[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.

Pancreatic insulinomas: diagnosis and surgical treatment of 74 patients.

OBJECTIVE: To summarize retrospectively the experience in diagnosis and surgical treatment of pancreatic insulinoma. METHOD: 74 patients who had been operated on and confirmed pathologically from July 1967 to July 2001 were enrolled. They were 37 men and 37 women, aged 41.91 years on average. RESULTS: In all patients with typical Whipple's triad, the ratio of insulin to glucose was measured over 0.3 for at least one time. 52.70% of the patients were once misdiagnosed, and only 20.27% of them were correctly diagnosed in a year after onset of symptoms. Their average course of the disease was 3.36 years. B-ultrasonography and endoscopic ultrasonography (EUS) showed a low positive rate for localization of insulinoma. CT and magnetic resonance imaging (MRI) could correctly detected 63.41% and 63.64% of tumors respectively, in sharp contrast to a localization rate of 90% for arterial stimulation and venous sampling (ASVS). Single insulinoma was observed in 66 patients (89.19%), multiple insulinoma in 2 (2.70%), hyperplasia in 4 (5.41%), and malignant insulinoma in 2 (2.70%). Most (85.29%) of the benign insulinomas were less than 2 cm in diameter. Simple enucleation was the major operative procedure for benign tumors. In 88.52% of the patients, glycemia increased to normal in 30 minutes after tumor excision, and in the remaining patients within 2 hours. 97.26% of the patients experienced temporary hyperglycemia but recovered in a week. The major complications of insulinoma included pancreatic fistulae (27.27%) and pancreatitis (5.19%). CONCLUSIONS: Better recognization of insulinoma and its rational examination are essential to early diagnosis. CT can be first used for localization, otherwise ASVS is used. Surgery is the major choice for the treatment of insulinoma, but cautions should be taken to pancreatic fistulae after operation.

Transjugular intrahepatic portosystemic shunt for liver transplantation.

OBJECTIVES: To assess transjugular intrahepatic portosystemic shunt (TIPSS) as an effective bridge between the control of variceal bleeding or refractory ascites and orthotopic liver transplantation (OLTx) and to examine whether TIPSS influences the operative procedures of OLTx. METHODS: Five patients treated by TIPSS prior to OLTx were retrospectively reviewed. RESULTS: The patients were followed up for 2-7 months (average 4.2 months) after transplantation. Transplantation was performed at a mean of 9.6 months (range 0.2-24.7) after TIPSS insertion. In four patients, stents were predominantly intrahepatic and they did not interfere with OLTx. In one patient, the stent extended into the portal vein, requiring removal during OLTx by division of the stent with the recipient portal vein. All patients are alive and none has portal vein thrombosis. No difference was observed in operation time, blood transfusion, and the length of hospital stay. CONCLUSIONS: TIPSS is an effective bridge to OLTx for the control of variceal hemorrhage or refractory ascites. Our results suggest that TIPSS does not increase surgical morbidity or mortality, but optimal TIPSS placement within the liver is emphasized to facilitate subsequent OLTx.