Prospective development study of the Versius Surgical System for use in transoral robotic surgery: an IDEAL stage 1/2a first in human and initial case series experience.

PURPOSE: Transoral robotic surgery is well established in the treatment paradigm of oropharyngeal pathology. The Versius Surgical System (CMR Surgical) is a robotic platform in clinical use in multiple specialities but is currently untested in the head and neck. This study utilises the IDEAL framework of surgical innovation to prospectively evaluate and report a first in human clinical experience and single centre case series of transoral robotic surgery (TORS) with Versius. METHODS: Following IDEAL framework stages 1 and 2a, the study evaluated Versius to perform first in human TORS before transitioning from benign to malignant cases. Iterative adjustments were made to system setup, instrumentation, and technique, recorded in accordance with IDEAL recommendations. Evaluation criteria included successful procedure completion, setup time, operative time, complications, and subjective impressions. Further evaluation of the system to perform four-arm surgery was conducted. RESULTS: 30 TORS procedures were successfully completed (15 benign, 15 malignant) without intraoperative complication or conversion to open surgery. Setup time significantly decreased over the study period. Instrumentation challenges were identified, urging the need for TORS-specific instruments. The study introduced four-arm surgery, showcasing Versius' unique capabilities, although limitations in distal access were observed. CONCLUSIONS: TORS is feasible with the Versius Surgical System. The development of TORS-specific instruments would benefit performance and wider adoption of the system. 4-arm surgery is possible however further evaluation is required. Multicentre evaluation (IDEAL stage 2b) is recommended.

Soft Tissue Robotic Assisted Orbital Surgery Using da Vinci SP: A Cadaveric Experience.

PURPOSE: Robotic surgical techniques have transformed many surgical specialties however robotic techniques and applications have been much more limited in ophthalmology. This study aims to evaluate the feasibility of robotic assisted orbital surgery using a single-port novel robotic platform, the da Vinci SP. METHODS: A series of orbital procedures were performed in cadaveric specimens utilizing the da Vinci SP robotic system. The procedures performed included lacrimal gland dissection and biopsy, medial and lateral orbital wall dissections, enucleation, and lid-sparing orbital exenteration. Successful completion of each procedure was defined by the operating surgeon and was considered the primary outcome and marker of feasibility. RESULTS: Seven cadaveric procedures were performed in 3 cadaveric specimens. All 7 procedures were completed successfully without complication. Setup optimization occurred throughout the study and setup and operative times were acceptable. Three instrument arms and 1 endoscope were utilized throughout the study allowing 3 arm operating and dynamic retraction. Instrument size was found to limit surgical access and precision particular at the orbital apex. CONCLUSIONS: This preclinical study demonstrates that the da Vinci SP can be utilized within the orbit and is feasible for several applications. Robotic surgical systems offer significant advantages over conventional techniques and should be embraced. However, current commercially available robotic platforms are not optimized for the orbit and have their limitations although they may be suitable for some clinical applications.

Setting up a nurse-led 2-week-wait head and neck cancer diagnostic service.

The number of urgent '2-week-wait' referrals to hospital for people with suspected head and neck cancer being sent by primary care is constantly growing and it is becoming increasingly difficult for head and neck cancer services to meet this demand. In order for trusts to meet their Faster Diagnosis Standards, there needs to be an effective and efficient way to ensure there is capacity for patients to receive the appropriate assessments and diagnostic investigations without compromising the quality of care delivered. This article presents the proposal of introducing a nurse-led 2-week-wait clinic to meet the ever-growing demands on the service. There is discussion of the consultant-led training programme used to upskill an advanced nurse practitioner in a single-centre study, as well as explanation of the processes followed to maintain patient safety throughout the pilot project. There will also be consideration of clinical governance and discussion of how patient satisfaction with the novel service will be measured.

Water soluble swallow for leak detection after total laryngectomy post radiotherapy.

AIM: Pharyngeal leak (PL) and pharyngocutaneous fistula (PCF) are serious complications following total laryngectomy and their incidence is higher in the salvage setting. The aim of this study is to describe the accuracy of water soluble swallow (WSS) to rule out salivary postoperative leak after salvage total laryngectomy (STL) to expedite start of oral intake. MATERIAL AND METHODS: Retrospective study including patients undergoing STL between 2008 and 2021 at Guy's Hospital. WSS was routinely performed within 15 days post operation. RESULTS: Sixty-six patients underwent STL. Nine developed clinically diagnosed PCF; one died before having WSS. Fifty-six patients underwent WSS post STL. WSS was performed within 15 days after STL when no postoperative complications occurred (76.8%). Among patients undergoing WSS with no clinical suspicion for fistula (56), PL was identified in 15 cases (26.8%). They were managed conservatively; PCF was avoided in 7(46.7%) cases. Three patients (7.3%) developed PCF after having started oral intake with a negative WSS. These three cases were further analysed, 2 cases where recorded at the beginning of the studied period when less experience was available possibly leading to incorrect results. Sensitivity and negative predictive value (NPV) for fistula prediction were 72.7% and 92.7%, respectively. CONCLUSION: Taking into account the high NPV of WSS, it is safe to start oral intake after negative WSS. Further studies to evaluate its accuracy earlier on after SLT are justified taking into account the results and the impact that delayed feeding has on patient's quality of life.

Management of Obscurely Dilated Common Bile Duct with Normal Liver Function Tests: A Pragmatic Approach.

OBJECTIVE: Dilated common bile duct (CBD) (8-15 mm) with normal liver function tests is seen not infrequently, while management of such patients is ambiguous. We propose a treatment algorithm for this cohort of patients after observing them over a period of 8 years. METHODS: Seventy-eight such patients were managed from 2009 to 2017 and categorized as: Group A-dilated CBD with post-cholecystectomy status (n = 15); B-dilated CBD with cholelithiasis (n = 34); C-dilated CBD without cholelithiasis (n = 16); D-dilated CBD with no cause identified and underwent CBD excision (n = 13). Causes for CBD dilatation were evaluated. The outcome of patients in Group B + C without any cause (n = 33) was compared with Group D. RESULT: Median age, CBD diameter, bilirubin and alkaline phosphatase were 51 years (13-79), 10 mm (8-20), 0.6 mg/dl (0.2-2.5) and 126 IU (60-214), respectively. Group-A patients who did not manifest any cause of CBD dilatation were managed conservatively. The aetiology was identified in 17/50 patients in Group B & C [acute pancreatitis (n = 6), passed CBD calculi (n = 3), perivaterian diverticulum (n = 3), viral aetiology (n = 4) and tumour (n-1)]. In Group-C, 7 patients with no obvious cause underwent endoscopic sphincterotomy, pancreatoduodenectomy (n = 1), and the rest were managed conservatively (n = 8). There was no significant difference in the complication between Group B + C (without any cause) and Group D (3/33 vs. 1/13; p = 0.58) at a median follow-up of 72 months (30-90). CONCLUSION: Dilated CBD with normal LFT's without apparent cause is mostly benign and of no consequence. Excision of the CBD is not required for most of these patients.

Open versus percutaneous tracheostomy in COVID-19: a multicentre comparison and recommendation for future resource utilisation.

PURPOSE: The COVID-19 pandemic placed an unprecedented demand on critical care services for the provision of mechanical ventilation. Tracheostomy formation facilitates liberation from mechanical ventilation with advantages for both the patient and wider critical care resource, and can be performed using both percutaneous dilatational and surgical techniques. We compared outcomes in those patients undergoing percutaneous dilatational tracheostomy to those undergoing surgical tracheostomy and make recommendations for provision of tracheostomy services in any future surge. METHODS: Multicentre multidisciplinary retrospective observational cohort study including 201 patients with COVID-19 pneumonitis admitted to an ICU in one of five NHS Trusts within the South London Adult Critical Care Network who required mechanical ventilation and subsequent tracheostomy. RESULTS: Percutaneous dilatational tracheostomy was performed in 124 (62%) of patients, and surgical tracheostomy in 77 (38%) of patients. There was no difference between percutaneous dilatational tracheostomy and surgical tracheostomy in either the rate of peri-operative complications (16.9 vs. 22.1%, p = 0.46), median [IQR(range)] time to decannulation [19.0 (15.0-30.2 (5.0-65.0)] vs. 21.0 [15.5-36.0 (5.0-70.0) days] or mortality (13.7% vs. 15.6%, p = 0.84). Of the 172 patients that were alive at follow-up, two remained ventilated and 163 were decannulated. CONCLUSION: In patients with COVID-19 pneumonitis that require tracheostomy to facilitate weaning from mechanical ventilation, there was no difference in outcomes between those patients that had percutaneous dilatational tracheostomy compared with those that had surgical tracheostomy. Planning for future surges in COVID-19-related critical care demands should utilise all available resource and expertise.

Tracheostomy, ventilatory wean, and decannulation in COVID-19 patients.

PURPOSE: COVID-19 patients requiring mechanical ventilation can overwhelm existing bed capacity. We aimed to better understand the factors that influence the trajectory of tracheostomy care in this population to facilitate capacity planning and improve outcomes. METHODS: We conducted an observational cohort study of patients in a high-volume centre in the worst-affected region of the UK including all patients that underwent tracheostomy for COVID-19 pneumonitis ventilatory wean from 1st March 2020 to 10th May 2020. The primary outcome was time from insertion to decannulation. The analysis utilised Cox regression to account for patients that are still progressing through their tracheostomy pathway. RESULTS: At the point of analysis, a median 21 days (IQR 15-28) post-tracheostomy and 39 days (IQR 32-45) post-intubation, 35/69 (57.4%) patients had been decannulated a median of 17 days (IQR 12-20.5) post-insertion. The overall median age was 55 (IQR 48-61) with a male-to-female ratio of 2:1. In Cox regression analysis, FiO2 at tracheostomy ≥ 0.4 (HR 1.80; 95% CI 0.89-3.60; p = 0.048) and last pre-tracheostomy peak cough flow (HR 2.27; 95% CI 1.78-4.45; p = 0.001) were independent variables associated with prolonged time to decannulation. CONCLUSION: Higher FiO2 at tracheostomy and higher pre-tracheostomy peak cough flow are associated with increased delay in COVID-19 tracheostomy patient decannulation. These finding comprise the most comprehensive report of COVID-19 tracheostomy decannulation to date and will assist service planning for future peaks of this pandemic.

Tracheostomy care and decannulation during the COVID-19 pandemic. A multidisciplinary clinical practice guideline.

PURPOSE: Traditional critical care dogma regarding the benefits of early tracheostomy during invasive ventilation has had to be revisited due to the risk of COVID-19 to patients and healthcare staff. Standard practises that have evolved to minimise the risks associated with tracheostomy must be comprehensively reviewed in light of the numerous potential episodes for aerosol generating procedures. We meet the urgent need for safe practise standards by presenting the experience of two major London teaching hospitals, and synthesise our findings into an evidence-based guideline for multidisciplinary care of the tracheostomy patient. METHODS: This is a narrative review presenting the extensive experience of over 120 patients with tracheostomy, with a pragmatic analysis of currently available evidence for safe tracheostomy care in COVID-19 patients. RESULTS: Tracheostomy care involves many potentially aerosol generating procedures which may pose a risk of viral transmission to staff and patients. We make a series of recommendations to ameliorate this risk through infection control strategies, equipment modification, and individualised decannulation protocols. In addition, we discuss the multidisciplinary collaboration that is absolutely fundamental to safe and effective practise. CONCLUSION: COVID-19 requires a radical rethink of many tenets of tracheostomy care, and controversy continues to exist regarding the optimal techniques to minimise risk to patients and healthcare workers. Safe practise requires a coordinated multidisciplinary team approach to infection control, weaning and decannulation, with integrated processes for continuous prospective data collection and audit.

Laparoscopic cholecystectomy in patients with portal cavernoma without portal vein decompression.

INTRODUCTION: Laparoscopic cholecystectomy (LC) in patients with extrahepatic portal vein obstruction causing portal cavernoma (PC) is considered high risk because of portosystemic collateral veins in the hepatocystic triangle. The literature is limited to isolated case reports. We describe our experience of LC in patients with PC. PATIENTS AND METHODS: Data of patients with PC who underwent LC for symptomatic gallstones or related complications was reviewed. Patients with simultaneous cholecystectomy with splenorenal shunt and open cholecystectomy were excluded. Pre-operative evaluation consisted of complete blood count, international normalisation ratio and liver function tests, ultrasound of the abdomen with Doppler, contrast-enhanced computerised tomography, magnetic resonance cholangiopancreatography and esophagogastroscopy as indicated. A standard four-port LC was performed. The technical principles followed were to avoid injury to the collateral veins, liberal use of energy sources and division of dominant collateral veins between clips. RESULTS: Seven adult patients including three females underwent LC. Three patients had thrombosis of previous surgical shunt with persistent PC. The remaining four patients did not have any indication for shunt surgery. Successful LC was performed in six patients. The median duration of surgery was 170 (130-250 min). Blood transfusion was not required. All the patients had uneventful post-operative recovery. The histopathology of gall bladder consists of acute cholecystitis in three patients and chronic cholecystitis in four. CONCLUSION: LC is feasible in patients with PC at a centre with experience in both laparoscopic and portal hypertension surgeries. Excellent outcome with low rate of conversion to open surgery can be achieved.

Global Tracheostomy Collaborative: data-driven improvements in patient safety through multidisciplinary teamwork, standardisation, education, and patient partnership.

There is growing recognition of the need for a coordinated, systematic approach to caring for patients with a tracheostomy. Tracheostomy-related adverse events remain a pervasive global problem, accounting for half of all airway-related deaths and hypoxic brain damage in critical care units. The Global Tracheostomy Collaborative (GTC) was formed in 2012 to improve patient safety and quality of care, emphasising knowledge, skills, teamwork, and patient-centred approaches. Inspired by quality improvement leads in Australia, the UK, and the USA, the GTC implements and disseminates best practices across hospitals and healthcare trusts. Its database collects patient-level information on quality, safety, and organisational efficiencies. The GTC provides an organising structure for quality improvement efforts, promoting safety of paediatric and adult patients. Successful implementation requires instituting key drivers for change that include effective training for health professionals; multidisciplinary team collaboration; engagement and involvement of patients, their families, and carers; and data collection that allows tracking of outcomes. We report the history of the collaborative, its database infrastructure and analytics, and patient outcomes from more than 6500 patients globally. We characterise this patient population for the first time at such scale, reporting predictors of adverse events, mortality, and length of stay indexed to patient characteristics, co-morbidities, risk factors, and context. In one example, the database allowed identification of a previously unrecognised association between bleeding and mortality, reflecting ability to uncover latent risks and promote safety. The GTC provides the foundation for future risk-adjusted benchmarking and a learning community that drives ongoing quality improvement efforts worldwide.

Recommendation of a practical guideline for safe tracheostomy during the COVID-19 pandemic.

PURPOSE: The COVID-19 pandemic is placing unprecedented demand upon critical care services for invasive mechanical ventilation. There is current uncertainty regarding the role of tracheostomy for weaning ventilated patients with COVID-19 pneumonia. This is due to a number of factors including prognosis, optimal healthcare resource utilisation, and safety of healthcare workers when performing such a high-risk aerosol-generating procedure. METHODS: Literature review and proposed practical guideline based on the experience of a tertiary healthcare institution with 195 critical care admissions for COVID-19 up until 4th April 2020. RESULTS: A synthesis of the current international literature and reported experience is presented with respect to prognosis, viral load and staff safety, thus leading to a pragmatic recommendation that tracheostomy is not performed until at least 14 days after endotracheal intubation in COVID-19 patients. Practical steps to minimise aerosol generation in percutaneous tracheostomy are outlined and we describe the process and framework for setting up a dedicated tracheostomy team. CONCLUSION: In selected COVID-19 patients, there is a role for tracheostomy to aid in weaning and optimise healthcare resource utilisation. Both percutaneous and open techniques can be performed safely with careful modifications to technique and appropriate enhanced personal protective equipment. ORL-HNS surgeons can play a valuable role in forming tracheostomy teams to support critical care teams during this global pandemic.

Robotic Head and Neck Surgery: History, Technical Evolution and the Future.

The first application of robotic technology in surgery was described in 1985 when a robot was used to define the trajectory for a stereotactic brain biopsy. Following its successful application in a variety of surgical operations, the da Vinci® robot, the most widely used surgical robot at present, made its clinical debut in otorhinolaryngology and head and neck surgery in 2005 when the first transoral robotic surgery (TORS) resections of base of tongue neoplasms were reported. Subsequently, the indications for TORS rapidly expanded, and they now include tumours of the oropharynx, hypopharynx, parapharyngeal space, and supraglottic larynx, as well as obstructive sleep apnoea (OSA). The da Vinci® robot has also been successfully used for scarless-in-the-neck thyroidectomy and parathyroidectomy. At present, the main barrier to the wider uptake of robotic surgery is the prohibitive cost of the da Vinci® robotic system. Several novel, flexible surgical robots are currently being developed that are likely to not only enhance patient safety and expand current indications but also drive down costs, thus making this innovation more widely available. Future directions relate to overlay technology through augmented reality/AR that allows real-time image-guidance, miniaturisation (nanorobots), and the development of autonomous robots.

Transoral Robotic Surgery: Image Guidance and Augmented Reality.

Transoral robotic surgery (TORS) is being used increasingly as an alternative to conventional open procedures, as its minimally invasive approach results in significant benefits for the patient. This includes faster recovery times and better functional outcomes, less postoperative pain and morbidity associated with open access, shorter operative times, and a reduction in the risk of infection. However, the confined working spaces and sensory deficit, due to a lack of haptic sensation, and proximity to critical vasculature and other vitally important anatomical structures bestow significant challenges on the surgeon. Recent advances in the field of surgical image guidance show promise in helping address these issues. This overview considers a number of important recent developments, all of which exploit imaging technologies that, to a lesser or greater extent, are integrated with the surgical robot platform. In its most advanced form, this combination of technologies results in a fusion of visual information such that the operative field is combined with navigational cues and representations of key anatomical structures through augmented reality registration and overlay. In terms of registration accuracy, image guidance as applied to TORS procedures is an exciting proposition, since the regions of interest (e.g., the tongue base, oropharynx) are typically adjacent to and enclosed by rigid anatomy. Clinical indications and overall effectiveness are discussed together with the limitations of the current technologies. Where appropriate, directions for future work are identified.

Robotic Parathyroid Surgery: Current Perspectives and Future Considerations.

Robotic parathyroidectomy represents a novel surgical approach in the treatment of primary hyperparathyroidism when the parathyroid adenoma has been pre-operatively localised. It represents the "fourth generation" in the evolution of parathyroid surgery following a process of surgical evolution from cervicotomy and 4-gland exploration to a variety of minimally invasive, open and endoscopic, targeted approaches. The existing evidence (levels 2-3) supports it as a feasible and safe technique with equivalent results to targeted open parathyroidectomy for primary hyperparathyroidism in carefully selected patients. However, it takes longer to perform and is more costly than conventional parathyroidectomy. It offers superior cosmesis by completely avoiding a neck scar making it a valid option for those patients who for biological and/or cultural reasons may wish to avoid a neck scar. Robotic parathyroidectomy is not for every patient, surgeon, or hospital. Its application should be confined to high-volume centres and experienced surgeons. Intensive training and proctorship are required for its safe implementation combined with careful patient selection. This particularly relates to the patient's body habitus (BMI < 30 kg/m2) and concordance among the different imaging modalities used pre-operatively. With robotic market competition driving down costs, its role may change. For now, robotic parathyroidectomy occupies a niche role and can only be justified in a select subset of patients.

Transoral Robotic Surgery for Obstructive Sleep Apnoea-Hypopnoea Syndrome.

Obstructive sleep apnoea-hypopnoea (OSAH) syndrome constitutes a major health care problem. Surgical modalities for the treatment of OSAH are regaining momentum in view of the increasing prevalence of OSAH and the low compliance rates associated with continuous positive airway pressure. There are several investigations to complement clinical examination in accurately determining the level of airway collapse to ensure correct patient selection and a targeted surgical approach. The most commonly employed include drug-induced sleep endoscopy and imaging with the tongue base and epiglottis often revealed as the major sites of airway narrowing during sleep. In the continuing search for the optimal approach to address these areas, transoral robotic surgery (TORS) has been successfully used for tongue base reduction and epiglottoplasty. With sufficient experience, this technique is safe and well tolerated. Meticulous work-up and careful patient selection are crucial. Multiple studies have demonstrated very good short-term results of TORS for OSAH, with significant reduction in both the Apnoea-Hypopnea Index (AHI) and Epworth Sleepiness Score (ESS). With the appropriate infrastructure, proctoring, and access to robotic surgical technology, it is possible for these results to be reproduced more widely. Further prospective long-term clinical evaluation will ultimately determine the exact role of TORS in the treatment of OSAH.

Next-Generation Robotic Head and Neck Surgery.

Following the inception of transoral robotic surgery (TORS) in 2005, the field of robotic head and neck surgery has undergone refinement and innovation. Optimizing patient outcome, preserving function, and limiting morbidity are the key drivers. The next leap forward is another generation of flexible robotic surgical systems. Several such systems are under clinical and preclinical evaluation. A new single-port (Sp) robotic surgical architecture is now available integrating three fully articulating instruments and a flexible three-dimensional high-definition camera delivered through a 25-mm cannula. Preclinical feasibility studies of the Sp in human cadaver and porcine models suggest improved application compared to existing platforms for oropharyngeal and nasopharyngeal resection. With 3-handed manipulation of tissue, traction and countertraction may be used to deliver a more precise surgical dissection of head and neck anatomy than is currently possible. The single-port design permits greater access and maneuverability for the bedside surgical assistant. An alternative currently available in clinical use includes the Flex® system using a robotic camera and manually controlled endoscopic instruments. The Cambridge Medical Robotics Versius system is undergoing preclinical evaluation for TORS and may offer a novel modular approach. All of these systems allow the head and neck surgeon to reach further beyond the upper aerodigestive tract with greater agility and precision, expanding the boundaries of minimal access head and neck surgery.

Robotic Thyroid Surgery: Current Perspectives and Future Considerations.

Robotic transaxillary thyroidectomy, pioneered in South Korea, is firmly established throughout the Far East but remains controversial in Western practice. This relates to important population differences (anthropometry and culture) compounded by the smaller mean size of thyroid nodules operated on in South Korea due to a national thyroid cancer screening programme. There is now level 2 evidence (including from Western World centres) to support the safety, feasibility, and equivalence of the robotic approach to its open counterpart in terms of recurrent laryngeal nerve injury, hypoparathyroidism, haemorrhage, and oncological outcomes for differentiated thyroid cancer. Moreover, robotic thyroidectomy has been shown to be superior to open surgery for certain patient-reported outcome measures, namely scar cosmesis and pain. Downsides include its high cost, longer operative time, and risk of complications not encountered in open thyroidectomy (brachial plexus neurapraxia). Careful patient selection is paramount as this procedure is not for every patient, surgeon, or hospital. It should only be undertaken by high-volume surgeons operating as part of a multidisciplinary robotic team in specialised centres. Novel robotic approaches utilising the retroauricular and transoral routes for thyroidectomy have recently been described but further studies are required to establish their respective role in modern thyroid surgery.

Ileostomy site approach for adhesiolysis and laparoscopic cholecystectomy in a hostile abdomen: A novel technique.

INTRODUCTION:: Gallstones are an etiological factor in 23%-54% of patients with acute pancreatitis. A small proportion of these patients will also have intestinal complications requiring necrosectomy with diverting loop ileostomy. Later, these patients require cholecystectomy and ileostomy reversal. Laparoscopic cholecystectomy is fraught with difficulty in these patients due to dense intra-abdominal adhesions, and many surgeons resort to an open approach. We describe a technique which takes advantage of the ileostomy site for initial access. MATERIALS AND SURGICAL TECHNIQUE: Ileostomy reversal is done and a SILS™ (Covidien, Mansfield, Massachusetts, USA) port is inserted under direct vision, through the ileostomy site. Adhesiolysis is done through the SILS™ port. Additional ports are inserted and standard steps are followed for cholecystectomy. CONCLUSION: The use of ileostomy incision as the first port facilitates adhesiolysis and subsequent port placement in the hostile abdomen encountered in these patients. We describe a novel technique of ileostomy reversal and laparoscopic cholecystectomy using SILS™ port.

Computed Tomography (CT) and Magnetic Resonance (MR) Findings in Xanthogranulomatous Cholecystitis: Retrospective Analysis of Pathologically Proven 30 Cases - Tertiary Care Experience.

BACKGROUND: To study CT and MR findings in xanthogranulomatous cholecystitis (XGC). MATERIAL/METHODS: Retrospective analysis of 30 histopathologically confirmed cases of XGC. Seventeen patients underwent CECT and 13 underwent MRI. The following features were studied - wall thickness, intramural nodules, pericholecystic stranding, wall thickness, THAD, fat in gallbladder wall, cholelithiasis, infiltration, biliary dilatation, lymph nodes, complications. RESULTS: The majority of cases (22/30) showed discontinuous mucosal lining. Discontinuous mucosal lining was seen in all cases with wall thickness >10 mm, 75% of cases with wall thickness between 3-10 mm and none in normal wall thickness (p=0.03). Diffuse wall thickening was seen in 23 cases, focal thickening in 3 and polypoidal wall thickening in 2 cases. Polypoidal thickening was seen in gallbladder carcinoma. Intramural nodules were present in 87.5% of cases with discontinuous mucosal lining. Pericholecystic stranding was seen in 19, biliary dilatation in 12, liver infiltration in 13 and fat in 7 cases. Lymphadenopathy was seen in 1 case with gallbladder carcinoma. Four cases showed a signal drop in the intramural nodules on chemical shift MRI. CONCLUSIONS: Discontinuous mucosal lining is evident in xanthogranulomatous cholecystitis. Diffuse wall thickening, intramural nodules, continuous or discontinuous mucosal lining and cholelithiasis may indicate XGC rather than gallbladder carcinoma. Based on correlation with pathophysiological findings, we conclude that discontinuous mucosal lining is not an unusual finding in cases of XGC. Advances in knowledge: Being aware of the radiological findings described in this article may be helpful in making preoperative radiological diagnosis of XGC. Mucosal lining may be continuous or discontinuous in XGC.

Outcome of TORS to tongue base and epiglottis in patients with OSA intolerant of conventional treatment.

PURPOSE: Transoral robotic surgery (TORS) of the tongue base with or without epiglottoplasty represents a novel treatment for obstructive sleep apnea (OSA). The objective was to evaluate the clinical efficacy of TORS of the tongue base with or without epiglottoplasty in patients who had not tolerated or complied with conventional treatment (continuous positive airway pressure or oral appliance). METHODS: Four-year prospective case series. The primary outcome measure was the apnea-hypopnea index (AHI) in combination with the Epworth Sleepiness Score (ESS). Mean oxygen saturation levels (SaO2) before and after TORS on respective sleep studies were also recorded. Secondary outcome measures included operative time and complications. Patient reported outcome measures (PROMs) assessed included voice, swallow and quality of life. RESULTS: Fourteen patients underwent TORS for tongue base reduction with ten having additional wedge epiglottoplasty. A 64 % success rate was achieved with a normal post-operative sleep study in 36 % of cases at 6 months. There was a 51 % reduction in the mean AHI (36.3 ± 21.4 to 21.2 ± 24.6, p = 0.02) and a sustained reduction in the mean Epworth Sleepiness Score (p = 0.002). Mean SaO2 significantly increased after surgery compared to pre-operative values (92.9 ± 1.8 to 94.3 ± 2.5, p = 0.005). Quality of life showed a sustained improvement 3 months following surgery (p = 0.01). No major complications occurred. CONCLUSIONS: TORS of the tongue base with or without epiglottoplasty represents a promising treatment option with minimal morbidity for selected patients with OSA. Long-term prospective comparative evaluation is necessary to validate the findings of this study.