[Clinical features and prognoses of re-operated patients for persistent/recurrent papillary thyroid carcinoma].

Objective: To investigate the clinicopathological characteristics and the survival of re-operated patients for persistent/recurrent papillary thyroid carcinoma (PTC) and risk factors for re-recurrence after the second operation. Method: A retrospective analysis of 69 cases underwent re-operation for persistent/recurrent PTC in Sichuan Cancer Hospital from January 2010 to December 2016 was performed. There were 21 males and 48 females, aged 14-85 (44.8) years old. According to the imaging after initial treatment, they were divided into a recurrence group (42 cases) and a persistent disease/residual group (27 cases). The positive rates of ipsilateral paratracheal lymph node metastases at re-operation were calculated and compared by chi-square test. Patients were divided into different subgroups according to potential risk factors for re-recurrence. Kaplan-Meier (K-M) method was used for survival analysis. Results: The positive rate of ipsilateral paratracheal lymph node metastasis in recurrence group (15/42, 35.7%) was significantly lower than that in the persistent disease/residual group (17/27, 63.0%) (χ2=4.91, P<0.05). The follow-up period after re-operation was 60-104 months, with a median of 66 months, and 8 patients were lost to follow-up. Permanent hypoparathyroidism occurred in 2 cases (2.9%) and permanent recurrent laryngeal nerve palsy in 1 case (1.4%). Twenty patients had structural recurrences and/or distant metastases. The 5-year disease-specific survival rate was 92.8% and the 5-year recurrence-free survival rate was 68.1%. Survival analysis was performed on risk factors such as age≥55 years old, recurrent tumor diameter ≥4 cm, number of positive lymph nodes ≥ 10, and obvious extracapsular invasion (ENE). Among them, age and diameter of recurrent tumor had significant influences on recurrence-free survival rate (χ2 was 6.36, 8.17, respectively, both P values<0.05). There was a statistically significant difference in recurrence-free survival rates between ENE(+) group and ENE(-) group (χ2=5.52, P<0.05). Conclusion: For the re-operated patients due to persistence/ recurrence PTC, attention should be paid to protecting the parathyroid gland and recurrent laryngeal nerve during re-operation. Timely and effective postoperative follow-up for patients aged ≥ 55 years, with recurrent tumor diameter ≥ 4 cm and ENE(+), can significantly improve their prognoses.

[Comparison of three kinds of free flaps used in patients with oral and oropharyngeal tumors].

Objective: To compare the recovery and quality of life of patients with oral and oropharyngeal tumors treated with three kinds of free soft tissue flaps. Methods: The clinical data of 103 patients, including 66 males and 37 females, aged 26-74 years, who underwent primary repair of defects after resection of oral and oropharyngeal tumors in Sichuan Tumor Hospital from July 2014 to August 2020 were analyzed. Anterolateral thigh flap (ALTF) was used in 43 patients, radial forearm free flap (RFFF) in 45 patients, and lateral arm free flap (LAFF) in 15 patients. Postoperative qualities of life of patients were evaluated by the university of Washington quality of life questionnaire and oral health impact scale (HIP-14 Chinese edition). SPSS 23.0 software was used for statistical analysis. Results: The T staging of RFFF or LAFF group was significantly lower than that of ALTF group (P<0.05). There was no significant difference in mean flap areas between ALTF group ((55.87±27.38) cm2) and LAFF group ((49.93±19.44) cm2), while RFFF group had smaller mean flap area ((33.18±6.05) cm2) than ALTF group (t=5.311, P<0.001) and LAFF group (t=3.284, P=0.005). In terms of oral functions including swallowing, mastication, taste and spitmouth, there were no significant differences between LAFF group and RFFF group (P>0.05), but both groups had better oral functions than ALTF group (P<0.05). There was no significant difference in appearance scores between LAFF group (75(75, 75)) and ALTF group (75(75,75) vs.75(75,75),Z=-1.532, P=0.126), and both groups had higher scores than RFFF group (50(50, 75),Z values were -3.447 and -3.005 respectively, P<0.05). RFFF group had higher speech score (100(67, 100)) than LAFF group (67(50, 76),Z=-2.480, P<0.05) and ALTF group (67(33, 67),Z=-5.414, P<0.05). ALTF group had lower mean score of quality of life than RFFF group [72(56,77) vs.79(69, 89),Z=-3.070, P<0.05), but there was no statistical difference in the mean scores of qualities of life between ALTF group and LAFF group (Z=1.754, P=0.079). According to the evaluation of oral health impact scale (HIP-14 Chinese version) 1 year after surgery, individual item scores and the average score of all items in ALTF group were lower than those in RFFF and LAFF groups (P<0.05), with no significant difference between RFFF group and LAFF group (P>0.05). Conclusions: RFFF has unique advantages for small tissue defects, while ALTF is suitable for large tissue defects, such as buccal penetrating defect, whole tongue and near whole tongue defect, and LAFF is a compromise choice between ALTF and RFFF. ALTF is inferior to RFFF and LAFF in oral functional reconstruction, including swallowing, chewing, taste and spittle. ALTF and LAFF are superior to RFFF in postoperative appearance.

[Posterior sternocleidomastoid border approach of gasless transaxillary endoscopic thyroidectomy in patients with papillary thyroid carcinoma: comparison with sternocleidomastoid fascia approach].

Objective: To examine the posterior sternocleidomastoid border approach which elevated whole sternocleidomastoid in gasless transaxillary endoscopic thyroidectomy. Methods: The clinical data of 46 patients with papillary thyroid carcinoma treated with gasless transaxillary endoscopic thyroidectomy from May 2019 to June 2020 at Department of Head and Neck Surgery, Sichuan Cancer Hospital was analyzed retrospectively. There were 9 males and 37 females, aged (38.6±12.0) years (range: 19 to 74 years). Fourteen and 32 cases performed posterior sternocleidomastoid border and sternocleidomastoid fascia approach, respectively. Comparative analysis were performed on clinical characters, surgical outcomes, postoperative complications, postoperative pain score, and quality-of-life of postoperative 1 month by t test, Wilcoxon rank sum test, Fisher exact test and χ2 test,respectively. Resuts Complete exposure of central compartment was higher (11/14 vs. 34.4%(11/32),χ²=7.624, P=0.006), more lymph nodes was retrieved (4.2±2.9 vs. 2.0±2.5, t=2.663, P=0.011) in posterior sternocleidomastoid border approach. There were no significant differences between groups in postoperative complications such as recurrent laryngeal nerve palsy (1/14 vs. 3.1%(1/32), P=0.521) and transient hypoparathyroidism (0 vs. 6.2%(2/32), P=1) and pains and quality-of-life. Conclusion: Posterior sternocleidomastoid border approach of gasless transaxillary endoscopic thyroidectomy is safe and reliable and has the advantage of central compartment dissection without increasing trauma.

[Preliminary application value of ultrasound contrast agent with enteral nutritional suspension as mixed medium in locating indwelling nasointestinal tube in critically ill patients].

Objective: To evaluate the value of ultrasound contrast agent with enteral nutrition suspension as mixed medium in locating indwelling nasointestinal tube in critically ill patients. Methods: Total of 45 critically ill patients had nasointestinal tube indwelled were collected from June 1,2018 to April 1,2019 in the Intensive Care Unit of Zhejiang Provincial People's Hospital, including 30 males and 15 females, with an average age of (63±17) years.Enteral nutritional suspension Peptisorb Liquid was used as research medium,with the ultrasonic imaging performance of it confirmed by in vitro and in vivo experiments.The optimal mixing ratio of microbubble ultrasound contrast agent and Peptisorb Liquid was confirmed by in vitro experiment, then the mixture was quietly placed and its stability was dynamically observed. The nasointestinal tube was confirmed in the digestive tract by conventional ultrasound and then the ultrasound contrast mode turned on. Ultrasound contrast agent with Peptisorb Liquid as mixed medium was injected into the nasointestinal tube and the tube direction and end position were observed and recorded in real time. Abdominal X-ray examination or CT was used as the gold standard for verifying the location of the nasointestinal tube and the same result represented successful positioning. Results: The in vitro and in vivo experiments showed that Peptisorb Liquid had good ultrasound imaging uniformity and penetrating power, which could clearly show the range and boundary of the filling intestine cavity; the in vitro experiment showed that the ultrasound contrast agent prepared with the microbubble ultrasound contrast agent and Peptisorb Liquid by the ratio of 1∶1 000 and 1∶500 which had the best imaging effect and the best distribution uniformity, with the best stability within 10 minutes after quietly placed. Nasointestinal tubes were successfully located by using ultrasound contrast agent with enteral nutritional suspension as mixed medium in 95.6%(43/45) of the patients collected in this study,including success at one attempt in 39 cases, the operating time was (1.6±0.5) minutes and 4 cases were successfully located after multiple operations with (5.1±0.5) minutes, the tube bent in the stomach in one case and flexed back into the stomach from the descending duodenum in another. The operation failed in 2 cases (4.4%). No significant complications occurred during the examination. Conclusion: The ultrasound contrast agent with enteral nutritional suspension as mixed medium has the advantages of both, which can conveniently, safely and effectively locate the direction and end position of nasointestinal tube in critically ill patients.

[The significance and latest progress of extrathyroidal extension of thyroid cancer].

Extrathyroidal extension of thyroid cancer has been an important adverse factor affecting the prognosis of patients. According to the latest NCCN (National Comprehensive Cancer Network) guidelines, extrathyroidal extension is the surgical guide fortotal thyroidectomy in newly diagnosed patients, and its incidence in differentiated thyroid cancer is 5%-34%, belonging to T3-T4 stage.In the eighth edition of thyroid cancer AJCC staging, the T3 stage was first divided into T3a (tumor>4 cm and limited to the thyroid) and T3b (gross extrathyroidal extension invading only strap muscles from a tumor of any size), and the "minimal extrathyroidal extension(tumor invasion intoperithyroidal soft tissue or strap muscle invasion)"of the seventh edition was removed from the T stage and changed to the gross extrathyroidal extension invading only strap muscles, but there is still much controversy. It can be seen that different degrees of "extrathyroidal extension" have significant differences in the survival and prognosis of thyroid cancer. This article reviews the latest research progress of extrathyroidal extension, and discusses the significance and clinical research progress of it.

[Progression of diagnosis and treatment of medullary thyroid carcinoma].

Objective: To review and summarize recent update on preoperative diagnostic criteria, treatment and postoperative follow-up for medullary thyroid carcinoma. Methods: The relevant literatures and guidelines about medullary thyroid carcinoma were analyzed and summarized. Results: In the early stages of the disease radical surgery still dominated. Ultrasound results suggested that prophylactic lateral neck dissection was required for patients with high risk factors or high levels of carcinoembryonic antigen and calcitonin need prophylactic. Early hereditary medullary carcinoma could receive prophylactic thyroidectomy based on RET gene test results. Advanced progressive medullary thyroid carcinoma could be treated with palliative surgery,molecular targeted drugs and chemotherapy. Conclusions: The prognosis of medullary thyroid carcinoma is poor and lymph node metastasis is easy to occur early. The extent of initial operation should be enough. Locally advanced or distant metastatic medullary thyroid carcinoma can be treated with palliative surgery,molecular targeted drugs and chemotherapy.

[Discussion about the safety of outpatient thyroid surgery].

Thyroid tumors are one of the most common diseases, and the thyroidectomy surgery increases. The outpatient surgery is the new trend in clinic. Is it suited for the thyroidectomy? In this article, we will analyse the setting of hospital, surgeon, surgery, patients, and so on, to prove the safety for the outpatient thyroidectomy. After the analysis, the safety of outpatient thyroidectomy surgery will be ensured only if strictly controlling the condition of hospital, surgeons and patients, and following the relation indications.

[Advances in the treatment of sinonasal malignancy].

Sinonasal neoplasms are common tumors in the head and neck.The types of tumor pathological tissues are complex and diverse, and the incidence of malignant tumors is relatively low.The malignant tumor of paranasal sinuses is occult, and most of them are locally advanced.Although surgery is the main treatment for such diseases, the specific treatment plan is still controversial.This article reviews the treatment of sinonasal malignancy.

[Research progress in pathogenesis, treatment and prognosis of HPV positive head and neck squamous cell carcinoma].

Head and neck squamous cell carcinoma (HNSCC) is the sixth common malignant tumors of whole body with a high incidence, which accounts for 90% of the head and neck malignant tumors. Previous studies have shown the risk factors, such as tobacco and alcohol, are related to the occurrence and development of HNSCC. However, recent studies have shown that the non-tobacco and non-alcohol related HNSCC increased year by year. At the same time, more and more studies have shown that HNSCC is related to the infection with human papilloma virus (HPV), and the occurrence and development of HPV-positive HNSCC has own characteristics in epidemiology, pathogenesis, treatment and prognosis. In this paper the research progress for HPV-positive HNSCC is reviewed.

[Application of virtual reality in surgical treatment of complex head and neck carcinoma].

Objective: To investigate the application of virtual reality technology in the preoperative evaluation of complex head and neck carcinoma and he value of virtual reality technology in surgical treatment of head and neck carcinoma. Methods: The image data of eight patients with complex head and neck carcinoma treated from December 2016 to May 2017 was acquired. The data were put into virtual reality system to built the three-dimensional anatomical model of carcinoma and to created the surgical scene. The process of surgery was stimulated by recognizing the relationship between tumor and surrounding important structures. Finally all patients were treated with surgery. And two typical cases were reported. Results: With the help of virtual reality, surgeons could adequately assess the condition of carcinoma and the security of operation and ensured the safety of operations. Conclusions: Virtual reality can provide the surgeons with the sensory experience in virtual surgery scenes and achieve the man-computer cooperation and stereoscopic assessment, which will ensure the safety of surgery. Virtual reality has a huge impact on guiding the traditional surgical procedure of head and neck carcinoma.

[Experts consensus on the management of the right heart function in critically ill patients].

To establish the experts consensus on the right heart function management in critically ill patients. The panel of consensus was composed of 30 experts in critical care medicine who are all members of Critical Hemodynamic Therapy Collaboration Group (CHTC Group). Each statement was assessed based on the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) principle. Then the Delphi method was adopted by 52 experts to reassess all the statements. (1) Right heart function is prone to be affected in critically illness, which will result in a auto-exaggerated vicious cycle. (2) Right heart function management is a key step of the hemodynamic therapy in critically ill patients. (3) Fluid resuscitation means the process of fluid therapy through rapid adjustment of intravascular volume aiming to improve tissue perfusion. Reversed fluid resuscitation means reducing volume. (4) The right ventricle afterload should be taken into consideration when using stroke volume variation (SVV) or pulse pressure variation (PPV) to assess fluid responsiveness.(5)Volume overload alone could lead to septal displacement and damage the diastolic function of the left ventricle. (6) The Starling curve of the right ventricle is not the same as the one applied to the left ventricle,the judgement of the different states for the right ventricle is the key of volume management. (7) The alteration of right heart function has its own characteristics, volume assessment and adjustment is an important part of the treatment of right ventricular dysfunction (8) Right ventricular enlargement is the prerequisite for increased cardiac output during reversed fluid resuscitation; Nonetheless, right heart enlargement does not mandate reversed fluid resuscitation.(9)Increased pulmonary vascular resistance induced by a variety of factors could affect right heart function by obstructing the blood flow. (10) When pulmonary hypertension was detected in clinical scenario, the differentiation of critical care-related pulmonary hypertension should be a priority. (11) Attention should be paid to the change of right heart function before and after implementation of mechanical ventilation and adjustment of ventilator parameter. (12) The pulmonary arterial pressure should be monitored timingly when dealing with critical care-related pulmonary hypertension accompanied with circulatory failure.(13) The elevation of pulmonary aterial pressure should be taken into account in critical patients with acute right heart dysfunction. (14) Prone position ventilation is an important measure to reduce pulmonary vascular resistance when treating acute respiratory distress syndrome patients accompanied with acute cor pulmonale. (15) Attention should be paid to right ventricle-pulmonary artery coupling during the management of right heart function. (16) Right ventricular diastolic function is more prone to be affected in critically ill patients, the application of critical ultrasound is more conducive to quantitative assessment of right ventricular diastolic function. (17) As one of the parameters to assess the filling pressure of right heart, central venous pressure can be used to assess right heart diastolic function. (18). The early and prominent manifestation of non-focal cardiac tamponade is right ventricular diastolic involvement, the elevated right atrial pressure should be noticed. (19) The effect of increased intrathoracic pressure on right heart diastolic function should be valued. (20) Ttricuspid annular plane systolic excursion (TAPSE) is an important parameter that reflects right ventricular systolic function, and it is recommended as a general indicator of critically ill patient. (21) Circulation management with right heart protection as the core strategy is the key point of the treatment of acute respiratory distress syndrome. (22) Right heart function involvement after cardiac surgery is very common and should be highly valued. (23) Right ventricular dysfunction should not be considered as a routine excuse for maintaining higher central venous pressure. (24) When left ventricular dilation, attention should be paid to the effect of left ventricle on right ventricular diastolic function. (25) The impact of left ventricular function should be excluded when the contractility of the right ventricle is decreased. (26) When the right heart load increases acutely, the shunt between the left and right heart should be monitored. (27) Attention should be paid to the increase of central venous pressure caused by right ventricular dysfunction and its influence on microcirculation blood flow. (28) When the vasoactive drugs was used to reduce the pressure of pulmonary circulation, different effects on pulmonary and systemic circulation should be evaluated. (29) Right atrial pressure is an important factor affecting venous return. Attention should be paid to the influence of the pressure composition of the right atrium on the venous return. (30) Attention should be paid to the role of the right ventricle in the acute pulmonary edema. (31) Monitoring the difference between the mean systemic filling pressure and the right atrial pressure is helpful to determine whether the infusion increases the venous return. (32) Venous return resistance is often considered to be a insignificant factor that affects venous return, but attention should be paid to the effect of the specific pathophysiological status, such as intrathoracic hypertension, intra-abdominal hypertension and so on. Consensus can promote right heart function management in critically ill patients, optimize hemodynamic therapy, and even affect prognosis.

[Quick confirmation of nasointestinal tube placed below pylorus in critically ill patients by duodenal bulb ultrasonic anatomy locating method].

Objective: To investigate the value of duodenal bulb ultrasonic anatomy locating method quickly confirm nasointestinal tube placed below pylorus in critically ill patients. Methods: A total of 56 critically ill patients with nasointestinal tube posting surgery by blindly inserting method were collected from March 1 st, 2016 to August 1 st, 2016 in the Department of Critical Care Medicine of Zhejiang Provincial People's Hospital.In these patients, the duodenal bulbs were rapidly detected and located by ultrasonic anatomy locating method and at the same time observed whether nasointestinal tube echogram were in them or not. If nasointestinal tube echogram was observed in duodenal bulbs that meant nasointestinal tube placed below pylorus successfully. If disturbed by ultrasound artifacts or other reasons, injected gas into the nasointestinal tube could help to confirm when hyperechoic strip emerged. Gastrointestinal decompression or gastrointestinal motion promoting drug could help to reduce the interference of abdominal cavity or bowel gas if necessary. The results were compared with the abdominal X examination to vertify the accuracy of this method, and at the same time recorded its total time-consuming and its related complications. Results: The duodenal bulbs were rapidly located by ultrasonic anatomy locating method in 53 cases(94.6%) time-consuming(42±23)s. Nasointestinal tubes observed in duodenal bulb were confirmed to be placed below pylorus successfully in 52 cases(92.9%)time-consuming(140±94)s.There were no obvious complications in all patients. Conclusion: Duodenal bulb ultrasonic anatomy locating method is a safe, simple and convenient method with high accuracy that can quickly confirm whether nasointestinal tube placed below pylorus in critically ill patients or not.