Roxanne Luo1, Grace S. Li2, Gianlorenzo Dionigi3
1Southern Medical University, Guangzhou, China; 2AOT Editorial Office, AME Publishing Company; 1Department of Human Pathology in Adulthood and Childhood ''G. Barresi’', University Hospital “G. Martino”, University of Messina, Messina, Italy.
Correspondence to: Grace S. Li. AOT Editorial Office, AME Publishing Company. Email: aot@amegroups.com.
Editor's Note: On the weekend of 19–20 March 2022, the 7th Chinese Research Hospital Association Thyroid Disease Summit and the 3rd Symposium on Endoscopic Thyroid Surgery of Shangdu Medical Forum of Henan Provincial Health Science and Technology Society were successfully held online. The summit not only allowed greater insights into the standardized treatment of thyroid cancer but also provided an opportunity for sharing new concepts and new technology in this field. Prof. Gianlorenzo Dionigi, full professor of surgery at the University of Milan (Italy), gave a keynote speech titled “Injury and Repair of Recurrent Laryngeal Nerve in Thyroid Surgery” and was interviewed the editorial office of Annals of Thyroid, AME Publishing Company after the meeting.
AOT: Could you please give some comments on the application of neuromonitoring technology in Italy and China?
Prof. Dionigi: Firstly, I really believe that the standards of use of neuromonitoring technology are extremely high in both China and in Italy. There are intermittent and continuous use. Furthermore, proper use of this technology with standardized fashion and the guidance, for example, V1 and V2 stimulation, L1 and L2 stimulation, and stimulation of the superior nerve. Secondly, I think both in China and in Italy, there are great collaboration on neuromonitoring and related research on it.
AOT: What is the biggest challenge in repairing the recurrent laryngeal nerve injury?
Prof. Dionigi: The surgery of repairing the recurrent laryngeal nerve injury is very challenging. Firstly, this event is quite rare. Because injuries of the recurrent laryngeal nerve are most commonly traction injury, compression injury or thermal injury, it is quite rare to repair an injured recurrent laryngeal nerve in the case of the section. The second issue is that you need a very skillful maneuver and techniques to recompose the injured nerve in both sides. Finally, it is challenging to follow up the patient and to know whether the repair we did on the recurrent laryngeal nerve is functioning.
AOT: What do you think needs to be improved in the current application of neuromonitoring technology in thyroid surgery?
Prof. Dionigi: There are two issues, both of them related to companies. The first is about the cost. The cost of continuous mode of application of neuromonitoring technology is very high. Thus, I hope that in the near future, more competitions between companies will decrease the cost of this technology. The second issue is about simplification of this technology. For the continuous mode of application, we need to simplify the technique, for example, maybe without opening the carotid sheath and putting the continuous probe on the back of the nerve.
AOT: What changes will the maturity of neuromonitoring technology bring to neurophysiology?
Prof. Dionigi: There is great maturity in both surgeons and neuromonitoring technology. Both Chinese surgeons and Italian surgeons know very well about this technology. I want to talk about the maturity of neurophysiology and neuropathology. I think that the future direction of the research is to understand the relationship between vagal nerve stimulation, recurrent nerve stimulation and superior nerve stimulation. And we should also understand the outcomes are not only about vocal cord movement, but also about the quality of voice; not only about the swallowing disorders, but also about breathing disorders. I think these will be challenges of the future about neurophysiology and neuropathology of stimulation. We should pay attention to all these nerves, quality of voice, and the vocal cord injury.
AOT: How would you see the future of neuromonitoring technology in the diagnosis and treatment of thyroid diseases?
Prof. Dionigi: The real reason why we're using neuromonitoring is that we cannot predict the variability of the recurrent laryngeal nerve of a patient. Therefore, I hope that in the future, we can predict the variability of the recurrent laryngeal nerve. Only with the EMG data of the amplitude of V1, we can predict the difficulty of the dissection.
AOT: In your opinion, how can we strengthen the international cooperation of neuromonitoring technology in thyroid surgery?
Prof. Dionigi: This is a very important question. I think that the future direction of this collaboration is to build a platform to gather all the EMG data from continuous neuromonitoring or intermittent neuromonitoring from different centers in China and in Italy. All the EMG data are from patients we operate. We should build a network for continuous neuromonitoring or intermittent neuromonitoring. With this kind of platform or network, we can give important answers to neurophysiology and neuropathology for the future of our patient.
Expert introduction
Figure 1 Photo of Prof. Gianlorenzo Dionigi.
Gianlorenzo Dionigi (Figure 1) is Professor of Surgery since 2013. In 2012 he has been appointed for Chairman of the 1st Division of Surgery, University Hospital in Varese, Italy. He is founder and head of the Research Center for Endocrine Surgery at the Department of Surgical Sciences and Human Morphology, School of Medicine, University of Insubria in Varese (Italy) since 2004.
Prof. Dionigi has experience with neural monitoring starting in 2004 of approximately 5,000 cases of intermitted and 500 of continuous IONM. Prof. Dionigi published peer-reviewed publications and book chapters on IONM both on guidelines, technique, experimental, clinical research, cost analysis and learning curve for IONM. He has led IONM surgical presentations and live “hands-on” surgeries to thyroid surgical units in Asia, North America, South America, Middle East and Europe.
Acknowledgments
Funding: None.
Footnote
Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Thyroid for the series “Meet the Professor”. The article did not undergo external peer review.
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form. The series “Meet the Professor” was commissioned by the editorial office without any funding or sponsorship. RL reports that he was an intern editor of AME Publishing Company from February 17, 2022 to April 17, 2022. GL reports that she is a full employee of AME Publishing Company. GD declares no conflicts of interest.
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