甲状腺手术后喉返神经监测与术后气道并发症：一项多变量国家外科质量改进计划分析

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中文摘要

背景： 甲状腺手术中喉返神经损伤可导致具有临床意义的气道损害，尤其是在肺储备有限的患者中。尽管术中神经监测被广泛用于减少神经损伤，但其与术后气道并发症的关联尚未得到充分描述。本研究评估甲状腺切除术后术中神经监测的趋势及其与术后气道损害的关系。
方法： 我们使用国家外科质量改进计划数据库，对2018年至2022年间接受甲状腺手术的成年患者进行了一项回顾性队列研究。患者按是否使用术中神经监测进行分层。主要结局是术后气道损害，定义为延长通气（术后>48小时）和计划外术后再插管。次要结局包括喉返神经损伤、颈部血肿和肺炎。进行单变量和多变量分析，以确定与气道并发症独立相关的因素。
结果： 共纳入33,211例患者；23,757例（71.5%）在术中神经监测下接受手术。在单变量分析中，接受术中神经监测的患者术后气道损害发生率低于未监测者（0.4% vs 0.6%，P = .048）。尽管个体气道事件不常见且组间无显著差异，但术中神经监测与较低的喉返神经损伤发生率相关（5.7% vs 6.5%，P < .001）。在多变量分析中，术前呼吸困难、美国麻醉医师协会分级III级或更高、晚期肿瘤分期（T3-4）、慢性阻塞性肺疾病、年龄较大和手术时间较长与术后气道损害风险增加独立相关。在调整患者、肿瘤和手术因素后，术中神经监测仍与术后气道损害风险降低独立相关（比值比，0.64；P = .04）。在美国麻醉医师协会分级III级或更高患者的亚组分析中，喉返神经监测与较低的调整后术后气道损害比值比相关（调整后比值比，0.68），与总体队列中的发现一致，尽管估计值受低事件率限制。
结论： 在这个大型全国性队列中，术中喉返神经监测与甲状腺切除术后术后气道并发症减少独立相关。气道风险主要由患者合并症、生理储备、疾病严重程度和手术复杂性驱动。这些发现表明，喉返神经监测可能对高风险手术患者获益最大。

英文摘要

BACKGROUND: Recurrent laryngeal nerve injury during thyroid surgery can result in clinically significant airway compromise, particularly in patients with limited pulmonary reserve. Although intraoperative nerve monitoring is widely used to reduce nerve injury, its association with postoperative airway complications has not been well characterized. This study evaluates trends in intraoperative nerve monitoring and its relationship with postoperative airway compromise after thyroidectomy.
METHODS: We performed a retrospective cohort study of adult patients who underwent thyroid surgery between 2018 and 2022 using the National Surgical Quality Improvement Program database. Patients were stratified by use of intraoperative nerve monitoring. The primary outcome was postoperative airway compromise, defined as prolonged ventilation (>48 hours postoperatively) and unplanned postoperative reintubation. Secondary outcomes included recurrent laryngeal nerve injury, neck hematoma, and pneumonia. Univariate and multivariate analyses were performed to identify factors independently associated with airway complications.
RESULTS: A total of 33,211 patients were included; 23,757 (71.5%) underwent surgery with intraoperative nerve monitoring. On univariate analysis, patients undergoing intraoperative nerve monitoring had lower rates of postoperative airway compromise compared with those without monitoring (0.4% vs 0.6%, P = .048). Although individual airway events were infrequent and did not differ significantly between groups, intraoperative nerve monitoring was associated with a lower rate of recurrent laryngeal nerve injury (5.7% vs 6.5%, P < .001). On multivariable analysis, preoperative dyspnea, American Society of Anesthesiologists class III or higher, advanced tumor stage (T3-4), chronic obstructive pulmonary disease, older age, and longer operative time were independently associated with increased odds of postoperative airway compromise. After adjustment for patient, tumor, and operative factors, intraoperative nerve monitoring remained independently associated with decreased odds of postoperative airway compromise (odds ratio, 0.64; P = .04). In subgroup analysis of patients with American Society of Anesthesiologists class III or higher, recurrent laryngeal nerve monitoring was associated with lower adjusted odds of postoperative airway compromise (adjusted odds ratio, 0.68), consistent with findings in the overall cohort, though estimates were limited by low event rates.
CONCLUSION: In this large national cohort, intraoperative recurrent laryngeal monitoring was independently associated with reduced postoperative airway complications after thyroidectomy. Airway risk was driven primarily by patient comorbidity, physiologic reserve, disease severity, and operative complexity. These findings suggest that recurrent laryngeal nerve monitoring may be of greatest benefit in high-risk surgical patients.