Morbidity related to the lip-split mandibulotomy approach: a systematic and narrative review.

The lip-split mandibulotomy (LSMA) is an access procedure that has been used in head and neck (H&N) surgery as an aid to surgical resection of inaccessible tumours of the postertior oral cavity and oropharynx. Anecdotal evidence suggests that it has significant morbidity. Voices of concern within the H&N surgical community suggest that it has been abandoned in favour of technological advances such as robotic surgery. We report here the first (to our knowledge) registered systematic review of its kind, documenting the safety and efficiency of LSMA in H&N surgery. We performed a PRISMA-guided systematic review (PROSPERO-registered) and identified reports using a search algorithm in MEDLINE/EMBASE. LSMA-related surgical complications were recorded using the Clavien-Dindo classification. Secondary outcomes included swallowing dysfunction, facial cosmesis, and patient satisfaction recorded in health-related quality of life questionnaires (HRQoL). From 125 studies identified, 54 met the inclusion criteria (3872 patients). The LSMA mortality rate was 0%; we did not identify a single case of perioperative death. The median rate of osteoradionecrosis was 5.4%, whereas fistula formation was 5.7%. Malunion was noted in 4.9%. Other complications (surgical site infection, plate exposure) were around 5%. There was significant between-study variation with regards to swallowing assessment tools, but overall there was no significant difference in outcomes. This was also the case for the HRQoL questionairres. LSMA is a safe procedure with an acceptable rate of complications, and should definitely remain in the armamentarium of H&N surgery.

Pre-treatment loss to follow-up and treatment delay among bacteriologically-confirmed tuberculosis patients diagnosed in Mandalay Region, Myanmar.

BACKGROUND: Pre-treatment loss to follow-up (PTLFU) among tuberculosis (TB) patients is a global public health problem, because such patients are highly infectious and experience high mortality. There is no published evidence on this issue from Myanmar. OBJECTIVE: To determine PTLFU and treatment delays (> 7 days duration between the date of diagnosis and starting anti-TB treatment) and their associated demographic, clinical, and health system-related factors among bacteriologically confirmed (sputum smear-positive and/or Xpert-positive) TB patients diagnosed in public health facilities of the Mandalay Region between January and June 2017. METHOD: This was a cohort study involving secondary analysis of routine programme data. Every bacteriologically confirmed TB patient in the laboratory register was tracked for at least 3 months in the treatment register. Patients neither found in the treatment register nor referred out for treatment were considered PTLFU. RESULTS: Of the 1365 bacteriologically confirmed patients diagnosed, 1051 (77%) started on anti-TB treatment, 200 (15.6%) were referred for treatment to health facilities outside the study area, and 114 (8.4%, 95% CI 7.0%-9.9%) did not initiate anti-TB treatment (PTLFU). PTLFU was significantly higher in those with TB/HIV co-infected (18%), sputum smear-negative but Xpert MTB-positive patients (31%), and patients diagnosed at a moderate- or high-volume facility (> 50 patients tested form TB during the study period) (~ 10%). Of the 940 patients with dates recorded, 46 (5%) had a treatment delay of more than 7 days. Patients aged 45-64 years had higher risk of treatment delay compared to those aged 15-44 years. About 97% of records did not have a phone number recorded. CONCLUSION: PTLFU and treatment delay were relatively low in the Mandalay Region. While this is reassuring, urgent steps must be taken to address those that are lost, which includes improving documentation of phone numbers to improve 'trackability', instituting proactive measures to trace patients lost in the care pathway, and introducing an indicator in the national tuberculosis programme (NTP) monthly report to monitor and review PTLFU. Patient subgroups with higher PTLFU should receive priority attention.