Middle ear barotrauma in hyperbaric oxygen therapy.

INTRODUCTION: Middle ear barotrauma (MEB) is a common complication of hyperbaric oxygen (HBO2) therapy. The purpose of this study was to determine the overall incidence of MEB and evaluate for differences in the incidence of MEB at different rates of compression (ROC). The study also sought to identify other potential risk factors for MEB. METHODS: A retrospective chart review was performed on patients undergoing HBO2 at an academic regional level 1 trauma center. The MEB overall incidence as well as incidence at different ROC were determined. RESULTS: 236 patients representing 4,981 treatments were analyzed. The overall incidence of MEB was 43.2%. There was no statistically significant difference in the incidence of MEB at different ROC. There was a statistically significant higher incidence of TEED 4 MEB in intubated patients (p < 0.0001). The vast majority of MEB was minor when considering severity based on overall lower TEED scores of 1 or 2 (84%). DISCUSSION: The overall incidence of MEB in this study is consistent with those previously reported. It is important to note that a vast majority of MEB was minor. This supports HBO2 as a safe treatment modality with minimal overall risk. The current study supports standardization of most treatment protocols to a ROC of 2 psi/minute.

Modeling perioperative risk: can numbers speak louder than words?

Perioperative care is one of the most complex segments of medicine, because it imposes unique and unprecedented stress on the patient and requires the participation of multiple medical specialists. For this reason, the concept of risk management is ideally suited for application in the perioperative period. The authors believe that risk stratification systems applied to perioperative management should address the three dimensions of patient condition, surgical risk and invasiveness, and anesthetic complexity. They have proposed a system that integrates these factors to document and communicate the relevant elements affecting the "shape" of preoperative patients. Admittedly far short of the ideal formula, we hope this nonetheless prompts efforts to establish more uniform means of assessment and communication and provides a foundation for this endeavor. The old adage can be modified: "if your patient rates more than two ASPIRIN, call me before the morning (of surgery)."

Improvement of swallowing ability in advanced oesophageal cancer.

Without different types of palliation the patients with inoperable oesophageal cancer have a poor quality of life, rapid weight loss which leads to death. The aim of palliation is the complete relief of dysphagia. Our modified procedure is a simplified way of a well known method described by Tytgat in 1986. The prosthesis is positioned under continuous visual control using only local anaesthesia. This method is safe and not expensive. During the last three years 73 consecutive patients were treated with palliative fiberoscopic intubation with Tygon prosthesis. 46 patients had esophageal carcinoma, 19 had gastric, 8 had pulmonary carcinoma obstructing the gullet. Among them 11 patients had bronchoesophageal fistula. The early complications were perforations (7) bleeding (2), and later complications: food impaction (5) tumor overgrowth (5) and tube migration (2). The mortality was 2%. All patients have received antibiotic prevention. Although the improvement of life quality is more important than extension of life, for many patients survival will be prolonged due to improved nutrition as a result of treatment. This study summaries our experience with this technique and analyzes the problems and complications encountered in our patients.

Palliative endoscopic management of obstructive esophagogastric cancer: laser or prosthesis?

One hundred forty-four patients with unresectable malignant strictures of the upper digestive tract were managed by palliative endoscopic methods: 116 by intubation and 28 by YAG laser phototherapy. The success rate was 95% for intubation and 100% for laser. The morbidity rate was 13.8% for intubation (perforation 7.8%, bleeding 3.4%, and aspiration pneumonia 2.2%) and 3.6% (one perforation) for laser. The mortality rate was 4.3% for intubation and 0% for laser. Specific indications for intubation were esobronchial fistulas, extensive strictures, and very long stenotic lesions. Very high cervical strictures and nonocclusive asymmetrical tumors were better treated with laser. In select cases, combined therapy can be useful. We conclude that both methods are highly efficient in restoring patency and relieving dysphagia. Further large scale randomized trials are necessary to compare functional results and survival rate.