A radikalitás helye a benignus pajzsmirigybetegségek sebészi kezelésében a nervus rekurrens anatómiai sajátságainak tükrében = The place of radical surgical approach in the treatment of benign multinodular goitre from the aspect of the anatomical variations of the recurrent laryngeal nerve

Előfordul, hogy meg szubtotalis pajzsmirigy-reszekciot kovetően is az indirekt laringoszkopia rekurrens paresist igazol. Szinte minden sebesz kidolgozott mar valamilyen egyeni technikat a nervus rekurrens vedelmeben. A szerzők arra kerestek valaszt, hogy az idegtapintasi eljaras kellően hatekony-e a mindennapi, radikalitasra torekvő sebeszi gyakorlatban. Anyag es modszer: 2001. januar 1. es 2008. december 31. kozott 1228 nervus laryngeus rekurrenst preparaltak ki 702 pajzsmirigyműtet soran. Minden betegnel megtalaltak es a gegebe lepesig kovettek azokat. A golyva a betegek 38,6%-aban (271/702) substernalis terjedest mutatott, mig tracheakompressziot es diszlokaciot 19,5%-ban (137/702) eszleltek. 8,4%-ban recidiv pajzsmirigy-elvaltozas miatt tortent a beavatkozas. Lobectomiara 82,2%-ban kerult sor (1009/1228), near totalis reszekciot 15,5%-ban (191/1228), mig szubtotalis reszekciot mindossze 2,3%-ban (28/1228) vegeztek. Eredmenyek: Az idegtapintasi eljaras 80,7%-ban segitette a rekurrens megtalalasat (991/1228), 8,7%-ban azonban fals pozitivnak bizonyult (107/1228), mig 10,6%-ban (130/1228) egyaltalan nem segitett helyenek pontos tisztazasaban. A modszer a jobb es bal oldal vonatkozasaban markans kulonbseget mutatott. Mig jobb oldalon mindossze 3,4%-ban eszleltek fals pozitivitast, addig bal oldalon ez 14,3%-nak bizonyult. Ugyanakkor viszont, mig bal oldalon csak 4,8%-ban volt sikertelen a tapintasi kiserlet, jobb oldalon ez 16,2%-nak adodott. Definitiv rekurrens paresist 0,8%-ban eszleltek (10/1228), mig tranziens paresissel 1,4%-ban (17/1228) szembesultek. Okkult malignitast 5,6%-ban talaltak (39/702). Kovetkeztetesek: Velemenyuk szerint napjainkban mar nem maradt indikacioja a szubtotalis reszekcionak meg benignus multiplex gobos golyva eseteben sem, mivel klinikai es patofiziologiai evidenciak vannak arra vonatkozoan, hogy a maradek allomany a recidiva bolcsője, annak osszes potencialis veszelyforrasaval egyutt. Az idegtapintasi modszer hasznos eleme a radikalis pajzsmirigyműteteknek, de csak az orientacio szempontjabol, a vizualizalast nem helyettesiti. | From time to time there is a surprise at the end of surgery – even after subtotal resection – when a vocal cord is observed on indirect laryngoscopy to be non-functional. Surgeons are highly individualistic and develop their own special ways of locating and protecting the nerve. The present study has tried to clarify whether relying on palpation alone during surgery is safe enough in each case. Materials and methods: Between 01.01.2001 and 31.12.2008, 1228 recurrent laryngeal nerve (RLN) were exposed in 702 patients on thyroid surgery. The RLN was found and traced until the laryngeal entry point in all patients. Substernal spreading was noted in 38.6% (271/702), while tracheal compression or dislocation was present in 19.5% (137/702). Recurrent thyroid disease counted for 8.4% (59/702) of all cases. Total thyroid lobectomy was carried out in 82.2% (1009/1228), near-total thyroidectomy in 15.5% (191/1228), and subtotal resection only in 2.3% (28/1228). Results: Palpation was helpful in 80.7% (991/1228), proved false positive in 8.7% (107/1228), while in 10.6% (130/1228) it did not provide any help in the localization. The palpability of the RLN showed marked discrepancy between the two sides. False positivity was noted with palpation in 3.4% (21/625) and 14.3% (86/603) on the right and left side, respectively. On the other hand, palpation helped localization in 4.8% (29/603) on the left side, while the same figure was 16.2% (101/603) on the right side. Definitive RLN palsy was experienced in 0.8% of all cases (10/1228), whilst transient paresis was encountered in 1.4% (17/1228). Occult malignancy was noticed in 5.6% (39/702). Conclusions: No indication has been left for subtotal resection. Even if benign multinodular goitre is present, since the clinical and pathophysiological evidences suggest that multinodular goitre affects the entire gland, any surgery that leaves potentially abnormal thyroid tissue in situ carries a risk of recurrent disease. RLN palpatory method is a useful part of thyroid surgery but it is suitable for rough orientation only.