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BACKGROUND: Pathologic complete response after neoadjuvant chemoradiotherapy for rectal cancer is associated with improved survival. It is unclear whether residual carcinoma in situ portends a similar outcome. OBJECTIVE: To compare the survival of patients with locally advanced rectal cancer who received neoadjuvant therapy and achieved pathologic carcinoma in situ versus pathologic complete response. DESIGN: Retrospective cohort study. SETTING: National public database. PATIENTS: A total of 4594 patients in the National Cancer Database from 2006 to 2016 with locally advanced rectal cancer who received neoadjuvant therapy, underwent surgery, and had node-negative ypTis or ypT0 on final pathology were included. Of these, 4321 patients (94.1%) had ypT0 and 273 (5.9%) had ypTis on final pathology. MAIN OUTCOME MEASURE: Overall survival. RESULTS: The median age was 60 years, and 1822 patients (39.7%) were women. On initial staging, 54.5% (n = 2503) had stage II disease and 45.5% (n = 2091) had stage III disease. The ypTis group had decreased overall survival compared to the ypT0 group (HR 1.42; 95% CI, 1.04-1.95; p = 0.028). Other factors associated with decreased overall survival were older age at diagnosis, increasing Charlson-Deyo score, and poorly differentiated tumor grade. Variables associated with improved survival were female sex, private insurance, and receipt of both neoadjuvant and adjuvant chemotherapy. For the total cohort, there was no difference in survival between clinical stage II and stage III. LIMITATIONS: Standard therapy versus total neoadjuvant therapy could not be abstracted. Overall survival was defined as the time from surgery to death from any cause or last contact, allowing for some erroneously misclassified deaths. CONCLUSIONS: ypTis is associated with worse overall survival than ypT0 for patients with locally advanced rectal cancer who receive neoadjuvant chemoradiotherapy followed by surgery. For this cohort, clinical stage was not a significant predictor of survival. Prospective trials comparing survival for these pathologic outcomes are needed. See Video Abstract . SUPERVIVENCIA DEL CNCER DE RECTO PARA EL CARCINOMA RESIDUAL IN SITU VS RESPUESTA PATOLGICA COMPLETA DESPUS DE LA TERAPIA NEOADYUVANTE: ANTECEDENTESLa respuesta patológica completa después de la quimiorradioterapia neoadyuvante para el cáncer de recto se asocia con una mayor supervivencia. No está claro si el carcinoma residual in situ presagia un resultado similar.OBJETIVOComparar la supervivencia de pacientes con cáncer de recto localmente avanzado que recibieron terapia neoadyuvante y lograron un carcinoma patológico in situ versus una respuesta patológica completa.DISEÑOEstudio de cohorte retrospectivo.ESCENARIOBase de datos pública nacional.PACIENTESSe incluyeron 4,594 pacientes de la Base de Datos Nacional de Cáncer de 2006 a 2016 con cáncer de recto localmente avanzado que recibieron terapia neoadyuvante, fueron sometidos a cirugía y tuvieron ganglios negativos, ypTis o ypT0 en el reporte patológico final. 4.321 (94,1%) tuvieron ypT0 y 273 (5,9%) tuvieron ypTis en el reporte final.PRINCIPALES MEDIDAS DE RESULTADOSupervivencia general.RESULTADOSLa mediana de edad fue de 60 años. 1.822 pacientes (39,7%) fueron mujeres. El 54,5% (n = 2.503) tuvo la enfermedad en estadio II y el 45,5% (n = 2.091) tuvo la enfermedad en estadio III según la estadificación inicial. El grupo ypTis tuvo una supervivencia general reducida en comparación con el grupo ypT0 (HR 1,42, IC 95 % 1,04-1,95, p = 0,028). Otros factores asociados con una menor supervivencia general fueron una edad más avanzada al momento del diagnóstico, un aumento de la puntuación de Charlson-Deyo y un grado tumoral poco diferenciado. Las variables asociadas con una mejor supervivencia fueron el sexo femenino, el seguro privado y la recepción de quimioterapia neoadyuvante y adyuvante. Para la cohorte total, no hubo diferencias en la supervivencia entre el estadio clínico 2 y el estadio 3.LIMITACIONESNo se pudo resumir el tratamiento estándar versus el tratamiento neoadyuvante total. La supervivencia general se definió como el tiempo transcurrido desde la cirugía hasta la muerte por cualquier causa o último contacto, lo que permite algunas muertes erróneamente clasificadas.CONCLUSIONESypTis se asocia con una peor supervivencia general que ypT0 en pacientes con cáncer de recto localmente avanzado que reciben quimiorradioterapia neoadyuvante seguida de cirugía. Para esta cohorte, el estadio clínico no fue un predictor significativo de supervivencia. Se necesitan ensayos prospectivos que comparen la supervivencia de estos resultados patológicos. ( Traducción-Dr Osvaldo Gauto ).
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Terapia Neoadyuvante , Estadificación de Neoplasias , Neoplasia Residual , Neoplasias del Recto , Humanos , Masculino , Femenino , Persona de Mediana Edad , Neoplasias del Recto/terapia , Neoplasias del Recto/patología , Neoplasias del Recto/mortalidad , Terapia Neoadyuvante/métodos , Terapia Neoadyuvante/estadística & datos numéricos , Estudios Retrospectivos , Anciano , Tasa de Supervivencia , Proctectomía , Respuesta Patológica CompletaRESUMEN
BACKGROUND: Creation of a tension-free colorectal anastomosis after left colon resection or low anterior resection is a key requirement for technical success. The relative contribution of each of a series of known lengthening maneuvers remains incompletely characterized. OBJECTIVE: The aim of this study was to compare technical procedures for lengthening of the left colon before rectal anastomosis. DESIGN: A series of lengthening maneuvers was performed on 15 fresh cadavers. Mean distance gained was measured for each successive maneuver, including 1) high inferior mesenteric artery ligation, 2) splenic flexure takedown, and 3) high inferior mesenteric vein ligation by the ligament of Treitz. SETTING: Cadaveric study. MAIN OUTCOME MEASURES: The premobilization and postmobilization position of the proximal colonic end was measured relative to the inferior edge of the sacral promontory. Measurements of the colonic length relative to the sacral promontory were taken after each mobilization maneuver. The inferior mesenteric artery, sigmoid colon, and rectum specimen lengths were measured. The distance from the inferior border of the sacral promontory to the pelvic floor was measured along the sacral curvature. RESULTS: Mean sigmoid colon resection length was 34.7 ± 11.1 cm. Before any lengthening, baseline reach was -1.3 ± 4.2 cm from the sacral promontory. Inferior mesenteric artery ligation yielded an additional 11.5 ± 4.7 cm. Subsequent splenic flexure takedown added an additional 12.8 ± 9.6 cm. Finally, inferior mesenteric vein ligation added an additional 11.33 ± 6.9 cm, bringing the total colonic length to 35.7 ± 14.7 cm. BMI and weight negatively correlated with length gained. LIMITATIONS: The study was limited by nature of being a cadaver study. CONCLUSIONS: Stepwise lengthening maneuvers allow significant additional reach to allow a tension-free left colon to rectal anastomosis. See Video Abstract . ESTUDIO CADAVRICO DE MANIOBRAS DE ALARGAMIENTO COLNICO TRAS UNA SIGMOIDECTOMA: ANTECEDENTES:La creación de una anastomosis colorrectal libre de tensión tras una resección de colon izquierdo o tras una resección anterior baja es un requisito clave para el éxito relacionado con la técnica quirúrgica. La relativa contribución de las diversas maniobras de alargamiento permanece caracterizada de manera incompleta.OBJETIVO:El propósito de este estudio fue la de comparar procedimientos técnicos de alargamiento del colon izquierdo previo a la anastomosis rectal.DISEÑO:Una serie de maniobras de alargamiento fueron realizados en 15 cadáveres frescos. La distancia promedio ganada fue medida para cada maniobra sucesiva, incluyendo (1) ligadura alta de la arteria mesentérica inferior, (2) descenso del ángulo esplénico, (3) ligadura alta de la vena mesentérica interior mediante el ligamento de Treitz.AJUSTES:Estudio cadavérico.PRINCIPALES MEDIDAS DE RESULTADO:La posición premobilizacion y postmobilizacion del extremo proximal del colon fue medido tomando en cuenta el borde inferior del promontorio sacro. Las mediciones de la longitud colónica en relación al sacro fueron tomadas luego de cada maniobra de movilización. Fueron tomadas así mismo las longitudes de la arteria mesentérica inferior, el colon sigmoides y recto. Las distancias desde el borde inferior del promontorio sacro al suelo pelvico fueron medidas a lo largo de la curvatura sacra.RESULTADOS:Average sigmoid colon resection length was 34.7 ± 11.1 cm. Prior to any lengthening, baseline reach was -1.3 ± 4.2 cm from the sacral promontory. Inferior mesenteric artery ligation yielded an additional 11.5 ± 4.7 cm. Subsequent splenic flexure takedown added an additional 12.8 ± 9.6 cm. Finally, inferior mesenteric vein ligation added an additional 11.33 ± 6.9 cm, bringing the total colonic length to 35.7 ± 14.7 cm. BMI and weight negatively correlated with length gained.LIMITACIONES:Este estudio tuvo como limitación la naturaleza de haber sido un estudio cadavérico.CONCLUSIONES:Maniobras de alargamiento permiten un alcance adicional significativo permitiendo de esta manera una anastomosis de colon izquierdo a recto libre de anastomosis. (Traducción-Dr Osvaldo Gauto ).
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Anastomosis Quirúrgica , Cadáver , Colon Sigmoide , Arteria Mesentérica Inferior , Humanos , Colon Sigmoide/cirugía , Colon Sigmoide/anatomía & histología , Anastomosis Quirúrgica/métodos , Femenino , Masculino , Ligadura/métodos , Arteria Mesentérica Inferior/cirugía , Arteria Mesentérica Inferior/anatomía & histología , Recto/cirugía , Anciano , Colectomía/métodos , Venas Mesentéricas/cirugía , Venas Mesentéricas/anatomía & histología , Colon Transverso/cirugía , Colon/cirugía , Anciano de 80 o más AñosRESUMEN
INTRODUCTION: The true prevalence and pathogenesis of diverticulosis is poorly understood. Risk factors for diverticulosis are presently unclear, with most clinicians attributing its development to years of chronic constipation. Previous studies have been limited by their failure to include young, ethnically diverse patient populations. METHODS: Patients who presented to the emergency department of our hospital from January-September 2019 and underwent abdominal computerized tomography (CT) scan for the evaluation of appendicitis were included. CT's were reviewed for the presence of diverticulosis. Risk factors for diverticulosis were determined for two age groups: >40 and ≤ 40. RESULTS: A total of 359 patients were included in the study. The median age was 38.57.1% were male. 81.6% were Hispanic. 43.5% had colonic diverticulosis on CT. 198 patients (55.1%) were ≤ age 40. The rate of diverticulosis in this group was 35.3% (n = 70). Those with diverticulosis were not significantly older (median age 29 versus 27, P = 0.061) but had a higher median body mass index (BMI) (28.4 versus 25.3, P = 0.003) compared to those without diverticulosis. On multivariate analysis, no characteristics were associated with the presence of diverticulosis for this group. Over age 40, 53.4% of patients (n = 86) had diverticulosis. Patients with diverticulosis were more likely to be Hispanic (95.3% versus 73.3%, P ≤ 0.001), less likely to be Asian (2.4% versus 16.0%, P = 0.004), had a higher median BMI (28.7 versus 25.5, P ≤ 0.001), and were more likely to use alcohol (30.2% versus 14.7%, P = 0.024) than those without diverticulosis. On multivariate analysis, characteristics associated with the presence of diverticulosis were BMI >30 (odds ratio OR 2.22, 95% confidence interval CI 1.03-4.80), Hispanic ethnicity (OR 10.05, 95% CI 1.74-58.26), and alcohol use (OR 3.44, 95% CI 1.26-9.39). CONCLUSIONS: There was a higher rate of asymptomatic diverticulosis in the <40 cohort than previously reported in the literature. Obesity, alcohol use, and Hispanic ethnicity were associated with the presence of diverticulosis in patients > age 40, but no risk factors for diverticulosis were identified for patients ≤ age 40, suggesting that diverticular pathogenesis may differ by age. Constipation was not a risk factor for diverticulosis in either age group. The data regarding the prevalence of diverticulosis in Hispanic patients is lacking and should be the focus of future inquiry.
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Diverticulosis del Colon , Divertículo , Humanos , Masculino , Adulto , Femenino , Prevalencia , Colonoscopía , Diverticulosis del Colon/complicaciones , Diverticulosis del Colon/diagnóstico , Diverticulosis del Colon/epidemiología , Factores de Riesgo , Divertículo/diagnóstico por imagen , Divertículo/epidemiología , Divertículo/complicaciones , Estreñimiento/epidemiología , Estreñimiento/etiologíaRESUMEN
INTRODUCTION: Guidelines for pediatric mandibular reconstruction (PMR) are not well-established. One must consider the growing craniofacial skeleton, mixed dentition, long-term dental occlusion, need for secondary reconstruction, and speech development. The traditional guideline (bone defect > 5âcm) for use of vascularized bone grafts (VBG) is not applicable given the variation of pediatric mandibular size and growth. We seek to propose a novel algorithm for PMR. MATERIALS AND METHODS: An Institutional Review Board approved retrospective review of patients who underwent PMR for tumor resections between 2005 and 2019 evaluated patients' demographics, complications, resection index (RI) (resection length to mandibular length), and surgical outcomes. Outcomes based on RI were analyzed to establish guidelines for VBG utilization. RESULTS: Twenty-four patients underwent PMR at a mean age of 9.1âyears (range: 1 - 18). The mandibular defect (mean± standard deviation) fornon-VBG (nâ =â18) and VBG (nâ =â6) was 6.6â±â3.0âcm and 12.8â±â4.3âcm, respectively. The VBG group had fewer return trips to the operating room (Pâ =â0.028) and fewer major complications (Pâ=â0.028). When non-VBG with RI > 32% were compared to <32%, there was statistically less returns to the operating room for complications and a lower rate of early (< 30âdays) major complications. DISCUSSION: Our algorithm proposes an RI cutoff of 32% for VBG use for PMR. Patients with a sizable soft tissue defect, previous chemotherapy and/or radiation, planned adjuvant chemotherapy and/or radiation therapy, or a history of failed non-VBG should undergo reconstruction using VBG.
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Neoplasias Mandibulares , Reconstrucción Mandibular , Algoritmos , Trasplante Óseo , Niño , Humanos , Mandíbula/cirugía , Neoplasias Mandibulares/cirugía , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
PURPOSE: To determine the true need for orthognathic surgery in patients with repaired cleft lip and/or palate (CL/P) at a high-volume craniofacial center. METHODS: An institutional retrospective review of patients with CL/P born between 1975 and 2008 was performed. Patients with adequate documentation reflecting cleft care who wereâ≥â18âyears at the time of last craniofacial/dentistry follow-up were included. Patients with non-paramedian clefts or a comorbid craniofacial syndrome were excluded. Primary outcome variable was the total proportion of patients with CL/P who either underwent or were referred for orthognathic surgery Le Fort I (LF1) to correct midface hypoplasia. Secondary outcome variables were associations between cleft phenotype, midface hypoplasia severity, and number of cleft related surgeries with the eventual LF1âreferral/recipiency. RESULTS: One hundred seventy-seven patients with CL/P met inclusion criteria. A total of 90/177 (51%) patients underwent corrective LF1; however, 110/177 (62%) of patients were referred for surgery. Patients with secondary cleft palate involvement were referred for and underwent LF1 at significantly greater rates than those without secondary palate involvement (referred: 65% versus 13%, Pâ=â0.001; underwent: 55% versus 0%, Pâ<â0.001). Patients with bilateral cleft lip/palate were referred for and underwent LF1 at significantly higher rates than those with unilateral cleft lip/palate (referred: 71.0% versus 50.4%, P=â0.04; underwent: 84% versus 71%, Pâ=â0.02). Number of secondary palate surgeries was positively correlated with increased LF1 referral (Pâ=â0.02) but not LF1 recipiency (Pâ=â0.15). CONCLUSIONS: The incidence of orthognathic surgery redundant in patients with repaired CL/P was 51% at our institution, marginally above the higher end of previously reported rates. However, this number is an underrepresentation of the true requirement for LF1 as 62% of patients were referred for surgical intervention of midface hypoplasia. This distinction should be considered when counseling families.
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Labio Leporino , Fisura del Paladar , Cirugía Ortognática , Labio Leporino/cirugía , Fisura del Paladar/cirugía , Humanos , Maxilar , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
ABSTRACT: Competing hypotheses for the development of midface hypoplasia in patients with cleft lip and palate include both theories of an intrinsic restricted growth potential of the midface and extrinsic surgical disruption of maxillary growth centers and scar growth restriction secondary to palatoplasty. The following meta-analysis aims to better understand the intrinsic growth potential of the midface in a patient with cleft lip and palate unaffected by surgical correction. A systematic review of studies reporting cephalometric measurements in patients with unoperated and operated unilateral cleft lip and palate (UCLP), bilateral cleft lip and palate (BCLP), and isolated cleft palate (iCP) abstracted SNA and ANB angles, age at cephalometric analysis, syndromic diagnosis, and patient demographics. Age and Region-matched controls without cleft palate were used for comparison. SNA angle for unoperated UCLP (84.5â±â4.0°), BCLP (85.3â±â2.8°), and ICP (79.2â±â4.2°) were statistically different than controls (82.4â±â3.5°), (all P ≤ 0.001). SNA angles for operated UCLP (76.2â±â4.2°), BCLP (79.8â±â3.6°), and ICP (79.0â±â4.3°) groups were statistically smaller than controls (all P ≤ 0.001). SNA angle in unoperated ICP (nâ=â143) was equivalent to operated ICP patients (79.2â±â4.2° versus 79.0â±â4.3° Pâ=â0.78). No unoperated group mean SNA met criteria for midface hypoplasia (SNAâ<â80). Unoperated UCLP/BLCP exhibit a more robust growth potential of the maxilla, whereas operated patients demonstrate stunted growth compared to normal phenotype. Unoperated ICP demonstrates restricted growth in both operated and unoperated patients. As such, patients with UCLP/BCLP differ from patients with ICP and the factors affecting midface growth may differ.Level of Evidence: IV.
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Labio Leporino , Fisura del Paladar , Cefalometría , Labio Leporino/complicaciones , Labio Leporino/cirugía , Fisura del Paladar/complicaciones , Fisura del Paladar/cirugía , Humanos , Maxilar/cirugíaRESUMEN
AIM: LigaSure™ is an electro-surgical device that has increasingly been utilized in haemorrhoid surgery. However, recent literature has highlighted a possible increased risk of delayed postoperative bleeding following LigaSure haemorrhoidectomy (LH). We aim to evaluate the rates of postoperative bleeding following LigaSure compared to Ferguson (closed) haemorrhoidectomy (FH). METHODS: A retrospective cohort study was undertaken at our single academic safety-net county hospital from August 2016 through July 2019 evaluating patients who received FH or LH. Patient demographics, surgical data, postoperative emergency department visit for pain or bleeding within 30 days and resulting transfusion requirement, and rates of readmission and interventions within 30 days were collected. RESULTS: Sixty-one FH and 66 LH patients were identified. The groups had no difference in demographics. The LH group and FH group had similar rates of postoperative emergency department visits (29% vs. 23%, P = 0.454), as well as visits for bleeding (20% vs. 11%, P = 0.204). The average operating time was also significantly shorter with LH (14.5 min vs. 24.9 min, P ≤ 0.001). On multivariate analysis, male sex (OR 7.28, 95% CI 1.88-28.25) and haemorrhoid grade ≤2 (OR 4.64, 95% CI 1.31-16.49) were significantly associated with postoperative bleeding on multivariate analysis. Use of LH was not independently associated with postoperative bleeding risk (OR 1.89, 95% CI 0.70-5.11). CONCLUSIONS: LH and FH have similar risks for postoperative bleeding and other complications. Male sex and haemorrhoid Grades 1 or 2 may be associated with increased postoperative bleeding risk. Excisional haemorrhoidectomy should be undertaken with caution for male patients with lower internal haemorrhoid grades.
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Hemorreoidectomía , Hemorroides , Hemorreoidectomía/efectos adversos , Hemorroides/cirugía , Humanos , Masculino , Dolor Postoperatorio , Hemorragia Posoperatoria/epidemiología , Hemorragia Posoperatoria/etiología , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
INTRODUCTION: Pediatric mandibular reconstruction requires a grafted segment of sufficient height and stability to support dental implant placement. Double barreling and mandibular distraction osteogenesis (MDO) after reconstruction are two techniques to achieve this, but they have only been reported with fibular grafts. Rib grafts not only have a lower donor site morbidity than fibular grafts, but they also provide adequate defect coverage in children. As such, we propose their use with either a double barrel technique or with MDO. METHODS: Three pediatric patients underwent mandibular resection and reconstruction using rib grafting. One patient underwent single rib graft placement with subsequent vertical rib distraction. In the remaining two patients, a double-barreled rib technique was used, stacked horizontally in one patient and vertically in the other. RESULTS: From March 2018 to May 2019, three patients with an average age of 11 underwent resection of mandibular tumors or tumor-like lesions followed by immediate reconstruction with rib graft. Due to postoperative wound complications, the graft was completely removed in one patient. The remaining two patients had an uneventful recovery with dental implants planned for one and fully osseointegrated in the other. None of the patients experienced donor-site complications. CONCLUSION: This case series supports the utility and versatility of autogenous rib grafts as a reconstructive option in children. Not only is rib an excellent bone source with low donor site morbidity, but its height can be augmented through MDO or double barreling, facilitating the successful placement of implants and oral rehabilitation in pediatric patients.
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Neoplasias Mandibulares , Reconstrucción Mandibular , Trasplante Óseo , Niño , Humanos , Mandíbula/cirugía , Neoplasias Mandibulares/cirugía , CostillasRESUMEN
ABSTRACT: Over the last 3 years a shift at our institution has taken place in which patients who would have been offered nasoalveolar molding (NAM) as an adjunct to cleft lip repair (repair after 3 months) have instead undergone early cleft lip repair (ECLR) (2-5 weeks of life) without NAM. This study sought to examine the financial and social impact of the transition away from NAM to ECLR. The efficacy of NAM is limited by patient compliance to a rigorous treatment schedule requiring weekly visits for appliance adjustments. Nasoalveolar molding patients required an average of 11 dental visits, accounting for $2132 in indirect lost income per family. Average direct charges for NAM totaled $12,290 for the hospital, physician, and appliance costs. Over the entire study period, the cumulative direct cost of NAM separate from the surgical repair of the lip was $970,910. Following the introduction of ECLR as an alternative to NAM with standard lip repair, NAM usage decreased by 48% and unilateral cleft lip patients undergoing NAM decreased by 86%. Those diverted from NAM to ECLR resulted in a decreased healthcare cost burden of $368,700 ($111,727 per year). In addition to the time burden, the financial burden of NAM is significant. Early cleft lip repair without NAM is more cost effective. Nasoalveolar molding has significantly decreased utilization since the implementation of ECLR. We believe that ECLR, with increased experience, long-term data, and increased awareness, has the potential to decrease the burden of health care costs in the United States.
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Labio Leporino , Fisura del Paladar , Proceso Alveolar/cirugía , Labio Leporino/cirugía , Fisura del Paladar/cirugía , Humanos , Modelado Nasoalveolar , Nariz/cirugíaRESUMEN
ABSTRACT: Developing midface hypoplasia is common after palatoplasty and has been hypothesized to be influenced by the timing of hard palate repair. This meta-analysis assesses the risk of developing midface hypoplasia based on age at hard palate repair. A Pubmed PRISMA systematic review and meta-analysis was completed for literature focused on palatoplasty and midface hypoplasia published between 1970 and 2019. Cephalometric data were extracted and categorized by age at hard palate repair: <6, 7 to 12, 13 to 18, 19 to 24, and 25 to 83 months. Analysis of these groups and a control were compared using independent T-tests and Spearman correlation coefficients. SNA angles for each group were 77.9â±â3.1° (<6 months), 77.7â±â4.2° (7-12 months), 78.7â±â4.2° (13-18 months), 75.1â±â4.2° (19-24 months), 75.5â±â4.8° (25-83 months), and were statistically different than the control group 82.4â±â3.5° (P < 0.0001). Hard palate repair at 13 to 18 months had a statistically significant greater SNA angle than all other groups except for the repair at <6 months group (Pâ=â0.074). As age at hard palate closure increased beyond 18 months, the SNA decreased, corresponding to a more hypoplastic maxilla (Spearman's correlation coefficient -0.381, Pâ=â0.015). Analysis suggests that younger age at the time of repair is less likely to create in midface hypoplasia in adulthood. Minimizing midface hypoplasia in cleft palate patients by optimizing algorithms of care is a practical way to decrease the burden of disease on patients, families and medical systems. Further studies are needed to evaluate the role of technique on outcomes.Level of Evidence: IV.
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Labio Leporino , Fisura del Paladar , Procedimientos de Cirugía Plástica , Adulto , Biometría , Cefalometría , Labio Leporino/cirugía , Fisura del Paladar/cirugía , Humanos , Maxilar/cirugía , Paladar Duro/cirugíaRESUMEN
ABSTRACT: Midface hypoplasia is one of the most significant sequelae of cleft lip and/or palate surgery. A complete understanding of the rate of orthognathic surgery across varying cleft phenotypes is a powerful tool for educating patients and families as to the treatment course that the patient will incur during their lifetime. Understanding the average rates of orthognathic intervention also can act to develop metrics for outcome evaluation with different treatment protocols. Attempting to identify the average rates of orthognathic intervention, the authors conducted a systematic review and meta-analysis by combining studies from 1987 to 2016 describing the frequency of orthognathic intervention on the different cleft phenotypes as the primary outcome. Secondary outcomes included identification of surgical protocol, age of patient at orthognathic intervention, and the method by which patients were evaluated for orthognathic intervention. The rate of orthognathic surgery was 38.1% for bilateral cleft lip and palate (BCLP), 30.2% for unilateral cleft lip and palate (UCLP), 4.4% for isolated cleft palate (ICP), and 1.8% for patients with isolated cleft lip (ICL). 71% (nâ=â10) reported using lateral cephalograms for orthognathic surgery evaluation and only one of those studies reported specific objective cephalometric measurements for orthognathic intervention. Our findings demonstrated that BCLP possessed the highest rate of orthognathic intervention followed by UCLP, ICP, and ICL. ICP and ICL both possessed low rates of orthognathic intervention. By sharing our findings, the authors hope to provide a useful tool for informing patients' families as to their risk of needing orthognathic intervention.
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Labio Leporino , Fisura del Paladar , Cirugía Ortognática , Procedimientos Quirúrgicos Ortognáticos , Cefalometría , Labio Leporino/cirugía , Fisura del Paladar/cirugía , Humanos , Estudios RetrospectivosRESUMEN
PURPOSE: Our study introduces a novel anesthetic protocol for neonates without using volatile agents with the goal to minimize potentially neurotoxic and pro-apoptotic agents. The authors evaluated the short-term safety and efficacy of our anesthetic protocol in patients undergoing early cleft lip repair (ECLR). METHODS: A retrospective review of ECLR patients who underwent repair before 2.5âmonths of age within the last 4.3âyears was performed. This sample was comprised of 2 groups, those who received either a standard volatile gas-based regimen or a dexmedetomidine-based neonatal anesthetic protocol (DBNAP). Patient demographics, medication dosing, anesthetic time (induction to extubation), major and minor complications, and medication side effects were compared between the 2 cohorts. RESULTS: A total of 101 patients underwent ECLR. All patients were American Society of Anesthesiologists class 1 or 2. Mean age at surgery was 31â±â13âdays and mean anesthetic time was 179â±â36âminutes. DBNAP was used in 65 patients while the standard anesthetic protocol was used in 36 patients. Patient weight was significantly lower in the DBNAP group (4.01â±â0.61 versus 4.38â±â0.72âkg, Pâ =â0.007). There were no significant differences between the 2 cohorts when comparing anesthetic time, emergence time, complication rate, or medication side effects. CONCLUSION: For patients undergoing ECLR, DBNAP is perioperatively equivalent to the anesthetic standard of care, demonstrating no major complications and acceptable rates of minor complications and medication side effects.
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Anestesia Dental , Anestésicos , Labio Leporino , Preescolar , Labio Leporino/cirugía , Humanos , Recién Nacido , Estudios RetrospectivosRESUMEN
ABSTRACT: The understanding of cleft lip etiology and approaches for surgical repair have evolved over time, allowing for improved ability to restore form and function. The variability of cleft lip presentations has necessitated a nuanced surgical approach with multidisciplinary cleft care. The earliest documentation of unilateral cleft lip repair predates the 19th century, with crude outcomes observed before the advent of curved incisions and advancement flaps. In the 20th century, straight line, quadrilateral flap, and triangular flap repairs were introduced to mitigate post-repair surgical scarring, increase lip length, and restore the symmetry of the Cupid's bow. Towards the latter part of the century, the development of rotation-advancement principles allowed for improved functional and aesthetic outcomes. Future technical improvements will continue to address the goals of lip and nasal symmetry, muscular continuity, precise scar concealment, and improved patient satisfaction in an increasing range of cleft phenotypes and during subsequent years of growth.
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Labio Leporino , Procedimientos de Cirugía Plástica , Labio Leporino/cirugía , Estética Dental , Humanos , Labio/cirugía , Colgajos QuirúrgicosRESUMEN
Craniometaphyseal dysplasia (CMD) is a rare genetic disease affecting bone metabolism with sclerosis of craniofacial bones. Orthognathic surgery has rarely been described in this patient population due to the bony thickness, making osteotomies challenging. We present a 19-year-old male with CMD with malocclusion, severe midface hypoplasia, and obstructive sleep apnea. With the aid virtual planning, we safely performed a combined LeFort III/I midface advancement to correct a negative overjet to improve occlusal balance, decrease scleral show, and diminish daytime sleepiness.
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Anomalías Craneofaciales , Hipertelorismo , Procedimientos Quirúrgicos Ortognáticos , Adulto , Enfermedades del Desarrollo Óseo , Anomalías Craneofaciales/diagnóstico por imagen , Anomalías Craneofaciales/cirugía , Humanos , Hiperostosis , Masculino , Osteotomía Le Fort , Adulto JovenAsunto(s)
Infecciones por Coronavirus , Pandemias , Neumonía Viral , Telemedicina , Betacoronavirus , COVID-19 , Humanos , SARS-CoV-2 , Comunicación por VideoconferenciaRESUMEN
BACKGROUND: Increase in opioid prescribing practices has occurred with concurrent increases in the levels of abuse, addiction, and diversion of opioid pain medication. With 82.5 opioid prescriptions prescribed for every 100 U.S. citizens, the need for more effective strategies aimed at improving opioid disposal exist. Our study sought to examine the planned rates of appropriate opioid disposal after introduction of an activated charcoal home drug disposal system (Deterra®) in combination with formalized opioid disposal education. METHODS: Participants were recruited from an academic, public safety-net hospital and grouped into 3 cohorts, no formalized opioid disposal education (No Education), written and verbal patient education on appropriate opioid disposal (Education), and Deterra® in addition to formalized opioid disposal education (Deterra). Outcomes included patients reporting unacceptable methods of opioid disposal, storage of unused opiates, and patient satisfaction with disposal instructions. RESULTS: Reported unacceptable opioid disposal decreased from 80.6% (n = 87) in the no education group to 20% (n = 10) in the education group to 6% (n = 3) in the Deterra group (P < .001). Education decreased long-term storage of opioid medication after completion of usage from 42% (n = 36) to 2% (n = 1), P < .001. Between the education and Deterra groups, more patients felt that the disposal instructions were clear (94% (n = 47) vs 73% (n = 36), P = .006) and more followed acceptable disposal instructions (80% (n = 39) vs 94% (n = 47) P < .001). CONCLUSION: Deterra® along with formal opioid disposal education increases patients reporting plans for compliance with appropriate opioid disposal.
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Analgésicos Opioides , Pautas de la Práctica en Medicina , Humanos , Analgésicos Opioides/uso terapéutico , Escolaridad , Dolor Postoperatorio/tratamiento farmacológicoRESUMEN
It is important to understand advances in treatment options for rectal cancer. We attempt to highlight advances in rectal cancer treatment in the form of a systematic review. Early-stage rectal cancer focuses on minimally invasive endoluminal surgery, with importance placed on patient selection as the driving factor for improved outcomes. To achieve a complete pathologic response, various neoadjuvant chemoradiation regimens have been employed. Short-course radiation therapy, total neoadjuvant chemotherapy, and others provide unique advantages with select patient populations best suited for each. With a clinical complete response, a "watch and wait" non-operative surveillance has been introduced with preliminary equivalency to radical resection. Various modalities for total mesorectal excision, such as robotic or transanal, have advantages and can be utilized in select patient populations. Tumors demonstrating solid organ or peritoneal spread, traditionally defined as unresectable lesions conveying a terminal diagnosis, have recently undergone advances in hepatic and pulmonary metastasectomy. Hepatic and pulmonary metastasectomy has demonstrated clear advantages in 5-year survival over standard chemotherapy. With the peritoneal spread of colorectal cancer, HIPEC with cytoreductive therapy has emerged as the preferred treatment. Understanding the various therapeutic interventions will pave the way for improved patient outcomes.
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PURPOSE: In thoracic endovascular aortic repair (TEVAR), the left subclavian artery (LSA) is often occluded. Although most patients tolerate this, some develop ischemic symptoms to the brain or left upper extremity (LUE). A revascularization procedure may be associated with significant complications. The purpose of this review was to assess the incidence of LSA occlusion, resulting ischemic symptoms, and complications related to revascularization operations in trauma patients compared to non-trauma patients. METHODS: Studies from 2010 to 2020 were fully reviewed if they discussed incidence of LSA coverage, LUE ischemia, carotid-subclavian bypass, or complications associated with carotid-subclavian bypass. RESULTS: Seventeen articles were included in this analysis. A total of 167 patients were identified as trauma cases. Incidence of LSA occlusion in trauma was 91/167 (54%) compared to 281/1446 (19%) in the population exclusive of trauma (p < 0.001). Following LSA occlusion, the rate of LUE claudication/ischemia was 21/56 (38%) for trauma, compared to 12/193 (6%) in non-trauma cases (p < 0.001). The overall complication rate after carotid-subclavian rescue bypass was 29.2% (33/112), with phrenic nerve palsy (24%), recurrent laryngeal nerve palsy (5%), and pseudoaneurysm (1.7%) being the most common. CONCLUSION: LSA coverage following TEVAR is common and associated with significant complications, often requiring operative management. The incidence of ischemic complications after occlusion of the LSA is significantly higher in the trauma population. Revascularization procedures to correct the occlusion have a high rate of complications.
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Enfermedades de la Aorta , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Traumatismos Torácicos , Humanos , Arteria Subclavia/cirugía , Aorta Torácica/cirugía , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/métodos , Procedimientos Endovasculares/métodos , Resultado del Tratamiento , Factores de Riesgo , Enfermedades de la Aorta/complicaciones , Enfermedades de la Aorta/cirugía , Isquemia/cirugía , Traumatismos Torácicos/complicaciones , Estudios RetrospectivosRESUMEN
BACKGROUND: Cleft lip and/or palate affects approximately one in 700 live births. Optimal timing for repair of cleft lip has yet to be objectively validated. Earlier repair takes advantage of a high degree of plasticity within the nasal cartilage and maxilla. The authors present patients enrolled in an early cleft lip repair protocol facilitating effective repair of the cleft lip and nostril. METHODS: American Society of Anesthesiologists class I to II patients with unilateral cleft lip and/or palate undergoing repair before 3 months of age were enrolled over 5 years. Perioperative data, surgical and anesthetic complications, preoperative and postoperative nostril breadth, nostril width, nasal angle, lip length, frontal nasal breadth, and commissure length measured as ratios between the cleft and noncleft sides were abstracted. Early cleft lip repair and nasoalveolar molding patients were matched for cleft lip severity using the cleft width ratios and compared. RESULTS: The surgical and anesthetic complication rate for 100 early cleft lip repair patients was 2 percent. Operative and anesthetic times were 123 ± 37 minutes and 177 ± 34 minutes, respectively. Hospital length of stay was 1 ± 0 day. Age at repair between early cleft lip repair and nasoalveolar molding was 33 ± 15 days and 118 ± 33 days, respectively. After early cleft lip repair, preoperative to postoperative distance from symmetry for all anthropomorphic measurements improved ( p < 0.001). Comparing severity-matched early cleft lip repair to nasoalveolar molding patients, similar improvements were observed, suggesting equivalent results ( p > 0.05). CONCLUSION: Early cleft lip repair provides an efficacious method for correcting the cleft lip and nasal deformity that simulates nasoalveolar molding. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.