Is intraoperative nerve monitoring useful for surgical training in thyroid surgery?

OBJECTIVES: Parathyroid glands and recurrent laryngeal nerves (RLNs) are at risk during thyroid surgery. However, the identification of the nerves has reduced these risks. Intraoperative nerve monitoring (IONM) during thyroid surgery has gained widespread acceptance as an aid to the gold standard of visually identifying the RLN. The aim of the present study was to evaluate the effect of the identification of the RLN during thyroidectomy by using IONM. MATERIAL AND METHODS: Seven hundred forty-eight patients were included in our prospectively designed study. Of these 748 patients, 1496 nerves at risk were studied. Group 1 consisted of 736 nerves that were identified using IONM, whereas Group 2 consisted of 760 visually identified nerves. RESULTS: In the non-IONM group, the rate of temporary nerve palsy was lower in patients operated by experienced surgeons than in patients operated by residents (p= 0.001). In the IONM group, RLN injury rates were similar between experienced surgeons and residents. CONCLUSION: In spite of the fact that the duration of the operation was lower with IONM, the abbreviated duration may not appear to have clinical significance. The main advantage is for less experienced surgeons. IONM significantly decreases RLN palsy rates of the surgeons with limited experience in thyroid surgery.

Intraoperative nerve monitoring is useful for surgical training in thyroid surgery.

OBJECTIVE: Parathyroid glands and recurrent laryngeal nerves (RLNs) are at risk during thyroid surgery. However, the identification of the nerves reduced these risks. Intraoperative nerve monitoring (IONM) during thyroid surgery has gained widespread acceptance as an aid to the gold standard of visually identifying the RLN. The aim of the present study was to evaluate the effect of the identification of the RLN during thyroidectomy by using IONM. MATERIAL AND METHODS: Seven hundred forty-eight patients were included in our prospectively designed study. Of these 748 patients, 1496 nerves at risk were studied. Group 1 consisted of 736 nerves that were identified using IONM, whereas Group 2 consisted of 760 visually identified nerves. RESULTS: In the non-IONM group, the rate of temporary nerve palsy was lower in patients who were operated by experienced surgeons than in patients who were operated by residents (p=0.001). In the IONM group, RLN injury rates were similar between experienced surgeons and residents. CONCLUSION: In spite of the fact that the duration of the operation was lower with IONM, the abbreviated duration may not appear to have clinical significance. The main advantage is for less experienced surgeons. IONM significantly decreases RLN palsy rates of surgeons with limited experience in thyroid surgery.

Effect of intra-abdominally administered mesalazine (5-aminosalicylic acid) in experimental peritonitis.

OBJECTIVE: In this study, the effect of mesalazine was studied on TNF alpha IL-1 beta, IL-6, and C-reactive protein (CRP) levels and inflammatory changes in rat lungs with experimental peritonitis. METHODS: In total, 24 male Sprague-Dawley rats weighing 250-280 g were used in the study.The rats were divided into three groups based on no irrigation or irrigation with isotonic solution or mesalazine. Secondary peritonitis was generated by cecum penetrations. Group I, no irrigation was given after the development of peritonitis; Group II, irrigation was performed using isotonic solution 24 h after the development of peritonitis. GROUP III: irrigation was performed using mesalazine 24 h after the development of peritonitis. Blood samples were taken in the 48th hour for measuring TNF alpha, IL-1 beta, IL-6, and CRP levels. Lung tissue samples were taken for examining the effect of mesalazine in the development of systemic sepsis. RESULTS: TNF alpha, IL-1 beta, and CRP levels were significantly low in Group III than in the other groups (p<0.005). In the histologic examination, leucocyte infiltration in the lung was found low in Group III. CONCLUSION: TNF alpha, IL-1 beta, and CRP levels and leucocyte infiltration in the lung were found to be low in rats that were administered peritoneal irrigation using mesalazine after the development of secondary peritonitis. Peritoneal irrigation using mesalazine may be useful in patients requiring surgery due to secondary peritonitis.

The "forgotten" goiter after total thyroidectomy.

INTRODUCTION: "Forgotten" goiter is an extremely rare disease which is defined as a mediastinal thyroid mass found after total thyroidectomy. PRESENTATION OF CASE: We report two cases with forgotten goiter. One underwent total thyroidectomy due to thyroid papillary cancer and TSH level was in normal range one month after surgery. The thyroid scintigraphy scan revealed mediastinal thyroid mass. The second case underwent total thyroidectomy due to Graves' disease and TSH level was low after surgery. At postoperative seventh year, patients were admitted to our Endocrinology Division due to persistent hyperthyroidism and CT scan revealed forgotten thyroid at mediastinum. Both patients underwent median sternotomy and mass excision, there was no morbidity detected after second surgical procedures. DISCUSSION: In the majority of cases forgotten goiter is the consequence of the incomplete removal of a plunging goiter. Although in some cases, it may be attributed to a concomitant, unrecognized mediastinal goiter which is not connected to the thyroid with a thin fibrous band or vessels. Absence of signs like mediastinal mass or tracheal deviation in preoperative chest X-ray do not excluded the substernal goiter. CONCLUSION: Retrosternal goiter should be suspected if the lower poles could not be palpated on physical examination and when postoperative TSH levels remained unchanged.

Nonfunctional adrenal lesions without loss of signal intensity on MRI: whose problem is it? The patient's? The surgeon's?

BACKGROUND: Current indications for adrenalectomy include functional adrenal tumors and potentially malignant tumors based on imaging studies. We evaluated the effectiveness of magnetic resonance imaging (MRI) in obtaining a correct preoperative diagnosis. METHOD: Fifty-three patients with nonfunctional adrenal lesions were analyzed. Indications for adrenalectomy of nonfunctional adrenal lesions included >6 cm in size and ≤6 cm in size with atypical characteristics on MRI. Lesions with a size of >6 cm, local invasion, irregular margins, and chemical-shift imaging that demonstrated no loss of signal intensity on out-of-phase images were considered suspected of malignancy. RESULTS: Adrenal lesions of >6 cm in size exhibited an 80-fold increased prediction of malignancy (OR: 80; 95% CI 7.8-813), whereas irregular margins and local invasion exhibited a 45-fold (OR: 45; 95% CI 6.4-312.5) and a 12-fold (OR: 12; 95% CI 4.6-30.6) increased occurrence of malignancy, respectively. The loss of signal intensity did not affect the prediction of malignancy. CONCLUSION: The rate of unnecessary tumor resections that are <6 cm in size can be decreased by performing adrenal biopsies in selected cases or by short-term follow-up to prevent the insufficiency of imaging techniques.