Human robotic surgery with intraoperative tissue identification using rapid evaporation ionisation mass spectrometry.

Instantaneous, continuous, and reliable information on the molecular biology of surgical target tissue could significantly contribute to the precision, safety, and speed of the intervention. In this work, we introduced a methodology for chemical tissue identification in robotic surgery using rapid evaporative ionisation mass spectrometry. We developed a surgical aerosol evacuation system that is compatible with a robotic platform enabling consistent intraoperative sample collection and assessed the feasibility of this platform during head and neck surgical cases, using two different surgical energy devices. Our data showed specific, characteristic lipid profiles associated with the tissue type including various ceramides, glycerophospholipids, and glycerolipids, as well as different ion formation mechanisms based on the energy device used. This platform allows continuous and accurate intraoperative mass spectrometry-based identification of ablated/resected tissue and in combination with robotic registration of images, time, and anatomical positions can improve the current robot-assisted surgical platforms and guide surgical strategy.

Systematic review and meta-analysis of laryngeal reinnervation techniques in adults with unilateral and bilateral vocal fold palsies.

OBJECTIVE: To evaluate the outcomes of reinnervation techniques for the treatment of adult unilateral vocal fold paralysis and bilateral vocal fold paralysis. METHODS: A literature review was conducted in the Embase and Medline databases in English, with no limitations on the publication date. The outcome parameters of interest included visual, subjective perceptual, acoustic, aerodynamic analysis and electromyography. A meta-analysis with a random-effects model and inverse variance was calculated. RESULTS: The systematic Preferred Reporting Items for Systematic Reviews and Meta-Analyses approach resulted in 27 studies, totalling 803 patients (747 unilateral cases and 56 bilateral cases). Thyroid cancer and/or surgery had caused unilateral vocal fold paralysis in 74.8 per cent of cases and bilateral vocal fold paralysis in 69.6 per cent of cases. Statistically significant improvements in patients were observed for voice, deglutition and decannulation (bilateral vocal fold paralysis). Meta-analysis of 10 reinnervation techniques was calculated for the maximum phonation time of 184 patients. CONCLUSION: Reinnervation was shown to improve voice, swallowing and decannulation, but studies lacked control groups, limiting generalisability. Larger studies with controls are needed.

Litigation in thyroid surgery: a pan-specialty review of National Health Service (UK) data.

OBJECTIVE: Thyroid surgery carries risks that significantly impact patients. This paper describes the landscape of thyroid surgery related litigation claims in the National Health Service from April 2015 to April 2020, to establish learning points in order to improve patient care and minimise litigation risk. METHODS: Data were requested from National Health Service Resolution and Hospital Episode Statistics. Claims were classified into operative and non-operative causes. Subspecialty information, incident details and claim costings were analysed. RESULTS: Sixty claims were identified. Thirty-eight claims (63.3 per cent) were closed, with an average total claim cost of £68 816 and average damages paid of £36 349. Claims related to diagnostic issues were most common (n = 19); of claims associated with operative causes (n = 30), those relating to nerve injury were most common (n = 8), with issues of nerve monitoring and consent being cited. CONCLUSION: Utilisation of well-established protocols will likely reduce litigation in thyroid surgery, as we move towards a landscape in which the patient journey is thoroughly scrutinised for targeted improvements.

Preoperative Evaluation of Thyroid Cancer: A Review of Current Best Practices.

OBJECTIVE: The incidence of thyroid cancer has significantly increased in recent decades. Although most thyroid cancers are small and carry an excellent prognosis, a subset of patients present with advanced thyroid cancer, which is associated with increased rates of morbidity and mortality. The management of thyroid cancer requires a thoughtful individualized approach to optimize oncologic outcomes and minimize morbidity associated with treatment. Because endocrinologists usually play a key role in the initial diagnosis and evaluation of thyroid cancers, a thorough understanding of the critical components of the preoperative evaluation facilitates the development of a timely and comprehensive management plan. The following review outlines considerations in the preoperative evaluation of patients with thyroid cancer. METHODS: A clinical review based on current literature was generated by a multidisciplinary author panel. RESULTS: A review of considerations in the preoperative evaluation of thyroid cancer is provided. The topic areas include initial clinical evaluation, imaging modalities, cytologic evaluation, and the evolving role of mutational testing. Special considerations in the management of advanced thyroid cancer are discussed. CONCLUSION: Thorough and thoughtful preoperative evaluation is critical for formulating an appropriate treatment strategy in the management of thyroid cancer.

Emerging Imaging Technologies for Parathyroid Gland Identification and Vascular Assessment in Thyroid Surgery: A Review From the American Head and Neck Society Endocrine Surgery Section.

Importance: Identification and preservation of parathyroid glands (PGs) remain challenging despite advances in surgical techniques. Considerable morbidity and even mortality result from hypoparathyroidism caused by devascularization or inadvertent removal of PGs. Emerging imaging technologies hold promise to improve identification and preservation of PGs during thyroid surgery. Observation: This narrative review (1) comprehensively reviews PG identification and vascular assessment using near-infrared autofluorescence (NIRAF)-both label free and in combination with indocyanine green-based on a comprehensive literature review and (2) offers a manual for possible implementation these emerging technologies in thyroid surgery. Conclusions and Relevance: Emerging technologies hold promise to improve PG identification and preservation during thyroidectomy. Future research should address variables affecting the degree of fluorescence in NIRAF, standardization of signal quantification, definitions and standardization of parameters of indocyanine green injection that correlate with postoperative PG function, the financial effect of these emerging technologies on near-term and longer-term costs, the adoption learning curve and effect on surgical training, and long-term outcomes of key quality metrics in adequately powered randomized clinical trials evaluating PG preservation.

A Pilot Study of Augmented Intelligence Risk-Based Stratification for Endocrine Surgical Waiting List Prioritisation.

Introduction The New Deal for Surgery report encouraged using new technology in healthcare to address the 377,689 patients in England awaiting National Health Service (NHS) hospital treatment in July 2022. During the pandemic's second wave, this pilot study investigated the utility of COMPASS Surgical List Triage (COMPASS SLT; C2-Ai, Cambridge, England), an augmented intelligence-based system, in assisting surgical decision-making on patient prioritisation. Data generated from COMPASS SLT was compared to data from the British Association of Endocrine and Thyroid Surgeons' (BAETS) and Federation of Surgical Specialties Associations' (FSSA) prioritisation guidance. Methods A cohort of thyroidectomy and parathyroidectomy patients on the surgical waiting list at Imperial College Healthcare NHS Trust, London, United Kingdom, was used. COMPASS SLT calculated individuals' mortality and significant morbidity risk (risk >2.5%). Significant morbidity risk was set at 2.5% or above following internal model validation, thus reducing the risk of model overfitting occurring with COMPASS SLT. The additional increase in mortality and morbidity due to treatment delay was calculated. Actual treatment time was aligned to the treatment delay (in weeks) experienced by each patient. Results Twenty-nine patients, with a median age of 43 years and a waiting time of 18 weeks at the onset of the second wave, were enrolled. Non-statistically significant differences (p=0.937) between the FSSA and BAETS classifications were identified. However, cohort size could promote a type II error. An increase in median mortality and morbidity risk (p<0.001) arising from treatment delay and decisions based on the FSSA and BAETS classifications were identified. Conclusion COMPASS SLT can supplement clinical decision-making. An augmented intelligence tool can provide clinicians objectivity and flexibility in prioritising patients, with information on individual morbidity and mortality.

Scoping review of approaches used for remote-access parathyroidectomy: A contemporary review of techniques, tools, pros and cons.

After our coauthors described the first remote-access parathyroidectomy (RAP) series in 2000, several other approaches were developed. No systematic review has been performed to classify and evaluate RAP techniques. We performed a literature search using PubMed and Cochrane Library (CENTRAL). A total of 71 studies met our inclusion/exclusion criteria. RAP can be categorized into five approaches: (1) endoscopic and robotic axillary, (2) anterior chest, (3) transoral, (4) retroauricular, and (5) a combination of these approaches. The limited data in the literature suggest that the cure rates and safety of RAP are in no way inferior to those of open parathyroidectomy. Each approach has its advantages and disadvantages, and the recommendations for the selection of each approach are listed. The selection of approach methods might depend on the surgeon's experience and familiarity and the patient's preference and disease status.

Pediatric intraoperative nerve monitoring during thyroid surgery: A review from the American Head and Neck Society Endocrine Surgery Section and the International Neural Monitoring Study Group.

Children are more likely to experience recurrent laryngeal nerve (RLN) injury during thyroid surgery. Intraoperative nerve monitoring (IONM) may assist in nerve identification and surgical decision making. A literature review of pediatric IONM was performed and used to inform a monitoring technique guide and expert opinion statements. Pediatric IONM is achieved using a variety of methods. When age-appropriate endotracheal tubes with integrated surface electrodes are not available, an alternative method should be used. Patient age and surgeon experience with laryngoscopy influence technique selection; four techniques are described in detail. Surgeons must be familiar with the nuances of monitoring technique and interpretation; opinion statements address optimizing this technology in children. Adult IONM guidelines may offer strategies for surgical decision making in children. In some cases, delay of second-sided surgery may reduce bilateral RLN injury risk.

Clarifying optimal outcome measures in intermittent and continuous laryngeal neuromonitoring.

BACKGROUND: Intraoperative neuromonitoring (IONM) techniques have evolved over the past decade into intermittent IONM (I-IONM) and continuous IONM (C-IONM) modes of application. Despite many prior publications on both types of IONM, there remains uncertainty about what outcomes should be measured for each form of IONM. The primary objective of this paper is to define categories of benefit for I-IONM/C-IONM and to clarify and standardize their reporting outcomes. METHODS: Expert review consensus statement utilizing modified Delphi methodology. RESULTS: I-IONM provides diagnosis, classification, and prevention of nerve injury through accurate and early nerve identification. C-IONM provides real-time information on nerve functional integrity and thus may prevent some types of nerve injury but cannot assist in nerve localization. Sudden mechanisms of nerve injury cannot be predicted or prevented by either technique. CONCLUSIONS: I-IONM and C-IONM are complementary techniques. Future studies evaluating the utility of IONM should focus on outcomes that are appropriate to the type of IONM being utilized.

Correlation of Preoperative Imaging Findings and Parathyroidectomy Outcomes Support NICE 2019 Guidance.

CONTEXT: Preoperative localization studies are standard practice in patients undergoing parathyroidectomy for primary hyperparathyroidism (pHPT). The most common modalities are neck ultrasound (US) and sestamibi scanning. However, the nature of pHPT is changing, with imaging increasingly yielding negative results. Numerous studies suggest unlocalized disease is associated with poor outcomes, calling into question whether such patients are best treated conservatively. OBJECTIVE: This study aims to correlate parathyroidectomy outcomes with preoperative imaging in a single, high-volume institution. METHODS: Data from a prospectively maintained departmental database of operations performed from 2017 to 2019 were analyzed. All patients undergoing first-time surgery for sporadic pHPT were included. Data collected included patient demographics, preoperative imaging, surgical strategy, and postoperative outcomes. RESULTS: A total of 609 consecutive parathyroidectomies were included, with a median age of 59 years (range 20-87 years). The all-comer cure rate was 97.5%; this was 97.9% in dual localized patients (those with positive US and sestamibi), compared to 95.8% in the dual unlocalized group (those with negative US and sestamibi) (P = 0.33). Unilateral neck exploration was the chosen approach in 59.9% of patients with double-positive imaging and 5.7% of patients with double-negative imaging (otherwise, bilateral parathyroid visualization was performed). There was no significant difference in postoperative complications between patients undergoing unilateral or bilateral neck exploration. CONCLUSIONS: Patients with negative preoperative imaging who undergo parathyroidectomy are cured in almost 96% of cases, compared to 98% when the disease is localized. This difference does not reach statistical or clinical significance. These findings therefore support current recommendations that all patients with pHPT who are likely to benefit from operative intervention should be considered for parathyroidectomy, irrespective of preoperative imaging findings.

Radiofrequency ablation and related ultrasound-guided ablation technologies for treatment of benign and malignant thyroid disease: An international multidisciplinary consensus statement of the American Head and Neck Society Endocrine Surgery Section with the Asia Pacific Society of Thyroid Surgery, Associazione Medici Endocrinologi, British Association of Endocrine and Thyroid Surgeons, European Thyroid Association, Italian Society of Endocrine Surgery Units, Korean Society of Thyroid Radiology, Latin American Thyroid Society, and Thyroid Nodules Therapies Association.

BACKGROUND: The use of ultrasound-guided ablation procedures to treat both benign and malignant thyroid conditions is gaining increasing interest. This document has been developed as an international interdisciplinary evidence-based statement with a primary focus on radiofrequency ablation and is intended to serve as a manual for best practice application of ablation technologies. METHODS: A comprehensive literature review was conducted to guide statement development and generation of best practice recommendations. Modified Delphi method was applied to assess whether statements met consensus among the entire author panel. RESULTS: A review of the current state of ultrasound-guided ablation procedures for the treatment of benign and malignant thyroid conditions is presented. Eighteen best practice recommendations in topic areas of preprocedural evaluation, technique, postprocedural management, efficacy, potential complications, and implementation are provided. CONCLUSIONS: As ultrasound-guided ablation procedures are increasingly utilized in benign and malignant thyroid disease, evidence-based and thoughtful application of best practices is warranted.

Differentiated Thyroid Cancer: A Health Economic Review.

The incidence of differentiated thyroid cancer (DTC) is rising, mainly because of an increased detection of asymptomatic thyroid nodularity revealed by the liberal use of thyroid ultrasound. This review aims to reflect on the health economic considerations associated with the increasing diagnosis and treatment of DTC. Overdiagnosis and the resulting overtreatment have led to more surgical procedures, increasing health care and patients' costs, and a large pool of community-dwelling thyroid cancer follow-up patients. Additionally, the cost of thyroid surgery seems to increase year on year even when inflation is taken into account. The increased healthcare costs and spending have placed significant pressure to identify potential factors associated with these increased costs. Some truly ground-breaking work in health economics has been undertaken, but more cost-effectiveness studies and micro-cost analyses are required to evaluate expenses and guide future solutions.

The volume and outcome relationship for thyroidectomy in England.

PURPOSE: The delivery of surgical care in England has seen a momentum towards centralisation within larger volume hospitals and surgical teams. The aim of this study was to investigate outcomes in England in relationship to hospital and surgeon annual volumes for total thyroidectomy. METHODS: Data were extracted from the Hospital Episodes Statistics (HES) database for England. A 6-year period (April 2012-March 2018 inclusive) for all adult admissions for thyroidectomy was used in the analysis. The primary outcome measure used was a length of hospital stay greater than 2 days or an emergency readmission within 30 days following surgery. This was used as a proxy for surgical complications. A multilevel modelling strategy was used to adjust for hierarchy and potentially confounding. RESULTS: Data for 22,823 total thyroidectomies across 144 hospital trusts were used for analysis. For total thyroidectomy, larger volume surgeons had reduced levels of post-surgical complications; length of stay > 2 and > 4 days; emergency readmission at 30 days; and hypoparathyroidism, vocal cord palsy, stridor, and tracheostomy at 1-year post-surgery. Larger hospital volume was associated with lower levels of emergency readmission at 30 days and hypoparathyroidism at 1 year. CONCLUSIONS: There is significant correlation between surgeon volume and clinical outcome for total thyroidectomy. The relationship was approximately linear, and a low-volume threshold could not be defined.

Medullary Thyroid Cancer Patient's Assessment of Quality of Life Tools: Results from the QaLM Study.

BACKGROUND: Medullary thyroid cancer (MTC) is a neuroendocrine tumour and a rare variant of thyroid cancer with different aetiology, presentation and treatment to differentiated thyroid cancer. Currently available thyroid cancer-specific quality of life (QoL) tools focus on issues and treatments more relevant to patients with differentiated thyroid cancer and therefore may not address issues specific to a MTC diagnosis and cancer journey. METHOD: This prospective multicentre randomised study involved 204 MTC patients completing four quality of life questionnaires (QOLQ) and stating their most and least preferred. The questionnaires were a general instrument, the EORTC QLQ-C30, two disease-specific tools, the MD Anderson Symptom Inventory (MDASI) thyroid module and the City of Hope Quality of Life Scale/THYROID (amended) and the neuroendocrine questionnaire, EORTC QLQ-GINET21. Patients were randomised to complete the four questionnaires in one of 24 possible orders and then answered questions about which tool they preferred. The primary outcome measure was patients' preferred QoL instrument for describing their concerns and for facilitating communication with their healthcare professional. Secondary analyses looked at differences between preferred QOLQs amongst patient subgroups (WHO performance status [0 and 1+], disease stage: early [T1-3, N0 or N1A], metastatic [T4, any T N1b] and advanced [any T any N M1], and type of MTC [sporadic and inherited]), identification of MTC patients' least preferred questionnaire and clinicians' views on the QoL tools in terms of their ability to highlight problems not otherwise ascertained by a standard clinical review. RESULTS: No evidence of a difference was observed for most preferred QOLQ (p = 0.650). There was however evidence of a difference in least preferred questionnaire in the cohort of 128 patients who stated their least preferred questionnaire (p = 0.042), with 36% (46/128) of patients choosing the EORTC QLQ-GI.NET21 questionnaire. Subgroup analyses showed that there was no evidence of a difference in patients' most preferred questionnaire in sporadic MTC patients (p = 0.637), patients with WHO PS 0 or 1+ (p = 0.844 and p = 0.423) nor when comparing patients with early, advanced local or metastatic disease (p = 0.132, p = 0.463 and p = 0.506, respectively). Similarly, subgroup analyses on patients' least preferred questionnaires showed no evidence of differences in sporadic MTC patients (p = 0.092), patients with WHO PS 0 or 1+ (p = 0.423 and p = 0.276), nor in early or metastatic disease patients (p = 0.682 and p = 0.345, respectively). There was however some evidence to suggest a difference in least preferred questionnaire in patients with advanced local stage disease (p = 0.059), with 43% (16/37) of these patients choosing the EORTC QLQ-GI.NET21 questionnaire. CONCLUSIONS: MTC patients regardless of their performance status, disease aetiology and disease burden did not express a preference for any one particular questionnaire suggesting any of the tools studied could be utilized in this patient cohort. The least preferred questionnaire being a gastrointestinal NET specific tool suggests that diarrhoea was not a significant symptom and concern for the population studied.

Viral Infectivity in Patients Undergoing Tracheotomy With COVID-19: A Preliminary Study.

OBJECTIVE: To establish the presence of live virus and its association with polymerase chain reaction (PCR) positivity and antibody status in patients with COVID-19 undergoing tracheotomy. STUDY DESIGN: Prospective observational study. SETTING: Single institution across 3 hospital sites during the first wave of the COVID-19 pandemic. METHODS: Patients who were intubated for respiratory wean tracheotomy underwent SARS-CoV-2 PCR nasal, throat, and endotracheal tube swabs at the time of the procedure. These were assessed via quantitative real-time reverse transcription PCR. The tracheal tissue excised during the tracheotomy was cultured for SARS-CoV-2 with Vero E6 and Caco2 cells. Serum was assessed for antibody titers against SARS-CoV-2 via neutralization assays. RESULTS: Thirty-seven patients were included in this study. The mean number of days intubated prior to undergoing surgical tracheotomy was 27.8. At the time of the surgical tracheotomy, PCR swab testing yielded 8 positive results, but none of the 35 individuals who underwent tissue culture were positive for SARS-CoV-2. All 18 patients who had serum sampling demonstrated neutralization antibodies, with a minimum titer of 1:80. CONCLUSION: In our series, irrespective of positive PCR swab, the likelihood of infectivity during tracheotomy remains low given negative tracheal tissue cultures. While our results do not undermine national and international guidance on tracheotomy after day 10 of intubation, given the length of time to procedure in our data, infectivity at 10 days cannot be excluded. We do however suggest that a preoperative negative PCR swab not be a prerequisite and that antibody titer levels may serve as a useful adjunct for assessment of infectivity.

Immediate and partial neural dysfunction after thyroid and parathyroid surgery: Need for recognition, laryngeal exam, and early treatment.

BACKGROUND: Laryngeal dysfunction after thyroid and parathyroid surgery requires early recognition and a standardized approach for patients that present with voice, swallowing, and breathing issues. The Endocrine Committee of the American Head and Neck Society (AHNS) convened a panel to define the terms "immediate vocal fold paralysis" and "partial neural dysfunction" and to provide clinical consensus statements based on review of the literature, integrated with expert opinion of the group. METHODS: A multidisciplinary expert panel constructed the manuscript and recommendations for laryngeal dysfunction after thyroid and parathyroid surgery. A meta-analysis was performed using the literature and published guidelines. Consensus was achieved using polling and a modified Delphi approach. RESULTS: Twenty-two panelists achieved consensus on five statements regarding the role of early identification and standardization of evaluation for patients with "immediate vocal fold paralysis" and "partial neural dysfunction" after thyroid and parathyroid surgery. CONCLUSION: After endorsement by the AHNS Endocrine Section and Quality of Care Committee, it received final approval from the AHNS Council.

Emergency airway training: "Who are you going to FONA?"

OBJECTIVES: To demonstrate face and content validity of a home-made simulation model as a training tool for front of neck access (FONA) procedures. DESIGN: This was a prospective evaluation study, in which experienced otolaryngologists and trainees were recruited to complete 3 tasks using our FONA model. SETTING: The study was completed during regular simulation training days and international conferences. PARTICIPANTS: A total of 52 participants completed the questionnaire and were included in the study; 25 were experts and 27 were trainees. MAIN OUTCOME MEASURES: All participants completed a validated 15-item questionnaire using a 5-point likert scale to assess the model across 4 domains: face validity (FV), global content (GC), task-specific content (TSC) and curriculum applicability (CTR). RESULTS: There were no statistically significant differences between the groups ratings for FV, GC, TSC or CTR (P = .76, .13, .4 and .67, respectively). The model achieved a median FV of 4 (IQR 4-5) with the agreement of experienced and trainee groups (68.9% and 92%, respectively). The median GC validity score was 5 (IQR 4-5) with the agreement of 87.6% and 98.4% in respected groups. The model achieved a median TSC of 4.8 (IQR 4-5) with the agreement of 54.5% and 99% in respected groups. The median CTR score was 5 (IQR 4-5) with the agreement of 54.4% and 100% in respected groups. CONCLUSION: Our home-made FONA model achieved face and content validity for training and is safe and affordable for teaching basic front of neck access skills to otolaryngology trainees.

Cochlear Implant Reliability: Reporting of Device Failures.

The aim of this study was to investigate the adequacy of the reporting of cochlear implant device failures. Data from a parallel study involving over 6300 children [1] was used to calculate the instantaneous failure rate for explantations. We found that this is comparable to what manufacturers term 'Cumulative Failure Percentage' (CFP). This finding raises concerns about the information provided by manufacturers on the reliability of their implants.

Cochlear Implant Reliability: On the Reporting of Rates of Revision Surgery.

The aim of this study was to determine the magnitude of the risks associated with cochlear implantation. Results from a pool of thirty clinical studies involving cochlear implantation in over 6300 children were obtained from an internet search. The relevant data were transformed to a common time base (patient time) to allow an evaluation of events following implantation. The main outcome measure was cumulative survival probability for all-cause revision surgery. Over 10 years this was estimated to be 0.71. Thus, at 10 years post-implantation close to 30% of children with unilateral implants will have undergone revision surgery. This figure is considerably greater than that commonly reported for overall revision rates and illustrates the importance of interpreting results with respect to the relevant time frame. When non and low-use is incorporated into the analysis the above figure rises to about 37% of children affected. The findings raise concerns about the information provided to both individuals and regulatory bodies regarding the risks associated with cochlear implantation. The consequences for bilateral implantation are apparent. Our recommendations are i) a full disclosure to parents and children of the true magnitude of the risks and ii) for a body with significant expertise in reliability and systems engineering, and no conflicts of interest, to play a major role in the regulatory management of this service.