A newly identified variation at the entry of the recurrent laryngeal nerve into the larynx.

OBJECTIVES: We aimed to highlight a new anatomical variation of the recurrent laryngeal nerve (RLN), and to emphasize its implications for thyroid surgery. METHODS: A prospective study was carried out in a group of 3,078 consecutive thyroidectomies from 1998 to 2008. Total, near-total, subtotal, and partial thyroidectomy were performed for various thyroid diseases. The RLN was routinely identified and exposed in its entire course until the entry into the larynx. The postoperative complications of patients with different variations were compared. RESULTS: 4,241 RLNs were successfully identified in all patients unilaterally or bilaterally. In addition to extralaryngeal branching and nonrecurrent laryngeal nerves, an unreported variation was identified in 44 RLNs (1.04%) at their entries into the larynx. The variation happened at the trunk or the branches of the RLN entering the larynx far from the posterior of cricothyroid joint, and the entry was higher than the superior cornu of the thyroid cartilage and the arch of the cricoid. The median distance from the entry to the posterior of cricothyroid joint was more than 5 mm. As the trunk or the branches had to travel along the lateral edge of the upper 1/3 of the thyroid before entering the larynx, the incidence of RLN palsy was higher than that in extralaryngeal branching variations (p < .05). CONCLUSION: This newly discovered variation of the RLN is more vulnerable to injury and should be brought to the attention of surgeons.

The plication and splinting procedure for idiopathic sclerosing encapsulating peritonitis.

Idiopathic sclerosing encapsulating peritonitis (ISEP) is a rare cause of small intestinal obstruction. Histologically, ISEP is characterized by a thick fibrotic membrane encasing the small bowel without any apparent pathophysiological factors. While ISEP is predominantly present congenitally in female adolescents from subtropical region, it has been identified throughout the world. Evidence-based effective diagnostics and treatments are pitifully thin. We experienced six cases, four males and two females, which exhibited symptoms in their later thirties and forties. Five patients presented with acute and subacute intestinal obstruction, and one patient with cryptorchidism and seminoma was referred. Due to the limitation in distention and motility of bowel loops of ISEP, imaging exams may not be very reliable for accurate diagnosis and estimation of obstruction progress. They were successfully treated with the mesenteric plication and intraluminal splinting procedures. Two cases had an uneventful postoperative period, and the returns of normal bowel function were delayed in the other four patients. Two recurrences of small bowel obstructions were noted over a mean follow-up period of 33 months with mild symptoms. This article reviews the patterns of clinical presentations, diagnostic clues, and theories of potential risk factors of ISEP as well as its controversial surgical managements.

The feasibility of total or near-total bilateral thyroidectomy for the treatment of bilateral multinodular goiter.

OBJECTIVE: To evaluate the feasibility and safety of total and near-total bilateral thyroidectomy for the treatment of bilateral multinodular goiter. METHODS: 346 patients with a diagnosis of bilateral multinodular goiter were randomly divided into two groups. 165 patients underwent total thyroidectomy or near-total thyroidectomy (group A), while 181 patients were exposed to a partial or subtotal thyroid gland removal treatment (group B). The incidences of postoperative complications and recurrence rate were monitored during the average follow-up period of 36 and 39 months, respectively. RESULTS: Six and two patients from groups A and B, respectively, were diagnosed with papillary carcinoma and excluded from the study. Transient recurrent laryngeal nerve paralysis occurred in three patients each from group A (1.89%, 3/159) and group B (1.68%, 3/179) postoperatively. Injury to superior laryngeal nerve was confirmed in three patients (two in group A and one in group B). Eleven (6.92%, 11/159) and nine (5.03%, 9/179) cases in groups A and B, respectively, suffered from transient hypocalcemia symptoms. There was no statistical difference in complications between two groups. Permanent hypoparathyroidism was not observed in either group. No recurrence was observed in group A, while 12 cases (6.70%, 12/179) were observed in group B. The recurrence rate was significantly different between the two groups (p <.05). CONCLUSION: It is safe and feasible to perform either total or near-total thyroidectomy in patients with bilateral multinodular goiter. These treatments provide decisive advantages over partial and subtotal thyroidectomies in terms of the recurrence and reoperation rate with comparable postoperative complications.