Unrepaired Complete Tracheal Rings: Natural History and Management Considerations

Objectives To document the natural growth pattern of unrepaired complete tracheal rings (UCTRs) and describe the patient population managed conservatively. Study Design Case series with chart review. Setting Tertiary pediatric academic center. Subjects/Methods Medical records of patients with confirmed complete tracheal rings on bronchoscopy from 1993 to 2017 were reviewed. Patients aged 0 to 18 who had documented tracheal sizing over time and did not require surgical intervention were included. Exclusion criteria included tracheal stenosis not caused by complete tracheal rings. Comorbidities and airway characteristics were documented in addition to endoscopic findings. These were compared with children requiring surgical repair. Results In total, 149 patients with complete tracheal rings were identified. Twenty-five had UCTRs for an overall 16.8% rate of conservative management. Nineteen patients met inclusion criteria and underwent a total of 90 microlaryngoscopy and bronchoscopies (MLBs) with sizing. The growth of the UCTRs over time, based on MLB sizing, was chronicled. The median airway growth noted was 0.38 mm/y. A moderately strong positive correlation was seen between age and airway size ( rs = 0.72, P < .0001). Children with UCTRs were less likely to have long-segment involvement than those who required repair (92%, P = .024). Conclusions A select group of children with complete tracheal rings can be managed expectantly without surgical intervention. Conservative management may be less successful in children with long-segment complete tracheal rings. Airway growth does occur in this population and can be monitored over time. Having a standardized method for sizing UCTRs allows for more effective communication between providers and assurance of continued growth of the airway while following these patients.

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Restorative minimally invasive interventions in patients with colostomy

Kazan medical journal ◽

10.17816/kmj2018-1004 ◽

2018 ◽

Vol 99 (6) ◽

pp. 1004-1008

Author(s):

F Sh Akhmetzyanov ◽

N A Valiev ◽

A N Daminov ◽

B Sh Bikbov

Keyword(s):

Surgical Intervention ◽

Surgical Trauma ◽

Distal Stump ◽

Inclusion Criteria ◽

Exclusion Criteria ◽

Intestinal Continuity ◽

Intestinal Stoma ◽

The Right ◽

Medical Indications ◽

Oncology Center

Aim. To show the benefits of performing mini-access restorative phase on the colon in patients with colostomy. Methods. A retrospective analysis of the results of closure stomy operations in 2011-2017 in two emergency cancer departments of Republican Clinical Oncology Center MH RT was conducted. The inclusion criteria of the study were: 1) surgical intervention for acute intestinal obstruction in colorectal cancer performed in RCOC; 2) mandatory removal of the primary tumor during the first surgery; 3) the presence of a functioning intestinal stoma formed during the first surgery; 4) fixation of both stumps in one stoma. The exclusion criteria were refusal to restore the continuity of the colon for medical indications and the patient's refusal to undergo the surgery. Results. The study included 11 males (44 %) and 14 females (56 %). The age interval was 49 to 81 years, of which 12 patients were over 70 years old (48 %), the average age was 67.7 ± 5.4 years. The tumor removed at the first stage was localized in the right parts of the colon in 5 patients (20 %), and in the left in 20 patients (80 %). By the stages of the malignant process, the patients were distributed as follows: stage B - 14 cases (56 %), stage C - 10 (40 %), stage D - 1 (4 %). The average duration of the surgery was 53 ± 14.38 minutes (40 to 123). The postoperative period was 10.8 ± 1.92 days on average (5 to 18). Conclusion. Restoration of intestinal continuity through mini-paracolostomy access is technically rational, as due to the mini-access the patient undergoes minor surgical trauma; the anatomical proximity of the anastomosed bowel stumps excludes the difficulties associated with the search for the distal stump in the traditional method of recovery; the duration of the postoperative hospital stay decreases significantly.

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Conservative Management of Postoperative Chylous Fistula with Octreotide and Peripheral Total Parenteral Nutrition

Ear Nose & Throat Journal ◽

10.1177/014556131709600702 ◽

2017 ◽

Vol 96 (7) ◽

pp. 264-267 ◽

Cited By ~ 6

Author(s):

Jason Y.K. Chan ◽

Eddy W.Y. Wong ◽

S.K. Ng ◽

C. Andrew van Hasselt ◽

Alexander C. Vlantis

Keyword(s):

Parenteral Nutrition ◽

Total Parenteral Nutrition ◽

Neck Dissection ◽

Conservative Management ◽

Surgical Intervention ◽

Case Series ◽

Somatostatin Analogue ◽

Left Neck ◽

Neck Irradiation ◽

Chylous Fistula

Postoperative chylous fistula after neck dissection is an uncommon complication associated with significant patient morbidity. Octreotide acetate is a somatostatin analogue established in the treatment of chylothorax; however, its utility in the management of cervical chylous fistulae has not been fully evaluated. The investigators hypothesized that chylous fistula can be managed by a combination of octreotide and peripheral total parenteral nutrition (TPN). A retrospective review of cases compiled at our institution from 2009 to 2015 was conducted. Ten patients, all men, were identified as having a postoperative chylous fistula after a neck dissection. All patients were treated with peripheral TPN. and intravenous octreotide. Mean age of the patients was 63.0 years (range 49 to 82). Five (50.0%) had a neck dissection for the management of metastatic nasopharyngeal carcinoma and had previous neck irradiation. In 8 (80%) patients, chylous fistula occurred in the left neck. Seven (70.0%) of the leaks occurred within the first 2 postoperative days. Eight (80%) leaks were controlled using TPN and octreotide, with 2 (20%) patients requiring surgical intervention. No factors were significant in the successful conservative management of chylous fistulae. One patient with a chylous fistula of 1,800 ml/day was managed successfully without surgical intervention. The results of this case series suggest that chylous fistulae may be managed conservatively with octreotide and TPN. However, long-term evaluation is needed to define if and when surgical intervention is required for control.

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Conservative Management of Postoperative Chylous Fistula with Octreotide and Peripheral Total Parenteral Nutrition

Ear Nose & Throat Journal ◽

10.1177/014556131709600720 ◽

2017 ◽

Vol 96 (7) ◽

pp. 264-267 ◽

Cited By ~ 1

Author(s):

Jason Y.K. Chan ◽

Eddy W.Y. Wong ◽

S.K. Ng ◽

C. Andrew van Hasselt ◽

Alexander C. Vlantis

Keyword(s):

Parenteral Nutrition ◽

Total Parenteral Nutrition ◽

Neck Dissection ◽

Conservative Management ◽

Surgical Intervention ◽

Case Series ◽

Somatostatin Analogue ◽

Left Neck ◽

Neck Irradiation ◽

Chylous Fistula

Postoperative chylous fistula after neck dissection is an uncommon complication associated with significant patient morbidity. Octreotide acetate is a somatostatin analogue established in the treatment of chylothorax; however, its utility in the management of cervical chylous fistulae has not been fully evaluated. The investigators hypothesized that chylous fistula can be managed by a combination of octreotide and peripheral total parenteral nutrition (TPN). A retrospective review of cases compiled at our institution from 2009 to 2015 was conducted. Ten patients, all men, were identified as having a postoperative chylous fistula after a neck dissection. All patients were treated with peripheral TPN and intravenous octreotide. Mean age of the patients was 63.0 years (range 49 to 82). Five (50.0%) had a neck dissection for the management of metastatic nasopharyngeal carcinoma and had previous neck irradiation. In 8 (80%) patients, chylous fistula occurred in the left neck. Seven (70.0%) of the leaks occurred within the first 2 postoperative days. Eight (80%) leaks were controlled using TPN and octreotide, with 2 (20%) patients requiring surgical intervention. No factors were significant in the successful conservative management of chylous fistulae. One patient with a chylous fistula of 1,800 ml/day was managed successfully without surgical intervention. The results of this case series suggest that chylous fistulae may be managed conservatively with octreotide and TPN. However, long-term evaluation is needed to define if and when surgical intervention is required for control.

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DOZ047.42: The value of rigid tracheobronchoscopy for the diagnosis of tracheomalacia in esophageal atresia patients

Diseases of the Esophagus ◽

10.1093/dote/doz047.42 ◽

2019 ◽

Vol 32 (Supplement_1) ◽

Author(s):

I P Aanen ◽

B Pullens ◽

J van Rosmalen ◽

R M H Wijnen

Keyword(s):

Sensitivity And Specificity ◽

Esophageal Atresia ◽

Surgical Intervention ◽

Medical Center ◽

Primary Repair ◽

Demographic Data ◽

P Value ◽

Inclusion Criteria ◽

Exclusion Criteria ◽

Low Sensitivity

Abstract Aim of the Study The aim of this study is to evaluate routine airway endoscopy prior to the closure of the trachea-esophageal fistula (TOF) and esophageal atresia (EA) repair in a tertiary medical center concerning pre- and postoperative tracheomalacia. Methods We evaluated all patients with EA born between 2013 and 2016 who underwent routine rigid tracheobronchoscopy (TBS) before primary repair of the EA at our center. Inclusion criteria included peroperative rigid TBS performed by an otolaryngologist. Exclusion criteria included impossibility to determine pre- and or postoperative TM (because of logistic or medical reasons). Demographic data, comorbidities, surgical intervention, TBS findings, and subsequent surgical management were analyzed. Main Results Twenty-four patients with EA were included in this study. Eight of the 24 patients developed postoperative TM. Of these 8 patients with TM, 5 were diagnosed at the preoperative TBS (62.5%). Of the 16 patients without postoperative TM, there were 6 patients (37.5%) with peroperative diagnosed TM. So the sensitivity and specificity of routine airway endoscopy prior to EA-repair are, respectively, 62.5% (CI 30.4%–86.5%) and 62.5% (CI 38.5%–81.6%). Concerning postoperative TM, there is a significant higher appearance in females versus males (P-value 0.021). There was no significant causality between mean gestational age, birth weight, type of EA, type of surgery (open or thoracoscopic), presence of gastroesophageal reflux disease, and the appearance of postoperative TM. Conclusions Preoperative TBS can be useful for the evaluation of tracheoesophageal fistula but has a low sensitivity and specificity to detect postoperative TM.

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EPID-14. OCCURRENCE OF SYSTEMIC CANCER IN PATIENTS WITH OLIGODENDROGLIOMAS: POPULATION CHARACTERIZATION AND COMPLICATIONS

Neuro-Oncology ◽

10.1093/neuonc/noz175.314 ◽

2019 ◽

Vol 21 (Supplement_6) ◽

pp. vi77-vi77

Author(s):

Erika Horta ◽

James Snyder ◽

Tobias Walbert

Keyword(s):

Chart Review ◽

Statistical Significance ◽

Histological Diagnosis ◽

Anaplastic Oligodendroglioma ◽

Inclusion Criteria ◽

Gynecological Cancers ◽

Exclusion Criteria ◽

Genetic Syndrome ◽

Prior Chemotherapy

Abstract Following clinic observations of patients with the diagnosis of oligodendroglioma and a systemic cancer, a chart review was done to understand the possible complications that a systemic cancer might bring to the treatment of the patient. Inclusion criteria was histological diagnosis of diffuse or anaplastic oligodendroglioma and another non-skin systemic cancer. Exclusion criteria was the diagnosis of genetic syndrome that predispose tumorigenesis. A total of 12 patients and 13 cancers were identified. 1p19q co-delection information was available for all patients except for 2. The most common systemic cancers were breast (46%) and gynecological cancers (16%). Different from CBTRUS data, men were underrepresented, being 31% of the patients, but difference did not reach statistical significance (p =0.08). Regarding age, patients were older than expected (53 + 12 years old, p< 0.0001). Systemic cancer was diagnosed after the oligodendroglioma diagnosis in 54% of the cases. Age at the diagnosis of systemic cancer was 54 + 10 years old. All patients are alive, except for two. Thromboembolism was seen in 25% of the patients (p=0.2 when comparing with literature for oligodendroglioma), and occurred always after the oligodendroglioma diagnosis. Thrombocytopenia was not associated to prior chemotherapy. No deviation of glioma treatment was seen. This chart review of patients with Oligodendroglioma and a systemic cancer identifies that this population is older than expected and thromboembolism rates are similar to the literature. The overrepresentation of women in this cohort represents the profile of systemic cancer that accompanied oligodendrogliomas. It is unclear why breast and other gynecological cancers were the most common. Further studies, likely multicentric due to the rarity of this diagnosis, as further research in large repository data should be performed to confirm this finding.

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Characteristics of Anterior Lens Opacities in Children

The Open Ophthalmology Journal ◽

10.2174/1874364101711010084 ◽

2017 ◽

Vol 11 (1) ◽

pp. 84-88 ◽

Cited By ~ 2

Author(s):

Lena Dixit ◽

Michael Puente ◽

Kimberly G. Yen

Keyword(s):

High Frequency ◽

Chart Review ◽

Pediatric Patients ◽

Surgical Intervention ◽

Retrospective Chart Review ◽

Common Type ◽

Lens Opacities ◽

Polar Type ◽

Over Time ◽

Systemic Associations

Background: Anterior lens opacities (ALO) are found in 3-14% of pediatric patients with cataracts. No clear guidelines exist in the management and treatment of these cataracts. Objective: To evaluate pediatric patients with anterior lens opacities and assess rate of amblyopia and need for surgery over time. Methods: A retrospective chart review was performed on patients with unilateral and bilateral anterior lens opacities (ALOs) seen between January 2008 and December 2014. Size, location, and type of ALO were noted. Refractive error, necessity for treatment of amblyopia, and interventions were recorded. Results: A total of 31 patients were included in the study. 17 patients had unilateral ALOs and 14 had bilateral ALOs. The majority of the cataracts (90.3%) were centrally located. The most common type of cataract was the polar type of cataract and the vast majority (48.4%) was < 1mm in size. 38.7% of patients had concurrent ocular conditions and 9.7% had systemic associations. 28.6% of patients with bilateral cataracts and 35.3% of the patients with unilateral cataracts were treated for amblyopia. Three patients required cataract surgery. Conclusion: About half of anterior lens opacities are less than 1mm in size and the majority are of the polar type. Risk of amblyopia in these patients is higher than in the general population. Anisometropia is the most common cause of amblyopia. Ocular associations are seen at a relatively high frequency and systemic associations can occur but are uncommon. The need for surgical intervention is infrequent; however, growth of ALOs and associated cortical changes may be risk factors for surgery.

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Arytenoid prolapse: A source of obstruction following laryngotracheoplasty

Otolaryngology ◽

10.1016/j.otohns.2009.01.002 ◽

2009 ◽

Vol 140 (5) ◽

pp. 752-756 ◽

Cited By ~ 7

Author(s):

Catherine K. Hart ◽

Gresham T. Richter ◽

Robin T. Cotton ◽

Michael J. Rutter

Keyword(s):

Airway Obstruction ◽

Sleep Disordered Breathing ◽

Chart Review ◽

Surgical Intervention ◽

Case Series ◽

Upper Airway ◽

Common Features ◽

Potential Source ◽

Design Case ◽

Second Procedure

Objective: Arytenoid prolapse is a potential source of upper airway obstruction following laryngotracheoplasty, and may be difficult to identify. We explored the incidence, clinical features, etiology, and surgical approach to patients with arytenoid prolapse following laryngotracheoplasty. Study Design: Case series with chart review. Subjects and Methods: The charts of 93 patients diagnosed with arytenoid prolapse following laryngotracheoplasty from 1981 to 2007 were reviewed. Results: The incidence was 5.7 percent (93/1634). Forty-nine patients had unilateral prolapse; 44 had bilateral prolapse. Average time from laryngotracheoplasty to presentation was 36.8 months. Common symptoms were dyspnea on exertion, tracheostomy dependence, and sleep-disordered breathing. Fifty-four patients (58%) required surgical intervention, with arytenoid reduction performed in 45 patients. Nine underwent reduction during revision laryngotracheoplasty or cricotracheal resection. Fourteen patients required a second procedure for persistent prolapse. Thirty-nine (42%) required no intervention. Symptom resolution or decannulation was achieved in all patients in whom prolapse was the source of obstruction. Statistically significant differences were found when anterior vs posterior graft utilization was compared. Conclusions: Arytenoid prolapse is a cause of airway obstruction following laryngotracheoplasty. Subtle airway complaints and decannulation failures are common features. Both endoscopic and open procedures can successfully treat arytenoid prolapse. Potential etiologies are discussed.

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Optic Nerve Sheath Decompression

Surgery of the Eyelid, Lacrimal System, and Orbit ◽

10.1093/oso/9780195340211.003.0027 ◽

2011 ◽

Author(s):

Thomas N. Hwang ◽

Timothy J. McCulley

Keyword(s):

Optic Nerve ◽

Intracranial Pressure ◽

Conservative Management ◽

Weight Control ◽

Visual Loss ◽

Surgical Intervention ◽

Case Series ◽

Optic Nerve Sheath ◽

Nerve Sheath ◽

Csf Shunting

Optic nerve sheath decompression (ONSD) or fenestration refers to a surgical technique that creates a window through the dural and arachnoid meningeal layers of the retrobulbar optic nerve sheath to release pressure on the optic nerve. ONSD for treatment of visual loss secondary to refractory papilledema was first described by DeWecker in 1872. Later that century, Carter and Müller published the second case series of optic nerve sheath fenestrations. However, despite these and several additional reports, the clinical benefit of performing this procedure was still questioned. In addition, alternative cerebrospinal shunting procedures were developed for patients with increased intracranial pressure. Renewed interest arose in 1964 when Hayreh demonstrated the effectiveness of ONSD in relieving experimental papilledema in rhesus monkeys. Various supporting clinical publications have since followed, starting with Smith, Hoyt, and Newton’s description in 1969 of relief of chronic papilledema by ONSD. Surgical intervention is considered for patients with progressive visual loss secondary to elevated intracranial pressure (ICP) in whom conservative management, such as medications (acetazolamide and furosemide) and weight control, has failed. Occasionally surgery is used primarily in patients whose visual function has already reached a critical level. Examples include patients in whom vision has declined to a disabling level in hopes that rapid papilledema resolution will result in some visual return. Surgery is also considered primarily in those with little remaining vision, in whom any further visual loss would carry substantial functional impact should conservative management fail. Once surgical intervention is deemed necessary, ONSD is one of several options. Cerebrospinal fluid (CSF) shunting in the form of ventricular–peritoneal (VP) or lumbar–peritoneal (LP) shunting can be considered. A deciding factor for some is the presence of headache, which is more effectively managed with VP or LP shunting. Comparative trials of ONSD and other CSF shunting procedures are lacking. Consequently, some medical centers opt for ONSD as the first-line surgical option, while others recommend alternative shunting procedures. At present, the only uniformly accepted therapeutic indication for ONSD is management of visual loss related to elevated ICP. The most common setting for ONSD is idiopathic intracranial hypertension.

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EPID-27. OCCURRENCE OF SYSTEMIC CANCER IN PATIENTS WITH ASTROCYTOMA: POPULATION CHARACTERIZATION AND COMPLICATIONS

Neuro-Oncology ◽

10.1093/neuonc/noz175.327 ◽

2019 ◽

Vol 21 (Supplement_6) ◽

pp. vi80-vi80

Author(s):

Erika Horta ◽

James Snyder ◽

Tobias Walbert

Keyword(s):

Breast Cancer ◽

Cancer Diagnosis ◽

Anaplastic Astrocytoma ◽

Chart Review ◽

Histological Diagnosis ◽

Second Cancer ◽

Inclusion Criteria ◽

Exclusion Criteria ◽

Genetic Syndrome ◽

Prior Chemotherapy

Abstract It is unclear how the diagnosis of a second cancer influences the treatment and complications of patients with astrocytoma. A chart review of patients with astrocytoma and a second systemic cancer was performed to understand the possible complications that a systemic cancer diagnosis might bring to the treatment of the patient. Inclusion criteria was the histological diagnosis of diffuse or anaplastic astrocytoma and another non-skin systemic cancer. Exclusion criteria was the diagnosis of any genetic syndrome that predisposes tumorigenesis. A total of 17 patients were identified. The most common systemic cancer was thyroid (22) followed by colon and breast cancer (each one 17%). Men were 59% of the patients (p= 0.38), but older (60 +14 years, p=0.003) when compared to CBTRUS data. Systemic cancer was diagnosed before astrocytoma in 61% of the cases. Age at the diagnosis of systemic cancer was 48 +14 years. Only 9% of the patients who had systemic cancer before astrocytomas survived 5 years, what is less than expected when compared with literature, (p=0.02). Those also survived less than the patients that had systemic cancer after the diagnosis of astrocytomas (8.1+6.4 years). Thromboembolism was seen in 12.5% (p=0.8), always after the astrocytoma diagnosis. Thrombocytopenia was not related to prior chemotherapy. In patients with systemic cancer diagnosed while on treatment for astrocytoma, a delay or shortened course of the treatment was seen in rare cases, and one patient had their course of treatment for astrocytoma shortened. The conclusion of this chart review of patients with the diagnosis of astrocytoma and a systemic cancer identifies that this population is older than expected and the diagnosis of systemic cancer before astrocytoma might predict a shorter survival.

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Epidemiological Assessment of GI BioFire Negative Tests at Parkview Health

Proceedings of IMPRS ◽

10.18060/23573 ◽

2019 ◽

Vol 2 (1) ◽

Author(s):

Brycen Ratcliffe, B.S. ◽

Candace Rodgers, R.N. ◽

R. Scott Stienecker, M.D.

Keyword(s):

Chart Review ◽

Retrospective Chart Review ◽

Cost Effective ◽

Inclusion Criteria ◽

Exclusion Criteria ◽

Negative Results ◽

Gastrointestinal Pathogens ◽

Potential Impact ◽

Antigen Testing ◽

Positive Results

Background and Hypothesis: With advances in multiplex PCR testing, many gastrointestinal pathogens can be identified in about an hour and provide 23% increased yield of pathogens (Beatty et al., 2016). At our facility, 60.4% of these samples return with no microorganisms found. This study implemented diagnostic stewardship principles by evaluating the negative GI BioFire multiplex results and ordering patterns of providers at Parkview Health. Design: This retrospective chart review of 300 negative GI BioFire results from 2018 pulled demographics and records from Parkview LIS and EPIC software. Inclusion Criteria: negative gastrointestinal BioFire results. Exclusion Criteria: positive results, negative results outside the study period, any patient data not admitted at Parkview Health. Results: 57.0% of patients had diarrhea-associated co-morbidities. 14.3% had redundant tests. 51.0% were administered laxatives, 72.3% were administered antibiotics. 73.4% did not follow ACG guidelines stating diarrhea must have persisted longer than seven days. 79.3% had laxatives concurrently administered or did not follow ACG guidelines. 19.7% had endoscopic procedures within eight weeks of assay testing. 14.4% of providers documented a non-C Diff suspicion when ordering assay. 18.9% had non-reported diarrhea consistency. 45.9% were hospitalists, 5.5% were surgeons, and 17.9% were infectious disease or gastroenterologists. 78.3% had at least one C-Diff diarrhea risk factor. Conclusion and Potential Impact: This data suggests using appropriate algorithms for GI BioFire and utilizing C-Diff antigen testing is more cost effective and should be used before GI BioFire for those with risk factors. Following ACG guidelines, and deferring those administered laxatives would remove over three-quarters of negative panels. Documentation of stool consistency, volume and suspicious etiologies are essential to furthering diagnostic stewardship. These recommendations will save approximately $1,036,399 after consideration for C-Diff antigen testing replacement per year for Parkview Health.

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