Transoral treatment of Zenker diverticulum: flexible endoscopy versus endoscopic stapling. A retrospective comparison of outcomes.

Transoral stapled diverticulo-esophagostomy (TSDE) has gained increased popularity in surgical treatment of Zenker diverticulum (ZD). One of the advantages of this approach is early rehabilitation with significant decrease in patient morbidity and time to resumption of oral intake as compared with open treatment. The section of the septum between the diverticulum and the esophagus with a flexible endoscopic (ES) approach has also been proposed since mid-90s as an alternative for treatment of ZD. Both these approaches are a minimally invasive approach to treat ZD. We compared the TSDE management of ZD versus the ES treatment in a retrospective consecutive series of patients who were referred to either the ES or surgical unit of our Institute. Fifty-eight consecutive patients underwent treatment for ZD either by TSDE or ES. The two techniques were evaluated for length of hospital stay, diverticulum size, resumption of oral intake, resolution of dysphagia, and complications. Clinical outcome was evaluated throughout a symptom score from 0 to 3, calculated before and after the procedure. The two groups were compared on the various parameters using a Mann--Whitney test. Twenty-eight patients underwent ES and 30 TSDE for ZD. In both groups, a significant decrease in postoperative versus preoperative dysphagia was reported. The average length of hospital stay wasn't significantly different in the two groups (3.38 days for TSDE vs. 2.42 days for ES). The overall complication rate was similar in the two groups. There were two cases in the ES group and three cases in the TDSE group that required an ES revision to take down a residual diverticular wall that produced a mild but persistent dysphagia. Minimally invasive treatment of ZD both with ES and with TSDE is a valuable option for this disease: both techniques are safe and effective, with similar outcome in terms of hospital stay, symptom reduction, and complication rate. Long-term results have to be evaluated.

Transoral surgical removal of a giant fibrolipoma of the esophagus: case report.

An esophageal mass of more than 20 cm in length was diagnosed in a patient who presented with persistent dysphagia. Diagnosis of an endo-esophageal tumour was made by barium swallow; esophagoscopy confirmed the presence of a capsulated pink endo-esophageal mass. MRI confirmed the presence of a large capsulated mass within the esophagus, that appeared to be adipose tissue; a small stalk originating at the level of the upper esophageal sphincter was described and the polyp extended down to the gastroesophageal junction. Demonstration of the site and length of the stalk allowed a transoral removal of the mass, performed through a Weerda diverticuloscope (Karl Storz Endoskopie Gmbh, Tuttlingen Germany), a technique that has never been described before. Histology confirmed the mass as a fibrolipoma. The authors discuss both the role of MRI in diagnosis and treatment planning and the technique of transoral excision.

Efficacy of autofluoroscence videoendoscopy in the diagnosis of laryngeal lesions.

Aim of this prospective preliminary study was to assess effectiveness and reliability of autofluorescence endoscopy in the diagnosis of laryngeal lesions, in particular, evaluating whether it could represent an improvement in comparison to standard endoscopy alone. A total of 81 laryngeal biopsy specimens, taken from 46 consecutive patients who underwent intra-operative endoscopic assessment in a period of 2 years, were examined. Thirteen patients underwent the procedure for presumed benign lesions; the other 33 cases for pre-operative endoscopic suspicion of pre-cancerous or cancerous lesions. In our experience, autofluorescence evaluation seemed to accurately delineate the limits of the tumour and the possible presence of second primary, proving a useful guide in the choice of sites to make a biopsy. In particular, this endoscopic method has proved to be characterized by higher sensitivity and specificity not inferior to standard endoscopy, both in the discrimination between benign and preneoplastic/neoplastic lesions and between pre-neoplastic and neoplastic. Correct choice of the application field is mandatory in order to obtain the maximum effectiveness of this method. Autofluorescence endoscopy, in fact, was found to be very useful in the evaluation of untreated tissues with suspected pre-cancerous or cancerous lesions. On the contrary, in the study of "frankly benign" laryngeal lesions, this exam does not improve upon the results obtained by standard endoscopy but increases the risk of false positives. The best results can be obtained only by integration of data provided by both white-light and accurate auto-fluorescence endoscopic assessment.

Cranial and cervical nerve injuries after carotid endarterectomy: a prospective study.

BACKGROUND: The purpose of this study was to review the outcome of patients who had cranial and cervical nerve injuries after carotid endarterectomy (CEA). METHODS: This prospective study reviewed 200 consecutive CEAs. Preoperative and postoperative cranial nerve assessment was completed on all patients. Neurologic evaluation included routine direct fiberoptic laryngoscopy. Patients found to have no neurologic injury had no further follow-up. Patients with postoperative peripheral neurologic dysfunction were enrolled for regular long-term follow-up to assess delayed recovery. RESULTS: Overall, 25 (12.5%) nerve injuries were identified in 24 patients. There were 11 (5.5%) hypoglossal, 8 (4%) recurrent laryngeal, 2 (1%) superior laryngeal, 2 (1%) marginal mandibular, and 2 (1%) greater auricular nerve injuries. None of the patients were lost to follow-up. All nerve dysfunctions were transient, with all but 4 nerves recovering completely within 6 months. The recovery took from 1 week to 37 months, with a mean recovery time of 5.8 months. Two patients with recurrent laryngeal nerve dysfunction were found to have prolonged full recovery time (i.e., 31 and 37 months, respectively). Two patients successfully underwent contralateral CEA, although movement of the opposite vocal cord was not fully restored. CONCLUSIONS: Cranial nerve injury after CEA is a common occurrence and can be classified as a "major" or "minor" complication, depending on the severity of the clinical consequences. Extended follow-up will identify the specific subset of patients with a late complete nerve recovery.

Minimally invasive surgery for Zenker diverticulum: analysis of results in 95 consecutive patients.

OBJECTIVE: To assess the effectiveness of transoral stapled diverticulum esophagostomy in relieving symptoms and decreasing outflow resistance at the pharyngoesophageal junction in patients with Zenker diverticulum. DESIGN: Cohort study. From April 1, 1992, until May 31, 1996, the operation was attempted in 95 patients. The median follow-up was 23 months (range, 13-48 months). SETTING: Tertiary care university hospital. PATIENTS: There were 74 men and 21 women, with a median age of 64 years (age range, 37-92 years). All complained of dysphagia and pharyngo-oral regurgitation, and 18 (20%) suffered from recurrent aspiration pneumonia. The median size of the pouch measured by flexible endoscopy was 4 cm (range, 2.5-8 cm). INTERVENTION: The septum between the diverticulum and the esophageal lumen was divided under general anesthesia using a linear endostapler introduced through a Weerda endoscope. In most patients, 2 applications of the endostapler with a modified anvil were used. Operative time averaged 23 minutes. MAIN OUTCOME MEASURES: Morbidity, symptom score, patient's satisfaction, videofluorographic barium transit, hypopharyngeal intrabolus pressure, upper esophageal clearance of radioisotope. RESULTS: A switch to open surgery was required in 3 patients (3.1%), due to difficult exposure of the common wall in 2 cases and a mucosal tear in the other. No postoperative morbidity or mortality was recorded. Oral feeding was started the following day and the median hospital stay was 3 days (range, 2-8 days). Five patients complained of persistent symptoms; 3 of them underwent another endosurgical operation, 1 underwent laser treatment by means of flexible endoscopy, and 1 eventually required open surgery. All patients are asymptomatic at the latest follow-up visit. Postoperative radiologic studies showed free flow of barium in all patients. Manometry showed a significant reduction of hypopharyngeal intrabolus pressure over preoperative values (P=.003). Radionuclide studies showed a significant reduction of upper esophageal residual activity at 1 minute compared with preoperative values (P=.006). CONCLUSIONS: Endosurgical approach to hypopharyngeal diverticula larger than 2 cm is safe and effective. Symptom relief, elimination of the pouch, and decreased outflow resistance at the pharyngoesophageal junction can be obtained without morbidity and with a short hospital stay.

Assessment and treatment of neurogenic and non-neurogenic tumors of the parapharyngeal space.

The clinical and pathologic findings in eleven cases of parapharyngeal space tumors are described. The anatomy of this area and diagnostic procedures are discussed. Investigations should include a few basic examinations such as sialogram-computed tomographic (CT) scan, carotid angiogram, and echography. Several surgical approaches are considered in relation to the site and the size of the neoplasm. Prognosis depends on the histologic type of the tumor.

Endoscopic dilation of acquired tracheobronchial stenosis in infants.

Acquired tracheobronchial strictures in infants are associated with significant morbidity. Their treatment requires different types of therapeutic procedures depending on the severity and location of the stenosis. We successfully dilated five children (ages between 1 and 23 months) with acquired tracheobronchial (stenoses two carinal and three of the mainstem bronchi) using a new technique. Gruentzig balloon catheters of different caliber were introduced into the tracheal lumen of apneic children under endoscopic vision. Three infants required four dilations and in the other two cases only two procedures were necessary. One complication occurred during dilation and resulted in a pneumothorax caused by a partial-bronchial disruption. At follow-up (range, 18-36 months; mean, 23.4 months) all five children were clinically improved. In the four cases without complications the chest x-rays were normal and the last bronchoscopy showed tracheobronchial trees with normal calibers. The child who developed a pneumothorax during attempted dilation recovered. In this child, dilation of the right upper lobe bronchus was unsuccessful. Dilation was attempted without visualization of the bronchus and the stricture. Our limited experience confirms that pneumatic balloon catheters can successfully treat acquired tracheobronchial stenoses in infants. To avoid complications, strict criteria need to be applied in the selection of cases with tracheobronchial stenoses.

Primary laryngeal malignant fibrous histiocytoma: review of the literature and report of seven cases.

After describing 4 new cases of malignant fibrous histiocytoma of the larynx (3 cases had been recently published), the authors review the literature, from which it appears that 16 such lesions of the larynx have been reported (including their 7 cases). Malignant fibrous histiocytoma usually occurs in the soft tissues, tendons and joints of the upper and lower extremities, and is uncommon in the head and neck--though not exceptional. The lesion is a mesenchymal tumor probably of histiocytic origin and may be divided into 6 subtypes, i.e., pleomorphic, fibrous, giant cell, angiomatoid, myxoid and inflammatory, to be distinguished on the basis of the predominant feature. The tumor has an aggressive biologic behavior as it tends to recur and to metastasize to distant organs. The treatment of choice is surgery and adjuvant combination chemotherapy which at times may improve the survival rate.

Tailored approach to Zenker's diverticula.

BACKGROUND: Zenker's diverticula (ZD) can be treated by diverticulostomy or open surgery (upper esophageal sphincter myotomy and diverticulectomy or diverticulopexy). The aim of this study was to compare the outcome of the two alternative treatments. METHODS: Fifty eight patients were scored for symptoms and upper esophageal sphincter (UES) pressure; relaxations and intrabolus pressures were recorded by manometry. Treatment depended on operative risk and ZD size. Twenty four patients with high surgical risk and/or a <3-cm or >5-cm pouch underwent diverticulostomy; the other 34 had open surgery. RESULTS: Mortality was nil. Five patients had postoperative complications after open surgery (p<0.05). Hospital stay was shorter after diverticulostomy (p<0.001). Follow-up (41 months; range, 1-101) was obtained in 53 patients. Postoperative manometry showed a UES pressure reduction, improved UES relaxation, and lower intrabolus pressure in both groups (p<0.05). In the diverticulostomy group, three patients complained of severe dysphagia. vs none in the open surgery group (p<0.05). CONCLUSION: Diverticulostomy is safe, quick, and effective for most patients with medium-sized ZD, but open surgery offers better long-term results and should be recommended for younger, healthy patients with small or very large diverticula.

The safety of home tracheostomy care for children.

Home tracheostomy care avoids prolonged hospitalization for tracheostomized children who must remain cannulated for a long time; however the safety aspects of this form of management are still under discussion. Since 1987 the authors have tutored parents in tracheostomy care. Once parental training was complete and the necessary equipment (aspirator, humidifier, etc) provided, children in stable condition were discharged and had period follow-up as outpatients. Thirty-four children had a total of 710 months in home care; 11 of them had decannulation. The only reported complications were two partial obstructions of the cannula and two accidental decannulations. The low number of documented accidents and the parents' profound appreciation in having their children at home indicate that patients with a tracheostomy in need of long-term care can be safely managed at home.

Endoscopic diverticulotomy for the treatment of Zenker's diverticulum: results in 102 patients with staple-assisted endoscopy.

Endoscopic diverticulotomy for the treatment of Zenker's diverticulum has been reported infrequently in the literature and has engendered considerable controversy. Between March 1992 and September 1996, we attempted to treat 102 patients with endoscopic treatment for pharyngoesophageal diverticula. In 98 patients, the endoscopic surgery was successfully completed. Conversion to open surgery was required in 4 patients (3.92%). One cartridge of staples in 16 patients (16.32%), 2 cartridges in 78 patients (79.59%), and 3 cartridges in 4 patients (4.08%) were used, according to the size of the diverticulum; the median duration of the procedure was 20 minutes (10 to 60 minutes). No postoperative morbidity or mortality was recorded. Oral feeding was started following radiologic control after a median of 2 days; the median hospital stay was 4 days. The median follow-up is 16 months (1 to 45 months). Four patients operated on before the introduction of the modified stapler showed a persistent diverticular pouch: 3 underwent repeat endoscopic operation, and 1 underwent conventional open surgery. All treated patients are asymptomatic. Manometric study performed in 15 patients showed a significant reduction of basal upper esophageal sphincter pressure compared to preoperative data (48.30+/-21.74 versus 29.38+/-5.68 mm Hg; p<.01). We therefore recommend endoscopic diverticulotomy, considering that the procedure is relatively safe and effective, with minimal patient discomfort, and the results are equal to those of the external approach. This procedure offers the advantages of short hospitalization, rapid convalescence, brief operative time, absence of skin incision. predictable resolution of symptoms, and reduced morbidity.

The importance of acoustic impedance measurements in middle ear pathology during acute viral respiratory illness in the first year of life.

The very high incidence of ME pathology in epidemic bronchiolitis prompted the systematic use of impedance measurement tests in a study of the otitic process. Data were assembled of 44 children admitted to the paediatric clinic with acute viral respiratory infection (in the last year). On account of the high incidence (97%), the precocity of occurrence (1-12 months), the slow rehabilitation and the frequency of relapses, the ME pathology in these children indicates the importance of a correct approach to the problems of relapsing otitis in infants. Patients were treated with aerosol therapy (mucolytic substance), nasal drops (with vasoconstrictors), and only in very serious cases with antibiotics. For the latter, cortisonic therapy is inadvisable, while it is absolutely necessary to follow up with periodic controls until the tympanogram becomes normal. The impedance findings (prevalent type B curves, with inability to evoke the stapedius reflex, over periods of several months) and their resolution in type AC or C curves led us to consider not only the organic problem, but also the functional hearing problem during the first year of life, and the possible longterm repercussion.

Surgical treatment of cervical anastomotic leaks following esophageal reconstruction.

Cervical anastomotic leaks occurring in the early postoperative period after esophageal reconstruction are life-threatening complications, with a mortality rate similar to that of intrathoracic leaks if the posterior wall of the anastomosis is affected. Prompt diagnosis and aggressive surgical treatment is vital. The surgical procedures commonly used are often inadequate or unsatisfactory because of the difficulties encountered in the subsequent reconstruction. Twelve patient with an early cervical anastomotic leak following elective esophageal surgery were treated using an original surgical technique which allows diversion and simple delayed reconstruction of the anastomosis without risk of late stricture. Uncontrolled mediastinal sepsis accounted for the three deaths of the series and occurred in patients with a leak of the posterior anastomotic wall in whom definitive surgical treatment was delayed.

Long-term survival in response to combined chemotherapy and radiotherapy in laryngeal small cell carcinoma.

Fourteen patients with small cell carcinoma of the larynx are studied. This represents the largest series, from a single institution, reported in the literature. This neoplasm is usually highly aggressive and the prognosis very poor, but, in our experience, combined chemo- and radiotherapy can significantly improve the clinical course of the disease. Three of six patients who received this combined modality treatment are still clinically disease-free more than six years after the initial diagnosis.

[Therapeutic effects of ribostamycin in postoperative antibiotic treatment. Comparisons and results]. / Effetti terapeutici della ribostamicina nel trattamento antibiotico post-operatorio. Confronti e risultati.

20 patients have been treated, 10 with ribostamycin sulphate, 5 with gentamycin and 5 with sodium cephalotin. Patients were selected at random from those who had undergone abdominal, thoracic or cervical operations. Doses were 1000-2000 mg i.m. for ribostamycin, 4-8 g i.v. for cephalotin, and 160-240 mg i.m. for gentamycin. Mean treatment time was 12.5 days. Indices of therapeutic activity, parameters of liver and renal function and otovestibular function are indicated. The therapeutic activity of ribostamycin was very good and no side-effects were observed.

[Surgical emergency in thyroid disease: acute respiratory failure caused by tracheal obstruction]. / Emergenza chirurgica in patologia tiroidea: insufficienza respiratoria acuta da ostruzione tracheale.

Diagnostic and therapeutic approach to emergency due to acute and severe respiratory compromise by thyroid goiters with tracheal obstruction is discussed. Such an alarming condition was observed in 5 (2.3%) out of 215 mediastinal goiters operated between 1967-91. Retrospective and critical analysis of these cases pointed out that preventive removal of a large goiter is the best prophylaxis; first management is not surgical, although urgent features. Admission to intensive care center and endotracheal intubation allow an adequate interpretation of the pathologic condition and operative troubles and risks. Diagnostic investigations, effective and kept to a minimum (chest x-ray, tracheo-laryngoscopy, TAC), must be carried out without delaying thyroidectomy and prolonging intubation for days. The extraction of goiter is nearly always performable by the cervicotomic way. Whenever necessary endotracheal intubation obviates the need of tracheostomy for solving transient postoperative complications such as laryngeal oedema, local hematoma and recurrent nerves stupor.

[1% bifonazole lotion in the therapy of otomycosis]. / Bifonazolo lozione 1% nella terapia delle otomicosi.

Twenty-five patients suffering from otomycosis were treated once daily with bifonazole lotion 1% for a period of 4-15 days (means +/- DS 9.5 +/- 2.6 days). Two days before the end of the treatment complete resolution of the clinical picture in 23/23 patients was observed. Direct mycological and cultural examinations undertaken during the same control visit showed complete eradication of the responsible fungi in all 23 patients. Two-four weeks after the end of therapy a further control visit was carried out, during which 2/21 cases with clinical and mycological relapses were seen; both patients had chronic otitis. Tolerability of bifonazole was satisfactory in all cases but one, who interrupted treatment because of pain and local hyperemia where the lotion had been applied. In some patients suffering from chronic otitis application of the lotion caused slight and short-lasting pain and burning of the ear.

[Benign laryngotracheal stenoses in pediatric age]. / Stenosi laringo-tracheali benigne in età pediatrica.

The diagnosis and treatment of infants and children with laryngo-tracheal pathology has changed substantially over the last 20 years. The change is the result of the continued evolution of diagnostic instruments, surgical techniques and new advancements in critical care medicine. Abnormalities in the development of the larynx may lead to congenital subglottic stenosis. A variety of pathogenic processes, either inflammatory or iatrogenic, also may damage the cricoid cartilage and lead to subglottic stenosis. The stenosis may involve alone or in combination the subglottis, glottis, upper cervical trachea. In this article the author reports a 12 years experience in 114 patients affected by benign laryngo-tracheal stenosis. These patients are classified in two groups: 1) 75 patients with congenital stenosis, 2) 39 patients with acquired stenosis. For the diagnose video-endoscopy has been used, and for the classification the Cotton's technique has been used. To get the best results in this pathology it is very important to have a multidisciplinary approach.

Fibrous dysplasia of middle turbinate associated with Widal syndrome: endoscopic treatment of a rare case.

Fibrous dysplasia, a rare bony disease, is characterised by substitution of normal bone with immature tissue embedded in a fibrous stroma. It can be either monostotic or involve several bones. Fibrous dysplasia is usually asymptomatic but, in the advanced stage, pain due to neural compression or pathological fractures may occur. In the case of cranio-facial involvement, ocular, masticatory, respiratory or auditory functional alterations are possible. A case of fibrous dysplasia, limited to the middle turbinate and associated with Widal triad (sinus-nasal polyposis, asthma, acetyl salicylic acid intolerance), is described. Craniofacial computed tomography revealed enlargement of left middle turbinate with characteristic "ground-glass" appearance. The patient underwent anterior bilateral functional endoscopic sinus surgery with near-total resection of left middle turbinate. Histopathological examination confirmed the diagnosis of fibrous dysplasia. After 2 years the patient is still asymptomatic. Videorhinoscopy shows good sinus-nasal patency without disease recurrence. Even though exceptional, localization of fibrous dysplasia at middle turbinate has been described, therefore, it must be considered in the differential diagnosis of the craniofacial ossifying disorder. For localized and symptomatic lesions, endoscopic surgery is an effective option. Scrupulous life-long follow-up is necessary due to the high percentage of recurrence and possible malignant degeneration.

Contact laser surgery in treatment of vocal fold paralysis.

Vocal fold paralysis is a pathological condition characterised by varying degrees of respiratory distress in relation to the degree of glottic stenosis. Dyspnoea may be present even when resting and may even require emergency tracheotomy. Frequently, the patient arrives for attention after the onset of exertional dyspnoea associated with a certain degree of dysphonia. The causes may be central or peripheral, more commonly iatrogenic following thyroid or tracheal surgery or secondary to injury. The aim of all surgical techniques used in the treatment of vocal fold paralysis is to restore a lumen sufficient to guarantee adequate breathing through the natural airway, without the patient having to permanently maintain the tracheotomy tube, while preserving acceptable phonatory quality. Between 1990 and 2001, at the Padua Hospital Unit of Endoscopic Airway Surgery, 48 patients (27 female, 21 male) were treated for respiratory distress secondary to vocal fold paralysis. At the beginning of this experience, 7 patients underwent arytenoidectomy with the Ossoff technique. In 34 cases, a modified Dennis-Kashima posterior cordectomy was performed. In 7 patients, since widening of the airway was necessary, cordectomy was extended to the false homolateral chord in 5 cases and to the arytenoid vocal process in another 2. In 9 patients, the operation was carried out with a Nd Yag (1064 nm) contact laser; the remaining 39 were treated with a GaArAl (810 nm) diode laser in use since 1995. Satisfactory results were obtained in all patients first treated by us and not already tracheotomised (35). In 23 cases (66%), results were considered "good" since no exertional dyspnoea occurred. In 12 patients (34%), the result was considered "sufficient" since there was no resting dyspnoea and normal everyday activity could be undertaken. Of the 13 patients already tracheotomised on arrival, 11 (85%) were decanulated on average 2 months after surgery. In conclusion, the present results show that endoscopic posterior cordectomy, performed by contact diode laser, gives reliable results, is rapid and simpler to perform than arytenoidectomy and guarantees a sufficient airway without impairing swallowing, while maintaining entirely acceptable voice quality.