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.

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.

[Carcinoid tumor of the papilla of Vater]. / Vater papilla carcinoid.

Carcinoid tumor of the papilla of Vater is extreme rare. Only 73 cases have been reported in the world literature to date and only 1 case in Hungary. This tumor differs clinically and has a different prognosis from other carcinoid tumors of the gastrointestinal tract as it is more aggressive. The clinical feature is determined by the expansion and infiltrative nature of the tumor. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic biopsy (EB) are the most accurate methods of diagnosis, while endoscopic ultrasonography (EUS) is the most important method to decide the surgical strategy. Depending on the tumor size and the grade of invasion of other structures surgical treatment can be local excision or radical resection. We present a 67-year-old female patient with obstructive jaundice, caused by carcinoid tumor of the papilla of Vater. Diagnosis was obtained by ERCP and EB. Because of the signs of local invasion emerging on EUS a pylorus preserving pancreatoduodenectomy was performed. Six months after the operation there is no evidence of recurrence.

[Antral ectopic pancreas causing gastric outlet obstruction]. / Gyomorürülési zavart okozó antrális ectopiás pancreas.

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.