Recurrent Branch Research Articles

Anatomical Variation of the Recurrent Motor Branch of the Median Nerve.

The recurrent motor branch (RMB) of the median nerve has commonly thought to originate proximal to the terminal digital branches, although its anatomical course and number may vary. We report a rare variation of the RMB that arose from the second common palmar digital nerve. The median nerve bifurcated into the first and second common palmar digital nerves distal to the transverse carpal ligament, with the RMB dividing from the second common palmar digital nerve and traveling retrograde to enter the abductor pollicis brevis muscle. This high origin variation may be at increased risk of injury during procedures of the hand.

Clinical-applied anatomy of the carpal tunnel regarding mini-invasive carpal tunnel release.

Carpal tunnel release is a widely performed procedure. Despite a high success rate, iatrogenic neurovascular injuries can occur which lead to a painful and unsatisfying outcome. This study conducted a detailed examination of the anatomy of the carpal tunnel and the proximity of neurovascular structures that are particularly susceptible to injury, especially in the context of minimally invasive carpal tunnel release procedures. The anatomy of the carpal tunnel of 104 wrists of 52 body donors was examined. The precise anatomical location and the presence of variations were recorded for the median nerve, ulnar nerve, ulnar artery and Berrettini branch. The distance between the median nerve, the ulnar artery, the ulnar nerve, and the Berrettini branch was measured in a proximo-distal and radio-ulnar direction in relation to the distal ulnar end of the carpal tunnel. The authors identified four main dangerous anatomical situations. (1) A proximal separation of the Long-Finger/Ring-Finger branch of the median nerve together with a narrow safe-zone; (2) an ulnar take-off of the recurrent muscle branch of the median nerve with a close radio-ulnar distance to the distal ulnar end of carpal tunnel; (3) an ulnar arterial arch lying close to the transverse carpal ligament; and (4) a proximal Berrettini branch also lying close to the latter. All situations are illustrated by photographs. Additionally, the authors present a sonographic carpal tunnel assessment protocol in order to reduce the risk of injury of any neurovascular structure in the proximity of the carpal tunnel. Certain patients may inherently face an increased risk of neurovascular injuries during minimally invasive carpal tunnel releases due to their anatomical variations. Four potentially risky scenarios were clearly illustrated. Consequently, one may consider conducting a preoperative ultrasound assessment of neurovascular structures at risk, when endoscopic or ultrasound-guided tunnel release are planned. In high-risk patients, open surgery should be preferred. II.

Unusual Motor Hand Neuropathies: Causes, Diagnosis, and Evaluation of Motor Impairments.

Background Isolated hand motor nerve injuries, specifically those affecting the recurrent motor branch of the median nerve and the deep motor branch of the ulnar nerve, are rarely reported in medical literature. Diagnosing and quantifying these injuries pose significant challenges due to their uncommon nature and the variety of mechanisms that can cause them. Methodology This study reviews six unusual cases of isolated damage to the recurrent motor branch of the median nerve and the deep motor branch of the ulnar nerve, including cases with combined injuries. The etiologies include various traumatic and compressive mechanisms, such as a blow from the thenar to the back of a knife blade, long-distance cycling, impact from a broken shovel handle, knife injury, and damage from a screw while using a cordless screwdriver. In one case, the cause was indeterminate. Diagnostic methods involved clinical evaluation, electrophysiological testing (nerve conduction studies and electromyography), and high-resolution ultrasound imaging. A thorough medical history was also crucial in understanding the injury mechanisms. Results The cases demonstrated a range of causes for isolated hand motor nerve injuries, with both traumatic and compressive mechanisms identified. The diagnostic process highlighted the value of integrating clinical assessments, electrophysiological data, and ultrasound imaging to accurately diagnose and understand the extent and nature of the injuries. Conclusions Isolated motor nerve injuries in the hand can arise from diverse and often unexpected causes. Comprehensive clinical evaluation, supported by electrophysiological testing and ultrasound imaging, is essential for accurate diagnosis and management. A detailed medical history is invaluable in identifying the mechanism of injury, which is critical for developing an appropriate treatment plan. The study underscores the importance of a multidisciplinary approach in diagnosing and treating these rare neuropathies.

Anatomical and biomechanical characteristics of basivertebral foramen and its clinical significance.

Basivertebral foramen is a natural orifice in the posterior wall of the vertebral body existing in humans and mammals, through which the basal vertebral vein, branch of lumbar artery and recurrent branch of spinal nerve enter and exit the vertebral body. Basivertebral foramen changes the local microstructure of the vertebral body, resulting in cortical defect and sparse trabecular bone in the central region of the vertebral body, thus affecting its biomechanical characteristics and making its central region a "weak" area of the vertebra. Some characteristic injuries of the vertebra are related to basivertebral foramen, such as vertebral compression fracture and intervertebral cleft, vertebral burst fracture and posterior upper vertebral fracture fragment, and cement leakage during treatment. In this article, the anatomical and developmental biological characteristics of basivertebral foramen, the impact of basivertebral foramen on biomechanical characteristics, and the treatment of basivertebral foramen related vertebral diseases are reviewed, in order to provide references for the clinical diagnosis and treatment of vertebral injuries.

Bilateral multiple recurrent branch retinal vein occlusions secondary to hypercoagulopathy associated with multiple mutations: A rare case report

Abstract: Retinal vein occlusions (RVOs) are relatively common vascular disorders, often resulting in significant visual impairment. We present an intriguing case of a 53-year-old male with recurrent bilateral branch RVOs stemming from underlying hypercoagulopathy. This complex scenario encompassed simultaneous bilateral RVO occurrences and subsequent unilateral recurrences. Despite the absence of systemic comorbidities or conventional risk factors, genetic assessment unveiled notable heterozygous mutations involving Factor V Leiden (G1691A) and Factor II (PT G20210A), along with a homozygous methylenetetrahydrofolate reductase A1298C mutation. While routine hematological indicators remained largely unremarkable, the marked efficacy of anti-vascular endothelial growth factor (anti-VEGF) agents, particularly when administered promptly, emerged as a noteworthy therapeutic avenue. This case underscores the imperative of scrutinizing thrombotic mutations in youthful patients with recurrent RVOs, accentuating the favorable retinal response to anti-VEGF interventions and emphasizing the rewards of timely clinical intervention.

Concurrent Carpal Tunnel Syndrome and Recurrent Motor Branch of the Median Nerve Compression: A Diagnostic Complexity.

Concurrent Carpal Tunnel Syndrome and Recurrent Motor Branch of the Median Nerve Compression: A Diagnostic Complexity.

Anatomical Observation and Clinical Significance of the Medial Branch of the Lumbar Dorsal Rami.

Anatomical study. This study aimed to elaborate on the anatomical characteristics of the medial branch of the lumbar dorsal rami and to discuss its possible clinical significance. Radiofrequency ablation targeting the medial branch of the lumbar dorsal rami has been increasingly used in the clinical management of facetogenic low back pain (FLBP). Nonetheless, attention is also being given to complications such as atrophy of the lumbar soft tissues and muscles. Therefore, a more detailed understanding of the innervation pattern on the facet joint may improve the precision of nerve ablation therapy for FLBP. An anatomical study of eight human specimens was carried out. The anatomic characteristics of the medial branch were observed and recorded. The medial branch originates from the lumbar dorsal rami, running close to the root of the posterolateral side of the superior articular process of the inferior cone. When passed through the mamillo-accessory ligament, it turns direction to the medial and caudal side, running in the multifidus muscle. In our study, each medial branch sent out two to five branches along the way. All the medial branches in L1-L4 gave off one to two small branches when crossing the facet joint and innervated the joint of the lower segment. Nineteen medial branches (23.75%) gave off recurrent branches to innervate the joint at the upper segment. The anatomical features of the medial branch remain similar in each lumbar segment. There are two types of joint branches, including the articular fibers that emanate from the medial branch as it runs along the medial border of the facet joint and the recurrent branch from the medial branch that innervates the upper facet joint. Moreover, an anastomotic branch was found in the medial branches between different segments.

Rare Median Nerve and Digital Nerve Tumor Resection and Distal Nerve Transfers: A Report of 2 Cases.

We present 2 cases of median nerve reconstruction using distal nerve transfers after resection of unusual benign median nerve tumors. Critical sensation was restored in case 1 by transferring the fourth common digital nerve to first web digital nerves. Thumb opposition was regained by transferring the abductor digiti minimi ulnar motor nerve branch to the recurrent median motor nerve branch. Critical sensation was restored in case 2 by transferring the long finger ulnar digital nerve to the index finger radial digital nerve. Distal nerve transfers, even with short grafts, are reliable median nerve deficit treatments, sparing the need for larger autologous nerve grafts and late tendon opponensplasties.

Recurrent motor branch neuropathy in carpal tunnel syndrome: An ultrasound study.

The reason for the variable rate of progression of patients with carpal tunnel syndrome (CTS) to thenar muscles impairment is not fully understood. The aim of this study was to evaluate the occurrence of ultrasound signs of recurrent motor branch (RMB) neuropathy in patients with CTS and to correlate imaging findings with clinical and electrophysiological data. Two cohorts were recruited, one consisting of CTS patients with electrodiagnostic evidence of prolonged median distal motor latency from wrist to thenar eminence and another consisting of sex- and age-matched healthy controls. Ultrasound reliability of RMB measurement was assessed by the calculation of the interclass correlation coefficient (ICC). Patients were evaluated with electrodiagnostic tests and asked to complete the Boston Carpal Tunnel Questionnaire. The difference between the RMB diameter in patients and controls was analyzed using a t test. Correlations between RMB diameter and other parameters were assessed using linear mixed models. 46 hands from 32 patients with CTS and 50 hands from 50 controls were evaluated. The intra- and interobserver agreements in RMB measurement were very good (ICC = 0.84; 95% confidence interval [CI], 0.75 to 0.90) and good (ICC = 0.79; 95% CI, 0.69 to 0.87). The RMB diameter was significantly larger in patients than in controls (P < .0001). No significant correlation was found between the RMB diameter and other variables, except for BMI and median nerve cross-sectional area. Ultrasound is reliable in identifying the RMB and characterizing its abnormalities. In this patient cohort, ultrasound allowed for detection of definite signs of RMB compression neuropathy.

Ultrasound Imaging and Guidance for Distal Peripheral Nerve Pathologies at the Wrist/Hand.

Ultrasound has emerged as a highly valuable tool in imaging peripheral nerve lesions in the wrist region, particularly for common pathologies such as carpal tunnel and Guyon's canal syndromes. Extensive research has demonstrated nerve swelling proximal to the entrapment site, an unclear border, and flattening as features of nerve entrapments. However, there is a dearth of information regarding small or terminal nerves in the wrist and hand. This article aims to bridge this knowledge gap by providing a comprehensive overview concerning scanning techniques, pathology, and guided-injection methods for those nerve entrapments. The median nerve (main trunk, palmar cutaneous branch, and recurrent motor branch), ulnar nerve (main trunk, superficial branch, deep branch, palmar ulnar cutaneous branch, and dorsal ulnar cutaneous branch), superficial radial nerve, posterior interosseous nerve, palmar common/proper digital nerves, and dorsal common/proper digital nerves are elaborated in this review. A series of ultrasound images are used to illustrate these techniques in detail. Finally, sonographic findings complement electrodiagnostic studies, providing better insight into understanding the whole clinical scenario, while ultrasound-guided interventions are safe and effective for treating relevant nerve pathologies.

En bloc resection of total thyroid and bilateral central compartment lymph nodes via a gasless transoral approach in papillary thyroid carcinoma.

The current study presents a preliminary exploration of en bloc resection via a gasless transoral approach in papillary thyroid carcinoma. This study aimed to summarize and explore the efficacy and safety of en bloc resection of total thyroid and bilateral central compartment lymph nodes via a gasless transoral approach in patients with papillary thyroid carcinoma. This study was conducted between January 2021 and December 2021. It involved 30 patients with bilateral papillary thyroid carcinoma who had undergone en bloc resection of the total thyroid and bilateral central compartment lymph nodes via a gasless transoral approach using a three-trocar and four-instrument technique at The First Affiliated Hospital of the University of Science and Technology of China. The key steps and difficulties of the operation were summarized, and the clinicopathological characteristics and surgical complications of patients were analyzed. All operations were successful without conversion to open surgery. The pathological diagnosis was bilateral papillary thyroid carcinoma. The mean maximum tumor diameter was 0.85 ± 0.51cm (range 0.3-2.5 cm). There was no case of gross capsular invasion. The mean number of harvested central compartment lymph nodes was 11.36 ± 5.36. Central compartment lymph node metastases were found in 16 patients (53.3%) with a mean of 1.53 ± 2.39. On the other hand, lymphocytic thyroiditis was observed in 12 cases (40%), and microscopic capsular invasion was observed in five cases (16.6%). All patients had normal parathyroid hormone levels after the operation. However, one patient developed hoarseness after the operation due to injury of the recurrent laryngeal nerve branch, but there was no numbness of the mandible and lower lip or infection of the oral incision. The study revealed that the three-trocar and four-instrument technique can be used in the en bloc resection of total thyroid and bilateral central compartment lymph nodes via a gasless transoral approach without disconnecting the thyroid isthmus. As a result, the operation is considered effective and safe. Therefore, this technique may be a better surgical method for patients with bilateral thyroid cancer and cosmetic needs.

Minimally Invasive Carpal Tunnel Release Using a Hook Knife through a Small Transverse Carpal Incision: Technique and Outcome.

Compared to the classic open technique, limited exposure techniques have the advantages of less scar pain, more grip and pinch strength, and earlier return to daily life. We evaluated the effectiveness and safety of our novel method of minimally invasive carpal tunnel release using a hook knife through a small transverse carpal incision. This study included 111 carpal tunnel decompressions in 78 patients who underwent carpal tunnel release from January 2017 to December 2018. We performed carpal tunnel release using a hook knife through a small transverse incision just proximal to the wrist crease under local infiltration of lidocaine with tourniquet inflation in the upper arm. All patients were tolerable during the procedure and discharged following the procedure on the same day. At an average of 29.4 months of follow-up (range, 12-51 months), all but one patient (99%) revealed complete or near complete symptomatic recovery. The average of the symptom severity score on the Boston questionnaire was 1.31 ± 0.30 and the average of the functional status score was 1.19 ± 0.26. The final mean Quick Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH) score was 8.66 (range, 2-39). There was no superficial palmar arch injury or nerve injury of the palmar cutaneous branch, recurrent motor branch, or median nerve itself as a complication of the procedure. No patient showed any wound infection or wound dehiscence. Our carpal tunnel release using a hook knife through a small transverse carpal incision performed by an experienced surgeon is a safe and reliable method that is expected to have the benefits of simplicity and minimal invasiveness.

The Effect of Transcutaneous Vagus Nerve Stimulation on Laryngeal Muscle Flexibility with Lexical Tone Imitation.

Transcutaneous vagus nerve stimulation (tVNS) is a non-invasive technique that applies electrical currents through surface electrodes at selected locations to reorganize the brain neural network based on neuroplasticity. The therapeutic effect of tVNS has been reported related to the sensory neural network, but few studies are on the motor neural network. We hypothesized that when applying the tVNS to the recurrent laryngeal branch of the vagus nerve, the laryngeal muscles responsible for speech will become more flexible, and their motor activities will be enhanced. To examine this hypothesis, Chinese lexical tones were adopted to be imitated by the healthy English native speakers. Preliminary results indicated the positive tVNS effect and its potential clinical application.

Tips and tricks for maximising access to the middle cranial fossa using the superior lateral orbital portal.

Transorbital endoscopic approaches are becoming increasingly popular for skull base pathologies; the superior lateral orbital portal is one such approach to the middle cranial fossa. This paper provides a technical description that maximises the surgical portal and minimises morbidity. A superior lid crease incision is made extending laterally and the orbital rim is exposed. A subperiosteal dissection of the lateral and superior orbit is performed, with elevation of periosteum off Whitnall's tubercle, ligation of the recurrent branch of the middle meningeal artery, and identification of the superior orbital fissure. The lacrimal keyhole is then drilled away. The middle cranial fossa is accessed by drilling posterior to the orbital rim to expose: the temporalis muscle anterior-laterally, the dura of the temporal lobe posterior-laterally, the anterior cranial fossa superiorly and the periorbita medially. These surgical steps can maximise the surgical portal and minimise morbidity, with avoidance of injury to surrounding structures.

Effectiveness of an Endoscopic Recurrent Branch Release Procedure Combined with Standard Endoscopic Carpal Tunnel Release Surgery Compared to Standard Endoscopic Carpal Tunnel Release Surgery Alone: A Propensity Score-Matched Study

Background: The purpose of this study is to compare the effectiveness of endoscopic release of the recurrent branch from surrounding soft tissue in combination with standard endoscopic carpal tunnel release (ECTR) surgery to standard ECTR surgery alone in patients with established abductor pollicis brevis (APB) muscle weakness. Methods: Using propensity score matching, we compared the recovery rates of postoperative clinical symptoms in patients with idiopathic carpal tunnel syndrome in whom the preoperative Medical Research Council (MRC) scale of the APB muscle (MRC-APB) was zero (no contraction) and with undetectable distal motor latency (DML) of APB, to those who underwent standard ECTR surgery alone and those who underwent recurrent branch release in addition to standard ECTR. Results: Forty-nine hands in the recurrent branch release group and 49 hands in the standard ECTR surgery group were extracted. There were statistically significant differences in postoperative recovery rate from MRC-APB 0 to '4 or 5' at 30 months (OR: 2.42; 95% CI: 1.03-5.67; p = 0.04) and at final follow-up (OR: 2.64; 95% CI: 1.11-6.26; p = 0.03). There were statistically significant differences in postoperative recovery of MRC-APB scales at 24 months (p = 0.03), 30 months (p = 0.02) and at final follow-up (p = 0.02). There were statistically significant differences in postoperative recovery of DML (p = 0.04). Conclusions: Endoscopic release of the recurrent branch in combination with standard ECTR surgery showed better recovery rates in MRC-APB and DML recovery compared to standard ECTR surgery alone. Level of Evidence: Level III (Therapeutic).

The Diagnosis and Treatment of Arytenoid Dislocation

Vocal fold paralysis and arytenoid dislocation are the differential symptoms for unilateral vocal fold movement disorder. However, their diagnosis is difficult. To diagnose dislocation, it is necessary to understand the movements characteristic of unilateral fold paralysis. A particularly important finding of paralysis is the passive gliding movement that is displaced in the cranial direction during phonation. The presence of this movement is diagnostic of paralysis rather than dislocation. A number of previous reports on dislocation have diagnosed the presence of this passive movement as dislocation. In Japan, the term ‘fixation’ is often used to describe the position of the paralyzed vocal folds, as in ‘mid-position fixation’ or ‘sub-median fixation’. There seems to be a misconception that ‘paralyzed vocal cords are immobilized’. In the case of dislocation, by contrast, the muscular process is unable to move beyond the midline of the articular surface, and the movement of the arytenoid is severely restricted and immobile. It has been misunderstood that immobility is paralysis while wobbling is dislocation. However, paralysis is the presence of wobbling movement (passive gliding movement), and dislocation is immobilization and inability to move. Dislocations have previously been divided into two categories of anterior and posterior dislocations, but vertical dislocations have not been mentioned. In past reports, the terms ‘anterior’,‘posterior’,‘medial’, and ‘lateral’ have been used to refer to the position of dislocation. However, these terms do not indicate the position in the vertical direction. We divided the cricoid facet into four areas: mediocaudal, laterocaudal, mediocranial and laterocranial. We published on recurrent adductor branch paralysis in 2010. Gradually, the concept of partial laryngeal palsy has become more widespread. Looking at previous reports, adductor branch paralysis may have been included in many studies diagnosing posterior dislocation (mediocranial). Understanding the characteristics of adductor branch paralysis is crucial. It is important to understand the three-dimensional arrangement of the arytenoid cartilage for the diagnosis of unilateral vocal fold movement disorder and clarifying the characteristics of paralysis.

DEF-Net: A Dual-Encoder Fusion Network for Fundus Retinal Vessel Segmentation

The deterioration of numerous eye diseases is highly related to the fundus retinal structures, so the automatic retinal vessel segmentation serves as an essential stage for efficient detection of eye-related lesions in clinical practice. Segmentation methods based on encode-decode structures exhibit great potential in retinal vessel segmentation tasks, but have limited feature representation ability. In addition, they don’t effectively consider the information at multiple scales when performing feature fusion, resulting in low fusion efficiency. In this paper, a newly model, named DEF-Net, is designed to segment retinal vessels automatically, which consists of a dual-encoder unit and a decoder unit. Fused with recurrent network and convolution network, a dual-encoder unit is proposed, which builds a convolutional network branch to extract detailed features and a recurrent network branch to accumulate contextual features, and it could obtain richer features compared to the single convolution network structure. Furthermore, to exploit the useful information at multiple scales, a multi-scale fusion block used for facilitating feature fusion efficiency is designed. Extensive experiments have been undertaken to demonstrate the segmentation performance of our proposed DEF-Net.

Repairing large skin defect of hand with modified dorsal metacarpal artery reverse island flap

To investigate the effectiveness of modified dorsal metacarpal artery reverse island flap based on two adjacent recurrent branches of dorsal metacarpal arteries in repairing large skin defect of the hand. Between September 2017 and March 2021, 15 cases of large skin defect of the hand were treated. There were 11 males and 4 females with an average age of 42 years (range, 24-66 years). The injury causes included machine twist injury in 6 cases, pound injury in 5 cases, and crush injury in 4 cases. The injured parts included 6 cases of finger skin defect and 9 cases of distal skin defect of palm and dorsum of hand, all of which had tendon, joint, and bone exposure. The interval from injury to operation ranged from 2 to 6 hours (mean, 4 hours). The defect sizes after thorough debridement ranged from 3.5 cm×3.0 cm to 8.0 cm×4.5 cm. The modified dorsal metacarpal artery reverse island flap with a range of 3.8 cm×3.3 cm to 9.0 cm×5.0 cm was used to repair the defect, and the flap donor site was repaired with full-thickness skin graft. All the flaps survived successfully after operation, and the wounds in the recipient site and the skin grafts in the donor site healed by first intention. All patients were followed up 9-24 months, with an average of 14 months. The appearance of the flap was good, and its texture and color were similar to those of the surrounding normal tissue. There was no obvious scar contracture, depression, and pigmentation in the donor site. At last follow-up, the static two-point discrimination of the flap was 8-20 mm, with an average of 13.6 mm. According to the Michigan Hand Outcome Questionnaire, 5 patients were very satisfied with the appearance of the flap, and 10 patients were satisfied. The modified dorsal metacarpal artery reverse island flap based on two adjacent recurrent branches of dorsal metacarpal arteries has reliable blood supply, larger harvested area, simple procedure, and minimal donor site damage, which is suitable for emergency repair of large skin defect of the hand.

Prevention of intraoperative injuries of the laryngeal nerves. Literature review and own data

Based on the recent literature data, the analysis has been performed for the causes of the laryngeal nerve injuries and methods of their prevention during thyroid surgery. Literature data demonstrate that over the past 20 years the incidence of the laryngeal nerve injuries remained stable, from 0.1 to 3.0 % and more. It does not tend to decrease despite the introduction of neuromonitoring. The authors presented the peculiarities of monitoring the recurrent nerves and the external branch of the superior laryngeal nerve and options for evaluating its results.&#x0D; Based on own clinical material, the authors performed the comparative assessment of the number and nature of the laryngeal nerve injuries and resulted phonation disorders after surgical treatment of patients with goiter. The first group consisted of 208 patients who underwent only visual identification of recurrent nerves of the larynx during thyroid surgery. To prevent injuries of the external branch of the superior laryngeal nerve, the method of gradual and separate ligation of the superior thyroid artery and its branches on the thyroid capsule was used. The second group involved 201 patients who underwent surgery using intraoperative neuromonitoring of the recurrent and external branches of the superior laryngeal nerve by the author’s method.&#x0D; Analysis of the number of injuries from our own clinical material showed that in the group using intraoperative neuromonitoring they were almost 2.5 times less than in the group of patients who underwent surgeries with visual identification of nerves. It was established that the use of intraoperative neuromonitoring enabled an increase of the number of the identified laryngeal nerves and reduction in the rate of their trauma, laryngeal paresis and phonation disorders. It has been emphasized that intraoperative neuromonitoring does not replace the visual identification of laryngeal nerves, but complements it. In complex cases, its results are crucial for making a technical decision during the surgery.&#x0D; The amended topographic and anatomical proportions of the organs of the anterior part of the neck in different clinical forms of goiter create conditions for intraoperative injuries of the laryngeal nerves. The possibility of their occurrence and their number depend only on the correctness of the surgeon’s actions and their adequacy to the clinical situation. In order to prevent these injuries, the following important requirements for the surgeon and the technology of performing goiter surgery should be considered: knowledge of the anatomy of the anterior, lateral parts of the neck, larynx, superior anterior and posterior mediastinum; possession of elements of technology and sequence of surgery on the thyroid depending on the clinical situation, in particular cervical, thoracic, recurrent goiter, compression syndrome; dry operating field and calm, without haste of performance of operation at adequate lighting. In the complicated situations of tissue differentiation optics should be used as well as an intraoperative intermittent or continuous neuromonitoring.&#x0D;

Covered stent treatment for arterial complications after pancreatic surgery: risk assessment for recurrence and peri-stent implantation management.

ObjectivesTo explore the risk factors for recurrence of arterial complications after pancreatectomy during the period of covered stent implantation and to provide some opinions on peri-stent implantation management.MethodsData on patients implanted with covered stents due to arterial complications after pancreatectomy between January 2017 and December 2021 were analyzed retrospectively. Technical success, clinical success, recurrence, and survival were evaluated to elucidate the practicability of covered stents. Wilson score, Random Forest, logistic regression, and Pearson’s chi-square test with bootstrap aggregation were performed for determining the perioperative risk factors for recurrence.ResultsAmong all fifty-five patients, success stent implantation (technical success) was achieved 100%. Patients who were hemodynamically stabilized without further treatment for artery complications in situ (clinical success) accounted for 89.1%. Based on statistical analysis, pre-stent implantation pancreatic fistula was identified as a robust recurrence-related risk factor for preoperative assessment (p = 0.02, OR = 4.5, 95% CI [1.2, 16.9]; pbootstrap = 0.02). Post-stent implantation pancreatic fistula (p = 0.01, OR 4.5, 95% CI [1.4, 14.6]; pbootstrap < 0.05) and SMA branches or GDA stumps (p = 0.02, OR 3.4, 95% CI [1.1, 10.3]) were relevant to recurrence. The survival rate during hospitalization was 87.3%. All survivors were free from recurrence during the subsequent follow-up. Vasospasm and stent occlusion were observed as short-term and long-term complications, respectively.ConclusionA covered stent implantation is a feasible and effective treatment option for post-pancreatectomy arterial complications. Rigorous management of pancreatic fistula, timely detection of problems, sensible strategies during stent implantation, and reasonable anticoagulation therapy are necessary for a better prognosis.Key Points • A covered stent is feasible for various artery-related complications after pancreatectomy and has an ideal therapeutic effect. • Pancreatic fistula during the perioperative period of the covered stent is an independent risk factor for recurrent arterial complications and SMA branches or GDA stumps are prone to be recurrent offending arteries. • Rigorous management of pancreatic fistula, timely detection of problems, sensible strategies during stent implantation, and reasonable anticoagulation therapy are necessary for a better prognosis. Supplementary InformationThe online version contains supplementary material available at 10.1007/s00330-022-09134-2.