Extent of cervical lymph node dissection: Recommendations from the Francophone Association for Endocrine Surgery, the French Society of Endocrinology and the French Society of Nuclear Medicine.

When metastatic ipsilateral central lymph nodes from thyroid cancer are identified pre- or intraoperatively (cN1a), ipsilateral central lymph node dissection should be performed concomitantly with thyroidectomy. When the patient is N1a on one side, contralateral prophylactic central lymph node dissection can also be considered. Prophylactic ipsilateral lymph dissection is not recommended. Ipsilateral compartment lymph node dissection is recommended in the corresponding sector for treatment of thyroid cancer with lymph node involvement (cN1b). Lymph node dissection can be limited to sectors III and IV when one of these sectors (or both) is involved and ultrasound does not demonstrate involvement of the other lateral sectors. Associated prophylactic lymph node dissection of sectors IIA and IIB is not recommended, while lymph node dissection of sector V (and exceptionally sector I) is indicated only when metastatic lymph nodes are proven. Prophylactic lymph node dissection of sector VB can be considered when positive lymph nodes are identified in sectors II, III and IV. When isolated metastatic lateral lymph nodes are identified (cN1b), prophylactic central (sector VI) lymph node dissection is recommended on the same side as the lateral compartment in addition to ipsilateral lateral lymph node compartment dissection. The level of evidence is insufficient to recommend prophylactic lateral lymph node dissection on the contralateral side for unilateral cN1b tumors. This type of lymph node dissection can be discussed for tumors that are at high risk of recurrence, bilateral tumors, in case of ipsilateral lateral lymph nodes > 3cm or in presence of > 4 metastatic lymph nodes in the central compartment.

Exploration of peripancreatic lymphatic pathways in a live porcine model.

Pancreatic cancer is associated with a poor prognosis, mainly due to lymph node invasion and lymph node recurrence after surgical resection, even after extended lymphadenectomy. The peripancreatic lymphatic system is highly complex and the specific lymphatic drainage of each part of the pancreas has not been established. The aim of this study was to determine the lymphatic drainage pathways specific to each part of the pancreas on live pigs using Patent Blue. The pancreases of 14 live pigs were injected in different parts of the gland. The technique was efficient and reproducible. The diffusion patterns were similar for each location and were reported. Our results in pigs allowed us to define specific nodal relay stations and lymphatic drainage for each part of the pancreas and confirm that independent anatomical-surgical pancreatic segments can be described. It is interesting to note that lymphatic drainage for the upper part of the proximal part of pancreas (duodenal lobe) occurred on the left side of the portal vein. This suggests that lymph node resection during cephalic duodenopancreatectomy in humans should be extended to the left side of the mesenteric vein, and probably to the right side of the superior mesenteric artery, as recently suggested. These results could help surgeons perform safe anatomical-segmental pancreatic resections with accurate lymphadenectomies and improve survival in patients with pancreatic cancer. Based on these results we will perform an innovative prospective study. Patent Blue will be injected into different parts of the gland in patients operated for pancreatic resection, and lymphatic diffusion of the dye will be recorded in relation to their origin from the theoretical pancreatic segments (ClinicalTrials.gov Identifier: NCT03597230).

Experimental study of pedicled subcostal artery perforator (SCAP) flap: A new application in breast reconstruction.

BACKGROUND: Latissimus dorsi flap is the gold standard for pedicled breast reconstruction but is limited by donor site scarring, which is difficult to conceal, and a high rate of post-operative seroma. We investigated the anatomic characteristics and feasibility of using a subcostal artery perforator (SCAP) flap, which was taken from the flank area and vascularised by a perforator artery through a subcostal pedicle, for a breast reconstruction. METHODS: A literature review was undertaken to determine the anatomy of the SCAP flap pedicle and the vascular supply to this dermal-fat flap. Pedicled SCAP flaps were dissected on cadavers to identify the anatomy of the perforator arteries and the pedicle length. Pedicled SCAP flaps were then tunnelled through the chest area to evaluate their feasibility for breast reconstruction. RESULTS: Twelve SCAP flaps were prepared on six cadavers. Mean pedicle length was 17 cm (14.5-20 cm). Mean flap size was 13 × 18 cm (11.5 × 15.5-15 × 21 cm). For each flap, a pedicle of sufficient length was dissected to allow the tunnelling of the flap and to perform breast reconstruction with a dermal-fat flap of adequate size. In all cases, an SCAP flap was prepared, without taking muscle, to reduce the risk of parietal complications at the donor site in future clinical applications. CONCLUSION: Pedicled SCAP flap is a feasible option in breast reconstruction and could represent a less arduous surgical alternative to free flaps for some patients. Donor site scarring was acceptable. Clinical application of SCAP flaps should be investigated further.

Unraveling Pancreatic Segmentation.

BACKGROUND: Limited pancreatic resections are increasingly performed, but the rate of postoperative fistula is higher than after classical resections. Pancreatic segmentation, anatomically and radiologically identifiable, may theoretically help the surgeon removing selected anatomical portions with their own segmental pancreatic duct and thus might decrease the postoperative fistula rate. We aimed at systematically and comprehensively reviewing the previously proposed pancreatic segmentations and discuss their relevance and limitations. METHODS: PubMed database was searched for articles investigating pancreatic segmentation, including human or animal anatomy, and cadaveric or surgical studies. RESULTS: Overall, 47/99 articles were selected and grouped into 4 main hypotheses of pancreatic segmentation methodology: anatomic, vascular, embryologic and lymphatic. The head, body and tail segments are gross description without distinct borders. The arterial territories defined vascular segments and isolate an isthmic paucivascular area. The embryological theory relied on the fusion plans of the embryological buds. The lymphatic drainage pathways defined the lymphatic segmentation. These theories had differences, but converged toward separating the head and body/tail parts, and the anterior from posterior and inferior parts of the pancreatic head. The rate of postoperative fistula was not decreased when surgical resection was performed following any of these segmentation theories; hence, none of them appeared relevant enough to guide pancreatic transections. CONCLUSION: Current pancreatic segmentation theories do not enable defining anatomical-surgical pancreatic segments. Other approaches should be explored, in particular focusing on pancreatic ducts, through pancreatic ducts reconstructions and embryologic 3D modelization.

Anatomical and CT approach of the adipose tissue: application in morbid obesity.

PURPOSE: The importance and proportion of visceral adipose tissue (VAT) represent the best criterion to define obesity. Because VAT value is difficult to obtain in clinical practice, the indication for bariatric surgery is still based at present on Body Mass index (BMI), even though BMI is a poor predictor of obesity-related morbid complications. This correlation study aimed at determining a simple and accurate computed tomography (CT) anatomic marker, which can be easily used clinically, well correlated with the volume of VAT and consequently with morbid complications. METHODS: We studied 108 CT scans of patients presenting with morbid obesity. Several simplified measures (external and internal abdominal diameters and circumferences) were conducted on CT scan view, going through the fourth lumbar vertebra (L4), in addition to various vertebral measurements (area of the vertebra, sagittal and transversal diameters), VAT and subcutaneous adipose tissue (SAT). Then, we reported the simplified measures values on the vertebral areas, and we calculated the Bertin index. Finally, we conducted a correlation study between all variables to obtain accurate VAT measurements. RESULTS: The internal abdominal circumference and the Bertin index showed the best correlations with VAT in morbidly obese patients (r = 0.84 and 0.85, respectively). BMI and anthropometric measures were not correlated with VAT. CONCLUSION: CT scan study allows to simply approximate VAT value in morbidly obese patients. An abdominal CT scan could be part of the tests used in the evaluation of obese patients to base therapeutic strategies on VAT values and not on BMI as it is the case today.

Human developmental anatomy: microscopic magnetic resonance imaging (µMRI) of four human embryos (from Carnegie Stage 10 to 20).

BACKGROUND AND AIM: Technological advances in the field of biological imaging now allow multi-modal studies of human embryo anatomy. The aim of this study was to assess the high magnetic field µMRI feasibility in the study of small human embryos (less than 21mm crown-rump) as a new tool for the study of human descriptive embryology and to determine better sequence characteristics to obtain higher spatial resolution and higher signal/noise ratio. METHODS: Morphological study of four human embryos belonging to the historical collection of the Department of Anatomy in the Faculty of Medicine of Reims was undertaken by µMRI. These embryos had, successively, crown-rump lengths of 3mm (Carnegie Stage, CS 10), 12mm (CS 16), 17mm (CS 18) and 21mm (CS 20). Acquisition of images was performed using a vertical nuclear magnetic resonance spectrometer, a Bruker Avance III, 500MHz, 11.7T equipped for imaging. RESULTS: All images were acquired using 2D (transverse, sagittal and coronal) and 3D sequences, either T1-weighted or T2-weighted. Spatial resolution between 24 and 70µm/pixel allowed clear visualization of all anatomical structures of the embryos. CONCLUSION: The study of human embryos µMRI has already been reported in the literature and a few atlases exist for educational purposes. However, to our knowledge, descriptive or morphological studies of human developmental anatomy based on data collected these few µMRI studies of human embryos are rare. This morphological noninvasive imaging method coupled with other techniques already reported seems to offer new perspectives to descriptive studies of human embryology.

A rare cause of chronic abdominal pain: recurrent sub-torsions of an accessory spleen.

Accessory spleen is defined as one, two, or three nodules of additional ectopic splenic parenchyma hung by a vascular pedicle generally near the spleen. Despite a relatively high frequency (from 10 to 30 % of the population based on autopsy studies), most accessory spleens are asymptomatic. Although cases of accessory spleen were clearly described in the literature, this perplexing diagnosis is often delayed and rarely made preoperatively. We report episodic recurrences of abdominal pain in a 66-year-old man attributed to iterative sub-torsions of an accessory spleen, as well as a comprehensive review of the literature.

Sirenomelia: a new type, showing VACTERL association with Thomas syndrome and a review of literature.

Sirenomelia or "mermaid syndrome" is a rare congenital anomaly known since antiquity. This congenital anomaly is defined as a polymalformative syndrome that associates major muscle and skeleton abnormalities (unique lower limbs) with visceral abnormalities (unilateral or bilateral renal agenesis, anomalies of the abdominal vascularisation). This phenotype, typical of sirenomelia syndrome, may be more or less severe. The pathogenic mechanisms of this syndrome are still debated and its etiology remains unknown. We report here a new type of sirenomelia that we observed in a fetus belonging to the collection of the Department of Anatomy of Reims, which led us to perform a comprehensive review of the literature on the subject: this type has never been reported and cannot be classified according to the Stocker and Heifetz classification. Moreover, this case also presents a VACTERL association with Thomas syndrome.

Double ischemic ileal stenosis secondary to mesenteric injury after blunt abdominal trauma.

The authors describe a rare case in which blunt abdominal trauma resulted in mesenteric injury with delayed double ischemic ileal stenosis. Abdominal computed tomography demonstrated stenotic ileal loop with mural thickening. At surgery, a double stenotic bowel loop was found adjacent to a healed defect in the mesentery. Histological examination of the two resected segments showed fibrotic and ischemic lesions within the mesentery. Ischemic intestinal stenosis from mesenteric injury should be considered in the differential diagnosis in patients suffering from intestinal occlusion with a history of blunt abdominal trauma.