Intraoperative nerve monitoring in laryngotracheal surgery. / Neuromonitorización intraoperatoria en cirugía laringotraqueal.

Laryngotracheal surgery has an inherent risk of injury to the recurrent laryngeal nerves (RLN). These complications go from minor dysphonia to even bilateral vocal cord paralysis. The intraoperative neuromonitoring of the RLN was developed in the field of thyroid surgery, in order to preserve nerve and vocal cord function. However, tracheal surgery requires in-field intubation of the distal trachea, which limits the use of nerve monitoring using conventional endotracheal tube with surface electrodes. Given these challenges, we present an alternative method for nerve monitoring during laryngotracheal surgery through the insertion of electrodes within the endolaryngeal musculature by bilateral puncture.

To operate or not to operate? Assessing NSQIP surgical outcomes in trisomy 18 patients.

BACKGROUND: Trisomy 18 is associated with a wide range of potentially fatal congenital conditions. Historically, clinical attitudes on treatment have been ambiguous, with palliative care as the standard of care. The aim of our study was to provide a descriptive analysis of surgical outcomes in patients with trisomy 18. STUDY DESIGN: We identified patients with trisomy 18 aged 0-18 years using the NSQIP-Pediatric database from 2012 to 2017 and analyzed demographics, surgery types, and perioperative characteristics of patients with trisomy 18 patients undergoing surgical intervention. Additionally, a case-match analysis was performed to assess surgical outcome differences. RESULTS: A total of 310 patients with trisomy 18 were identified. Thirty-one percent were >5 years of age and 73% were female. The most common surgical types were general surgery procedures (57.4%), followed by orthopedics (18.1%) and ENT (10.3%). Operations performed increased from 8% (2012) to 26% (2017), and only 23% of patients had previous cardiac surgery. Majority of patients had no prior history of malignancy (95%) and 5% had a tracheostomy placed. Discharge to home was achieved in 74% of patients, with a median total hospital length of stay of 5 days (IQR 17). Furthermore, 90% survived over 30 days from the operation. Thirty-two patients had readmissions and the most common reasons were dehydration, gastrostomy infection or malfunction. Surgical site infections occurred in <3% of patients. No differences in complications, length of stay, reoperations, and readmissions were identified by case-match analysis. CONCLUSION: In this data set, patients with trisomy 18 undergoing noncardiac surgical procedures experience excellent surgical outcomes with minimal morbidity and low mortality. Most patients more than a year of age will experience similar outcomes to patients without trisomy 18. TYPE OF STUDY: Treatment study (retrospective comparative study) LEVEL OF EVIDENCE: Level III.

Novel technique for management of esophageal strictures: double "J" stents and the use of urologic dilators.

Current management of esophageal strictures using multiple dilations is the standard of care for symptomatic relief and cure. Diverse arrays of techniques have been developed with similar success rates. In this study we suggest the use of urologic dilator as a safe, alternative method for the management of esophageal strictures. We report a case of a patient with a history of severe, recurrent esophageal stricture secondary to tracheo-esophageal fistula repair, treated using Amplatz urologic dilators and double J stent as a mechanical temporizer for an esophageal stricture at risk for complete stenosis. Under general anesthesia, a flexible endoscope was passed into the proximal esophagus to visualize the stricture. A glide wire was passed through the stricture and its placement was confirmed by fluoroscopy. The endoscope was then removed and a series of urologic dilators sizing from 12Fr to 32Fr were passed through the stricture under fluoroscopic vision. Following this, a double "J" stent was left in place for further dilation sessions and to prevent complete stenosis. In conclusion, urologic dilators demonstrate a novel and simple technique for the treatment of esophageal strictures. This patient had no reported complications, and patient was able to tolerate the double "J" stent during dilation sessions.

Impaired Gut-Systemic Signaling Drives Total Parenteral Nutrition-Associated Injury.

BACKGROUND: Total parenteral nutrition (TPN) provides all nutritional needs intravenously. Although lifesaving, enthusiasm is significantly tempered due to side effects of liver and gut injury, as well as lack of mechanistic understanding into drivers of TPN injury. We hypothesized that the state of luminal nutritional deprivation with TPN drives alterations in gut-systemic signaling, contributing to injury, and tested this hypothesis using our ambulatory TPN model. METHODS: A total of 16 one-week-old piglets were allocated randomly to TPN (n = 8) or enteral nutrition (EN, n = 8) for 3 weeks. Liver, gut, and serum were analyzed. All tests were two-sided, with a significance level of 0.05. RESULTS: TPN resulted in significant hyperbilirubinemia and cholestatic liver injury, p = 0.034. Hepatic inflammation (cluster of differentiation 3 (CD3) immunohistochemistry) was higher with TPN (p = 0.021). No significant differences in alanine aminotransferase (ALT) or bile ductular proliferation were noted. TPN resulted in reduction of muscularis mucosa thickness and marked gut atrophy. Median and interquartile range for gut mass was 0.46 (0.30-0.58) g/cm in EN, and 0.19 (0.11-0.29) g/cm in TPN (p = 0.024). Key gut-systemic signaling regulators, liver farnesoid X receptor (FXR; p = 0.021), liver constitutive androstane receptor (CAR; p = 0.014), gut FXR (p = 0.028), G-coupled bile acid receptor (TGR5) (p = 0.003), epidermal growth factor (EGF; p = 0.016), organic anion transporter (OAT; p = 0.028), Mitogen-activated protein kinases-1 (MAPK1) (p = 0.037), and sodium uptake transporter sodium glucose-linked transporter (SGLT-1; p = 0.010) were significantly downregulated in TPN animals, whereas liver cholesterol 7 alpha-hydroxylase (CyP7A1) was substantially higher with TPN (p = 0.011). CONCLUSION: We report significant alterations in key hepatobiliary receptors driving gut-systemic signaling in a TPN piglet model. This presents a major advancement to our understanding of TPN-associated injury and suggests opportunities for strategic targeting of the gut-systemic axis, specifically, FXR, TGR5, and EGF in developing ameliorative strategies.