[An anastomotic loop between the recurrent nerves--an anatomical description]. / Ansa anastomotica fra i nervi ricorrenti--descrizione anatomica.

The authors present the results of twelve dissections of the neck carried out during autopsy on non-conserved human corpses. The investigation, centered on the anatomic study of the laryngeal nerve within the framework of the European Research Group on the Larynx (G.R.E.L.), revealed the presence of a connecting nervous anatomic branch between the recurrent laryngeal nerves which was observed in 10 of the 12 corpses examined. Despite a revision of national as well as international literature concerning ramifications and anastomosis of the recurrent laryngeal nerves, the authors were unable to find description of this anastomotic ansa. The anatomic reliefs related to this branch are extremely interesting, although research is still in its initial phase. This ramification is situated between the trachea and the oesophagus and the location of the branching-off point from the recurrent nerves as well as the crossing point of the nervous bundle with the oesophagus-tracheal axis vary greatly. The detachment of the ansa from the recurrent trunk is located at the intrathoracic level, while the crossing with the posterior paries of the trachea is located in proximity of the cervicomediastinal junction. The constant presence of this nervous entity encourages us to continue and extend our research, most of all towards microscopic and ultrastructural anatomy as well as towards histomorphometric studies which can give us precious indications. Moreover, electrophysiological studies are in program so as to enable us to gather the largest amount of useful data regarding any possible use of this anatomic entity.

[Panendoscopy in the research of multiple malignant synchronous occult tumors in patients with cancer of the upper aero-digestive tract]. / La panendoscopia nella ricerca dei tumori maligni multipli sincroni occulti in pazienti portatori di cancro delle vie aero-digestive superiori.

The Authors consider the result obtained in the diagnosis of malignancies simultaneous neoplasia in patients with a tumour of the head and neck. The study was conducted on 337 patients on 750 observed in the last seven years with a squamous-cell carcinoma at different stages of keratinization, who underwent an ORL examination, bronchoscopy and esophagogastroduodenoscopy, sometimes with intravital staining. Bronchoscopy was conducted on 297 patients, esophagogastruoduodenoscopy on 300. Altogether 260 were subject to both techniques and 77 to only one procedure. Endoscopy released a second tumour in 4 cases on 297 (1.34%) of the bronchus and in 5 cases on 300 (1.66%) of the esophagus. The percentage amounts to 3.46% in 260 patients subject to both examinations. Our study released a malignancies cells (18 cases on 216); this number was not confirmed by istological examination on bronchial biopsy. Our collaborators consider this result as pollution derived from cells coming from clear tumour in expansion. Our study, obtained from a substantial number of cases, justify the use of panendoscopy screening in conjunction with routine studies; although this procedure is aggressive, it is acceptable, because these second tumours have been discovered in early and asintomatic stage and were not found in the radiological examination.

[Chronic hyperplastic parathyroiditis: the anatomico-clinical and pathogenetic aspects]. / Paratiroidite cronica iperplastica: considerazioni anatomo-cliniche e patogenetiche.

The authors described a case of chronic hyperplastic parathyroiditis with hyperparathyroidism occurred in a patient undergone to surgery for laryngeal carcinoma. The morphological picture, the clinical date and the review of the previous studies suggest some hypothesis about the pathogenesis of the chronic hyperplastic parathyroiditis: parainfectious origin, anomalous embryonal development, environmental factors and autoimmune process are considered. The latter pathogenetic mechanism is likely to be involved in most of cases.

Surgical anatomy of the superior laryngeal nerve.

The authors report on their anatomic findings in 42 surgical dissections of the superior laryngeal nerve. Better knowledge of this anatomy should enable a more conservative cervical surgery and help in attempts at nervous rehabilitation of laryngeal paralysis.

The influence of intraoperative central venous pressure on delayed graft function in renal transplantation: a single-center experience.

INTRODUCTION: Delayed graft function (DGF) is a common complication in kidney transplantation. We sought to evaluate possible correlates for DGF including intraoperative parameters, focusing on fluid replacement and central venous pressure (CVP) values among patients undergoing kidney transplantation at our center. METHODS: One hundred fifty-five cadaveric donor transplantations performed at our center between 2001 and 2005 were selected for the study. We compared intraoperative parameters together with 15 other clinical and socio-demographic recipient and donor variables among patients experiencing DGF (n = 58) versus those with immediate graft function (IGF; n = 97). All significant variables at P < .05 upon univariate analysis were entered into a multivariate logistic regression model to identify risk factors for DGF. RESULTS: CVP at awakening of ≤8 mm Hg (odds ratio [OR] = 3.53; 95% confidence interval [CI], 1.63-7.63), fluid input during surgery ≤2.250 mL (OR = 2.12; 95% CI, 1.00-4.51), and recipient age ≥50 years (OR = 2.72; 95% CI, 1.11-6.68) were the strongest correlates of DGF. CONCLUSIONS: Our data suggested that reduced intraoperative perfusion as measured using CVP monitoring might increase DGF risk. This study provides the rationale to further investigate the optimal CVP target during this surgery.

Parathyroid surgery in primary hyperparathyroidism: an update.

The best approach to parathyroid removal in primary hyperparathyroidism (HPT) is still a major topic in neck surgery. The present report reviews our experiences with 71 patients operated by parathyroidectomy (PTX) between 1978 and 1987. Preoperative computed tomography, sonographic and double-tracer subtraction scanning examination allowed a precise assessment of the number and the topography of the diseased glands. Consequently, 65 patients underwent partial "selective" PTX, with removal of one or two glands, while 6 patients underwent subtotal PTX. The surgical results can be summarized as follows: full success in 67 cases (94.4%); persistent hypercalcemic syndrome in 3 cases (4.2%); recurrence of HPT in 1 case (1.4%). One case of persistent hypercalcemia was solved by reoperation. Thus, the total success rate was definitively assessed at 95.8%. As a complication of surgery a long-lasting postoperative hypocalcemic syndrome was observed in only 2 patients following subtotal parathyroidectomy. Our overall findings show that an attentive preoperative study by means of modern imaging techniques usually allows a "selective" partial PTX with good results and a low risk of complications.

[Laryngocele. Possibilities and limitations of surgical treatment under direct microlaryngoscopy]. / Laringocele. Possibilità e limiti del trattamento chirurgico in microlaringoscopia diretta.

Three cases of laryngocele are reported, which were managed by surgery under direct microlaryngoscopy with excellent clinical and functional results, both at short and long term. According to the classification of Y. Lacomme, two patients had an internal or vestibular laryngocele, which was of the low type in one of them and of the middle type in the other. In the first case the pouch and the false vocal fold lying over it were completely removed under direct microlaryngoscopy. In the second case the laringeal cavity was marsupialized after extensive resection of the false fold and part of the lateral wall of the vestibule. Over a short period of time both patients were symptom-free and eventually recovered completely. In the third case tha laryngocele was of a classic mixed type. The patient, who risked suffocation, was elderly (77 years of age) and extremely debilitated. A few days earlier he had had an emergency tracheotomy for severe respiratory failure. Surgery under direct microlaryngoscopy consisted in removing the false fold and the internal laryngocele. About one and ahalf months later, the tracheostomy opening had closed and the latero-cervical pouch had been gradually reduced. The latter was drained abundantly into the laryngeal lumen and remained as an external laryngocele. When the patient is in good enough condition, the laryngocele will be completely removed by means of the most suitable among the common external-approach surgical techniques.

[Comparative study of pre and post-operative dynamic respiratory indices in subjects undergoing total laryngectomy]. / Studio comparativo degli indici respiratori dinamici pre e post-operatori in soggetti sottoposti a laringectomia totale.

A spirometric measurement was carried out on patients with cancer of the laryn before and after surgery for total laryngectomy at the Istituto Policattedra of the University of Parma ENT Clinic. Postoperative spirometry was performed by means of a Vitalograph apparatus with the mouthpiece positioned right over the tracheal opening. The parameters considered were the dynamic respiratory indices (CV/MEVS - MEVS/CV). Forty patients was mostly based on the fact that, prior to laringectomy, all of them had been subjected to a spirometric measurement for aneasthesiologic purposes. According to the results obtained, the patients can be divided into three groups. The first group consists of 10 subjects in whom no improvement was observed in their MEVS value, which in some instances had actually worsened. The second group is composed of 20 patients in whom the spirometric values remained more or less steady. The third group comprises 20 patients who showed a marked improvement of their respiratory indices. In some of the latter patients the values obtained were even better than those in the normal range. However, the overall average results are not statistically significant, except for an average 9% improvement of MEVS due, as expected, to a reduction of the dead space following total laryngectomy and a corresponding, though very slight, 4% improvement of the Tiffenau ratio.

[Use of the Montgomery prosthesis in the treatment and prevention of anterior commissural synechiae secondary to bilateral cordectomy]. / L'impiego della protesi di Montgomery nel trattamento e nella prevenzione delle sinechie commessurali anteriori secondarie cordectomia bilaterale.

The authors report the results obtained with the use of the Montgomery silicone prosthesis for the prevention or treatment of thick and sometimes partially stenosing synechiae of the anterior commissure following bilateral cordectomy by median thyrotomy. The umbrella-shaped prosthesis consists of two silicone sheets which are perpendicular to each other. The vertical sheet is of variable length and, once placed in position, it separates at the anterior commissure the two portions of larynx operated on, so that they may be adequately reepithelized. This procedure was used in three patients undergoing internal subperichondral cordectomy by median thyrotomy, due to a malignancy in both vocal folds which, however, was not extended to the anterior commissure. In two patients the prosthesis was fitted in during the main surgical procedure to prevent an excess of scar tissue; in the third patient, by contrast, it was used to treat a thick, partially stenosing synechia in the commissure secondary to cordectomy, which had already been unsuccessfully managed under direct microlaryngoscopy. In the three patients the prostheses were left in place for 2 and a half, 3, and 3 and a half months, respectively, with no major irritation or inflammation inside the larynx. No supportive tracheotomy had to be performed, and only in one case was the prosthesis secured externally by percutaneous stitching. On indirect laryngoscopy several months after the prosthesis was removed, two patients showed a perfectly healed larynx; in the third patient a very small amount of scar tissue in excess was still present, but it did not affect his respiratory function.

The value of CT scans in improving laryngoscopy in patients with laryngeal cancer.

This retrospective study assessed the value of computed tomography (CT) scan with contrast in improving the staging accuracy of indirect and direct laryngoscopy. We compared the preoperative staging obtained by the two latter procedures with postoperative histopathological findings in 187 patients operated on for laryngeal cancer. Of these cancers, 98 were supraglottic, 82 glottic and 7 subglottic in origin. The staging accuracy of laryngoscopy was 51.3% and CT was 70.1%. When the two procedures were combined, the staging accuracy was 80.2%. The accuracy of the CT increased from glottic to supraglottic to subglottic tumors, although the accuracy of laryngoscopy decreased in the same direction. Laryngoscopy alone tended to understage larger tumors (pT3 and pT4), whereas CT underestimated the smaller ones (pT1 and pT2). Our data suggest that in order to plan the best treatment both laryngoscopy and CT should be used in making the diagnosis.

The pectoralis major myocutaneous flap in head and neck reconstructive surgery: 16 years of experience.

Wide defects resulting after resection of malignant tumors of the head and neck need an adeguate closure. In the last 16 years, 85 pectoralis major myocutaneous island flap procedures were carried out for the immediate reconstruction of surgical defects following extirpation of malignant tumors at various sites of the upper aerodigestive tract. The final functional and cosmetic results were satisfactory. Partial necrosis was observed in four cases. We did not have any cases of total flap necrosis. Post-operative fistulas were encountered in 14 cases (surgical closure was not necessary). The application and complications of the pectoralis major myocutaneous flap placed at cervical level are reviewed. The aspects of postoperative swallowing function of such surgery are discussed. Reconstruction with the pectoralis major myocutaneous flap is a safe and versatile procedure, yielding good clinical and functional results in patients with advanced head and neck tumors.