臺灣博碩士論文加值系統

背景：
溫度傷害(thermal injury)是甲狀腺手術中喉返神經受傷常見的機轉之一。此熱傷害通常是無形的且容易在術中被忽略。本實驗主要探討喉返神經的溫度耐受性(thermal tolerance)，並且藉由使用連續性術中監測評估喉返神經熱損傷時之肌電圖表現。
方法：
本實驗採用十隻迷你豬(n= 20條喉返神經)進行研究。術中神經監測採用迷走神經自動周期性刺激(automated periodic stimulation)；所誘發的聲門肌肌電圖經由氣管內管表面電極接收，同時連續性紀錄神經受到不同溫度之生理食鹽水沖洗時所對應之肌電圖訊號變化。
結果：
在此試驗性研究(n=4)中發現，以逐漸增溫(40/45/50/55℃)之生理食鹽水沖洗喉返神經60秒之過程中，肌電圖訊號均維持穩定；但當水溫升至60℃時，肌電圖出現快速的訊號喪失(n=4)。另16條喉返神經用於進一步深入探討及比較神經受到固定溫度但暴露於不同時間(60/70℃，20/30秒) (各n=4)之熱損傷時肌電圖的表現。研究發現肌電圖訊號在以60℃和70℃熱水沖洗時呈現快速訊號喪失，且所有受損之神經呈第一型節段性(segmental “type 1”)之病灶。八條以60℃熱水傷害之喉返神經有6條出現部分訊號恢復(16–35%)，但所有以70℃傷害之神經皆無恢復情形。所有神經訊號喪失點雖肉眼不可見但卻能以神經偵測儀探查。
結論：
本研究顯示60℃是喉返神經熱損傷之臨界溫度。術中神經監測可用於早期偵測及評估急性熱損害情形，並指導甲狀腺手術中與能量裝置(energy-based devices)相關或熱能治療之應用。

Objective:
Thermal injury to the recurrent laryngeal nerve (RLN) may not be visually apparent and may go unrecognized intraoperatively. This study aimed to investigate the heat thermal tolerance of RLN and evaluate the electrophysiologic correlates of electromyographic (EMG) signal change during an acute RLN heat damage.
Study Design and Methods:
Prospective porcine model with continuous intraoperative neuromonitoring (CIONM). Ten pigs (20 RLNs) undergoing CIONM had their EMG tracings recorded and correlated with heated normal saline (NS) irrigation of varying temperature and duration.
Results:
In the initial pilot study, the EMG was without change during incremental heated NS irrigation (40/45/50/55℃ for 60 seconds), but adverse EMG combined events (CE) (amplitude decrease with a concordant latency increase) occurred and degraded to loss of signal (LOS) (by 17.5±1.3 seconds) when the temperature was elevated to 60℃ (n=4). Another 16 RLNs were evaluated to further compare the EMG pattern after various degrees of thermal stress (60/70℃ for 30/20 seconds). EMG recordings showed CEs and LOS in all RLNs, and only six of eight RLNs with 60℃ exposure showed slight EMG amplitude recovery (16%–35%) after 20 minutes. None of the injured nerve segments were visually apparent but all were detectable by IONM.
Conclusion:
Sixty degrees Celsius is a critical temperature to cause RLN thermal injury. CIONM can be used as a tool for the early detection of acute thermal stress and may guide use of energy-based devices during thyroid procedures.

1. 致謝詞 -------------------------------------------------------------------------1
2. 目次 ----------------------------------------------------------------------------2
3. 論文摘要
3.1 中文摘要 ---------------------------------------------------------------- 4
3.2 英文摘要 ---------------------------------------------------------------- 6
4. 論文正文
4.1 前言 Introduction -------------------------------------------------------8
4.2 研究材料與方法 Materials and Methods --------------------------10
4.2.1 Animal and Anesthesia ----------------------------------------- 10
4.2.2 IONM Equipment and Setting ---------------------------------11
4.2.3 Operation and Experimental Design --------------------------12
4.2.4 Study Design -----------------------------------------------------13
4.2.1.1 Critical Temperature Study ----------------------------14
4.2.4.2 Thermal Dose Study -------------------------------------15
4.3 研究結果 Results -----------------------------------------------------16
4.3.1 EMG Waveform Outcome -------------------------------------16
4.3.1.1 Critical Temperature Study -----------------------------16
4.3.1.2 Thermal Dose Study -------------------------------------17
4.3.2 Histological Outcome -------------------------------------------18
4.4 討論 Discussion -------------------------------------------------------19
4.5 結論 Conclusion -------------------------------------------------------24
5. 附圖與附表 Figures and Table -------------------------------------------25
6. 參考文獻 References ------------------------------------------------------33
7. 附錄 Supplements ----------------------------------------------------------38

1.Kern KA. Medicolegal analysis of errors in diagnosis and treatment of surgical endocrine disease. Surgery 1993; 114:1167-1173; discussion 1173-1164.
2.Chiang FY, Wang LF, Huang YF, Lee KW, Kuo WR. Recurrent laryngeal nerve palsy after thyroidectomy with routine identification of the recurrent laryngeal nerve. Surgery 2005; 137:342-347.
3.Moley JF, Lairmore TC, Doherty GM, Brunt LM, DeBenedetti MK. Preservation of the recurrent laryngeal nerves in thyroid and parathyroid reoperations. Surgery 1999; 126:673-677; discussion 677-679.
4.Steurer M, Passler C, Denk DM, Schneider B, Niederle B, Bigenzahn W. Advantages of recurrent laryngeal nerve identification in thyroidectomy and parathyroidectomy and the importance of preoperative and postoperative laryngoscopic examination in more than 1000 nerves at risk. Laryngoscope 2002; 112:124-133.
5.Dralle H, Sekulla C, Haerting Jet al. Risk factors of paralysis and functional outcome after recurrent laryngeal nerve monitoring in thyroid surgery. Surgery 2004; 136:1310-1322.
6.Chiang FY, Lu IC, Kuo WR, Lee KW, Chang NC, Wu CW. The mechanism of recurrent laryngeal nerve injury during thyroid surgery--the application of intraoperative neuromonitoring. Surgery 2008; 143:743-749.
7.Snyder SK, Lairmore TC, Hendricks JC, Roberts JW. Elucidating mechanisms of recurrent laryngeal nerve injury during thyroidectomy and parathyroidectomy. J Am Coll Surg 2008; 206:123-130.
8.Randolph GW. Surgery of the Thyroid and Parathyroid Glands. . Philadelphia, PA: Saunders 2013.
9.Randolph GW, Dralle H, Abdullah Het al. Electrophysiologic recurrent laryngeal nerve monitoring during thyroid and parathyroid surgery: international standards guideline statement. Laryngoscope 2011; 121 Suppl 1:S1-16.
10.Chiang FY, Lee KW, Chen HCet al. Standardization of Intraoperative Neuromonitoring of Recurrent Laryngeal Nerve in Thyroid Operation. World J Surg 2010; 34:223-229.
11.Francis DO, Pearce EC, Ni S, Garrett CG, Penson DF. Epidemiology of vocal fold paralyses after total thyroidectomy for well-differentiated thyroid cancer in a Medicare population. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery 2014; 150:548-557.
12.Jeannon JP, Orabi AA, Bruch GA, Abdalsalam HA, Simo R. Diagnosis of recurrent laryngeal nerve palsy after thyroidectomy: a systematic review. International journal of clinical practice 2009; 63:624-629.
13.Dionigi G. Energy based devices and recurrent laryngeal nerve injury: the need for safer instruments. Langenbeck''s archives of surgery / Deutsche Gesellschaft fur Chirurgie 2009; 394:579-580; author reply 581-576.
14.Wu CW, Dionigi G, Sun Het al. Intraoperative neuromonitoring for the early detection and prevention of RLN traction injury in thyroid surgery: A porcine model. Surgery 2014; 155:329-339.
15.Dionigi G, Alesina PF, Barczynski Met al. Recurrent laryngeal nerve injury in video-assisted thyroidectomy: lessons learned from neuromonitoring. Surg Endosc 2012; 26:2601-2608.
16.Gharib H, Hegedus L, Pacella CM, Baek JH, Papini E. Clinical review: Nonsurgical, image-guided, minimally invasive therapy for thyroid nodules. The Journal of clinical endocrinology and metabolism 2013; 98:3949-3957.
17.Wu CW, Lu IC, Randolph GWet al. Investigation of optimal intensity and safety of electrical nerve stimulation during intraoperative neuromonitoring of the recurrent laryngeal nerve: a prospective porcine model. Head &; neck 2010; 32:1295-1301.
18.Lu IC, Chang PY, Hsu HTet al. A comparison between succinylcholine and rocuronium on the recovery profile of the laryngeal muscles during intraoperative neuromonitoring of the recurrent laryngeal nerve: A prospective porcine model. The Kaohsiung journal of medical sciences 2013; 29:484-487.
19.Xu D, Pollock M. Experimental nerve thermal injury. Brain : a journal of neurology 1994; 117 ( Pt 2):375-384.
20.Bunch TJ, Bruce GK, Mahapatra Set al. Mechanisms of phrenic nerve injury during radiofrequency ablation at the pulmonary vein orifice. Journal of cardiovascular electrophysiology 2005; 16:1318-1325.
21.Dionigi G, Donatini G, Boni Let al. Continuous monitoring of the recurrent laryngeal nerve in thyroid surgery: a critical appraisal. International journal of surgery (London, England) 2013; 11 Suppl 1:S44-46.
22.Schneider R, Przybyl J, Hermann M, Hauss J, Jonas S, Leinung S. A new anchor electrode design for continuous neuromonitoring of the recurrent laryngeal nerve by vagal nerve stimulations. Langenbeck''s archives of surgery / Deutsche Gesellschaft fur Chirurgie 2009; 394:903-910.
23.Phelan E, Schneider R, Lorenz Ket al. Continuous vagal IONM prevents recurrent laryngeal nerve paralysis by revealing initial EMG changes of impending neuropraxic injury: a prospective, multicenter study. The Laryngoscope 2014; 124:1498-1505.
24.Melck AL, Wiseman SM. Harmonic scalpel compared to conventional hemostasis in thyroid surgery: a meta-analysis of randomized clinical trials. International journal of surgical oncology 2010; 2010:396079.
25.Papavramidis TS, Sapalidis K, Michalopoulos Net al. UltraCision harmonic scalpel versus clamp-and-tie total thyroidectomy: a clinical trial. Head &; neck 2010; 32:723-727.
26.Duan YF, Xue W, Zhu F, Sun DL. FOCUS harmonic scalpel compared to conventional hemostasis in open total thyroidectomy - a prospective randomized study. Journal of otolaryngology - head &; neck surgery = Le Journal d''oto-rhino-laryngologie et de chirurgie cervico-faciale 2013; 42:62.
27.Ruggiero R, Gubitosi A, Conzo Get al. Sutureless thyroidectomy. International journal of surgery (London, England) 2014; 12 Suppl 1:S189-193.
28.Coiro S, Frattaroli FM, De Lucia Fet al. A comparison of the outcome using Ligasure small jaw and clamp-and-tie technique in thyroidectomy: a randomized single center study. Langenbeck''s archives of surgery / Deutsche Gesellschaft fur Chirurgie 2015.
29.Schneider R, Randolph GW, Sekulla Cet al. Continuous intraoperative vagus nerve stimulation for identification of imminent recurrent laryngeal nerve injury. Head Neck 2013; 35:1591-1598.