Postoperative risk stratification in oral squamous cell carcinoma.

Postoperative prognostic stratification using the Union for International Cancer Control (UICC) TNM 8th edition staging rules (UICC 8) may identify additional groups of patients who could benefit from adjuvant radiotherapy. Currently, selection for such treatment is not based on all known prognostic factors, and their relative importance may vary depending on the overall risk category. The objective of this study therefore was to evaluate these possibilities. We retrospectively studied 644 patients who had surgery with curative intent for oral squamous cell carcinoma (OSCC) between March 2006 and February 2017. The outcomes of interest were disease-specific survival (DSS) and locoregional recurrence (LRR). Patients were re-staged according to the UICC 8 staging rules. Putative clinical and pathological prognostic variables were evaluated and hazard ratios estimated. Regression analysis was done to identify independent prognostic factors, and iterative analyses identified clinically-relevant risk categories with a minimum of residual prognostic variables. The significance of recognised pathological prognostic factors differed according to the overall risk category. An intermediate risk group comprising patients with pN1 disease as well those with pT3 disease solely on the basis of a depth of invasion (DOI) of more than 10 mm, was identified. A trial to evaluate the benefit or otherwise of adjuvant radiotherapy in this group is now required. Individual prognostic risk factors should be considered within the context of the overall risk category in patients with OSCC.

Postoperative complications after head and neck operations that require free tissue transfer - prevalent, morbid, and costly.

To understand and reduce the impact of postoperative complications, we studied 568 patients who had had operations over 72 months in our hospital. Multivariate analysis indicated that factors indicative of coexisting conditions (including activated systemic inflammation) and the complexity of the operation are primary determinants of postoperative complications. The enhanced recovery after surgery (ERAS) care pathway did not have an effect on their occurrence or severity. Systematic study of patients' toleration of major head and neck operations is required, as optimal perioperative care pathways remain elusive.

A comparison of skin graft success in the head & neck with and without the use of a pressure dressing.

BACKGROUND: The success of skin grafting is dependent on the interplay between many factors including nutrient uptake and vascular in-growth. To allow this, it is important that the graft is immobile and traditionally a 'pressure dressing' has been placed over the graft to improve outcome and graft 'take'. We present the findings of our comparative study of full-thickness skin grafts performed in the head, neck and face region over a period of 24 months. We felt that there was an unacceptably high infection rate and graft failure using pressure dressings. METHODS: Data was collected retrospectively from the case notes on 70 patients who had undergone full-thickness skin grafting to the head, neck and face over a 2 year period. Thirty-five patients underwent grafting with pressure dressing and 35 without. The group with the pressure dressing had the same 'bolster' specification-type dressing and those without had their graft 'quilted' in and chloramphenicol ointment applied topically. Success was determined by the percentage 'take' of the grafts and absence of infection i.e. purulence. RESULTS: Infection in those with a pressure dressing stood at 26 % in contrast to those without, at 9 %. Without a pressure dressing we observed no total graft failures, compared to 6 % in those with a pressure dressing. CONCLUSIONS: The results confirmed the perception that there was a higher infection and graft failure rate where a pressure dressing was applied; however, this was not a statistically significant difference and a randomised control trial with a larger sample size would be required to validate the results.

Oral and oropharyngeal cancer in the West of Scotland-long-term outcome data of a prospective audit 1999-2001.

We prospectively studied patients from the west of Scotland who presented with a primary cancer of the oral cavity or oropharynx over a period of 24 months from November 1999, and report long-term outcomes and prognostic factors. A total of 481 patients had squamous cell carcinoma (SCC), 5-year disease-specific survival (DSS) was 50%, and overall survival (OS) was 35%. One hundred were not suitable for treatment with curative intent, and factors other than stage were important in this decision. Of those treated with curative intent, 249 had SCC of the oral cavity (5-year DSS 67%; OS 42%), and 132 had SCC of the oropharynx (5-year DSS 62%; OS 42%). Multivariate analysis showed that pathological nodal stage (p=0.051, 95% CI 0.998-1.955), and perineural invasion (p=0.001, 95% CI 0.186-0.666) were prognostic indicators. Improved results using intensive treatment protocols that have been seen in trials are not likely to translate directly into a general population of patients with head and neck cancer. Algorithms that allow several pathological prognostic indicators to be incorporated into decisions about adjuvant treatment should be used.

Facial atrophy following accidental subcutaneous extrusion of sodium hypochlorite.

Facial atrophy of the buccal fat pad following inadvertent subcutaneous extrusion of sodium hypochlorite is very rare. It is a complication which leaves the patient with a defect which is very difficult to treat. We present the case of a 46-year-old lady who presented with almost complete unilateral atrophy of the buccal fat pad. She has undergone multiple surgeries over the past two years. We highlight the precautions that must be taken to prevent such a complication and the difficulties in rehabilitating such a patient.

Bisphosphonate osteonecrosis: a protocol for surgical management.

We present a protocol for the management of a subgroup of patients with bisphosphonate osteonecrosis who presented with painful, exposed, necrotic, alveolar bone. It is simple and can easily be adapted to suit anatomical variations of the oral cavity. Current guidelines based on consensus for the management of bisphosphonate-induced osteonecrosis fail to provide mucosal coverage, which is a primary requirement in managing the condition. We have evaluated the results of a group of 15 patients and analysed their postoperative progress for 24 months.

Prospective study of morbidity associated with open reduction and internal fixation of the fractured condyle by the transparotid approach.

We present a summary of a prospective study of 50 consecutive cases into the morbidity associated with open reduction and internal fixation of the fractured mandibular condyle through the transparotid approach. It is acceptably safe, and the data can now be presented to patients to help them make an informed choice about options for treatment.

The management of renal failure in patients with liver disease. Experiences from a district general hospital.

AIM: To compare the pre-existing management of patients with Hepatorenal Syndrome (HRS) in the gastroenterology unit of the Royal Alexandra Hospital, Renfrewshire, with the published evidence based studies. METHOD: A retrospective, 6-month, case record review of patients diagnosed with HRS was performed. An evidence-based protocol for the diagnosis and management of HRS was introduced into the unit, to aid patient treatment prospectively. After 6 months, both compliance with the protocol, and patient outcomes were analysed. RESULTS: Eleven patients were identified in the first part of the audit cycle, all of whom died. Seven were identified in the second cycle. Two had their renal function successfully corrected and one was discharged from hospital. Renal impairment and staging of liver disease was equivalent in both groups. The second group received more appropriate and aggressive therapy. Alcohol was the causative aetiology of liver disease in all patients. CONCLUSIONS: Targetted therapy in patients with severe liver disease and HRS can improve renal parameters. Previous studies have shown this to be linked with improved patient outcomes.

Impact of alcohol related disease and inpatient workload of gastroenterologists in Scotland.

BACKGROUND: Concern among Scots gastroenterologists about alcohol related illness prompted this inpatient prevalence study during the winter of 2000-01. AIMS: To study gastrenterology inpatient workload due to alcohol-related illness, to determine how much was specialty specific, and if there were regional variations. METHODS: 40 Consultant gastrenterologists throughout Scotland collected data on the prevalence of alcohol related conditions among inpatients under their care on each of three specified days during the winter of 2000/2001. All inpatients under the care of participating consultants on the designated study days were included in the study. Overall return rate was 65%. Patients were categorised as follows; (a) general medical inpatients admitted for reasons other than alcohol related illness (b) general medical inpatients with no gastrointestinal or liver disease, but whose admission to hospital was primarily related to alcohol misuse, (c) gastrointestinal (including liver) inpatients admitted for reasons unrelated to alcohol intake, and with no alcohol related disease, and (d) gastrointestinal inpatients whose admission to hospital resulted from alcohol related disease. Additionally the numbers of patients with (e) decompensated liver disease of all causes, (f) decompensated alcoholic liver disease, and (g) the numbers "blocking" acute beds after initial hospitalisation with an alcohol related illness were collected. RESULTS: Overall, 829 general medical and 538 gastroenterology inpatients were entered in the study; total 1367 (705 male, 662 female). Of these, 25% (337/1367) were admitted because of alcohol related illness: 15% (201/1367) had decompensated alcoholic liver disease. Of 538 gastroenterology inpatients, 238 (44%) had problems related to alcohol and 201 of these (37% of all gastoenterology inpatients) had decompensated alcoholic liver disease. Of 246 inpatients with decompensated liver disease, 82% (201) had alcoholic liver disease. Alcohol related illness was significantly more prevalent among male inpatients in the West of Scotland. 10% of specialist gastroentelogy beds were occupied by patients whose discharge was delayed because of alcohol related problems. CONCLUSION: Most Scottish gastroenterlogists contribute to general medical receiving but their specialist inpatient workload is dominated by treatment of patients with alcohol related disease. (44% in gastroenterology v 12% in general medicine). Inpatients with decompensated alcoholic liver disease form 37% of gastroenterology workload. Alcohol related disease contributes to delayed discharge in acute medical units, especially in gastroenterology wards. There are regional differences in prevalence of alcohol related disease, which is greatest in male inpatients in the West of Scotland. Here, alcoholic liver disease accounts for nearly a decompensated liver disease. The findings point to a need to review the current patterns of acute service provision for alcohol related illnesses, so as to assess and improve both the linical effectiveness and cost effectiveness of care, and to ensure that alternatives to acute hospital admission are available when appropriate. This need should not be neglected while efforts are simultaneously being made to improve the early detection of alcohol abuse and prevent irreversible alcohol related disease.

Analysis of alcohol-related admissions in gastroenterology, cardiology and respiratory medicine.

A 4 week study of medical inpatients was performed to look at prevalence of alcohol-related problems in three different sub-specialties. Alcohol-related conditions accounted for 51% of gastroenterology inpatients, and 65% of these patients had alcoholic liver disease. In contrast, the cardiologists and respiratory physicians managed for less alcohol-related pathology, accounting for only 6% of inpatients in each specialty. Alcohol-related conditions were three times commoner in men. Patients admitted due to alcohol had longer lengths of stay, and experienced higher morbidity and mortality. These findings have important implications for health care planning and provision. They highlight a need for specialist training to be given to staff who deal with alcohol-related conditions on a daily basis. There is also a significant public health issue raised by these results regarding public attitudes in Scotland towards alcohol abuse and the increasing burden it is placing on the NHS.

Open reduction and internal fixation of fractured mandibular condyles by a retromandibular approach: surgical morbidity and informed consent.

Treatment of fractured mandibular condyles remains controversial. In this paper we present data collected prospectively on 42 fractured condyles treated by open reduction and internal fixation. The central issue, which is sometimes forgotten, is the informed consent of our patients. To this end we have looked at the surgical morbidity related to the retromandibular approach.

Consultants workload due to alcohol related conditions in acute medical receiving gastroenterology and endocrinology.

A four-week survey was performed into the incidence of alcohol related problems in the acute medical receiving unit, and the prevalence of alcohol related cases in a ward shared between two gastroenterologists and an endocrinologist. Alcohol related conditions were the commonest reason for acute admission (19%). Gastroenterologists, in contrast to their colleagues have a substantial workload related to alcohol, especially chronic liver disease. These patients have longer lengths of stay with higher morbidity and mortality than those without alcohol related conditions. The reason for these differences and the implications for service planning are discussed.

Transient hemi-diaphragmatic paralysis following neck surgery: report of a case and review of the literature.

Diaphragmatic paresis following trauma to the phrenic nerves is a rare complication after neck surgery. The resulting elevation of the ipsilateral hemi-diaphragm is diagnosed on post-operative chest radiography and may be confirmed by ultrasound or fluoroscopy. When unilateral, this may lead to respiratory, cardiac or gastrointestinal symptoms and atelectasis and pulmonary infiltrates on radiography. If nerve damage is bilateral a period of ventilation may be required.

Mass carbon monoxide poisoning.

The largest occurrence of carbon monoxide poisoning in Britain demonstrates the potential for mass accidental poisoning. It emphasises the need for strict public health controls and the importance of good liaison between emergency services to ensure that such events are quickly recognised and that the necessary resources are organised.

A grading system in day surgery: effective utilization of theatre time.

An in-house audit revealed a theatre utilization time in the day surgery unit of 70%. The reason identified for this poor theatre utilization was patient selection by the clerical staff based on a fixed number of cases per session. A grading system which estimated the anticipated duration of operation time was introduced as the basis for patient selection in the day surgery. A pilot study of 20 patients revealed that the system was both effective and simple to implement. It was therefore adopted. A re-audit of a further 299 patients treated using the grading system revealed that theatre utilization time had increased from 70 to 98%. The number of patients treated per session also increased, thus effectively reducing the waiting list. The grading system can be used in all clinical specialities providing day case surgery and we recommend it.

Treatment of retrobulbar haemorrhage in accident and emergency departments.

Retrobulbar haemorrhage is a rare complication of orbital injury or surgery. After injury the first clinicians to see these patients are often the staff of accident and emergency departments. This survey was instigated after several patients had been referred to our care irreversibly blind. A multiple choice questionnaire was devised and sent to 90 doctors working in accident and emergency departments in Scotland. A total of 57 (63%) were returned of which 55 were complete enough to analyse. The range of respondents was: consultants (n = 6), associate specialists (n = 3), senior registrars (n = 3), registrars (n = 4), senior house officer (n = 35), and clinical assistants (n = 4). Twenty nine of the 35 senior house officers (83%) were unable to diagnose and treat retrobulbar haemorrhage. Most consultants, senior registrars, registrars and associate specialists were significantly better in the diagnosis and treatment of this condition (P = 0.001). We conclude that there is an unacceptably high incidence of blindness as a result of inappropriate diagnosis and treatment of retrobulbar haemorrhage. We have therefore designed a protocol for accident departments which should help reduce the incidence of blindness.

Retrobulbar haemorrhage: can blindness be prevented?

Retrobulbar haemorrhage is a rare complication following orbital trauma or surgery occurring in less than 1 per cent of cases. Early diagnosis and treatment of this complication may save the vision of the affected eye. This paper illustrates cases where diagnosis was not made and blindness resulted. We also present two cases of successful treatment due to early diagnosis.

A comparison of omeprazole and ranitidine in the prevention of recurrence of benign esophageal stricture. Restore Investigator Group.

BACKGROUND/AIMS: Dilatation combined with subsequent pharmacological control of gastroesophageal reflux represents a logical but poorly documented approach to the management of benign esophageal stricture. This large trial (366 patients) aimed to assess whether omeprazole as the most effective available medication for gastroesophageal reflux disease prevents recurrent stricture formation. METHODS: Patients (n = 366) were randomized in a double-blind study to undergo either omeprazole (20 mg once daily; 180 evaluable patients) or ranitidine therapy (150 mg twice daily; 185 evaluable patients) for 1 year after dilatation to 12-18-mm diameter (36-54F gauge). Subsequently, endoscopy and dilatation were performed when clinically indicated and endoscopy on completion. Symptoms were assessed at clinic visits every 3 months and using weekly diary cards. RESULTS: Fewer patients undergoing omeprazole therapy required redilatation compared with those on ranitidine (43 of 143 [30%] vs. 66 of 143 [46%] by 12 months; P < 0.01), and patients in the omeprazole group needed fewer redilatations during the year (0.48 vs. 1.08; P < 0.01). On completion, symptom relief favored omeprazole: 76% of patients in the omeprazole group were free of dysphagia (compared with 64% in the ranitidine group; P < 0.05); 83% were able to accept a normal diet (69%; P < 0.01); and 65% were completely asymptomatic (43%; P < 0.001). CONCLUSIONS: Omeprazole, 20 mg once daily, was more effective than ranitidine, 150 mg twice daily, as prophylaxis against stricture recurrence and in providing symptom relief.

Rapid healing of gastric ulcers with lansoprazole.

BACKGROUND: Lansoprazole is a new proton pump inhibitor which powerfully decreases acid secretion. METHODS: We compared the efficacy and short-term safety of lansoprazole against ranitidine in the healing of gastric ulcer. This was a parallel group, comparative multicentre, prospectively randomized, double-blind study which included 250 patients with gastric ulcer, 219 of whom had follow-up endoscopic data. RESULTS: Both lansoprazole 30 mg and 60 mg daily produced significantly more rapid healing of gastric ulcer than ranitidine 300 mg nightly with healing rates after 4 weeks of 78% (P < 0.05), 84% (P < 0.01) and 61%, respectively. After 8 weeks, the corresponding healing rates were 99%, 97% and 91% (P = 0.08). Symptom relief was similar for all treatment groups, but fewer antacids were used by patients receiving lansoprazole. Sixty-nine patients experienced 91 adverse events; the incidence, pattern and severity was similar across all three treatment groups. CONCLUSIONS: Lansoprazole 30 mg and 60 mg once daily had similar efficacy. Both were superior to ranitidine 300 mg nocte in healing gastric ulcer. The short-term safety profile of lansoprazole was similar to ranitidine. These data indicate that lansoprazole should be used at a dose of 30 mg once daily for the treatment of gastric ulcers.