Tracheostomy during the COVID-19 pandemic in Malaysia; a revised guideline

Performing tracheostomy on COVID-19 patients poses a significant risk to the procedural team. Such procedures should be evaluated individually via close communication between the otorhinolaryngology-head and neck surgeon and the intensivist. Comprehensive examination and preparation should be well-planned before tracheostomy, optimal technique during tracheostomy and special care following the surgery. We would like to highlight our revised guidelines at Hospital Kuala Lumpur, Malaysia on the timing of tracheostomy, management of anticoagulant and the surgical planning in COVID-19 patients during these challenging times.

Fecal calprotectin for detection of postoperative endoscopic recurrence in Crohn's disease: systematic review and meta-analysis

BACKGROUND

Anastomotic recurrence is frequent in patients with Crohn's disease (CD) following ileocecal resection. The degree of endoscopic recurrence, quantified by the Rutgeerts score (RS), correlates with risk of clinical and surgical recurrence. Several studies demonstrate the accuracy of fecal calprotectin (FC) for detection of endoscopic recurrence, however the optimal threshold FC value remains to be established. The aim of our meta-analysis was to evaluate the accuracy of common FC cut-offs for detection of endoscopic recurrence.

METHODS

We performed a systematic literature search for studies evaluating postoperative recurrence in CD which reported RS and FC levels. Endoscopic recurrence was defined as RS = 2-4 (or RS ⩾ 2). We calculated pooled diagnostic sensitivity, specificity, diagnostic odds ratio (DOR) and constructed summary receiver operating characteristic (SROC) curves for each available FC cut-off value.

RESULTS

A total of 54 studies were retrieved; 9 studies were eligible for analysis. Diagnostic accuracy was calculated for FC values of 50, 100, 150 and 200 µg/g. A significant threshold effect was observed for all FC values. The optimal diagnostic accuracy was obtained for FC value of 150 µg/g, with a pooled sensitivity of 70% [95% confidence interval (CI) 59-81%], specificity 69% (95% CI 61-77%), and DOR 5.92 (95% CI 2.61-12.17). The area under the SROC curve was 0.73.

CONCLUSION

FC is an accurate surrogate marker of postoperative endoscopic recurrence in CD patients. The FC cut-off 150 μg/g appears to have the best overall accuracy. Serial FC evaluations may eliminate or defer the need for colonoscopic evaluation in up to 70% of postoperative CD patients.

Capsule Endoscopy, Magnetic Resonance Enterography, and Small Bowel Ultrasound for Evaluation of Postoperative Recurrence in Crohn's Disease: Systematic Review and Meta-Analysis

BACKGROUND

Anastomotic recurrence is frequent in patients with Crohn's disease (CD) following ileocecal resection. The degree of endoscopic recurrence, quantified by the Rutgeerts score (RS), is correlated with the risk of clinical and surgical recurrence. Noninvasive modalities such as capsule endoscopy (CE), magnetic resonance enterography (MRE), and intestinal ultrasound (US) may yield similar information without the need for ileocolonoscopy (IC). The aim of our meta-analysis was to evaluate the accuracy of those modalities for detection of endoscopic recurrence in postoperative CD patients.

METHODS

We performed a systematic literature search for studies comparing the accuracy of CE, MRE, and US with IC for detection of postoperative recurrence in CD. We calculated pooled diagnostic sensitivity, specificity, diagnostic odds ratio (DOR), and area under the curve (AUC) for each comparison.

RESULTS

A total of 135 studies were retrieved; 14 studies were eligible for analysis. For CE, the pooled sensitivity was 100% (95% CI, 91%-100%), specificity was 69% (95% CI, 52%-83%), DOR was 30.8 (95% CI, 6.9-138), and AUC was 0.94. MRE had pooled sensitivity of 97% (95% CI, 89%-100%), specificity of 84% (95% CI, 62%-96%), DOR of 129.5 (95% CI, 16.4-1024.7), and AUC of 0.98. US had pooled sensitivity of 89% (95% CI, 85%-92%), specificity of 86% (95% CI, 78%-93%), DOR of 42.3 (95% CI, 18.6-96.0), and AUC 0.93.

CONCLUSIONS

CE, MRE, and US provide accurate assessment of postoperative endoscopic recurrence in CD. These modalities should gain wider use for detection of postoperative recurrence; the prognostic value of those diagnostic findings merits evaluation in further prospective studies.

First branchial cleft anomalies have relevance in otology and more

INTRODUCTION

First branchial cleft anomalies account for less than 8% of all branchial abnormalities. Their rarity and diverse presentations have frequently led to misdiagnosis and inappropriate treatment. In a trend towards specialisation/subspecialisation, first branchial cleft duplication anomalies, with their varied clinical manifestations, may possibly present to an Otology, Head and Neck Surgery, Paediatric Otolaryngology, Maxillofacial or even a General Paediatric and General Surgery practice. There is a need to highlight the clinical features which can aid in accurate diagnosis.

CLINICAL PICTURE, TREATMENT AND OUTCOME

A case of an adult with Work Type 2 first branchial cleft duplication anomaly presenting as a collaural fistula is described. It first presented as a recurrent upper neck abscess in childhood. The diagnosis had previously been missed although the patient was able to clearly establish a correlation between digging of the ipsilateral ear and precipitation of the abscess. Instead of an epidermal web, a myringeal lesion in the form of a fibrous band-like was present. The lesion was completely excised with no further recurrence.

CONCLUSION

This case highlights useful diagnostic features both from the history and physical examination. The specialist/subspecialist must be aware of this condition and be mindful of its possible cross specialty/subspecialty symptoms and signs. Together with a good understanding of the regional embryology and anatomy, the lesion can be diagnosed early at initial presentation with the potential for best treatment outcomes.