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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_987_Библиотеки_им_академика_М_И_Перельмана.pdf
88
J. X. Wu and R. Raghunathan
• Mobilize and retract the sternocleidomastoid muscle (SCM) laterally, which will
reveal the omohyoid muscle, carotid sheath, and lateral neck lymph nodes.
Excision ofNodal Packet
• Superior Margin—either:
– identify spinal accessory nerve (CN XI) along its course from the SCM to its
course underneath the posterior belly of digastric muscle; or:
– based on imaging and exam, choose the superior extent of nodal burden below
the spinal accessory nerve.
• Transect brofatty tissue from the internal jugular vein to the SCM at the superior border, taking care to avoid injury to vagus nerve within carotid sheath,
cervical rootlets, and the phrenic nerve posteriorly.
• Lateral Margin: Incise the cervical fascia along the posterior border of the
SCM from the superior margin down to the clavicle, exposing the
nodal packet.
• The omohyoid muscle must be transected to provide full view of the
nodal packet.
• Transect the brofatty tissue laterally, taking care not to injure the cervical rootlets at the deep aspect (some rootlets may need to be sacriced).
• Raise the brofatty packet, lateral to medial, off the scalene muscles taking care
to avoid injury to phrenic nerve which lies deep to brofatty packet.
• Now, that the nodal packet is pedicled onto carotid sheath, trace the vagus nerve
from superior extent down to clavicle.
• With vagus nerve in full view, divide attachments of nodal packet to carotid
sheath and to the jugular vein.
• Medial Margin: Transect the medial brofatty attachments of nodal packet to
lateral aspect of sternohyoid muscle.
• Transect medial attachment of omohyoid muscle, the mid-portion of the muscle
is sent with nodal packet.
• Inferior Margin: All brofatty tissue at the inferior margin between the phrenic
nerve and internal jugular vein should be clamped and tied to minimize the possibility of a chyle leak.
• Avoid attempts to dissect the thoracic duct when possible; the walls of the duct
are friable and likely to shear. It is preferable to encircle the duct and ligate it
with a tie.
• Now, the nodal packet is freed and sent to Pathology.
• Perform a Valsalva maneuver and inspect the inferior margin for a chyle leak, if
a leak is present, attempts should be made to ligate the tract and consider leaving
a closed suction drain.
• Inspect and palpate high level II and behind the carotid artery for any missed
nodes; these are the most common areas for missed persistent disease. After
ensuring hemostasis is adequate, close platysma and skin layers.
10 Central andLateral Neck Dissection: Techniques andPotential Complications
89
Complex Situations
Invasion ofJugular Vein
• Densely adherent disease to the internal jugular vein can require vein ligation.
• Ligate ends with stick-tie or suture ligature.
• Ideally avoid contralateral lateral neck dissection if the ipsilateral vein is transected, and perform a staged procedure to allow compensation of venous
drainage.
Chyle Leak
• Chyle leaks occur at the inferior aspect of the nodal dissection, usually due to
disruption of thoracic duct on the left, but can occur on the right due to transection of large lymphatic channels.
• If detected intraoperatively:
– Attempt to identify and ligate lymphatic channel/thoracic duct.
– Use a rotational ap of sternocleidomastoid muscle or strap muscle to pack
the area.
– Use brin glue to seal the area.
– Leave a closed suction drain.
• If detected postoperatively:
– Place patient on medium-chain triglyceride or non-fat diet, advance slowly to
regular once output becomes more serous and<30cc/day.
– Drain can be removed once output <30cc/day on regular diet.
– High, persistent output may require embolization of thoracic duct with inter-
ventional radiology or ligation of the thoracic duct with thoracic surgery.
Complications andManagement
Complications from LND can be signicant, as high as 50% [16], including: transient postoperative hypoparathyroidism (46%) and hypocalcemia (16%), permanent
ear pain, chronic neck pain and paresthesias (11%), injury to the spinal accessory
nerve (20%), and chyle leak (33.6%) in addition to hematoma, and seroma [12, 13,
16, 26]. Injury to the spinal accessory nerve leads to shoulder weakness and limita-
tion of movement, which may resolve with physiotherapy.
Management of transient biochemical abnormalities and vascular injury are the
same as discussed above in Sect. 10.2.5 Central neck dissection—Complications
and management. The management of thoracic duct injury is discussed in Sect.
10.3.4.2 Chyle leak.
90
J. X. Wu and R. Raghunathan
References
1. Haugen BRM, Alexander EK, Bible KC, etal. 2015 American Thyroid Association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer.
Thyroid. 2016;26:1–133.
2. Kim E, Park JS, Son KR, etal. Preoperative diagnosis of cervical metastatic lymph nodes in
papillary thyroid carcinoma: comparison of ultrasound, computed tomography and combined
ultrasound with computed tomography. Thyroid. 2008;18:411–8.
3. Stulak JM, Grant CS, Farley DR, etal. Value of preoperative ultrasonography in the surgical
management of initial and reoperative papillary thyroid cancer. Arch Surg. 2006;141:489–94.
4. Yeh MW, Bauer AJ, Bernet VA, etal. American Thyroid Association statement on preoperative
imaging for thyroid cancer surgery. Thyroid. 2015;25:3–14.
5. Musacchio MJ, Kim AW, Vijungco JD, etal. Greater local recurrence occurs with “berry picking” than neck dissection in thyroid cancer. Am Surg. 2003;69:191–6. discussion 196-7
6. Robbins KT, Medina JE, Wolfe GT, etal. Standardizing neck dissection terminology. Arch
Otolaryngol Head Neck Surg. 1991;117:601–5.
7. Robbins KT, Clayman G, Levine PA, et al. Neck dissection classication update. Arch
Otolaryngol Head Neck Surg. 2002;128:751–8.
8. Robbins KT, Shaha AR, Medina JE, etal. Consensus statement on the classication and terminology of neck dissection. Arch Otolaryngol Head Neck Surg. 2008;134:536–8.
9. Cooper DS, Doherty GM, Haugen BR, etal. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid.
2009;19:1167–214.
10. Grubbs EG, Evans DB.Role of lymph node dissection in primary surgery for thyroid cancer. J
Natl Compr Cancer Netw. 2007;5:623–30.
11. Sippel RS.Neck dissection for differentiated thyroid cancer. Waltham MA: UpToDate; 2021.
http://www.uptodate.com. Accessed December 16 2022
12. Randolph GW.Surgery of the thyroid and parathyroid glands. 3rd ed. Philadelphia: Elsevier,
Inc.; 2021.
13. Doherty GM.Complications of thyroid and parathyroid surgery. In: Mulholland MW, Doherty
GM, editors. Complications in surgery. 2nd ed. Philadelphia: Lippincott Williams and Wilkins;
2011. p.550–66.
14. Wada N, Suganuma N, Nakayama H.Langenbeck's Arch Surg. 2007;392:417–22.
15. NCCN Thyroid Carcinoma Clinical Practice Guidelines. Version 3.2022. November 1 2022.
https://www.nccn.org/professionals/physician_gls/pdf/thyroid.pdf. Accessed 16 Dec 2022.
16. Stack BC, Ferris RL, Goldenberg D.ATA consensus review and statement regarding the anatomy, terminology and rationale for lateral neck dissection in differentiated thyroid cancer.
Thyroid. 2012;22:501–8.
17. Wells SA Jr, Asa SL, Dralle H, etal. Revised American Thyroid Association guidelines for the
management of medullary thyroid carcinoma. Thyroid. 2015;25:567–610.
18. Shin DH, Mark EJ, Suen HC, etal. Pathologic staging of papillary carcinoma of the thyroid with
airway invasion based on the anatomic manner of extension to the trachea: a clinicopathologic
study based on 22 patients who underwent thyroidectomy and airway resection. Hum Pathol.
1993;24(8):866–70.
19. Gillenwater AM, Goepefert H. Surgical management of laryngotracheal and esophageal
involvement by locally advanced thyroid cancer. Semin Surg Oncol. 1999;16(1):19–29.
20. Machens A, Hinze R, Thomusch O.Pattern of nodal metastasis for primary and reoperative
thyroid cancer. World J Surg. 2002;26:22–8.
21. Schuff KG, Weber SM, Givi B, etal. Efcacy of nodal dissection for treatment of persistent/
recurrent papillary thyroid cancer. Laryngoscope. 2008;118:768–75.
10 Central andLateral Neck Dissection: Techniques andPotential Complications
22. Robenshtok E, Fish S, Bach A, etal. Suspicious cervical lymph nodes detected after thyroidectomy for papillary thyroid cancer usually remain stable over years in properly selected
patients. J Clin Endocrinol Metab. 2012;97:2706–13.
23. Kim SY, Kim S-M, Chang H, et al. Long-term outcomes of ethanol injection therapy for
locally recurrent papillary thyroid cancer. Eur Arch Otorrinolaringol. 2017;274:3497–501.
24. Bible KC, Kebebew E, Brierley J, etal. 2021 American Thyroid Association guidelines for
management of patients with anaplastic thyroid cancer. Thyroid. 2021;31:337–86.
25. Caron NR, Tan YY, Ogilvie JB, Triponez F.Selective modied radical neck dissection for
papillary thyroid cancer—is level I, II and V dissection always necessary? World J Surg.
2006;30:833–40.
26. Cheah WK, Arici C, Ituarte PHG, etal. Complications of neck dissection for thyroid cancer.
World J Surg. 2002;26:1013–6.
91
Chapter 11
Interventional Endocrinology: Techniques,
Indications, andPotential Complications
ReaganA.Collins andJenniferH.Kuo
Background
• The incidence of thyroid nodules has increased over 300% over the last several
decades with a prevalence of up to 68% among the general population depending
on the mode of detection (palpation, ultrasound, autopsy) [1–4].
• Thyroid lobectomy or total thyroidectomy is the rst-line surgical treatment for
most benign, symptomatic thyroid nodules and thyroid cancer [2, 5, 6].
• However, there are several drawbacks to surgery [2, 5, 7–12]:
– Leaves the patient with a permanent scar.
– May require the patient to be on long-term replacement therapy.
– Comes with inherent risks including:
Hypoparathyroidism for total thyroidectomy.
Laryngeal palsy.
Hemorrhage.
Wound infection.
• To potentially reduce/obviate some of these risks, minimally invasive tech-
niques—ethanol ablation and thermal ablation—have emerged over the last several decades.
• Ethanol ablation was rst introduced in the early 1990s [13].
R. A. Collins
Division of Surgical Oncology, Department of Surgery, Massachusetts General Hospital,
Boston, MA, USA
J. H. Kuo (*)
Section of Endocrine Surgery, Department of Surgery, Columbia University,
New York, NY, USA
e-mail: jhk2029@cumc.columbia.edu
Switzerland AG 2024
R. M. Gartland, J. A. Lee (eds.), Endocrine Surgery Clerkship, Contemporary
Surgical Clerkships, https://doi.org/10.1007/978-3-031-62091-1_11
93© The Author(s), under exclusive license to Springer Nature
94
• Soon after, several thermal ablation techniques emerged. These currently include
radiofrequency ablation, microwave ablation, laser ablation, and high-intensity
focused ultrasound.
• Interventional endocrinology is an emerging eld that uses percutaneous, image-
guided, minimally invasive procedures to address certain endocrine pathology.
R. A. Collins and J. H. Kuo
Techniques
Ethanol Ablation
• Ethanol ablation is a chemical ablation technique where 99–100% ethanol is
targeted directly into the thyroid lesion [12].
• Mechanisms of cellular death via ethanol ablation include:
– Cellular dehydration with protein denaturation and coagulative necrosis.
– Blood vessel thrombosis with tissue ischemia.
• Most effective for simple cystic thyroid lesions.
Thermal Ablation
• Thermal ablation includes:
– Radiofrequency ablation.
– Laser ablation.
– Microwave ablation.
– High-intensity focused ultrasound (HIFU).
• Thermal ablation uses heat energy to generate coagulative necrosis of the thyroid
tissue. The ablation zone then gradually decreases until it disappears completely.
Each ablation method accomplishes this through varying techniques [1, 2, 9, 12, 14].
• Radiofrequency ablation [15] (Fig.11.1).
– Most common ablation method.
– Generally performed as an outpatient procedure under local anesthesia.
– An ultrasound-guided electrode is inserted into the skin of the neck and into
the thyroid nodule ➔ the electrode tip uses an alternating electric current that
agitates tissue ions to generate frictional heat around the electrode ➔ the heat
then expands to cause immediate destruction of the target zone.
– Limited by the heat-sink effect.
Ablation Zone
Comparative Visualization on Ultrasound
ab
a bc
11 Interventional Endocrinology: Techniques, Indications, andPotential Complications
RF Electrode
95
R
Fig. 11.1 Transverse view of radiofrequency ablation of a thyroid nodule visualized on ultrasound
(a) and representative schematic (b)
Fig. 11.2 Ultrasound set-up and patient positioning for laser ablation (a), ultrasound probe and
bracket positions on neck (b), and ultrasound probe and inserted optical bers (c)
• Laser ablation [16] (Fig.11.2).
– Thermally ablates tissue by using an optical ber that delivers light energy.
• Microwave ablation [17].
– Generates an electromagnetic eld using a generator, power distribution sys-
tem, and antennae ➔ the electromagnetic eld increases the kinetic energy
and temperature of water molecules producing tissue-heating effects ➔ this
leads to tissue necrosis.
• High-intensity focused ultrasound [18] (Fig.11.3).
– Uses a large diameter ultrasound probe (6cm).
– Uses acoustic energy that causes the rapid expansion and collapse of micro-
bubbles present in thyroid tissue ➔ this process generates heat and causes
coagulative necrosis of the tissue.
L
96
Fig. 11.3 High-intensity
focused ultrasound device
with interface, treatment
head, cooling balloon, and
power generator
R. A. Collins and J. H. Kuo
Indications
• Patients with benign nodules who may consider ablation techniques are those
who [19, 20]:
– Have symptomatic or cosmetic concerns.
– Have anxiety over continued growth or progression of disease.
– Refuse surgery or for whom surgery is contraindicated.
• Guidelines for indications for interventional endocrinology techniques most
strongly support their use in the management of benign, non-functioning thyroid
nodules.
• More recently, recommendations have expanded to include other indications
including autonomously functioning nodules, and in some cases, thyroid cancer.
• A comprehensive list of indications for each interventional endocrinology
method can be found in Table11.1.
• Contraindications include [12]:
– Moderate to large well-differentiated thyroid cancer.
– Medullary or anaplastic thyroid cancer.
– Primary treatment of metastatic lymph node disease.
– Primary treatment of indeterminate nodules, proled suspicious or malignant.
11 Interventional Endocrinology: Techniques, Indications, andPotential Complications
Microwave
ablation
Yes
High- intensity focused
ultrasound
Yes
the United States
the United States only if
Yes
LA or RFA are not
available
No but performed outside
the United States
Yes; only if not a
candidate for surgery/RAI
outside the United
States for RAI
refractory, high
surgical risk or
those who refuse
surgery
No data No but performed
Yes; RAI refractory, high
surgical risk or those who
refuse surgery
outside the United
States for patients
who refuse surgery
or who cannot
No data No but performed
Maybe; emerging clinical
trial evidence in the
United States
undergo an
operation
97
candidate for
surgery/RAI
high surgical risk or
those who refuse
surgery
Yes Yes Yes No but performed outside
Yes Yes Yes No but endorsed outside
Indication Ethanol ablation Laser ablation Radiofrequency ablation
Primary treatment of simple or
recurring thyroid cysts
Primary treatment of benign
Table 11.1 Indications for interventional endocrinology methods in the United States
non-functioning nodules
Yes Yes; only if not a
Primary treatment of benign,
Yes Yes; RAI refractory,
autonomously functioning
nodules
Treatment of recurrent, metastatic
cancers or lymph nodes in
non-surgical candidates
clinical trial
evidence in the
United States
Yes Maybe; emerging
Primary treatment of low-risk
papillary thyroid microcarcinoma
RAI radioactive iodine, LA laser ablation, RFA radiofrequency ablation
98
R. A. Collins and J. H. Kuo
Outcomes
• Outcomes are typically evaluated based on nodule volume reduction and
improvement in clinical symptoms.
• Patients who undergo thermal ablation may have fewer complications, preserva-
tion of thyroid function, and increased patient satisfaction as compared to surgery [11, 21].
• Of the ablation methods, RFA is the most commonly used and has shown the
most promise in terms of long-term efcacy. Following RFA, there is signicant
improvement in symptoms, cosmetics, and nodule volume [12, 13].
Volume Reduction
• Nodule volume reduction of greater than 50% is the main measure of success for
interventional techniques and the greatest volume reduction is typically observed
within the rst month of ablation.
• For benign thyroid nodules volume reduction rates of up to 68% after 3months,
up to 74.3% after 6months, and up to 82% after 12months have been previously
reported [7, 22–25]. Long-term nodule reduction of 81% may last through a
5-year follow-up period [22, 23].
• For low-risk papillary thyroid carcinoma, preliminary volume reduction rates of
up to 100% at 60-month follow-up have been reported with no tumor progression, distant metastasis, or delayed surgery [26–28].
• For recurrent thyroid cancer, positive outcomes and good efcacy in controlling
recurrence have also been reported in patients who refuse or are ineligible for
surgery [29–31].
Symptoms andCosmetic Outcomes
• Symptom and cosmetic concerns are the major motivating factors for patients to
opt for thermal ablation given the positive post-operative outcomes.
• Post-treatment outcomes include [7, 11, 22, 24, 25]:
– Symptom and cosmetic score improvement after thermal ablation.
– High patient satisfaction.
– Good post-operative quality of life.
– Short post-operative recovery time.
Complications
• Nodule regrowth is the major long-term concern following ablation.
• For laser ablation, nodule regrowth may occur in approximately 25% of patients
at short and mid-term follow-up.