Outcomes and survival of tracheostomised patients during the COVID-19 pandemic in a third level hospital.

PURPOSE: Analyse the evolution and outcomes of COVID-19 tracheostomised patients. Clarify if this cohort presents an increased risk of haemorrhagic complications and verify the correlation between some risk factors with increased mortality. METHODS: A retrospective single-centre observational study of a prospective cohort of all COVID-19 patients admitted to our centre between March and April 2020. A control group was obtained from a historical cohort of patients who required tracheostomy due to prolonged invasive mechanical ventilation (IMV) before 2020. RESULTS: A total of 1768 patients were included: 67 tracheostomised non-COVID-19 patients (historic cohort), 1371 COVID-19 patients that did not require ICU admission, 266 non-tracheostomised COVID-19 patients and 64 tracheostomised COVID-19 patients. Comparing the obesity prevalence, 54.69% of the tracheostomised COVID-19 patients were obese and 10.53% of the non-tracheostomised COVID-19 patients (p < 0.001). The median of ICU admission days was lower (p < 0.001) in the non-tracheostomised cohort (12.5 days) compared with the COVID-19 tracheostomised cohort (34 days). The incidence of haemorrhagic complications was significantly higher in tracheostomised COVID-19 patients (20.31%) compared with tracheostomised non-COVID-19 patients (5.97%) and presented a higher percentage of obesity, hypertension, diabetes and smoking, significantly different from the historic cohort (p < 0.001). A Cox model showed that tracheostomy had no statistically significant effect on mortality in COVID-19 patients. CONCLUSION: Obesity and smoking may be risk factors for tracheostomy in COVID-19 patients, tracheostomised COVID-19 patients present a higher risk of bleeding complications than those admitted for other reasons and an elevated LDH and INR on ICU admission may be associated with increased mortality.

Role of jejunoplasty in complex esophageal reconstruction.

INTRODUCTION: Esophageal reconstruction is a very complex surgical procedure, burdened by significant morbidity. Gastroplasty and coloplasty have classically been used. Free jejunal plasty has shown to be a very good option in the treatment of cervical esophagus pathology, but the role of supercharged jejunoplasty in thoracic esophagus reconstruction is still controversial. METHODS: A retrospective study of esophageal reconstructions with jejunoplasties performed in our unit between January 2011 and December 2019. Epidemiological data, indications, surgical technique, and morbidity and mortality were analyzed. RESULTS: 67 procedures of esophageal reconstruction were performed, 10 of which were jejunoplasties: 5 free jejunums and 5 supercharged. Morbidity, mortality, mean stay and withdrawal time from enteral feeding were lower in free than in supercharged jejunums. CONCLUSIONS: Supercharged jejunoplasty was the last option for reconstruction of the thoracic esophagus. Median sternotomy access provides an excellent approach to the anterior mediastinum and the internal mammary vessels. The free jejunum would be the first choice, with the indemnity of the rest of the esophagus, in the reconstruction of the cervical esophagus.

Hyperfractionated radiotherapy: improvement of survival in locally advanced nasopharyngeal carcinoma.

OBJECTIVES: Standard treatment with concomitant chemotherapy (CT) and radiotherapy (RT) for nasopharyngeal cancer has shown rates of locoregional control of 80% and has improved the rate of 5-year survival to 67% to 84%. Hyperfractionated radiotherapy (HFRT) may increase locoregional control of tumors of the head and neck, but the addition of concomitant CT involves an unacceptable level of toxicity. Adding induction CT may control distant metastasis. Here we compare the results of our protocol with induction CT followed by HFRT alone with the results obtained with concomitant treatments. METHODS: Between October 1994 and May 2002, 46 patients with nasopharyngeal carcinoma were treated with HFRT. The patients with N+ or T4 lesions also received cisplatin-based induction CT (55%). RESULTS: The patients received a mean of 3 CT cycles (range, 2 to 5). At 5 years, the rate of progression-free survival was 66% (range, 51.3% to 82.1%), and the global survival rate was 75.7% (range, 61.9% to 89.5%). CONCLUSIONS: The use of HFRT in association with induction CT in patients with the greatest risk of metastasis may be as effective as concomitant CT-RT for treatment of nasopharyngeal cancer. Efforts should now concentrate on minimizing the acute and chronic toxicities.

Salvage surgery after head and neck squamous cell carcinoma treated with bioradiotherapy.

BACKGROUND: The purpose of this study was to describe the results and complications of primary site salvage surgery after head and neck squamous cell carcinoma (HNSCC) treated with bioradiotherapy. METHODS: We conducted a retrospective chart review of 268 patients treated with bioradiotherapy between March 2006 and December 2013 at the Hospital Universitari de Bellvitge-ICO. RESULTS: Fifty-nine patients developed local recurrence or had residual disease with a 1-year and 3-year overall survival of 47% and 15.4%, respectively. Salvage surgery was feasible in 22 patients (37.3%). There were 16 complications in these 22 patients (72.7%), 11 (50%) of which were major. Bilateral neck dissection was identified as a risk factor for complications. CONCLUSION: Salvage surgery after bioradiotherapy is associated with a high rate of complications. Neck dissection seems to be related to an increased rate of complications with no survival improvement. © 2016 Wiley Periodicals, Inc. Head Neck 39: 116-121, 2017.

Analysis of predisposing factors for complications of percutaneous tracheostomy.

Since the turn of the century, percutaneous tracheostomy (PT) has become an alternative to the classic open technique and is an elective procedure in intensive care units at most centers. We conducted a prospective study to identify and quantify the complication rate with PT and to analyze this procedure's association with potential risk factors. Our study population was made up of 114 patients-83 men (72.8%) and 31 women (27.2%), aged 18 to 81 years (mean: 57 ± 15)-who underwent PT at our center over an 18-month period. We sought to determine if there were any associations between PT complications and sex, previous fibroscopy, cervical length, cervical risk factors, and general risk factors. Generally minor complications were noted in 15 patients (13.2%); 13 patients experienced hemorrhage, 1 exhibited subcutaneous emphysema, and 1 had a vagal reaction that resolved with medical treatment. Only 3 of these cases (2.6%) were considered to be clinically relevant: 1 hemorrhage (which was treated with ligation), the emphysema (which resolved spontaneously), and the vagal reaction (which resolved with medical treatment). Statistically, we found that PT complications were significantly correlated with two factors: coagulopathy (p = 0.015) and hemodynamic instability (p = 0.017). Even so, these complications were not clinically significant, and they resolved with conservative treatment measures. Given the low incidence and mild degree of these complications, we consider PT to be a safe procedure, even in patients with a high risk of hemorrhage or cervical anatomic difficulties.

[Free radial forearm flap in head and neck: our experience]. / Colgajo antebraquial radial en cabeza y cuello: nuestra experiencia.

INTRODUCTION: Oncologic surgery leads to important defects and sequelae, as well as notable cosmetic and functional alterations. In this aspect reconstructive surgery has an essential role, allowing more radical excision and lower associated functional and cosmetic morbidities. The aim of this study was to present and evaluate the experience and results of the reconstructive microsurgery unit in our centre's ENT department. METHODS: Retrospective study of procedures performed between 2006 and 2012. RESULTS: A total of 36 cases were reviewed. The primary tumour was found in the oropharynx (58%) in the majority of cases. In 5 cases the procedure was performed for reconstruction and fistula closure (4 pharyngostoma and 1 tracheoesophageal fistula). Failure from total necrosis was 16% (6/36). No associated mortality has been reported. The most common postoperative complications were wound dehiscence in 5 patients and pharyngostoma (fistula) in 5 cases. Prior radiotherapy significantly influenced the increase in the overall incidence of complications (P<05). CONCLUSIONS: Reconstructive surgery currently plays an important role in surgery for head and neck cancer. The radial forearm flap is a safe, reliable method for reconstruction of most defects in the ENT field. This type of intervention provides greater autonomy and safety in surgical oncology.

Facial reanimation surgery with micro-vascular gracilis free flap for unilateral facial palsy.

INTRODUCTION AND OBJECTIVES: Micro-neurovascular free muscle flap transfer is currently the procedure of choice for long-standing facial paralysis. We present a case series of patients treated with gracilis muscle free flap with motor innervation by the masseteric nerve. We discuss the surgical technique and quantify the movement granted by the muscle, the improvement in quality of life and aesthetic results. MATERIALS AND METHODS: We report ten patients with unilateral facial paralysis who underwent free gracilis muscle flap, between the years 2010 and 2012 in two tertiary hospitals. RESULTS: It is not reported any failure of the microsuture with survival of all flaps. The muscle movement was quantified by vectors at rest and contraction with an average of 1.7 cm that initiated around the fourth month after surgery. Patients also reported a significant improvement in symmetry at rest as well as oral and ocular competition. CONCLUSION: As currently presented in literature, microvascular free flaps are the technique of choice for facial reanimation. In our experience, we believe that gracilis muscle flap innervated by the masseteric nerve is a reliable and secure technique that provides adequate functional and aesthetic results.