The triad of non-recurrent laryngeal nerve; three associated predicting variants in the era of nerve monitoring: A case report

INTRODUCTION AND IMPORTANCE

The prediction and early identification of non-recurrent laryngeal nerve (RLN) may minimize risk of injury. It could be associated with other coincident variants that predict non-RLN, leading to its proper identification.

CASE PRESENTATION

A patient with multinodular goiter underwent total thyroidectomy under intraoperative neuromonitoring (IONM) guidance. Preoperative thoracic computerized tomography (CT) scan/angiography revealed aberrant right subclavian artery (ARSA). During thyroid surgery, the vagus nerve (VN) was identified in the neurovascular bundle. An anatomic variation of the VN was observed, as it was medially placed in relation to the common carotid artery (CCA). Pre-dissection electrophysiological stimulus of the VN (V1) was negative. Thus, a right non-RLN was identified with careful surgical dissection. The branching point of the non-RLN on the VN was identified, and non-RLN was fully exposed until the laryngeal entry. IONM revealed that V1 signal was negative if derived distal to the non-RLN separation, and positive if derived proximal to the non-RLN separation.

CLINICAL DISCUSSION

ARSA detected by preoperative CT scan is associated with non-RLN. The medial course of the VN in relation to the CCA was found as a coincident anatomic variant with the non-RLN. Absence of pre-dissection V1 signal by IONM was an electrophysiological variant associated with the non-RLN.

CONCLUSION

ARSA is a reliable variant for predicting the non-RLN. VN medial to the CCA and absence of electrophysiological V1 signal could precisely predict the non-RLN. Therefore, the coincidence of three anatomical and electrophysiological variants with non-RLN could lead to the prediction of non-RLN.

Intraoperative Monitoring and Preservation of Anatomic Integrity of Palsied Recurrent Laryngeal Nerve is Extremely Meaningful During Redo Thyroid Surgery

Redo thyroid surgery on patients with unilateral recurrent laryngeal nerve (RLN) palsy certainly poses a great surgical challenge. We present a case of a patient with unilateral vocal cord (VC) palsy who underwent redo thyroid surgery under intraoperative neuromonitoring. The patient's normal speaking voice was maintained after the primary surgery, even though preoperative laryngoscopy showed an immobile right VC with a normal structure. During reoperation, surgical exploration revealed the anatomical integrity of palsied RLN with extralaryngeal terminal bifurcation. The electrophysiological stimulation of the vagus nerve and palsied RLN generated wave amplitudes (V1: 242, R1: 347, R2: 352 and V2: 152 µV). Despite positive amplitudes, postoperative laryngoscopy confirmed RLN palsy and corresponding VC paralysis but preserved the structure of the immobile VC. Even palsied RLN should be monitored during redo surgery. A positive signal delineates at least partial neural transmission despite VC palsy. The preservation of anatomical integrity of palsied RLN for eventual partial conductivity may be vital in preserving the normal structure of VC and maintaining the patient's voice despite its immobility. Key Words: Surgery, Redo thyroidectomy, Recurrent laryngeal nerve injury, Vocal cord palsy.

Anatomical and functional identification of the external branch of the superior laryngeal nerve: classification based on morphology and electrophysiological monitoring

BACKGROUND

Motor function of the external branch of superior laryngeal nerve (EBSLN) is vital for voice quality. We studied the rate of EBSLN identification and integrity in the era of intraoperative neuromonitoring (IONM).

METHODS

Anatomic and functional identification of 515 EBSLNs-at-risk was performed under the guidance of IONM that motor integrity was electrophysiologically checked. The functional integrity was assessed with crico-thyroid muscle (CTM) twitches and/or recordable waveform amplitude. We tried to establish the systematic classification of EBSLN identification and integrity.

RESULTS

Visual, electrophysiological and total identification rates were 64.3%, 31.6% and 95.9%, respectively. We could identify 4.1% of EBSLNs neither anatomically nor electrophysiologically. We recorded CTM twitches alone or both CTM twitches and wave amplitude in 203(39.4%) and 291(56.5%) branches respectively. Identification features of EBSLNs were systematically classified under three main types: Visualized-monitored (1), non-visualized-monitored (2), unidentified (3), and electrophysiological integrity of EBSLNs under two subtypes: CTM twitches alone (a) and CTM twitches and wave amplitude (b).

CONCLUSION

Dedicated thyroid surgeon could visually identify EBSLNs. IONM contribution significantly increases the identification rate. Systematic classification of identification and electrophysiological integrity of EBSLNs may increase comprehensive knowledge about its motor function that is crucial for complication-free thyroidectomy.

Anatomy and motor function of extra-laryngeal branching patterns of the recurrent laryngeal nerve; an electrophysiological study of 1001 nerves at risk

INTRODUCTION

Safe thyroid surgery depends on a deep knowledge of human neck anatomy, including the recurrent laryngeal nerve (RLN). Anatomic variations such as extra-laryngeal terminal branching (ETB) are common.

PATIENTS AND METHODS

We studied the ETB pattern of 1001 RLNs at risk in 596 patients. We identified and exposed the location of division points on the cervical part of bifid RLN. The function of nerve branches was assessed through intraoperative nerve monitoring (IONM).

RESULTS

Bifid RLNs was identified in 39.6% of patients. The nerve-based prevalence of ETB was 28.5%. The prevalence of ETB for the right and left RLN was 21.8% and 35.5%, respectively (p < 0.001). The location of the division point was found in the middle, distal, and proximal segments in 48.8%, 33.3%, and 18% of bifid RLNs, respectively. Electrophysiological monitoring revealed motor functions in all anterior and in 7% of posterior branches. The rate of injury was 0.4%, and 1.1% in single trunk and bifid nerves, respectively (p = 0.360), and 3.9% in nerves with proximal branching (p = 0.084).

CONCLUSIONS

The ETB prevalence is high and showing division points in different cervical segments of the RLN. All anterior branches and some posterior branches contain motor fibers. Knowledge and awareness of these anatomic and functional variations are mandatory for every thyroid surgeon to avoid misidentification and misinterpretation of human RLN anatomy.

Targeted axillary biopsy and sentinel lymph node biopsy for axillary restaging after neoadjuvant chemotherapy

Purpose

Accurate restaging of the axilla after neoadjuvant chemotherapy (NAC) is an important issue to ensure deescalating axillary surgery in patients with initial metastatic nodes. We aimed to present our results of targeted axillary biopsy (TAB) combined with sentinel lymph node biopsy (SLNB) for axillary restaging after NAC.

Methods

In 64 breast cancer patients who underwent NAC, biopsy-proven positive nodes were marked with clips before NAC, and ultrasound-guided wire localization of clip-marked nodes was performed after NAC. Patients underwent TAB and SLNB for post-NAC axilla restaging.

Results

Identification rates of post-NAC TAB and SLNB were 98.4% and 87.5%, respectively (P = 0.033). Histopathology revealed a nodal pathologic complete response (pCR) rate of 47% in which axillary lymph node dissection (ALND) was avoided. TAB alone and SLNB alone detected residual disease in 29 (85.3%) and 20 (58.8%) patients (P = 0.029), respectively. Whereas rates of up to 97% had been achieved with a combination of TAB and SLNB. The pCR rates after NAC were 64.3% for human epidermal growth factor receptor 2 positive and triple-negative tumors and 13.6% in luminal tumors (P = 0.0002).

Conclusion

Pathologic analysis following TAB combined with SLNB revealed the pCR rates to NAC in a considerable number of patients that provided de-escalation of axillary surgery. A combination of SLNB and TAB was found to be an accurate procedure in establishing residual nodal disease. This combined procedure in patients with initially positive nodes was a reliable method for post-NAC axillary restaging.

Separate thyrothymic thyroid remnant; clinically crucial anatomic variation

Purpose

The anatomical variations of the thyroid gland including separate thyroidal remnant at the thyrothymic area are of significance during thyroid surgery for “total” thyroidectomy, and for recurrent goitre. In the present study, we aimed to detect the separate rests of thyroidal tissue in the thyrothymic region.

Methods

The thyrothymic region was explored for identification, dissection, and excision of separate thyroidal remnants in 134 patients who underwent primary thyroid surgery. In this series, we studied the incidence and anatomical features of the thyrothymic remnant and its relation with other embryologic remnants.

Results

Overall, 222 sides of the thyroid were explored in this study. An entirely separate thyrothymic remnant of the thyroid was identified and excised in 8 of 134 patients (6%). Mean size of removed remnants was 36.4 mm (range, 29–45 mm) in diameter. The incidences of pyramidal lobe (PL) and Zuckerkandl's tubercle (ZT) were 71.6% and 59.7%, respectively. The thyrothymic remnant coexisted with PLs in 4 patients. Four patients had all 3 embryologic remnants: thyrothymic remnant, PLs, and ZTs.

Conclusion

An entirely separate thyroidal remnant at the thyrothymic area is not a rare variation. The considerably large size of a remnant may threaten the completeness of thyroidectomy and may result in recurrence if it is left behind after thyroid surgery. Awareness, identification, and excision of the separate remnant at the thyrothymic area and the other embryologic remnants are critical for ensuring completeness of thyroidectomy and preventing recurrences.

Video-endoscopic Tension-free Groin Hernia Repair via Total Extraperitoneal Approach

Introduction

Tension-free repair of groin hernias with synthetic material by video-endoscopic surgery is a widely accepted method that is performed by various approaches. We aim to present our results of video-endoscopic tension-free repair of groin hernias via the total extraperitoneal (TEP) approach.

Methods

Between September 2016 and December 2018, 124 patients with groin hernias underwent tension-free repair using prolene mesh by video-endoscopic surgery via the TEP approach. This is a retrospective analysis of 110 (88.7%) male and 14 (11.3%) female patients with a mean age of 48.1 years. Groin hernia types, locations of hernias, intraoperative and postoperative complications, results of the mean 24-month follow-up, and recurrence rate were reported.

Results

A total of 134 hernias were repaired in 124 patients who had 53 (42.7%) right, 61 (49.2%) left, and 10 (8.1%) bilateral groin hernias. The most common hernia type was an indirect inguinal hernia in 83/134 (62%) groin hernias. A total of 119 (88.8%) and 15 (11.2%) hernias were primary and recurrent, respectively. Seroma was detected in two (1.6%) patients in the early postoperative period. The mean duration of hospital stay was 1.4 (1-3) days. During the follow-up period, hernia recurrence was determined in three (2.4%) patients. Hernia recurrence was detected among patients who were operated on during the first half of the study.

Conclusion

Tension-free repair of groin hernias by video-endoscopic technique via the TEP approach can be performed with very low complication and recurrence rates. The success of the TEP approach increases parallel to increasing surgical experience. The results of hernia repair via the TEP approach are highly satisfactory and encouraging, especially when attention is paid to proper patient selection during the learning curve period.

Inverse 'D' incision technique in treatment of pilonidal sinus disease; excision with minimal tissue loss, closure without tension and lateral location of the suture line

Purpose

Surgical excision is the preferred treatment modality for sacrococcygeal pilonidal sinus (PS). Notably, the desirable features of an ideal surgical intervention are excision with minimal tissue loss, closure without tension, and a lateral suture line. The present study aimed to investigate early outcomes of surgical excision through the inverse D (ᗡ) incision based on tissue loss, wound tension, and suture line location.

Methods

This prospective study was comprised of 80 patients with PS in whom excision of PS was performed through the ‘ᗡ’ incision to minimize tissue loss with a tensionless primary surgical wound closure. The suture line was located laterally in all patients. Early and late postoperative complications, duration of hospital stay, return to work, and recurrence rates were investigated. The mean duration of the follow-up period was 36 months.

Results

Sixty-three patients (78.8%) were male. PS in all patients was surgically removed by subcutaneous excision through a ‘ᗡ’ incision. Laterally placed surgical wounds were closed primarily with interrupted vertical mattress sutures. No general complications were encountered. Five patients (6.3%) experienced early postoperative surgical site complications. On average, the duration of hospital stay and return to work were 2.4 days and 3.8 days, respectively. Recurrence was seen in 1 case (1.3%) during the follow-up period. Satisfaction score was high in 83.8% of patients.

Conclusion

The method of sinus excision using the ‘ᗡ’ incision with a primary suture facilitates excision with minimal tissue loss and closure without tension with an off-midline suture. It is both a simple and effective surgical technique for the treatment of sacrococcygeal PS.

Recurrent Goiter Presented with Marine-Lenhart Syndrome 27 Years After Initial Surgery

Marine-Lenhart syndrome (MLS), a rare form of hyperthyroidism, is the coexistence of Graves' disease (GD) and autonomously functioning thyroid nodule(s). Herein, we report a case of recurrent goiter presented with MLS. A 52-year-old man presented at our department with recurrent goiter, exophthalmia, and symptoms of hyperthyroidism. In addition to clinical signs and thyroid eye disease, suppressed thyroid-stimulating hormone (TSH) and high free thyroxine (FT4) and autoantibody levels lead to the diagnosis of GD. Thyroid ultrasound and nuclear scan showed the presence of a large, solid, and functioning "hot" nodule in the right lobe. Thus, in recurrent goiter cases, the diagnosis was MLS, wherein autoimmune hyperthyroidism was associated with the functioning nodule. Following medical control with methimazole, the patient underwent total excision of recurrent goiter. Levothyroxine (LT4) therapy was prescribed to maintain normal serum hormone levels. At follow-up, the gradual decrease in serum levels of autoantibody was detected. This patient is a very rare example of MLS that occurs in recurrent goiter case. Clinical signs, serum hormone and autoantibody levels, thyroid ultrasound, and nuclear scan establish the correct diagnosis of this specific and rare disorder. Thyroid surgery and total removal of glandular tissue provides definitive control of hyperthyroidism and obviates autoimmune reaction.

Visual and electrophysiological identification of the external branch of superior laryngeal nerve in redo thyroid surgery compared with primary thyroid surgery

Purpose

Thyroid reoperations are surgically challenging because of significant anatomical variance. Visual and functional identification of the external branch of the superior laryngeal nerve (EBSLN) were studied in 2 groups of patients who underwent primary and redo thyroid surgery.

Methods

This study was conducted on 200 patients: 100 patients with redo and 100 patients with primary thyroid surgery. In addition to visual identification, nerve branches were functionally identified by intraoperative nerve monitoring (IONM). Visual, functional, and total identification rates of the EBSLN in both primary and redo surgery were determined and compared between the 2 groups.

Results

We attempted to identify 138 and 170 EBSLNs at risk in redo and primary surgery, respectively. Visual identification rates were 65.3% and 30.4% (P < 0.001) in primary and redo surgery groups, respectively. In total, 164 (96.5%) and 97 EBSLNs (70.3%) were identified in primary and redo surgery, respectively (P < 0.001), including the use of IONM. In primary surgery group, 53 nonvisualized EBSLNs of 164 identified nerves (32.3%) were determined by IONM alone. In redo surgery group, 55 of 97 identified nerves (56.7%) were determined by IONM alone (P < 0.001).

Conclusion

Both visual and total identification rates of the EBSLN are significantly decreased in reoperative thyroidectomy. IONM increases the total identification rate of the EBSLN in primary and redo thyroid surgery. Electrophysiological monitoring makes a substantial contribution to the identification of the EBSLN both in primary and especially in redo thyroid surgery.

Nonrecurrent Laryngeal Nerve: Precise Detection by Electrophysiological Nerve Monitoring

Complication-free thyroid surgery is mainly based on the motor integrity of the recurrent laryngeal nerve (RLN). The nonrecurrent laryngeal nerve (non-RLN) is a rare anatomical variation that may increase the risk of vocal cord palsy. Early identification and exposure of the non-RLN may minimize injury risk. This case report presents functional detection of the non-RLN by intraoperative neuromonitoring (IONM).

Total thyroidectomy was performed under the guidance of IONM on a patient with bulky multinodular goiter. The first step of IONM is pre-dissection stimulation (V1) of the right vagus nerve (VN). V1 at a standard distal point was negative as indicated by the absence of both a sound signal and wave amplitude. The right VN was then followed proximally and dissected under the guidance of IONM. This dissection established a proximal point creating a positive signal that led us to determine the separation point of the non-RLN. The right non-RLN arising from the proximal VN was identified and fully exposed until laryngeal entry. Its motor integrity was confirmed with post-dissection signals. The left RLN was identified at the usual anatomical position that was fully exposed and preserved during thyroid surgery. Total thyroidectomy was then accomplished without complication. The postoperative period was uneventful. Postoperative laryngoscopy confirmed normal vocal cord function.

The non-RLN is accurately identified by IONM during the early part of the thyroid surgery. The absence of a distal VN signal is predictive of the non-RLN. IONM-guided proximal dissection of the right VN leads to the identification of the non-RLN. The prediction of the non-RLN by the absence of a VN signal during an early stage of surgery may prevent or minimize the risk of nerve injury.

Motor Interconnections Between Superior and Inferior Laryngeal Nerves

Introduction Anatomical studies on human cadavers have established anastomoses between laryngeal nerves. However, we need to functionally identify motor communication via these anastomoses between the recurrent laryngeal nerve (RLN) and the external branch of the superior laryngeal nerve (EBSLN) in living bodies. We aim to establish motor interconnections using intraoperative nerve monitoring (IONM). Methods IONM of 112 EBSLNs and RLNs in 62 thyroidectomy cases was used to establish motor functions of laryngeal nerves. Electrophysiological parameters were recorded, and cricothyroid muscle (CTM) contraction was observed after stimulation of laryngeal nerves. Results Eighty (71.4%) EBSLNs were visually identified, and 109 (97.3%) EBSLNs were functionally identified with CTM contraction. Stimulation of 74 (67.9%) EBSLNs induced contraction of laryngeal muscles and generated wave amplitude from intrinsic laryngeal musculature. The stimulation of the RLN induced CTM contraction in 65 (58%) of the 112 muscles. The mean conductivity powers of the EBSLN and of the RLN to intrinsic laryngeal musculature were calculated as 231.3 µV and 1354.5 µV, respectively. Conclusion Recordable waveform amplitude with EBSLN stimulation yielded motor relations between laryngeal nerves. CTM contraction after stimulation of the RLN confirmed these relations. These results of IONM established motor interconnections between superior and inferior laryngeal nerves in the majority of patients. The EBSLN may have an effect on motor innervations for intrinsic laryngeal muscles via motor interconnections.

Effects of Erdosteine on Experimental Acute Pancreatitis Model

OBJECTIVE

To create acute pancreatitis condition experimentally in rats using cerulein, and to reveal histopathological effects in pancreatic tissue with erdosteine.

STUDY DESIGN

An experimental study.

PLACE AND DURATION OF STUDY

Department of General Surgery, Duzce University, Turkey, from June to October 2014.

METHODOLOGY

Thirty male Wistar albino rats were divided into three groups. No procedures were applied to Group 1. The rats in Group 2 and Group 3 were injected cerulein, to establish an experimental pancreatitis model and the blood amylase and lipase values were examined. The rats in Group 3 were given 10 mg/kg erdosteine. This treatment was continued for another 2 days and the rats were sacrificed. The pancreatic tissues were examined histopathologically for edema, inflammation, acinar necrosis, fat necrosis, and vacuolization.

RESULTS

The lipase and amylase values and the histopathological examination of pancreatic tissues evidenced that the experimental acute pancreatitis model was established and edema, inflammation, acinar necrosis, fat necrosis, and vacuolization were observed in the pancreatic tissues. The statistical results suggest that erdosteine can decrease the edema, inflammation, acinar necrosis, fat necrosis and vacuolization scores in the tissues.

CONCLUSION

The severity of acute pancreatitis, induced by cerulein in rats, is reduced with the use of erdosteine.

Intraoperative Monitoring of External Branch of the Superior Laryngeal Nerve: Functional Identification, Motor Integrity, and its Role on Vocal Cord Function

PURPOSE

Beside recurrent laryngeal nerve (RLN), protection of the external branch of the superior laryngeal nerve (EBSLN) is required for complication-free thyroid surgery. This study investigates the contribution of intraoperative neuromonitoring (IONM) to identification and motor integrity of the EBSLN.

METHODS

This prospective study was performed on 245 EBSLNs in 147 patients with thyroid surgery. The rate of visual identification, contribution of IONM to functional localization, the rate and levels of recordable waveform amplitude from vocal cord (VC) movement were determined during surgery.

RESULTS

164 (66.9%) EBSLNs were visually identified and additional 74 branches were functionally identified by IONM. Additional identification rate of IONM was 30.2%. Seven (2.9%) EBSLNs could not be identified during surgery. Cricothyroid muscle (CTM) twitch established functional integrity in 97.1% of EBSLNs. Electrophysiological stimulation of 151 (63.4%) EBSLNs created waveform amplitude >100 µV that mean amplitude level was calculated as 186 µV, and an amplitude >300 µV was recorded in 19 of 151 (12.6%) EBSLNs.

CONCLUSIONS

In addition to visual identification, surgeons can functionally localize the EBSLN with the assistance of IONM that CTM twitch is a reliable evience for functional integrity of the EBSLN. In the majority of patients, stimulation of the EBSLN creates recordable waveform amplitude thus the EBSLN appears to be a second source of motor innervations for intrinsic laryngeal muscles.

Toxic Adenoma in a Patient with Thyroid Hemiagenesis

Thyroid hemiagenesis (TH) is a rare congenital anomaly that is usually asymptomatic. Functional disorders of the thyroid make the patient symptomatic. TH is usually and incidentally established during evaluation of patients with symptomatic thyroid pathology. We report the case of a patient of TH who became symptomatic with hyperactivity of the gland. The patient presented with signs and symptoms of thyrotoxicosis. Physical examination revealed asymmetric nodular goiter at the right lobe. Biochemical analysis established the diagnosis of hyperthyroidism. Ultrasound of the thyroid gland revealed the absence of the left lobe and a large, solitary hypoechoic solid nodule in the right lobe. Nuclear scan showed the absence of the left lobe and revealed a large, autonomous solitary nodule in the right lobe. The diagnosis was a toxic adenoma. After medical control of hyperthyroidism, the patient was surgically treated with hemithyroidectomy. We prescribed postoperative replacement medication with L-thyroxin. Hyperthyroidism makes TH cases symptomatic. Thyroid ultrasound and scintigraphy incidentally discover agenesis of one lobe during evaluation of thyrotoxicosis. Hemithyroidectomy, including the autonomous nodule, is the procedure of choice for patients with toxic adenoma. Hemithyroidectomy in TH cases technically becomes a total thyroidectomy with a need for postoperative thyroid replacement therapy.

Coexistence of Right Nonrecurrent Nerve and Bifurcated Recurrent Laryngeal Nerve Pointed by Zuckerkandl's Tubercle

The recurrent laryngeal nerve (RLN) has many anatomical variations and various relations with adjacent structures. Identification and total exposure of the cervical part of the RLN was performed during operations on the thyroid gland. An extremely rare anatomical variation of the nerve was encountered during the surgical procedure. Coexistence of both right RLN and non-RLN was observed in one patient surgically treated with total thyroidectomy. We first exposed the right RLN with an extralaryngeal terminal bifurcation at its usual position. Thereafter, we also identified an ipsilateral non-RLN joining the anterior branch of the RLN just before laryngeal entry. A Zuckerkandl's tubercle has pointed out the junction of the two nerves. In this period, the incidence of coexistence of non-RLN and RLN was 0.2% in our series. A non-recurrent course is a rare anatomical variation of the inferior laryngeal nerve. The coexistence of both non-RLN and RLN is an extremely rare anatomical finding which should be taken into account during thyroid surgery.

Location of motor fibers within branches of the recurrent laryngeal nerve with extralaryngeal terminal bifurcation; Functional identification by intraoperative neuromonitoring

BACKGROUND

Extralaryngeal terminal bifurcation (ETB) of the recurrent laryngeal nerve (RLN) is an anatomic variation that threatens the safety of thyroid operation. Therefore, it is important to identify motor function in nerve branches to preserve appropriate motor activity. Intraoperative neuromonitoring (IONM) is an accepted procedure to identify motor function of the RLN.

METHODS

We established the operative anatomy of RLNs with ETB in 47 patients. The main trunk, bifurcation point, and the branches were identified and exposed completely during thyroid operation. The location of motor fibers within nerve branches was investigated by identifying motor function via IONM. Wave amplitudes were recorded after electrophysiologic stimulation.

RESULTS

A total of 61 RLNs had ETBs with anterior and posterior branches. Bifurcation occurred early along the pre-arterial (proximal) segment in 13% of bifid RLNs. IONM showed motor function in all anterior branches. IONM identified motor activity in 4 (18%) posterior branches of 22 right, 3 (8%) posterior branches of 39 left, and 7 (12%) posterior branches of all 61 RLNs with ETB. The rate of recorded wave amplitudes of motor function in seven posterior branches was between 14 and 78% of those of corresponding anterior branches.

CONCLUSION

In the RLN, the anterior branch always and the posterior branch uncommonly contain motor fibers. Wave amplitude analysis showed that motor function in the posterior branch is weaker than that in the anterior branch. On the basis of the location of motor fibers in both branches, total exposure and preservation of anatomy and function of all branches of the RLN is mandatory for complication-free thyroid surgery. Electrophysiologic testing may be as an important adjunct to visualization of the nerve with anatomic variation.

Preoperative assessment of the axilla by surgeon performed ultrasound and cytology in patients with breast cancer

BACKGROUND

Preoperative evaluation of the axilla, an important prognostic determinant for patients with invasive breast cancer, is achieved by non- or minimally invasive methods to avoid the potential hazards of operative intervention. The aim of this study was to determine statistical power of axillary ultrasound (US) and US-guided fine needle aspiration cytology (FNAC) for evaluating axillary status.

METHODS

Axillary lymph nodes were imaged for malignant involvement by high resolution US in 93 breast cancer patients with clinically negative axilla. Cytological samples were obtained by US-guided FNAC from image-suspicious lymph nodes. Cytology-positive patients directly underwent axillary lymph node dissection (ALND). Patients with US and/or cytology-negative axilla underwent sentinel lymph node biopsy (SLNB). Using statistical analysis, US findings and US combined with FNAC were compared with SLNB and final pathology to measure performance.

RESULTS

US was suspicious for metastasis in 38 patients (41%), of whom 16 (42%) were cytology-positive. Axilla was positive in 36/93 patients (38.7%). Sixteen patients with positive FNAC directly underwent ALND. SLNB and/or final pathology was positive in 13/55 patients (23.7%) with negative US (false negative of US) and in 7/22 patients (31.8%) with positive US but negative cytology (false negative of FNAC). SLNB and/or final pathology was negative in 15/38 patients (39.5%) with positive US (false positive of US). Sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) of US alone were 63.8%, 73.6%, 69.8%, 60.5% and 76.3%, respectively, and 69.6%,100%, 81.6%, 100% and 68.1%, respectively, for US combined with FNAC.

CONCLUSION

Statistical measures of the US alone did not achieve a satisfactory value for excluding operative biopsy. US-negative and US-positive but cytology-negative cases still require SLNB for accurate evaluation of axillary status. On the other hand, US-guided positive cytology can obviate SLNB proceeding directly to ALND and avoiding frozen section of sentinel node(s).

Surgical anatomy of bilateral extralaryngeal bifurcation of the recurrent laryngeal nerve: similarities and differences between both sides

Background:

Anatomical variations of the recurrent laryngeal nerve (RLN) such as extralaryngeal terminal bifurcation is an important risk for its motor function.

Aims:

The objective is to study surgical anatomy of bilateral bifurcation of the RLNs in order to decrease risk of vocal cord palsy in patients with bifurcated nerves.

Materials and Methods:

Surgical anatomy including terminal bifurcation was established in 292 RLNs of 146 patients. We included patients with bilateral bifurcation of RLN in this study. Based on two anatomical landmarks (nerve-artery crossing and laryngeal entry), the cervical course of RLN was classified in four segments: Pre-arterial, arterial, post-arterial and pre-laryngeal. According to these segments, bifurcation point locations along the cervical course of RLNs were compared between both sides in bilateral cases.

Results:

RLNs were exposed throughout their entire courses. Seventy (48%) patients had bifurcated RLNs. We identified terminal bifurcation in 90 (31%) of 292 RLNs along the cervical course. Bilateral bifurcation was observed in 20 (28.6%) patients with bifurcated RLNs. Bifurcation points were located on arterial and post-arterial segments in 37.5% and 32.5% of cases, respectively. Pre-arterial and pre-laryngeal segments contained bifurcations in 15% of cases. Comparison of both sides indicated that bifurcation points were similar in 5 (25%) and different in 15 (75%) patients with bilateral bifurcation. Permanent nerve injury did not occur in this series.

Conclusion:

Bilateral bifurcation of both RLNs was observed in approximately 30% of patients with extralaryngeal bifurcation which is a common anatomical variation. Bifurcation occurred in different segments along cervical course of RLN. Bifurcation point locations differed between both sides in the majority of bilateral cases. Increasing surgeons’ awareness of this variation may lead to safely exposing bifurcated nerves and prevent the injury to extralaryngeal terminal branches of RLN.

Accuracy of unstimulated Basal serum thyroglobulin levels in assessing the completeness of thyroidectomy

Background

Complete excision is important for proper surgical treatment of thyroid disorders. Functional thyroid tissue can be identified based on the level of serum thyroglobulin (Tg), which is produced only by the thyroid follicular cells, and nuclear scan.

Methods

Serum thyroid stimulating hormone (TSH), free thyroxin (FT4), basal (unstimulated) Tg and anti-Tg antibody (anti-Tg ab) were measured at the sixth postoperative month in 100 patients with benign thyroid disorders treated by total thyroidectomy. Thyroid nuclear scan was obtained to identify functional remnant of the thyroid gland. The sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) of the Tg levels in assessing thyroid remnant were calculated.

Results

Positive scan showed thyroid remnant in 23 patients, among whom 16 were Tg positive (true positive) and seven were Tg negative (< 0.5 ng/mL) (false negative). In these patients, the nuclear scan revealed pyramidal lobe remnants. In 77 patients with negative scan, the Tg levels were also negative (true negative), and the PPV, NPV, sensitivity, specificity and accuracy of the Tg levels were 100%, 92%, 70%, 100% and 93%, respectively.

Conclusions

The positive basal Tg (> 0.5 ng/mL) level accurately indicated the functional thyroid remnant after total thyroidectomy. The negative Tg (< 0.5 ng/mL) level supported complete excision of the thyroid gland. The surgical completeness of total thyroidectomy was accurately evaluated based on the serum Tg levels. Therefore, serum Tg levels should be measured in postoperative follow-up to determine the completeness of total thyroidectomy.

Incidence and Surgical Importance of Zuckerkandl's Tubercle of the Thyroid and Its Relations with Recurrent Laryngeal Nerve

Background. Variations of recurrent laryngeal nerve (RLN) and Zuckerkandl's tubercle (ZT), which is posterior extension of lateral lobes, may affect safety of thyroidectomy. Methods. Total and hemithyroidectomy were surgical procedures in 60 and 40 patients, respectively. Surgical anatomy was studied in 87 right and 73 left lobes. Presence of ZT was noted and its incidence was determined. RLNs were identified and fully isolated. Relationship between ZT and RLN was established. Results. ZTs were identified in 66 (66%) patients and in 81 (51%) lobes. ZT was present in 53 (61%) right and in 28 (38%) left lobes. ZTs were bilateral in 15 (25%) of 60 total thyroidectomy cases. Smaller tubercles show the neurovascular crossing point. RLN was posterior (medial) to ZT in 76 (94%) occurrences. RLN was laying on anterior surface of ZT only in 5 (6%) instances. Conclusions. RLN is unusually laying lateral to ZT which is common structure in the thyroid. Lateral RLN may be more vulnerable to injury. Total thyroidectomy requires dissection of ZT adjacent to RLN. Based on unusual relations and variations, RLN should be fully isolated before excision of adjacent structures.

Three variations of the laryngeal nerve in the same patient: a case report

INTRODUCTION

A non-recurrent course is a rare anatomic variation of the inferior laryngeal nerve (ILN). Bilateral extra-laryngeal bifurcation of the ILN seldom occurs before its laryngeal entry. Anastomosis between the ILN and cervical sympathetic chain is another rare anatomic feature. The prevalence of extra-laryngeal branching of the non-recurrent nerve is unknown. We present an example of triple anatomic variations of ILNs in the same patient, and also two anatomic variations in the same nerve.

CASE PRESENTATION

A 56-year-old Caucasian man with a large toxic multi-nodular goiter was surgically treated with total thyroidectomy. Both his right and left ILNs were identified, fully exposed and preserved along their cervical courses. We discovered many variations during bilateral exploration of the two ILNs. His right ILN was non-recurrent. This non-recurrent ILN showed a terminal division before laryngeal entry. The left nerve had a usual course as a recurrent laryngeal nerve (RLN) at his tracheaesophageal groove. We also discovered bifurcation of his RLN beginning at a neurovascular (RLN and inferior thyroid artery) crossing point. Anterior and posterior branches of both nerves entered his larynx separately. The sympathetic inferior laryngeal anastomotic branch (SILAB) between the posterior branch of his left ILN and the cervical sympathetic chain was established in the distal part of the nerve before laryngeal entry.

CONCLUSION

A non-recurrent nerve and extra-laryngeal branching of the ILN are two different variations. The coincidence of a right non-recurrent ILN and bilateral bifurcation of both nerves is a very interesting feature. SILAB is a rare additional finding as a third anatomic variation in the same patient. Extra-laryngeal terminal division of a non-recurrent ILN is an extremely unusual anatomic finding. Two anatomic variations have occurred in the same nerve, like "the variation of the variation".

Malignant Mesenchymal Tumor of the Breast: Primary Chondrosarcoma

SUMMARY: BACKGROUND: Primary mesenchymal tumors are an extremely rare malignancy of the breast. CASE REPORT: A 52-year-old woman presented with a rapidly growing breast mass. Physical examination established a large and round mass with regular margins in the upper-outer quadrant of the right breast. Ultrasound showed a hypoechoic solid mass (41 × 36 mm) with lobulated contours. Mammography revealed a hyperdense and relatively regular-shaped mass giving the impression of a benign tumor. However, a pathologic report of atypical cells after fine needle aspiration necessitated surgical excision. The mass was removed with a wide local excision. The tumor was diagnosed as a high-grade chondrosarcoma of the breast by histopathological analysis. Following the final diagnosis, we performed a modified radical mastectomy based on the knowledge that this malignancy is generally refractory to radiotherapy. The regional lymph nodes and local adjacent tissues were free of metastasis. The tumor was negative for estrogen and progesterone receptors as well as HER2. CONCLUSION: Chondrosarcoma tends to grow rapidly. Physical examination usually reveals a large, round mass. The tumor is regular-shaped, round, and complex echoic on Mammography and ultrasound. It usually does not invade regional structures. Surgery remains the only effective treatment.

Lymphovascular invasion, as a prognostic marker in patients with invasive breast cancer

PURPOSE

The markers of prognosis are used to predict the clinical course of disease and the outcome for patients with invasive breast cancer. Our aim is to investigate the relationship of peritumoural lymphovascular invasion (LVI) with well-known prognostic markers.

PATIENTS AND METHODS

Eighty-one surgically treated patients with invasive breast cancer were evaluated in this study during a mean follow-up period of 46 months (12-72). The patient's age (menopausal status), tumour size, nuclear grade, axillary lymph node involvement, and hormone receptor status were determined as markers of the prognosis. The relationship of LVI with these markers was established.

RESULTS

Except for menopausal status (p = 0.25) a close relationship was found between the presence of LVI and studied prognostic factors. LVI was positive in 29% of T1, 54% of T2 (p = 0.028) and 100% of T3 tumours (p = 0.002). The rate of LVI (+) has increased gradually as 0%, 38% and 77% (p = 0.001) with grades 1, 2 and 3 respectively. Positive LVI has been determined in 85% (p < 0.0001) and 73% (p = 0.0004) of oestrogen and progesterone receptor negative tumours respectively. LVI was present in 14% and 73% (p < 0.0001) of patients with negative and positive axilla respectively. Metastatic cancer caused mortality in seven patients of whom 86% had more than four involved axillary nodes, and 100% LVI (+).

CONCLUSION

The high rate of positive LVI shows a close relationship with known markers of poor prognosis. The presence of LVI can predict a worse outcome for patients with invasive breast cancer. LVI may be used as an indicator of aggressive behaviour, metastatic ability (nodal and systemic) of the primary malignancy.

Effects of granulocyte-colony stimulating factor on the polymorphonuclear leukocyte activity and the course of sepsis in rats with experimental peritonitis

PURPOSE

Polymorphonuclear leucocytes (PML) play an essential role in the host immune response to severe infections. The effects of granulocyte-colony stimulating factor (G-CSF) on the PML immune functions during serious abdominal infection and course of sepsis, and on the survival in rats with peritonitis are the main subjects of this study.

METHODS

The first phase of the study was carried out on 30 Wistar-albino rats equally divided into three groups; Group 1 (control) sham laparotomy; Group 2 (peritonitis); and Group 3 (peritonitis+G-CSF) with fecal peritonitis created by a cecal puncture. At postoperative hours 3, 12, and 24, 0.5 ml normal saline was injected subcutaneously in groups 1 and 2, and 0.5 ml solution containing 50 microg/kg of G-CSF in group 3. The phagocytic and chemotactic activities of neutrophils and monocytes were evaluated by a flow cytometry analysis. The plasma lactate concentrations were assessed as a marker of tissue perfusion during sepsis. The second phase was a survival analysis, which was observed during 10 days on 20 rats equally divided into two groups; group 1 (peritonitis) and group 2 (peritonitis+G-CSF). 0.5 ml normal saline in group 1 and 50 microg/kg of G-CSF in group 2 was injected subcutaneously at the 3rd hour and twice daily.

RESULTS

Both the neutrophil- (1.636 vs 2.236) and monocyte-related (1.789 vs 2.465) phagocytic activities significantly (P < 0.001) improved after the G-CSF administration in the rats with peritonitis. In addition, the G-CSF treatment significantly (P < 0.0014) improved the chemotactic activity (1.18 vs 2.75) of neutrophils, and partly supported (P < 0.0952) the chemotactic activity (1.69 vs 2.37) of monocytes. The plasma lactate level (1.86 vs 4.9 mmol/l) was significantly (P < 0.0001) increased after septic changes due to experimental peritonitis. On the other hand, the lactate concentration was significantly (P < 0.001) decreased (4.9 vs 2.63 mmol/l) after the G-CSF administration. The survival was 20% at the 4th day and 0 at the 6th day in peritonitis, and 90% at the 4th day (P = 0.0055) and 80% at the 6th day (P = 0.0007) days in the peritonitis+G-CSF groups.

CONCLUSION

G-CSF enhances the immune functions of neutrophils and monocytes. The increased activities of these cells have a beneficial effect on the enhancement of the host immune response during severe infections. The improved immune function of PML due to the G-CSF treatment thus ameliorates the survival and the courses of sepsis, which is also defined by tissue perfusion and the cellular oxygen balance, which is affected by septic changes.

Prostaglandin E1 maintains structural integrity of intestinal mucosa and prevents bacterial translocation during experimental obstructive jaundice

The absence of bile in the gut lumen induces mucosal injury and promotes bacterial translocation (BT). Prostaglandin E (PGE) has a protective effect on the mucosal layer of the alimentary tract. We hypothesize that PGE1 may prevent BT by its beneficial action on the mucosa of the small bowel. Thirty Wistar albino rats were divided equally into 3 groups; Group 1 (control) underwent sham laparotomy, group 2 obstructive jaundice (OJ) and group 3 (OJ + PGE1) underwent common bile duct (CBD) ligation and transection. Groups 1 and 2 received; 1 mL normal saline and group 3 received 40 mg of the PGE1 analogue misoprostol dissolved in 1 mL normal saline administered by orogastric tube once daily. After 7 days, laparotomy and collection of samples for laboratory analyses were performed, including bacteriological analysis of intestine, mesenteric lymph nodes (MLNs), and blood, and histopathologic examination of intestinal mucosa to determine mucosal thickness and structural damage. Serum bilirubin and alkaline phosphatase levels confirmed OJ in all animals with CBD transection. The mucosal damage score was significantly reduced in jaundiced animals receiving PGE1 compared to jaundiced controls (2.15 +/- 0.74 vs 5.3 +/- 0.59; p < .00001) and mucosal thickness was greater (607 +/- 59.1 microm vs. 393 +/- 40.3 microm; p < .00001). The incidence of BT to MLNs decreased from 90% to 30% (p < .02) when jaundiced rats received PGE1. PGE1 treatment reduced the detection rate of viable enteric bacteria in the blood from 60% to 10% (p < .057). We conclude that administration of PGE1 provides protection against OJ-induced atrophy and damage of intestinal mucosa, and thereby prevents translocation of enteric bacteria to underlying tissues.

Breast abscess as a complication of human brucellosis

Breast abscess caused by human brucellosis is extremely rare. A 46-year-old woman received the diagnosis of brucellosis with positive serologic tests. Two weeks after the onset of symptoms, the case was complicated by vertebral (L5-S1) abscess which was treated by surgical drainage. One month after the diagnosis of brucellosis, the patient noticed a mass in her left breast. Breast palpation revealed a painless, mobile, round mass that was hypoechoic on ultrasound imaging. Purulent material was obtained by needle aspiration. Besides treatment of the breast abscess by needle aspiration, brucellosis was successfully controlled by prolonged antimicrobial treatment.

Clinical importance of solitary solid nodule of the thyroid in endemic goiter region

CONTEXT

Endemic area and iodine supplementation may affect the pathogenesis of the nodule which commonly occurs in endemic thyroid enlargement due to iodine deficiency.

AIMS

To establish pathological changes in solitary solid and larger nodule of the thyroid in endemic area.

SETTING AND DESIGN

Retrospective study in Surgical Department of University Hospital.

METHODS AND MATERIAL

We determined 44 surgically treated patients with solitary solid nodule in endemic goiter area in which the population routinely receives iodinated salt. The thyroid nodule was preoperatively evaluated with blood chemistry, ultrasound, nuclear scanning and FNAC. The results of preoperative evaluation, surgical interventions, and histopathological examination were analyzed.

STATISTICAL ANALYSIS

Student t test and Fisher's exact test.

RESULTS

Twenty (45%;20/44) patients with hot (autonomous) nodule have received the diagnosis of toxic adenoma. Twenty four patients had solitary solid and cold nodule. Total thyroidectomy was performed on two patients with papillary cancer (PTC) diagnosed by FNAC from cold nodules. Forty two patients have been treated with total excision of the lobe including hyper or hypoactive solitary solid nodule. Pathological examination has reported two more cases of PTC and one case of insular cancer arising from cold nodules. Completion thyroidectomy was performed on these 3 patients.

CONCLUSIONS

Solitary solid and large nodule is a common indication for thyroid surgery in endemic goiter area. High incidence of hyperthyroidism due to single autonomous nodule, and high rate of malignant change (mainly papillary cancer) in solitary hypoactive nodule arises from this series in endemic thyroid enlargement.

Surgery is the procedure of choice for the treatment of patients with toxic adenoma in an endemic goitre area

PURPOSE

Toxic adenoma is one of the main causes of hyperthyroidism. We investigated the efficacy of surgery in the treatment of toxic adenoma.

METHODS

Serum thyroid stimulating hormone (TSH) measurement, ultrasound and scintigraphy of the thyroid were made for diagnostic purpose. The safety of surgery was evaluated by postoperative clinical course of patients. The efficacy of surgery was determined by the function of the remaining thyroid tissue.

RESULTS

The incidence of hyperthyroidism was 53% in surgically treated patients with nodular goitre in our iodine deficient region. The cause of thyrotoxicosis was toxic adenoma in 15 patients (14%). Suppressed serum TSH levels indicated the hyperthyroidism in all of 15 patients. Solitary solid adenoma was found by ultrasonographic examination, and solitary autonomous hot nodule by thyroid scintigraphy. Surgical treatment consisted of unilateral total lobectomy. It was the primary treatment in 13 patients. Two patients had surgery as secondary treatment after unsuccessful primary radioactive iodine application. The early postoperative clinical course of all patients was uneventful. Thirteen patients who had surgery as primary treatment had normal thyroid function postoperatively contrary to other two patients who became hypothyroid after having unsuccessful radioiodine therapy, and surgery as the secondary treatment.

CONCLUSIONS

The incidence of hyperthyroidism and toxic adenoma is high in our surgically treated patients with nodular goitre. The diagnosis of toxic adenoma is not difficult by serum TSH measurements, and ultrasound and nuclear imaging of the thyroid. Surgery is effective and safe, and the treatment of choice for patients with toxic adenoma in order to control radically the hyperthyroidism and to achieve the goal of providing the euthyroid status.

Prostaglandins E1 and E2 analogues ameliorate mucosal injury secondary to distal colonic obstruction

After colonic obstruction, increased intraluminal pressure may impair blood circulation and cause mucosal injury that sometimes progresses to perforation. This experimental study aims to evaluated effects of prostaglandin E (PGE) analogues in order to prevent mucosal injury secondary to distal colonic obstruction. This study was carried out on 40 male Wistar rats equally divided into four groups: group 1, control; group 2, colonic obstruction by ligation of the sigmoid colon; group 3, obstruction and administration of PGE1; group 4, obstruction and administration of PGE 2. Mucosal structural changes were assessed and scored by histopathological examination at 24 h postoperatively. The thickness of the mucosal layer of the cecal wall was measured as 179.3 and 122 microm (p <.001) in the control and obstruction alone group, respectively. Mucosal thickness was preserved by PGE1 (170 microm) and PGE2 (157.3 microm) administration. The mean damage score was 0.73 in the control and 3.3 (p <.001) in the obstruction alone group. This score was significantly lower in obstruction groups treated with both PGE1 and PGE2, 1.13 and 1.26 respectively (p <.001). Both PGE1 and PGE2 (PGE1 better than PGE2) ameliorate mucosal injury during distal colonic obstruction. We concluded that the administration of PGE analogues in case of mechanical obstruction of the left colon was beneficial for preserving the structure of the mucosal layer.

Prostaglandins E1 and E2 analogues ameliorate mucosal injury secondary to distal colonic obstruction

After colonic obstruction, increased intraluminal pressure may impair blood circulation and cause mucosal injury that sometimes progresses to perforation. This experimental study aims to evaluated effects of prostaglandin E (PGE) analogues in order to prevent mucosal injury secondary to distal colonic obstruction. This study was carried out on 40 male Wistar rats equally divided into four groups: group 1, control; group 2, colonic obstruction by ligation of the sigmoid colon; group 3, obstruction and administration of PGE1; group 4, obstruction and administration of PGE 2. Mucosal structural changes were assessed and scored by histopathological examination at 24 h postoperatively. The thickness of the mucosal layer of the cecal wall was measured as 179.3 and 122 microm (p <.001) in the control and obstruction alone group, respectively. Mucosal thickness was preserved by PGE1 (170 microm) and PGE2 (157.3 microm) administration. The mean damage score was 0.73 in the control and 3.3 (p <.001) in the obstruction alone group. This score was significantly lower in obstruction groups treated with both PGE1 and PGE2, 1.13 and 1.26 respectively (p <.001). Both PGE1 and PGE2 (PGE1 better than PGE2) ameliorate mucosal injury during distal colonic obstruction. We concluded that the administration of PGE analogues in case of mechanical obstruction of the left colon was beneficial for preserving the structure of the mucosal layer.

Accuracy of serum C-reactive protein measurements in diagnosis of acute appendicitis compared with surgeon's clinical impression

Diagnosis of acute appendicitis is established generally by the surgeon's clinical impression. Today, negative laparotomy rate because of clinical diagnosis is still 15 to 25 percent.

PURPOSE

This study was designed to determine the accuracy of C-reactive protein (CRP) measurements in the diagnosis of acute appendicitis and to compare it with the surgeon's clinical diagnosis.

METHODS

One hundred eight consecutive patients were studied prospectively. Depending on results of the examination by a surgeon, patients underwent surgery for acute appendicitis. Serum CRP measurements were performed before the operations but were not taken into account for the decision of laparotomy to compare it with the surgeon's clinical diagnosis.

RESULTS

Histopathologic findings confirmed acute appendicitis in 90 patients. Normal appendixes were removed in the remaining 18 patients. Mean serum CRP value was 5 (range, 0-12.6) mg/l in patients with normal appendix, 33.8 (range, 5-85.1) mg/l in patients with nonperforated appendicitis, and 128.5 (range, 79.2-230) mg/l in patients with perforated appendixes. These differences were highly significant (P < 10(-6)). Serum CRP levels were normal in three patients with acute appendicitis. Thus, the false-negative rate of CRP was 3 percent. Of 18 patients with normal appendectomy serum CRP levels were slightly elevated in two patients. We determined, therefore, a false-positive rate of CRP as 11 percent. CRP levels were false-negative in three patients and false-positive in two patients. Thus, CRP levels were true (positive or negative) in the remaining 103 patients. On the other hand, the diagnosis depending on surgeon's clinical impression was true in 90 patients and false in 18 patients. This difference was statistically significant (P = 0.0035). In the present study the sensitivity, specificity, and accuracy of serum CRP measurements were calculated as 93.5, 80, and 91 percent, respectively.

CONCLUSION

We found that elevated serum CRP levels support surgeon's clinical diagnosis. We recommend CRP measurement as a routine laboratory test in patients with suspected diagnosis of acute appendicitis.