Chandan Kumar Jha

Comment on: Can we consider immediate complications after thyroidectomy as a quality metric of operation?

To the Editors: We read with interest the article entitled “Can we consider immediate complications after thyroidectomy as a quality metric of operation?” by Lifante et al. Congratulations to the authors for trying to define some quality indicators for thyroid operation through a very well-designed study with an honest presentation of the data. There is no way surgeons can overlook their complications, and this study has provided us with the insight that the complication rates are usually greater than the surgeon’s own estimate; hence, we must develop ways and means to monitor and improve on metrics of outcomes and recognition of complications. We share the authors view that the incidence of temporary recurrent laryngeal nerve (RLN) injury can serve as an indicator of quality of thyroid operation. In contrast, we believe that temporary hypoparathyroidism, as opposed to permanent hypoparathryoidism, is too complex a phenomenon to be considered as an indicator for the same. A host of patient, tumor, and technical factors, in addition to surgeon-related factors, have a bearing on the incidence of hypoparathyroidism, more so on temporary hypoparathyroidism. Compared to this, RLN injury is one complication that can be reduced by proper training, meticulous dissection during the operation, and use of neuromonitoring if available in difficult cases. The authors have mentioned that one of the limitations of their study was that they did not assess the quality of the voice. We would like to add that assessment of the quality of voice may be a very important quality indicator of a thyroid operation, but like temporary hypoparathyroidism, the quality of the voice is affected by a number of factors that are difficult for the surgeon to control. The other issue with assessing the quality of the voice is that it is not as straightforward as assessing vocal cord mobility or hypoparathyroidism, meaning that it is unlikely to be widely applied as a quality indicator especially in resourcelimited developing countries. In our view, temporary RLN palsy and permanent hypoparathyroidism should be the 2 minimum indicators that all thyroid surgeons should monitor routinely to assess their own practice.

Overt Skeletal Metastases in a Patient of Occult (Microscopic) Follicular Thyroid Carcinoma: a Rare Case

Occult follicular thyroid carcinoma (FTC) presenting as distant metastases is a rare occurrence. However, despite being occult in majority of these cases, primary tumor can be detected on thyroid imaging or during surgery. Here, we present an extremely rare case of an occult FTC with overt skeletal metastases in which primary tumor was discernible only on microscopic examination.

Letter to Editor in Response to the Article Entitled “Surgical Methods and Experiences of Surgeons Did Not Significantly Affect the Recovery in Phonation Following Reconstruction of the Recurrent Laryngeal Nerve”

Dear Sir, We read with interest the article entitled ‘‘Surgical Methods and Experiences of Surgeons did not Significantly Affect the Recovery in Phonation Following Reconstruction of the Recurrent Laryngeal Nerve (RLN)’’ by K. Yoshioka et al. published in World Journal of Surgery [1]. When it comes to the subject of voice and RLN resection and/or anastomosis, any article from Dr. Miyauchi’s group becomes a must read for all thyroid surgeons and it was the same again. The authors have shown that recovery of voice following resection and immediate reconstruction of RLN was not associated with gender, age, preoperative VCP, surgical method of reconstruction, or experience of the surgeon. At our institute we often operate on locally advanced thyroid carcinoma patients [2]. Some of these patients have gross invasion of RLN, which many times have to be resected in order to avoid leaving gross disease. We do not follow a policy of routine anastomosis, especially when a segment of nerve is resected. We have observed that the voice is generally well compensated in few weeks. Although we have not done a formal study on this subject, more often than not, patient’s subjective assessment of their own voice does not seem to differ in group of patients who had undergone anastomosis compared to those who have not had anastomosis following RLN resections. It brings us to the question that what was the correlation of the findings of maximum phonation time (MPT) and mean airflow rate (MFR) with the patient’s own assessment of quality of voice? Another query that we would like to make is that whether some or all of these patients underwent any voice therapy after nerve anastomosis? Voice is not just the function of RLN integrity, a host of other factors may also affect it [3–5], division of strap muscles, status of the external branch of superior laryngeal nerve being some of those which are important in case of thyroidectomy. And, this is why we felt that it would have been better if the control group could have been selected from the patients operated by the authors’ group who had been subjected to a uniform technique of thyroidectomy rather than those operated by other surgeons.

Ultrasound-Guided Placement of Central Venous Port Systems via the Right Internal Jugular Vein: Are Chest X-ray and/or Fluoroscopy Needed to Confirm the Correct Placement of the Device

1. We have a similar personal experience where we have found that central venous catheters can be safely placed in correct position most of the times with the use of ultrasound guidance, especially when access is made through the right internal jugular vein (IJV). We mostly placed implantable central venous port (CVP) in breast cancer patients, and depending on the site of breast lesion, we get equal chance to access right or left IJV. Low complication and high success rates of correct positioning of catheters through right IJV are well documented in the literature but, as authors have also pointed out, the access through left IJV or the subclavian veins is not so straightforward because of their anatomy [2, 3]. Hence, we do use routine fluoroscopic imaging, though not X-ray chest. What do authors have to say about that? Would they recommend routine fluoroscopy for CVP placement via left IJV or they would solely rely on USG and/or echocardiography. 2. The second comment is about the skin access site and technique of port placement. The authors have mentioned that they access the skin site for puncturing the IJV at the level of a transverse line passing through the thyroid notch. However, what we have observed in our day-to-day practice is that higher the sites of skin puncture more are the chances of catheter getting kinked on its way to port. Therefore, we in our practice tend to position the skin puncture site lower down in the neck. Considering that the port is placed at the lateral border of the second rib, this lower down positioning of the skin puncture site allows a wider angle at the apex of the catheter and decreases the probability of kinking and ensures an uninhibited flow. Kinking of catheter at the apex is an uncommon complication but can be distressing for the surgeons and the patients. In a recent article, Kehagias et al. [4] have described an ‘‘L-shaped tunneling technique’’ for tunneling of catheter and placement of the port. What kind of tunneling technique authors prefer?

Comment on: Potential role for carbon nanoparticles to guide central neck dissection in patients with papillary thyroid cancer.

To the Editors: We read with interest the article entitled “Potential role for carbon nanoparticles to guide central neck dissection in patients with papillary thyroid cancer” by Yu et al. The use of carbon nanoparticles as tracer for lymph nodes in the central neck has generated a lot of interest in recent times, and the current evidence suggests its usefulness in identifying the lymph nodes. The authors found that the number of dissected lymph nodes and small lymph nodes (<5 mm) in the carbon nanoparticle group was significantly greater than in the control group. They suggest that the use of carbon nanoparticle could help in a more radical dissection of the central neck. We have a few comments and queries:

The L-shaped tunneling technique for implantable port positioning avoids kinking

We read with interest the article entitled ‘The “L-shaped tunneling technique”: a modified technique facilitating a more discreet implantable port positioning’ by Kehagias E and Tsetis D (1). The authors have comprehensively described a configuration of the TIVAD catheter that at least is very helpful in avoiding the kinking of the catheter. The classical teaching is that the TIVAD catheters should be placed in a way that the apex of the catheter should lay in the supra-clavicular fossa and the catheter should appear in a shape of an “inverted V” on post procedural imaging (either x-ray chest or fluoroscopy). In fact, we were used to it until recently and it was not uncommon to find a kink at the apex of the V. This usually resulted in increased operative time for manipulation of the catheter and sometimes even the incision at the venous access site had to be enlarged to manipulate the catheter. What the authors have suggested in the “L-shaped tunnelling technique” appears very logical considering that it just aims at increasing the angle of the “V” and thereby converting an acute angle into a right angle, so that the final shape on imaging will appear as an “L” rather than an inverted “V”. Not sure why it took us so long to realise this simple physics? Having said all this, we would also like to make a comment on the positioning of the port suggested by the authors. The authors have said that they implant the port in a pocket created in the deltopectoral groove (1). We also had some cases where the pockets were created in a similar position, of course by mistake rather than by protocol, and we observed that assessing such ports at the time of drug infusion becomes a bit tricky due to more subcutaneous fat, relatively deeper location of the bony chest wall and curvature of the chest wall at that site. This makes the fixation of port for putting a needle into it more difficult compared to a port that is situated a bit more medially than the deltopectoral groove at the same level on the chest wall that the authors have suggested. Regarding the issue of cosmesis, we would like to add that cosmetic appearance is suitable in both positions of port placement, but in making a choice of one over the other, we would suggest that the patient’s preferred clothing style should be considered before deciding how laterally the port should be placed.

Fournier's Gangrene

A two-month-old male infant presented with progressive swelling over both sides of scrotum, moderate to high fever and listlessness since five days. The scrotal skin was reddened, edematous, tense, and shiny. There was an ulcerated lesion of size 5 × 5 centimeters present over both sides of the scrotum. The edges of the ulcer were edematous, reddened, and irregular. The floor had slough, with a purulent, fowl smelling discharge. Both the testes were exposed. Perineal and perianal area was otherwise normal (Fig. 1). A disgnosis of Fournier’s gangrene was made. The patient was treated with antibiotics in addition to wide surgical debridement. The surgical wound healed well after secondary suturing (Fig. 2).

Patterns of Use and Short-Term Outcomes of Minimally Invasive Surgery for Malignant Pheochromocytoma: A Population-Level Study

We read with interest the article entitled ‘Patterns of Use and Short-Term Outcomes of Minimally Invasive Surgery for Malignant Pheochromocytoma: A Population-Level Study’ [1]. Congratulations to the authors for reporting the largest cohort of the patients having this rare disease. They have done a commendable job, considering that it was an analysis of a database and that data were collected over a long period of time. Having said this, we would like to make few comments and have some of our queries answered:

Posterosuperior Lesion has a High Risk of Lateral and Central Nodal Metastasis in Solitary Papillary Thyroid Cancer.

(1) What was the average size of the thyroid lobe? Did majority of the patients included in this study also have co-existent goiter? The dimensions of a normal thyroid gland range from 40–60 mm in length and 13–18 mm in transverse and antero-posterior (A-P) diameter [2, 3]. Considering the dimensions of a normal thyroid gland, it seems a bit difficult to divide it into nine portions and particularly in coronal plane (AP diameter about 2 cm) unless most of the tumors are small (1 cm) or thyroid is enlarged it is difficult to divide it into three parts anterior, middle, and posterior and locate tumor within one of these portions. Forty patients in this study had tumor measuring more than 2 cm in size but only 21 of them were in ‘‘W’’ category, i.e., occupying more than one portions of the 9 portions proposed by the authors. Authors have mentioned that the 178 patients have tumor measuring less than 2 cm, but they did not provide the mean tumor size, but it seems that most of the tumors were small. We believe that the findings of this study would be more pertinent for papillary microcarcinoma rather than the bigger tumor; and in that scenario, it would definitely be of great help. (2) Authors have provided the percentage of metastases in various levels of cervical lymph nodes. Did they also find any correlation of location of the PTC within thyroid gland with a particular level of lymph node involvement?