甲状腺肿瘤手术中暴露并保护甲状旁腺的解剖与手术操作要点

目的　探讨甲状腺肿瘤手术中暴露并保护甲状旁腺的要点。 方法　对 2004年 1 月至2010 年 12 月 145例甲状腺弥漫性结节和甲状腺癌患者进行手术,分前、后3年两组,前3年组65例患者保留甲状腺后被膜,未寻找甲状旁腺;后3年组80例患者暴露并保护甲状旁腺,精细解剖观察被膜,尽量保存甲状旁腺的血供及完整性。术后进行动态监测血清钙变化,观察甲状旁腺的功能情况。 结果　在术中暴露并保护甲状旁腺后3年组中,术后甲状旁腺功能低下的机率较未寻找甲状旁腺前3年组患者明显降低,两组比较有统计学意义（P＜0.05）。 结论 在甲状腺肿瘤手术中,暴露并保护好甲状旁腺,可有效降低术后甲状旁腺功能低下的发生率。     

纳米碳颗粒显色对甲状旁腺的保护作用

BACKGROUND: So far there are many studies about the uses of nano-carbon tracers in the diagnosis and treatment of malignancies. However, little has been reported on the mechanism underlying protective effect of nano-carbon tracers on the parathyroid glands during thyroid cancer surgery. OBJECTIVE: To study the protective effect of nano-carbon tracers on the parathyroid in thyroid cancer surgery. METHODS: 180 cases of thyroid cancer were randomly divided into nano-carbon and control groups (n=90 per group): patients in the nano-carbon group were injected with nano-carbon tracers into the thyroid before surgery, and those in the control group underwent routine thyroid cancer surgery. Then comparisons of the operating time, incision length, blood loss, postoperative hospital stay, number of lymph node dissection, lymph node metastasis as well as hypoparathyroidism rate were performed between two groups. Besides, levels of serum calcium and parathyroid hormone in the two groups were detected at 3 days after surgery. RESULTS AND CONCLUSION: There were no significant differences in the operating time, incision length, blood loss, postoperative hospital stay and lymph node metastasis between the two groups (P > 0.05). The number of dissected lymph nodes of nano-carbon group was significantly higher than that of control group (P < 0.05); the mis-resection rate of parathyroid and hypoparathyroidism of nano-carbon group were significantly lower than those of control group (P < 0.05). Furthermore, the incidences of hypocalcemia and low parathyroid hormone of nano-carbon group were significantly lower than those of control group (P < 0.05). These results suggest that the nano-carbon tracer plays a protective role on the parathyroid glands in thyroid cancer surgery, which can reduce the mis-resection rate of parathyroid, as well as the incidences of hypoparathyroidism, hypocalcemia and low-level parathyroid hormone.     

Current practices in performing frozen sections for thyroid and parathyroid pathology

In this review article, current trends in thyroid and parathyroid frozen sections are discussed. In Japan and other countries, the numbers of thyroid frozen sections have been dramatically decreasing over the past decade. The decline in the number of thyroid frozen sections has been attributed to two major factors: highly diagnostic preoperative fine needle aspiration for papillary carcinomas, the most frequent type of thyroid cancers, and the acknowledgment in the literature of the disadvantageous frozen sections for follicular tumors. Several authors have argued that the frozen section of thyroid nodules should be limited only to cases that have a preoperative cytology diagnosis as "atypical" or "suspicious". In contrast, frozen sections for parathyroid glands have been increasing in numbers. This increase is thought to be largely due to the high number of parathyroidectomies for secondary hyperplasia in dialysis patients. Frozen sections are usually performed to confirm the removal of parathyroid tissue for either cyropreservation or auto-transplantation. It is concluded that thyroid and parathyroid frozen section examination is restricted to selected situations.     

Pathology of the parathyroid glands in hyperparathyroidism

This paper reviews the embryology, histology and pathology of the human parathyroid glands. It emphasizes those pathologic lesions which are found in the setting of clinical hyperparathyroidism. Also discussed are certain molecular features of hyperfunctioning parathyroid glands. The difficulties encountered in parathyroid FNA are reviewed and illustrated.     

甲状旁腺位置下降不全致持续性继发性甲状旁腺功能亢进一例

患者男,34岁,主诉"慢性肾功能衰竭腹膜透析3年伴皮肤瘙痒1年,行甲状旁腺切除术后4个月,再次出现皮肤瘙痒3月余"。4个月前测血甲状旁腺激素:155.7 pmol/L(参考值:1.3~9.3 pmol/L);颈胸部^99Tc^m-甲氧基异丁基异腈核素单光子发射计算机断层成像(singlephoton emission computed tomography, SPECT)扫描:甲状腺背侧左上、左下、右下异常放射性浓聚灶;甲状腺超声检查:甲状腺未见异常,于甲状腺背侧左上、左下及右下可见3枚低回声,最大径线分别为1.5 cm、1.5 cm及1.3 cm,形态规则,边界清晰。临床拟诊继发性甲状腺功能亢进(secondary hyperparathyroidism, SHPT),于2017年4月15日行"甲状旁腺切除术+右前臂自体移植术",术后病理证实切除左上、左下、右下3枚甲状旁腺增生结节。术后第1天查血甲状旁腺激素为40.6 pmol/L,术后2周查血甲状旁腺激素为134.8 pmol/L。术后1个月患者再次出现皮肤瘙痒。     

Histochemical study on systemic amyloid microdeposits with special reference to parathyroid intrafollicular deposits

Summary This study was carried out in order to define the histochemical behaviour of the substance present in follicles of normal parathyroid glands obtained at routine autopsies. It was noticed that these follicles with typical amyloid staining properties are constantly present in old persons; furthermore the amyloid in question presents histochemical characteristics which identify it as Apudamyloid.With this in mind we studied the possible, concomitant, systemic, amyloid microdeposits; we noticed that intrafollicular Apudamyloid of the parathyroid gland is often encountered together with immune deposits which are sometimes present in the same gland though not necessarily in the follicles.We are grateful to Mr. L. Bortoletto for his technical assistance.     

Arterial baroreflex sensitivity and blood pressure variabilities before and after carotid surgery

Summary Carotid surgery is frequently associated with postoperative blood pressure alterations. The role of baroreceptors with regard to these alterations was assessed in 50 patients by determining the pre- and postoperative mechanoreceptor sensitivity after Valsalva maneuver and intravenous injections of angiotensin and nitroglycerine as described by Smyth, Sleight and Pickering. In addition, blood pressure was monitored perioperatively and renin and aldosterone levels were measured. In patients with arterial hypertension a postoperative increase of receptor reactivity can be seen necessitating a reduction of antihypertensive therapy in more than 50% of cases. In normotensive patients no uniform response can be observed. A possible explanation for this effect might be the local increase of pressure in the operated vascular segment. The postoperative reintegration of receptor areas which had been adjusted to a reduced pressure level might induce a more sensitive response than can be seen for the remaining receptors, which usually are less responsive in hypertensive patients.     

The arterial blood supply of the pancreas: a review

Summary The gross anatomy of the pancreatic blood supply has been subjected to numerous studies. The results of such studies, however, have never been summarized in detail, even in the most important textbooks. For this reason, a certain confusion was generated, especially regarding the interpretation of the nomenclature used to identify pancreatic arteries. This review summarizes more than two centuries of studies of the gross anatomy of the pancreatic blood supply, clarifies the arterial nomenclature, and underlines the aspects about which anatomists are not in agreement. Moreover, it supplies, as far as possible, documentary evidence for numerous observations previously reported only verbally. For this purpose, more than 200 references were directly consulted to provide the anatomical background of the topic, and more than 1000 angiograms were studied to support the review with original figures. The present paper, on the superior pancreaticoduodenal and anterior superior pancreaticoduodenal arteries, is the first of a series of articles dealing with the pancreatic blood supply.

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Etude anatomo-radiologique de la vascularisation artérielle du pancréasI. Les artères pancréaticoduodénale supérieure et pancréaticoduodénale antérieure et supérieure

Résumé L'anatomie de la vascularisation du pancréas a fait l'objet de nombreux travaux. Les résultats de ces études n'ont jamais été récapitulés en détail, même dans les livres les plus importants. C'est pourquoi une certaine confusion est née, spécialement en ce qui concerne l'interprétation de la nomenclature utilisée pour indentifer les artères pancréatiques. Ce travail résume plus de deux siècles d'études d'anatomie générale de la vascularisation du pancréas, il clarifie la nomenclature des artères et souligne les points sur lesquels les anatomistes ne sont pas d'accord. En outre il fournit, autant que faire se peut, des documents concernant de nombreuses observations antérieures rapportées uniquement oralement. Dans ce but plus de 200 références ont été consultées directement pour fournir la documentation anatomique de ce sujet et plus de 1000 angiographies ont été étudiées pour illustrer ce travail avec des figures originales. Le présent article sur les artères pancréatico-duodénale supérieure et pancréatico-duodénale antéro-supérieure est le premier d'une série de travaux se rapportant à la vascularisation du pancréas.

     

Arterial blood supply of the maxillary sinus.

Knowledge of the arterial supply of the maxillary sinus region is essential for surgical treatment in this area (e.g., implantation of grafting materials, repair of injuries, sinus floor elevation). The goal of this study was to describe the arterial architecture of the maxillary sinus region in respect to sinus lift procedures. In 18 unfixed human cadavers, the arterial vessels of the head were injected with a mixture of latex and barium sulfate. Afterward, the arteries entering the maxilla were prepared. The number and calibers as well as anastomoses were carefully documented. In addition, we measured the distance between the alveolar ridge and the lower main branches. The arterial supply of the maxilla originated from the posterior superior alveolar artery as well as from the infraorbital artery. In all specimens we found an intraosseous anastomosis between these two vessels. The oral mucosa in the area of interest is supplied by the posterior superior alveolar artery and the infraorbital artery, and an extraosseous anastomosis was found in 44% of our cases. The two anastomoses build up a double arterial arcade, supplying the lateral wall of the antrum and parts of the alveolar process.     

甲状腺良性结节微波消融术中喉返神经及旁腺保护措施与解剖基础

目的 探讨超声引导下微波消融术治疗甲状腺良性结节过程中对喉返神经及甲状旁腺的损伤保护措施及其解剖基础。方法 选取2017年1月到2019年6月行1射频消融治疗的甲状腺疾病患者52例,观察术后结节大小、血流信号变化、甲状腺激素水平、并发症发生情况等。结果 术后超声随访结节的体积较治疗前不同程度缩小(P<0.05)。结论 加强隔离带技术可以有效保护喉返神经及甲状旁腺,降低损伤风险。     

Superior approach to the inferior laryngeal nerve in thyroid surgery: anatomy, surgical technique and indications

Goals of the study To describe the anatomical bases of the surgical access to the higher part of the thyroid lobe, with first location of the inferior laryngeal nerve at its laryngeal penetration, to discuss the advantages and disadvantages of this surgical technique and to determine the operational indications.Population and method A prospective study of surgical anatomy performed over a period of 18 months was conducted. A total of 25 (22 women and 3 men) patients with cervicothoracic goitre underwent total thyroidectomy. Thyroid lobectomies were performed using the technique of “capsular thyroidectomy”, with first location and complete dissection of the inferior laryngeal nerve. A neurostimulator was systematically used for the location of the inferior laryngeal nerve and also the external laryngeal nerve.Results The first detection of the inferior laryngeal nerve at the top of the thyroid lobe was positive in 49/50 cases. A superior parathyroid gland was found in 75% of cases and an inferior parathyroid gland in 37.5% of cases. The external laryngeal nerve was stimulated and respected in 12,5% of cases. No voice trouble, no laryngeal palsy and no definitive hypoparathyroidism occurred after surgery.Conclusion Safeguarding of the inferior laryngeal nerve is the principal and obligatory stake in thyroid surgery. Locating the inferior laryngeal nerve at the level of its laryngeal penetration at the superior pole of the thyroid region is necessary in cases of particular situations: huge cervicothoracic goitres, re-operative procedures and various anatomical variations. The use of a neurostimulator secures this technique.     

Arterial supply of forearm bones and its importance for the operative treatment of fractures

Summary The operative exposure of a fracture in an osteosynthesis causes disturbances in the blood supply, which often leads to a prolonged process of healing or even to healing problems, a fracture non-union, which is frequently located at the forearm. In order to damage the supplying vessels as little as possible, the position, direction and penetration of the arteries of radius and ulna are demonstrated and systematised in this study. Near the elbow arteries, coming from large adjoining vessels, penetrate the area of the capsular insertion. The nutrient arteries enter both bones in the second proximal quarter of diaphysis, at the radius from anterior to medial, at the ulna from anterior to anteroradial. Small vessels, which penetrate closely proximal to the articular surface in order to supply the distal forearm bones, come from an anastomosis between the radial, the interosseous and the ulnar arteries. In this study access vessels, choice and position of implants will be discussed.

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Vascularisation artérielle des os de l'avant-bras et son importance pour le traitement des fractures

Résumé L'abord d'un foyer de fracture en vue d'une ostéosynthèse perturbe la vascularisation artérielle des os, ce qui allonge la durée du processus de consolidation, cela peut même conduire à une pseudarthrose dont on connait la fréquence élevée au niveau de l'avantbras. Afin de limiter autant que possible les conséquences vasculaires de l'abord chirurgical, nous avons analysé et systématisé dans cette étude la position, la direction et les zones de pénétration des artères dans le radius et l'ulna. Au voisinage du coude les aa. nourricières des os provenant des vaisseaux voisins, pénètrent dans les os au niveau de la zone d'insertion capsulaire. Les aa. nourricières pénètrent les deux os de l'avant-bras au niveau du second quart proximal de la diaphyse; au niveau du radius cette pénétration se fait en avant et en dedans, au niveau de l'ulna en avant et en dehors. Les petits vaisseaux de la partie distale des deux os de l'avant-bras pénètrent juste en amont des surfaces articulaires et viennent d'une anastomose entre les aa. radiale, interosseuse et ulnaire. Dans cette étude l'abord des vaisseaux, le choix et la position des implants sont discutés.

     

Unusual blood supply to the pancreas by a dorsal pancreatic artery

A variation of the blood supply to the pancreas was observed in an 89-year-old female, in which the celiac trunk gave off four arteries the hepatic, splenic, left gastric arteries and an additional dorsal pancreatic artery. One of the branches the dorsal pancreatic artery joined with the superior mesenteric artery to form a longitudinal anastomosis. The anterior and posterior pancreaticoduodenal arcades arose from branches of the superior pancreaticoduodenal and the dorsal pancreatic arteries. The inferior pancreaticoduodenal artery, a branch of the superior mesenteric artery, was missing. The majority of the pancreas was, therefore supplied by the dorsal pancreatic artery. The clinical implications of this finding are that the size, location and course of a dorsal pancreatic artery should be established given its central role in the blood supply to the pancreas observed in the present study.     

Pituitary adenoma,primary parathyroid hyperplasia and papillary (non-medullary) thyroid carcinoma

Summary An acidophilic pituitary adenoma associated with primary nodular parathyroid hyperplasia and a small papillary thyroid carcinoma was discovered at the autopsy of a 44 year old female acromegalic. The thyroid carcinoma showed evidence of lymphatic spread. Several etiopathogenetic mechanisms for the non-medullary thyroid carcinomata associated with Multiple Endocrine Neoplasia (MEN) have been postulated, since the follicular epithelium of the thyroid does not belong to the neural ectoderm derivates unlike the C-cells of the thyroid, the adenohypophysis and probably the parathyroid glands. Apart from genetic influence, or coincidence, one has to rule out carcinogenic exposure or hormonal influence. Clinically speaking, one should always consider whether malignant thyroid disease coexists with hyperplastic or neoplastic parathyroid tissue.     

The blood supply of the deltoid muscle: Application to the deltoid flap technique

Summary The major ruptures of the rotators cuff point out the problem of their surgical repair. Various techniques are described in the literature, among them the deltoid flap technique, described by Apoil and Augereau. This technique points out the problem of a few cases of flap early necrosis (Saragaglia). We studied the deltoid arterial blood supply on 40 cadaveric shoulder, after coloured injection into the subclavian artery. Our study included 40 macroscopic and 15 radiographic observations. The thoracoacromial artery gave off two collaterals to the anterior part of the deltoid muscle. The first one, called the deltoid artery, ran into the anterior part of the deltoid, near the deltopectoral line. In 53%, it gave off a first superior collateral branch, which ran at 3 cm under the clavicle. The second one, called the acromial artery, ran deep to the anterior part of the deltoid muscle, near the clavicle and the acromion. The posterior circumflex humeral artery was the most important artery. It supplied the posterior and middle parts of the deltoid muscle. The anterior circumflex humeral artery supplied the anterior part of the deltoid muscle in 63%. In ten cases, we dissected a deltoid flap. In all the cases, the acromial artery was cut near the acromion. When the deltoid artery gives off its superior collateral branch, it was always cut. Then, this flap was only vascularized by its inferior aspect. These results show that the flap is located in a poorly supplied area. Thus, the flap necrosis could be explained by an insufficient anastomotic network. An operative technique modification could avoid this complication.

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Étude anatomique de la vascularisation artérielle du muscle deltoïde. Application au lambeau deltoïdien dans les grandes ruptures de la coiffe des rotateurs de l'épaule

Résumé Les ruptures de la coiffe des rotateurs de l'épaule présentant une vaste perte de substance tendineuse posent le problème de leur réparation chirurgicale. Plusieurs techniques ont été décrites dans la littérature pour leur réparation, dont la technique du lambeau deltoïdien (Apoil et Augereau). Dans notre expérience et celle de Saragaglia, cette technique peut se compliquer de nécrose aseptique précoce du lambeau dans quelques cas. Nous avons étudié la vascularisation artérielle du m. deltoïde sur 40 épaules de sujets non embaumés, après injection colorée de l'a. subclavière. Notre étude a comporté pour chaque épaule une observation macroscopique après dissection et une étude radiographique dans 15 cas. Nos résultats montrent que le lambeau deltoïdien est prélevé dans une zone de transition vasculaire. Nous pouvons diviser le lambeau en trois régions vasculaires correspondant aux trois pédicules artériels: aa. thoraco-acromiale, circonflexes humérales antérieure et postérieure. La préparation du lambeau s'accompagne obligatoirement de la section des collatérales de l'a. thoracoacromiale. La vascularisation du lambeau se trouve ainsi fragilisée. Sa nécrose pourrait s'expliquer par un réseau anastomotique défaillant et par la tension donnée lors de la suture à la coiffe restante. Une modification de la technique opératoire est à l'étude.

     

Antifibrinolytic therapy for prevention of hemorrhage during surgery of the thyroid gland

Summary The amount of fibrinolytic activity in the thyroid gland equals that of the prostate. In order to examine the effect of the antifibrinolytic drug tranexemic acid on perioperative bleeding saline or tranexemic acid were given randomized double blind to 76 consecutive patients who came for scheduled thyroid surgery. No significant differences were found in perioperative bleeding between patients in the treatment group (n=39) and control group (n=37).     

The arterial blood supply of the pancreas: a review: IV. The anterior inferior and posterior pancreaticoduodenal aa., and minor sources of blood supply for the head of the pancreas. An anatomical review and radiologic study

The present article is the fourth part of a comprehensive review of the arterial blood supply of the pancreas and completes the study of the arterial vascularization of the pancreatic head dealing with the anterior inferior and posterior inferior pancreaticoduodenal aa. and with some minor sources of blood supply not involving the classical system of the pancreaticoduodenal arches. The aim of this review is to summarise the anatomical studies, starting from Haller’s reports, and to supply, as far as possible with original material, angiographic evidence for the classic anatomical concepts. For this purpose, 1015 selective angiographs (celiac trunk and its branches, superior mesenteric a.) were taken from the angiographic archives of the Institutes of Radiology of Siena, Rome (Catholic University), and Perugia. These demonstrated the anterior inferior pancreaticoduodenal a., present in most instances, as arising from the inferior pancreaticoduodenal a., from a common trunk with the posterior inferior pancreaticoduodenal a. and the 1st jejunal a., from the 1st jejunal a. or from the superior mesenteric a.; on the other hand, the posterior inferior pancreaticoduodenal a. was more variable, originating from the inferior pancreaticoduodenal a., from a common trunk with the anterior inferior pancreaticoduodenal a. and the 1st jejunal a., from the superior mesenteric a., from the dorsal pancreatic a., or from a right accessory hepatic a. coming from the superior mesenteric a. In addition, minor branches to the head of the pancreas arose from the gastroduodenal a., the dorsal pancreatic a., the common hepatic a. and the inferior right phrenic a. Other origins of the inferior pancreaticoduodenal aa. previously reported, but not angiographically detectable with certainty, as well as further minor sources of blood supply to the head of the pancreas, have been listed. The differing opinions regarding the incidence of the various ways the inferior pancreaticoduodenal aa. arise are discussed and an attempt is made to explain the variability of the vascular anatomy of the pancreatic head on embryologic grounds.     

The arterial blood supply of the pancreas: a review III. The inferior pancreaticoduodenal artery

Summary This article is the third part of a comprehensive review on the pancreatic arterial blood supply and deals with the inferior pancreaticoducdenal a. The aim of this review is to summarise the anatomical studies, starting from Haller's reports, and to supply as far as possible, with original material, angiographic evidences for the classic anatomical notions. For this purpose, the overall research was carried out by picking out and studying 1015 selective angiographies (celiac trunk and its branches, superior mesenteric a.) taken from the angiographic archives of the Institutes of Radiology of Siena, Rome (Catholic University), and Perugia. Angiographically, the authors observed the inferior pancreaticoduodenal a., present in most instances, as arising from the superior mesenteric a., from the right accessory hepatic a., or from a common trunk with the first or the first two jejunal aa. Some variations of the course have been shown. The authors underline and discuss the discordant opinions still existing regarding the incidence of the different ways the inferior pancreaticoduodenal a. arises and the surgical importance of the variation of origin of this artery.

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La vascularisation artérielle du pancréas : une mise au point. III. L'artère pancréatico-duodénale inférieure

Résumé Cet article est la troisième partie d'une étude détaillée de la vascularisation artérielle du pancréas et traite de l'a. pancréatico-duodénale inférieure. Le but de ce travail est de résumer les études anatomiques, depuis la publication de Haller, et de fournir autant qu'il est possible, avec un matériel original, les preuves angiographiques des notions anatomiques classiques. Pour cela, la recherche complète a été menée sur le choix et l'ðude de 1015 angiographies sélectives (tronc coeliaque et ses branches, a. mésentérique supérieure) tirées des archives angiographiques des instituts de radiologie de Sienne, Rome (université catholique) et Pérouse. Sur les angiographies les auteurs ont observé l'a. pancréatico-duodénale inférieure, présente dans la plupart des cas, naissant de l'a. mésentérique supérieure, de l'a. hépatique droite accessoire, ou d'un tronc commun avec la première ou les deux premières aa. jéjunales. Quelques variantes ont été montrées dans son trajet. Les auteurs soulignent et discutent les opinions encore divergentes sur la fréquence des différentes origines de l'a. pancréatico-duodénale inférieure et sur leur importance chirurgicale.

     

Arterial supply of the upper cranial nerves: A comprehensive review

The arterial supply to the upper cranial nerves is derived from a complex network of branches derived from the anterior and posterior cerebral circulations. We performed a comprehensive literature review of the arterial supply of the upper cranial nerves with an emphasis on clinical considerations. Arteries coursing in close proximity to the cranial nerves regularly give rise to small vessels that supply the nerve. Knowledge of the arteries supplying the cranial nerves is of particular importance during surgical approaches to the skull base. Clin. Anat. 27:1159–1166, 2014. © 2014 Wiley Periodicals, Inc.     

Assessment of blood supply and usage pre- and during COVID-19 pandemic: A lesson from non-voluntary donation

BackgroundEnsuring steady stream of safe blood is the ultimate goal of blood transfusion practice. The current COVID-19 pandemic has affected almost every part of life and economy. Consequently, this study sets off to assess the effect of the pandemic on blood supply and blood transfusion in the University of Calabar Teaching Hospital.MethodsData from the Donor Clinic and Blood Group Serology Unit of the University of Calabar Teaching Hospital were retrospectively extracted to evaluate supply and use of blood before and during COVID-19 pandemic.ResultA total of 1638 donors were recorded within the study period. Age range 15–29 and 30–44 years constituted majority of the subjects (58.9% and 33.4%, respectively). The donor pool were male-dominated. Commercial donors (61.7%) and family replacement donors (30.6%) constituted majority of the donor pool. Most of the donor pool were students (37.1%), public servants (22.8%) and artisans (18.6%). A concomitant decrease of 26.1% and 18.9% were recorded in blood donation and request during the COVID-19 pandemic.ConclusionBlood supply was not significantly affected in our study center as both requests and donations decreased. Consideration for improving family replacement donation was advised.