Recurrent Nerve Palsy Research Articles

The clinical characteristics and treatment strategies of differentiated thyroid carcinoma in adolescents and children

Objective:To study the clinical characteristics and treatment strategies of differentiated thyroid carcinoma in adolescents and children.Method:From 1983 to 2014, total 2936 patients with the thyroid cancer were collected in our hospital, among which there were 85 patients of adolescents and children with 61 female and 24 male. The age was from 9 to 21 years old (median 18.3 years). There were 12 cases less than 14 years.The pathologic diagnoses were papillary carcinoma 76 cases and follicular carcinoma 9 cases. The clinical material, history of disease, clinical presentation, TNM classification, histopathological features, treatment method, and the final follow-up results were analyzed and studied. Result:Overall survival rate was 100%, follow-up from 0.5 to 31 years(medium 10.9 years), 10 year progression free survival rate was 87.1%. There was no mortality and 8(9.4%)cases occurred recurrence,who followed by surgery and resumed finally. There were 20 cases found extrathyroid extention, including 8 cases less than 14 years and 12 cases older than 15 years. The extrathyroid extention rate was significantly higher in cases of lower years(66.7%)than other group(16.4%)(P<0.01). Forty-nine(57.6%) cases were found lymphanods metastases, among them ≤14 years metastases rate 92.0%（11/12）significantly more than ≥15 years metastases rate 52.1%(38/73) (P<0.05). Three patients suffered with pulmonary metastases and all of them were ≤14 years patients. All of 85 patients were received surgery treatment included total, subtotal and oneside thyroidectomy. The neck lymph nodes were underwent modefied, radical or no neck dissection. Fifteen patients were received 131I therapy postoperatively, the dosage was 50～170 mCi. All of 85 patients were received TSH suppression therapy. 13 cases(15.3%) occurred complications,such as laryngeal recurrent nerve paralysis and hypoparathyroidism commonly. Conclusion:Majority of thyroid cancer for adolescents and children are papillary and follicular carcinoma. The histopathologic feature has significant invasion beyond thyroid capsula, and metastasis to the lymphanods and distante area,especially ≤14 years patients significant more than ≥15 years. The prognosis is favorable, it is few death from thyroid cancer. The treatment means is surgery to resect all of the disease, sometimes should perform total or neartotal thyroidectomy if there are distant metastasis and extensive invasion. It should pay attention to preserve the function of recurrent laryngeal nerve and parathyroid gland. Most of them can be performed unilateral lobectomy if the tumor located oneside thyroid gland. The lymphanode metastasis should be undertaken modified neck dissection, make effort to avoid radical neck dissection. It should be carful to use 131I internal radiation therapy and avoid the excessive treatment.

Prosthetic bypass for restenosis after endarterectomy or stenting of the carotid artery

ObjectiveThe objective of this study was to evaluate the results of prosthetic carotid bypass (PCB) with polytetrafluoroethylene (PTFE) grafts as an alternative to carotid endarterectomy (CEA) in treatment of restenosis after CEA or carotid artery stenting (CAS). MethodsFrom January 2000 to December 2014, 66 patients (57 men and 9 women; mean age, 71 years) presenting with recurrent carotid artery stenosis ≥70% (North American Symptomatic Carotid Endarterectomy Trial [NASCET] criteria) were enrolled in a prospective study in three centers. The study was approved by an Institutional Review Board. Informed consent was obtained from all patients. During the same period, a total of 4321 CEAs were completed in the three centers. In these 66 patients, the primary treatment of the initial carotid artery stenosis was CEA in 57 patients (86%) and CAS in nine patients (14%). The median delay between primary and redo revascularization was 32 months. Carotid restenosis was symptomatic in 38 patients (58%) with transient ischemic attack (n = 20) or stroke (n = 18). In this series, all patients received statins; 28 patients (42%) received dual antiplatelet therapy, and 38 patients (58%) received single antiplatelet therapy. All PCBs were performed under general anesthesia. No shunt was used in this series. Nasal intubation to improve distal control of the internal carotid artery was performed in 33 patients (50%), including those with intrastent restenosis. A PTFE graft of 6 or 7 mm in diameter was used in 6 and 60 patients, respectively. Distal anastomosis was end to end in 22 patients and end to side with a clip distal to the atherosclerotic lesions in 44 patients. Completion angiography was performed in all cases. The patients were discharged under statin and antiplatelet treatment. After discharge, all of the patients underwent clinical and Doppler ultrasound follow-up every 6 months. Median length of follow-up was 5 years. ResultsNo patient died, sustained a stroke, or presented with a cervical hematoma during the postoperative period. One transient facial nerve palsy and two transient recurrent nerve palsies occurred. Two late strokes in relation to two PCB occlusions occurred at 2 years and 4 years; no other graft stenosis or infection was observed. At 5 years, overall actuarial survival was 81% ± 7%, and the actuarial stroke-free rate was 93% ± 2%. There were no fatal strokes. ConclusionsPCB with PTFE grafts is a safe and durable alternative to CEA in patients with carotid restenosis after CEA or CAS in situations in which CEA is deemed either hazardous or inadvisable.

Clinical analysis of risk factors for central compartment lymph node metastasis in stage cNO papillary thyroid microcarcinoma and preventive dissection

Objective To discuss the clinical characteristics for central compartment lymph node metastasis in stage cNO papillary thyroid microcarcinoma and significance and feasibility of preventive dissection, aimed to provide reference for clinical treatment. Methods Reviewed the clinical data of 277 patients with stage cN0 papillary thyroid microcarcinoma from Jul. 2011 to Dec. 2015 underwent surgery in the Department of General Surgery of Lianyungang East Hospital. Evaluated the necessity of prophylactic central lymph node dissection. Adopted chi square test and Logistic regression to analyze its relationship with patients′ gender, age, tumor number, tumor size, enveloped infiltration, single and bilateral tumor. All 277 patients underwent primary radical resection with ipsilateral central lymph node dissection. The specimen of resection was analyzed by routine pathology. Results The positive rate of thyroid papillary microcarcinoma lymph node metastasis was 36.8% (102/277). The elements of male patients (P=0.023), age 0.5 cm (P=0.019) had high positive rate. The multivariable analysis showed that male patients (OR=2.63, P 0.5 cm (OR=2.13, P=0.009) were independent risk factors for CLN metastasis.Forty-three (15.5%) cases had transient parathyroid function. No Permanent recurrent nerve paralysis and hyperparathyroidism occurred in this group. Conclusions Prophylactic central lymph node dissection is helpful for accurate staging of tumor classification and risk assessment, has important significance, on the follow-up of patients after treatment of choice. For male patients, age 0.5 cm, enveloped infiltration, the central compartment lymph node dissection may be necessary. Key words: Papillary thyroid carcinoma; Prophylactic lymph node cleaning; Lymphatic metastasis; Chi-square distribution; Neck dissection

Systematic lymphadenectomy versus sampling of ipsilateral mediastinal lymph-nodes during lobectomy for non-small-cell lung cancer: a systematic review of randomized trials and a meta-analysis

To re-examine the evidence for recommendations for complete dissection versus sampling of ipsilateral mediastinal lymph nodes during lobectomy for cancer. We searched for randomized trials of systematic mediastinal lymphadenectomy versus mediastinal sampling. We performed a textual analysis of the authors' own starting assumptions and conclusion. We analysed the trial designs and risk of bias. We extracted data on early mortality, perioperative complications, overall survival, local recurrence and distant recurrence for meta-analysis. We found five randomized controlled trials recruiting 1980 patients spanning 1989-2007. The expressed starting position in 3/5 studies was a conviction that systematic dissection was effective. Long-term survival was better with lymphadenectomy compared with sampling (Hazard Ratio 0.78; 95% CI 0.69-0.89) as was perioperative survival (Odds Ratio 0.59; 95% CI 0.25-1.36, non-significant). But there was an overall high risk of bias and a lack of intention to treat analysis. There were higher rates (non-significant) of perioperative complications including bleeding, chylothorax and recurrent nerve palsy with lymphadenectomy. The high risk of bias in these trials makes the overall conclusion insecure. The finding of clinically important surgically related morbidities but lower perioperative mortality with lymphadenectomy seems inconsistent. The multiple variables in patients, cancers and available treatments suggest that large pragmatic multicentre trials, testing currently available strategies, are the best way to find out which are more effective. The number of patients affected with lung cancer makes trials feasible.

Neuropathie héréditaire par hypersensibilité à la pression : à propos de 3 observations chez l’enfant

Hereditary neuropathy with liability to pressure palsy (HNPP) is an autosomal dominant neuropathy. It is characterized by recurrent sensory and motor nerve palsies, usually precipitated by minor trauma or compression. Even though rare in childhood, this disorder is probably underdiagnosed given its wide spectrum of clinical symptoms. We review three separate cases of HNPP diagnosed in children with various phenotypes: fluctuating and distal paresthesias disrupting learning at school, cramps related to intensive piano practice, and discrete muscle weakness with no functional complaint. Family history should be carefully reviewed to identify potential undiagnosed HNPP cases, as in our three reports. Electrophysiological study is essential for the diagnosis, with a double advantage: to confirm the presence of focal abnormalities in clinically symptomatic areas and to guide molecular biology by revealing an underlying demyelinating polyneuropathy. The diagnosis of HNPP is confirmed by genetic testing, which in 90% of cases shows a 1.5-Mb deletion of chromosome 17p11.2 including the PMP22 gene. Patients are expected to make a full recovery after each relapse. However, it is very important for both the patient and his or her family to establish a diagnosis in order to prevent recurrent palsy brought on by situations involving prolonged immobilizations leading to nerve compression.

Complications of Bilateral Neck Dissection in Thyroid Cancer From a Single High-Volume Center

The morbidity of bilateral lateral neck dissection (BLND) for thyroid cancers has not been described in detail. This study delineates the specific complications arising from BLND for thyroid cancers at a single high-volume center. To determine the morbidity associated with BLNDs for differentiated thyroid cancers at our institution. This was a retrospective review of medical records performed to identify patients having undergone BLNDs for thyroid cancers by a single surgeon at an academic, tertiary medical center in Toronto, Ontario, Canada, from 1988 to 2015. Patients who underwent BLND for papillary, follicular, or medullary thyroid cancers were identified through operative procedure codes and review of operative and pathology reports. The indication for this procedure was suspicious bilateral lateral compartment on imaging and clinical examination. Sixty-two patients who underwent BLND for thyroid cancers, with or without total thyroidectomy and central compartment dissection, were identified. The main outcome measures for this study were unanticipated medical or surgical complications during the operation or in the postoperative period. Secondary measures were oncologic outcomes, including regional structural or biochemical recurrence. Of the 62 patients, 24 were male (39%), and 38 (61%) were female. Their mean age was 46 years (range, 17-80 years). The overall risk of permanent hypoparathyroidism was 37%. There was 1 case of unanticipated permanent recurrent nerve paralysis and 1 case of temporary nerve paresis. Postoperative chyle fistula occurred in 6 cases (10%). There were 3 readmissions within 30 days of surgery, 1 pulmonary embolism, and 1 perioperative mortality. Fifty percent of patients had pN0 contralateral necks despite preoperative clinical suspicion. Four patients were found to have anaplastic thyroid cancers intraoperatively. Five patients (8%) developed nodal recurrence in the neck. Four patients died of their disease within available follow-up (mean, 3.2 years). Bilateral lateral neck dissection for thyroid cancers confers a significant amount of morbidity, including a significant rate of hypoparathyroidism. Knowledge of the complications of this procedure, especially in the setting of questionable survival benefit, may assist in preoperative decision-making and patient counseling.

The effect of thyroid gland weight on early complications in total thyroidectomy: Cerrahpasa experience

In this study we aimed to show whether thyroid gland weight has an effect on early and late complications in thyroidectomy done in an experienced center. 721 patients in Istanbul University Cerrahpasa Medical Faculty General Surgery Department, in whom sutureless total thyroidectomy with vessel sealing devices were done, were retrospectively evaluated from January 2012 to December 2015. Reoperations, plonjan goiter, patients with capsule invasion and lymph node metastases who were operated due to thyroid cancer were excluded in the study. Demographic data, operation indications, operation duration, incision length, postoperative complications of the patients were recorded. The complications were recurrent nerve paralysis, hypocalcemia, hematoma and wound infection. These complications were compared according to the thyroid gland weight separately. Also, each complication group was divided into four groups, according to thyroid gland weight, as below 30 grams, 30-60 grams, 60-90 grams and heavier than 90 grams. The effect of thyroid gland weight on postoperative complications was evaluated. 22.2 % of the patients (n=160) were males and 77.8 % (n=561) were females. Mean age of the patients was 48,58±SD (18-85) years. Recurrent laryngeal nerve paralysis was seen in 5.68% (n=82) of the 721 patients, to whom vocal cord examination was done. Hypocalcemia symptoms in 5.54% of the patients (n=40), wound infections in 0.97% (n=7) of the patients and hemorrhage in 0.69% (n=5) of the patients were seen. Mean thyroid gland weight in patients with thyroid surgery complication was 56.1±SD (15-315) grams, while it was 56,94±SD (20-795) grams for noncomplicated thyroid surgery. The complications were divided into four groups. When these groups were compared according to thyroid gland weight separately, it was seen that thyroid gland weight does not affect early complications (p >0,5). Total thyroidectomy, when done in an experienced center, is the suggested surgery, which has 1% complication rate and the least recurrence rate. In our study, there was no statistically significant difference. This may be due to lighter thyroid gland weights in our study.

食道癌術後反回神経麻痺の管理：消化器外科，耳鼻咽喉科，看護師，言語聴覚士によるチーム医療

食道癌術後反回神経麻痺の管理：消化器外科，耳鼻咽喉科，看護師，言語聴覚士によるチーム医療

頚動脈内膜剝離術と冠動脈バイパス術の一期的手術の有用性

The purpose of this study was to evaluate the efficacy of combined carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG). Between April 2006 and April 2014, a total of 57 patients with carotid artery stenosis underwent CEA in our institution. Among them, 7 patients (12.3%; 5 males, 2 females; mean age 74.9 ± 4.5 years) with significant coronary artery disease underwent combined CEA and CABG. Three patients had symptomatic stenosis, with mean degree of stenosis of 71 ± 20% according to the North American Symptomatic Carotid Endarterectomy Trial method. Although one patient (14%) developed postoperative recurrent nerve paralysis, and another patient (14%) died due to postoperative intra-thoracic hemorrhage, technical success had been obtained in all 7 patients without any peri-operative neurological or cardiac complications. It is well known that 30% to 40% of patients with carotid stenosis have coronary artery disease. When CABG is performed in cases of significant carotid stenosis, the risk of perioperative stroke increases. One of the approaches to solve this problem is combined CEA and CABG. Though it might a need longer time for surgery and carries a higher risk of surgical bleeding compared with a single surgery, it can decrease both neurological and cardiac ischemic complications. In our experience, combined CEA and CABG is a preferred surgical approach for high-risk patients.

Indications and Morbidity of Reoperative Thyroid Surgeries in a Military Hospital of Senegal.

Objectives To describe reoperative thyroid surgeries in our department. Study Design Retrospective cross-sectional and descriptive study at the Ouakam Military Hospital in Dakar (Senegal), over a period of eight and a half years. Methods The study involved all records of patients who had a reoperative thyroidectomy regardless of the indication and time of the second surgery. Parameters evaluated for first and reoperative surgery were time interval between the two surgeries, operative indications, surgical procedures, intraoperative findings, pathological examination, and morbidity. Results 30 records of patients were selected out of a total of 698 thyroidectomies (4.3%). Thyroid cancers diagnosed on first surgical specimens were the first indications of reoperations (46.67%) followed by neck hematoma (20%). Completion thyroidectomy with a prophylactic central lymph nodes dissection was the most performed surgical procedure (43.33%) followed by haemostasis (20%). During reoperation, we found active bleeding (20%), textiloma (6.67%), and fourth branchial cleft fistula (3.33%). The morbidity accounted for 10%: lymphorrhea, permanent hypocalcemia, and permanent recurrent nerve palsy, in one case, respectively. There were no statistically significant differences between the morbidity in patients reoperated on and the one for patients operated on once. Conclusion We did not find an increased risk of postoperative morbidity after reintervention.

Total aortic arch replacement with the frozen elephant trunk procedure in acute DeBakey type I aortic dissections.

In patients with acute aortic dissection involving the arch and the descending aorta (AADA DeBakey type I), performing a total aortic arch replacement with the frozen elephant trunk (FET) procedure for supposedly better long-term results is still controversial. From February 2004 to April 2016, 94 patients with AADA DeBakey type I had an FET procedure (80% men, age 58 ± 12 years). During the early period (Group 1, 2004-10), the FET technique was performed using non-branched grafts. Thirty-two percent (9/28) underwent concomitant aortic valve-sparing root procedures. More recently (Group 2, 2010-16), branched FET grafts were used in 66 patients (76% men, age: 56 ± 12 years). Fifty-six percent (37/66) underwent concomitant aortic valve-sparing root procedures. Patients showed a high rate of malperfusion syndrome (Group 1: 29% vs Group 2: 38%, P = 0.48). In-hospital mortality was 12% (Group 1: 21% vs Group 2: 9%, P = 0.17). Stroke and rethoracotomy for bleeding occurred in 15% (Group 1: 11% vs Group 2: 17%) and 20% (Group 1: 21% vs Group 2: 20%; P = 1.00) of patients, respectively. Postoperative recurrent nerve palsy and spinal cord injury rates were 18% (Group 1: 14% vs Group 2: 20%) and 5% (Group 1: 7% vs Group 2: 5%; P = 0.63). During follow-up, 11 patients (12%) required reoperation on the downstream aorta (open surgical: n = 6/94, 6%, endovascular: n = 5/94; 5%). Survival tended to be superior in Group 2 (5 years: Group 1: 68% vs Group 2: 80%; P = 0.17). The FET procedure improves short- and long-term outcome, especially for AADA DeBakey I with malperfusion.

Vagal and recurrent laryngeal nerves neuromonitoring during thyroidectomy and parathyroidectomy: A prospective study

ObjectivesThe aim of the study was to stimulate the vagal and the recurrent laryngeal nerves during and after thyroidectomy or parathyroidectomy, to record muscle responses, interpret the electrophysiological modifications and identify prognostic factors for postoperative vocal fold mobility. Patients and methodsA prospective study monitored 151 vagal nerves and 144 recurrent laryngeal nerves in 114 patients. Seven patients (14 vagal nerves) underwent continuous monitoring via an automatic periodic stimulation (APS®) electrode. In 15 patients (21 vagal nerves), the stimulation threshold was studied. Muscle response was recorded on direct vagal and/or recurrent laryngeal nerve stimulation by a monopolar electrode or direct repeated stimulation via an electrode on the vagal nerve. In case of signal attenuation on the first operated side, surgery was not extended to the contralateral side. ResultsThe vagal nerve stimulation checked inferior laryngeal nerve integrity and recurrent status, without risk of false negatives. The vagal nerve stimulation threshold, before and after dissection, that induced a muscle response of at least 100μV ranged from 0.1 to 0.8mA. Similarity between pre- and post-dissection responses to supramaximal stimulation, defined as 1mA, on the one hand, and between post-dissection vagal and laryngeal recurrent nerve responses on the other correlated with normal postoperative vocal cord mobility. Conversely, muscle response attenuation below 100μV and increased latency indicated a risk of vocal fold palsy. ConclusionVagal nerve stimulation allows suspicion or elimination of lesions on the inferior laryngeal nerve upstream of the stimulation point and detection of non-recurrent inferior laryngeal nerve. Intermittent monitoring assesses nerve function at the moment of stimulation, while continuous monitoring detects the first signs of nerve injury liable to induce postoperative recurrent nerve palsy. When total thyroidectomy is indicated, signal attenuation on the first operated side casts doubt on continuing surgery to the contralateral side in the same step.

Functional assessment of glottal insufficiency treated by hyaluronic acid injection: Retrospective 20-case series

ObjectivesThe objectives of the present study were to describe hyaluronic acid injection to the vocal folds as treatment for glottal insufficiency, assess indications and report vocal results at 1 month and later than 6 months postoperatively. Patients and methodsA single-center retrospective study was performed for the period March 2012 to August 2015. Inclusion criteria comprised: unilateral recurrent nerve palsy or vocal fold closure defect with conserved mobility. Exclusion criteria comprised: previous thyroplasty, severe swallowing disorder, and cognitive disorder hindering subjective vocal assessment. Restylane® injection was performed under general or local anesthesia. The Vocal Handicap Index (VHI), maximum phonation time (MPT) and GRBAS (Grade, Roughness, Breathiness, Asthenia, Strain) score were assessed preoperatively and at 1 month and more than 6 months postoperatively. ResultsTwenty patients were included: 14 with unilateral recurrent nerve palsy and 6 with vocal fold closure defect. Restylane® injection was performed under general anesthesia in 16 patients and local anesthesia in 4 (20%). At 1-month assessment, there was significant reduction in VHI (by 36 points; P=0.0001) and GRBAS score (by 6.95 points; P=0.0001) and significant increase in MPT (by 4.95sec; P=0.0001). At 6 months, VHI, MPT and GRBAS scores remained significantly improved (respectively, P=0.0002, P=0.001 and P=0.0001), without significant difference from 1-month levels. Three patients had minor complications; two recovered normal vocal fold mobility. ConclusionHyaluronic acid injection was effective in treating glottal failure, improving objective and subjective vocal parameters, which remained satisfactory even 6 months postoperatively.

Clinical Cases: Pericardial disease39Diagnostic difficulties of a vasculitis caused by uncommon cardiovascular manifestation40Pericardial mass in a post-surgery mitral endocarditis patient41Focal constrictive pericarditis: multimodality imaging

Clinical Cases: Pericardial disease39Diagnostic difficulties of a vasculitis caused by uncommon cardiovascular manifestation40Pericardial mass in a post-surgery mitral endocarditis patient41Focal constrictive pericarditis: multimodality imaging

Usefulness of the Clavien-Dindo Classification in Understanding the Limitations and Indications of Larynx-preserving Esophageal Reconstruction.

Background:The Clavien–Dindo (CD) classification is used to evaluate the severity of surgical complications. However, its usefulness in esophageal reconstruction has not been reported. To address this, this case series study used the CD classification to evaluate the complications after cervical esophageal reconstruction with free jejunum transfer or supercharged pedicled intestinal transfer.Methods:All consecutive patients who underwent esophageal cancer surgery with larynx-preserving free jejunum or pedicled ileocolic transfer in June 2012–December 2015 were identified. The postoperative complications were classified using the CD classification.Results:In total, 22 patients (20 men and 2 women; mean age, 63.3 years) underwent esophageal cancer reconstruction with larynx-preserving free jejunum transfer (n = 9) and supercharged pedicled intestinal transfer (n = 13). Seven patients underwent prophylactic tracheotomy. Four patients underwent emergent tracheotomy 1 or 5 days after surgery. The most frequent complication was recurrent nerve paralysis (RNP) (n = 8). Of these 8 RNP cases, 6 and 2 were classified as CD I and III complications, respectively. Pneumonia was the next most common complication (n = 7). Of these 7 pneumonia cases, 5 and 2 were classified as CD II and III, respectively. There were 2 cases of intestinal anastomosis leakage (CD II and III). On average, patients were able to start oral alimentation 15.1 (9–35) days after surgery.Conclusions:Our analysis with the CD classification suggested that vascularized free jejunum transfer or supercharge-drainage pedicled ileocolic transfer prevents postoperative intestinal anastomosis leakage and that prophylactic tracheotomy is especially indicated in cases with significant surgical damage in the cervical region.

右反回神経不全麻痺による嗄声を来した気管支性嚢腫の 1 手術例

右反回神経不全麻痺による嗄声を来した気管支性嚢腫の 1 手術例

Surgical Revascularization of Symptomatic Kinking of the Internal Carotid Artery.

To evaluate the safety and outcomes of surgical revascularization for patients with symptomatic kinking of the internal carotid artery (ICA). Twenty-five consecutive patients presented with symptomatic kinking of the ICA and a history of transient ischemic attack (TIA) or stroke were prospectively enrolled in this study. All patients were treated with ICA transection and end-to-side reimplantation at the level of the carotid bulb. Patients were followed up for a median of 32 months. There were no deaths or strokes within the 30 days of the treatment. No postprocedural thrombosis or narrowing of the ipsilateral ICA was observed. One (4%) patient had temporary recurrent nerve palsy, which was completely recovered at 4-week follow-up. One (4%) patient had a myocardial ischemic event. At the end of the 32-month follow-up, 1 (4%) patient developed ipsilateral minor stroke. No recurrent stenosis was detected by Doppler ultrasound. Surgical treatment for isolated, symptomatic kinking of the ICA and a history of TIA or stroke is safe, and the outcomes are acceptable.

Prognostic Impact of Postoperative Complications in 502 Patients With Surgically Resected Esophageal Squamous Cell Carcinoma: A Retrospective Single-institution Study.

To investigate the relationship between postoperative complications and long-term survival in patients with surgically resected esophageal squamous cell carcinoma (ESCC). Esophagectomy is the mainstay of curative treatment for ESCC; however, this complex procedure has high risks of postoperative morbidity and mortality. The impact of postoperative complications on long-term survival of such patients remains controversial. This retrospective single institution study included 502 consecutive patients who had undergone resection of ESCC. The Cox proportional hazard model was used to compute the hazard ratio (HR) for mortality. Postoperative complications (≥Clavien-Dindo classification grade 2) occurred in 217 patients (43%). Overall, postoperative complications did not affect long-term clinical outcomes of these patients. However, patients with pulmonary complications had worse overall survival than those without pulmonary complications [log rank P = 0.0002; univariate HR = 1.51, 95% confidence interval (CI) 1.20-1.88, P = 0.0006; multivariate HR = 1.60, 95% CI 1.05-2.38, P = 0.029]. The effect of pulmonary complications was not significantly modified by clinical or pathological features (P for all assessed interactions >0.05). In addition, postoperative chylothorax was also associated with poor overall survival (log rank P = 0.0021), whereas surgical site infection, recurrent nerve paralysis, cardiovascular complication, and anastomotic leakage were not. Postoperative pulmonary complications may be an independent predictor of poorer long-term survival in patients undergoing resection of ESCCs.

Adult Variant of Ophthalmologic Migraine with Recurrent 6th Cranial Nerve Palsy in 25yrs Old Ethiopian Patient: Case Report

According to ICHD-3 opthalmoplegic migraine (OM) is classified under Painful Cranial Neuropathies and other Facial Pains and the name is changed from Ophthalmoplegic migraine to Recurrent Painful Ophthalmoplegic Neuropathy (RPON). Frist described by Gubler In 1860, who described a patient who had recurrent episodes of 3rd Cranial nerve Paresis during otherwise typical migraine attacks. The paresis persisted beyond the headache phase of the attack, as evidence support more than 24hrs. After three decades in 1890, Charcot called this condition “Ophthalmoplegic Migraine”. It’s characterized by repeated attacks of paresis of one or more ocular cranial nerves (commonly the oculomotor Nerve), occasionally cranial IV and VI with ipsilateral headache. Ophthalmoplegic ‘migraine’ incidence was rare in the general population, more happened in children, with incidence of 0.7 per 1,000,000 in general population. Different pathogenesis is postulated currently including, ischemia, compressive and demyelinating causes. Though frequent involvement of 6th cranial nerve is not common according to previously published articles, we report a 25yrs old female patient who presented with two episode of 6th cranial nerve palsy preceded by unilateral throbbing type of headache in which the first episode occurs 6yrs back and resolve within 4 weeks, the current left side abducent palsy is preceded by 3 days history of ipsilateral throbbing headache pain, in which patient complexly recovered after 10 weeks treatment of amitriptyline 25mg daily.

Bypass Operation for Unresectable Esophageal Cancer: Postoperative Complications After Thoracotomy Versus No Thoracotomy.

Patients with unresectable esophageal cancer suffer from dysphagia, causing severe malnutrition and reduced quality of life (QOL). We elect to perform bypass because patients can have greater long-term survival with chemoradiation following this operation. We sought to compare complications in cases of bypass without thoracotomy versus those with thoracotomy. Thirty-four locally advanced esophageal cancer patients between 2007 and 2014 were studied. Eighteen patients underwent thoracotomy, and 16 patients did not have a thoracotomy. CT was obtained to check the anastomosis and the oral stump of the esophagus and to measure the diameter of the intrathoracic esophagus. In the thoracotomy group, the rate of postoperative pulmonary complications was high. On the other hand, in the non-thoracotomy group, the rates of anastomotic leak and recurrent nerve paralysis were high. The stump of the esophagus was 2cm lower in the T group than in the nT group. As the esophagus shortens after division, the final difference in esophageal height between the groups was only around 1cm. We concluded that a viable gastric tube with a good blood supply as well as a careful cervical operation are the most important aspects of the esophageal bypass operation.