Elective nodal dissection for cN0 intermediate-grade parotid mucoepidermoid carcinoma: A NCDB study.

PURPOSE: To determine the occult nodal disease rate and whether elective regional lymph node dissection (RLND) confers any 10-year overall survival (OS) in cN0 intermediate-grade mucoepidermoid carcinoma (MEC) of the parotid gland. MATERIALS & METHODS: The National Cancer Database was reviewed from 2004 to 2016 on adults with cT1-4aN0M0 intermediate-grade parotid MEC undergoing resection with/without RLND. Comparisons between patients with and without RLND were made. Occult nodal rate and 10-year overall survival (OS) were determined. RESULTS: Out of 898 included patients with cN0 intermediate grade parotid MEC undergoing elective RLND, the occult nodal rate was 7.6%. This was significantly different from low-grade (3.9%) and high-grade (25.7%) cN0 disease. When stratified by pT-classification, marginal differences were identified between low-grade and intermediate-grade tumors, whereas high-grade tumors demonstrated increased occult nodal disease with low T-stage (pT1-pT2, 20.4% vs. 5.1%) and high T-stage (pT3-pT4a, 32.1% vs. 17.6%). Patients undergoing elective RLND were more often treated at an academic facility (53.8% vs. 41.2%), had higher pT3-pT4 tumors (19.2% vs. 10.4%), and more frequently underwent total/radical parotidectomy (46.0% vs. 29.9%) with adjuvant radiation therapy (53.8% vs. 41.0%) Cox-proportional hazard modeling did not identify RLND, regardless if stratified by nodal yield or pT-classification, nor nodal positivity as significant predictors of 10-year OS. CONCLUSIONS: The occult nodal disease in intermediate-grade parotid MEC is low and similar to low-grade. Elective RLND may have a limited impact on OS, though its effect on locoregional control remains unknown. LEVEL OF EVIDENCE: III.

Salivary gland surgery and nonviral respiratory-related hospitalizations in children with neurodevelopmental impairment.

OBJECTIVES: Neurodevelopmentally impaired (NI) children with chronic sialorrhea are at elevated risk for aspiration and respiratory tract infections. Direct resection or ligation ("DROOL") of the submandibular glands (SMG) with parotid duct ligation are surgical interventions intended to decrease salivary output. The objective of this study is to determine the impact of DROOL surgery on the incidence of nonviral respiratory-related (NVR) post-procedure hospital encounters including emergency department visits and admissions. METHODS: Retrospective case series of NVR related outcomes after DROOL surgery in children performed at a single institution, tertiary referral center. RESULTS: A total of 35 gastrostomy tube-dependent patients (60% male, average age 8.2 [SD 6.0] years) with NI underwent DROOL surgery (86% SMG excision). Pre- and post-surgical follow-up time was 3.6 and 3.2 years, respectively. Presurgical and postsurgical NVR hospital encounters occurred in 28 (80%) and 14 (40%) patients, respectively (p < 0.01). Mean (SD) postoperative NVR hospital encounters occurred less frequently when compared to presurgical period (0.4 [0.6] vs. 1.0 [1.2] per year, p < 0.01) with average change of -0.7 encounters per year (SD 1.4, 95% CI -1.0 to -0.2). Patients with encounters within a year preceding DROOL (OR 4.9, p = 0.04, 95% CI 1.1-22.8), or those with at least 3 preoperative encounters (OR 8.0, p = 0.01, 95% CI 1.6-40.3) were significantly associated with a postsurgical NVR event. Fewer patients used anti-sialorrhea medication postoperatively compared to preoperatively (60% vs. 17%, p < 0.01). No patient developed surgical site complications requiring operative interventions. CONCLUSIONS: DROOL surgery for chronic sialorrhea in patients with NI was associated with decreased hospitalization and ED visits for NVR respiratory events post-procedurally. Sialorrhea may be an actionable source of recurrent respiratory illnesses requiring hospitalizations.

Inpatient Type 1 Thyroplasty Versus Injection Laryngoplasty for Vocal Fold Movement Impairment After Extent type I and II Aortic Repair.

IMPORTANCE: Vocal fold motion impairment (VFMI) due to neuronal injury is a known complication following thoracic aortic repair that can impair pulmonary toilet function and post-operative recovery. OBJECTIVE: To demonstrate clinical outcomes of patients undergoing inpatient vocal fold medialization for VFMI after aortic surgery. DESIGN: A 15-year retrospective chart review (2005-2019) of 259 patients with postoperative VFMI after thoracic aortic surgery registry was conducted. Data included demographics, surgery characteristics, laryngology exam, and postoperative clinical outcomes. Medialization procedures consisted of type 1 thyroplasty and injection laryngoplasty. SETTING: Tertiary care hospital. PARTICIPANTS: Two hundred and fifty-nine patients (median age 61, 71% male) with VFMI post-thoracic aortic repair met inclusion criteria; inpatient vocal fold medialization was performed for 203 (78%) patients. One hundred and twenty-six. (49%) received type 1 thyroplasty and 77 (30%) received injection laryngoplasty procedures at a median 7 days (IQR 5-8 days) from extubation. MAIN OUTCOMES: Primary study outcome measurements consisted of median LOS, median ICU LOS, complications intra- and postoperatively, and pulmonary complications (post-medialization bronchoscopies, pneumonia, tracheostomy, etc.). RESULTS: Post-medialization bronchoscopy rates were significantly lower in the medialization (n = 11) versus the non-medialization group (n = 8) (5% vs 14%, P = .02) and significantly higher in the injection laryngoplasty group (n = 77) versus thyroplasty group (n = 126) (10% vs 2%, P = .02). Further analysis revealed no significant difference in overall LOS and pulmonary complications between the techniques. CONCLUSION: Inpatient thyroplasty and injection laryngoplasty are both effective vocal fold medialization techniques after extent I and II aortic repair. Thyroplasty may have a small pulmonary toilet advantage, as measured by need for post-medialization bronchoscopy, compared to injection laryngoplasty.

Free Flap Inset Techniques in Salvage Laryngopharyngectomy Repair: Impact on Fistula Formation and Function.

OBJECTIVE: To characterize pharyngocutaneous fistula (PCF) rates and functional outcomes following microvascular free tissue transfer (MVFTT) reconstruction of salvage total laryngectomy (STL) with a review of two different flap inset techniques and a review of the literature. METHODS: Retrospective review. RESULTS: Review of the literature revealed 887 patients who underwent STL MVFTT from 14 references. Ninety-six STL MVFTTs were performed by the authors, with 36 (38%) patients undergoing multilayer fascial underlay (MLFU) closure and 60 (62%) a standard single layer closure (SLC). One (3%) PCF occurred in the MLFU group compared to 12 (20%) in the SLC cohort (P = .03). Postoperative gastrostomy (G)-tube dependence was lower following MLFU closure compared to SLC (25% vs. 57%, P < .01), whereas pharyngoesophageal stricture (PES) (28% vs. 38%), tracheoesophageal puncture (TEP) placement (42% vs. 42%), and TEP usage (87% vs. 88%) did not significantly differ (P > .05). Compared to pooled rates from the literature, patients who underwent a MLFU MVFTT inset technique demonstrated significantly lower PCF incidence (3% vs. 23%, P < .01) without significant differences in PES (28% vs 23%, P = .55), G-tube dependence (25% vs. 23%, P = .25), or TEP placement (42% vs. 59%, P = .09). CONCLUSION: Despite MVFTT reconstruction after STL, G-tube dependence, PCF formation, and limitations of speaking rehabilitation (TEP) remain a significant issue. Modification of MVFTT inset may provide an opportunity to reduce PCF incidence without affecting other functional outcomes. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E875-E881, 2021.

Prognostic factors associated with achieving total oral diet after glossectomy with microvascular free tissue transfer reconstruction.

OBJECTIVE: Primary surgery followed by adjuvant therapy is the current standard of care in the multidisciplinary management of squamous cell carcinoma (SCC) of the oral tongue. Additionally, salvage glossectomy is used to treat recurrent base of tongue SCC. Microvascular free tissue transfer reconstruction (MVFTT) is utilized to maximize functional outcomes such as swallowing. We sought to identify prognostic factors related to achievement of a total oral diet in patients that underwent glossectomy with MVFTT. METHODS: Retrospective review at a tertiary care center from 2010 to 2015. RESULTS: 200 patients (69% male, mean age 60 years) met inclusion criteria. Extent of glossectomy was categorized as partial or hemiglossectomy (39%), tongue base resection with or without hemi-oral glossectomy (23%), composite resection with mandibulectomy (18%), and subtotal or total glossectomy (21%). Flap success rate was 96%. Median follow-up time was 14  months. A total oral diet was achieved by 49% of patients with median time to achievement of 31  days (IQR 9-209). Multivariate analysis identified body mass index  < 25 kg/m2, prior radiation therapy, adjuvant chemoradiation, and resection requiring subtotal or total glossectomy or concurrent mandibulectomy as independent risk factors for worse total oral diet achievement. CONCLUSION: Swallowing dysfunction represents a significant morbidity following glossectomy in the treatment of SCC. High BMI, smaller resection fields, and absence of prior radiation therapy or adjuvant chemoradiotherapy correlated with improved likelihood of obtaining a total oral diet. Patients should be appropriately counseled of this risk with emphasis placed on aggressive swallow rehabilitation in the post- treatment setting.

Routine admission to step-down unit as an alternative to intensive care unit after pediatric supraglottoplasty.

OBJECTIVE: To evaluate the feasibility and the outcomes for step-down (SD) unit admission as an alternative to intensive care unit (ICU) admission after supraglottoplasty in the pediatric patient. METHODS: A review of 98 patients who underwent supraglottoplasty from 2012 to 2017 at a tertiary referral pediatric hospital was performed. An SD unit had 1-to-3 nurse-to-patient ratio with noninvasive positive pressure ventilation capability. Data variables included demographics, comorbidities, preoperative and postoperative respiratory requirements, and length of stay. RESULTS: Routine admission to SD occurred for 85% patients while 15% patients were selectively admitted to ICU due to intubation requirement or perioperative respiratory distress. In SD, noninvasive respiratory support was required for 28 (34%) patients. Three (4%) required re-intubation and ICU transfer without delay in care. Patients at high risk for requiring respiratory support after surgery have a neurologic condition (OR 7.0, 95% 2.4-20.2, p < 0.01) or intrinsic pulmonary disease (OR 4.5, 95% CI 1.5-13.3, p < 0.01). Median length of stay was shorter for patients in step-down (1 day, IQR 1-2). CONCLUSION: Patients can be managed safely in a SD unit after supraglottoplasty supporting de-escalation of care. Patients with neurologic and pulmonary comorbidities may have higher respiratory needs postoperatively. Prospective studies are warranted to further optimize resource allocation.

Early versus late inpatient awake transcervical injection laryngoplasty after thoracic aortic repair.

BACKGROUND: Vocal fold movement impairment (VFMI), a known complication following thoracic aortic surgery, has been associated with poorer surgical outcomes, including higher pulmonary complications and longer length of stay (LOS). Awake transcervical injection laryngoplasty in the inpatient setting serves to augment pulmonary toilet function for affected patients. This study investigates clinical outcomes of patients who underwent early versus late injection laryngoplasty following aortic surgery. METHODS: A 5-year review (2011-2016) of 35 patients who underwent inpatient injection laryngoplasty for VFMI following aortic repair was conducted. Data included demographics, surgery parameters, laryngologic evaluation, pulmonary complications, LOS, and mortality. Early injection was defined as within 5 days from extubation. Statistical analyses were performed using SPSS, version 17.0 (IBM Corp., Armonk, NY). RESULTS: All 35 patients (mean age 56, 77% male) underwent left vocal-fold injection laryngoplasty without complication. There were 15 (43%) early procedures and 20 (57%) late procedures. Mean LOS for early and late injection groups (13 vs. 20 days, respectively) significantly differed (P = 0.04, 95% confidence interval (CI) 0.3 to 14.4). Early laryngoplasty cohorts experienced less pulmonary complications (20%) than those who had late medialization (50%), but this did not reach significance (P = 0.06, 95% CI -0.3 to 8.1). The most common complication type in both groups was therapeutic bronchoscopy. CONCLUSION: Early awake injection laryngoplasty within 5 days from extubation is feasible and may improve clinical outcomes for patients with VFMI following aortic repair. Further prospective studies on this approach for VFMI after thoracic surgery are needed. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:144-147, 2018.

Genome-wide association study identifies common genetic variants associated with salivary gland carcinoma and its subtypes.

BACKGROUND: Salivary gland carcinomas (SGCs) are a rare malignancy with unknown etiology. The objective of the current study was to identify genetic variants modifying the risk of SGC and its major subtypes: adenoid cystic carcinoma and mucoepidermoid carcinoma. METHODS: The authors conducted a genome-wide association study in 309 well-defined SGC cases and 535 cancer-free controls. A single-nucleotide polymorphism (SNP)-level discovery study was performed in non-Hispanic white individuals followed by a replication study in Hispanic individuals. A logistic regression analysis was applied to calculate odds ratios (ORs) and 95% confidence intervals (95% CIs). A meta-analysis of the results was conducted. RESULTS: A genome-wide significant association with SGC in non-Hispanic white individuals was detected at coding SNPs in CHRNA2 (cholinergic receptor, nicotinic, alpha 2 [neuronal]) (OR, 8.55; 95% CI, 4.53-16.13 [P = 3.6 × 10(-11)]), OR4F15 (olfactory receptor, family 4, subfamily F, member 15) (OR, 5.26; 95% CI, 3.13-8.83 [P = 3.5 × 10(-10)]), ZNF343 (zinc finger protein 343) (OR, 3.28; 95% CI, 2.12-5.07 [P = 9.1 × 10(-8)]), and PARP4 (poly(ADP-ribose) polymerase family, member 4) (OR, 2.00; 95% CI, 1.54-2.59 [P = 1.7 × 10(-7)]). Meta-analysis of the non-Hispanic white and Hispanic cohorts identified another genome-wide significant SNP in ELL2 (meta-OR, 1.86; 95% CI, 1.48-2.34 [P = 1.3 × 10(-7)]). Risk alleles were largely enriched in mucoepidermoid carcinoma, in which the SNPs in CHRNA2, OR4F15, and ZNF343 had ORs of 15.71 (95% CI, 6.59-37.47 [P = 5.2 × 10(-10)]), 15.60 (95% CI, 6.50-37.41 [P = 7.5 × 10(-10)]), and 6.49 (95% CI, 3.36-12.52 [P = 2.5 × 10(-8)]), respectively. None of these SNPs retained a significant association with adenoid cystic carcinoma. CONCLUSIONS: To the best of the authors' knowledge, the current study is the first to identify a panel of SNPs associated with the risk of SGC. Confirmation of these findings along with functional analysis of identified SNPs are needed.

Outcomes of anomalous left coronary artery from pulmonary artery repair: beyond normal function.

BACKGROUND: Anomalous left coronary artery from pulmonary artery (ALCAPA) is associated with high mortality if left uncorrected. We describe long-term outcomes after surgical repair and ventricular function changes on long-term follow-up. METHODS: A retrospective review of patients who had ALCAPA repair from January 1996 to December 2011 was completed. Ventricular function was assessed by shortening fraction and ejection fraction, left ventricular end-diastolic dimension, and severity of mitral regurgitation. Speckle tracking echocardiography served as a marker of early myocardial dysfunction. RESULTS: In total, 34 patients underwent ALCAPA repair at median age of 5 months (range, 3 days to 39 years). Surgical interventions included coronary translocation in 31 patients (91%), Takeuchi repair in 2 (6%), and coronary ligation in 1 patient (3%). Concomitant mitral valve repair was performed in 5 patients (15%). No patient required mechanical circulatory support postoperatively. There was no early mortality. At median follow-up of 6 years (range, 1 month to 14 years), there were 5 reoperations: 2 heart transplants (6%), 1 mitral valve replacement (3%), 1 coronary artery bypass graft (3%), and 1 ventricular septal defect closure (3%); there was 1 death 2 years after surgery. Ejection fraction improved from 21% ± 6% to 60% ± 7% (p = 0.008), mean shortening fraction from 25% ± 14% to 38% ± 5% (p = 0.01), mean left ventricular end-diastolic dimension Z-score from 6.0 ± 3.8 to 0.9 ± 0.7 (p < 0.001), and number of patients with moderate-severe mitral regurgitation from 44% (15 of 34) to 5% (1 of 21). All patients had normal ejection fraction and shortening fraction at last follow-up. Speckle tracking echocardiography showed decreased global longitudinal (p = 0.01) and circumferential strain (p = 0.03) for 11 of 14 patients (79%). CONCLUSIONS: Excellent outcomes are achieved with repair of ALCAPA without mechanical circulatory support and with low reintervention rates. Normal ejection fraction and shortening fraction do not accurately convey myocardial dysfunction in these patients.

Routine computed tomography in the evaluation of vocal fold movement impairment without an apparent cause.

OBJECTIVE: Routine computed tomography (CT) for vocal fold movement impairment (VFMI) without an apparent cause is common. However, given increased cancer risk associated with ionizing radiation exposure, our purpose is to evaluate the utility of routine scans for these patients. STUDY DESIGN: Retrospective case series. SETTING: Houston, Texas. SUBJECTS AND METHODS: A 5-year review of patients with VFMI diagnosed at an academic institution was conducted. For patients without an apparent cause (eg, recent head, neck, or cardiothoracic surgery or known malignancy), CT head/neck and chest was performed to evaluate the recurrent laryngeal nerve course. Data included demographics, symptoms, radiography, and interventions. Statistical analyses were performed via χ(2) analysis. RESULTS: Of 406 patients with VFMI, 47 (11%) patients had no apparent cause clinically. Routine CT revealed abnormalities in 10 (21%) patients, of which only 3 (6%) could account for VFMI: benign thyroid adenoma (1), papillary thyroid cancer (1), and an esophageal mass (1). The most common lesion detected involved the thyroid. Demographic data and symptom type were not significantly associated with detection of a VFMI-attributable lesion on CT. Overall, routine CT did not identify a focal etiology in 94% patients with VFMI without an apparent cause. CONCLUSION: Routine pan-CT evaluation failed to reveal an etiology in 94% of patients with VFMI without an apparent cause. Patients may be subjected to health risks associated with radiation exposure without significant diagnostic benefit. Further studies should consider more judicious use of CT in the context of risk factors and safer imaging modalities as the initial diagnostic step.

Utility of routine postoperative visit after appendectomy and cholecystectomy with evaluation of mobile technology access in an urban safety net population.

BACKGROUND: The value of routine postoperative visits after general surgery remains unclear. The objective of this study was to evaluate the utility of routine postoperative visits after appendectomy and cholecystectomy and to determine access to mobile technology as an alternative platform for follow-up. METHODS: Retrospective review of 219 appendectomies and 200 cholecystectomies performed at a safety net hospital. One patient underwent both surgeries. Patient demographics, duration of clinic visit, and need for additional imaging, tests or readmissions were recorded. Access to mobile technology was surveyed by a validated questionnaire. RESULTS: Of 418 patients, 84% percent completed a postoperative visit. At follow-up, 58 patients (14%) required 70 interventions, including staple removal (16, 23%), suture removal (4, 6%), drain removal (8, 11%), additional follow-up (20, 28%), medication action (16, 21%), additional imaging (3, 4%), and readmission (1, 1%). Occupational paperwork (62) and nonsurgical clinic referrals (28) were also performed. Average check-in to check-out time was 100 ± 54 min per patient. One intervention was performed for every 7.8 h of time in the clinic. Additionally, 88% of the surveyed population reported access to cell phone technology, and 69% of patients <40 y had smartphone access. CONCLUSIONS: Routine in-person follow-up after surgery consumes significant time and resources for patients and healthcare systems but has little impact on patient care. Most of the work done in the clinic is administrative and could be completed using mobile technology, which is pervasive in our population.

Contemporary experience with surgical treatment of aortic valve disease in children.

OBJECTIVES: Surgical treatment of aortic valve (AoV) disease in childhood involves complex decisions particularly in very small patients. There is no consensus regarding the optimum surgical option. The objective of this review was to analyze a contemporary experience of AoV surgery in a large children's hospital. METHODS: A retrospective review of children (aged ≤ 18 years) undergoing AoV repair or replacement from June 1995 to December 2011 was carried out. RESULTS: A total of 285 AoV operations (97 repairs, 188 replacements) were performed on 241 patients. Hospital survival for repair was 98% and for replacements was 97%. At follow-up of repairs, there were 16 (17%) reoperations and 3 (3%) late deaths. Follow-up of AoV replacements demonstrated 31 (16%) reoperations (homograft 27, autograft 3, mechanical 1) and 8 (4%) late deaths (homograft 5, autograft 2, mechanical 1). Freedom from reintervention or death (FRD) was found to be lower in repairs for infants (P = .048) and truncal valves (P < .05). For AoV replacements, infants and patients who had concomitant CHD or homografts (P < .0001) had lower FRD. Cox regression analysis for AoV replacements identified infants and homograft root replacements at a higher risk for death/reoperation. CONCLUSIONS: AoV repairs and replacements were generally found to be associated with low death and reoperation rates at long-term follow-up. Infants had a lower freedom from reintervention or death after either an AoV repair or replacement, although truncal valve repairs and AoV replacement in patients with concomitant CHD were associated with lower valve survival. Among the valve options, homograft root replacement had a higher risk of death/reoperation and lowest freedom from reintervention or death.

Infectious complications and outcomes in children supported with left ventricular assist devices.

BACKGROUND: Infectious complications constitute a major cause of morbidity and death in adult patients supported with left ventricular assist devices (VADs). The incidence and patient outcomes related to infectious complications in pediatric patients on VAD support remain largely unknown. The aim of this study was to determine the incidence of infection among pediatric VAD recipients and to characterize the microbiology, associated risk factors, and clinical outcome. METHODS: We conducted a retrospective record review of all patients undergoing VAD support for ≥2 weeks at Texas Children's Hospital from June 1999 to December 2011. Infections were categorized as VAD-specific, VAD-related, or non-VAD-related using the International Society for Heart and Lung Transplantation (ISHLT) definitions for VAD infections. RESULTS: Fifty-two VADs were implanted in 51 patients; of these, 35 patients (69%) had 92 infections while receiving VAD support. These included 10 VAD-specific infections, 23 VAD-related infections, and 59 non-VAD infections. The overall rate of VAD infections (specific + related) was 8/1,000 days of VAD support. The most common pathogens were Staphylococcus aureus, coagulase-negative staphylococci, Pseudomonas aeruginosa, and Candida spp. Of 8 deaths that occurred during VAD support, 3 (37.5%) were directly related to infections. Continuous-flow VAD (p = 0.0427) and prior cardiac transplantation with rejection (p = 0.0191) were significantly associated with development of VAD infections. CONCLUSIONS: Infectious complications are common in pediatric patients undergoing VAD support. VAD infections do not prevent successful cardiac transplantation in children.

Insertional mutagenesis by a hybrid piggyBac and sleeping beauty transposon in the rat.

A hybrid piggyBac/Sleeping Beauty transposon-based insertional mutagenesis system that can be mobilized by simple breeding was established in the rat. These transposons were engineered to include gene trap sequences and a tyrosinase (Tyr) pigmentation reporter to rescue the albinism of the genetic background used in the mutagenesis strategy. Single-copy transposon insertions were transposed into the rat genome by co-injection of plasmids carrying the transposon and RNA encoding piggyBac transposase into zygotes. The levels of transgenic Tyr expression were influenced by chromosomal context, leading to transgenic rats with different pigmentation that enabled visual genotyping. Transgenic rats designed to ubiquitously express either piggyBac or Sleeping Beauty transposase were generated by standard zygote injection also on an albino background. Bigenic rats carrying single-copy transposons at known loci and transposase transgenes exhibited coat color mosaicism, indicating somatic transposition. PiggyBac or Sleeping Beauty transposase bigenic rats bred with wild-type albino rats yielded offspring with pigmentation distinct from the initial transposon insertions as a consequence of germline transposition to new loci. The germline transposition frequency for Sleeping Beauty and piggyBac was ∼10% or about one new insertion per litter. Approximately 50% of the insertions occurred in introns. Chimeric transcripts containing endogenous and gene trap sequences were identified in Gabrb1 mutant rats. This mutagenesis system based on simple crosses and visual genotyping can be used to generate a collection of single-gene mutations in the rat.