Feasibility, Safety, and Provider Perspectives of Bipolar Electrosurgical Cautery Device for (Opportunistic or Complete) Salpingectomy at the Time of Cesarean Delivery

OBJECTIVE

 The aim of the study is to evaluate the use of a bipolar electrocautery device for complete salpingectomy at cesarean to improve procedure completion rates, operative time, and surgeon reported satisfaction as compared with standard bilateral tubal ligation (BTL) and suture-cut-tie salpingectomy.

STUDY DESIGN

 This is a prospective cohort study of women undergoing planned, non-emergent cesarean with desired sterilization with complete salpingectomy utilizing a bipolar electrocautery device. Study patients were compared with historic controls from a randomized controlled trial (RCT) of complete salpingectomy via suture-cut-tie method versus BTL conducted at our institution (SCORE trial, NCT02374827). Outcomes were compared with groups from the original RCT.

RESULTS

 Thirty-nine women were consecutively enrolled (12/2018-11/2019) into the device arm of the study and compared with the original SCORE cohort (n = 40 BTL, n = 40 salpingectomy without a device). Salpingectomy performance with the bipolar electrocautery device was successfully completed in 100% (39/39) of enrolled women, with one device failure requiring the use of a second device, as compared with 95% (38/40) in the BTL (p = 0.49) and 67.5% (27/40) in salpingectomies without a device (p < 0.001). Mean operative time of sterilization procedure alone demonstrated device use as having the shortest operative time of all (device salpingectomy 5.0 ± 3.6 vs. no device 18.5 ± 8.3 minutes, p < 0.001; and vs. BTL 6.9 ± 5.0, p = 0.032). Mean sterilization procedure endoscopic band ligation (EBL) was demonstrated to be significantly different between each group, least amongst BTL followed by device (6.3 ± 4.8 vs. 8.4 ± 24.8, p < 0.001), and most by suture-cut-tie method (17.7 ± 14.3, p < 0.001 compared with device). Surgeon reported attitudes of complete salpingectomy performance in general practice outside an academic setting was greater with a device than without (79.5 vs. 35.3%; p < 0.001).

CONCLUSION

 Use of a bipolar electrocautery device improved operative times and surgeon satisfaction for salpingectomy at cesarean over standard suture ligation. Device use improved surgeon reported outcomes and may improve incorporation of complete salpingectomy at cesarean.

KEY POINTS

· Electrocautery bipolar device use was safe at the time of salpingectomy during cesarean.. · Greater surgeon satisfaction occurs using a device than without.. · Decreased surgical time with device use is seen making the procedure equal to BTL..

Managing recurrent nosebleeds in children: a retrospective review of 718 children attending a nurse-led epistaxis clinic

OBJECTIVE

This review assessed the effectiveness of the nurse-led children's epistaxis clinic in streamlining patient care and avoiding unnecessary general anaesthesia.

METHODS

A retrospective case note review was conducted of children attending the nurse-led epistaxis clinic between 2019 and 2021.

RESULTS

A total of 718 children were seen over three years. Twelve (1.7 per cent) had a known coagulopathy. Of the children, 590 (82 per cent) had visible vessels and 29 (4 per cent) had mucosal crusting. Silver nitrate cautery was attempted under topical anaesthesia in 481 children, with 463 (96 per cent) successful cauterisations. Fifteen (3 per cent) were cauterised under general anaesthesia. Of the children, 706 (99 per cent) were prescribed nasal antiseptic preparations; this was the sole treatment for 58 (8 per cent). Blood investigations were requested for eight children (1 per cent) and haematology referral for three (0.4 per cent).

CONCLUSION

This is the largest published series of children's nosebleeds. Given the short-lived benefit from cautery, it is suggested that general anaesthesia should not be offered routinely. However, improved haematology referral criteria are required to increase underlying diagnosis.

Feasibility and safety of bipolar radiofrequency track cautery during percutaneous image-guided abdominal biopsy procedures

PURPOSE

The purpose of this study was to assess the feasibility and safety of using a bipolar radiofrequency track cautery device during percutaneous image-guided abdominal biopsy procedures in at-risk patients.

METHODS

Forty-two patients (26-79 years old; female 44%) with at least one bleeding risk factor who underwent an abdominal image-guided (CT or US) biopsy and intended bipolar radiofrequency track cautery (BRTC) were retrospectively studied. An 18G radiofrequency electrode was inserted through a 17G biopsy introducer needle immediately following coaxial 18G core biopsy, to cauterize the biopsy track using temperature control. Bleeding risk factors, technical success, and adverse events were recorded.

RESULTS

BRTC was technically successful in 41/42 (98%) of procedures; in one patient, the introducer needle retracted from the liver due to respiratory motion prior to BRTC. BRTC following percutaneous biopsy was applied during 41 abdominal biopsy procedures (renal mass = 12, renal parenchyma = 10, liver mass = 9, liver parenchyma = 5, splenic mass or parenchyma = 4, gastrohepatic mass = 1). All patients had one or more of the following risk factors: high-risk organ (spleen or renal parenchyma), hypervascular mass, elevated prothrombin time, renal insufficiency, thrombocytopenia, recent anticoagulation or anticoagulation not withheld for recommended interval, cirrhosis, intraprocedural hypertension, brisk back bleeding observed from the introducer needle, or subcapsular tumor location. No severe adverse events (grade 3 or higher) occurred. Two (2/41, 5%) mild (grade 1) bleeding events did not cause symptoms or require intervention.

CONCLUSION

Bipolar radiofrequency track cautery was feasible and safe during percutaneous image-guided abdominal biopsy procedures. IRB approval: MBG 2022P002277.

Winograd Wedge Resection Matrixectomy versus Partial Nail Avulsion with Chemical Cautery: A Tertiary Institution's Clinical Outcomes and Proposed Triaging Protocol

BACKGROUND

Onychocryptosis, or ingrown toenail, is a common condition affecting patients of varying age groups, although usually, younger patients are affected.

METHODS

We compared two techniques used in our institution: Winograd wedge resection with matrixectomy (WG-M) versus partial nail avulsion with phenolization of the nail matrix (PNA-P).

RESULTS

Primary outcomes of interest were presence of nail regrowth and patient satisfaction postoperatively. Secondary outcomes were postoperative pain (within the first 2 weeks and after 2 weeks), postoperative inflammation, and healing time. A total of 65 patients were included in this study: 44 patients (19 female and 25 male patients), with a mean age of 45.7 years (range, 16-83 years) underwent WG-M in the orthopedic surgery department, whereas a total of 21 patients (10 female and 11 male patients), with a mean age of 44.5 years (range, 13 to 75 years) underwent PNA-P in the podiatry department. In patients who underwent WG-M, there was one case of regrowth (2.3%) compared with no regrowth cases (0%) in the PNA-P group. There was no significant difference in regrowth rate between the two procedures (P = .494). The satisfaction rate was high for both procedures: 100% patients in the WG-M group rated themselves better than before surgery, compared with 95.7% in the PNA-P group.

CONCLUSIONS

From our study, we conclude that both techniques (WG-M and PNA-P) are able to achieve similar clinical outcomes, with the PNA-P procedure being less invasive and less resource intensive, and also achieving a shorter healing time.

Gomco circumcision in the office in patients heavier than 5.5 Kg and/or older than 3 months

INTRODUCTION

Although most pediatric urologists do not perform clamp circumcisions in boys older than 3 months or heavier than 5.5 kg, there are no universally accepted guidelines on the optimal patient age or weight.

OBJECTIVE

To compare outcomes of office circumcision within and outside these traditional patient parameters.

METHODS

This is a retrospective review of circumcisions performed by a single surgeon from 2019 to 2022. Demographics reviewed include age and weight at time of circumcision, gestational weeks at birth, as well as post-procedure: bleeding, planned and unplanned visits, adhesions/concealment, and interventions related to the circumcision. "Active Bleeding" was defined as bleeding occurring after discharge requiring intervention with pressure, sutures, or cautery. "All Bleeding" included Active Bleeding, and cases where bleeding was controlled at home with pressure, stopped by the time of arrival at clinic or emergency department, and immediate bleeding after circumcision controlled before discharge.

RESULTS

During the study period, 773 Gomco circumcisions were performed. A total of 603 patients (78%) had post-procedure evaluation 2 weeks after circumcision. 574 patients (74%) were less than 5.5 kg and 199 (26%) over. Only age corrected for gestation was used in the study: 658 (85%) were younger than 3 months and 115 (15%) older. There was no significant difference in Active Bleeding based on weight (p = 0.3819) or age (p = 0.2798), and no difference in All Bleeding based on weight (p = 0.2072). There was a significant difference (p = 0.0258) in All Bleeding based on age. There was also a significant difference in unexpected visits based on weight (p = 0.0258) and age (p = 0.0131). With regards to adhesions, there was no statistical significant differences when comparing weight or age. However, older and heavier boys had significantly more concealment (5% vs <1%).

DISCUSSION

Our study showed Active Bleeding rates 0.5-0.9% higher in the older and heavier group, although the difference did not reach statistical significance. We found a significantly increased rate of unexpected post-procedure visits of around 3.5-4.7% in those patients older than 3 months and heavier than 5.5 kg. Also, post -procedure concealment was significantly increased in the older and heavier boys. Modifications of the dressing for high risk groups could reduce the risk of bleeding, and efforts on pre-circumcision education of the families might ameliorate unexpected visits. Exlcuding patients with hidden penis or performing penoscrotal skin tacking at the time of the gomco circumcision could decrease concealment rates in the higher risk patients.

CONCLUSIONS

Gomco clamp circumcision is safe in patients over 5.5 kg and older than 3 months, with a less than 1% higher risk of bleeding, which in the current study was controlled without the need for general anesthesia or transfusions. Broadening the inclusion criteria for office clamp circumcisions could reduce costs and make the procedure available to patients who cannot afford to have the surgery under general anesthesia.

Endoscopic Suture With Chemocauterization: An Effective Treatment of Congenital Pyriform Sinus Fistula

OBJECTIVE

Endoscopic cauterization is an effective method for treating pyriform sinus fistula (PSF). However, these approaches sometimes result in a higher failure rate. We present an effective technique utilizing suture combined with chemocauterization as first-line treatment in patients with PSF and evaluate the safety and efficacy of its use in 126 patients.

STUDY DESIGN

Retrospective study.

SETTING

Tertiary referral center.

METHODS

Retrospective case review of patients treated between March 2012 and June 2021 at our institution with descriptive statistical analysis.

RESULTS

A total of 126 patients with PSF were included in this study with a mean age of 14.7 years. There was no sex predilection. The majority of patients presented with a left-sided neck lesion (89.7%). Ten patients presented following prior attempts at the surgery of the PSF at another institution; 8 via open surgery and 2 following endoscopic CO2 laser cauterization; other patients only had a history of repeat incision and drainage or antibiotic treatment. The success rate of obliteration of the internal opening was 96.83% after a single treatment without complications. Following reoperation, a successful outcome was achieved in the remaining 4 patients. Length of stay ranged from 10 to 14 days. No recurrences occurred within 12 to 120 months followed-up.

CONCLUSION

Endoscopic suture combined with chemocauterization is a safe and effective treatment of PSF. Surgery can be performed during the acute cervical inflammatory period without increased risk of complication or recurrence, however, patients found to have acute changes affecting the pyriform sinus should be treated with a staged surgery strategy.

Mini-Incision Direct Festoon Access, Cauterization, and Excision (MIDFACE): A 12-Year Analysis of a Novel Festoon Surgery

BACKGROUND

Surgical festoon management often entails aggressive dissection, flaps, unsightly scars, prolonged recovery, and high recurrence rates. The authors present outcomes with subjective and objective evaluation of an office-based, novel, minimally invasive (1-cm incision) festoon repair: mini-incision direct festoon access, cauterization, and excision (MIDFACE).

METHODS

Charts of 75 consecutive patients from 2007 to 2019 were evaluated. Photographs of 39 patients who met inclusionary criteria were evaluated by three expert physician graders for festoon and incision visibility (339 randomly scrambled preoperative and postoperative photographs taken with and without flash and from four different views: close-up, profile, full-frontal, and worm's eye) using paired t tests and Kruskal-Wallis tests for statistical evaluation. Surveys returned by 37 of 75 patients were evaluated for patient satisfaction and possible contributing factors to festoon formation or exacerbation.

RESULTS

There were no major complications in the 75 patients who underwent MIDFACE. Physician grading of photographs of 39 patients (78 eyes, 35 women; four men; mean age, 58 ± 7.7 years) demonstrated statistically significant sustained improvement in festoon score postoperatively up to 12 years regardless of view or flash. Incision scores were the same preoperatively and postoperatively, indicating incisions could not be detected by photography. Average patient satisfaction score was 9.5 on a Likert scale of 0 to 10. Possible factors for festoon formation or exacerbation included genetics (51%), pets (51%), prior hyaluronic acid fillers (54%), neurotoxin (62%), facial surgery (40%), alcohol (49%), allergies (46%), and sun exposure (59%).

CONCLUSION

MIDFACE repair results in sustained improvement of festoons with an office-based, minimally invasive procedure with high patient satisfaction, rapid recovery, and low recurrence.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Anton de Haen (1704-1776) and his extraordinary "portentosum infundibulum" case: the futile skull cauterization of a blind patient with a craniopharyngioma

Anton de Haen (1704-1776) became one of the most influential physicians in the Habsburg Empire as a reformer of clinical instruction at Vienna Citizen's Hospital (Bürgerspital), where he introduced the bedside teaching method he had learned from Herman Boerhaave in Leyden, Holland. He also promoted the meticulous recording of clinical observations and the use of postmortem studies to identify the cause of death in hospitalized patients. Among the numerous clinicopathological reports compiled in his monumental 18-volume work Rationis Medendi in Nosocomio Practico, published in 1761, was the first documented patient with amenorrhea caused by a pituitary tumor, appearing in the 6th volume. This 20-year-old amaurotic woman, who had suffered from chronic excruciating headache, died after the unsuccessful application of a cauterizing iron to her temporal bone. At the autopsy, a large solid-cystic and calcified tumor with gross characteristics typical of adamantinomatous craniopharyngioma was found encroaching on the infundibulum and third ventricle. This is the first known account of an infundibulo-tuberal lesion associated with the impairment of sexual functions, predating by 140 years the pathological evidence for a sexual brain center sited at the basal hypothalamus. In this paper, the authors analyze the historical importance and impact of de Haen's foundational report on the fields of neuroendocrinology and neurosurgery.

Historical use of silver nitrate for the management of epistaxis - evidence-based practice?

OBJECTIVE

Epistaxis is one of the most common emergencies presenting to the ENT service, and silver nitrate cautery is the mainstay of epistaxis treatment in most centres worldwide. This review aimed to ascertain the historical evidence behind current common practice.

METHOD

A review was conducted of historical published literature pertaining to epistaxis management.

RESULTS

Silver in medicine dates back to 4000 BC, with silver nitrate first being used in 69 BC. Modern medical use for epistaxis is documented in case reports over the last 200 years.

CONCLUSION

The precise origin and evidence-based practice of using silver nitrate for epistaxis is not well-established or understood. The mechanism of action is questionable; novel research of silver nitrate for this common ENT emergency presentation may be required.

Application of Bipolar Cauterization During Standard Percutaneous Nephrolithotomy

Introduction: We aimed to evaluate the efficacy of bipolar cauterization for tract site bleeding during standard percutaneous nephrolithotomy (PCNL). Methods and Materials: We defined tract site bleeding as when the visual field across the parenchymal tract starts to bleed while the sheath of a balloon dilator is being withdrawn just before the operation is completed. Among 181 patients, 90 patients showed no significant bleeding, and 91 patients required further procedures to resolve tract site bleeding. In cases of unresolved tract site bleeding, either nephrostomy placement (n = 60) or cauterization (n = 31) was performed. The outcomes of three groups (no procedure group, nephrostomy group and cauterization group) were compared. Results: The median decrease in hemoglobin at 2-hour intervals postoperatively was -1.75, -1.0, and -0.2 in the nephrostomy, cauterization, and no procedure groups, respectively (P < .001). There were 25 patients (41.7%) who received transfusions in the nephrostomy group, whereas only 1 patient (3.2%) received a transfusion in the cauterization group (P < .001). Conclusion: The bipolar cauterization of bleeding points at the end of PCNL could efficiently decrease tract site bleeding and reduce the need for transfusion. Clinical Research Information Service (https://cris.nih.go.kr/cris; No. KCT0008303).

The Arterial Pattern of the Upper Nasal Septum (S-Point) and Potential Role in Severe Epistaxis

OBJECTIVES

The previously described S-point, corresponds to the medial projection of the middle turbinate axilla in the superior nasal septum and has been identified as a common source of severe epistaxis. The objective is to define the anatomical patterns of vascularization of the S-point area that could explain its clinical relevance.

METHODS

Thirty-three nasal septums of latex-injected formalin-embalmed and fresh human cadaveric heads were dissected to analyze the arterial arrangement of the S-point area. Measurements and patterns of vascularization were described.

RESULTS

The S-point area, was consistently surrounded by a single or multiple arterial anastomotic arches consistently formed superiorly by the anterior ethmoidal and posterior ethmoidal artery branches, and inferiorly by the posterior septal artery. The caliber of the arterial arches was typically larger than the caliber of the arterial branches supplying them. A single arch was present in 36.3% of septums, and multiple arches in 63.6%. The mean distance from the S-point to the anterior limit of the arch was 9 mm, to the posterior arch when the present was 3 mm, to the superior limit 6 mm, to the inferior limit 6 mm, and to the nasal roof was 10 mm.

CONCLUSION

This study demonstrates the dense arterial configuration of the S point area, which is characterized by a single or multiple vascular arches of greater caliber than the branches of origin. This finding could explain why the S-point area is a frequent source of epistaxis, and guide its surgical cauterization when an obvious vascular ectasia is not visualized.

LEVEL OF EVIDENCE

N/A Laryngoscope, 133:2075-2080, 2023.

Evaluation of the Urinary System Diseases Sections in the Book Cerrahiyetü'l Haniyye (Imperial Surgery) by Sabuncuoğlu Şerefeddin

OBJECTIVES

Şerefeddin Sabuncuoğlu (1385-1465) is a medical scholar who wrote the first illustrated surgical book (Cerrahiyetü'l Haniyye [Imperial Surgery]) in the history of Turkish and Islamic medicine. Sabuncuoğlu benefited from the books of medical scholars before him and translated the book et-Tasreef of Abul-Qasim Khalaf Ibn Abbas Alzahrawi (Albucasis), which was the most important surgical book of its time. In this study, the urinary system disease sections of the textbook by Şerefeddin Sabuncuoğlu were examined.

MATERIALS AND METHODS

Cerrahiyetü'l Haniyye and et-Tasreef were evaluated by comparative textual analysis methodology in terms of urinary system diseases and its treatments.

RESULTS

The textbooks contain the same definitions of the cauterization of the kidney, cauterization of the urinary bladder, the treatment of urine retention, bladder irrigation with the syringe, and the forms of the instruments for the extraction of a stone from men and women. Şerefeddin Sabuncuoğlu made additions to the kidney and bladder cauterization and bladder irrigation sections. Colorful miniatures containing images of the procedures performed on the patients are found in Cerrahiyetü'l Haniyye.

CONCLUSIONS

The urinary system disease section in Cerrahiyetü'l Haniyye is a translation of et-Tasreef in general, with some additional information and drawings. The surgical instruments and procedures described by both physicians have reached the present day with changes.

Sensor-Based Automated Detection of Electrosurgical Cautery States

In computer-assisted surgery, it is typically required to detect when the tool comes into contact with the patient. In activated electrosurgery, this is known as the energy event. By continuously tracking the electrosurgical tools’ location using a navigation system, energy events can help determine locations of sensor-classified tissues. Our objective was to detect the energy event and determine the settings of electrosurgical cautery—robustly and automatically based on sensor data. This study aims to demonstrate the feasibility of using the cautery state to detect surgical incisions, without disrupting the surgical workflow. We detected current changes in the wires of the cautery device and grounding pad using non-invasive current sensors and an oscilloscope. An open-source software was implemented to apply machine learning on sensor data to detect energy events and cautery settings. Our methods classified each cautery state at an average accuracy of 95.56% across different tissue types and energy level parameters altered by surgeons during an operation. Our results demonstrate the feasibility of automatically identifying energy events during surgical incisions, which could be an important safety feature in robotic and computer-integrated surgery. This study provides a key step towards locating tissue classifications during breast cancer operations and reducing the rate of positive margins.

Recurrent Epistaxis Throughout the Lifespan: A Clinical Review

Epistaxis is a common otolaryngologic complaint experienced by 60 percent of the U.S. population and can be the result of either local or systemic disturbance. Most nosebleeds arise from an anastomotic region along the anterior nasal septum known as Kiesselbach's plexus. However, roughly ten percent of nosebleeds originate posteriorly from the sphenopalatine branch of the maxillary artery. Posterior nosebleeds can be more difficult to control and are frequently associated with systemic derangement. Patients presenting with a nosebleed should first be assessed for airway patency and hemodynamic stability. Once the patient is confirmed to be acutely stable, pre-existing clots should be cleared from the nasal cavity and the nasal alae should be compressed against the septum for ten to fifteen minutes. Application of a topical vasoconstricting agent can also be considered at this time. If the nosebleed persists and the location of the bleed can be visualized, chemical or electrical cautery can be used. If the site of the bleed cannot be identified, nasal packing materials in the form of lubricant-impregnated ribbon gauze or readymade nasal packing devices can be placed to tamponade the bleed. Following failure of these conservative treatment modalities, otolaryngologist consultation should be sought. Next steps in management may include arterial ligation or embolization.

Intracranial Meningiomas Developed after Traditional Scalp Thermal Cautery Treatment in Childhood: Clinical Reports and Gene Expression Analysis

BACKGROUND

Human skin cautery, a traditional thermal therapy, is traced back to Hippocrates beyond the 5th century. Those ancient healers used this method to control bleeding and infection and remove cancerous tumors. Such traditional procedure is still in practice in several regions of Asia and Africa to treat certain conditions. There is a lack of reports in the literature regarding the long-term complication and the possible tumorigenesis following traditional treatment with thermal cauterization. Here, we report two patients with intracranial meningiomas and investigate the gene expression profile for a patient. Cases presentations: We report two adult patients who presented with a headache and hemiparesis over six months. Brain magnetic resonance imaging (MRI) scans of both patients revealed intracranial meningiomas. During preoperative preparation of the patients, cautery marks were noticed over the scalp region above the intracranial tumors site, which was performed during childhood. The patients underwent uneventful resection of meningiomas with no local recurrence over a 5-year follow up. In addition, we performed a biofunctional genetic microarray expression analysis on the affected meningioma.

CONCLUSION

There is a lack of evidence-based scientific reports in the literature regarding the long-term complications and tumorigenesis following aggressive treatment with thermal cauterization. Herein, we report the first possible association between previous scalp traditional cautery and the development meningioma in two patients and discuss a proposed causal relationship. However, further advanced studies and research should be done to support, or reject, our hypothesis.

Huaier granule prevents the recurrence of early-stage hepatocellular carcinoma after thermal ablation: A cohort study

ETHNOPHARMACOLOGICAL RELEVANCE

Clinical trials have demonstrated that Trametes robinophila Murr (Huaier granule) can inhibit recurrence and metastasis after hepatocellular carcinoma (HCC) resection, but its efficacy as an adjuvant therapy after thermal ablation of early HCC is unknown.

AIM OF THE STUDY

To analyze the prognostic value and side effects of Huaier granules in HCC patients undergoing thermal ablation.

MATERIALS AND METHODS

Clinical information from 340 eligible subjects with early-stage HCC who were admitted to our department from September 1, 2008 to January 1, 2019 was extracted from the electronic medical record database. They were divided into the thermal ablation + TCM group and the thermal ablation group. Differences in their overall survival (OS), progression-free survival (PFS), extrahepatic metastatic rate (EMR), and therapeutic side effects (TSEs) between the two groups were compared. Beneficiaries of the integrated treatment and adequate treatment length were predicted.

RESULTS

The median follow-up was 32.5 months (range 2-122 months). The 1-year, 3-year and 5-year OS rates in the integrated treatment group and the control group were 93.2% vs. 92.6%, 54.5% vs. 51.4%, 23.5% vs. 19.7% (p = 0.110, HR 0.76(0.54-1.07)). The 1-year, 3-year and 5-year PFS rates were 78.8% vs. 69.4%, 50.6% vs. 40.6%, 35.3% vs. 26.5%, respectively (p = 0.020, HR 0.67(0.48-0.94)). The median OS (35 vs. 31 months) and PFS (24 vs. 12.5 months) were longer in the integrated treatment group. The EMR in the integrated treatment group was significantly lower than that in the control group (p = 0.018, HR 0.49 (0.27-0.89)). Patients with any two of the following three factors might be predicted to be beneficiaries of the integrated treatment, including younger than 65 years (p =0.039, HR 0.70 (0.50-0.98)), single tumor (p = 0.035, HR 0.70 (0.50-0.98), and tumor size ≤3 cm (p = 0.029, HR 0.69 (0.50-0.96). Patients with continuous oral administration of TCM following ablation had a lower probability of recurrence and metastasis within 2 years (p = 0.015, HR 0.67 (0.49-0.93)). Although the integrated treatment group reported a higher incidence of nausea and emesis, there were no significant differences between the two groups.

CONCLUSION

TCM following ablation may prolong PFS and suppress recurrence in patients with HCC, with continuous oral administration for more than 2 years maybe experience a greater benefit. The TSEs of the treatment are mild and can be tolerated.

Suppurative Thyroiditis: A Management Paradigm Based on Microbiology

OBJECTIVE

The aim of this study was to determine if microbiological cultures can guide management of suppurative thyroiditis.

DESIGN

This study is a retrospective case series set in 2 tertiary care academic hospitals.

METHODS

The microbiological cultures from patients with suppurative thyroiditis who underwent incision and drainage from July 2004 to June 2018 were reviewed. Those who had confirmed pyriform sinus tracts and underwent surgical intervention were included in the study.

RESULTS

Fifteen patients satisfied the criteria for inclusion. All had confirmed pyriform sinus tracts and underwent successful intervention. Endoscopic cautery was the most common intervention followed by complete open excision. Five cultures grew alpha Streptococcus, 6 had Eikenella, and 4 Prevotella. Combinations of Eikenella + Prevotella were seen in 3, and 1 sample had all 3 bacteria. Two cultured methicillin-susceptible Staphylococcus aureus alone. One culture was sterile.

CONCLUSIONS

The presence of oral flora in an intrathyroidal abscess is confirmatory evidence of a pyriform sinus tract. Further investigations are not needed, and early definitive intervention can be planned.

Etiology, Management, and Outcome of Pediatric Epistaxis

OBJECTIVE

Epistaxis in children is one of the most common causes for seeking professional medical help. Patients may be treated by several disciplines with various approaches to pediatric epistaxis. We reviewed cases of pediatric epistaxis from an otorhinolaryngologist's point of view.

METHODS

A retrospective chart review was performed on all patients younger than 18 years presenting with epistaxis to the Department of Otorhinolaryngology at the University of Bonn, Germany.

RESULTS

Sixty episodes of epistaxis in 58 patients were included in the study. Mean age was 10.1 ± 4.5 years. In terms of risk factors, 3 patients had a hemorrhagic diathesis, 3 had taken medication that interfered with hemostasis, and 8 had a history of previous trauma, most of which was digital manipulation. Twenty-six patients did not need invasive therapy. Twenty-six patients received cauterization to control the bleeding, and 4 patients needed surgery. The necessity for surgery was mainly noncooperation.

CONCLUSIONS

Epistaxis in children is seldom serious. However, hemorrhagic diathesis needs to be kept in mind as a potential cause of epistaxis. In most cases, careful instruction of the patients and the relatives concerning nasal mucosal care is sufficient. If cauterization is necessary, silver nitrate coagulation should be preferred over electrocoagulation.

[Right pyriform sinus fistula with infection of left neck: a case report]

In this article, a case of right pyriform fossa fistula, with left cervical infection as the main manifestation is reported. Ultrasound showed that there was an inhomogeneous echo mass in the dorsal side of the left lobe of thyroid. MRI showed that there were infectious signal behind the bilateral thyroid gland, but mainly on the left side. Fistula was found in the right pyriform fossa under suspension laryngoscope, and CO₂ laser cauterization was performed to cauterize this fistula.

Aquablation with subsequent selective bipolar cauterization versus holmium laser enucleation of the prostate (HoLEP) with regard to perioperative bleeding

INTRODUCTION

To compare the surgical methods of Aquablation followed by selective hemostasis by bipolar cauterization with holmium laser enucleation of the prostate (HoLEP) with regard to the risk of perioperative bleeding complications.

MATERIALS AND METHODS

A retrospective comparison was carried out on a total of 382 patients who had undergone either Aquablation (n = 167) or HoLEP (n = 215) at our hospital between April 2018 and July 2020. The following were studied: Hb loss, the need for packed red blood cell transfusions and surgical revisions due to bleeding from the prostatic fossa.

RESULTS

Transfusions were not necessary in the Aquablation group, while one man who underwent HoLEP had to receive a transfusion. Revision surgery due to bleeding was necessary during the early postoperative course in 13.2% of Aquablations and in 9.8% of HoLEPs (statistically not significant; p = 0.329). The perioperative Hb loss was comparable in both entire collectives (Aquablation 1.37 +/- 1.13 mg/dL, HoLEP 1.22 +/- 1.03 mg/dL; statistically not significant; p = 0.353). For subgroup analysis the groups Aquablation and HoLEP were into three subgroups respectively according to sonographically determined preoperative prostate volume ('small' < 40 mL, 'medium' 41-80 mL, 'large' > 80 mL). There were no significant differences between the subgroups regarding need for transfusions and hematuria-related complications.

CONCLUSIONS

The rate of perioperative hematuria related complications of Aquablation with subsequent selective hemostasis equals those found after holmium laser enucleation.

[Experience of diagnosis and treatment of fibrovascular polyp of the hypopharynx]

Objective:To explore and analyze the imaging examinations, clinical presentation, operative methods complication and the surgical outcomes of fibrovascular polyp of the hypopharynx （hFVP）. Methods:The clinical data of 10 patients with hFVP were analyzed retrospectively from January 2015 to June 2020 at the First Affiliated Hospital of Zhengzhou University.Results: All the 10 cases were sporadic. The locations of pedicle: 5 cases were found in pyriform sinus （4 on the left side, 1 on the right side） ,3 cases were found in lateral pharyngeal wall （on the right side），and 2 cases were found in postcricoid space. Among 10 cases, 8 cases were treated with endoscopic coblation cauterization,1 case had excision of endoscopic laryngeal forcep, and 1 case for endoscopic CO2 laser treatment as well as coblation cauterization. Follow up for 5.9-71.4 （30.9） months showed that 7 cases had no recurrence, 2 cases had no connection, 1 cases had recurrence once. One patient recurred once underwent the last operation with transcervical approach as well as tracheotomy,and no recurrence was found in the follow up of 13.2 months. Conclusion:Fibrovascular polyp of the hypopharynx is rare benign submucosal neoplasm clinically, and endoscopic coblation cauterization is a good choice. Recurrent fibrovascular polyp of the hypopharynx can be treated by endoscopic coblation cauterization again, so that patients with multiple recurrences whose polyps are giant or euangiotic can consider the transcervical approach, if necessary, the tracheotomy will also be given.

Focal bladder neck cautery associated with low rate of post-Aquablation bleeding

INTRODUCTION To determine if focal bladder neck cautery is effective in reducing bleeding following prostate tissue resection for benign prostatic hyperplasia using Aquablation.

MATERIALS AND METHODS

Consecutive patients at 11 countries in Asia, Europe and North America who underwent Aquablation for symptomatic benign prostatic hyperplasia between late 2019 and January 2021 were included in the analysis. All patients received post-Aquablation non-resective focal cautery at the bladder neck.

RESULTS

A total of 2,089 consecutive Aquablation procedures were included. Mean prostate size was 87 cc (range 20 cc to 363 cc). Postoperative bleeding requiring transfusion occurred in 17 cases (0.8%, 95% CI 0.5%-1.3%) and take-back to the operating room for fulguration occurred in 12 cases (0.6%, 95% CI 0.3%-1.0%). This result compares favorably (p < .0001) to the previously published hemostasis transfusion rate of 3.9% (31/801) using methods performed in the years 2014 to 2019.

CONCLUSIONS

In prostates sizes averaging 87cc (range 20 cc-363 cc), Aquablation procedures performed with focal bladder neck cautery that required a transfusion postoperatively occurred in a remarkably low number of cases.

Case Report: Crying Blood

SIGNIFICANCE

Hemolacria (bloody tears) is a rare clinical presentation with varied underlying etiologies. Thorough clinical evaluation is essential to diagnosis and management.

PURPOSE

This study aimed to report unilateral hemolacria in a known contact lens wearer with an occult, palpebral, conjunctival pyogenic granuloma and review the literature.

CASE REPORT

A 21-year-old female contact lens wearer presented to the clinic after three episodes of sudden painless bloody tears from the right eye. She was referred to the oculoplastic clinic for evaluation. On everting her right upper lid, a fleshy, nontender, ovoid, pedunculated mass was found attached to the palpebral conjunctiva of the right, nasal, upper tarsus. Surgical excision was performed in the office, and pathological examination of the lesion was consistent with pyogenic granuloma.

CONCLUSIONS

Unilateral hemolacria should raise clinical suspicion for a hidden conjunctival lesion such as pyogenic granuloma, although other more sinister causes of hemolacria must also be considered. Thorough evaluation including eyelid eversion is critical in identifying and managing occult conjunctival lesions.

[Consensus on pediatrics epistaxis: Causes, clinic and treatment]

Epistaxis is defined as bleeding from the vestibule, nasal cavity or nasopharynx. It represents 3 % of Emergency Room consultations. Thirty per cent of children under 5 years of age have an episode of epistaxis. The average age of presentation is between 7.5 and 8.5 years. It predominates in males (56-67 %). Nasal obstruction (nasal discharge) is the most associated symptom (46 %). The origin can be anterior or posterior, with the previous ones being the most frequent. An integral approach is necessary to determine the etiology (primary or secondary). The main purposes of the treatment are bleeding control and the underlying cause and the prevention of recurrence. Most hemorrhages are self-limiting; however, nasal tamponade and cauterization are required in cases of recurrence and/or severity. When these techniques fail, endoscopic management, angiography-embolization, and open surgical ligation may be used.

[Point electro-cauterization versus holmium laser cauterization in the treatment of post-ejaculation hematuria]

OBJECTIVE

To investigate the advantages and disadvantages of point electro-cauterization (PEC) and holmium laser cauterization (HLC) in the treatment of post-ejaculation hematuria.

METHODS

From January 2015 to December 2018, 73 patients with post-ejaculation hematuria, aged 24－63 (36.8 ± 4.2) years, underwent PEC (n = 35) or HLC (n = 38) after failure to respond to 3 months of conservative treatment. We compared the hospital days, total hospitalization expenses, maximum urinary flow rate (Qmax), average urinary flow rate (Qavg), Hamilton Anxiety Rating Scale (HAMA) score, postoperative duration of hematuria, and recurrence rate at 3 and 6 months after surgery.

RESULTS

All the patients experienced first ejaculation but no post-ejaculation hematuria at 1 month after operation. The recurrence rates were lower in the PEC than in the HLC group at 3 months (5.71% vs 2.63%, P > 0.05) and 6 months postoperatively (8.57% vs 5.26%, P > 0.05). Compared with the baseline, the Qmax was decreased from (18.56 ± 2.53) ml/s to (13.68 ± 3.31) ml/s (P < 0.05) and the Qavg from (14.35 ± 2.26) ml/s to (9.69±1.84) ml/s in the PEC group at 1 month after surgery (P < 0.01), but neither showed any statistically significant difference in the HLC group. Mild to moderate anxiety was prevalent in the patients preoperatively, particularly in those without job or regular income and those with a long disease course or frequent onset, the severity of which was not correlated with age, education or marital status. The HAMA score was decreased from18.65 ± 4.33 before to 12.35 ± 3.63 after surgery in the PEC group (P < 0.01), and from 16.88 ± 2.11 to 6.87 ± 4.36 in the HLC group (P < 0.01). The mean hospital stay was significantly longer in the former than in the latter group (［5.2 + 1.3］ vs ［3.4 ± 0.5］ d, P < 0.01), while the total cost markedly lower (［6.35 ± 1.20］ vs ［12.72 ± 2.15］ thousand RMB ¥, P < 0.05).

CONCLUSIONS

Both PEC and HLC are safe and effective for the treatment of post-ejaculation hematuria, with no significant difference in the recurrence rate at 3 and 6 months after operation, but their long-term effect needs further follow-up studies. PEC may increase the risk of negative outcomes of the postoperative urinary flow rate, while HLC has the advantages of better relieving the patient's anxiety, sooner discharge from hospital and earlier recovery from postoperative hematuria, though with a higher total cost than the former.

Single-site laparoscopic burnia for inguinal hernias in girls: comparison with open repair

BACKGROUND

Burnia is a suturless repair for inguinal hernias in girls. It is performed under laparoscopy by grabbing the sac, inverting it into the peritoneal cavity, and cauterizing. The aim of this study is to report our experience with single-site laparoscopic burnia (BURNIA) and compare them with open repair (OPEN).

METHODS

With IRB approval, pediatric female patients younger than 18 years of age who underwent inguinal hernia repair between January 2015 and December 2017 were enrolled. Medical records were retrospectively reviewed. The patients were divided into two groups, BURNIA and OPEN.

RESULTS

198 patients were included. In BURNIA, 49 patients underwent bilateral repairs, and 50 patients underwent 51 unilateral repairs (one patient had metachronous contralateral hernia). In OPEN, 27 patients underwent bilateral repairs, and 72 patients underwent 77 unilateral repairs (five patients had metachronous contralateral hernias). The mean age of BURNIA was similar to OPEN for bilateral repairs (49.1 ± 36.6 vs. 43.7 ± 26.4 months, p = 0.46), but significantly older for unilateral repairs (54.6 ± 29.8 vs. 29.0 ± 31.4, p < 0.01). The mean operation time of BUNIA was similar to OPEN for bilateral repairs (24.2 ± 7.6 vs. 22.4 ± 8.6 min, p = 0.35), but significantly longer for unilateral repairs (19.2 ± 7.0 vs, 13.6 ± 8.8 min, p < 0.01). The mean follow-up duration of BURNIA was significantly shorter than OPEN for bilateral and unilateral repairs, respectively (32.5 ± 8.8 vs. 45.4 ± 4.8 months, p < 0.01) (30.2 ± 8.8 vs. 39.1 ± 9.6 months, p < 0.01). No conversion was required in BURNIA. There were no complications and no recurrence in all patients.

CONCLUSIONS

Single-site laparoscopic burnia is technically feasible, and as safe and effective as open inguinal hernia repair.

Pediatric hydrocephalus outcomes in Lusaka, Zambia

OBJECTIVE

Hydrocephalus is a global disease that disproportionally impacts low- and middle-income countries. Limited data are available from sub-Saharan Africa. This study aims to be the first to describe pediatric hydrocephalus epidemiology and outcomes in Lusaka, Zambia.

METHODS

This retrospective cohort study included patients < 18 years of age who underwent surgical treatment for hydrocephalus at Beit-CURE Hospital and the University Teaching Hospital in Lusaka, Zambia, from August 2017 to May 2019. Surgeries included ventriculoperitoneal shunt insertions, revisions, and endoscopic third ventriculostomies (ETVs) with or without choroid plexus cauterization (CPC). A descriptive analysis of patient demographics, clinical presentation, and etiologies was summarized, followed by a multivariable analysis of mortality and 90-day complications.

RESULTS

A total of 378 patients met the inclusion criteria. The median age at first surgery was 5.5 (IQR 3.1, 12.7) months, and 51% of patients were female (n = 193). The most common presenting symptom was irritability (65%, n = 247), followed by oculomotor abnormalities (54%, n = 204). Postinfectious hydrocephalus was the predominant etiology (65%, n = 226/347), and 9% had a myelomeningocele (n = 32/347). It was the first hydrocephalus surgery for 87% (n = 309) and, of that group, 15% underwent ETV/CPC (n = 45). Severe hydrocephalus was common, with 42% of head circumferences more than 6 cm above the 97th percentile (n = 111). The median follow-up duration was 33 (IQR 4, 117) days. The complication rate was 20% (n = 76), with infection being most common (n = 29). Overall, 7% of the patients died (n = 26). Postoperative complication was significantly associated with mortality (χ2 = 81.2, p < 0.001) with infections and CSF leaks showing the strongest association (χ2 = 14.6 and 15.2, respectively, p < 0.001). On adjusted multivariable analysis, shunt revisions were more likely to have a complication than ETV/CPC or primary shunt insertions (OR 2.45 [95% CI 1.26-4.76], p = 0.008), and the presence of any postoperative complication was the only significant predictor of mortality (OR 42.9 [95% CI 12.3-149.1], p < 0.001).

CONCLUSIONS

Pediatric postinfectious hydrocephalus is the most common etiology of hydrocephalus in Lusaka, Zambia, which is similar to other countries in sub-Saharan Africa. Most children present late with neglected hydrocephalus. Shunt revision procedures are more prone to complication than ETV/CPC or primary shunt insertion, and postoperative complications represent a significant predictor of mortality in this population.

[Bilateral pyriform sinus fistulas: a case report]

A 6 year-old boy, who complained right neck abscesses and X-ray showed left pyriform fistula, was diagnosed as bilateral pyriform sinus fistulas. For bilateral pyriform sinus fistulas, endoscopic CO2laser cauterization should be the first treatment choice.

Intraoperative coagulopathy during cesarean section as an unsuspected initial presentation of COVID-19: a case report

BACKGROUND

The world's understanding of COVID-19 continues to evolve as the scientific community discovers unique presentations of this disease. This case report depicts an unexpected intraoperative coagulopathy during a cesarean section in an otherwise asymptomatic patient who was later found to have COVID-19. This case suggests that there may be a higher risk for intrapartum bleeding in the pregnant, largely asymptomatic COVID-positive patient with more abnormal COVID laboratory values.

CASE

The case patient displayed D-Dimer elevations beyond what is typically observed among this hospital's COVID-positive peripartum population and displayed significantly more oozing than expected intraoperatively, despite normal prothrombin time, international normalized ratio, fibrinogen, and platelets.

CONCLUSION

There is little published evidence on the association between D-Dimer and coagulopathy among the pregnant population infected with SARS-CoV-2. This case report contributes to the growing body of evidence on the effects of COVID-19 in pregnancy. A clinical picture concerning for intraoperative coagulopathy may be associated with SARS-CoV-2 infection during cesarean sections, and abnormal COVID laboratory tests, particularly D-Dimer, may help identify the patients in which this presentation occurs.

Prevention and Management of Operating Room Fire: An Interprofessional Operating Room Team Simulation Case

INTRODUCTION

Operating room (OR) fire can be a devastating and costly event to patients and health care providers. Prevention and effective management of such fires may present difficulties even for experienced OR staff.

METHODS

This simulation involved a 52-year-old man presenting for excisional biopsy of a cervical lymph node to be performed under sedation. Participants were expected to identify and manage both contained and uncontained fires resulting from ignition by electrosurgical cautery. We conducted weekly multidisciplinary simulations in the mock OR at Massachusetts General Hospital. Participants included surgery and anesthesiology residents, certified registered nurse anesthetists, registered nurses, and surgical technicians. Participants were unaware of the scenario content. Each 90-minute session was divided into three parts: an orientation (10 minutes), the case with rapid cycle debriefing (65 minutes), and a final debriefing with course evaluations (15 minutes). Equipment consisted of a simulation OR with general surgery supplies, general anesthesia equipment, a high-fidelity Laerdal SimMan 3G simulator, a code cart, a defibrillator, dry ice for smoke effects, and a projector with a fire image.

RESULTS

From April to June 2015, 86 participants completed this simulation. Participants reported that the simulation scenario was realistic (80%), was relevant to their clinical practice (93%), changed their practice (82%), and promoted teamwork (80%).

DISCUSSION

Prevention and management of OR fire require collaboration and prompt coordination between anesthesiologists, surgeons, and nurses. This simulation case scenario was implemented to train multidisciplinary learners in the identification and crisis management of such an event.

Allosteric Cannabinoid Receptor 1 (CB1) Ligands Reduce Ocular Pain and Inflammation

Cannabinoid receptor 1 (CB1) activation has been reported to reduce transient receptor potential cation channel subfamily V member 1 (TRPV1)-induced inflammatory responses and is anti-nociceptive and anti-inflammatory in corneal injury. We examined whether allosteric ligands, can modulate CB1 signaling to reduce pain and inflammation in corneal hyperalgesia. Corneal hyperalgesia was generated by chemical cauterization of cornea in wildtype and CB2 knockout (CB2-/-) mice. The novel racemic CB1 allosteric ligand GAT211 and its enantiomers GAT228 and GAT229 were examined alone or in combination with the orthosteric CB1 agonist Δ8-tetrahydrocannabinol (Δ8-THC). Pain responses were assessed following capsaicin (1 µM) stimulation of injured corneas at 6 h post-cauterization. Corneal neutrophil infiltration was also analyzed. GAT228, but not GAT229 or GAT211, reduced pain scores in response to capsaicin stimulation. Combination treatments of 0.5% GAT229 or 1% GAT211 with subthreshold Δ8-THC (0.4%) significantly reduced pain scores following capsaicin stimulation. The anti-nociceptive effects of both GAT229 and GAT228 were blocked with CB1 antagonist AM251, but remained unaffected in CB2-/- mice. Two percent GAT228, or the combination of 0.2% Δ8-THC with 0.5% GAT229 also significantly reduced corneal inflammation. CB1 allosteric ligands could offer a novel approach for treating corneal pain and inflammation.

Tongue base varix as a source of oral bleeding: A case report

RATIONALE

Oral bleeding is usually diagnosed after by referral to other department for the differential diagnosis of hematemesis or hemoptysis. If a patient presents with blood in the oral cavity with no obvious source, generally upper airway, pulmonary, or gastroesophageal lesions are considered likely bleeding foci. The tongue base is an unusual site for laryngopharyngeal varices and only a few cases have been reported.

PATIENT CONCERNS

Although varix at the tongue base in patients with liver cirrhosis has been rarely described, physicians must consider variceal bleeding from the tongue base when presented with oral bleeding. In such cases, bleeding foci can be identified and controlled by laryngoscopy. We describe the case of a 42-year-old woman complaining of small amount of hemoptysis with variceal bleeding at the tongue base controlled by laryngoscopic excision and cauterization.

DIAGNOSIS

A diagnosis of tongue base varix was made based on medical history, clinical manifestations, laryngoscopic findings and pathologic features for the patient.

INTERVENTIONS

The successful laryngoscopic procedures were performed.

OUTCOMES

The patient has shown no recurrent oral bleeding during follow-up.

LESSONS

Variceal bleeding in the tongue base is likely to cause serious massive hemorrhage. We need to consider this possibility when presented with a patient with intraoral bleeding but no evidence of hemoptysis or hematemesis.

HIGHER LESION NUMBERS RESULT IN HIGHER RECURRENCE RATES: A RETROSPECTIVE COHORT STUDY IN CONDYLOMATA ACUMINATA TREATED WITH ELECTROCAUTERIZATION

Condylomata acuminata (anogenital warts/CA) is the most frequent sexually transmitted disease with high recurrence rates in young adults resulting in considerable morbidity. An analysis performed on the five-year retrospective data of the CA patients who have visited our dermatology clinic, was aimed at the success rate of treatment with electrocauterization and recurrence dynamics, as well at determining the demographic structure of the patients. 237 patients with CA, who were treated at our hospital's dermatology clinic with electrocauterization under local anesthesia, during 2012-2017 were followed up retrospectively. The lesion number of each patient was recorded at the first visit. All the visible lesions were removed and cleared in all patients in all sessions. After the treatment, each patient was followed up every three months for one year. The data on demographic features, disease duration, lesion counts, treatment efficacy, and recurrence rates were statistically analyzed. Males were older in age and had higher number of recurrences after treatment compared to females (36.7 vs. 30.8; p=0.0015), but there was no statistically significant difference in disease durations prior to the first visit. Total recurrence ratios and the relevant patient numbers were 26.4% (n=53) and 22.2% (n=8) for male and female patients respectively (p=0.0001). For both male and female patients, the lesion numbers recorded at the first visit were found significantly higher in the patients with recurrence, compared to the patients without recurrence (p=0.0027 and p=0.0006, respectively). Electrocauterization is an effective modality in treatment of CA and the recurrence rate is relatively low in comparison to the published data on recurrence with other ablative therapy methods. The significantly higher recurrence in males may be the result of more risky (frivolous) sexual behavior adopted by them. Due to the higher probability of recurrence, the patients with multiple lesions should be followed closely after the treatment.

To Pack or Not to Pack: Inpatient Management of Epistaxis in the Elderly

BACKGROUND

Epistaxis is common in elderly patients, occasionally necessitating hospitalization for the management of severe bleeds. In this study, we aim to explore the impact of nasal packing versus nonpacking interventions (cauterization, embolization, and ligation) on outcomes and complications of epistaxis hospitalization in the elderly.

METHODS

The 2008-2013 National Inpatient Sample was queried for elderly patients (≥65 years) with a primary diagnosis of epistaxis and accompanying procedure codes for anterior and posterior nasal packing or nonpacking interventions.

RESULTS

A total of 8449 cases met the inclusion criteria, with 62.4% receiving only nasal packing and 37.6% receiving nonpacking interventions. On average, nonpacking interventions were associated with a 9.9% increase in length of stay and a 54.0% increase in hospital charges. Comorbidity rates did not vary between cohorts, except for diabetes mellitus, which was less common in the nonpacking cohort (26.6% vs 29.0%; P = .014). Nonpacking interventions were associated with an increased rate of blood transfusion (24.5% vs. 21.8%; P = .004), but no significant differences in rates of stroke, blindness, aspiration pneumonia, infectious pneumonia, thromboembolism, urinary/renal complications, pulmonary complications, cardiac complications, or in-hospital mortality. Comparing patients receiving ligation or embolization, no differences in length of stay, complications, or in-hospital mortality were found; however, embolization patients incurred 232.1% greater hospital charges ( P < .001).

CONCLUSION

Nonpacking interventions in the elderly do not appear to be associated with increased morbidity or mortality when compared to nasal packing only but appear to be associated with increased hospital charges and length of stay. Embolization in the elderly results in greater hospital charges but no change in outcome when compared to ligation.

Cauterisation versus fibrin glue for conjunctival autografting in primary pterygium surgery (CAGE CUP): study protocol of a randomised controlled trial

INTRODUCTION

Pterygium is a non-cancerous growth of the conjunctival tissue over the cornea that may lead to visual impairment in advanced stages, restriction of ocular motility, chronic inflammation and cosmetic concerns. Surgical removal is the treatment of choice, but recurrence of pterygium is a frequent problem. It has been previously shown that fibrin glue may result in less recurrence and may take less time than sutures for fixing the conjunctival graft in place during pterygium surgery. However, fibrin glue is a biological material and it carries the risk of transmitting infectious agents from pooled and single-donor blood donors and anaphylaxis in susceptible individuals. Cauterisation is another surgical option, and it would be advantageous to know whether cauterisation may be superior surgical option compared with fibrin glue. This protocol describes the rationale and design of the randomised controlled trial (RCT) in which we will compare cauterisation versus fibrin glue for conjunctival autografting in primary pterygium surgery.

METHODS AND ANALYSES

This will be a parallel group RCT comparing cauterisation versus fibrin glue for conjunctival autografting in primary pterygium surgery. Computer-generated randomisation will be used, and allocation concealment will be conducted using sequentially numbered opaque sealed envelopes. Surgeons will not be blinded to the procedures, but participants, other investigators and outcome assessors will be blinded. Adult participants with primary pterygium operated in a tertiary hospital in Split, Croatia, will be included. Primary outcome will be recurrence of pterygium, defined as any regrowth of tissue from the area of excision across the limbus onto the cornea after 180 days.

ETHICS AND DISSEMINATION

The trial was approved by the ethics review board of the University Hospital Split (500-03/17-01/68). Results will be disseminated at conferences and through peer-reviewed publications.

TRIAL REGISTRATION NUMBER

NCT03321201; Pre-results.

Endoscopic-guided coblation treatment of nasal telangiectasias in hereditary hemorrhagic telangiectasia: "How I do it"

INTRODUCTION

Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disease that leads to frequent epistaxis. It can have a significant impact on quality of life. Many reports exist regarding various therapies to address the epistaxis.

MATERIALS AND METHODS

We presented our technique for addressing the epistaxis associated with HHT.

RESULTS

Patients are treated in the operating room while they are under general anesthesia. A local anesthetic is injected sublabially, and oxymetazoline is dripped into the nose. The coblation wand is used to treat the telangiectasias. Bevacizumab is then injected into the nasal cavity bilaterally.

CONCLUSION

The coblation wand, with or without adjunctive bevacizumab injection, is a technically feasible intervention for patients with HHT that all providers can perform.

Endoscopic Treatment versus Shunting for Infant Hydrocephalus in Uganda

BACKGROUND

Postinfectious hydrocephalus in infants is a major health problem in sub-Saharan Africa. The conventional treatment is ventriculoperitoneal shunting, but surgeons are usually not immediately available to revise shunts when they fail. Endoscopic third ventriculostomy with choroid plexus cauterization (ETV-CPC) is an alternative treatment that is less subject to late failure but is also less likely than shunting to result in a reduction in ventricular size that might facilitate better brain growth and cognitive outcomes.

METHODS

We conducted a randomized trial to evaluate cognitive outcomes after ETV-CPC versus ventriculoperitoneal shunting in Ugandan infants with postinfectious hydrocephalus. The primary outcome was the Bayley Scales of Infant Development, Third Edition (BSID-3), cognitive scaled score 12 months after surgery (scores range from 1 to 19, with higher scores indicating better performance). The secondary outcomes were BSID-3 motor and language scores, treatment failure (defined as treatment-related death or the need for repeat surgery), and brain volume measured on computed tomography.

RESULTS

A total of 100 infants were enrolled; 51 were randomly assigned to undergo ETV-CPC, and 49 were assigned to undergo ventriculoperitoneal shunting. The median BSID-3 cognitive scores at 12 months did not differ significantly between the treatment groups (a score of 4 for ETV-CPC and 2 for ventriculoperitoneal shunting; Hodges-Lehmann estimated difference, 0; 95% confidence interval [CI], -2 to 0; P=0.35). There was no significant difference between the ETV-CPC group and the ventriculoperitoneal-shunt group in BSID-3 motor or language scores, rates of treatment failure (35% and 24%, respectively; hazard ratio, 0.7; 95% CI, 0.3 to 1.5; P=0.24), or brain volume (z score, -2.4 and -2.1, respectively; estimated difference, 0.3; 95% CI, -0.3 to 1.0; P=0.12).

CONCLUSIONS

This single-center study involving Ugandan infants with postinfectious hydrocephalus showed no significant difference between endoscopic ETV-CPC and ventriculoperitoneal shunting with regard to cognitive outcomes at 12 months. (Funded by the National Institutes of Health; ClinicalTrials.gov number, NCT01936272 .).

Prenatal surgery for myelomeningocele and the need for cerebrospinal fluid shunt placement

OBJECT

The Management of Myelomeningocele Study (MOMS) was a multicenter randomized trial comparing the safety and efficacy of prenatal and postnatal closure of myelomeningocele. The trial was stopped early because of the demonstrated efficacy of prenatal surgery, and outcomes on 158 of 183 pregnancies were reported. Here, the authors update the 1-year outcomes for the complete trial, analyze the primary and related outcomes, and evaluate whether specific prerandomization risk factors are associated with prenatal surgery benefit.

METHODS

The primary outcome was a composite of fetal loss or any of the following: infant death, CSF shunt placement, or meeting the prespecified criteria for shunt placement. Primary outcome, actual shunt placement, and shunt revision rates for prenatal versus postnatal repair were compared. The shunt criteria were reassessed to determine which were most concordant with practice, and a new composite outcome was created from the primary outcome by replacing the original criteria for CSF shunt placement with the revised criteria. The authors used logistic regression to estimate whether there were interactions between the type of surgery and known prenatal risk factors (lesion level, gestational age, degree of hindbrain herniation, and ventricle size) for shunt placement, and to determine which factors were associated with shunting among those infants who underwent prenatal surgery.

RESULTS

Ninety-one women were randomized to prenatal surgery and 92 to postnatal repair. The primary outcome occurred in 73% of infants in the prenatal surgery group and in 98% in the postnatal group (p < 0.0001). Actual rates of shunt placement were only 44% and 84% in the 2 groups, respectively (p < 0.0001). The authors revised the most commonly met criterion to require overt clinical signs of increased intracranial pressure, defined as split sutures, bulging fontanelle, or sunsetting eyes, in addition to increasing head circumference or hydrocephalus. Using these modified criteria, only 3 patients in each group met criteria but did not receive a shunt. For the revised composite outcome, there was a difference between the prenatal and postnatal surgery groups: 49.5% versus 87.0% (p < 0.0001). There was also a significant reduction in the number of children who had a shunt placed and then required a revision by 1 year of age in the prenatal group (15.4% vs 40.2%, relative risk 0.38 [95% CI 0.22-0.66]). In the prenatal surgery group, 20% of those with ventricle size < 10 mm at initial screening, 45.2% with ventricle size of 10 up to 15 mm, and 79.0% with ventricle size ≥ 15 mm received a shunt, whereas in the postnatal group, 79.4%, 86.0%, and 87.5%, respectively, received a shunt (p = 0.02). Lesion level and degree of hindbrain herniation appeared to have no effect on the eventual need for shunting (p = 0.19 and p = 0.13, respectively). Similar results were obtained for the revised outcome.

CONCLUSIONS

Larger ventricles at initial screening are associated with an increased need for shunting among those undergoing fetal surgery for myelomeningocele. During prenatal counseling, care should be exercised in recommending prenatal surgery when the ventricles are 15 mm or larger because prenatal surgery does not appear to improve outcome in this group. The revised criteria may be useful as guidelines for treating hydrocephalus in this group.

An update on epistaxis

BACKGROUND

Epistaxis is one of the most common ear, nose and throat (ENT) emergencies to present to general practitioners (GPs). The management of epistaxis has evolved significantly in recent years, including the use of nasal cautery and packs. Successful treatment requires knowledge of nasal anatomy, and potential risks and complications of treatment.

OBJECTIVE

Epistaxis is often a simple and readily treatable condition. However, given the potential consequences of a significant bleed, GPs should have an understanding of the causes, potential risks and emergency management.

DISCUSSION

Epistaxis can be classified into anterior or posterior bleeds, the former being the most common. Anterior bleeds can often be treated with cauterisation with silver nitrate sticks, provided there is good preparation, correct equipment and assistance close at hand. If there is a lack in any of these aspects, prompt use of nasal packing and referral to an emergency department or a specialist ENT service is recommended.

30 years of preventive studies of uterine cervical cancer 1982-2012

The studies for the prevention of uterine cervical cancer in Panama City began in a private institute, impelled by the high incidence of cancer. The preventive programs were initiated with the support of the Obstetrics and Gynecology Institute of the University of Padua in Italy. In these studies, we applied the methodological diagnostics of this Institute with certain modifications adapted to our needs. The diagnosis, treatment, and follow-up were carried out under the protocol of the University of Padua. We achieved a diagnosis of oncogenic risk (OR) in 6,411 patients which corresponded to 5,498 cases of human papillomavirus (HPV), 1,150 cases of dysplasia, 210 cases of cancer, and 794 cases of OR. From 2011, polymerase chain reaction (PCR) was also applied with the aim to improve the accuracy of the diagnosis. With this method the prevalence of pathologies were HPV infections both in healthy patients or in patients cured from HPV. Patients were treated by means of local destructive treatments (LDT), basically with cryotherapy and cauterization. We can consider these results as successful prevention and suggest to extend a preventive program to all the population.

[Preliminary experiences of endoscopic CO₂ laser cauterization for treatment of congenital pyriform sinus fistula]

OBJECTIVE

To evaluate the effectiveness of endoscopic CO₂ laser cauterization (ECLC) as a definitive treatment of congenital pyriform sinus fistula (CPSF).

METHODS

Eleven patients with CPSF underwent ECLC between January 2011 to March 2013 at Guangdong General Hospital. Of the 11 patients aging from 20 to 672 months (median: 60 months), there were 4 males and 7 females; 10 lesions located in the left necks and 1 located in the right; 6 untreated previously and 5 recurrent; 10 sinus (with internal opening) and 1 fistula. The presentations included reduplicative neck swelling, pain, or a fistulous opening with purulent discharge at the anterior neck region. Preoperative examinations included barium esophagogram, CT, MRI and so on. Six patients had at least received one time incision and drainage procedure previously. All patients had been treated with antibiotics in acute infection period. After inflammation subsided, the openings of pyriform sinus fistula were confirmed by esophagoscopy and then ECLC on internal opening was routinely performed.Esophagoscopy was carried out again by 3 months later in every patient, the same technique would be performed immediately if the internal opening was not completely closed.

RESULTS

The existence of an orifice in the pyriform fossa was identified by esophagoscopy in 11 patients. In 9 patients, the treatment was successful and the internal opening completely closed after the first ECLC. However, the other 2 patients received the second cauterization 3 months later because of the incomplete close of the internal opening. The average number of treatments was 1.2 times. No complications such as dysphagia, hoarseness occurred with the endoscopic procedure. Both the patients and their families were satisfied with the cervical appearance. All the patients had an uneventful recovery and remained no symptom from 11 to 35 months (median: 24 months).

CONCLUSION

The endoscopic CO₂ laser cauterization is safe, effective, repeatable and minimally invasive, which can be suggested as first-line treatment for congenital pyriform sinus fistula.