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1.
Acta Neurochir (Wien) ; 166(1): 120, 2024 Mar 02.
Artículo en Inglés | MEDLINE | ID: mdl-38430312

RESUMEN

BACKGROUND: The management of craniopharyngiomas is challenging due to their high rate of recurrence following resection. Excision of recurrent tumors poses further surgical challenges due to loss of arachnoidal planes and adherence to anatomical structures. The endoscopic endonasal approach (EEA) offers a favorable alternative to transcranial approaches for primary craniopharyngiomas. However, the safety and efficacy of EEA for recurrent tumors, specifically after a prior transcranial approach, needs further investigation. METHODS: We performed a systematic review using PubMed to develop a database of cases of recurrent craniopharyngiomas previously treated with a transcranial approach. RESULTS: Fifteen articles were included in this review with a total of 75 cases. There were 50 males and 25 females with a mean age of 38 years (range 2-80). One prior transcranial surgery was done in 80.0% of cases, while 8.0% had two and 12.0% had more than two prior surgeries. Radiotherapy after transcranial resection was given in 18 cases (24.0%). Following EEA, vision improved in 60.0% of cases, and vision worsened in 8.6% of the cases. Of cases, 64.4% had pre-existing anterior hypopituitarism, and 43.8% had diabetes insipidus prior to EEA. New anterior hypopituitarism and diabetes insipidus developed in 24.6% and 21.9% of cases, respectively following EEA. Gross total resection (GTR) was achieved in 64.0%, subtotal resection in 32.0%, and partial resection in 4.0% revision EEA cases. GTR rate was higher in cases with no prior radiotherapy compared to cases with prior radiotherapy (72.0% vs 39.0%, p = 0.0372). The recurrence rate was 17.5% overall but was significantly lower at 10.0% following GTR (p = 0.0019). The average follow-up length was 41.2 months (range, 1-182 months). CONCLUSION: The EEA can be utilized for resection of recurrent or residual craniopharyngiomas previously managed by a transcranial approach.


Asunto(s)
Craneofaringioma , Diabetes Insípida , Hipopituitarismo , Neoplasias Hipofisarias , Humanos , Craneofaringioma/diagnóstico por imagen , Craneofaringioma/cirugía , Craneofaringioma/patología , Endoscopía , Neoplasias Hipofisarias/cirugía , Neoplasias Hipofisarias/patología
2.
Am J Otolaryngol ; 45(4): 104288, 2024.
Artículo en Inglés | MEDLINE | ID: mdl-38640811

RESUMEN

PURPOSE: There is sparse literature discussing the impact of smoking on postoperative outcomes following surgical treatment of Zenker's diverticulum. In this study, we seek to characterize differences in the management and outcomes of open Zenker's diverticulectomy based on patient smoking status. METHODS AND MATERIALS: This paper is a retrospective cohort review. The 2005-2018 American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) database was queried for patients undergoing open Zenker's diverticulectomy. Chi-square and multivariable logistic regression were performed to determine statistical associations between postoperative outcomes and smoking status. RESULTS: Of the 715 identified patients, 70 (9.8 %) were smokers and 645 (91.2 %) were non-smokers. Smokers were younger than non-smokers (mean 63.9 vs. 71.7 years, p < 0.001) and more likely to have a prolonged operative time (20.0 % vs. 11.6 %, p = 0.044). On multivariable regression analysis controlling for demographics and comorbidities, smokers had greater odds than non-smokers for developing overall postoperative complications (OR: 2.776, p = 0.013), surgical infections (OR: 3.194, p = 0.039), medical complications (OR: 3.563, p = 0.011), and medical infections (OR: 1.247, p = 0.016). Smokers also had greater odds for requiring ventilation/intubation (OR: 8.508, p = 0.025) and having a prolonged postoperative stay (OR: 2.425, p = 0.030). CONCLUSION: In a cohort of patients undergoing transcervical Zenker's diverticulectomy, smokers are at increased risk for overall complications, medical complications, medical infections, surgical infections, prolonged postoperative stay, and ventilation/intubation.


Asunto(s)
Complicaciones Posoperatorias , Fumar , Divertículo de Zenker , Humanos , Divertículo de Zenker/cirugía , Masculino , Femenino , Persona de Mediana Edad , Anciano , Estudios Retrospectivos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Fumar/efectos adversos , Resultado del Tratamiento , Tempo Operativo , Procedimientos Quirúrgicos Otorrinolaringológicos/métodos , Procedimientos Quirúrgicos Otorrinolaringológicos/efectos adversos
3.
Am J Otolaryngol ; 43(5): 103571, 2022.
Artículo en Inglés | MEDLINE | ID: mdl-35963106

RESUMEN

OBJECTIVE: Tuberculous otitis media (TOM) is a rare extrapulmonary manifestation of tuberculosis (TB) and remains challenging to diagnose due to non-specific symptoms. This systematic review identifies clinical characteristics, diagnostic evaluation, and outcomes in cases of TOM. METHODS: A comprehensive literature search utilizing the PubMed, CINAHL, Scopus, and Cochrane Library databases was conducted for relevant articles published between 2000 and 2021. Cases involving adult patients with TOM were included. Non-English studies, animal studies, and reviews were excluded. RESULTS: 41 case reports and 7 case series were included, comprising data from 67 patients. The mean age was 40 years (range, 19-87 years) and the majority were female (n = 46, 68.7 %). The mean symptom duration was 12.8 months (range, 0.25-120 months). Common symptoms included otorrhea (n = 60, 89.6 %), HL (n = 58, 86.6 %), otalgia (n = 19, 28.4 %), and FP (n = 18, 26.9 %). Otoscopy revealed tympanic membrane (TM) perforation in 45 patients (67.2 %). Most patients were diagnosed with tissue biopsy (n = 53, 79.1 %). Surgical interventions were performed in 48 patients (71.6 %) and 63 patients (94.0 %) were prescribed anti-TB chemotherapy. Long-term sequelae (e.g., HL, FP, and TM perforation) were noted in 39 patients (58.2 %) at a mean follow-up of 18.8 months (range, 1-120 months). CONCLUSION: TOM should be included in the differential diagnosis of chronic suppurative otitis media. Histopathological examination is a reliable diagnostic method. Early detection and management are recommended for optimizing outcomes. LEVEL OF EVIDENCE: 3b.


Asunto(s)
Otitis Media Supurativa , Otitis Media , Tuberculosis , Perforación de la Membrana Timpánica , Oído Medio/patología , Femenino , Humanos , Masculino , Otitis Media/complicaciones , Otitis Media/diagnóstico , Otitis Media/patología , Otitis Media Supurativa/complicaciones , Otitis Media Supurativa/diagnóstico , Otitis Media Supurativa/terapia , Tuberculosis/complicaciones , Tuberculosis/diagnóstico , Tuberculosis/patología , Perforación de la Membrana Timpánica/patología
4.
Am J Otolaryngol ; 43(5): 103550, 2022.
Artículo en Inglés | MEDLINE | ID: mdl-35917657

RESUMEN

OBJECTIVE: The larynx is the most common site of localized head and neck amyloidosis. Our study aimed to review the clinical features, treatments, and outcomes associated with localized laryngeal amyloidosis (LA). We also compared these features between two different time periods to evaluate the evolution of LA management. METHODS: A literature search using PubMed, CINAHL, Embase, and Cochrane Library identified cases of LA published between 1891 and 2021. Biopsy-proven cases of localized LA were included. Non-English studies, animal studies, and reviews were excluded. RESULTS: 282 patients (1891-1999: 142 patients, 2000-2021: 140 patients) from 129 studies were included. Results are reported as 1891-2000 vs. 2000-2021: Mean age was 48.5 years (range, 8-90 years) vs. 46.0 years (range, 9-84 years). The most common presenting symptoms were dysphonia (n = 30, 95 % vs. n = 127, 96 %) and difficulty breathing (n = 37, 27 % vs. n = 35, 27 %). A total of 62 (44 %) vs. 46 (33 %) lesions were found in the true vocal folds and 35 (25 %) vs. 59 (42 %) were found in the false vocal folds. 133 (94 %) vs. 137 (98 %) patients underwent surgical interventions to investigate and/or treat LA. Recurrent LA was reported in 27 (19 %) vs. 33 (24 %) patients with a mean time to recurrence of 25.4 months (range, 0.3-132 months) vs. 34.5 months (range, 0.8-144 months). Of cases reporting survival rate, 104 (97 %) vs. 107 (99 %) were alive at source study endpoints. CONCLUSION: LA typically exhibits an indolent course; therefore, early intervention may address longstanding symptoms. Recurrent disease poses a clinical challenge in patients with LA.


Asunto(s)
Amiloidosis , Enfermedades de la Laringe , Laringe , Amiloidosis/diagnóstico , Amiloidosis/patología , Amiloidosis/terapia , Ronquera , Humanos , Enfermedades de la Laringe/diagnóstico , Enfermedades de la Laringe/patología , Enfermedades de la Laringe/terapia , Laringe/patología , Pliegues Vocales/patología
5.
Oper Tech Otolayngol Head Neck Surg ; 33(2): 103-111, 2022 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-35502266

RESUMEN

The Coronavirus-19 (COVID-19) pandemic has caused disruptions in the normal patient care workflow, necessitating adaptations within the healthcare profession. The objective of this article is to outline some of these adaptations and considerations necessitated by COVID-19 within the subspeciality of rhinology and endoscopic skull base surgery.

6.
Acta Neurochir (Wien) ; 162(3): 641-647, 2020 03.
Artículo en Inglés | MEDLINE | ID: mdl-31811470

RESUMEN

BACKGROUND: The "double flap" reconstruction technique, comprised of a simultaneous vascularized pedicled pericranial flap (PCF) and pedicled nasoseptal flap (NSF), can be used to repair anterior skull base defects after a combined cranionasal or transbasal-endoscopic endonasal approach (EEA) has been performed to remove malignant anterior skull base tumors. The use of two vascularized flaps may potentially decrease the incidence of post-radiation flap necrosis and postoperative cerebrospinal fluid (CSF) leaks after radiation therapy. METHODS: We conducted a retrospective review of a prospective skull base database on patients who underwent the double flap reconstruction technique after a combined transbasal-EEA approach. Data collected for each patient included demographics, method of tumor resection and repair, complications, tumor recurrence, and follow-up. RESULTS: Nine patients who underwent a combined transbasal-EEA approach for resection of anterior skull base tumors with significant intracranial extension followed by reconstruction of the cranial base using the double flap technique. Four were men and five were women, with a mean age of 49 years (range, 15-68 years). There was no postoperative CSF leakage detected or complications of infection, meningitis, mucocele, or tension pneumocephalus after a mean follow-up of 35.7 months (range, 4.5-98 months). Seven of the nine patients underwent adjuvant radiation without flap necrosis. Local tumor recurrence was not observed in any of the patients at last follow-up; however, one patient developed distant brain metastasis. CONCLUSION: The simultaneous PCF and NSF double flap reconstruction is an effective technique in preventing postoperative CSF leakage and post-radiation necrosis when repairing anterior skull base defects after combined transbasal-EEA approaches. This technique may be useful in patients anticipated to undergo postoperative radiation therapy.


Asunto(s)
Cirugía Endoscópica por Orificios Naturales/efectos adversos , Procedimientos de Cirugía Plástica/métodos , Complicaciones Posoperatorias/cirugía , Neoplasias de la Base del Cráneo/cirugía , Base del Cráneo/cirugía , Adolescente , Adulto , Anciano , Pérdida de Líquido Cefalorraquídeo/epidemiología , Pérdida de Líquido Cefalorraquídeo/etiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Nariz/cirugía , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Procedimientos de Cirugía Plástica/efectos adversos , Colgajos Quirúrgicos/cirugía
7.
Am J Otolaryngol ; 41(6): 102567, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32920475

RESUMEN

OBJECTIVES: The current analysis queries rhinologists' attitudes about the use of telemedicine, including the degree to which it has impacted practice patterns during the COVID-19 pandemic. Our objective was to survey rhinologists and understand the extent to which telemedicine serves as a rejoinder to in-person consultation: appreciation of relevant factors may be important in planning for present and future considerations. METHODS: A 14-question anonymous survey sent out to the American Rhinologic Society (ARS) membership in April 2020. It included demographic factors and detailed questions examining the extent of telemedicine use. Numerous topics including the degree of use, satisfaction with services, and utility of services were evaluated. RESULTS: There were 134 respondents. Most reported seeing ≤30% of typical in-person volume, with 14.8% not seeing any patients at all. 88.1% used telemedicine; 82.0% reported some level of satisfaction with telemedicine. The vast majority utilized platforms employing audio and video (83.3%), and a plurality reported spending 5-15 min on calls. Numerous reasons were cited for the use of telemedicine, including significant public health benefits amid the crisis (89.7%). Only 12.0% of respondents reported using telemedicine for hospital consultation. CONCLUSION: Rhinologists have embraced telemedicine during the COVID-19 pandemic in an attempt to improve accessibility, patient satisfaction, and revenue stream. When utilized appropriately, this technology obviates the need for seeing at-risk patients and performing procedures such as nasal endoscopy. Only a minority of rhinologists was dissatisfied, viewing this as a temporary fix during the pandemic.


Asunto(s)
Otorrinolaringólogos , Pautas de la Práctica en Medicina/estadística & datos numéricos , Telemedicina/estadística & datos numéricos , Actitud del Personal de Salud , Betacoronavirus , COVID-19 , Infecciones por Coronavirus/epidemiología , Humanos , Pandemias , Neumonía Viral/epidemiología , SARS-CoV-2 , Encuestas y Cuestionarios , Estados Unidos/epidemiología
8.
Am J Otolaryngol ; 41(6): 102569, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32683188

RESUMEN

OBJECTIVES: To evaluate the impact of the novel coronavirus pandemic on practice patterns, clinical behavior, personal health, and emotional/psychological concerns of rhinologists. METHODS: A 15-question survey was sent out to the American Rhinologic Society's (ARS) membership to determine the impact of COVID-19 during the crisis. Demographic factors and practice patterns were collected and evaluated. RESULTS: There were 224 total respondents out of 835 ARS members queried (26.8% response rate). Study queries were sent in April 2020. Notably, 17.8% reported illness in themselves or their staff and 74.4% noted a psychological/emotional impact. A plurality of rhinologists noted their practice volume and in-office procedure volume has become 20.0% and 0.0% of their prior volumes, respectively. In addition, 96.2% were noted to be using telemedicine in our subspecialty. CONCLUSION: In addition to severely impacting volume and the perception of future decreases in patients and revenue, the COVID-19 pandemic has had a physical and emotional impact on rhinologists in ways that need to be further studied. These data include significantly novel and objective information. The COVID-19 crisis also reveals the important role of telemedicine in rhinology. Guidelines regarding personal protective equipment for in-office visits, nasal endoscopy, and other in-office and operating room procedures would be particularly helpful as future waves are expected.


Asunto(s)
Actitud del Personal de Salud , Infecciones por Coronavirus/epidemiología , Otorrinolaringólogos , Neumonía Viral/epidemiología , Pautas de la Práctica en Medicina/estadística & datos numéricos , Betacoronavirus , COVID-19 , Endoscopía/estadística & datos numéricos , Humanos , Visita a Consultorio Médico/estadística & datos numéricos , Otorrinolaringólogos/psicología , Pandemias , Equipo de Protección Personal/estadística & datos numéricos , SARS-CoV-2 , Encuestas y Cuestionarios , Telemedicina/estadística & datos numéricos , Estados Unidos/epidemiología
9.
Am J Otolaryngol ; 41(6): 102746, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-33198053

RESUMEN

With the ongoing development of the COVID-19 pandemic, research continues to emerge regarding the pathophysiology, characteristics, and treatment considerations for patients with COVID-19. No reports have highlighted the specific challenges posed in the management of pediatric patients with COVID-19 who present with complicated rhinosinusitis. In this report, we discuss our preoperative, intraoperative, and postoperative multidisciplinary treatment strategy for these cases and provide two examples of complicated rhinosinusitis cases in COVID-19 patients, treated with two different approaches. Pearls, insights, and a brief review of the literature are discussed.


Asunto(s)
Infecciones por Coronavirus/complicaciones , Neumonía Viral/complicaciones , Rinitis/virología , Sinusitis/virología , Adolescente , Betacoronavirus , COVID-19 , Prueba de COVID-19 , Niño , Técnicas de Laboratorio Clínico , Terapia Combinada , Infecciones por Coronavirus/diagnóstico , Infecciones por Coronavirus/diagnóstico por imagen , Infecciones por Coronavirus/terapia , Humanos , Masculino , Pandemias , Neumonía Viral/diagnóstico por imagen , Neumonía Viral/terapia , Rinitis/diagnóstico por imagen , Rinitis/terapia , SARS-CoV-2 , Sinusitis/diagnóstico por imagen , Sinusitis/terapia
10.
Am J Otolaryngol ; 40(3): 358-363, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-30819541

RESUMEN

OBJECTIVE: Variation in weather patterns is often cited as a risk factor for epistaxis although robust studies investigating specific climate factors are lacking. As society is increasingly utilizing the Internet to learn more about their medical conditions, we explore whether Internet search activity related to epistaxis is influenced by fluctuations in climate. METHODS: Internet search activity for epistaxis-related search terms during 2012-2017 were extracted from Google Trends and localized to six highly populated cities in the US: New York, New York; Los Angeles, California; Chicago, Illinois; Houston, Texas; Philadelphia, Pennsylvania; and Atlanta, Georgia. Data were compared to local average monthly climate data from the National Centers for Environmental Information for the same time period. RESULTS: Spearmen correlations (r) were statistically strongest for dew point temperature (rNewYork = -0.82; rPhiladelphia = -0.74; rChicago = -0.65; rAtlanta = -0.49, rLosAngeles = -0.3). This was followed closely by relative humidity (rNewYork = -0.63; rPhiladelphia = -0.57; rLosAngeles = -0.44; rAtlanta = -0.42; rHouston = -0.40) and average temperature (rNewYork = -0.8; rPhiladelphia = -0.72; rChicago = -0.62; rAtlanta = -0.45). Overall, correlations were most significant and predictable for cities with the greatest seasonal climate shifts (New York, Philadelphia, and Chicago). The weakest environmental factor was barometric pressure, which was found to be moderately positive in Atlanta (rbarometric = 0.31), Philadelphia (rbarometric = 0.30) and New York (rbarometric = 0.27). CONCLUSIONS: Google Trends data for epistaxis-related search activity responds closely to climate patterns in most cities studied, thus underscoring the potential utility of Internet search activity data as a resource for epidemiologic study and for the identification of at risk populations.


Asunto(s)
Clima , Epistaxis/epidemiología , Internet/estadística & datos numéricos , Utilización de Procedimientos y Técnicas/estadística & datos numéricos , Motor de Búsqueda/estadística & datos numéricos , Población Urbana/estadística & datos numéricos , Tiempo (Meteorología) , Presión Atmosférica , Humanos , Humedad , Factores de Riesgo , Temperatura
11.
Ann Surg ; 268(2): 193-200, 2018 08.
Artículo en Inglés | MEDLINE | ID: mdl-29334559

RESUMEN

OBJECTIVE: The aim of this study was to evaluate sex differences in full professorship among a comprehensive, contemporary cohort of US academic surgeons. SUMMARY OF BACKGROUND DATA: Previous work demonstrates that women are less likely than men to be full professors in academic medicine, and in certain surgical subspecialties. Whether sex differences in academic rank exist across all surgical fields, and after adjustment for confounders, is not known. METHODS: A comprehensive list of surgeons with faculty appointments at US medical schools in 2014 was obtained from Association of American Medical Colleges (AAMC) faculty roster and linked to a comprehensive physician database from Doximity, an online physician networking website, which contained the following data for all physicians: sex, age, years since residency, publication number (total and first/last author), clinical trials participation, National Institutes of Health grants, and surgical subspecialty. A 20% sample of 2013 Medicare payments for care was added to this dataset. Multivariable regression models were used to estimate sex differences in full professorship, adjusting for these variables and medical school-specific fixed effects. RESULTS: Among 11,549 surgeon faculty at US medical schools in 2014, 1692 (14.7%) were women. Women comprised 19.4% of assistant professors (1072/5538), 13.8% of associate professors (404/2931), and 7.0% of full professors (216/3080). After multivariable analysis, women were less likely to be full professors than men (adjusted odds ratio: 0.76, 95% confidence interval: 0.6-0.9). CONCLUSION: Among surgical faculty at US medical schools in 2014, women were less likely than men to be full professors after adjustment for multiple factors known to impact faculty rank.


Asunto(s)
Movilidad Laboral , Docentes Médicos/organización & administración , Médicos Mujeres/organización & administración , Sexismo/estadística & datos numéricos , Cirujanos/organización & administración , Adulto , Anciano , Anciano de 80 o más Años , Estudios Transversales , Docentes Médicos/estadística & datos numéricos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Médicos Mujeres/estadística & datos numéricos , Análisis de Regresión , Estudios Retrospectivos , Factores Sexuales , Cirujanos/estadística & datos numéricos , Estados Unidos
12.
Neurosurg Focus ; 44(5): E4, 2018 05.
Artículo en Inglés | MEDLINE | ID: mdl-29712518

RESUMEN

OBJECTIVE Observation and neurosurgical intervention for unruptured intracranial aneurysms (UIAs) in the elderly population is rapidly increasing. Cerebral aneurysm coiling (CACo) is favored over cerebral aneurysm clipping (CAC) in elderly patients, yet some elderly individuals still undergo CAC. The cost-effectiveness of treating UIAs requires further exploration. Understanding the effect of intervention on hospital charges and length of stay (LOS) as well as perioperative mortality and complications can further shed light on its economic impact. The purpose of this study was to analyze the cost and perioperative outcomes of UIAs in elderly patients (≥ 65 years of age) after CACo or CAC intervention. METHODS Retrospective cohorts of CACo and CAC admissions were extracted from National (Nationwide) Inpatient Sample data obtained between 2002 and 2013, forming parallel intervention groups to compare the following outcomes between elderly and nonelderly patients: average LOS and mean hospital admission costs, in-hospital mortality, and complications. Covariates included sex, race or ethnicity, and comorbidities. RESULTS Elderly patients undergoing CAC experienced an average LOS of 8.0 days, whereas elderly patients undergoing CACo stayed an average of 3.2 days. The mean hospital charges incurred during admission totaled $95,960 in the elderly patients who underwent CAC versus $87,960 in the ones who underwent CACo. Elderly patients in whom CAC was performed had a 2.2% rate of in-hospital mortality, with a 2.6 greater adjusted odds of in-hospital mortality than nonelderly patients treated with CAC. In contrast, elderly patients who underwent CACo had a 1.36 greater adjusted odds of in-hospital mortality than their nonelderly counterparts. Compared to nonelderly patients receiving both interventions, elderly individuals had a significantly higher prevalence of various comorbidities and incidence of complications. Elderly patients who received CAC experienced a 10.3% incidence rate of perioperative stroke, whereas their CACo counterparts experienced this complication at a rate of 3.5%. Elderly patients treated with CAC had greater odds of perioperative acute renal failure, whereas their CACo counterparts had greater odds of perioperative deep venous thrombosis and pulmonary embolism. CONCLUSIONS Intervention with CAC and CACo in the elderly is resource intensive and is associated with higher risk than in the nonelderly. Those deciding between intervention and conservative management should consider these risks and costs, especially the 2.2% postoperative mortality rate associated with CAC in the elderly population. Further comparative cost-effectiveness research is needed to weigh these costs and outcomes against those of conservative management.


Asunto(s)
Análisis Costo-Beneficio , Procedimientos Endovasculares/economía , Aneurisma Intracraneal/economía , Atención Perioperativa/economía , Complicaciones Posoperatorias/economía , Instrumentos Quirúrgicos/economía , Adulto , Anciano , Estudios de Cohortes , Análisis Costo-Beneficio/tendencias , Bases de Datos Factuales/economía , Bases de Datos Factuales/tendencias , Procedimientos Endovasculares/tendencias , Femenino , Humanos , Aneurisma Intracraneal/mortalidad , Aneurisma Intracraneal/cirugía , Tiempo de Internación/economía , Tiempo de Internación/tendencias , Masculino , Persona de Mediana Edad , Atención Perioperativa/tendencias , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/mortalidad , Estudios Retrospectivos , Instrumentos Quirúrgicos/tendencias , Resultado del Tratamiento
13.
Neurosurg Focus ; 44(4): E8, 2018 04.
Artículo en Inglés | MEDLINE | ID: mdl-29606049

RESUMEN

OBJECTIVE There has been much debate regarding the optimal surgical approach for resecting olfactory groove meningiomas (OGMs). In this paper, the authors analyzed the factors involved in approach selection and reviewed the surgical outcomes in a series of OGMs. METHODS A retrospective review of 28 consecutive OGMs from a prospective database was conducted. Each tumor was treated via one of 3 approaches: transbasal approach (n = 15), pure endoscopic endonasal approach (EEA; n = 5), and combined (endoscope-assisted) transbasal-EEA (n = 8). RESULTS The mean tumor volume was greatest in the transbasal (92.02 cm3) and combined (101.15 cm3) groups. Both groups had significant lateral dural extension over the orbits (transbasal 73.3%, p < 0.001; combined 100%), while the transbasal group had the most cerebral edema (73.3%, p < 0.001) and vascular involvement (66.7%, p < 0.001), and the least presence of a cortical cuff (33.3%, p = 0.019). All tumors in the combined group were recurrent tumors that invaded into the sinonasal cavity. The purely EEA group had the smallest mean tumor volume (33.33 cm3), all with a cortical cuff and no lateral dural extension. Gross-total resection was achieved in 80% of transbasal, 100% of EEA, and 62.5% of combined cases. Near-total resection (> 95%) was achieved in 20% of transbasal and 37.5% of combined cases, all due to tumor adherence to the critical neurovascular structures. The rate of CSF leakage was 0% in the transbasal and combined groups, and there was 1 leak in the EEA group (20%), resulting in an overall CSF leakage rate of 3.6%. Olfaction was preserved in 66.7% in the transbasal group. There was no significant difference in length of stay or 30-day readmission rate between the 3 groups. The mean modified Rankin Scale score was 0.79 after the transbasal approach, 2.0 after EEA, and 2.4 after the combined approach (p = 0.0604). The mean follow-up was 14.5 months (range 1-76 months). CONCLUSIONS The transbasal approach provided the best clinical outcomes with the lowest rate of complications for large tumors (> 40 mm) and for smaller tumors (< 40 mm) with intact olfaction. The role of EEA appears to be limited to smaller, appropriately selected tumors in which olfaction is already absent. EEA also plays an important adjunctive role when combined with the transbasal approach for recurrent OGMs invading the sinonasal cavity. Careful patient selection using an individualized, tailored strategy is important to optimize surgical outcomes.


Asunto(s)
Neoplasias Meníngeas/cirugía , Meningioma/cirugía , Recurrencia Local de Neoplasia/cirugía , Procedimientos Neuroquirúrgicos , Adulto , Endoscopía/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Cavidad Nasal/cirugía , Procedimientos Neuroquirúrgicos/métodos , Nariz/cirugía , Estudios Retrospectivos , Resultado del Tratamiento
14.
Microsurgery ; 38(5): 504-511, 2018 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-29218804

RESUMEN

OBJECTIVE: Diabetes is associated with microvascular pathology and may predispose patients undergoing microvascular surgery to complications. This study assesses diabetes as a risk factor for complications following free flap surgery of the head and neck. PATIENTS AND METHODS: In this retrospective cohort study, data on free flap surgeries of the head and neck between 2005 and 2014 was collected from the National Surgical Quality Improvement Program (NSQIP) database. A propensity-matching algorithm (PSM) was used to equilibrate distribution of numerous covariates between the diabetic and nondiabetic cohorts. A sub-analysis was performed to examine the impact of insulin-dependency. RESULTS: The initial dataset contained 2187 free flaps of the head and neck. After implementing PSM, a new population was created containing 506 total cases with 253 DM patients. The majority of cases were male and white. The matched cohort did not contain any demographics or comorbidities associated with DM. Complications significantly elevated in the DM group were severe bleeding (P = .046), postoperative ventilation greater than 48 hours (P < .001), and pneumonia (P < .048). In patients with insulin-dependent diabetes, reintubation (P = .005), cardiac arrest (P = .010), severe bleeding (P = .006), overall surgical complications (P = .015), and overall complications (P = .005) were significantly increased. CONCLUSION: This study examines the impact of diabetes on postoperative complications following free flap reconstruction of the head and neck. Propensity score matching was utilized. Analysis of the PSM cohort suggests that diabetic patients have elevated rates of postoperative pulmonary complications. Additionally, patients with insulin-dependent diabetes have significantly elevated rates of medical and surgical complications.


Asunto(s)
Complicaciones de la Diabetes/epidemiología , Colgajos Tisulares Libres/trasplante , Cabeza/cirugía , Cuello/cirugía , Procedimientos de Cirugía Plástica/efectos adversos , Neumonía/epidemiología , Complicaciones Posoperatorias/epidemiología , Adulto , Anciano , Anciano de 80 o más Años , Minería de Datos , Bases de Datos Factuales , Femenino , Supervivencia de Injerto , Hemorragia/etiología , Humanos , Intubación Intratraqueal , Masculino , Persona de Mediana Edad , Neumonía/etiología , Neumonía/terapia , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/terapia , Ventilación Pulmonar , Estudios Retrospectivos , Factores de Riesgo
15.
Biol Blood Marrow Transplant ; 23(7): 1203-1207, 2017 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-28286198

RESUMEN

Autologous hematopoietic stem cell transplantation (auto-HSCT) has improved survival in patients with multiple myeloma (MM) and is increasingly used in elderly patients. The aim of this study was to characterize and compare in-hospital complications and mortality after auto-HSCT in younger (< age 65) versus elderly (> age 65) MM patients utilizing the Nationwide Inpatient Sample. Over a 3-year period (2008 to 2010), 2209 patients with MM were admitted to US hospitals for auto-HSCT. The median age was 59 years, with 1650 patients (74.7%) younger than age 65 and 559 patients (25.3%) 65 or older. Overall, in-hospital mortality in MM patients after auto-HSCT was rare (1.5%) and there was no significant difference in mortality between elderly and younger patients. Elderly patients did have a significantly increased mean length of stay (18.6 days + 10.8 days [SD] versus 16.8 days + 7.2 days [SD], P < .001) and mean total hospital charges ($161,117 + $105,008 [SD] versus $151,192 + $78,342 [SD] , P = .018) compared with younger patients. Elderly patients were significantly more likely than younger patients to develop major in-hospital post-transplantation complications such as severe sepsis (odds ratio [OR], 2.70; 95% confidence interval [CI], 1.40 to 5.21; P = .003), septic shock (OR, 3.10; 95% CI, 1.43 to 6.71; P = .004), pneumonia (OR, 1.62; 95% CI, 1.06 to 2.46; P = .024), acute respiratory failure (OR, 3.44; 95% CI, 1.70 to 6.96; P = .001), endotracheal intubation requiring prolonged mechanical ventilation (OR, 2.19; 95% CI, 1.06 to 4.55; P = .035), acute renal failure (OR, 2.14; 95% CI, 1.38 to 3.33; P = .001), and cardiac arrhythmias (OR, 2.06; 95% CI, 1.52 to 2.79; P <.001). These data may help guide informed consent discussions and provide a focus for future studies to reduce treatment-related morbidity in elderly MM patients undergoing auto-HSCT.


Asunto(s)
Trasplante de Células Madre Hematopoyéticas/efectos adversos , Acondicionamiento Pretrasplante/efectos adversos , Trasplante Autólogo/efectos adversos , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Trasplante de Células Madre Hematopoyéticas/métodos , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Mieloma Múltiple/mortalidad , Acondicionamiento Pretrasplante/métodos , Trasplante Autólogo/métodos , Adulto Joven
16.
J Surg Res ; 212: 48-53, 2017 05 15.
Artículo en Inglés | MEDLINE | ID: mdl-28550921

RESUMEN

BACKGROUND: Medical malpractice is a growing concern for physicians in all fields. Surgical fields have some of the highest malpractice premiums and litigation rates. Pancreaticoduodenectomy (PD) has become a popular procedure; however, it is still associated with significant morbidity and mortality. This study is the first to analyze factors involved in litigation regarding PD cases. METHODS: The Westlaw database was searched for jury verdicts and settlements using the terms "medical malpractice" and "pancreaticoduodenectomy". Twenty-nine cases from 1991 to 2012 were initially collected. Seven entries not involving PD and three duplicate cases were excluded. Nineteen cases were included for analysis. RESULTS: Of the 19 cases included in the analysis, three (15.8%) reached a settlement, three (15.8%) were ruled in favor of the plaintiff, and 13 (68.4%) were ruled in favor of the physician. The average settlement award was $398,333 (range, $195,000-500,000), and the average plaintiff award was $4,288,869 (range, $1,066,608-10,300,000). The most common factors raised in litigation included PD being allegedly unnecessary (47.4%), followed by postoperative negligence and misdiagnosis (36.8% each). CONCLUSIONS: The most common factors present in litigation included the allegation that PD was unnecessarily performed. The cases that are awarded large monetary sums are those that involve continued medical care. Ways to improve patient safety and limit litigation include increasing transparency and communication with a thorough discussion between surgeon and patient of the most common topics of litigation discussed.


Asunto(s)
Mala Praxis/estadística & datos numéricos , Pancreaticoduodenectomía/legislación & jurisprudencia , Especialidades Quirúrgicas/legislación & jurisprudencia , Bases de Datos Factuales , Errores Diagnósticos/legislación & jurisprudencia , Errores Diagnósticos/estadística & datos numéricos , Humanos , Mala Praxis/economía , Mala Praxis/legislación & jurisprudencia , Especialidades Quirúrgicas/economía , Especialidades Quirúrgicas/estadística & datos numéricos , Estados Unidos , Procedimientos Innecesarios/estadística & datos numéricos
17.
Am J Otolaryngol ; 38(5): 560-564, 2017.
Artículo en Inglés | MEDLINE | ID: mdl-28716300

RESUMEN

OBJECTIVES: Analyze postoperative complications after free flap surgery based on PGY training level. METHODS: Data on free flap surgeries of the head and neck performed from 2005 to 2013 was collected from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Cases identifying the status of resident participation in the surgery and the PGY level were included. RESULTS: There were 582 cases with primary surgeon data available. 63 cases were performed with a junior resident, 211 were performed with the assistance of a senior resident, 279 cases were performed with a fellow, and 29 cases were performed by an attending alone without resident involvement. The overall complication rate was 55.2%. There was no statistically significant difference in the rate of complications between groups (47.6%, 59.7%, 53.0%, 58.6%, p=0.277). After controlling for all confounding variables using multivariate analysis there was no significant difference in morbidity, mortality, readmissions, and reoperation amongst the groups. Furthermore, when comparing resident versus fellow involvement using multivariate analysis there were no significant differences in morbidity (OR=0.768[0.522-1.129]), mortality (OR=1.489[0.341-6.499]), readmissions (OR=1.018[0.458-2.262]), and reoperation (OR=0.863[0.446-1.670]). CONCLUSION: Resident and fellow participation in microvascular reconstructive cases does not appear to increase 30-day rates of medical, surgical, or overall complications.


Asunto(s)
Competencia Clínica , Colgajos Tisulares Libres , Neoplasias de Cabeza y Cuello/cirugía , Internado y Residencia , Procedimientos de Cirugía Plástica/educación , Complicaciones Posoperatorias/epidemiología , Adulto , Anciano , Anciano de 80 o más Años , Bases de Datos Factuales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Mejoramiento de la Calidad , Procedimientos de Cirugía Plástica/efectos adversos , Reoperación , Estudios Retrospectivos , Resultado del Tratamiento
18.
Neurosurg Focus ; 41(6): E5, 2016 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-27903113

RESUMEN

Resection remains the mainstay of treatment for craniopharyngiomas with the goal of radical resection, if safely possible, to minimize the rate of recurrence. Endoscopic endonasal and microscopic transcranial surgical approaches have both become standard methods for the treatment for craniopharyngiomas. However, the approach selection paradigm for craniopharyngiomas is still a point of discussion. Choosing the optimal surgical approach can play a significant role in maximizing the extent of resection and surgical outcome while minimizing the risks of potential complications. Craniopharyngiomas can present with a variety of different sizes, locations, and tumor consistencies, and each individual tumor has distinct features that favor one specific approach over another. The authors review standard cranial base techniques applied to craniopharyngioma surgery, using both the endoscopic endonasal approach and traditional open microsurgical approaches, and analyze factors involved in approach selection. They discuss their philosophy of approach selection based on the location and extent of the tumor on preoperative imaging as well as the advantages and limitations of each surgical corridor, and they describe the operative nuances of each technique, using a personalized, tailored approach to the individual patient with illustrative cases and videos.


Asunto(s)
Craneofaringioma/cirugía , Microcirugia/métodos , Neuroendoscopía/métodos , Neoplasias Hipofisarias/cirugía , Adulto , Anciano , Niño , Craneofaringioma/diagnóstico por imagen , Femenino , Humanos , Masculino , Persona de Mediana Edad , Procedimientos Neuroquirúrgicos/métodos , Neoplasias Hipofisarias/diagnóstico por imagen
19.
Ann Otol Rhinol Laryngol ; 125(1): 5-11, 2016 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-26180176

RESUMEN

OBJECTIVE: Transsphenoidal surgery (TSS) harbors a potential for hypopituitarism, cerebrospinal fluid (CSF) leaks, and other complications. We utilized the Nationwide Inpatient Sample Database (NIS) to compare inpatient complication rates between Cushing's disease (CD) and non-Cushing's disease (NCD) patients undergoing TSS. METHODS: Inpatient hospitalization data for 960 CD and 12 110 NCD patients who underwent TSS between 2002 and 2010 were accessed. Demographic information, outcomes, and complication rates were evaluated. RESULTS: Patients with CD had a female predilection (81.7%) and were younger (40.5 ± 14.4 years) than NCD patients (47.8% female; 52.1 ± 16.3 years) (P < .001). Length of stay and total charges did not differ between groups. Patients with CD had significantly greater postoperative diabetes insipidus rates (14.0% vs 9.6%, P < .001) and urinary/renal complications (1.7% vs 0.9%, P = .027). After adjusting for possible confounders, the relationship between urinary/renal complications and CD status strengthened. There was no difference in rates of CSF leak and iatrogenic pituitary disorders overall. CONCLUSION: No differences were noted in the rate of early CSF leaks between postoperative TSS CD and NCD patients. Postoperative diabetes insipidus did not significantly differ between groups after adjusting for confounders. Only odds of urinary/renal complications in CD patients was significant after adjustment.


Asunto(s)
Hipersecreción de la Hormona Adrenocorticotrópica Pituitaria (HACT)/cirugía , Complicaciones Posoperatorias , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Casos y Controles , Pérdida de Líquido Cefalorraquídeo/epidemiología , Estudios de Cohortes , Bases de Datos Factuales , Femenino , Hospitalización , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Obesidad/complicaciones , Hipersecreción de la Hormona Adrenocorticotrópica Pituitaria (HACT)/complicaciones , Resultado del Tratamiento
20.
Am J Otolaryngol ; 37(5): 398-406, 2016.
Artículo en Inglés | MEDLINE | ID: mdl-27452125

RESUMEN

PURPOSE: Adenoid cystic carcinoma (ACC) is a rare malignant epithelial neoplasm of secretory glands of the upper aerodigestive tract. It accounts for 3-5% of head and neck malignancies and most commonly arises from the minor salivary glands of the oral cavity. The clinical behavior of ACC from specific anatomic subsites, including the oral cavity, is not well described in the literature. We aim to elucidate patient demographics, clinicopathologic features, incidence, and survival trends for oral cavity ACC (OCACC). METHODS: Retrospective population-based analysis of OCACC in the SEER database between 1973 and 2012. RESULTS: 1066 OCACC patients were identified, of which 57.7% were female (P<0.0001). Incidence was 0.049 per 100,000. Whites were most commonly affected (81.1%). The hard palate was the most commonly involved subsite (44.1%). Nodal involvement was seen in 8.4% of cases and distant metastasis was present in 6.2% of cases at the time of presentation. Disease-specific survival (DSS) rates at 1, 5, 10, 15, and 20years were 97.4%, 83.9%, 69.9%, 57.6%, and 46.2%, respectively. Females had a higher 5-year DSS (87.8%) than males (78.4%, P=0.0004). Cases treated with surgery had a favorable prognosis regardless of whether they received radiotherapy (P<0.0001). Nodal involvement reduced 5-year DSS by 51.6% (P<0.0001), while distant metastasis reduced 5-year DSS by 46.4% (P<0.0001). CONCLUSIONS: OCACC is a rare malignancy with females and whites being more commonly affected. At presentation, regional and distant metastases are uncommon. Poor prognostic indicators include male gender, nonsurgical therapy, nodal involvement, and distant metastasis.


Asunto(s)
Carcinoma Adenoide Quístico/epidemiología , Neoplasias de la Boca/epidemiología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Carcinoma Adenoide Quístico/patología , Supervivencia sin Enfermedad , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Neoplasias de la Boca/patología , Clasificación del Tumor , Estudios Retrospectivos , Programa de VERF , Tasa de Supervivencia , Estados Unidos/epidemiología , Adulto Joven
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