Monitorização do nervo laríngeo recorrente em tireoidectomias: Revisão sistemática e Meta-análise.
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Data
2018-07-12
Autores
Siqueira, Tamires Ferreira [UNESP]
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Editor
Universidade Estadual Paulista (Unesp)
Resumo
Introdução: A paralisia de pregas vocais caracteriza-se como uma das principais complicações e sequelas após a tireoidectomia. A técnica convencional compreende a identificação visual do trajeto do nervo para sua preservação e a neuromonitorização do nervo laríngeo recorrente (NLR) durante a cirurgia de tireóide visa a redução do risco de paralisias por injúria ao NLR, porém sua utilidade ainda é discutível. Objetivos: Determinar através de revisão sistemática se o uso da neuromonitorização do NLR durante tireoidectomias realmente apresenta benefícios comparado á técnica convencional de identificação somente do nervo durante a cirurgia, especialmente em termos de redução do risco de paralisia de prega vocal, seja transitória ou permanente. Materiais e Métodos: A pesquisa nas principais bases de dados, MEDLINE via PUBMED, LILACS, SCOPUS, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL); clinicaltrials.gov e fontes adicionais foi realizada em Maio de 2018. Uma revisão sistemática e meta-análise foram feitas usando o modelo de efeitos fixos. O GRADE foi usado para classificar a qualidade das evidências. Os desfechos primários avaliados foram o total de paralisias do NLR por nervos em risco, paralisias transitórias e permanentes e o tempo de cirurgia comparando-se as duas técnicas. Como desfechos secundário avaliou-se o tempo de cirurgia. Foi realizada análise de subgrupos de pacientes de alto e baixo risco de injuria do NLR. Também avaliamos como análise de subgrupos as paralisias transitórias e permanentes em grupo de pacientes de alto e baixo risco de injúria do NLR. Resultados: Quatro ensaios clínicos randomizados envolvendo 1.379 pacientes submetidos à tireoidectomia utilizando a neuromonitorização ou com a identificação somente do NLR, sendo 2.605 o número total de nervos em risco foram avaliados. A neuromonitorização diminuiu o risco do total paralisias (transitórias e permanentes) de prega vocal em tireoidectomias (RR 0,64; IC 95% de 0,43 a 0,95, I 2 = 30%), assim como diminuiu o risco de paralisias transitórias (RR 0,60; IC 95% de 0,38 a 0,95, I 2 =10%), porém não diminuiu o risco de paralisias permanentes (RR 0,84; IC 95% de 0,36 a 1,93, I 2 = 0%). A análise da média do tempo de cirurgia foi conduzida em dois estudos, entretanto como a heterogeneidade entre os estudos foi maior que 75% a metanálise não foi apropriada para estabelecer a diferença do tempo médio de cirurgia entre os grupos. Quanto a análise de subgrupos, observou-se que a neuromonitorização não diminuiu o risco de paralisias transitórias (RR 0,61; IC 95% de 0,28 a 1,31, I 2 = 0%) e nem o risco de paralisias permanentes de prega vocal em tireoidectomias de baixo risco (RR 1,03; IC 95% de 0,21 a 5,07, I 2 não aplicável). Assim como também não diminuiu o risco de paralisias transitórias (RR 0,75; IC 95% de 0,18 a 3,07, I 2 = 71%) e de paralisias permanentes de prega vocal em tireoidectomias de alto risco (RR 0,69; IC 95% de 0,27 a 1,79, I 2 = 4%). Conclusões: Essa meta-análise utilizando apenas ensaios clínicos randomizados demonstrou que a neuromonitorização do nervo laríngeo recorrente em tireoidectomias possivelmente reduz ligeiramente o risco de paralisia transitória das pregas vocais, mas provavelmente faz pouca ou nenhuma diferença no risco de paralisia permanente.
Introduction: Vocal cord paralysis is characterized as one of the main complications and sequels after thyroidectomy. The conventional technique comprises the visual identification of the nerve path for its preservation and recurrent laryngeal nerve (RLN) neuromonitoring during thyroid surgery aims to reduce the risk of paralysis due to injury to the RLN, but its usefulness is still debatable. Objectives: To determine through systematic review if the use of neuromonitoring of the RLN during thyroidectomies actually presents benefits compared to the conventional technique of only identification of the nerve during surgery, especially in terms of reducing the risk of vocal fold paralysis, whether transient or permanent. Materials and Methods: The search in the main databases, MEDLINE, LILACS, SCOPUS, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL); clinicaltrials.gov and additional sources was performed in May 2018. A systematic review and meta-analysis was done using the fixed-effects model. GRADE was used to classify the quality of the evidence. The primary endpoints evaluated were the total nerve paralysis for nerves at risk, transient and permanent paralyzes, and surgery time comparing the two techniques. As secondary outcomes, the time of surgery was evaluated. We also evaluated as subgroup analysis the transient and permanent paralysis in a group of patients with high and low risk of RLN injury. Results: Four randomized clinical trials involving 1.379 patients undergoing thyroidectomy using neuromonitoring or with identification only of the RLN, of which 2.605 was the total number of nerves at risk evaluated. Neuromonitoring reduced the risk of total (transient and permanent) vocal fold paralysis after thyroidectomies (RR 0.64, 95% CI 0.93 to 0.95, I 2 = 30%), as well as decreased the risk of transient paralysis (RR 0.60, 95% CI 0.38 to 0.95, I 2 = 10%), but did not decrease the risk of permanent paralysis (RR 0.84, 95% CI 0.36 to 1.93, I2 = 0%). The analysis of the mean time of surgery was conducted in two studies, however, the heterogeneity between the studies was greater than 75% and the meta-analysis was not appropriate to establish the difference in the mean time of surgery between the groups. As the analysis of subgroups, it was observed that neuromonitoring did not reduce the risk of transient paralysis (RR 0.61, 95% CI 0.28 to 1.31, I 2 = 0%) and neither the risk of permanent paralysis in low-risk thyroidectomies (RR 1.03, 95% CI 0.21 to 5.07, I2 not applicable). As it also did not reduce the risk of transient paralysis (RR 0.75, 95% CI 0.18 to 3.07, I2 = 71%) and permanent vocal fold paralysis in high-risk thyroidectomies (RR 0, 69, 95% CI 0.27 to 1.79, I 2 = 4%). Conclusions: This meta-analysis using only randomized clinical trials has demonstrated that recurrent laryngeal nerve neuromonitoring in thyroidectomies possibly slightly reduces the risk of transient vocal fold paralysis but probably makes little or no difference in the risk of permanent paralysis.
Introduction: Vocal cord paralysis is characterized as one of the main complications and sequels after thyroidectomy. The conventional technique comprises the visual identification of the nerve path for its preservation and recurrent laryngeal nerve (RLN) neuromonitoring during thyroid surgery aims to reduce the risk of paralysis due to injury to the RLN, but its usefulness is still debatable. Objectives: To determine through systematic review if the use of neuromonitoring of the RLN during thyroidectomies actually presents benefits compared to the conventional technique of only identification of the nerve during surgery, especially in terms of reducing the risk of vocal fold paralysis, whether transient or permanent. Materials and Methods: The search in the main databases, MEDLINE, LILACS, SCOPUS, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL); clinicaltrials.gov and additional sources was performed in May 2018. A systematic review and meta-analysis was done using the fixed-effects model. GRADE was used to classify the quality of the evidence. The primary endpoints evaluated were the total nerve paralysis for nerves at risk, transient and permanent paralyzes, and surgery time comparing the two techniques. As secondary outcomes, the time of surgery was evaluated. We also evaluated as subgroup analysis the transient and permanent paralysis in a group of patients with high and low risk of RLN injury. Results: Four randomized clinical trials involving 1.379 patients undergoing thyroidectomy using neuromonitoring or with identification only of the RLN, of which 2.605 was the total number of nerves at risk evaluated. Neuromonitoring reduced the risk of total (transient and permanent) vocal fold paralysis after thyroidectomies (RR 0.64, 95% CI 0.93 to 0.95, I 2 = 30%), as well as decreased the risk of transient paralysis (RR 0.60, 95% CI 0.38 to 0.95, I 2 = 10%), but did not decrease the risk of permanent paralysis (RR 0.84, 95% CI 0.36 to 1.93, I2 = 0%). The analysis of the mean time of surgery was conducted in two studies, however, the heterogeneity between the studies was greater than 75% and the meta-analysis was not appropriate to establish the difference in the mean time of surgery between the groups. As the analysis of subgroups, it was observed that neuromonitoring did not reduce the risk of transient paralysis (RR 0.61, 95% CI 0.28 to 1.31, I 2 = 0%) and neither the risk of permanent paralysis in low-risk thyroidectomies (RR 1.03, 95% CI 0.21 to 5.07, I2 not applicable). As it also did not reduce the risk of transient paralysis (RR 0.75, 95% CI 0.18 to 3.07, I2 = 71%) and permanent vocal fold paralysis in high-risk thyroidectomies (RR 0, 69, 95% CI 0.27 to 1.79, I 2 = 4%). Conclusions: This meta-analysis using only randomized clinical trials has demonstrated that recurrent laryngeal nerve neuromonitoring in thyroidectomies possibly slightly reduces the risk of transient vocal fold paralysis but probably makes little or no difference in the risk of permanent paralysis.
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Palavras-chave
Tireoidectomia, Paralisia de prega vocal, Neuromonitorização, Meta-análise, Revisão sistemática, Thyroidectomy, Vocal fold paralysis, Neuromonitoring, Meta-analysis, Systematic review