Intraoperative carbon nanoparticles mapping in secondary total thyroidectomy for recurrent thyroid nodules: Results of a 8-criterion case-match study (case control study).

BACKGROUND: The extent of total thyroidectomy in the management of multinodular goiter remains unclear. Compared to primary thyroidectomy, secondary total thyroidectomy is more difficult to perform and carries a significantly higher risk of postoperative complications such as recurrent laryngeal nerve (RLN) palsy or hypoparathyroidism. In this study, we aimed to evaluate the efficacy and safety of intraoperative carbon nanoparticle (CN) mapping in patients undergoing secondary total thyroidectomy. METHODS: We performed a case-matched analysis of a prospectively maintained database using 8 specific criteria to compare perioperative outcomes after primary total thyroidectomy to those after secondary total thyroidectomy with intraoperative CN mapping. The criteria included age, sex, operative procedure, RLN/parathyroid glands (PGs) exploration, preoperative vocal cord calcium abnormalities, and pathological results. Thirty-five patients underwent secondary total thyroidectomy with intraoperative CN mapping due to recurrent thyroid nodules or development of nodules suspicious for malignancy after subtotal thyroidectomy. Fifty exact matches for all 8 criteria were identified from the database in our previous study, which included records of 3078 primary thyroidectomies without CNs. Perioperative outcomes, surgical technique, and complications were analyzed. RESULTS: The RLNs were successfully identified in all 35 patients. Among three patients that experienced slight hoarseness, one had an RLN end-to-end anastomosis with subsequent improvement in the during the 12-month follow-up period. Two patients experienced changes in vocal tone, but recovered after several months. Two patients underwent parathyroid auto-transplantations, and subsequently presented with transient hypocalcaemia. Their symptoms gradually remitted within one year. Except for mean operation time, there were no statistically significant differences in complications between the primary total thyroidectomies and the secondary total thyroidectomy with CNs. CONCLUSIONS: Intraoperative CN mapping, expert knowledge of the jugular anatomy, and standardized resection procedures can minimize the incidence of complications such as RLN palsy and hypoparathyroidism after secondary total thyroidectomy.

Anatomical variations of the recurrent laryngeal nerve in Chinese patients: a prospective study of 2,404 patients.

The recurrent laryngeal nerve (RLN) shows some anatomical variations that can potentially compromise the safety of thyroid surgery. The purpose of this prospective study was to identify the anatomical variations of the RLN in Chinese patients undergoing thyroid surgery. Between January 2007 and December 2013, 2,404 Chinese patients were hospitalized for thyroid surgery with dissecting of the RLN unilaterally or bilaterally. The patients consisted of 510 men and 1,894 women, with a median age of 45.0 years. Overall 3,275 RLNs, including 1,576 left- and 1,699 right-side nerves, were dissected. The anatomical variations were identified in 690 RLNs, including 305 left- and 385 right-side nerves. We identified as many as seven RLN anatomical variations in Chinese patients. These findings indicate that anatomical variations of the RLN are common, and the identification of these anatomical variations of the RLN can help to minimize the risk of post-operative RLN paralysis.

Confirmation of an anatomic variation of the recurrent laryngeal nerve at site of entry into the larynx in Chinese population.

OBJECTIVE: This study was aimed at analyzing the frequency of the newly reported variation and the frequency of postoperative palsy associated with three different kinds of known variations. METHODS: We conducted a retrospective study on the data of 2068 consecutive Chinese patients who underwent thyroidectomy. The study included 1362 left and 1507 right (2869 in total) RLNs. RESULTS: Among all the RLNs, 548 were found to have variations at the laryngeal entry of the RLN. The most frequent variation was extralaryngeal branching (n=322), followed by the fan-shaped branching (n=201). Our newly identified variation was also noted in 25 of our patients. In these cases, the RLN entered the larynx from sites that were distant from the posterior cricothyroid joint. The distance from the entry of the RLN to the back of cricothyroid joints was over 5mm. Compared to the rates reported from other countries, the rate of the first type of variation is lower, while that of the second type is higher. The frequency of the new variation has not been reported in other populations, but it is consistent with our previous finding. The incidence of postoperative palsy was greater for RLNs with the first and third types of variations than in the normal RLNs. CONCLUSION: We confirmed that the incidence of patients with the new type of variation of the RLN at the entry of the larynx was about 1% in Chinese. Awareness among surgeons regarding this variation is important to avoid postoperative palsy.

New variation of right recurrent laryngeal nerve: cases report.

The recognition of variation in recurrent laryngeal nerves is important for both surgeons and the prognosis of patients undergoing surgery of the neck. Here, we reported a new variation of the right recurrent laryngeal nerves in five patients with thyroid surgery. The new variation is characterized by the additional ascending intracranial branches after division of laryngeal branches.

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.

[A variation of the recurrent laryngeal nerve at its entry to larynx found in the thyroid surgery].

OBJECTIVE: To describe a new variation of the recurrent laryngeal nerve (RLN) at its entry to larynx. METHODS: A retrospective study including 3 078 consecutive cases received thyroidectomy was performed from January 1998 to December 2008. The age ranged from 15 to 82 years, 2 395 cases were female and 683 cases were male. A total of 4 241 RLNs were exposed successfully for avoiding the injury of the nerve. A kind of variation of the RLN was reported in this study. RESULTS: Forty-four varied RLNs were identified at the entry into the larynx (1.0%, 44/4241). Variation happened at the truck or the branches of RLN entering the larynx far from the posterior cricothyroid joints. The distance from the entry to the back of cricothyroid joints was over 5 mm. Among these, eight RLNs (23.5%, 8/34) walked distally from the dorsal cricothyroid joint without extra laryngeal branches and entered the larynx at the abnormal point. There were four different kinds of sub-variations identified: type I: there was no branch in RLN and the varied RLN entered the larynx far from the posterior cricothyroid joints, total 35 cases (79.6%, 35/44); type II: there were two branches in RLN, one branch entered the larynx at the posterior cricothyroid joints and the other far from the posterior cricothyroid joints, total 5 cases (11.4%, 5/44); type III: there were two branches in RLN, and both branches entered the larynx far from the posterior cricothyroid joints, total 3 cases (6.8%, 3/44); type IV: there were three branches in RLN, the lateral branch of the varied RLN entered the larynx far from the posterior cricothyroid joints, total 1 case (2.2%, 1/44). Four varied RLNs were injured during the operation (9.1%, 4/44). CONCLUSION: The variation of RLN reported in this study is more dangerous and should be paid more attention to lower the injury of the nerve.

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.

[Whether the impairment of grafted liver was induced by the inflammatory cells in cold and warm ischemia after transplantation].

OBJECTIVE: To investigate whether the impairment of grafted liver after transplantation was induced by the same inflammatory cells in cold and warm ischemia. METHODS: Male SD rats were divided into two groups randomly, 24 grafted livers in each group were stored for 120 or 240 min at 4 degrees Centigrade Ringer's solution. Also male SD rats were divided into three groups, in which 24 grafted livers in each group were experienced warm ischemia ranged from 90, 120 to 150 min from non-heart-beating donor. The recipients were killed after 1, 3, 6, and 24 hours of transplantation for sample collection. RESULTS: Along with the prolongation of cold and warm ischemia time, the serum ALT and AST levels were increased gradually after transplantation. Light microscopy showed some necroses in hepatocytes after 3 and 6 hours of transplantation in cold ischemia, and some neutrophilic infiltration in sinusoids. There were a large number of hepatocytes necroses after 3, 6 hours of transplantation in warm ischemia from non-heart-beating donor and a lot of lymphocytic infiltration in sinusoids. The findings in electron microscopy were as the same as those found in light microscopy, and the lymphocytes which infiltrated in sinusoids in warm ischemia were identified as T lymphocytes in electron microscopy. CONCLUSIONS: The impairment of grafted livers after transplantation seems to be induced by two different inflammatory cells in cold and warm ischemia, that is, neutrophils mediate the cold ischemia-reperfusion, and T lymphocytes mediate the warm ischemia-reperfusion from non-heart-beating donor.