Place and value of the recurrent laryngeal nerve (RLN) palpatory method in preventing RLN palsy during thyroid surgery

BACKGROUND

In recent years, certain publications have appeared confirming that intraoperative palpation of the recurrent laryngeal nerve (RLN) is a very reliable method.

METHOD

The characteristics of the surgical anatomy of 1023 RLN have been summarized on the basis of intraoperative palpability, running down, branching variations, thickness, and laryngeal entry site.

RESULTS

Palpation was helpful in 81.4% (833/1023), proved false positive in 8.2% (84/1023), and in 10.4% (106/1023) it was of no help in the exact localization. Definitive RLN palsy was experienced in 0.78% of all cases (8/1023), while transient paresis was encountered in 1.2% (12/1023). Only a moderately strong stochastic correlation could be found between RLN palsies and those nerves which were nonpalpable and atypical, which showed the joint occurrence of being both thinner than normal and branching already before the plane of the inferior thyroid artery (Cramer's associate coefficient, C = 0.383).

CONCLUSION

Palpation alone cannot substitute visualization and proper surgical dissection of the nerve.

Somatosensory hypersensitivity in the referred pain area in patients with chronic biliary pain and a sphincter of Oddi dysfunction: new aspects of an almost forgotten pathogenetic mechanism

BACKGROUND AND AIMS

Somatosensory hyperalgesia in the referred pain area (RPA) in patients with acute or chronic abdominal pain syndromes may result from the convergence of nerve fibers from visceral and somatic tissues at the spinal and supraspinal levels. Chronic biliary pain in patients with the postcholecystectomy syndrome (i.e., biliary hypersensitivity) may be explained by persistent hyperexcitability of neurons in the central nervous system (CNS). The aim of this study was to evaluate the cutaneous neural sensory perception in the RPA in patients with chronic postcholecystectomy biliary pain and a sphincter of Oddi (SO) dysfunction (SOD).

METHODS

Forty-two patients with persistent biliary pain and suspected SOD, 27 age-matched healthy volunteers, and 18 age-matched asymptomatic cholecystectomized controls were prospectively investigated by quantitative sensory testing (Neurometer CPT). The biliary symptoms and the severity of pain were classified on a visual analog pain severity scale system via a previously validated and standardized questionnaire. The patients helped the doctors locate the RPA in the right upper quadrant. The sensory detection threshold was determined noninvasively (Neurometer CPT) with transcutaneous electrical stimulation at 5, 250, and 2,000 Hz, and different current intensities (range from 0.01 to 9.99 mA) applied in a single (patient) blinded method. These three frequencies selectively excite small unmyelinated (C fibers), small myelinated (A-delta), and large myelinated (A-beta) fibers, which transmit dull pain, sharp pain, and touch, respectively. The contralateral region of the abdomen left upper quadrant served as the control area. The sensory current perception threshold ratio (SCPTR) of the data measured in the contralateral area and the RPA was calculated.

RESULTS

The SCPTRs in the definite SOD patients with biliary pain, healthy volunteers, the asymptomatic cholecystectomized controls, and the symptomatic cholecystectomized patients but without SOD were 2.32 +/- 1.4 versus 1.06 +/- 0.24 versus 0.97 +/- 0.16 versus 0.83 +/- 0.35 at 2,000 Hz; 2.19 +/- 1.0 versus 1.01 +/- 0.26 versus 1.02 +/- 0.25 versus 0.88 +/- 0.35 at 250 Hz; and 2.19 +/- 1.1 versus 1.12 +/- 0.26 versus 0.99 +/- 0.37 versus 0.84 +/- 0.32 at 5 Hz, respectively. Significant hypersensitivity was detected in the RPA at different stimulation frequencies in the SOD patients with biliary pain versus the cholecystectomized controls: at 5 Hz: P = 0.00001; at 250 Hz: P = 0.00001; and at 2,000 Hz: P = 0.0001, respectively.

CONCLUSION

Continuous visceral pain (biliary pain) caused by local inflammatory/sensitizing processes or a CNS malfunction could lead to significant hypersensitivity of the peripheral nociceptive nerve fibers in SOD patients. Postcholecystectomy pain may be explained by persistent hyperexcitability of the nociceptive neurons in the CNS with or without objective motility disorders of the SO.

[Malignant gastrointestinal stromal tumor arising in a duodenal diverticulum]

Malignant gastrointestinal stromal tumor arising in a duodenal diverticulum. The authors describe the case of a 74-year-old male patient who was operated on for a GIST found in a large duodenal diverticulum, co-using gastrointestinal bleeding. This diverticulum--including the tumor--was removed by resection the distal part of the stomach and proximal third of duodenum. The histology revealed malignant gastrointestinal stromal tumor (GIST). 6 months after the operation he remained tumor free according to the control examinations. On the basis of new pathologic classification we summarise the signs, the diagnostic and therapeutic possibilities and the histologic characteristics of gastrointestinal stromal tumors.

[Antral ectopic pancreas causing gastric outlet obstruction]

Ectopic pancreas is an uncommon clinical finding. It is rare for heterotopic pancreas tissue to cause symptoms, however every disease of the pancreas may develop in it. The most common sites for ectopic pancreas are the submucosal layer of the stomach and the small intestine. Symptomatic ectopic pancreas usually causes diagnostic difficulties. Surgical excision is recommended if the patient has complaints. We report the case of a 32-year-old man. We performed subtotal gastrectomy because of a submucosal, antral tumour, that caused gastric outlet obstruction. The histological examination verified ectopic pancreas tissue. The patient recovered without any complications.

[Synchronous carcinoma of the esophagus and the thyroid gland]

INTRODUCTION

Incidence of synchronous or metachronous carcinomas with primer esophageal malignancy together can be estimated at 17% and these disorders manifest mostly in the stomach.

CASE REPORT

The authors report the medical history of a 55-year-old man whose symptomatic middle third esophageal carcinoma was cured with esophagectomy and two field lymphadenectomy. Stomach was used for substitution. Histological examination verified pT2N1M0 tumor and metastasis of papillary thyroid carcinoma from the lymph node removed from near to the right recurrent nerve. Five weeks after the esophageal resection a total thyroidectomy and a central lymph node dissection was performed. The synchronous thyroid carcinoma was located into the inferior pole of right lobe. Currently the patient is without symptoms and plaints, the complex oncological treatment is in progress.

DISCUSSION

The incidence of a synchronous carcinoma of the esophagus and the thyroid gland is an extreme rarity. The basic difference connected to the tumorbiological behaviors of these two malignancies is found in the growing tendency and in the direction of lymphogen spreading. The common point is the recurrent nerve lymphatic chains in the thoracic dome. This is the reason that after the R0 resection of a middle third esophageal carcinoma the histological evaluation of a lymph node obtained from right recurrent nerve lymphatic chain shed light on the asymptomatic synchronous thyroid cancer.

CONCLUSION

In cases of operable esophageal carcinomas located into its middle or lower third the importance of a correct lymphadenectomy could not be emphasize enough. During the routine preoperative examinations it would be necessary to make cervical ultrasonography too.

The place of gastro-jejuno-duodenal interposition following limited esophageal resection

OBJECTIVE

Although stomach is the best choice for reconstruction after esophagectomy from the viewpoint of safety and ease, an intrathoracic stomach, nevertheless, is a poor long-term substitute. This anatomical configuration abolishes normal antireflux mechanisms and places the acid-excreting stomach subject to biliary reflux, moreover, in an adjacent position to the esophagus within the negative-pressure environment of the thorax.

METHODS

Between 1995 and 2002, 27 patients with high-grade neoplasia-as early Barrett's carcinoma-or non-dilatable peptic stricture underwent limited surgical resection of the distal esophagus and esophagogastric junction. In 11 of these cases, the reconstruction was performed with gastro-jejuno-duodenal interposition. The long-term functional results of this specially adapted form of interposition reconstruction have been evaluated. The postoperative follow-up period ranged between 24 and 95 months (mean 68 months). Nine patients (9/11=81.8%) have agreed to undergo endoscopy, radiographic contrast-swallow examination, and 24-h ambulatory esophageal pH and bilirubin monitoring.

RESULTS

Three out of nine patients (3/9=33%) demonstrated abnormal levels of esophageal acid exposure during the 24-h study period, whilst none had any evidence of bilirubin exposure in the esophageal remnant. Endoscopy revealed that three patients had reflux esophagitis in the remnant esophagus: Los Angeles A=2, C=1. No stomal or jejunal ulceration at the gastro-jejunal anastomosis could be observed. Histopathologic assessment of the squamous epithelial biopsies demonstrated microscopic evidence of inflammation: minor in two cases, moderate in one and major in one case; however, none of them had evidence of columnar metaplasia in the esophageal remnant at a median of 68 months after surgery. The majority of the patients have been doing well since the operation: 8/9 (88%)=Visick I-II.

CONCLUSIONS

Gastro-jejuno-duodenal interposition represents an adequate 'second-best' method of choice if technical difficulties emerge with jejunal or colon interposition following limited resection of the esophagus performed due to early Barett's carcinoma or non-dilatable peptic stricture.

[Muir-Torre syndrome]

Muir-Torre syndrome patients have multiple visceral malignancies along with cutaneous sebaceous tumors and keratoacanthomas. We describe a history of a 64-year-old male patient with 13 tumours, who survived 13 years. The initial ascending colon adenocarcinoma was followed by some different tumors of the skin: adenoma and carcinoma of sebaceous glands, epidermoid and basaloid carcinoma and other benign tumors. The last time developed rectal adenocarcinoma was operated.