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Maza G, Sharma A. Topical Hemostatic Agents and Risk of Postoperative Hemorrhage After Transoral Robotic Surgery. EAR, NOSE & THROAT JOURNAL 2024:1455613241233097. [PMID: 38380626 DOI: 10.1177/01455613241233097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024] Open
Abstract
Objective: Postoperative hemorrhage is the most common complication of transoral robotic surgery (TORS). The available research literature on topical hemostatic agents is deficient, despite their wide use. This study aims to evaluate the frequency and severity of hemorrhagic events after TORS procedures, performed with various topical hemostatic agents. Methods: This study was planned as a retrospective review to identify postoperative hemorrhage events in a database of all consecutive adult patients who required TORS from January 1, 2015, to April 1, 2020. All procedures were performed in one single institution by the same surgeon. In 2017, bovine gelatin matrix with thrombin (BgMT) was replaced by the porcine gelatin matrix with thrombin (PgMT) for all procedures. Postoperative hemorrhage was identified, along with hemostatic agents employed and other variables. Results: A cohort of 80 TORS procedures was obtained from a population of 78 individuals (60 males:18 females). BgMT was used in 28 procedures (35%), and five cases of postoperative hemorrhage were identified (17.8%), two of them were severe. PgMT was used in 52 procedures (65%) just observing one minor hemorrhagic event (1.92%). Although a significant difference was observed for total events between groups (P = .0183), there was no difference between major or severe hemorrhagic events (P = .1196). The overall rate of major and severe postoperative hemorrhage in the study population was 2.5% (n = 80). Conclusions: This is the first study to evaluate topical hemostatic agents during TORS procedures. The PgMT group had a reduced incidence of total postoperative hemorrhages, although there was no difference in the number of severe hemorrhagic events. The overall simplicity and cost-effectiveness of these agents would support their use, particularly considering the potential risk associated with airway hemorrhage.
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Affiliation(s)
- Guillermo Maza
- Department of Otolaryngology-Head and Neck Surgery, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Arun Sharma
- Department of Otolaryngology-Head and Neck Surgery, Southern Illinois University School of Medicine, Springfield, IL, USA
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2
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Larsen MHH, Channir HI, Madsen AKØ, Rubek N, O'Leary P, Kjærgaard T, Kehlet H, von Buchwald C. Why in hospital following transoral robotic lingual tonsillectomy? Acta Otolaryngol 2023; 143:796-800. [PMID: 37897327 DOI: 10.1080/00016489.2023.2265983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 09/22/2023] [Indexed: 10/30/2023]
Abstract
BACKGROUND The reported hospital length of stay (LOS) following transoral robotic surgery lingual tonsillectomy (TORS-L) is variable, with limited understanding of the factors requiring hospitalization and no evidence-based criteria for discharge. AIMS/OBJECTIVES This observational cohort study investigated factors hindering discharge following TORS-L in a well-defined postoperative care program. METHODS Patients were included between August 2020 and October 2022. A discharge scheme was filled out twice daily, specifying the factor(s) for hospitalization among patients undergoing TORS-L. This trial was a sub-investigation of a national multicentre randomized clinical trial (RCT) testing the efficiency of high-dose dexamethasone on postoperative pain control. Participation in the RCT demanded admission to the fourth postoperative day as dexamethasone/placebo was given intravenously in repeated dosages till day 4 postoperatively. RESULTS Eighteen patients were included in the analysis. The main factor for hospitalization was nutritional difficulties, while pain was a limiting factor for discharge only on the first postoperative 1-3 days. More than half of the patients could have potentially been discharged on postoperative day 2 when omitting the RCT treatment plan in the analysis. CONCLUSION The study estimates that the majority of patients may be discharged on postoperative day 2 following TORS-L.
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Affiliation(s)
- Mikkel Hjordt Holm Larsen
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Hani Ibrahim Channir
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Anne Kathrine Østergaard Madsen
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Niclas Rubek
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Padraig O'Leary
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Aarhus University Hospital, Copenhagen, Denmark
| | - Thomas Kjærgaard
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Aarhus University Hospital, Copenhagen, Denmark
| | - Henrik Kehlet
- Section of Surgical Pathophysiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian von Buchwald
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
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Practice patterns in transoral robotic surgery: results of an American head and neck society survey. J Robot Surg 2022; 17:549-556. [PMID: 35933632 DOI: 10.1007/s11701-022-01448-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 07/21/2022] [Indexed: 10/15/2022]
Abstract
To understand perioperative practices for transoral robotic surgery (TORS) among academic medical centers. An electronic cross-sectional survey was distributed to fellows and program directors participating in 49 American Head and Neck Society fellowships. Operative decisions, medical and swallowing management, and disposition planning were assessed. Thirty-eight responses were collected (77.6%). Twenty-three centers (60.5%) performed > 25 cases annually with the remainder performing fewer. The da Vinci Si was the most commonly used platform (n = 28, 73.7%). A majority of institutions advocated tailored resection to adequate margins (n = 27, 71.1%) over fixed subunit-based resection (n = 11, 28.9%). Most surgeons (n = 29, 76.3%) performed neck dissection concurrent with TORS, and 89.5% (n = 34) routinely ligated external carotid artery branches. A minority of institutions (n = 17, 45.9%) endorsed a standardized TORS care pathway. Antibiotic choices and duration varied, the most common choice being ampicillin/sulbactam (n = 21, 55.3%), and the most common duration being 24 h or less (n = 22, 57.9%). Multimodal analgesia was used at 36 centers (94.7%), steroids at 31 centers (81.6%), and pharmacologic venous thromboembolic prophylaxis at 29 centers (76.3%). Nasogastric feeding tubes were placed during surgery at 20 institutions (54.1%). Speech-language pathologists routinely performed postoperative swallow evaluations at 29 (78.4%) sites. Practice patterns are variable among institutions performing TORS. While certain surgical and postoperative practices were quite common, many institutions reported no standard TORS care pathway. Further understanding of the impact of individual practices on outcomes is necessary to develop evidence-based perioperative protocols for TORS.
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Wadhavkar N, Jorgensen JB, Bollig CA. Association of comorbidity score with perioperative outcomes following transoral robotic surgery: National analysis. Head Neck 2022; 44:1655-1664. [PMID: 35484962 PMCID: PMC9321542 DOI: 10.1002/hed.27070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 03/29/2022] [Accepted: 04/19/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The association of comorbidities with perioperative outcomes after transoral robotic surgery (TORS) is not well-defined in the literature. METHODS Using the National Cancer Database, 4004 patients with T1-T2 oropharyngeal cancer between 2010 and 2017 were stratified based on their Charlson-Deyo Comorbidity Class (CDCC). Thirty-day unplanned readmissions, 30-day mortality, and 90-day mortality were compared using chi-square test and logistic regression. Hospital length of stay (LOS) was compared using the Kruskal-Wallis test. RESULTS LOS was greater for patients with CDCC 2 or 3 compared to CDCC 0 or 1 (p < 0.001). Increasing age and CDCC ≥3 were associated with 30-day mortality (CDCC ≥3: odds ratio [OR] 5.55, 95% confidence interval [CI] 1.59-19.45). CDCC ≥3 (OR 2.61, 95%CI 1.09-6.27) was significantly associated with 30-day readmissions. CONCLUSION This national analysis demonstrates greater rates of unplanned 30-day readmissions, longer hospitalizations, and increased 30- and 90-day mortality after TORS in patients with CDCC ≥3.
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Affiliation(s)
- Neha Wadhavkar
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Jeffrey B Jorgensen
- Division of Otolaryngology - Head and Neck Surgery and Communicative Disorders, Prisma Health Upstate, Greenville, South Carolina, USA
| | - Craig A Bollig
- Department of Otolaryngology - Head and Neck Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
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Philips R, Topf MC, Vimawala S, Luginbuhl A, Curry JM, Cognetti DM. Risk factors for gastrostomy tube dependence in transoral robotic surgery patients. Am J Otolaryngol 2022; 43:103175. [PMID: 34418824 DOI: 10.1016/j.amjoto.2021.103175] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 06/26/2021] [Accepted: 08/04/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To determine the rate of gastrostomy tube dependence after transoral robotic surgery (TORS), and to determine which patient or surgical factors increase the likelihood of gastrostomy tube dependence. METHODS Retrospective chart review of all patients who underwent TORS for oropharyngeal squamous cell carcinoma (OPSCC) at a single institution from January 2011 through July 2016. Patients who underwent TORS for recurrent OPSCC were excluded. Primary outcome was gastrostomy tube (g-tube) dependence. Univariable and multivariable logistic regression were performed to identify risk factors for g-tube dependence at 3-months and 1-year. RESULTS A total of 231 patients underwent TORS during the study period. At 3-month follow-up, 58/226 patients (25.7%) required g-tube. At 1-year and 2-year follow-up, 8/203 (3.9%) and 5/176 (2.8%), remained dependent on g-tube, respectively. Advanced T stage (T3) (OR = 6.07; 95% CI, 1.28-28.9) and discharge from the hospital with enteral access (OR = 7.50; 95% CI, 1.37-41.1) were independently associated with increased risk of postoperative gastrostomy tube dependence at 1 year on multivariable analysis. CONCLUSIONS Long-term gastrostomy tube dependence following TORS is rare, particularly in patients that receive surgery alone. Patients with advanced T stage tumors have poorer functional outcomes. Early functional outcomes, as early as discharge from the hospital, are a strong predictor for long-term functional outcomes.
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Affiliation(s)
- Ramez Philips
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, 925 Chestnut Street, 6th Floor, Philadelphia, PA 19107, USA.
| | - Michael C Topf
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, 1215 21st Ave. S. Suite 7209, Nashville, TN 37232, USA
| | - Swar Vimawala
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, 925 Chestnut Street, 6th Floor, Philadelphia, PA 19107, USA
| | - Adam Luginbuhl
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, 925 Chestnut Street, 6th Floor, Philadelphia, PA 19107, USA
| | - Joseph M Curry
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, 925 Chestnut Street, 6th Floor, Philadelphia, PA 19107, USA
| | - David M Cognetti
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, 925 Chestnut Street, 6th Floor, Philadelphia, PA 19107, USA
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Feng AL, Holcomb AJ, Abt NB, Mokhtari TE, Suresh K, McHugh CI, Parikh AS, Holman A, Kammer RE, Goldsmith TA, Faden DL, Deschler DG, Varvares MA, Lin DT, Richmon JD. Feeding Tube Placement Following Transoral Robotic Surgery for Oropharyngeal Squamous Cell Carcinoma. Otolaryngol Head Neck Surg 2021; 166:696-703. [PMID: 34154449 DOI: 10.1177/01945998211020302] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To identify factors that may predict the need for feeding tubes in patients undergoing transoral robotic surgery (TORS) in the perioperative setting. STUDY DESIGN Retrospective chart review. SETTING Academic tertiary center. METHODS A retrospective series of patients undergoing TORS for oropharyngeal squamous cell carcinoma (OPSCC) was identified between October 2016 and November 2019 at a single tertiary academic center. Patient data were gathered, such as frailty information, tumor characteristics, and treatment, including need for adjuvant therapy. Multiple logistic regression was performed to identify factors associated with feeding tube placement following TORS. RESULTS A total of 138 patients were included in the study. The mean age was 60.2 years (range, 37-88 years) and 81.9% were male. Overall 82.9% of patients had human papilloma virus-associated tumors, while 28.3% were current or former smokers with a smoking history ≥10 pack-years. Eleven patients (8.0%) had a nasogastric or gastrostomy tube placed at some point during their treatment. Five patients (3.6%) had feeding tubes placed perioperatively (<4 weeks after TORS), of which 3 were nasogastric tubes. Six patients (4.3%) had feeding tubes placed in the periadjuvant treatment setting for multifactorial reasons; 5 of which were gastrostomy tubes. Only 1 patient (0.7%) was gastrostomy dependent 1 year after surgery. Multiple logistic regression did not demonstrate any significant predictive variables affecting perioperative feeding tube placement following TORS for OPSCC. CONCLUSIONS Feeding tubes are seldom required after TORS for early-stage OPSCC. With appropriate multidisciplinary planning and care, patients may reliably avoid the need for feeding tube placement following TORS for OPSCC.
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Affiliation(s)
- Allen L Feng
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Andrew J Holcomb
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Nicholas B Abt
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Tara E Mokhtari
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Krish Suresh
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher I McHugh
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Anuraag S Parikh
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Allison Holman
- Department of Speech, Language, and Swallowing Disorders, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Rachael E Kammer
- Department of Speech, Language, and Swallowing Disorders, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Tessa A Goldsmith
- Department of Speech, Language, and Swallowing Disorders, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Daniel L Faden
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel G Deschler
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Mark A Varvares
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Derrick T Lin
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Jeremy D Richmon
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
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7
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Jackson RS, Stepan K, Bollig C, Sharma RK, Patel M, Massa S, Puram SV, Zevallos JP, Pipkorn P, Zenga J. Outcomes of HPV-Negative Oropharyngeal Cancer Treated With Transoral Robotic Surgery. Otolaryngol Head Neck Surg 2021; 165:682-689. [PMID: 33752484 DOI: 10.1177/0194599821996647] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The incidence of oropharyngeal squamous cell carcinoma (OPSCC) is increasing secondary to human papillomavirus (HPV)-related disease. Despite this, outcomes of patients with HPV-negative OPSCC undergoing transoral robotic surgery (TORS) are largely unknown. STUDY DESIGN Analysis of the National Cancer Database (NCDB). SETTING Not applicable. METHODS The 2015 participant user file from the NCDB was analyzed between 2010 and 2015 for patients with OPSCC who underwent TORS and neck dissection. Kaplan-Meier survival analysis was used to estimate overall survival of the study population. Univariable Cox survival analyses was used to determine significant associations between demographic, tumor, and treatment characteristics and overall survival (OS). RESULTS There were 164 patients (124 male and 40 female) with a mean age of 58 years (30-89 years). Median follow-up was 34 months. Five-year OS was 78% (95% CI, 70%-86%). Patients with early stage disease (pT1-2, N0-1) had significantly improved OS compared to patients with advanced T- or N-stage disease (log-rank 0.011; 5-year OS: 88% [95% CI, 78%-98%] vs 66% [95% CI, 50%-82%]). CONCLUSION Very few patients in the NCDB underwent TORS for HPV-negative OPSCC, but those who did had favorable outcomes, especially in early stage disease. Based on these findings, TORS may be considered in the treatment algorithm for patients with HPV-negative OPSCC. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Ryan S Jackson
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Katelyn Stepan
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Craig Bollig
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Rahul K Sharma
- Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Mihir Patel
- Department of Otolaryngology-Head and Neck Surgery, Winship Cancer Institute at Emory, Atlanta, Georgia, USA
| | - Sean Massa
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Sidharth V Puram
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Jose P Zevallos
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Patrik Pipkorn
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Joseph Zenga
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Sandelski MM, Drejet SM, Zimmer D, Yesensky JA, Moore M, Mantravadi AV, Sim MW. Evaluating the risks and benefits of ketorolac in transoral robotic surgery. J Robot Surg 2021; 15:885-889. [PMID: 33453022 DOI: 10.1007/s11701-021-01190-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 01/07/2021] [Indexed: 10/22/2022]
Abstract
Transoral Robotic Surgery (TORS) is increasingly used for oropharyngeal neoplasms and obstructive sleep apnea. Post-operative pain and bleeding remain concerns. Ketorolac has proved to be a safe alternative or addition to narcotics in other operations, but has not been thoroughly evaluated in TORS. A retrospective review was carried out on all TORS cases at our institution between April 2012 and March 2019, with the vast majority of cases performed starting in 2017. Post-operative bleed rates were compared between those who received Ketorolac and those who did not. Secondary outcomes evaluated included post-operative pain scores and need for feeding tube upon discharge. A total of 81 TORS cases were evaluated, with 37 patients receiving Ketorolac. Six (7.4%) patients reported post-operative bleeding, with one major and five minor bleeds. The patient with major bleeding requiring operative intervention did not receive Ketorolac. All five patients with minor bleeding received Ketorolac, but no bleeds occurred in the immediate post-operative setting while receiving Ketorolac. The average time of bleeding was 8 days post-operative. There were no significant differences in pain scores or time to feeding tube removal. This preliminary study shows that Ketorolac use in the postoperative pain management after TORS does not increase major bleeding risk without benefits in pain management. There was increased risk of minor bleeding not requiring intervention, but this was not significant. Future prospective studies are needed to determine if it improves pain and swallowing and decreases narcotic requirements following TORS.
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Affiliation(s)
| | - Sarah M Drejet
- Department of Otolaryngology, Head and Neck Surgery, Indiana University School of Medicine, 1130 W. Michigan Street, Suite 400, Indianapolis, IN, 46202, USA
| | - David Zimmer
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jessica A Yesensky
- Department of Otolaryngology, Head and Neck Surgery, Indiana University School of Medicine, 1130 W. Michigan Street, Suite 400, Indianapolis, IN, 46202, USA
| | - Michael Moore
- Department of Otolaryngology, Head and Neck Surgery, Indiana University School of Medicine, 1130 W. Michigan Street, Suite 400, Indianapolis, IN, 46202, USA
| | - Avinash V Mantravadi
- Department of Otolaryngology, Head and Neck Surgery, Indiana University School of Medicine, 1130 W. Michigan Street, Suite 400, Indianapolis, IN, 46202, USA
| | - Michael W Sim
- Department of Otolaryngology, Head and Neck Surgery, Indiana University School of Medicine, 1130 W. Michigan Street, Suite 400, Indianapolis, IN, 46202, USA.
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Larsen MHH, Scott SI, Kehlet H, von Buchwald C. Days alive and out of hospital a validated patient-centred outcome to be used for patients undergoing transoral robotic surgery: protocol and perspectives. Acta Otolaryngol 2021; 141:95-98. [PMID: 33107363 DOI: 10.1080/00016489.2020.1814964] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Days Alive and Out of Hospital (DAOH) has been validated as a suitable clinical trial outcome. It can be used as a proxy for surgical quality and reflects both procedure specific morbidity and mortality. AIMS/OBJECTIVES We propose DAOH as a supplement to established patient-related and objective outcomes, since it adds information on health care burden. Two upcoming studies incorporating DAOH are planned and will report DAOH for patients undergoing transoral robotic surgery. METHODS Firstly, a multicentre national prospective cohort study investigating DAOH with a 1-year follow-up after TORS is planned. Secondly a retrospective study of DAOH with a 1-year follow-up period will be performed using our institute's, the largest TORS center in Scandinavia, transoral robotic surgery (TORS) database. The database consists of more than 250 patients with more than 300 procedures performed between 2013 and 2018. CONCLUSION AND SIGNIFICANCE The planned studies of DAOH may, when applied to TORS, contribute to a better interpretation of post-treatment morbidity and provide a basis for further interventional studies to enhance recovery, perioperative optimization, and serve as a comparison tool between treatment modalities.
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Affiliation(s)
- Mikkel Hjordt Holm Larsen
- Department of Otorhinolaryngology, Head and Neck Surgery & Audiology, Rigshospitalet, Copenhagen, Denmark
| | - Susanne Irene Scott
- Department of Otorhinolaryngology, Head and Neck Surgery & Audiology, Rigshospitalet, Copenhagen, Denmark
| | - Henrik Kehlet
- Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen, Denmark
| | - Christian von Buchwald
- Department of Otorhinolaryngology, Head and Neck Surgery & Audiology, Rigshospitalet, Copenhagen, Denmark
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Stokes W, Ramadan J, Lawson G, Ferris FRL, Holsinger FC, Turner MT. Bleeding Complications After Transoral Robotic Surgery: A Meta-Analysis and Systematic Review. Laryngoscope 2020; 131:95-105. [PMID: 32108347 DOI: 10.1002/lary.28580] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 01/21/2020] [Accepted: 01/24/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Postoperative hemorrhage is the most common complication of transoral robotic surgery (TORS), the severity of which can range from minor bleeding treated with observation to catastrophic hemorrhage leading to death. To date, little is known about the incidence, risk factors, and management of post-TORS hemorrhage. STUDY DESIGN Systematic Review and Metanlysis. METHODS A systematic review of the published literature using the Cochrane Handbook for Systematic Reviews of Interventions was performed and examined TORS, postoperative hemorrhage, and the use of prophylactic transcervical arterial ligation (TAL). RESULTS A total of 13 articles were included in the analysis. To date, there have been 332 cases of hemorrhage following a total of 5748 TORS. The pooled median post-TORS hemorrhage rate was 6.47%. The overall incidence of minor and major hemorrhage was 5.29% and 2.90%. Patients with prior radiation (relative risk [RR] = 1.46, 95% confidence interval [CI] = 1.00-2.12), large tumors (RR = 2.11, 95% CI = 1.48-2.99), and those requiring perioperative coagulation (RR = 2.25, 95% CI = 1.54-3.28) had significantly higher relative risks of hemorrhage. There was no significant difference in the relative risk of overall hemorrhage with TAL. Looking at major hemorrhage, patients undergoing TAL had a large but insignificant relative risk reduction in post-TORS hemorrhage (RR = 0.40, 95% CI = 0.15-1.07). CONCLUSION The incidence of post-TORS hemorrhage is low (5.78%), and for major hemorrhage requiring emergent embolization, TAL, or tracheotomy to control hemorrhage it is even lower (2.90%). Large tumors, perioperative anticoagulation, and prior radiation were associated with significantly increased risk of post-TORS hemorrhage. TAL does not reduce the overall incidence of post-TORS hemorrhage but may lead to fewer severe hemorrhages. LEVEL OF EVIDENCE III Laryngoscope, 131:95-105, 2021.
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Affiliation(s)
- William Stokes
- Department of Otolaryngology-Head and Neck Surgery, West Virginia University Health Sciences Center, Morgantown, West Virginia
| | - Jad Ramadan
- Department of Otolaryngology-Head and Neck Surgery, West Virginia University Health Sciences Center, Morgantown, West Virginia
| | - Georges Lawson
- Department of Otolaryngology-Head and Neck Surgery, Université Catholique de Louvain Centre Hospitalier Universitaire de Mont-Godinne, Yvoir, Belgium
| | - F Robert L Ferris
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.,Department of Immunology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Floyd Christopher Holsinger
- Division of Head and Neck Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford University Medical Center, Palo Alto, California
| | - Meghan T Turner
- Department of Otolaryngology-Head and Neck Surgery, West Virginia University Health Sciences Center, Morgantown, West Virginia
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11
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Affiliation(s)
- Ghali E Ghali
- Department of Oral & Maxillofacial Surgery/Head & Neck Surgery, Louisiana State University Health Sciences Center - Shreveport, 1501 Kings Highway, Shreveport, LA 71103, USA
| | - Andrew T Meram
- Department of Oral & Maxillofacial Surgery/Head & Neck Surgery, Louisiana State University Health Sciences Center - Shreveport, 1501 Kings Highway, Shreveport, LA 71103, USA.
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12
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Unplanned readmission following transoral robotic surgery. Oral Oncol 2017; 75:127-132. [DOI: 10.1016/j.oraloncology.2017.11.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 10/25/2017] [Accepted: 11/04/2017] [Indexed: 11/19/2022]
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13
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Clayburgh D, Stott W, Bolognone R, Palmer A, Achim V, Troob S, Li R, Brickman D, Graville D, Andersen P, Gross ND. A randomized controlled trial of corticosteroids for pain after transoral robotic surgery. Laryngoscope 2017; 127:2558-2564. [DOI: 10.1002/lary.26625] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 02/14/2017] [Accepted: 03/23/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Daniel Clayburgh
- Department of Otolaryngology-Head and Neck Surgery; Oregon Health and Science University; Portland Oregon
| | - Will Stott
- Department of Otolaryngology-Head and Neck Surgery; Oregon Health and Science University; Portland Oregon
| | - Rachel Bolognone
- Department of Otolaryngology-Head and Neck Surgery; Oregon Health and Science University; Portland Oregon
| | - Andrew Palmer
- Department of Otolaryngology-Head and Neck Surgery; Oregon Health and Science University; Portland Oregon
| | - Virginie Achim
- Department of Otolaryngology-Head and Neck Surgery; Oregon Health and Science University; Portland Oregon
| | - Scott Troob
- Department of Otolaryngology-Head and Neck Surgery; Columbia University Medical Center; New York New York
| | - Ryan Li
- Department of Otolaryngology-Head and Neck Surgery; Oregon Health and Science University; Portland Oregon
| | - Daniel Brickman
- Levine Cancer Institute, Carolinas Health System; Charlotte North Carolina
| | - Donna Graville
- Department of Otolaryngology-Head and Neck Surgery; Oregon Health and Science University; Portland Oregon
| | - Peter Andersen
- Department of Otolaryngology-Head and Neck Surgery; Oregon Health and Science University; Portland Oregon
| | - Neil D. Gross
- Department of Otolaryngology-Head and Neck Surgery; MD Anderson Cancer Center; Houston Texas U.S.A
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14
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Feng AL, Razavi CR, Lakshminarayanan P, Ashai Z, Olds K, Balicki M, Gooi Z, Day AT, Taylor RH, Richmon JD. The robotic ENT microsurgery system: A novel robotic platform for microvascular surgery. Laryngoscope 2017; 127:2495-2500. [PMID: 28581249 DOI: 10.1002/lary.26667] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 04/09/2017] [Accepted: 04/12/2017] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Assess the feasibility of a novel robotic platform for use in microvascular surgery. STUDY DESIGN Prospective feasibility study. SETTING Robotics laboratory. METHODS The Robotic ENT (Ear, Nose, and Throat) Microsurgery System (REMS) (Galen Robotics, Inc., Sunnyvale, CA) is a robotic arm that stabilizes a surgeon's instrument, allowing precise, tremor-free movement. Six microvascular naïve medical students and one microvascular expert performed microvascular anastomosis of a chicken ischiatic artery, with and without the REMS. Trials were blindly graded by seven microvascular surgeons using a microvascular tremor scale (MTS) based on instrument tip movement as a function of vessel width. Time to completion (TTC) was measured, and an exit survey assessed participants' experience. The interrater reliability of the MTS was calculated. RESULTS For microvascular-naïve participants, the mean MTS score for REMS-assisted trials was 0.72 (95% confidence interval [CI] 0.64-1.07) and 2.40 (95% CI 2.12-2.69) for freehand (P < 0.001). The mean TTC was 1,265 seconds for REMS-assisted trials and 1,320 seconds for freehand (P > 0.05). For the microvascular expert, the mean REMS-assisted MTS score was 0.71 (95% CI 0.15-1.27) and 0.86 (95% CI 0.35-1.37) for freehand (P > 0.05). TTC was 353 seconds for the REMS-assisted trial and 299 seconds for freehand. All participants thought the REMS was more accurate and improved instrument handling and stability. The intraclass correlation coefficient for MTS ratings was 0.914 (95% CI 0.823-0.968) for consistency and 0.901 (95% CI 0.795-0.963) for absolute value. CONCLUSION The REMS is a feasible adjunct for microvascular surgery and a potential teaching tool capable of reducing tremor in novice users. Furthermore, the MTS is a feasible grading system for assessing microvascular tremor. LEVEL OF EVIDENCE NA. Laryngoscope, 127:2495-2500, 2017.
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Affiliation(s)
- Allen L Feng
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine
| | - Christopher R Razavi
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine
| | | | | | | | | | - Zhen Gooi
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine
| | - Andrew T Day
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine
| | - Russell H Taylor
- Department of Computer Science, Johns Hopkins University, Baltimore, Maryland, U.S.A
| | - Jeremy D Richmon
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine
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15
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Fang TJ, Lee LA, Huang BS, Lin CY, Hsu CL, Chang JTC, Yen TC, Liao CT, Chiang HC. What should we expect from robotic surgery for second primary oropharyngeal cancer? Eur Arch Otorhinolaryngol 2017; 274:3161-3168. [PMID: 28484837 DOI: 10.1007/s00405-017-4594-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 04/26/2017] [Indexed: 11/30/2022]
Abstract
The outcomes of second primary oropharyngeal cancer (SPOPC) may not be determined by oropharyngeal cancer but from the other index cancer as well. The management of (SPOPC) remains inconclusive and limited. Transoral robotic surgery (TORS) to maximize the functional outcomes without reducing oncologic effect is suggested as the primary treatment for selected oropharyngeal cancer. This study aimed to evaluate the feasibility and outcomes of TORS for the management of SPOPC. Patients who underwent TORS from January 2011 to June 2015 at a tertian referral center in Taiwan were recruited. Loco-regional status, overall survival (OS), disease-specific survival (DSS), and postoperative functional status were evaluated. Fifteen patients received TORS for SPOPC with curative intent, including eleven with tongue-base carcinomas, and four with tonsil carcinomas. One case was terminated because of inadequate exposure and the other 14 cases were completed with negative pathologic margins. Two-year OS and DSS were 53 and 77%, respectively. Patients with SPOPC occurring within 6 months had poorer outcomes (p = 0.044). The median time to feeding-tube removal was 5 days, and one patient had long-term gastric-tube dependence. Patients of age <65 years with synchronous SPOPC and esophageal cancer as the other index cancer were significant worse in oncologic outcomes. We concluded that TORS is a feasible alternative treatment in selected patients with SPOPC. Patients with metachronous T1-2 SPOPC without an esophageal primary can achieve excellent survival after TORS, while TORS can maximize functional preservation with limited destruction in patients with low life expectancy.
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Affiliation(s)
- Tuan-Jen Fang
- Department of Otolaryngology Head and Neck Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan. .,School of Medicine, Chang Gung University, Taoyuan, Taiwan. .,Head and Neck Oncologic Group, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan. .,, 5 Fu-Shin Street, Kweishan 333, Taoyuan, Taiwan.
| | - Li-Ang Lee
- Department of Otolaryngology Head and Neck Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan.,School of Medicine, Chang Gung University, Taoyuan, Taiwan.,Head and Neck Oncologic Group, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
| | - Bing-Shan Huang
- School of Medicine, Chang Gung University, Taoyuan, Taiwan.,Head and Neck Oncologic Group, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan.,Department of Radiation Oncology, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Chien-Yu Lin
- School of Medicine, Chang Gung University, Taoyuan, Taiwan.,Head and Neck Oncologic Group, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan.,Department of Radiation Oncology, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Cheng-Lung Hsu
- School of Medicine, Chang Gung University, Taoyuan, Taiwan.,Head and Neck Oncologic Group, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan.,Department of Medical Oncology, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Joseph Tung-Chieh Chang
- School of Medicine, Chang Gung University, Taoyuan, Taiwan.,Head and Neck Oncologic Group, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan.,Department of Radiation Oncology, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Tzu-Chen Yen
- School of Medicine, Chang Gung University, Taoyuan, Taiwan.,Head and Neck Oncologic Group, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan.,Department of Nuclear Medicine and Molecular Imaging Center, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Chun-Ta Liao
- Department of Otolaryngology Head and Neck Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan.,School of Medicine, Chang Gung University, Taoyuan, Taiwan.,Head and Neck Oncologic Group, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
| | - Hui-Chen Chiang
- Graduate School of Management, Ming Chung University, Taipei, Taiwan
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16
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Frenkel CH, Yang J, Zhang M, Altieri MS, Telem DA, Samara GJ. Compared Outcomes of Concurrent versus Staged Transoral Robotic Surgery with Neck Dissection. Otolaryngol Head Neck Surg 2017; 157:791-797. [DOI: 10.1177/0194599817706499] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective Outcomes of concurrent versus staged neck dissection with transoral robotic surgery have not been studied. This study compares outcomes of concurrent versus staged transoral robotic surgery and neck dissection. Design Retrospective administrative database analysis. Setting Article 28 licensed inpatient and outpatient care facilities in New York State. Subjects/Methods Adults undergoing transoral robotic surgery with staged or concurrent neck dissection from 2008 to 2014 were identified in the New York Statewide Planning and Research Collaborative System database. We compared complications, readmissions, subsequent procedures, and length of stay for concurrent versus staged procedures with multivariable logistic regression and multiple linear regression models. Results Of the 425 patients undergoing transoral robotic surgery and neck dissection, 333 had concurrent procedures, and 92 had staged. Risk-adjusted length of stay for concurrent procedures was 42.3% less than that of staged procedures ( P < .0001). Neck dissection timing was not associated with postoperative complications ( P = .41), readmissions ( P = .67), or additional procedures, including reconstruction, tracheostomy, or gastrostomy ( P = .17, .84, .82, respectively). Bleeding (7.8%) was the most common complication, and the majority (78.8%) required reoperation. Bleeding or surgical error was not associated with either concurrent or staged surgery (concurrent vs staged: adjusted odds ratio, 0.68; 95% CI, 0.35-1.37; P = .26). Conclusions Concurrent and staged procedures are equivalent with respect to adverse events, but length of stay is shorter for concurrent procedures. Cost and clinical benefits associated with length of stay are unknown, and it is reasonable to allow operator preference and patient factors to determine surgical logistics.
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Affiliation(s)
- Catherine H. Frenkel
- Department of General Surgery, Stony Brook University Medical Center, Stony Brook, New York, USA
| | - Jie Yang
- Department of Family, Population and Preventive Medicine, Stony Brook University, Stony Brook, New York, USA
| | - Mengru Zhang
- Department of Applied Mathematics and Statistics, Stony Brook University, Stony Brook, New York USA
| | - Maria S. Altieri
- Department of General Surgery, Stony Brook University Medical Center, Stony Brook, New York, USA
| | - Dana A. Telem
- Department of General Surgery, Stony Brook University Medical Center, Stony Brook, New York, USA
| | - Ghassan J. Samara
- Division of Otolaryngology–Head and Neck Surgery, Stony Brook University Medical Center, Stony Brook, New York, USA
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17
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Hay A, Migliacci J, Karassawa Zanoni D, Boyle JO, Singh B, Wong RJ, Patel SG, Ganly I. Complications following transoral robotic surgery (TORS): A detailed institutional review of complications. Oral Oncol 2017; 67:160-166. [PMID: 28351571 PMCID: PMC5407467 DOI: 10.1016/j.oraloncology.2017.02.022] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 01/06/2017] [Accepted: 02/20/2017] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To report the complications occurring following TORS and to identify the factors predictive of complications. METHODS Following IRB approval a retrospective analysis of all TORS operations at our institution was performed. Postoperative complications within 45days were collected and graded with the Clavien-Dindo system. Complications were categorized into groups: all complications, not related to TORS and TORS related. Unadjusted odds ratios were calculated to test association between patients with and without a complication. RESULTS 122 TORS operations were carried out between June 2010 and August 2015. 77% were male, with a median age of 57. There were 92 primary tumor resections, 10second head and neck primary resections, 13 salvage procedures and 7 other indications. Surgical resection involved 1, 2 or >3 sub-sites in 36%, 28% and 36% patients, respectively. Overall, there were 107 complications (66 TORS related, 41 non-TORS related) that occurred in 57 patients (47%). A major complication occurred in 23 patients (18%). 19 patients had a TORS related major complication and 6 patients experienced a non-TORS related major complication. There was a temporal trend in TORS related major complication rate decreasing from 33% in 2010 to 10% in 2015. Statistical analysis showed that the odds of having any complication were 3 times greater in patients over 60years old (p=0.017), and 2.5 times greater when there were more than 2 subsites resected (p=0.022). CONCLUSIONS Age over 60years and a larger extent of resection were the significant factors predictive of major complications.
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Affiliation(s)
- Ashley Hay
- Department of Surgery Head and Neck Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Jocelyn Migliacci
- Department of Surgery Head and Neck Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Daniella Karassawa Zanoni
- Department of Surgery Head and Neck Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Jay O Boyle
- Department of Surgery Head and Neck Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Bhuvanesh Singh
- Department of Surgery Head and Neck Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Richard J Wong
- Department of Surgery Head and Neck Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Snehal G Patel
- Department of Surgery Head and Neck Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Ian Ganly
- Department of Surgery Head and Neck Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
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18
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Heaton CM, Ahmed SR, Ryan WR. Transoral robotic surgery (TORS) for excision of a retropharyngeal intramuscular lipoma. Auris Nasus Larynx 2016; 44:742-744. [PMID: 27956103 DOI: 10.1016/j.anl.2016.10.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 10/10/2016] [Accepted: 10/31/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To describe the feasibility, effectiveness, and improved morbidity profile of transoral robotic surgery (TORS) for the excision of a retropharyngeal intramuscular lipoma. METHODS Case report of a robot-assisted transoral resection of a retropharyngeal intramuscular lipoma. RESULTS A 62-year-old woman presented with tongue pain and globus with dysphagia for six months. Transoral exam revealed a pharyngeal submucosal mass, and MRI demonstrated a prevertebral lipomatous lesion with protrusion into the airway. The patient elected for robot-assisted transoral surgical treatment. The patient tolerated the procedure well, experienced no complications, and was discharged on post-operative day one. At six months post-operatively, the patient was without dysphagia and was disease free on imaging. CONCLUSIONS TORS is an effective, safe, feasible, and likely more efficient way to excise a retropharyngeal intramuscular lipoma or other retropharyngeal masses.
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Affiliation(s)
- Chase M Heaton
- Division of Head and Neck Oncologic and Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, United States.
| | - Saqib R Ahmed
- Department of Surgery, University of California-San Francisco, United States
| | - William R Ryan
- Division of Head and Neck Oncologic and Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, United States
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19
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Frenkel CH, Yang J, Zhang M, Regenbogen E, Telem DA, Samara GJ. Trends and the utilization of transoral robotic surgery with neck dissection in New York State. Laryngoscope 2016; 127:1571-1576. [PMID: 27882552 DOI: 10.1002/lary.26345] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Revised: 07/26/2016] [Accepted: 09/02/2016] [Indexed: 11/12/2022]
Abstract
OBJECTIVES The timing of neck dissection (ND) in relation to transoral robotic surgery (TORS) is controversial. This study identifies local practice patterns and economic and social access disparities during adoption of TORS. STUDY DESIGN We analyzed utilization patterns of TORS and ND using the New York Statewide Planning and Research Cooperative System all-payer administrative database. Statewide head and neck cancer incidence from the Centers for Disease Control and Prevention (Bethesda, MD) was used to control for overall cancer incidence. METHODS Patient demographic, insurer, and institutional information of patients aged ≥ 18 (n = 225) years from 2008 to 2012 were evaluated. Temporal trends were analyzed with Poisson regression models for counts. RESULTS Transoral robotic surgery was used in 386 procedures, and 58.3% involved ND (n = 225). Concurrent ND was most frequent (n = 173), followed by staged TORS then ND (n = 44) and staged ND preceding TORS (n = 8). Caucasians were more likely than Blacks/Hispanics to undergo TORS (P = 0.03). Medicare (26.2%) and Medicaid (2.7%) payers comprised a minority of patients compared to those commercially insured (70.2%). Only 20% of patients received care outside a major urban center, and these patients were more likely to undergo staged procedures, P = 0.02. Staged procedures resulted in higher mean hospital charges (P = 0.02). CONCLUSION Concurrent TORS + ND, the most common practice in New York, is more cost-effective. Patients without commercial insurance, patients in racial minorities, or patients residing outside major urban centers may be targeted to improve care access disparities with respect to minimally invasive TORS technology. LEVEL OF EVIDENCE 2c. Laryngoscope, 127:1571-1576, 2017.
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Affiliation(s)
- Catherine H Frenkel
- Department of General Surgery, Stony Brook University Medical Center, Stony Brook, New York, U.S.A
| | - Jie Yang
- Department of Family, Population and Preventive Medicine, Stony Brook University Medical Center, Stony Brook, New York, U.S.A
| | - Mengru Zhang
- Department of Applied Mathematics and Statistics, Stony Brook University Medical Center, Stony Brook, New York, U.S.A
| | - Elliot Regenbogen
- Division of Otolaryngology-Head and Neck Surgery, Stony Brook University Medical Center, Stony Brook, New York, U.S.A
| | - Dana A Telem
- Department of General Surgery, Stony Brook University Medical Center, Stony Brook, New York, U.S.A
| | - Ghassan J Samara
- Division of Otolaryngology-Head and Neck Surgery, Stony Brook University Medical Center, Stony Brook, New York, U.S.A
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20
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Meccariello G, Cammaroto G, Montevecchi F, Hoff PT, Spector ME, Negm H, Shams M, Bellini C, Zeccardo E, Vicini C. Transoral robotic surgery for the management of obstructive sleep apnea: a systematic review and meta-analysis. Eur Arch Otorhinolaryngol 2016; 274:647-653. [PMID: 27221389 DOI: 10.1007/s00405-016-4113-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2015] [Accepted: 05/20/2016] [Indexed: 11/30/2022]
Abstract
Obstructive sleep apnea-hypopnea syndrome (OSAHS) is a serious social health problem with significant implications on quality of life. Surgery for OSAHS has been criticized due to a lack of evidence to support its efficacy as well as the heterogeneous reporting of published outcomes. Moreover, the transoral robotic surgery (TORS) in the management of OSAHS is still in a relative infancy. Nevertheless, a review and meta-analysis of the published articles may be helpful. Among 195 articles, eight studies were included in the analysis. The mean of enrolled patients was 102.5 ± 107.9 (range 6-289) comprising a total of 820 cases. The mean age was 49 ± 3.27 and 285 patients underwent a previous sleep apnea surgery. The uvulopalatopharyngoplasty (UPPP) was the most common palatal procedure. The mean rate of failure was 34.4 % (29.5-46.2 %). Complications occurred in 21.3 % of the patients included in the analysis, most of them were classified as minor. Transient dysphagia represented the most common complication (7.2 %) followed by bleeding (4.2 %). TORS for the treatment of OSAHS appears to be a promising and safe procedure for selected patients seeking an alternative to continuous positive airway pressure (CPAP), although further researches are urgently needed.
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Affiliation(s)
- Giuseppe Meccariello
- Otolaryngology and Stomatology Unit, Department of Head-Neck Surgeries, G.B. Morgagni-L.Pierantoni Hospital, Azienda USL della Romagna, via Carlo Forlanini, 34, Forlì, Italy.
| | - Giovanni Cammaroto
- Department of Otorhinolaryngology, University of Messina, Messina, Italy
| | - Filippo Montevecchi
- Otolaryngology and Stomatology Unit, Department of Head-Neck Surgeries, G.B. Morgagni-L.Pierantoni Hospital, Azienda USL della Romagna, via Carlo Forlanini, 34, Forlì, Italy
| | - Paut T Hoff
- Department of Otolaryngology-Head and Neck Surgery, St Joseph Mercy Health System, Ann Arbor, MI, USA
| | - Matthew E Spector
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - Hesham Negm
- Department of Otolaryngology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Medhat Shams
- Department of Otolaryngology Head and Neck Surgery, Rumailah Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Chiara Bellini
- Otolaryngology and Stomatology Unit, Department of Head-Neck Surgeries, G.B. Morgagni-L.Pierantoni Hospital, Azienda USL della Romagna, via Carlo Forlanini, 34, Forlì, Italy
| | - Ermelinda Zeccardo
- Otolaryngology and Stomatology Unit, Department of Head-Neck Surgeries, G.B. Morgagni-L.Pierantoni Hospital, Azienda USL della Romagna, via Carlo Forlanini, 34, Forlì, Italy
| | - Claudio Vicini
- Otolaryngology and Stomatology Unit, Department of Head-Neck Surgeries, G.B. Morgagni-L.Pierantoni Hospital, Azienda USL della Romagna, via Carlo Forlanini, 34, Forlì, Italy
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21
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Justin GA, Chang ET, Camacho M, Brietzke SE. Transoral Robotic Surgery for Obstructive Sleep Apnea: A Systematic Review and Meta-Analysis. Otolaryngol Head Neck Surg 2016; 154:835-46. [PMID: 26932967 DOI: 10.1177/0194599816630962] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Accepted: 01/15/2016] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To perform a systematic review of the international biomedical literature evaluating the effectiveness, complications, and safety of transoral robotic surgery (TORS) for the treatment of obstructive sleep apnea (OSA). DATA SOURCES PubMed/MEDLINE, Embase, and EMB Reviews databases were searched up to November 27, 2015. REVIEW METHODS Two authors systematically and independently searched for articles on TORS for the treatment of OSA in adults that reported either outcomes for the apnea-hypopnea index (AHI), lowest oxygen saturation percentage (LSAT) or changes in the Epworth Sleepiness Scale (ESS), and/or rates and types of complications associated with the operation. RESULTS In total, 181 records were identified and 16 articles met inclusion criteria. Transoral robotic surgery was almost always combined with other sleep surgery procedures. The summary estimate of the decrease in AHI using TORS as part of a multilevel surgical approach was 24.0 (95% confidence interval [CI], 22.1-25.8; P < .001, I(2) = 99%). The summary estimate of a decrease in ESS score was 7.2 (95% CI, 6.6-7.7; P < .001, I(2) = 99%) and of the overall surgical "success" (defined as AHI <20 and 50% reduction) was 48.2% (95% CI, 38.8%-57.7%; P < .001, I(2) = 99%). Three large studies reported on their total complication rates with an average of 22.3% (range, 20.5%-24.7%). CONCLUSIONS The initial results for the use of TORS as part of a multilevel surgical approach for OSA are promising for select patients. However, the cost and morbidity may be greater than with other techniques offsetting its advantages in visualization and precision. More prospective studies are needed to determine the optimal role of this tool.
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Affiliation(s)
- Grant A Justin
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Edward T Chang
- Department of Otolaryngology-Head and Neck Surgery, Tripler Army Medical Center, Honolulu, Hawaii, USA
| | - Macario Camacho
- Department of Otolaryngology-Head and Neck Surgery, Tripler Army Medical Center, Honolulu, Hawaii, USA
| | - Scott E Brietzke
- Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
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22
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TORS for Obstructive Sleep Apnea–Hypopnea Syndrome. CURRENT OTORHINOLARYNGOLOGY REPORTS 2016. [DOI: 10.1007/s40136-016-0110-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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23
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Helman SN, Schwedhelm T, Kadakia S, Wang Y, Schiff BA, Smith RV. Transoral Robotic Surgery in Oropharyngeal Carcinoma. Arch Pathol Lab Med 2015; 139:1389-97. [DOI: 10.5858/arpa.2014-0573-ra] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context
The incidence of oropharyngeal squamous cell carcinoma has increased during the past decade and is related primarily to the human papillomavirus. This change in etiology, from tobacco and alcohol to human papillomavirus, has resulted in improved survival for the disease. In the United States, open resection had largely been replaced by concurrent chemotherapy and/or radiotherapy by the early 2000s. The advent of transoral surgery has led to an increase in surgery as the primary treatment for both early- and advanced-stage oropharyngeal squamous cell carcinoma because it has potential advantages over open surgery and nonsurgical modalities.
Objective
To provide an overview of transoral robotic surgery for oropharyngeal squamous cell carcinoma and contrast it with other surgical and nonsurgical modalities.
Data Sources
Articles from 2000 to 2014 were accessioned on PubMed and reviewed for utility by the primary authors.
Conclusions
Transoral surgery has become more commonly used as a minimally invasive approach to treat oropharyngeal tumors. Other strategies, including radiation, chemotherapy with radiation, and open surgery, are still important treatment approaches. The treatment options for an individual patient rely on multiple factors, including the tumor location and size, features of the tumor, and patient comorbidities. The continued study of these techniques is important to match the patient with the most appropriate treatment.
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Affiliation(s)
| | | | | | | | | | - Richard V. Smith
- From the Department of Otolaryngology/Head and Neck Surgery, New York Eye and Ear Infirmary–Mount Sinai Health System, New York, New York (Drs Helman and Kadakia); Albert Einstein College of Medicine, Bronx, New York (Mr Schwedhelm); and the Departments of Pathology (Dr Wang) and Otorhinolaryngology–Head and Neck Surgery (Drs Schiff and Smith), Montefiore Medical Center, Albert Einstein College o
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24
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Mandal R, Duvvuri U, Ferris RL, Kaffenberger TM, Choby GW, Kim S. Analysis of post-transoral robotic-assisted surgery hemorrhage: Frequency, outcomes, and prevention. Head Neck 2015; 38 Suppl 1:E776-82. [PMID: 25916790 DOI: 10.1002/hed.24101] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Transoral robotic-assisted surgery (TORS) carries a small, but not insignificant, risk of life-threatening postsurgical hemorrhage. The purpose of this study was to analyze all post-TORS hemorrhagic events at our institution to establish preventative recommendations. METHODS We conducted a retrospective review of 224 consecutive patients who underwent TORS for any indication at a single tertiary care institution. RESULTS Twenty-two patients (n = 22; 9.82%) had varying degrees of postoperative bleeding. An impaired ability to protect the airway at the time of hemorrhage increased the rate of severe complications. Prophylactic transcervical arterial ligation did not significantly decrease overall postoperative bleeding rates (9.1% vs 9.9%; p = 1.00); however, there was a trend toward decreased hemorrhage severity in prophylactically ligated patients (3.0% vs 7.3%; p = .7040). CONCLUSION Prophylactic transcervical arterial ligation may reduce the incidence of severe bleeding following TORS. Post-TORS patients displaying an inability to protect the airway should be strongly considered for prophylactic tracheostomy to assist airway protection. © 2015 Wiley Periodicals, Inc. Head Neck 38: E776-E782, 2016.
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Affiliation(s)
- Rajarsi Mandal
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Umamaheswar Duvvuri
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.,Veterans Affairs Pittsburgh Health System, Pittsburgh, Pennsylvania
| | - Robert L Ferris
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Garret W Choby
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Seungwon Kim
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Transoral robotic surgery for oropharyngeal squamous cell carcinoma. Curr Opin Otolaryngol Head Neck Surg 2015; 23:127-31. [DOI: 10.1097/moo.0000000000000136] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Heaton CM, Al-Shwaiheen F, Liu CSJ, Yom SS, Ryan WR. Prognostic significance of hyoid bone invasion in advanced base of tongue carcinoma treated by chemoradiation. Clin Otolaryngol 2015; 40:260-5. [PMID: 25641627 DOI: 10.1111/coa.12367] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/31/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To examine the prognostic influence of hyoid bone invasion in advanced base of tongue squamous cell carcinoma treated with chemoradiation. METHODS We retrospectively reviewed pre-treatment imaging (CT/MRI) for the presence or absence of hyoid bone invasion in patients with advanced (clinical T3 or T4a stage) base of tongue squamous cell carcinoma treated with chemoradiation from January 2001 to January 2011. We compared patients with hyoid bone invasion to those without based on the following metrics: 1-, 2- and 5-year locoregional recurrence-free survival, disease-free survival, disease-specific survival and overall survival. RESULTS Eleven of thirty-seven patients had hyoid invasion present on pre-treatment imaging. Average follow-up was 45 months. Patients with hyoid bone invasion were found to have lower percentages in all survival metrics measured compared to patients without, respectively, with statistical significance achieved in the following: 2-year locoregional recurrence-free survival: 36.4% versus 86.4% (P = 0.006), 5-year locoregional recurrence-free survival: 12.5% versus 63.6% (P = 0.05), 2-year disease-free survival: 36.4% versus 77.3% (P = 0.05), 5-year disease-free survival: 12.5% versus 63.3% (P = 0.05) and the Kaplan-Meier curve for locoregional recurrence-free survival (P = 0.0075). CONCLUSIONS Hyoid bone invasion by base of tongue squamous cell carcinoma may indicate a poorer prognosis despite treatment. Hyoid bone invasion may be a possible indication for intensification of treatment and/or may indicate a necessity for increasing the degree of post-treatment surveillance monitoring and imaging.
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Affiliation(s)
- C M Heaton
- Department of Otolaryngology - Head and Neck Surgery, University of California - San Francisco, San Francisco, CA, USA
| | - F Al-Shwaiheen
- School of Medicine, Graduate Program for Clinical Research, University of California - San Francisco, San Francisco, CA, USA
| | - C-S J Liu
- Division of Neuroradiology, Department of Radiology and Biomedical Imaging, University of California - San Francisco, San Francisco, CA, USA
| | - S S Yom
- Department of Otolaryngology - Head and Neck Surgery, University of California - San Francisco, San Francisco, CA, USA.,Department of Radiation Oncology, University of California - San Francisco, San Francisco, CA, USA
| | - W R Ryan
- Division of Head and Neck Oncologic/Endocrine/Salivary Surgery, Department of Otolaryngology - Head and Neck Surgery, University of California - San Francisco, San Francisco, CA, USA
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Eesa M, Montevecchi F, Hendawy E, D’Agostino G, Meccariello G, Vicini C. Swallowing outcome after TORS for sleep apnea: short- and long-term evaluation. Eur Arch Otorhinolaryngol 2015; 272:1537-41. [DOI: 10.1007/s00405-014-3480-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 12/25/2014] [Indexed: 10/24/2022]
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