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��bbb�bbbNNNNNN����Flow evaluation of the internal jugular vein after neck dissection
Erkan VURALKAN, MD Department of Otolaryngology, Trabzon Kanuni Education and Research Hospital, Trabzon, Turkey
Didem SONBAY, MD Department of Otolaryngology, Yalva� State Hospital, Isparta, Turkey
I_1k CONKBAYIR, MD Department of Radoiology, D1_kap1 Y1ld1r1m Beyaz1t Education and Research Hospital, Ankara, Turkey
Cem SAKA, MD Department of Otolaryngology, D1_kap1 Y1ld1r1m Beyaz1t Education and Research Hospital, Ankara, Turkey
Sibel AL0CURA TOKG�Z, Department of Otolaryngology, D1_kap1 Y1ld1r1m Beyaz1t Education and Research Hospital, Ankara, Turkey
0stemihan AKIN, Department of Otolaryngology, D1_kap1 Y1ld1r1m Beyaz1t Education and Research Hospital, Ankara, Turkey
Beh�et G�nsoy, MD Department of Otolaryngology, Gaziantep Ersin Aslan State Hospital, Gaziantep, Turkey

Corresponding author and address for correspondence: 
Erkan Vuralkan, MD
Department of Otorhinolaryngology,
Trabzon Kanuni Education and Research Hospital, Trabzon, Turkey
E-mail:  HYPERLINK "mailto:erkanvuralkan@hotmail.com" erkanvuralkan@hotmail.com
Tel: 00905053783847		Fax: 00904622302307
Flow evaluation of the internal jugular vein after neck dissection
Objective: To evaluate thrombosis, flow rate and changes in the caliber of the internal jugular vein after neck dissection.
Materials and methods: Sixteen patients who underwent twenty-two neck dissections that spared the internal jugular vein (IJV) were evaluated from December 2008 to September 2009 at our clinic. Preoperatively and postoperatively, the patency of the 22 IJVs was determined by duplex Doppler ultra-sound examinations. The patients were scanned in the supine position, and the patency and caliber of the IJVs were assessed. These examinations were administered preoperatively and at the postoperative 1st and 3rd months.
Results: There were significant differences in the caliber and flow rate of the IJV between the preoperative and 7-day postoperative evaluations. No significant difference in the caliber and flow rate of the IJVs were observed between the preoperative and the 1-month postoperative evaluation. The caliber and flow rate of the IJVs were determined to be within the normal range at the 3-month postoperative evaluation. Thrombus was not found in any patient postoperatively.
Conclusion: The reduction in the flow rate improved gradually in neck dissections that preserved the IJV. The protection of the internal jugular vein will minimize morbidity.
Key words: Internal jugular vein, thrombosis, caliber, neck dissection







Introduction
	Radical neck dissection (RND) was first described by Crile in 1906. The aim of the procedure is to remove lymph nodes from one side of the neck into which cancer cells may have migrated. The metastasis of tumors into the lymph nodes of the neck reduce survival and is the most important factor in the spread of cancer. The spinal accessory nerve, internal jugular vein and sternocleidomastoid muscle are sacrificed in this procedure. RND has been used for the treatment of patients with neck squamous cell carcinoma [1]. However, the sacrifice of these structures leads to cosmetic and functional deficits [2-7]. A desire to maximize control and minimize morbidity has prompted modifications to the classic neck dissection procedure. One such modification is the preservation of 1 or more non-lymphatic structures (e.g., the spinal accessory nerve, internal jugular vein or sternocleidomastoid muscle) [8]. Bocca described in detail the surgical steps of functional neck dissection; his efforts have led to this operation, which is usually defined as the Suarez-Bocca technique, becoming popular all over the world [8]. In this operation, the spinal accessory nerve, internal jugular vein and sternocleidomastoid muscle are preserved, and fibroadipose tissue is excised [9]. Functional neck dissection is successful when there is no metastasis or presence of lymphadenopathy less than 3 cm [8]. There is no consensus in terms of functional success despite this procedure being oncologically successful. The patency of the internal jugular vein is considered suspicious after the surgery [9-12].
	The incidence of a narrowed but patent vein after neck dissection has been reported as 3.8-64.7% [13-16]. In these reports, however, the definition of a �narrow vein� was vague; for example, a narrowed lumen was defined as occurring when the IJV had a markedly reduced caliber or when the diameter of the dissected IJV was one-half or less of the diameter of the undissected IJV. The finding of venous narrowing is regarded as one of the factors that could encourage thrombus formation after neck dissection [17].
	In this study, we evaluated thrombosis, flow rate and change in the caliber of the IJV after neck dissection.
Materials and Methods
We studied 16 patients who underwent 22 neck dissections that spared the internal jugular vein from December 2008 to September 2009 at our clinic. We did not include patients who underwent radiotherapy, neck surgery before this procedure or reconstruction with flaps. Twenty patients (90.9%) had no palpable lymphadenopathy before the surgery. Patients who were diagnosed with tongue and tonsilla palatina squamous cancer had palpable lymphadenopathy of less than 3 cm. 
The primary tumor sites are shown in Table 1. Neck disease was classified according to the criteria of AJCC. Bilateral neck dissection was performed in 6 patients. The branches of the internal jugular vein were ligated with 3-0 silk sutures without interfering with the diameter of vessel. We did not use electrocautery during the dissection.
Preoperatively and postoperatively, the patency of the 22 IJVs was determined by duplex Doppler ultra-sound examination. The scans were all performed by one person using a Doppler ultrasound machine (SSA-390A Power Vision 8000 Scanner�, Tokyo, Japan) with a 6-11 MHz Linear-Array transducer. The patients were scanned in the supine position, and the patency and caliber of the IJVs were assessed. These examinations were administered preoperatively and at the 1st and 3rd postoperative months.
The means � standard deviations were calculated, and Statistical analysis was performed with SPSS for Windows vr 11.0 package programme (SPSS Inc., Chicago, IL, USA, Customer number: 114094). The normality distribution was confirmed using the Shapiro�Wilk test. The paired samples t test was used to detect the differences between the mean values of the samples. The Wilcoxon Signed-Rank test was used to define the significant differences between the mean values of the samples that were not normally distributed. All differences with p<0.05 were considered statistically significant.
Results
	There were 14 (87.5%) male and 2 (12.5%) female patients, with a mean age of 56.7�9.06 (43-77) years. The mean preoperative vein diameter was 18.1�4.9 mm. The average flow rate was 19.9�5.4 mm/sec (range 8-31 mm/sec). At 7 days postoperative, the mean ratio of the IJV caliber was 9.5�2.9 mm (3-16 mm). The lowest flow rate was 5 mm/sec, the highest was 28 mm/sec, and the average was 11.7 � 7.9 mm/sec. There were significant differences in the caliber and flow rate of the IJVs between the preoperative and 7-day postoperative evaluations (p<0.05).
	The mean vein diameter was 13.7�5.4 mm (range 2 -25 mm) 1-month postoperative. The average flow rate was 5.6�4.0 mm/sec (range 3-14 mm/sec). No significant differences in the caliber and flow rate of the IJVs were observed between the preoperative and 1-month postoperative evaluations (p>0.05).
	The mean vein diameter was 22.0�4.6 mm (range 12-32 mm) at the 3-month postoperative evaluation. The average flow rate was 17.2�3.5 mm/sec (range 8-30 mm/sec). The caliber and flow rate of the IJVs were determined to be within the normal range at the 3-month postoperative evaluation. (Table 2) Thrombus was not found in any patient postoperatively.
Discussion
	There are several risk factors for internal jugular thrombosis after neck dissection. One of the risk factors for thrombus formation is narrowing of the IJV [17]. Non-operative factors and intraoperative technical events may impact the patency rate of the IJV following a neck dissection. The non-operative factors that have been reported are post-operative radiotherapy [17],  placement of a central catheter [18,19], external compression from a flap or drain [15] and infection.20,21 Surgical factors that can help avoid thrombosis include the following: atraumatic manipulation of the vein, avoiding thermal injury with electrocautery, avoiding desiccation of the jugular vein once it is denuded of adventitia and maintenance of the optimal flow characteristics by the ligation of jugular side branches far enough from the vein to avoid constriction of the diameter but close enough to prevent blind jugular side pouches, which may contribute to turbulent flow and retrograde thrombosis.22 In our study, we did not find any thrombus formation in the IJVs. We did not use atraumatic surgical cautery dissection or ligation of the branches of the IJVs.
	Fisher et al described the most important factors that cause IJV occlusion as trauma and pressure from a myocutaneous flap.14] Several studies showed that the patency of the IJV after neck surgery ranges from 70% to 97%.16,17,20,23 Duplex Doppler ultrasonography is readily available, inexpensive and non-invasive, and thrombus formation is shown easily by USG.24,25 In this study, Doppler ultrasonography was used because of its high sensitivity and specificity values. 
	After neck dissection, the incidence of thrombosis in the IJV was reported to be nearly 29.6%.3 The incidence of occlusion in the IJV was reported to be 0-4% after functional neck dissection.26-28. In our study, although the IJV diameter and flow rate decreased in the early postoperative period, no IJV thrombus was detected. The patients included in this study underwent primary closure without flap reconstruction.
	Radiotherapy is a cause of thrombus formation.14,15 Fibrosis around the IJV in patients who underwent surgery and radiotherapy is a risk factor for thrombus formation.14,15 Fibrosis reduces the caliber and flow rate of the IJV.17 Patients who received radiotherapy were excluded to enable only the effects of the surgical technique on the postoperative vein to be determined.
	Harada et al evaluated the patency of the IJV with computed tomography and USG in 76 patients after neck dissection. The patients had no postoperative occlusions. In the same study, the average postoperative diameter of the IJV was low in the early period but gradually increased within 3 months of the surgery [29]. Venous narrowing has been reported to be one of the factors that could encourage thrombus formation after neck dissection [30]. In our study, the average postoperative diameter of the IJV was low in the early period. We calculated these values as values up to the 3rd month. Thrombosis was not detected in the pre- or postoperative periods.
In summary, the reduction in the flow rate improved gradually for neck dissections that preserved the internal jugular vein. Decreasing the flow rate and vein caliber does not cause the formation of a thrombus. The protection of the internal jugular vein will minimize morbidity. 
References

1.	Crile G (1906) Excision of cancer of head and neck. JAMA 47:1780-6.
2.	Nahum AM, Mullally W, Marmor L (1961) A syndrome resulting from radical neck dissection. Arch Otolaryngol 74:424-8.
3.	Quraishi HA, Wax MK, Granke K, Romdan SM (1997) Internal jugular vein thrombosis after functional and selective neck dissection. Arch Otolaryngol Head Neck Surg 123:969-73.
4.	de Vries WAEJ, Balm AJM, Tiwari RM (1986) Intracranial hypertension following neck dissection . J Laryngol Otol 100:1427-31.
5.	Marks SC, Jaques DA, Hirata RM, Saunders Jr (1990) Blindness following bilateral radical neck dissection. Head Neck 12:342-5.
6.	Wenig BL, Heler KS (1987) The syndrome of inappropriate secretion of antidiuretic hormone (SIADH) following neck dissection. Laryngoscope 97:467-70.
7.	Cappiello J, Piazza C, Berlucchi M, Peretti G, De Zinis LOR, et al (2002) Internal jugular vein patency after lateral neck dissection: a prospective study. Eur Arch Otorhinolaryngol 259:409-12. 
8.	Veyseller B, Aksoy F, A�1kal1n M, Y1ld1r1m YS, Bayraktar FG0, et al (2010) Internal juguler ven ak1m1 ve devaml1l11n1n fonksiyonel boyun diseksiyonu sonras1nda power dubleks Doppler ultrasonografi ile deerlendirilmesi. Kulak Burun Bogaz Ihtis Derg 20(1):38-43.
9.	 Bocca E, Pignataro O (1967) A conservation technique in radical neck dissection. Ann Otol Rhinol  Laryngol 76:975-87.
10.	Leipzig B, Suen JY, English JL, Barnes J, Hooper M (1983) Functional evaulation of the spinal accessorry nevre. Am J Surg 146:526-30.
11.	Remmler D, Byers R, Scheetz J, Shell B, White G, et al (1986) A prospective study of shoulder disability resulting from radical and modified neck dissections. Head Neck 8:280-6.
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