Introduction: The benefit of intra-operative nerve monitoring (IONM) and vessel sealant devices (VSD) use in thyroidectomy procedures is highly controversial due to both the high costs and the lack of statistically significant data supporting their use. Using a large national cohort, we analyzed the utility of these technologies.
Method: We performed an analysis on the 2016 Thyroidectomy-targeted National Surgical Quality Improvement Project (NSQIP) Participant Use Data File. Uncomplicated and complicated cohorts were defined based upon surgical indication (uncomplicated: “single nodule or neoplasm/single nodule goiter”; complicated: all other indications). Using multivariate analyses adjusting for demographics and comorbidities, we examined the extent to which technology use (IONM or VSD) was associated with morbidities (recurrent laryngeal nerve damage [RLND] and hematoma), operation time (OT), and length of hospital stay (LOHS).
Results: Of the 5,871 patients identified, 5,312 (90.48%) were included in the IONM-specific analyses (uncomplicated: 1,946 [36.63%]; complicated: 3,366 [63.37%]), and 5,271 (89.78%) were included in the VSD-specific analyses (uncomplicated: 1,950 [36.99%]; complicated: 3,321 [63.01%]). As shown in FIgure 1, in uncomplicated cases, neither IONM nor VSD use had any effect on morbidity. In complicated cases, IONM use was associated with a decreased likelihood of RLN damage (aOR: 0.689; 95% CI: 0.518-0.916; p=0.010), while VSD use was associated with a decreased likelihood in POH formation (aOR: 0.559; 95% CI: 0.317-0.986; p=0.045). IONM significantly increased operation time in both uncomplicated (p<0.001) and complicated (p<0.001) cohorts; conversely multivariate analysis revealed that VSD decreased operation time in complicated cases by 6.42 minutes (95% CI: 1.1-11.73 minutes; p=0.018). Furthermore, IONM had no effect on post-operative hospital stay in multivariate analysis, while VSD decreased stay by 0.299 days (95% CI: 0.162-0.435 days; p<0.001) in complicated cases. Lastly, OTO-HNS use IONM more often than GS, while GS employ VSDs more frequently than OTO-HNS.
Conclusions: Our analysis demonstrates that in uncomplicated cases, neither IONM nor VSD result in a statistically significant benefit. They may also increase operation time, decreasing physician productivity, and increase healthcare costs. Hence, in uncomplicated cases, OTO-HNS may be overutilizing IONM, while GS may be overutilizing VSDs. In complicated cases, IONM seems to afford a protective effect against RLN damage; thus, its use may be considered in such settings. While the effect of VSDs on POH in complicated cases is less impactful, VSDs seem to decrease operation time and post-operative stay; hence, VSDs may provide financial benefit.