universität Marburg
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Abstract
Question
With an incidence of 1.9-32%, recurrent nerve palsy in thoracic surgery is a serious complication with far-reaching consequences. In particular, procedures on the aortic arch and left lung pose a significant risk of injury to the recurrent laryngeal nerve in the branch from the vagus nerve in the aortopulmonary window. The use of neuromonitoring, as used in thyroid surgery, has been discussed and successfully applied in some cases. Due to the necessity for single lung ventilation during lung surgery, the question arises whether it is technically possible to perform continuous neuromonitoring via a double lumen tube and how the lead electrodes should be arranged on the tube for this purpose.
For this purpose, patients with an indication for left thoracotomy were included in this study. All patients underwent a phoniatric examination by otolaryngology colleagues before and after surgery to exclude preexisting vocal fold pathology. The double lumen tube was fitted with two electrodes taped in series proximal to the tracheal cuff, and the respective distances were documented. During the operation, continuous stimulation of the vagus nerve was performed before the laryngeal recurrent nerve was discharged. A significant signal was defined as an amplitude of at least 165µV and it was documented whether a signal could be derived distally, proximally or at both electrodes.
Results
A total of 20 patients were included. There were no significant differences in sex, height, and weight. There was malignant disease in 14 cases and benign change in 6 patients. A double lumen tube was used in all patients, of which 18 were left running and 2 right running tubes in all sizes from 35 to 41Chr. In 18 patients a significant signal could be derived. In 14 patients, signal was detected only at the distal electrode, and in 4 patients, signal was detected at both electrodes. In none of the patients was a signal measured only proximally. In no case did a mild or severe event in the sense of a drop in amplitude in combination with a prolongation of latency occur during surgery; a loss-of-signal did not occur. No patient showed postoperative recurrent paresis.
Most significant signals could be derived at a distance of the electrode to the tracheal cuff of 10-11mm. From a distance of 74mm between tracheal cuff and electrode no signal was detectable.
Discussion
The study could confirm the existing research on the use of neuromonitoring and show that continuous neuromonitoring via a double lumen tube is technically feasible and safe to use. The lead electrode should be placed at least 10 mm from the tracheal cuff, but not further than 74 mm. Thus, if only one lead electrode is used, it can be positioned at the level of the vocal folds. Considering the previous studies using the products of different manufacturers of electrodes and double lumen tubes and our investigation, the cIONM will be applicable to the different combinations of materials. Limitations lie in the sample size of 20 patients. In addition, both the electrode arrangement and the possibility of lowering the recurrent sparing rate should be reviewed in a subsequent study.
Conclusion
Continuous intraoperative neuromonitoring via the double lumen tube in left thoracic surgery as an easy to use and for the patient safe method, offers the surgeon an additional safety in the context of the preparation. Especially in the therapy of lung carcinoma, lymph node dissection is a decisive step that influences the prognosis. Here, level 4-6 lymph nodes play a significant role as mediastinal lymph nodes in the aortopulmonary window. However, this poses a high risk to the function of the recurrent laryngeal nerve. Real-time intraoperative monitoring of function through the use of continuous neuromonitoring may potentially contribute to a significant risk reduction of recurrent nerve palsy. In addition to level 4-6 lymphadenectomy in lung surgery, potential applications are also found in cardiac and visceral surgery. Procedures close to the aortic arch, in pediatric cardiac surgery, as well as esophageal surgery represent risk interventions for the development of recurrent nerve palsy. Therefore, cIONM should also be implemented in this field.
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Dates
Created: 2022Issued: 2023-03-09Updated: 2023-03-09
Faculty
Medizin
Language
ger
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DoctoralThesis
Keywords
doublelumentubeneuromonitoringthoracic surgerylung surgeryvocal cord palsy
DFG-subjects
ThoraxchirurgieRecurrenspareseNeuromonitoringDoppellumentubusN. laryngeus recurrens
DDC-Numbers
610
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Jochens, Nora (0000-0003-2756-6752): Kontinuierliches, intraoperatives Neuromonitoring des N. laryngeus recurrens links über den Doppellumentubus - eine Feasibility-Studie. : Philipps-Universität Marburg 2023-03-09. DOI: https://doi.org/10.17192/z2023.0158.