Clinical practice guidelines in the management of pediatric foreign body aspiration and ingestion: a systematic evaluation using the AGREE II instrument

PURPOSE

Several clinical practice guidelines (CPGs) have been produced to optimize the diagnosis and management of pediatric foreign body aspiration and ingestion. However, to date there have been no critical evaluations of their methodological rigor or quality. Herein, we address this need via the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument.

METHODS

A literature search of Embase, MEDLINE via PubMed, and Scopus was performed up until February 25, 2021. Identified CPGs were then assessed by four independent reviewers trained in AGREE II. A scaled domain score of >60% was indicated as satisfactory quality. Intraclass correlation coefficients (ICC) were calculated to assess inter-reviewer agreement.

RESULTS

11 guidelines were assessed with only one being classified as high quality and others being either average (two) or low quality (eight). Domain 4 (clarity of presentation) achieved the highest mean score (66.41 ± 13.33%), while domain 5 (applicability) achieved the lowest score (10.80 ± 10.37%). ICC analysis revealed generally strong agreement between reviewers with a range of 0.60-0.98.

CONCLUSION

Quality appraisal using the AGREE II instrument suggests that the methodologic rigor and quality of current guidelines for the diagnosis and management of pediatric foreign body aspiration and ingestion need significant improvement.

Predicting reoperation and readmission for head and neck free flap patients using machine learning

BACKGROUND

To develop machine learning (ML) models predicting unplanned readmission and reoperation among patients undergoing free flap reconstruction for head and neck (HN) surgery.

METHODS

Data were extracted from the 2012-2019 NSQIP database. eXtreme Gradient Boosting (XGBoost) was used to develop ML models predicting 30-day readmission and reoperation based on demographic and perioperative factors. Models were validated using 2019 data and evaluated.

RESULTS

Four-hundred and sixty-six (10.7%) of 4333 included patients were readmitted within 30 days of initial surgery. The ML model demonstrated 82% accuracy, 63% sensitivity, 85% specificity, and AUC of 0.78. Nine-hundred and four (18.3%) of 4931 patients underwent reoperation within 30 days of index surgery. The ML model demonstrated 62% accuracy, 51% sensitivity, 64% specificity, and AUC of 0.58.

CONCLUSION

XGBoost was used to predict 30-day readmission and reoperation for HN free flap patients. Findings may be used to assist clinicians and patients in shared decision-making and improve data collection in future database iterations.

Factors Leading to Gastrostomy Tube and Tracheostomy Requirements in Patients Treated Initially With Radiotherapy and Salvaged With Surgery and Free Flap Reconstruction

OBJECTIVE

Patients with recurrent oropharyngeal cancer can achieve survival benefits from surgical salvage, and often require simultaneous free-flap reconstruction. Resection and reconstruction can impact function, leading to tube dependence.

PRIMARY OBJECTIVE

describe rates of tracheostomy and gastrostomy tube dependence after oropharyngeal resection and free flap after prior radiation.

SECONDARY OBJECTIVE

evaluate patient, tumor, and treatment factors associated with tube dependence.

STUDY DESIGN

Retrospective, multi-institutional cohort study. Patients treated from 2003 to 2020. Average follow-up 21.4 months.

SETTING

Five tertiary care centers.

METHODS

Consecutive cohort of patients undergoing resection and simultaneous free-flap reconstruction for oropharyngeal squamous cell carcinoma after head and neck radiation.

PRIMARY OUTCOMES

gastrostomy tube dependence and tracheostomy or tracheostoma 1 year after surgery. Univariable and multivariable logistic regression were performed to identify factors associated with dependence.

RESULTS

89 patients underwent oropharyngectomy and free-flap reconstruction; 18 (20%) underwent total laryngectomy as part of tumor extirpation. After surgery, 51 patients (57%) lived 12 months. Among patients alive at 12 months, 22 (43%) were at least partially-dependent on gastrostomy tube, and 15 (29%) had either tracheostomy or tracheostoma. On multivariable analysis, extensive glossectomy (OR 16.6, 95% CI 1.83-389, p = 0.026) and total laryngectomy (OR 11.2, 95% CI 1.71-105, p = 0.018) were associated with long-term gastrostomy tube. No factors were associated with long-term tracheostomy on multivariable analysis.

CONCLUSION

Even among long-term survivors after salvage resection and free-flap reconstruction, rates of tube dependence are significant. This multi-institutional review is the largest such study to the date and may help inform shared decision-making.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:2141-2147, 2023.

How Does Reduction Mammaplasty Surgical Technique Impact Clinical, Aesthetic, and Patient-Reported Outcomes?: A Comparison of the Superomedial and Inferior Pedicle Techniques

BACKGROUND

A comprehensive comparison of surgical, aesthetic, and quality of life outcomes by reduction mammaplasty technique does not exist. We sought to ascertain the effect of technique on clinical, aesthetic, and patient-reported outcomes.

METHODS

Patients with symptomatic macromastia undergoing a superomedial or inferior pedicle reduction mammoplasty by a single surgeon were identified. BREAST-Q surveys were administered. Postoperative breast aesthetics were assessed in 50 matched-patients. Patient characteristics, complications, quality of life, and aesthetic scores were analyzed.

RESULTS

Overall, 101 patients underwent reductions; 60.3% had a superomedial pedicle. Superomedial pedicle patients were more likely to have grade 3 ptosis (P < 0.01) and had significantly shorter procedure time (P < 0.01). Only the inferior pedicle technique resulted in wound dehiscence (P = 0.03) and reoperations from complications (P < 0.01). Those who underwent an inferior pedicle reduction were 4.3 times more likely to experience a postoperative complication (P = 0.03). No differences in quality of life existed between cohorts (P > 0.05). Superomedial pedicle patients received significantly better scarring scores (P = 0.03).

CONCLUSIONS

The superomedial pedicle reduction mammoplasty technique provides clinical and aesthetic benefits compared with the inferior pedicle technique.

Association of Head and Neck Anatomic Zones with Microvascular Reconstruction Outcomes

Background: Head and neck free flap survival relies on adequate tissue perfusion from the external carotid artery (ECA), and vessel length is inversely proportional to blood flow rate. Objective: Investigate whether distance from the ECA (as a proxy for pedicle vessel length) predicts flap survival or complications. Methods: Retrospective review of free flaps performed at three academic centers from 9/2006 to 8/2021. Flaps were categorized by distance from the ECA: orbit and above (zone 1), maxilla to parotid (zone 2), and mandible and below (zone 3). Secondary analysis assessed flap outcomes stratified by average historical pedicle length. Results: A total of 2,369 flaps were identified in zones 1 (n = 109), 2 (n = 1878), and 3 (n = 382). Rates of flap failure (4.9%) and perioperative complications (36.3%) did not differ by zone or pedicle length. Zone 3 flaps, most commonly located in the larynx and hypopharynx, had significantly higher rates of fistula and infection. Conversely, 30-day readmission rates were significantly lower in patients with zone 2 flaps (p < 0.001). Rates of all other complications did not differ significantly between zones. Conclusions: Proximity to mucosal anatomic sites was a more powerful predictor of free flap viability than pedicle length or ECA proximity.

Clinical practice guidelines on management of infantile hemangioma: a systematic quality appraisal using the AGREE II instrument

Infantile hemangiomas (IH) are the most common benign tumors of childhood. Timely diagnosis and management of higher-risk IH is key in avoiding permanent disfigurement, visual impairment, and life-threatening airway compromise. Here, we identify and critically appraise existing clinical practice guidelines (CPGs) for IH diagnosis and management. A systematic search of MEDLINE, SCOPUS, and EMBASE was conducted until August 2021. Four independent reviewers assessed each CPG utilizing the Appraisal of Guidelines for Research and Evaluation, 2nd edition (AGREE II). An scaled domain score of ≥60% demonstrated adequacy in a given domain. Intraclass correlation coefficients (ICC) assessed agreement and scoring consistency between the reviewers. Eight CPGs were eligible and included for critical appraisal. Only one CPG was classified as 'high quality', with the remaining seven guidelines being 'average' (n = 3) or 'low' (n = 4) quality. Six guidelines (75.0%) were conducted via nonsystematic literature searches. The 'Applicability' (40.4%±14.0) and 'Rigor of development' (46.9%±17.3) domains achieved the lowest scores, while the highest average scores were in 'Scope and purpose' (76.7%±11.3) and 'Editorial independence' (90.8%±13.0). We found high consistency between the four independent reviewers, with 'very good' (n = 5) or 'good' (n = 1) interrater reliability in all six AGREE II domains. Based on the AGREE II instrument, there is only one available high-quality consensus statement on the diagnosis and management of IH. Low scores in 'Rigor of development' and 'Applicability' suggest notable weaknesses in the development process and reporting quality of existing IH CPGs. Future guidelines should be backed by systematic literature searches and focus on guideline clinical translation.

Characterizing critical predictors of an academic career following head and neck fellowship in otolaryngology

BACKGROUND

Historically, graduating head and neck (HN) fellows outpace available academic HN positions, resulting in a highly competitive job market. We identified factors that associate with full-time academic HN positions post-HN fellowship.

METHODS

Graduates of American Head and Neck Society (AHNS)-accredited fellowships from 2005 to 2017 (n = 356) were extracted from the AHNS website.

RESULTS

From 2015 to 2017, the supply-demand mismatch for academic HN jobs improved. Of the 57.3% (n = 204) of graduating HN fellows who entered academia, 64% (n = 130) trained at just 10 fellowship institutions, 47% (n = 94) attended OHNS residency at an NIH top 40 funded institution, and 54% (n = 111) attended OHNS residency at an AHNS-accredited institution offering HN fellowship. After multivariate regression, number of manuscripts (OR = 1.14; p = 0.01) was significantly associated with initial academic job post-fellowship.

CONCLUSION

The recent improvement in supply-demand mismatch for academic jobs is promising for future HN fellows interested in academia.

Quality appraisal of clinical practice guidelines for the use of radiofrequency ablation in the treatment of thyroid nodules and cancer

INTRODUCTION

Radiofrequency ablation (RFA) has gained significant recent global interest in the treatment of benign thyroid nodules and thyroid cancer. It is a relatively new, minimally invasive, thermal ablation technique that is an alternative to surgery. Several clinical practice guidelines (CPGs), consensus statements, and recommendations currently exist for the use of RFA in the treatment of benign thyroid nodules and thyroid cancers. These documents have considerable variability amongst them, and to date, their quality and methodologic rigor have not been appraised.

OBJECTIVE

To identify and perform a quality appraisal of clinical practice guidelines for RFA in the treatment of benign thyroid nodules and thyroid cancer using the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool.

METHODS

A comprehensive literature search was performed in MEDLINE (via PubMed), EMBASE, and SCOPUS databases from inception to November 1, 2021. Four reviewers independently evaluated each guideline using the AGREE II instrument. Scaled domain scores were generated and the threshold used for satisfactory quality was >60%. Additionally, intraclass correlation coefficients (ICCs) were calculated to determine level of agreement between reviewers.

RESULTS

Seven guidelines were selected for final evaluation based on inclusion/exclusion criteria. Two guidelines were classified "high" quality, one "average" quality, and the rest "low" quality. The "Clarity and Presentation" (65.68 ± 26.1) and "Editorial Independence" (61.32 ± 25.8) domains received the highest mean scores, while the "Applicability" (32.14 ± 22.8) and "Rigor of Development" (45.02 ± 29.8) domains received the lowest mean scores. ICC statistical analysis showed high magnitude of agreement between reviewers with a range of (0.722-0.944).

CONCLUSION

Reflecting upon our quality appraisal, it is evident that the quality and methodologic rigor of RFA guidelines can be improved upon in the future. Our findings also elucidate the existing variability/discrepancies amongst guidelines in the indications and use of RFA.

Clinical practice guidelines for pain management after tonsillectomy: Systematic quality appraisal using the AGREE II instrument

PURPOSE

We identified and appraised clinical practice guidelines (CPGs) for the management of post-tonsillectomy pain using the Appraisal of Guidelines for Research and Evaluation (AGREE II) guideline research tool.

MATERIALS AND METHODS

We conducted a literature search to identify CPGs addressing pain management after tonsillectomy. CPGs meeting inclusion criteria were then appraised by four independent reviewers in six areas of quality, as defined by AGREE II. Scaled domain scores were calculated for each quality domain. Intraclass correlation coefficients (ICC) were calculated in each domain to assess interrater reliability across guideline appraisals.

RESULTS

Nine guidelines meeting inclusion criteria were identified from a systematic search of the literature. The American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) guideline detailing tonsillectomy and postoperative management in pediatric patients received the highest average score, with a mean of 90.1% in the six areas of quality. Three guidelines scored higher than >60% in five domains or more, defining 'high' quality per AGREE II: AAO-HNS, Scottish Intercollegiate Guides Network (SIGN), and Ontario Ministry of Health CPGs. The highest-scoring domain was domain 4: Clarity of presentation (87.4%) across guidelines, while the lowest scoring domain was domain 5: Applicability (49.4%). Variability in scaled domain scores between all CPGs was relatively consistent across domains, with a mean standard deviation of 22.4%. The average ICC calculated across all six domains was 0.78, indicating 'strong agreement' between reviewers regarding guideline quality.

CONCLUSION

Of the nine available guidelines detailing pain management following tonsillectomy we identified, only three (33%) were deemed 'high'-quality after appraisal using the AGREE II instrument, suggesting a need for development of novel, methodologically rigorous CPGs.

Quality appraisal of clinical practice guidelines for temporomandibular joint disorders using the AGREE II instrument

OBJECTIVE

We sought to systematically assess the quality of all clinical practice guidelines (CPGs) describing diagnosis and management of temporomandibular joint disorders (TMDs) using the Appraisal of Guidelines for Research and Evaluation instrument.

STUDY DESIGN

CPGs detailing all aspects of diagnosis and management (both conservative and nonconservative) for TMDs were reviewed.

RESULTS

Thirteen guidelines met inclusion criteria. The highest-scoring domain across guidelines was clarity of presentation (68.3%); the lowest-scoring domain was editorial independence (31.9%). The highest-scoring guideline described traditional Korean medicine approaches to the management of TMDs, earning a mean score of 79.2% across the six quality domains. Only three CPGs met a quality threshold of >60% in at least five domains, qualifying as 'high' per the Appraisal of Guidelines for Research and Evaluation criteria: these guidelines were the Korean medicine guidelines, Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) guidelines for diagnostic classification of TMDs, and the Japanese Society for the Temporomandibular Joint guidelines. An average intraclass correlation coefficient of 0.79 was calculated across all domains, denoting very strong agreement between independent reviewers.

CONCLUSION

We identified a significant lack of quality in multiple areas of CPG development for the diagnosis and therapeutic management of TMDs, suggesting a need for new comprehensive and rigorously developed guidelines addressing TMDs.

Reconstruction following transoral robotic surgery for head and neck cancer: Systematic review

We performed a systematic review to characterize reconstructive modalities and postoperative surgical outcomes following TORS resection. A search of the PubMed, SCOPUS, and EMBASE databases was conducted to identify studies describing patients undergoing reconstruction of TORS defects. Twenty-six studies met inclusion criteria, consisting of 260 patients who underwent TORS resection followed by reconstruction. Twenty-one studies reported tumor classification information, with TORS performed for 44 (23.0%) T1, 86 (45.0%) T2, 33 (17.3%) T3, and 28 (14.7%) T4 tumors. Eighteen distinct reconstructive modalities were described in the studies identified, including nine unique free flap types. The most commonly performed reconstruction was the radial forearm free flap (RFFF), accounting for 121/260 (46.5%) of reconstructions performed. Reported surgical complications included 5 pharyngocutaneous fistulae, 13 hemorrhagic complications, 24 infectious complications, and 5 free flap failures. Our findings demonstrate favorable surgical outcomes but minimal quantitative functional data to compare reconstructive options following TORS.

Postnatal outcomes and risk factor analysis for patients with prenatally diagnosed oropharyngeal masses

OBJECTIVES

To describe our experience treating prenatally diagnosed oropharyngeal masses in a novel, multidisciplinary collaboration. To identifying outcomes and risk factors associated with adverse postnatal outcomes.

METHODS

This is a sixty-two patient case series at an academic referral center. Patients with prenatally diagnosed oropharyngeal masses were identified through a programmatic database and confirmed in the electronic health record.

RESULTS

Sixty-two patient with prenatally diagnosed oropharyngeal mass were identified, with prenatal imaging at our institution confirming this diagnosis in fifty-seven patients, short term outcomes analysis conducted on forty-four patients, and long-term outcomes analysis conducted on seventeen patients. The most common pathology was lymphatic malformations (n = 27, 47.4%), followed by teratomas (n = 22, 38.6%). The median mass volume from all available patient imaging (n = 57) was 60.54 cm³ (range 1.73-742.5 cm³). Thirteen pregnancies were interrupted, six infants expired, and thirteen cases had an unknown fetal outcome. Confirmed mortality was 6/57 patients with imaging-confirmed oropharyngeal masses (10.5%). Fourteen (56%) of the surviving patients (n = 25) were delivered by Ex Utero Intrapartum Treatment (EXIT) procedure and the median NICU stay was thirty-six days (range: 3-215 days). There was no association between airway compression/deviation/displacement, stomach size, polyhydramnios, or mass size and mortality. Seventeen patients had more than one year of follow-up (mean 5.3 ± 2.4 years). These seventeen patients underwent general anesthesia a total of ninety-two times (mean 5.4 ± 4.3) and had a total of twenty-three mass-related surgeries. The great majority of patients required an artificial airway at birth, feeding support, and speech/swallow therapy.

CONCLUSIONS

Oropharyngeal mass involvement of key anatomic structures-the neck, upper thorax, orbit, and ear, has a greater association with mortality than mass size. Regardless of the size and involved structures, oropharyngeal masses are associated with a high burden of intensive medical care and surgical care beginning at or before birth.

P085 CLINICAL AND LONGITUDINAL PATIENT REPORTED OUTCOMES AFTER TRANSVERSUS ABDOMINIS RELEASE: A SINGLE SURGEON EXPERIENCE

Aim

Posterior component separation with transversus abdominis release (TAR) is a novel complex abdominal wall repair technique that maximizes medial myofascial flap advancement in a vascularized, pre-peritoneal plane. Here, we add to a growing body of literature on this technique by assessing longitudinal clinical and patient reported outcomes (PROs) after ventral hernia repair (VHR) with TAR.

Material and Methods

Adult patients undergoing VHR with TAR between 10/1/2015 and 01/15/2020 by a single surgeon were retrospectively identified. Patients with parastomal hernias and &lt;12 months of follow-up were excluded. Clinical outcomes and PROs using the Abdominal Hernia Questionnaire (AQH) and Hernia Related Quality of Life Survey (HerQLes) were assessed.

Results

57 patients were included with a median age and body mass index of 60 and 30.6 kg/m2, respectively. The average hernia defect was 384 cm2 [IQR 205-471], and all patients had retro-muscular mesh placed. The most common complications were delayed healing (19.3%) and seroma (14.0%). One patient required return to the OR for management of a complication and there were no cases of mesh infection or explantation. Previous hernia repair and concurrent panniculectomy were risk factors for developing any complication (p &lt; 0.05). One patient (1.8%) recurred at a median follow-up of 25.7 months [IQR 18.2-42.1]. Significant improvement in disease-specific PROs was observed and maintained throughout the follow-up period (pre to post p &lt; 0.05).

Conclusions

Longitudinal clinical and patient-reported outcomes after VHR with TAR are limited. We conclude that TAR is a safe and efficacious adjunct in the repair of complex hernia defects.

A systematic quality appraisal of clinical practice guidelines for Ménière's disease using the AGREE II instrument

PURPOSE

To systematically appraise clinical practice guidelines for the diagnosis and treatment of Ménière's disease using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument.

MATERIALS AND METHODS

A systematic literature search was performed to identify guidelines pertaining to the diagnosis and treatment of Ménière's disease. Data were abstracted from guidelines that met inclusion criteria and appraised by four independent reviewers in the six domains of quality defined by the AGREE II. Domain scores reflecting quality in each domain were calculated. Intraclass correlation coefficients (ICC) were calculated across domains to qualify interrater reliability.

RESULTS

Six guidelines were found to meet inclusion criteria after a systematic literature search. Of the six clinical practice guidelines appraised using the AGREE II, the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) guideline received the highest average score, with a mean of 90.7% spanning six quality domains. The guideline with the lowest average score across all domains was the European Position Statement on diagnosis and treatment of Ménière's disease, receiving an average score across domains of 34.6%. Overall quality scores of clinical practice guidelines for Ménière's disease had a standard deviation of 21.3%. Two guidelines met the quality threshold of > 60% in at least five domains, qualifying as 'high': AAO-HNS and National Institute for Health and Care Excellence. Average ICC across all six domains was 0.87, suggesting near total agreement between reviewers.

CONCLUSION

Ménière's disease remains a challenging entity to diagnose and treat; few existing clinical guidelines meet the standards of quality established by the AGREE II appraisal instrument.

Risk factor analysis and outcomes of airway management in antenatally diagnosed cervical masses

PURPOSE

To investigate antenatally-determined imaging characteristics associated with invasive airway management at birth in patients with cervical masses, as well as to describe postnatal management and outcomes.

STUDY DESIGN

A retrospective analysis of 52 patients with antenatally diagnosed neck masses was performed using single-center data from January 2008 to January 2019. Antenatal imaging, method of delivery, management, and outcomes data were abstracted from the medical record and analyzed.

RESULTS

Antenatal diagnosis of neck masses in this cohort consisted of 41 lymphatic malformations (78.8%), 6 teratomas (11.5%), 3 hemangiomas (5.8%), 1 hemangioendothelioma (1.9%), and 1 giant foregut duplication cyst (1.9%). Mean gestational age at time of diagnostic imaging was 29 weeks 3 days (range: 19w4d - 37w). Overall, 22 patients (42.3%) required invasive airway management at birth, specifically 18 patients (34.6%) required endotracheal intubation and 4 (7.7%) required tracheostomy. 15 patients (28.8%) underwent ex-utero intrapartum treatment (EXIT) for the purposes of securing an airway. Polyhydramnios, tracheal deviation and compression, and anterior mass location on antenatal imaging were significantly associated with incidence of invasive airway intervention at birth, EXIT procedure, and tracheostomy during the neonatal hospitalization (p < 0.025; Fisher's exact test). Logistic regression analysis demonstrated statistically significant association between increasing antenatally-estimated mass volume and incidence of invasive airway management at birth (p = 0.02). Post-natal cervical mass management involved surgical excision (32.7%), sclerotherapy (50%), and adjuvant therapy with rapamycin (17.3%). Demise in the neonatal period occurred in 4 (7.7%) patients.

CONCLUSION

This series documents the largest single-center experience of airway management in antenatally diagnosed cervical masses. Fetal imaging characteristics may help inform the appropriate method of delivery, airway management strategy at birth, and prenatal counseling.

Longitudinal Clinical and Patient-Reported Outcomes After Transversus Abdominis Release for Complex Hernia Repair With a Review of the Literature

PURPOSE

Posterior component separation with transversus abdominis release (TAR) enables medial myofascial flap advancement in complex abdominal wall reconstruction. Here, we add to a growing body of literature on TAR by assessing longitudinal clinical and patient-reported outcomes (PROs) after complex ventral hernia repair (VHR) with TAR.

METHODS

Adult patients undergoing VHR with TAR between 10/15/2015 and 1/15/2020 were retrospectively identified. Patients with parastomal hernias and <12 months of follow-up were excluded. Clinical outcomes and PROs were assessed.

RESULTS

Fifty-six patients were included with a median age and body mass index of 60 and 30.8 kg/m², respectively. The average hernia defect was 384 cm² [IQR 205-471], and all patients had retromuscular mesh placed. The most common complications were delayed healing (19.6%) and seroma (14.3%). There were no cases of mesh infection or explantation. Previous hernia repair and concurrent panniculectomy were risk factors for developing complications (P < .05). One patient (1.8%) recurred at a median follow-up of 25.2 months [IQR 18.2-42.4]. Significant improvement in disease-specific PROs was maintained throughout the follow-up period (before to after P < .05).

CONCLUSION

Transversus abdominis release is a safe and efficacious technique to achieve fascial closure and retromuscular mesh in the repair of complex hernia defects.

Contemporary treatment of keloids: A 10-year institutional experience with medical management, surgical excision, and radiation therapy

INTRODUCTION

We evaluate a single center's, decade-long experience utilizing 3 approaches to keloid treatment: corticosteroid medical management (MM), surgical excision (SE), and surgical excision + radiation therapy (SE + RT).

STUDY DESIGN

Patients undergoing keloid treatment were identified (2008-2017). Outcomes were symptomatology/cosmesis for MM, and recurrence and complications for SE and SE + RT. Logistic regression was used to determine factors associated with recurrence and complications.

RESULTS

284 keloids (95 MM, 94 SE, 95 S E + RT) corresponded to patients with a median age of 39.1 (IQR: 26.1-53), 68.1% Black, and followed-up for 15.4 months (IQR: 5.6-30.7). For MM, 84.6% and 72.5% reported improvement in cosmesis and symptoms, respectively. SE and SE + RT recurrence were 37.2 and 37.9%, respectively. In adjusted analyses, higher radiation doses were associated with decreased recurrence whereas male gender (OR 3.3) and postoperative steroids (OR 9.5) were associated with increased recurrence (p < 0.01). There were more complications in the SE + RT group.

CONCLUSIONS

MM resulted in at least some improvement. Recurrence rates after SE and SE + RT were similar. Female sex is protective, race does not affect outcomes.

Safety and Efficacy of Arterial Closure Devices Following Antegrade Femoral Access: A Case–Control Study

Purpose:

Vascular closure device (VCD) use following antegrade femoral access may present unique challenges relative to retrograde access. We retrospectively compared safety and efficacy of these devices between antegrade and retrograde patient cohorts undergoing percutaneous intervention.

Materials and Methods:

Over a 5-year period, a consecutive series of 107 limbs in 84 patients underwent VCD arteriotomy closure following percutaneous revascularization using an antegrade approach (VCD-A). Device deployment success rates, time to ambulation, and complication rates were compared to a contemporaneous control group of 401 limbs in 305 patients who underwent closure following retrograde access (VCD-R) during revascularization or embolization procedures.

Results:

Closure was attempted in VCD-A using 53 StarClose, 35 Perclose, and 19 Angio-Seal devices. Hemostasis (without supplemental manual compression) was achieved in 86/107 (80.4%) limbs. Closure was attempted in VCD-R using 215 StarClose, 119 Perclose, and 67 Angio-Seal devices with hemostasis in 357/401 (89.0%) limbs. Device deployment failure occurred in 7/107 (6.5%) of VCD-A and 20/401 (5.0%) of VCD-R ( P = .52), independent of specific device type. Femoral pseudoaneurysm developed in 1/107 and 1/401 of VCD-A and VCD-R ( P = .31), and minor hematoma developed in 3/107 and 8/401 of the VCD-A and VCD-R ( P = .61). Mean time to ambulation was 204.1 minutes in VCD-A and 204.8 minutes in VCD-R ( P = .97).

Conclusion:

Antegrade femoral closure was associated with high rates of technical success and low complications, similar to retrograde closure. Time to ambulation was the same in both groups despite higher heparin doses in the antegrade patients.

Inferior Vena Cava Reconstruction in Symptomatic Patients Using Palmaz Stents: A Retrospective Single-Center Experience

BACKGROUND

The use of stents for treating central venous occlusion is well described. Limited evidence exists related to Palmaz balloon-expandable stent use in inferior vena cava (IVC) reconstruction. We analyzed patency and complication rates after IVC reconstruction using Palmaz stents.

METHODS

From 2002 to 2019, 37 patients (mean age: 51 year) underwent IVC reconstruction with 68 Palmaz stents. Indications were symptomatic chronic venous obstruction in the infrarenal (n = 25) and intrahepatic (n = 12) IVC. Demographic, operative, and imaging data were evaluated. Clinical data, abdominal CT, and/or duplex ultrasound were used to determine patency at follow-up.

RESULTS

Restoration of caval patency was achieved in all patients, with complications in 2/37 (5.4%) patients (thrombus formation within the stent; stent embolization eight days after placement). Follow-up data were available for 27 patients. Primary patency was maintained through last follow-up in 19/27 (70%) patients (mean: 1.1 year), with successful stent redilation performed in 6 patients. Mean duration of primary-assisted patency (n = 5) was 1.2 year. Late lumen loss was (n = 13) was 40% during a mean time to follow-up of 2.0 years. Primary patency in patients with occlusion secondary to malignancy was 109 day (range: 1 day-1.0 year), whereas primary patency in patients with occlusion from other etiologies was 1.1 year (range: 2 day-5.9 year). The Kaplan-Meier analysis demonstrated primary and primary-assisted patency of 66% and 84%, respectively, at 24 and 48 months.

CONCLUSIONS

Palmaz balloon-expandable stents for IVC reconstruction is feasible and effective for symptomatic IVC occlusion. Risk of stent migration was low.