Endoscopic repeat isolated tricuspid valve surgery after left-sided valve replacement: valvuloplasty or replacement.

BACKGROUND: The strategy of isolated tricuspid valve surgery has undergone innovations in recent years. This study aimed to summarize our experience using an endoscopic approach to repeat isolated tricuspid valve surgery (RITS) after left-sided valve replacement (LSVR). METHODS: From June 2013 to May 2019, 79 patients underwent endoscopic RITS after LSVR at our institution. Patients were divided into the tricuspid valvuloplasty (TVP) group (N.=49) and the tricuspid valve replacement (TVR) group (N.=30); perioperative outcomes and follow-up results were compared. RESULTS: There were seven postoperative deaths (8.9%). In-hospital mortality was higher in the TVR group than in the TVP group, although this difference was not statistically significant (13.3% vs. 6.1%, P=0.417). More patients experienced residual moderate-to-severe tricuspid regurgitation (TR) at discharge in the TVP group than in the TVR group (26.7% vs. 0%, P=0.003). Five patients died from heart, and multiorgan failure during follow-up; the overall 3- and 5-year survival rates were 93.8% [95% confidence interval (CI): (87.1-99.9%)] and 85.3% (95% CI: 73.3-99.2%), respectively, and no significant differences were found between the two groups (P=0.103). The overall rates of the 3- and 5-year freedom from severe recurrent TR were 93.2% (95% CI: 85.9-99.9%) and 89.0% (78.7-99.9%), respectively, and no significant difference was found between groups (P=0.176). CONCLUSIONS: Repeat isolated tricuspid valve surgery after left-sided valve replacement is associated with adverse perioperative outcomes. Endoscopic access offers an alternative approach for RITS after LSVR with acceptable results. TVP results in lower surgical mortality than TVR while carrying a higher risk of residual moderate-to-severe TR.

In patients undergoing coronary artery bypass grafting, is endoscopic harvesting superior to open radial artery harvesting?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'In patients undergoing coronary artery bypass grafting, is endoscopic radial artery harvesting (ERAH) superior to open radial artery harvesting in terms of postoperative complications, mortality, graft quality and patency rates?'. Altogether 130 papers were found using the reported search, of which 5 represented the best evidence to answer the clinical question. Two studies were meta-analyses and 3 were randomized trials. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. In terms of graft quality, 2 randomized studies showed preserved endothelial integrity and vasoreactivity with ERAH, whereas 1 randomized study found superior endothelial function with open radial artery harvesting. Importantly, 3 studies showed graft patency was not compromised with ERAH. One meta-analysis reported no differences in graft patency between groups at 1 year [odds ratio (OR) 1.24] and up to 3-5-years follow-up (OR 1.81), as well as similar perioperative myocardial infarction rates (OR 0.80). Two meta-analyses found similar mortality in the perioperative period (OR 0.62-0.78) and up to 5 years (OR 0.64-0.67); ERAH reduced the incidence of perioperative wound complications (P-values 0.001-0.03); however, harvest times were increased with ERAH (P < 0.0005). We conclude that ERAH is non-inferior to open radial artery harvesting in terms of mortality, graft quality and patency rates, but superior in terms of reducing perioperative wound complications, with good cosmetic effect. However, these benefits come at the cost of increased harvesting time.

Radial artery harvesting in coronary artery bypass grafting surgery-Endoscopic or open method? A meta-analysis.

We analyzed the clinical outcomes of open radial artery harvesting (OAH) and endoscopic radial artery harvesting (EAH) undergoing coronary artery bypass grafting (CABG). We designed this meta-analysis conducted using Pubmed, Medline, the Cochrane Library, and EMBASE. Articles with comparisons of OAH and EAH undergoing CABG were included. Primary outcomes included the wound infection rate, the wound complication rate, neurological complications of the forearm, in-hospital mortality, long-term survival, and the patency rate. The results of our study included six randomized controlled trials (RCTs), two non-randomized controlled trials (NRCTs) with matching, and 10 NRCTs. In total, 2919 patients were included in 18 studies, while 1187 (40.7%) and 1732 (59.3%) patients received EAH and OAH, respectively. EAH was associated with a lower incidence of wound infection (RR = 0.29, 95% confidence interval (CI) = 0.14 to 0.60, p = 0.03), and neurological complications over the harvesting site (RR = 0.41, 95% CI = 0.27 to 0.62, p < 0.0001). There was no significant difference in 30-day mortality, long-term survival (over one year), and the graft patency rate. According to our analysis, endoscopic radial artery harvesting can improve the outcome of the harvesting site, without affecting the mortality, long-term survival, and graft patency.

Prognostic evaluation of serum long non-coding RNA H19 for endoscopic keyhole surgery or craniotomy in glioma.

BACKGROUND: Our study aims to explore the effect of serum long non-coding RNA (lncRNA) H19 level on the long-term prognosis of endoscopic keyhole surgery or craniotomy for glioma. METHODS: A total of 264 glioma patients were selected. Patients were randomly divided into the Craniotomy-high H19 group, the Craniotomy-low H19 group, the Endoscopic keyhole surgery-high H19 group and the Endoscopic keyhole surgery-low H19 group. RESULTS: Compared with adjacent tissues (5.19 ± 1.42), H19 level in cancer tissues (7.45 ± 1.60) and serum (6.44 ± 1.57) was significantly increased (P < 0.05). Compared with serum, H19 level in cancer tissues was significantly increased (P < 0.05). Pearson correlation analysis found that the relative expression level of serum H19 in glioma patients was positively correlated with cancer tissues (rPearson = 0.547, P < 0.001), but had no significant correlation with adjacent tissues (rPearson = 0.126, P = 0.207). The expression of H19 in serum was significantly related to WHO grade (rPearson = 0.514, P < 0.001). Compared with the Endoscopic keyhole surgery-high H19 group and the Endoscopic keyhole surgery-low H19 group, the survival rate of patients in the Craniotomy-high H19 group (χ2 = 17.115 and log-rank P < 0.001; χ2 = 18.406 and log-rank P < 0.001) and the Craniotomy-low H19 group was significantly reduced (χ2 = 15.007 and log-rank P < 0.001; χ2 = 16.121 and log-rank P < 0.001). Cox regression results showed that serum H19 level, craniotomy and WHO grade were risk factors for glioma. When H19 level was lower than 6.28, the 30-month survival rate of patients with the endoscopic keyhole surgery was 100%. CONCLUSION: For patients with low H19 level (<5.36), both endoscopic keyhole surgery and craniotomy are available, otherwise, endoscopic keyhole surgery is more recommended.

Outcomes of sinonasal mucosal melanomas with endoscopic and open resection: a retrospective cohort study.

PURPOSE: To compare the outcomes of Sinonasal Mucosal Melanomas (SNMM) treated with endoscopic and open resection. METHODS: A retrospective case review of 20 patients with SNMM treated surgically at UCSF. Kaplan-Meier analyses were calculated to determine outcome differences in endoscopic vs. open resections. RESULTS: From 2005 to 2014, 20 cases of SNMM were confirmed and treated at UCSF. All cases underwent surgical resection, with 10 cases by open resection and 10 cases by endoscopic resection. Using Kaplan-Meier analyses, the open resection group had a 1-year survival of 30% whereas endoscopic resection group was 80% (p = 0.032). Endoscopic resection showed improved survival at all time points after surgery compared to open resection. CONCLUSION: SNMM is a rare and aggressive tumor that is associated with low survival rates. In this small case series, endoscopic resection had improved survival outcomes compared to open resection.

Second-look endoscopy-guided therapy under sedation prevents early rebleeding after variceal ligation for acute variceal bleeding.

OBJECTIVES: To investigate whether second-look endoscopy (SLE)-guided therapy could be used to prevent post-endoscopic variceal ligation (EVL) early bleeding. METHODS: Consecutive cirrhotic patients with large esophageal varices (EV) receiving successful EVL for acute variceal bleeding (AVB) or secondary prophylaxis were enrolled. The patients were randomized into a SLE group and a non-SLE group (NSLE) 10 days after EVL. Additional endoscopic interventions as well as proton pump inhibitors and octreotide administration were applied based on the SLE findings. The post-EVL early rebleeding and mortality rates were compared between the two groups. RESULTS: A total of 252 patients were included in the final analysis. Post-EVL early rebleeding (13.5% vs 4.8%, P = 0.016) and bleeding-caused mortality (4.8% vs 0%, P = 0.013) were more frequently observed in the NSLE group than in the SLE group. However, post-EVL early rebleeding and mortality rates were reduced by SLE in patients receiving EVL for AVB only but not in those receiving secondary prophylaxis. Patients with Child-Pugh classification B to C at randomization (hazard ratio [HR] 8.77, P = 0.034), AVB at index EVL (HR 3.62, P = 0.003), discontinuation of non-selective ß-blocker after randomization (HR 4.68, P = 0.001) and non-SLE (HR 2.63, P = 0.046) were more likely to have post-EVL early rebleeding. No serious adverse events occurred during SLE. CONCLUSION: SLE-guided therapy reduces post-EVL early rebleeding and mortality rates in cirrhotic patients with large EV receiving EVL for AVB.

Endoscopic Tricuspid Valve Surgery is a Safe and Effective Option.

OBJECTIVE: Isolated tricuspid surgery through median sternotomy can be associated with a high morbidity and mortality. Reports of minimally invasive isolated tricuspid valve operations are rare, but the outcomes are encouraging. We present our experience of endoscopic isolated tricuspid valve surgery. METHODS: In our institution, 452 patients underwent endoscopic minimal access cardiac surgery between August 2008 and December 2018. A total of 90 patients underwent tricuspid valve surgery whether isolated or with other cardiac procedure. We further selected patients who had isolated tricuspid valve surgery (n = 24). Of these patients, 13 (54%) had more than one previous sternotomy. RESULTS: Tricuspid repair was performed in 18 patients (75%) with the remaining 6 (25%) having bioprosthetic tricuspid replacement. Three (12.5%) were performed with a beating heart, the remaining with endoaortic clamping and cardioplegia. There were no conversions to sternotomy. None of the patients had reoperation for bleeding, tamponade, or valve issues. Three patients (12.5%) required blood transfusion, 3 patients (12.5%) required renal dialysis, and 7 patients (29%) had respiratory complications such as chest infection, requiring continuous positive airway pressure (CPAP) with 2 being re-intubated. One patient (4.1%) died within 30 days from chest sepsis leading to multi-organ failure. Mean hospital stay was 11.1 ± 8.9 days (median of 8). All patients had mild or less regurgitation on follow-up echo at 6 months. CONCLUSIONS: Isolated tricuspid valve surgery can be performed through an endoscopic minimally access approach, with good results. It appears to provide better results than a sternotomy approach. A high repair rate can be achieved, and the procedure is particularly valuable in redo-surgery with low mortality and morbidity compared to historical sternotomy case series.

The endoscopic endonasal approach for sinonasal and nasopharyngeal adenoid cystic carcinoma.

OBJECTIVE: To determine factors affecting outcomes for patients with sinonasal and nasopharyngeal adenoid cystic carcinoma (SNACC) treated using the endoscopic endonasal approach (EEA) with preservation of key structures followed by adjuvant radiotherapy (RT). METHOD: Retrospective case series of 30 patients treated at the University of Pittsburgh between 2000 and 2014. Hospital records were reviewed for clinical and pathologic data. Outcome measures included overall survival (OS), disease-free survival (DFS), local recurrence-free survival (LRFS) and distant metastasis-free survival (DMFS) rates. RESULTS: The majority of patients had T4a and T4b disease (23.3%, and 63.3%). Microscopically positive margins were present in 21 patients (63.6%). Positive margins were present in nine patients (30.0%). The mean and median follow-up were 3.97 and 3.29 years. Five-year OS, DFS, LRFS, and DMFS were 62.66%, 58.45%, 87.54%, and 65.26%. High-/intermediate-grade tumors had worse DFS (P = .023), and LRFS (P = .026) (HR = 4.837, 95% CI, 1.181-19.812). No factors were associated with significantly worse DMFS. No patient suffered CSF leak, optic nerve, or internal carotid injury. The mean and median length of hospital stay was 4.1 days and 2.0 days (range: 0-32 days). CONCLUSION: Organ-preserving EEA with adjuvant RT for low-grade SNACC offers 5-year survival similar to that reported by other studies, which include radical, open skull base surgery. Patients with high-grade disease do poorly and may benefit from novel treatment strategies. For low-grade disease, organ-preserving EEA with RT may be the best option, offering a balance of survival, quality of life, and decreased morbidity for patients with this difficult-to-cure disease. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:1414-1421, 2020.

Pediatric multicenter cohort comparison of percutaneous endoscopic and non-endoscopic gastrostomy technique outcomes.

Enteral access is one of the mainstays of nutritional support. Several different modalities for gastrostomy placement are established. In pediatrics, however, there is a limited evidence base supporting the choice of 1 modality over the others. We retrospectively compared elective percutaneous endoscopically placed gastrostomy (PEG) with surgical and interventional radiology-placed gastrostomy outcomes using the Pediatric Hospital Inpatient Sample multicenter administrative database (Pediatric Health Information System). Pediatric patients (<18 years) undergoing planned elective gastrostomy (2010-2015) were included. Coded gastrostomy procedure subtype, patient demographic characteristics, chronic comorbidities and subsequent related outcomes, mortality, readmission, length of stay and total cost of admission were analyzed. Univariate analysis differentiated among gastrostomy techniques. The effect of gastrostomy on mortality and 30-day readmission were determined using a forward, stepwise, binary logistic regression. Generalized linear models were used to estimate the effect of gastrostomy type on length of stay and total cost. During the study period, 11,712 children underwent gastrostomy, including PEG (27%). Patients with chronic comorbidities were more, or as likely to undergo non-PEG procedures. Postoperatively, PEG patients were less likely to require mechanical ventilation and total parenteral nutrition (TPN). Gastrostomy type was not predictive of mortality; predictors included non-White race and need for mechanically assisted ventilation. Readmission following gastrostomy was common (29.5%), and more likely in PEG patients (OR 1.31). Predictors of readmission included earlier TPN (OR 1.39), cardiovascular (OR 1.17) and oncology (OR 4.17) comorbidities. Our study suggests that PEG placement entails similar length of stay and cost as in non-PEG gastrostomy. Patients undergoing PEG were less likely to require mechanical ventilation and TPN postoperatively. Mortality is similar in both groups although more likely with specific comorbidities. Racial background appeared to be associated with choice of gastrostomy, length of stay and mortality.

Margins in Sinonasal Squamous Cell Carcinoma: Predictors, Outcomes, and the Endoscopic Approach.

OBJECTIVES: To identify factors associated with positive margins following surgical management of sinonasal squamous cell carcinoma (SNSCC), especially with regard to endoscopic treatment. METHODS: In a retrospective analysis of adult patients with clinically staged tumor (T)1 to T4a SNSCC within the National Cancer Database (NCDB) from 2004 to 2014, factors were associated with positive margins using multivariable binary logistic regression. Cases from 2010 to 2014 had surgical approach (open vs. endoscopic) available and were analyzed in a subgroup to assess the association of surgical approach with margin status. The association of margin status with overall survival (OS) and additional therapy administration was also assessed. RESULTS: We identified 2,968 cases, of which 807 (27.2%) had positive margins. On multivariable analysis, factors associated with positive margins included higher T stage (T4a vs. T1: odds ratio [OR] 2.768 [95% CI 2.143-3.577]), less differentiated tumors (poorly differentiated vs. well differentiated: OR 1.403 [95% CI 1.060-1.856]), and tumors in the ethmoid sinus (vs. nasal cavity; OR 1.889 [95% CI 1.305-2.734]). Cases treated at higher volume facilities (HVFs) were associated with a lower likelihood of positive margins (OR 0.716 [95% CI 0.582-0.881]). Positive margins were associated with decreased OS (hazard ratio 1.672 [95% CI 1.464-1.908]) and an increased rate of additional therapy (OR 1.966 [95% confidence interval 1.597-2.421]). An endoscopic approach was not associated with an increased likelihood of obtaining positive margins (vs. open; OR 1.151 [0.903-1.651]). CONCLUSION: Positive margins were less likely when performed at HVFs and more likely in the ethmoid sinus than other subsites. Importantly, there was no association between positive margins and surgical approach. Endoscopic surgery may offer a safe, less invasive alternative to open surgery for select patients. LEVEL OF EVIDENCE: NA Laryngoscope, 130:E388-E396, 2020.

The cost of endoscopic treatment for walled-off pancreatic necrosis.

BACKGROUND: Use of minimally invasive techniques has reduced mortality in walled-off pancreatic necrosis (WON) but may be costly. The aim of this study was to evaluate the actual costs associated with the endoscopic management of patients with WON. METHODS: We included a retrospective cohort of WON patients treated with endoscopic, transgastric drainage and necrosectomy (ETDN) during 2013-2014. Costs were calculated for six sub-areas based on a micro-costing model. Students T-test and non-parametric analysis of variance were performed to evaluate costs in relation to disease etiology and outcome. RESULTS: We included 58 patients (50% men, median age 57 years). The most common etiologies were gallstones (57%) and alcohol (19%). Nine patients (16%) died during admission. The median length of stay was 50 days (IQR 31 days). Eighteen patients (31%) needed treatment in our intensive care unit with a median length of stay of 16 days (IQR 31 days). The mean costs and standard deviation of costs (SD) per patient were: diagnostic imaging $2,431 ($2,301), laboratory tests $3,579 ($2,477), blood products $982 ($1,734), endoscopic treatment $3,794 ($1,777), medicine $5,440 ($6,656), and ward cost $41,260 ($35,854). The mean total cost was $57,486 ($46,739). Post-ERCP pancreatitis and mortality predicted higher costs. CONCLUSIONS: This study sheds light on the different costs associated with endoscopic treatment of WON. As nearly three quarters of the costs are related to ward care, initiatives aimed at reducing the length of hospital stay may have a great impact on making endoscopic treatment more cost effective.

Pediatric elective therapeutic procedure complications: A multicenter cohort analysis.

BACKGROUND AND AIM: Current understanding of specific, therapeutic procedure-associated complications in pediatric patients remains limited. This study aims to determine the frequency of significant complications in pediatric age-range subjects following the principal therapeutic endoscopic procedures. METHODS: This study used retrospective multi-institutional, ICD-9-CM, Clinical Transaction Classification, and Current Procedural Terminology based database (Pediatric Hospital Information System) analysis. This study included demographic, chronic comorbidity, procedure type, and post-procedure outcomes defined through mortality, unplanned direct admission, emergency room, and inpatient admission and inpatient therapeutic events. RESULTS: During the study period, 18 018 patients underwent therapeutic endoscopy; 132 required direct (0.16%) or emergency room/inpatient (0.58%) admission within 5 days following the procedure; mortality was 0.01%. Most (50.75%) complications presented on the day of or 1 day post-procedure. Hispanic race and coexisting chronic comorbidities, especially gastrointestinal conditions, were identified risk factors for significant complications. Endoscopic dilatation and variceal ablation were most frequently associated with complications. Abdominal pain, gastrointestinal bleeding, and esophageal stricture were the most common diagnoses: 9.0% required intravenous antibiotics, 36.63% underwent chest imaging, 27.27% abdominal imaging, and 0.75% required blood transfusion. Readmission following esophageal dilatation was most likely to result in prolonged admission. CONCLUSION: In the pediatric population undergoing therapeutic endoscopy in the ambulatory setting, significant postoperative complications resulting in unplanned admission are rare. Complications can be anticipated in medically frail patients especially with gastrointestinal chronic illness. Procedures involving variceal ablation and esophageal dilatation entail the highest risk.

Hybrid coronary revascularization: Midterm outcomes of robotic multivessel bypass and percutaneous interventions.

OBJECTIVE: The purpose of this study was to investigate the outcomes of patients undergoing advanced hybrid coronary revascularization, defined as robotic beating-heart multivessel totally endoscopic coronary artery bypass combined with percutaneous coronary intervention. METHODS: This is a retrospective study. Among 308 consecutive patients who underwent totally endoscopic coronary artery bypass, 57 who underwent advanced hybrid coronary revascularization (mean age, 65.6 years) from July 2013 to September 2017 were included. Midterm survival and freedom from major adverse cardiac events, including death, myocardial infarction, and repeat revascularization, were analyzed. RESULTS: Multivessel totally endoscopic coronary artery bypass was successfully performed without conversion to thoracotomy. Bilateral internal thoracic artery grafting was used in 50 patients (87.7%). The mean operative time was 318.4 ± 51.0 minutes. The mean length of hospital stay was 3.0 ± 1.3 days. There was no 30-day mortality. Percutaneous coronary intervention was planned after totally endoscopic coronary artery bypass in 51 patients (89.4%). The target lesions were the right coronary artery only in 38 patients, the left circumflex artery only in 4 patients, and multiple lesions in 13 patients. Eventually, 2 patients did not receive percutaneous coronary intervention. Percutaneous coronary intervention attempt was unsuccessful in 8 lesions. Patency of the left/right internal thoracic artery was 95.2% (60/63) and 95.7% (45/47), respectively. Graft patency was 95.2% (40/42) in the left circumflex artery and 93.3% (14/15) in the diagonal branch. Three-year survival was 92.8%, and 3-year freedom from major adverse cardiac events was 80.2%. CONCLUSIONS: Advanced hybrid coronary revascularization is a safe and less-invasive approach with short hospital stay and good midterm outcomes.

Open Versus Endoscopic Approach for Sinonasal Melanoma: A Systematic Review and Meta-analysis.

BACKGROUND: Open resection (OR) of sinonasal mucosal melanoma (SNM) traditionally has been the gold standard for treatment. However, endoscopic resection (ER) has recently become a surgical alternative. The aim of this study was to compare survival outcomes between OR and ER of SNM. METHODS: A literature search encompassing PubMed, Embase, Cochrane Library, Web of Science, ClinicalTrials.gov, and Google Scholar was performed. Two reviewers independently screened for original studies comparing survival outcomes between OR and ER for SNM. Data were systematically collected on study design, patient demographics, outcomes, and level of evidence. Quality assessment was performed using the Newcastle-Ottawa scale (NOS). Meta-analysis of overall survival and disease-free survival was performed using random-effects models. RESULTS: The initial search yielded 2078 abstracts, of which 9 cohort studies were included for a total of 510 patients from 6 different countries. The average quality of all included studies using the NOS was 7.7 stars. Six out of 7 studies reported no differences in the stages of SNM between patients receiving ER versus OR. Overall survival was longer in the ER group versus OR group (hazard ratio [HR]: 0.68, 95% confidence interval [CI]: 0.49-0.95). There was no significant difference in disease-free survival between groups (HR: 0.59, 95% CI: 0.28-1.25). CONCLUSION: Based on the available literature, an endoscopic approach for SNM resection has survival outcomes that are similar or greater compared to an open approach.

Prognosis of endoscopic surgery and traditional open resection in mucosal melanoma of the nasal cavity and paranasal sinus.

Mucosal melanoma of the nasal cavity and paranasal sinus is always associated with poor prognosis, and 5-year overall survival does not exceed 40%. Our study aimed to compare the intraoperative conditions and prognosis of different surgical techniques to determine the optimum surgical approach for patients with mucosal melanoma of the nasal cavity and paranasal sinus. This was a retrospective analysis of 54 patients who received treatment at Beijing Tongren Hospital between January 2004 and December 2016. The patients were divided into two groups: those who received endoscopic surgery and those who underwent traditional open resection. The study analyzed the operative methods, the intraoperative conditions, and the prognosis of the patients. SAS JMP Pro software was used for statistical analysis of the data. There were 27 patients in the endoscopic surgery group and 27 patients in the open surgery group. Each group had the same distribution in terms of AJCC staging, with seven stage III, 12 stage IVA, and eight stage IVB patients in each group. There were statistically significant differences in operative time, complications, and cosmetic effects between the two groups, but no difference in local recurrence, disease-free survival, or overall survival. In the endoscopic surgery group and open surgery group, local recurrence rates were 14.81 and 11.11%, respectively, and metastasis rates were the same in both groups (40.74%). With regard to long-term prognosis, there was no statistically significant difference between the different surgical techniques, especially in terms of survival benefit. We believe that endoscopic surgery with protection of local function can be recommended for mucosal melanoma of the nasal cavity and paranasal sinus on the basis of its advantages in terms of shorter duration of surgery and fewer complications. In addition, it achieves better postoperative cosmetic effects with minimal scarring on the face of the patient, and thus improves postoperative quality of life.

Endoscopic surgery for primary sinonasal malignancies: Treatment outcomes and prognostic factors.

We retrospectively reviewed the cases of 85 patients with primary sinonasal malignancies who had undergone endoscopic surgery with curative intent achieved by "regional resection." Our goal was to assess the efficacy of endoscopic surgical treatment vis-à-vis traditional open surgery. Kaplan-Meier data analysis revealed that the 1-, 3-, and 5-year disease-specific survival rates were 82, 60, and 49%, respectively. Multivariate Cox model survival analysis revealed that male sex, certain pathologic types of cancer (i.e., undifferentiated carcinoma, olfactory neuroblastoma, and rhabdomyosarcoma), and T3/T4 category negatively impacted survival (adjusted hazard ratios: 3.601, 0.012, 0.287, 0.068, and 0.339, respectively; p < 0.05 for all). We also performed a separate analysis of 47 patients who had category T3 or T4 cancer to determine if the type of surgical approach is a prognostic factor. For this, we identified 20 new patients who had undergone open resection, and we compared them to 27 of our endoscopically treated patients who had similar clinical characteristics. We found that the type of surgical approach did not appear to be a prognostic factor (p > 0.10), although those patients who had undergone endoscopic resection had significantly shorter hospital stays (p < 0.001). We conclude that patients with primary sinonasal malignancies who are treated with endoscopic surgery have acceptable survival rates and therefore endoscopic surgery is justified in the hands of highly experienced surgeons in selected cases.

Surgical management of children presenting with surgical-needed tracheal stenosis.

OBJECTIVES: The purpose of this work was to assess epidemiological aspects, surgical approach, morbidity and mortality rates of patients presenting with tracheal stenosis requiring surgery, and the evolution of surgical techniques over the last years. METHODS: We performed a retrospective observational study from 1990 to 2017 in a pediatric tertiary-care center with needing surgery for tracheal stenosis. We analyzed clinical patients' characteristics, type of stenosis, type of surgery and follow-up. RESULTS: Twenty-eight children presented with tracheal stenosis, half of them with congenital stenosis (complete tracheal rings) and the other half with acquired stenosis (neoplasic or post intubation injury). 39.3% of these stenoses were associated with a vascular ring (61.5% in case of congenital stenosis). Depending on the extent of the stenosis and its origin, the surgery could be performed endoscopically or by an external approach. Enlargement tracheoplasty with an autograft (14.3%) was replaced by slide tracheoplasty with Cardio Pulmonary By-Pass (CPBP, 28.6%) with improved results for the treatment of long segment tracheal stenosis, involving more than 30% of the tracheal length (all were congenital in our study). Slide tracheoplasty has been performed since the late 90's in our institution. 25% of children have had a resection and anastomosis of the trachea because they had a stenosis involving less than 30% of tracheal length. Endoscopic surgery was performed for membranous stenoses, which were often seen after intubation or tracheotomy (32.1% of patients). CONCLUSION: Effective treatment of surgical tracheal stenosis was performed in 28 children between 1990 and 2015. Surgical techniques have evolved over time, leading to a better management of this rare and serious disease.

SERUM ELECTROLYTES AND OUTCOME IN PATIENTS UNDERGOING ENDOSCOPIC GASTROSTOMY.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is a gold standard for long term enteral feeding. Neurologic dysphagia and head/neck cancer are the most common indications for PEG as they can lead to protein-energy malnutrition and serum electrolyte abnormalities, with potential negative impact on metabolic balance. Refeeding syndrome may also be related with severe electrolyte changes in PEG-fed patients and contribute to poor prognosis. OBJECTIVE: This study aims to evaluate the changes in serum concentrations of the main electrolytes and its possible association with the outcome. METHODS: Retrospective study of patients followed in our Artificial Nutrition Clinic, submitted to PEG from 2010 to 2016, having head/neck cancer or neurologic dysphagia, who died under PEG feeding. Serum electrolytes (sodium, potassium, chlorine, magnesium, calcium and phosphorus) were evaluated immediately before the gastrostomy procedure. Survival after PEG until death was recorded in months. RESULTS: We evaluated 101 patients, 59 with electrolyte alterations at the moment of the gastrostomy. Sodium was altered in 32 (31.7%), magnesium in 21 (20.8%), chlorine in 21 (20.8%), potassium in 14 (13.8%), calcium in 11 (10.9 %) and phosphorus in 11 (10.9%). The survival of patients with low sodium (<135 mmol/L) was significantly lower when compared to patients with normal/high values, 2.76 months vs 7.80 months, respectively (P=0.007). CONCLUSION: Changes in serum electrolytes of patients undergoing PEG were very common. More than half showed at least one abnormality, at the time of the procedure. The most frequent was hyponatremia, which was associated with significantly shorter survival, probably reflecting severe systemic metabolic distress.

External aortic clamping versus endoaortic balloon occlusion in minimally invasive cardiac surgery: a systematic review and meta-analysis.

OBJECTIVES: Minimally invasive cardiac valve surgery is safe, effective and increasingly popular. It is performed worldwide with the use of either external aortic clamping or endoaortic balloon occlusion. METHODS: We conducted a literature search using MEDLINE, EMBASE, Scopus and Web of Science. Primary outcomes included aortic dissection, conversion to sternotomy, mortality, stroke and cross-clamp time. Secondary outcomes included atrial fibrillation, acute kidney injury, reoperation for bleeding, cardiopulmonary bypass times, myocardial infarction, use of intra-aortic balloon pump and length of hospital stay. The random effects model was used to calculate the outcomes of both binary and continuous data. RESULTS: Thirty retrospective studies were included in the meta-analysis. The incidence of aortic dissection (pooled odds ratio = 3.88, 95% confidence interval = 1.06-14.18; P =0.04) and conversion to sternotomy (pooled odds ratio = 3.07, 95% confidence interval = 1.33-7.10; P = 0.009) was higher in the endoaortic balloon occlusion group than in the external aortic clamping group, in whom a direct comparison was possible. The remaining observational studies did not show any significant differences in either group. There was no significant difference in 30-day mortality (P = 0.37), stroke (P = 0.26), cross-clamp time (P = 0.20), atrial fibrillation (P = 0.18), acute kidney injury (P = 0.49), reoperation for bleeding (P = 0.24), cardiopulmonary bypass time (P = 0.06), myocardial infarction (P = 0.74), use of intra-aortic balloon pump (P = 0.11) or length of hospital stay (P = 0.47). CONCLUSIONS: External aortic clamping may be safer than endoaortic balloon occlusion with respect to aortic dissection and conversion to sternotomy. However, mortality, length of stay, stroke, cross-clamp time and other cardiovascular complication rates were similar between the 2 techniques.

Eletrólitos séricos e prognóstico em doentes submetidos a gastrostomia endoscópica / Serum electrolytes and outcome in patients undergoing endoscopic gastrostomy

ABSTRACT BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is a gold standard for long term enteral feeding. Neurologic dysphagia and head/neck cancer are the most common indications for PEG as they can lead to protein-energy malnutrition and serum electrolyte abnormalities, with potential negative impact on metabolic balance. Refeeding syndrome may also be related with severe electrolyte changes in PEG-fed patients and contribute to poor prognosis. OBJECTIVE: This study aims to evaluate the changes in serum concentrations of the main electrolytes and its possible association with the outcome. METHODS: Retrospective study of patients followed in our Artificial Nutrition Clinic, submitted to PEG from 2010 to 2016, having head/neck cancer or neurologic dysphagia, who died under PEG feeding. Serum electrolytes (sodium, potassium, chlorine, magnesium, calcium and phosphorus) were evaluated immediately before the gastrostomy procedure. Survival after PEG until death was recorded in months. RESULTS: We evaluated 101 patients, 59 with electrolyte alterations at the moment of the gastrostomy. Sodium was altered in 32 (31.7%), magnesium in 21 (20.8%), chlorine in 21 (20.8%), potassium in 14 (13.8%), calcium in 11 (10.9 %) and phosphorus in 11 (10.9%). The survival of patients with low sodium (<135 mmol/L) was significantly lower when compared to patients with normal/high values, 2.76 months vs 7.80 months, respectively (P=0.007). CONCLUSION: Changes in serum electrolytes of patients undergoing PEG were very common. More than half showed at least one abnormality, at the time of the procedure. The most frequent was hyponatremia, which was associated with significantly shorter survival, probably reflecting severe systemic metabolic distress.

RESUMO CONTEXTO: A gastrostomia endoscópica percutânea (PEG) é a via de eleição preferencial para a nutrição entérica de longa duração. A disfagia neurológica e as neoplasias cervico-faciais constituem as principais indicações para PEG por poderem conduzir a desnutrição energético-proteica e alterações hidroeletrolíticas, com potencial impacto negativo no equilíbrio metabólico. A síndrome de realimentação pode também estar associada a alterações hidroeletrolíticas graves em doentes alimentados por PEG e contribuir para um mau prognóstico. OBJETIVO: Avaliar as alterações das concentrações séricas dos principais eletrólitos e a eventual associação entre os valores séricos alterados e o prognóstico dos doentes gastrostomizados. Métodos - Estudo retrospetivo realizado em doentes seguidos na Consulta de Nutrição Artificial do Hospital Garcia de Orta, propostos e submetidos a PEG, de 2010 a 2016 e que faleceram sob nutrição por PEG. Consideraram-se os valores séricos dos iões em estudo avaliados imediatamente antes do procedimento endoscópico de gastrostomia, obtidos por consulta do processo clínico. A sobrevida, após a realização da PEG até à morte foi registrada em meses. RESULTADOS: Avaliaram-se 101 doentes. A sobrevida média pós-gastrostomia foi 6,55 meses. Destes, 59 apresentaram alterações de alguns iões no momento da realização da PEG. O sódio estava alterado em 31 (30,6%), magnésio em 20 (19,8%), cloro em 19 (18,8%), potássio em 14 (13,8%), cálcio em 10 (9,9%) e o fósforo em 9 (8,9%). Quando comparada a sobrevida dos doentes com valores de sódio baixo (<135 mmol/L) com a dos doentes com valores normais/elevados, esta foi 2,76 meses vs 7,80 meses, respectivamente (P=0,007). CONCLUSÃO: As alterações dos eletrólitos séricos nos doentes submetidos a PEG foram muito frequentes, com mais de metade dos doentes a apresentarem pelo menos uma alteração aquando da realização do procedimento. A alteração mais frequente foi a hiponatrémia, associando-se a pior prognóstico com sobrevida significativamente mais curta, refletindo provavelmente um grave compromisso metabólico sistêmico.