Outcomes of intubation in difficult airways due to head and neck pathology.

The purpose of this study was to examine the impact of surgical pathology, anesthesiologist experience, and airway technique on surgically relevant outcomes in patients identified by preoperative laryngoscopy to have a difficult airway due to head and neck pathology. We prospectively recorded a series of 152 difficult airway cases due to head and neck pathology out of 2,145 direct laryngoscopies undertaken between November 2005 and June 2008. One of two senior anesthesiologists specializing in head and neck procedures intubated 101 (66.4%) of the 152 patients and did so 3.3 minutes faster (p = 0.51), with better oxygenation (87.3 vs. 81.8%; p = 0.02) and fewer airway plan changes (p = 0.001) than did other, nonspecialist anesthesiologists. Predictors of failure of the first intubation plan included: cancer diagnosis (p = 0.02), previous radiotherapy (p = 0.03), and supraglottic lesions (p = 0.03). Glottic/subglottic lesions required the most intubation attempts (p = 0.02). Awake fiberoptic intubation was the most common method used (44.7%) but resulted in a change in the airway plan in 6 cases (8.8%). Gas induction maintained the best oxygenation (p = 0.01). Awake tracheostomy was infrequent (1.3%) and took the longest (p = 0.006). We concluded that difficult airways due to head and neck pathology require teamwork and a backup plan. An anesthesiologist specializing in head and neck procedures may help to avoid adverse outcomes associated with cancer, especially previously irradiated supraglottic/glottic lesions, leading to a less frequent need for awake tracheostomy.

Robotic-assisted surgery for primary or recurrent oropharyngeal carcinoma.

OBJECTIVE: To determine the feasibility of robotic-assisted salvage surgery for oropharyngeal cancer. DESIGN: Retrospective case-controlled study. SETTING: Academic, tertiary referral center. PATIENTS: Patients who underwent surgical resection for T1 and T2 oropharyngeal cancer between 2001 and 2008 were classified into the following 3 groups based on type of resection: (1) robotic-assisted surgery for primary neoplasms (robotic primary) (n = 15), (2) robotic-assisted salvage surgery for recurrent disease (robotic salvage) (n = 7), and (3) open salvage resection for recurrent disease (n = 14). MAIN OUTCOME MEASURES: Data regarding tumor subsite, stage, and prior treatment were evaluated as well as margin status, nodal disease, length of hospital stay, diet, and tracheotomy tube dependence. RESULTS: The median length of stay in the open salvage group was longer (8.2 days) than robotic salvage (5.0 days) (P = .14) and robotic primary (1.5 days) resection groups (P < .001). There was no difference in postoperative diet between robotic primary and robotic salvage surgery groups. However, a greater proportion of patients who underwent open salvage procedures were gastrostomy tube dependent 6 months following treatment (43%) compared with robotic salvage resection (0%) (P = .06). A greater proportion of patients who underwent open salvage procedures also remained tracheotomy tube dependent after 6 months (7%) compared with robotic salvage or robotic primary patients (0%) (P = .48). No complications were reported in the robotic salvage group. Two patients who underwent open salvage resection developed postoperative hematomas and 2 developed wound infections. CONCLUSION: When feasible, robotic-assisted surgery is an acceptable procedure for resection of both primary and recurrent oropharyngeal tumors. Trial Registration clinicaltrials.gov Identifier: NCT00473564.

Anatomy and landmarks for branches of the brachial plexus: a vade mecum.

Exploration and repair of the brachial plexus and its branches demands a good comprehension of its intricate anatomy. To this end, landmarks for identifying this anatomy may prove useful to the clinician and surgeon. As such, a specific collection is lacking in the literature. Therefore, the following review of salient surgical anatomy and regional landmarks of the brachial plexus and its branches is provided. Our hopes are that these data will be useful during clinical and surgical procedures of these regions and act as a single, concise source for such information.

Pulmonary resection after concurrent chemotherapy and high dose (60Gy) radiation for non-small cell lung cancer is safe and may provide increased survival.

BACKGROUND: We have used doses of 60Gy or higher for neoadjuvant chemoradiotherapy for select patients with advanced non-small cell lung cancer (NSCLC), including patients with N2 disease and those with Pancoast lesions, to avoid gaps in radiotherapy in case surgery is ultimately not offered. METHODS: A retrospective cohort study using a prospective database. Patients underwent initial staging with CT, PET/CT and lymph node biopsy (mediastinoscopy, endoscopic esophageal ultrasound and endobronchial ultrasound) and then received neoadjuvant high dose radiotherapy and chemotherapy, followed by thoracotomy with intent to cure. RESULTS: Between January 1998 and June 2008 there were 216 patients who were eligible for this study. The median dose of radiation was 60Gy (range 60-72Gy). Lobectomy was performed in 152 patients (70%) about 7 weeks after radiotherapy finished (mean 51 days, range 34-89 days).The bronchus was buttressed with an intercostal muscle flap in 97% patients. Median hospital stay was 4.5 days (range 2-57). Major morbidity occurred in 17%. There were five (2.3%) deaths. There were no bronchial-pleural fistulas after lobectomy, but two occurred after right pneumonectomy. Predictors of morbidity were FEV(1) <50% (p<0.001), DLCO <60% (p<0.001) and age >75 years (p=0.008). The overall 5-year Kaplan-Meier survival was 34%. It was 42% for those who underwent R0 resection, 38% for those with initial N2 disease and 45% for the 71 complete responders. CONCLUSIONS: Pulmonary resection after high dose (>/=60Gy) neoadjuvant chemoradiotherapy is safe. Lobectomy can be safely performed and bronchopleural fistula prevented. Sixty Gy allows for maximal medical therapy in case resection is not offered. Since complete response rates may be higher than when 45Gy is used and since surgery is safe, its use deserves further investigation.

Anatomy and biomechanics of the vertebral aponeurosis part of the posterior layer of the thoracolumbar fascia.

There is significant paucity in the literature regarding vertebral aponeurosis. We were able to find only a few descriptions of this specific fascia in the extant medical literature. To elucidate further the anatomy of this structure, forty adult human cadavers were dissected. Both quantitation and anatomical observations were made of the vertebral aponeurosis. The vertebral aponeurosis was identified in 100% of specimens. This fascia was identified as a thin fibrous layer consisting of longitudinal and transverse connective tissue fibers blended together deep to the latissimus dorsi muscle. It attached medially to the spinous processes of the of the thoracic vertebrae; laterally to the angles of ribs; inferiorly to the fascia covering the serratus posterior inferior muscle (superficial lamina of the posterior layer of thoracolumbar fascia); superiorly it ran deep to the serratus posterior superior and splenius capitis muscles to blend with the deep fascia of the neck. At the level of the serratus posterior inferior muscle, the vertebral aponeurosis fused to form a continuous layer descending toward the sacrotuberous ligament covering the erector spinae muscle. Morphometrically, the mean length of the vertebral aponeurosis was 38 cm and the mean width was 24 cm. The mean thickness was three mm. There was no significant difference between left and right sides, gender or age with regard to vertebral aponeurosis length, width, or thickness (P > 0.05). During manual tension of the vertebral aponeurosis, the tensile force necessary for failure had a mean of 38.7 N. In all specimens, the vertebral aponeurosis was capable of holding sutures placed through its substance. We hope that these data will be of use for descriptive purposes and may potentially add to our understanding of the biomechanics involved in movements of the back. As back pain is perhaps the most common reason patients visit their physicians, additional knowledge of this anatomical region is important.