Implantación de un protocolo de seguridad del paciente en la cirugía de tiroides y paratiroides: resultados

Abstract

Introduction and objective: In 2021 we launched at Hospital Clinico Universitario in Valladolid a safety protocol during the thyroid and parathyroid surgery to avoid bilateral recurrent laryngeal nerve palsy. It is based on stopping the surgery if the signal less than 100 mV during the neuromonitoring of the first hemithyroidectomy after trying to increase the signal by relocating the orotracheal tube, verifying the electrodes, diminishing the salivation, and waiting. We wanted to analyze if the presence or absence of a signal implies recurrent laryngeal nerve palsy. If we stablish that positiveness indicates the absence of signal, we divide the patients in four groups: true positive (TP) if they had palsy, true negative (TN) if they had signal and not palsy, false positive (FP) if they didn’t have signal or palsy and false negative (FN) if they had palsy and signal. Method: Prospective observational longitudinal study. We collected the results of neuromonitoring 76 patients while thyroid surgery between March 17th 2021 and March 1st 2022. We also collected the pathology that required surgery, de laryngeal mobility, and the recovery of the palsy. Results: The 42%, 32 patients, were programmed for total thyroidectomy, 31.5% (24) for left hemithyroidectomy and 26.5% (20) for right hemithyroidectomy. Of all the right hemithyroidectomies all of them had signal and one had recurrent laryngeal nerve palsy (FN). Of all the left hemithyroidectomies one had no signal and had paralysis (TP) and other one had signal and paralyzed (FN). Of all the total thyroidectomies there were two occasions when the surgery had to be stopped, one of the cases with paralysis afterward (TP) and not the other one (FP). Of the 76 patients 93.4% were TN. Of the 32 patients programmed for total thyroidectomy two of them were stopped (6.25%). Of the 4 paralysis 50% recovered, one is permanent and the other one has been paralyzed for less than 12 months so we can’t consider it permanent. We have not found any difference between the pathologies associated. Discussion: We have had three cases with no signal and 2 of them (66%) had paralysis. Of the 2 total thyroidectomies that were stopped, one of them had paralysis. The use of this protocol implies that sometimes the surgery will be longer or stopped, causing a rise on the surgical time or double the surgeries to complete the treatment. Nevertheless, given the low rate of need to stop the surgery and the paralysis rate when there is no signal guarantees the use of this protocol. Conclusions: The establishment of a safety protocol during the thyroid and parathyroid surgery to lower the incidence of bilateral recurrent laryngeal nerve paralysis is appealing; it doesn’t affect very much to the surgical performance but an absence of signal implies a paralysis in 2 out of 3 cases. The presence of two FN makes us criticize the way we get the signal after the dissection.