Prospective multicentre study on barbed reposition pharyngoplasty standing alone or as a part of multilevel surgery for sleep apnoea

OBJECTIVES

The aim of this study was to demonstrate in a prospective multicentre study that Barbed Reposition Pharyngoplasty (BRP) procedure is safe and effective in management of obstructive sleep apnoea/hypopnea syndrome (OSAHS) patients.

DESIGN

Prospective study.

SETTING

Multicentre study.

PARTICIPANTS

Patients suffering from obstructive sleep apnoea.

MAIN OUTCOMES MEASURES

Values of postoperative apnoea-hypopnea index (AHI), oxygen desaturation index (ODI), epworth sleepiness scale (ESS).

RESULTS

111 Barbed Reposition Pharyngoplasty procedures standing alone or as a part of multilevel surgery for OSAHS, performed between January and September 2016, were analysed in 15 different centres. The average hospitalisation period was 2.5 ± 0.5 days. The mean patient age was 46.3 ± 10.5 years. The average body mass index at the time of the procedure was 27.9 ± 3.2, and the majority of the patients were men (83%). The mean preoperative and postoperative apnoea/hypopnea index was 33.4 ± 19.5 and 13.5 ± 10.3, respectively (P < .001). The mean preoperative and postoperative ESS score was 10.2 ± 4.5 and 6.1 ± 3.6, respectively (P < .001). The mean preoperative and postoperative ODI were 29.6 ± 20.7 and 12.7 ± 10.8, respectively (P < .001).

CONCLUSIONS

Patients undergoing BRP standing alone or as part of a multilevel approach for the treatment of OSAHS have a reasonable expectation for success with minimal morbidity.

The Role of Balloon Sinuplasty in the Treatment of Vacuum Rhinogenic Headache

In this study we tried to demonstrate how balloon sinuplasty could be an option in the treatment of the Rhinogenic Headache due to a probably disventilation of frontal sinus recess. 107 patients were included in the study with diagnosis of Rhinogenic Headache. The surgical group underwent bilateral balloon sinuplasty of the frontal sinus. The medical group underwent pharmacological treatment. Headaches characteristics were evaluated by a clinical personal diary. The severity was recorded by Visual Analog Scale 4 and 8 months after treatment. 98 out of 107 patients completed the protocol. In surgical group and in medical one the mean headache score improved at four and eight months follow up. The headache frequency attacks per month decrease from a preoperative frequency of 18 (±4 SD) in surgical group and 17 (±3 SD) in medical group to 3 (±1 SD) and 6 (±3 SD) respectively at 4 months control but increased slightly to 5 (±2 SD) and 12 (±4 SD) after 8 months. We concluded that the balloon sinuplasty should be considered as an effective alternative option after an accurate selection of surgical candidates. However, it is important a 6-8 month follow-up to evaluate the efficacy and stability of the treatment used.

Sigmoid volvulus: is it a possible complication after stapled transanal rectal resection (STARR)?

We report a case of sigmoid volvulus post-stapled transanal rectal resection (STARR) for obstructed defecation. The patient, a 68-yearold woman with chronic constipation and dolichosigma, two days post-STARR presented severe abdominal pain. CT revealed sigmoid ischemia. The patient underwent resection of the sigmoid colon with end colostomy (Hartmann's procedure). Can STARR procedure produce a serious complication as sigmoid volvulus in patient with dolichosigma and obstructed defecation syndrome?

Synchronous primary malignant tumors of the breast, caecum and sigma. Case report

We present the case of a patient with a double adenocarcinoma of the right colon and sigma associated with a bilateral infiltrating ductal breast carcinoma. Sigma and caecum bowel cancers were diagnosed at colonoscopy, with computerized tomography staging, while breast cancer was found with screening mammography. Following right hemicolectomy , sigmoidectomy and bilateral mastectomy the histology confirmed the presence of colonic adenocarcinoma and infiltrating and in situ lobular cancer. This case report reviews the treatment of synchronous neoplasia.

Benefits of laparoscopic colorectal surgery in the geriatric patient

BACKGROUND

Our aim is the retrospective valuation of results in over 75 year-old patients, with colorectal cancer, treated with laparoscopic and laparotomic surgery, considering how laparoscopic surgery has improved these patients' outcome.

PATIENTS AND METHODS

We took all over 75 year-old patients, affected by colorectal cancer, treated with colectomy. Patients has been divided into two groups: laparotomy group and laparoscopy group. Data concerning patients, i.e., age, sex, BMI, ASA, comorbidities, were collected with data concerning the operation (surgical time, conversion percentage). Postoperative outcomes - i.e., gas evacuation, bowel movements, solid and liquid feeding, need to ICU, complications, re-surgery, hospitalization and type of discharge, mortality - were evaluated.

RESULTS

A total of 145 patients are included: laparotomy 80 and laparoscopy 51. Two groups are homogeneous for age, sex, BMI, ASA, comorbidities. Surgical times are the same. Need to Intesive Care Unit (ICU) is lower in laparoscopy. Gas evacuation and bowel movements are earlier in laparoscopy. Liquid and solid diet is earlier in laparoscopy. Hospitalization was earlier after laparoscopy. Discharge at home is more frequent in laparoscopy. Major and minor complications are lower in laparoscopy. Post-operative mortality is lower in laparoscopy.

CONCLUSIONS

Laparoscopy improves over 75 year-old patients' outcomes, after elective surgery for colorectal cancer. Surgery trauma, anaesthesia, nutritional and hemodynamic alterations, are factors that break the old patients' fragile physiologic balance. Less traumatic surgery improves old patients' outcomes.

Laparoscopic colorectal resections performed over a seven-years period in a single Italian Centre

INTRODUCTION

Laparoscopic approach for treatment of colorectal lesion is gaining acceptance gradually. Evidence from numerous randomised controlled trials has shown the short-term benefits of laparoscopic colon resection over open surgery, and its long-term outcomes also does not differ considerably from those of open surgery. This study aims at a retrospective analysis of operative and short term outcomes of patients.

PATIENTS AND METHODS

All laparoscopic colon and rectal resections performed between September 2004 and September 2011 were included. The clinical parameters, operative parameters and short-term outcome details of laparoscopic colorectal surgery patients were collected from the retrospectively reviewed database.

RESULTS

A total of 347 patients, median age 71 years (range 32 to 96), underwent laparoscopic resection of the colon and rectum. The median Body Mass Index (BMI) was 26.5. The majority of the procedures were performed for malignant disease (97,1%) and the most common procedure was right colectomy (41%). The median duration of surgery was 202,3 minutes, with conversion to open surgery in 40 patients (11.5%). Complications occurred in 23 patients (6.6%). The median length of hospital stay was 8.9 days. In patients with malignant disease, the median number of lymph nodes removed was 14.9.

CONCLUSION

Our results show that laparoscopic approach for colon-rectal lesions is safe, feasible and produces favourable results. The most important aspect of surgery for malignant disease is the ability to remove radically the disease. However all data are still related to the experience of the operator.

Small bowel adenocarcinoma. Two case reports

Introduction. Small bowel adenocarcinoma is a rare tumor, with a still not well studied tumorigenesis process, and non-specific symptoms that cause a delay in the diagnosis and consequently a worst outcome for the patient. Videocapsule endoscopy (VCE) and double-balloon enteroscopy (DBE) have revolutionized the diagnosis and management of patients with small bowel diseases. Surgery is the treatment of choice when feasible, while the chemotherapeutic approach is still not well standardized. Case reports. Two cases in 2 months (two women 52 and 72-yr-old) of primary bowel adenocarcinoma is reported. The site of the tumor was in jejunum, instead of the most common site in duodenum. The patients underwent DBE with biopsy and ink mark. Laparoscopic-assisted bowel segmental resection was performed. The pathologic diagnosis was primary jejunum adenocarcinoma. No post-operative mortality or significant morbidities were noted. Conclusion. The combination of DBE and laparocopic-assisted bowel surgery represents an ideal diagnostic and therapeutic method.

[Laryngeal schwannoma treated with CO2 laser]

Neurinoma is a benign capsulate tumor originating from the Schwann cells of all nerve fibers outside the central nervous system, the sole exception being the optic and olfactory nerves. These tumors favor the head and neck district but rarely affect the larynx. This work presents the case of a 73-year-old woman treated in the emergency room for an episode of acute dispnea. The patient's case history indicated that for more than 10 years she had the sensation of a foreign body in the hypopharynx and stomatolalia. Direct hypopharyngo-laryngoscopy with a flexible fiberoptic showed a rounded submucosa neoformation 3.5 cm in diameter at the level of the left aryepiglottic fold, blocking the opening of the laryngeal vestibule. Laryngeal motility was perfectly preserved. The decision was made for prompt exeresis of the neoformation under direct microlaryngoscopy with a CO2 laser. Post-operative follow-up showed that all laryngeal functions were preserved. Three months later, the patient was still symptom-free and direct examination of the larynx showed no signs of recurrence. Histological diagnosis indicated a laryngeal schwannoma. Surgical removal is the treatment of choice and can be performed by endoscopy or through an external approach depending on the site and size of the tumor. Different external approaches have been described such as the median thyrofissure, lateral pharyngotomy and lateral thyrofissure. In the present case, although the neoformation was quite large, the decision was made to perform an endoscopy resection with CO2 laser, without resorting to a tracheotomy, reducing post-operative recovery to a minimum and preserving all laryngeal functions.

U-shaped free jejunal transplantation: improved technique and indications

Reconstruction of the oropharynx and the hypopharynx is difficult due to their wide diameters. We report eight cases of circumferential pharyngolaryngectomies for epidermoid carcinomas of the hypopharynx extended to the oropharynx and classified T4. Reconstruction was performed with a U-shaped free jejunal transplantation. This specific technique consists of a side to side anastomosis between two loops of jejunum. It facilitates reconstruction at the level of the oropharynx and diminishes postoperative complications.

[Comparative study of the effect of vasoconstrictive and balsamic agents in the decongestant nasal test]

The authors report a study of 60 subjects with mono or bilateral nasal obstruction of different etiologies (30 vasomotor rhinopathy, 30 septum deviations) evaluating the decongestion action of a vasoconstrictor. This substance for topic use was administered in pill form both in association with and without different balsamic substances. The patients underwent subjective evaluation using a visual analogy scale (VAS) and an objective test such as active anterior rhinomanometry (AAR) and acustic rhinometry (AR). All evaluations were performed under basal conditions and after the nasal decongestion test (NDT). The results were processed in order to evaluate: a) relationships between the subjective results (VAS) and the objective instrumental tests (AAR and AR); b) the mechanism by which the balsamic substances affect the symptoms. The purpose was to evaluate exactly how important balsamic substances are in topic vasoconstrictor preparations. Finally, an attempt was made to confirm the importance of the nasal decongestion test to provide a concise diagnostic picture and a suitable medical or surgical approach to "nasal obstruction" symptoms. Among other things, the results underline the importance of objective methods; thanks to their reliability they now provide an essential support in the surgical indications and in following-up every nasal obstruction treatment, even as regards forensic medicine. From a strictly pharmacological point of view, whether associated with balsamic substances or not, vasoconstrictors give similar results with all evaluation methods. On the other hand, the balsamic action is limited to a subjective sensation of increased nasal air flow stemming from the stimulation of cutaneous thermoreceptors in the vestibule. Although this sensation does not correspond to an objective reduction in nasal resistance, it cannot be neglected in the treatment of obstructive symptoms where the psychological component can play an important role.

Osmotic drugs in the treatment of cochlear disorders: a clinical and experimental study

On the grounds of positive results obtained with Meniere's patients, agents such as glycerol and mannitol have been included in the therapeutical protocol of other cochlear disorders presenting with hearing loss either of sudden onset, but not observed at an early stage, or accompanied by tinnitus and aural pressure. Intravenous infusions of either 10% glycerol or 18% mannitol were given to selected patients 3 to 6 times with a time interval of 1 to 3 days. Hearing loss, tinnitus and aural pressure were evaluated as improved, unchanged or worsened. In 33% of the glycerol group and 23.8% of the mannitol group we observed hearing threshold improvement, while aural fullness improved in 45% of the glycerol and 56.2% of the mannitol groups, and tinnitus was only relieved in 13.1% of the glycerol and 5.8% of the mannitol group. A parallel experimental study was carried out on guinea-pigs in order to shed light on the effects of mannitol and glycerol on the inner ear. Cochlear blood flow was measured with a laser Doppler flowmeter at the level of the basal turn of the cochlear lateral wall, both in normal and hydropic guinea-pigs, before and after osmotic intraperitoneal infusion. Basal values in the normal cochlea were much higher than in the hydropic one, and both mannitol and glycerol markedly influenced the local blood flow in the normal cochlea, giving few or no changes in the hydropic one.

[Differentiated carcinoma in autonomously functioning thyroid nodule: case report]

This paper report a case of autonomously functioning thyroid nodule, firstly occurred in a 13 years old women, complicated 9 years later by hyperthyroidism, with no response to thyreostatic treatment, hystologically diagnosed as papillary carcinoma, in a thyroid gland affected by Hashimoto's thyroiditis, with cervical bilateral lymph node metastasis. In literature the rate of coexisting hyperthyroidism, chronic thyroiditis and differentiated carcinoma is low; thus thyroid malignancies are very rare in young people. In this patient the large autonomously functioning nodule was entirely made of neoplastic tissue, while in the remaining thyroid there was no evidence of adenomatous tissue. Moreover, thyreostatic treatment failed in controlling hyperthyroidism. The Authors consider these facts as indirect evidences that this is a rare case of hyperfunctioning differentiated thyroid carcinoma.

[Plasmacytomas of the head and neck]

Neoplastic proliferation of plasma cells results in a population of immunologically homogeneous cells that can produce diffuse (multiple myeloma) or localized (extramedullary plasmacytomas and solitary plasmacytoma of bone) disease. In otorhinolaryngologic literature these neoplasms are rarely described and their nosological arrangement is often confused. The presence of a plasma cell neoplasm can be a surprise and sometimes a diagnostic challenge to the head and neck surgeon. Proper management of such lesions needs to be individualized according to their expected biologic behaviour. The recent observation of a case of maxillary sinus plasmacytoma suggested the Authors to carefully review the literature, drawing their attention mainly on the current histogenetic hypotheses and their consequences in therapeutic strategy. The correct diagnostic procedure is also explained, highlighting the difficulties due to both the protean nature of the disease and the still existing nosological confusion. The possibility of a plasma cell tumour should be never forgotten in presence of an head and neck neoplasm. Because these neoplasms may signal the presence of multiple mieloma, full evaluation is required to exclude disseminated disease. In light of recent histogenetic acquisitions it is suggested that extramedullary plasmacytomas can be classified among the so-called "mucosa-associated" lymphomas. Possible following differences in therapeutic approach and long-term follow-up are also indicated, stressing the role of surgery in managing these disorders. Surgical excision of extramedullary plasmacytomas followed by complementary radiotherapy on the site of tumour is proposed as the best treatment for these kind of neoplasms. This is in opposition with "classical" statement considering radiotherapy the only treatment for this kind of disorders.

[The CO2 laser treatment of melanotic lesions of the oral mucosa. A clinical case report]

The authors, in a careful review of the literature, talk about the melanotic lesions of the mucous membranes of the oral cavity, explaining the etiopathogenesis, the various classifications, the diagnosis and the therapy. They also expound the features of laser and its application in management of a clinical case of melanotic lesion of the oral cavity.

[Evaluation of the T parameter of TNM classification of tumors of the tonsillar region. Correlation of MR and pathological data]

The purpose of this study was to define MR accuracy in the evaluation of T Stage of tumors in the tonsillar region. Twenty-two patients with a squamous cell carcinoma of the tonsillar region were studied utilizing a superconductive scanner operating at 1.5 T. The study was performed with SE T1 and T2 images before contrast and short SE T1 after Gd-DPTA infusion. MR results were correlated with pathological data on T Stage (TNM classification) and on the relationships between tumors and surrounding structures. A positive correlation between MR and pathological data was obtained in 19/22 cases, with an MR accuracy of 86%. MR did not show the presence of 2 superficial lesions (MR T0, pathological T1), while one lesion was classified T2 with MR, instead of pathology T1. The accuracy of MR was 95% in the evaluation of the relationships between tumors and the base of the tongue and 100% for body of the tongue, retromolar trigone, valleculae, epiglottis, pre-epiglottis, parapharyngeal and masticator space. MR showed high accuracy in the evaluation of T Stage, above all utilizing Gd-DPTA infusion, with short SE T1 sequences. MR did not show the superficial lesions, but in these cases a deep extension of the disease was excluded.

[Total/near-total glossectomy for advanced carcinoma of the tongue]

Poor survival rates and the limited palliation afforded by radiotherapy alone, together with progress made in reconstructive surgery in restoring mucosal continuity after large resections, make total glossectomy reasonably indicated for treatment of advanced carcinoma of the tongue. The Authors reviewed 19 cases (17 males, 2 females, mean age 58.4 years) of total and near total glossectomy without laryngectomy treated at National Cancer Institute "Regina Elena" of Rome from 1990 to 1993 in order to evaluate oncological and functional results. All patients were reconstructed immediately, 16 with a pectoralis major flap, 2 with a nasolabial flap and 1 with a radial forearm free flap and were available for follow-up from 6 to 45 months (mean 29 months). There was no operative mortality and no patient needed total laryngectomy for aspiration. The rate of local recurrencies was 52.6%, most of them (75%) in patients who had undergone total/near total glossectomy for recurrence. Survival rate was 61.5% after 1 year and 20% after 2 years. 94% of patients resumed swallowing and independent oral alimentation (48% of them without any dysphagia); 84%; of the patients were decannulated and 48% produced easily intellegible speech. Data from our experience let us conclude that, in the light of the acceptable functional results obtained with reconstructive flaps, total glossectomy should be considered as the primary treatment modality in advanced carcinoma of the tongue (including T2 > 3 cm exceeding midline), and should not be reserved only for salvaging hopeless situations.

[The epidemiological features in carcinoma of the oral cavity]

In the present paper, the authors, after a review of some classifications of oral cavity carcinoma (TNM) staging, histological grading and clinical stadiation, deal with some epidemiological remarks according to Italian Tumours Registers from 1983 up to 1987. Incidence, mortality, distribution by age and anatomic site are shown with reference to standard and cut rates. At last, they underline the importance of an early diagnosis in order to give these patients, after therapy a better quality of life.

[Morbidity and the morphofunctional aspects of myocutaneous flaps used in the head and neck area]

The authors analysed the data obtained from their experiences in extensive head and neck resections as well as reconstructive treatments using myocutaneous flaps. They tried to evaluate the reconstructive approach in terms of morbidity and functional results. Sixty-nine patients, treated from January 90 to November 92 for advances intra-oral cancer, were considered in this study. The reconstructive procedure in 68 cases was the pectoralis major myocutaneous flap while in 5 cases the trapezius flap was utilized. Even though the oncological results were poor, the functional ones were quite encouraging. In fact, the assessment of speech and swallowing was extremely satisfactory in 83% of the cases. The morbidity related to both flap procedures was low and the patients' life quality was good. Indeed, the use of a free flap offers additional advantages, without necessarily compromising safety of the reconstruction. Free flaps in general allow greater leeway in flap design and donor-site choice than pedicled flaps. Several reports have already demonstrated the versatility, usefulness and reliability of these flaps, especially in intra-oral reconstruction. The intricate nature of microsurgery and the expense of microsurgical equipment inhibit this kind surgery in many institutions around the world where the standard myocutaneous flaps would be a more practical procedure. In conclusion, even those patients with a poor prognosis may be considered potential candidates for demolitive and reconstructive treatment with which satisfactory results may be obtained.

[The recurrent multifocal pleomorphic adenoma]

Pleomorphic adenoma (P.A.), the most common tumor of the salivary gland, demonstrates a peculiar clinicopathological behaviour for numerous reasons: the high recurrence rate following primary surgery (up to 50%), the appearance of malignancy (2-9%), the reported number of distant metastases histologically identical to the primary P.A. From among 71 cases of benign parotid tumors treated from Nov. 89 to Nov. 92 in the ENT Department of "Regina Elena", the National Cancer Institute in Rome, six particular cases showed multiple force of P.A. recurring after primary surgery performed from 3 to 32 years previously and are object of discussion in this study. All of these six cases had multiple recurrences, usually manifest as nodular clusters in the parotid area, while in three cases appeared as well a recurrence in the soft tissue of the neck, far removed from the parotid space, with no involvement of neck nodes as was revealed through histological examination following neck dissection. A hypothetical mechanism of diffusion is discussed. The Authors agree with the opinion which holds the surgeon's inability to successfully eradicate primary tumors responsible for the high frequency of recurrences. The surgical technique of "enucleation" is, in fact, inadequate in P.A. excision owing the high risk of mishandling or rupturing the tumor capsule with a consequent seeding of the tumor onto the surgical bed. Lateral lobectomy, with identification of the facial nerve, or total conservative parotidectomy (for deep lobe adenoma) are correct techniques in treating primary P.A.. The Authors also discuss management of recurrent P.A. in relation to facial nerve involvement. Preservation of the seventh nerve with eventual post-operative radiation should be considered an alternative to nerve sacrifice in selected cases of recurrent pleomorphic adenoma.