Surgical strategy for squamous cell carcinoma of the external auditory canal: management of locally advanced cases with skull base involvement

Objective Surgical indications for advanced-stage squamous cell carcinoma (SCC) of the external auditory canal (EAC) are highly dependent on the skull base surgery team. The aim of this study was to evaluate the surgical outcomes in patients with SCC of the EAC and to clarify the surgical indication of far advanced cases using the T4-subclassification. Methods Patients with SCC of the EAC who underwent curative treatment from 2002-2021 were retrospectively reviewed at our hospital. Clinical and surgical results, including operative data, overall survival (OS), and disease-specific survival (DSS) were analyzed. To clarify the surgical indication for advanced stage, we proposed the T4-subclassification. Results In 46 patients, the tumors were in T1 stage in 8 patients, T2 in 10, T3 in 5, and T4 in 23. The 5-year DSS with T1, T2, T3, and T4 tumors were 100%, 85.7%, 100%, and 61.7%, respectively. No prognostic impacts for margin status were found between the 5-year OS and DSS (p = 0.23 and p = 0.13). Patients with far advanced stage (T4b) tumors were significantly associated with shorter DSS than those with early stage (T1/T2) and advanced stage (T3/T4a) tumors (p = 0.007 and p = 0.03). Conclusion The present study focused on patients with SCC of the EAC at a University hospital over a period of 20-years, especially with skull base involvement, and a T4-subclassification was proposed. Complete tumor resection in an en bloc fashion could help to achieve a good survival rate even in patients with locally advanced tumors.

INSULINOMA AND METABOLIC URGENCY CASE REPORT

Insulinoma is a rare neuroendocrine tumor, occurring almost exclusively in the pancreas. Most often unique and benign in 90% of cases. Usually sporadic, 10% of lesions become part of type 1 multiple endocrine neoplasia. The main manifestation of insulinoma is hypoglycemia, which is a life-threatening metabolic emergency. The hypoglycemia occurring in this context are particularly serious and frequent with sometimes harmful cerebral consequences. Topographic diagnosis remains difficult due to the small size of the lesions justifying the importance of the preoperative imaging required for the location of the tumor. Enucleation is the surgical indication of choice in the presence of a sporadic insulinoma that is presumably benign. Pathological and immunohistochemical examination confirms the diagnosis of neuroendocrine tumor. Our observation is particular by the circumstances of discovery of the insulinoma, the severe nature of the symptoms.

Does Sleeve Gastrectomy Worsen Gastroesophageal Reflux Disease in Obese Patients? A Prospective Study

Background To evaluate the impact of laparoscopic sleeve gastrectomy (LSG) and gastric bypass (LGB) on gastroesophageal reflux disease (GERD). Methods GERD was evaluated by the Modified Italian Gastroesophageal reflux disease—Health-Related Quality of Life (MI-GERD-HRQL) questionnaire, pH-manometry, endoscopy, and Rx-esophagogram, before and 12 months after surgery. Based on these exams, patients without GERD underwent LSG, and patients with GERD underwent LGB. Results Thirteen and six patients underwent LSG and LGB, respectively. After LSG, the only statistically significant difference observed at pH-manometry was the median DeMeester score, from 5.7 to 22.7 (P = .0026). De novo GERD occurred in 6 patients (46.2%), with erosive esophagitis in one. The median MI-GERD-HRQL score improved from 3 to 0. Overall, nine patients underwent LGB, but three were lost to follow-up. Preoperative pH-manometry changed the surgical indication from LSG to LGB in 7 out of 9 patients (77.8%). Six patients who underwent LGB completed the study, and at pH-manometry, statistically significant differences were observed in the percentage of total acid exposure time, with the number of reflux episodes lasting >5 minutes and DeMeester score (P = .009). The median MI-GERD-HRQL score improved from 6.5 to 0. Statistically significant differences were not observed at endoscopy and Rx-esophagogram findings in both groups. Conclusions LSG has a negative impact on GERD, even in patients without preoperative GERD. LGB confirmed to be the intervention of choice in patients with GERD. Preoperative pH-manometry may identify patients with silent GERD, to candidate them to LGB rather than LSG. pH-manometry should be used more liberally to establish the correct surgical indication on objective grounds.

PP184 Twenty Years of Health Technology Assessments on Robotic Assisted Surgery: A Summary

IntroductionDa Vinci robotic-assisted surgery (RAS) has been evaluated by health technology assessment (HTA) organizations across the world. This study aimed to analyze the existing HTA reports over years, countries, and procedures.MethodsPublicly available health technology appraisal reports on RAS published from January 2000 to November 2020 were identified via a targeted literature search. The literature search was conducted in PubMed, the Centre for Reviews and Dissemination database, the International Network of Agencies for Health Technology Assessment database, and Google scholar. Reports related to the da Vinci RAS were included. Full texts of reports were used for the analysis.For the HTAs that recommended RAS, the directional conclusion was considered as positive. For HTA reports that discouraged the use of RAS, the directional conclusion was considered as negative. The rest were considered as neutral. The reports were analyzed by year, country, and procedure.ResultsWe identified 65 HTA reports comprising 128 procedure-level assessments of RAS by 42 HTA organizations in 21 countries over 20 years. The annual number of assessments increased over time. The countries that completed the most assessments were Sweden (14 reports, including 15 procedure-level assessments: 13% positive and 80% neutral) and Canada (11 reports, including 20 procedure-level assessments: 65% positive).The topics of the assessments covered 27 surgical indications in urology, gynecology, thoracic, general, and ear, nose, and throat. The conclusions of the HTAs varied by surgical indication. Prostatectomy (33 reports: 85% neutral or positive) was the most widely assessed surgical indication, followed by hysterectomy (16 reports: 81% neutral or positive), nephrectomy (15 reports: 73% neutral or positive), and rectal resection (10 reports: 100% neutral or positive).ConclusionsThe number and breadth of HTAs on RAS have grown at an increasing rate over the last 20 years. The directional conclusion of assessments varied by procedure and country. Further analysis is warranted to understand the factors contributing to HTA conclusions on RAS.

Clinical Significance and Prognostic Value of Hemostasis Parameters in 337 Patients with Acute Infective Endocarditis

(1) Background: The aim of this study was to assess the clinical significance and prognostic role of the main hemostasis parameters in infective endocarditis (IE): prothrombin time as international normalized ratio (PT-INR), activated partial thromboplastin time (aPTT), fibrinogen, D-dimers, platelet count, homocysteine. (2) Methods: We studied 337 patients with IE. Clinical, hemato-chemical and echocardiography parameters were analyzed. Coagulation parameters were measured on admission. (3) Results: D-dimers levels (p = 0.012) and a prolonged PT-INR (p = 0.013) were associated with higher in-hospital mortality, while prolonged aPTT (p = 0.021) was associated with increased 1-year mortality. Staphylococcus aureus (S. aureus) infection (p = 0.003), prosthetic valve endocarditis (PVE) (p = 0.001), surgical indication (p = 0.002) and higher D-dimer levels (p = 0.005) were independent predictors of in-hospital mortality. PVE (p = 0.001), a higher Charlson Comorbidity Index (p = 0.049), surgical indication (p = 0.001) and prolonged aPTT (p = 0.012) were independent predictors of 1-year mortality. Higher levels of D-dimers (p < 0.001) and a shorter aPTT (p < 0.001) were associated with embolic complications of IE. S. aureus etiology was bound to higher D-dimers levels (p < 0.001) and a shorter aPTT (p = 0.006). (4) Conclusions: Elevated D-dimers are associated with a higher risk for in-hospital mortality in IE patients. High D-dimers and a short aPTT are associated with a higher risk for embolic events in IE. A longer aPTT is associated with 1-year mortality.

Health insurance policy on surgical treatment of adult spinal deformity

Background: Recent burgeoning research on adult spinal deformity (ASD) has unveiled the benefits of surgical treatment and how to gain the benefits although these have only been around for 10 years.Current Concepts: During the last decade, the significance of pelvic incidence in the global spinal sagittal alignment and introductions of the Scoliosis Research Society-Schwab classification for ASD have been the guidelines of surgical treatment for ASD and the milestones for promising surgical results. However, one of the unsolved problems for the surgical treatment of ASD is the proximal junctional kyphosis, for which multifactorial causative factors have been suggested. Recent studies have focused on dynamic natures in patients with ASD during daily activities, which might be a clue for both prevention of proximal junctional kyphosis and a better level of surgical results. Even though a recent remarkable advancement for surgical treatment for ASD is present, the national guideline for reimbursement is still following the surgical indication for lumbar degenerative kyphosis published in 1988.Discussion and Conclusion: A significant gap exists between the national reimbursement guideline and generally held surgical indication for ASD surgery. Consequently, this huge gap raises trouble in both patients and surgeons. The patients with ASD cannot take an appropriate surgery for ASD, while the spine surgeons experience unreasonable adjustment of the cost by the Health Insurance Review and Assessment Service.