Outcome and survival following tracheostomy in patients ≥ 85 years old.

PURPOSE: To evaluate percutaneous dilatational tracheostomy in patients ≥ 85 years old: its complication rate and possible risk factors. In addition, to assess prognostic factors for short, intermediate and long term survival following the procedure. METHODS: A retrospective case-control study of 72 patients ≥ 85 years who received percutaneous dilatation tracheotomy (PTD), compared to a control group of younger patients (n = 182). Demographics, clinical and laboratory data were collected. Survival and risk for complications were analyzed. RESULTS: The study group's mean age was 89 ± 4. Twelve patients had complications, three (4.2%) were major. No significant difference was found in overall complication rates between the groups. Cerebrovascular disease with neurologic deficits and pre-procedure albumin levels were significantly associated with complications. Survival rates did not differ in 1 week and 1 month following procedure between study and control group. There was a significant difference in the 1-year survival rates between the patients ≥ 85 years and the control groups (18.1% vs. 34.4%, p = 0.01, respectively). Congestive heart failure, a frailty score > 0.27 and failure to wean from a cannula were associated with reduced 1-year survival. CONCLUSION: PTD is safe for patients ≥ 85 years. Complication risk factors and reduced survival should be discussed with patients and families before conducting tracheostomies. LEVEL OF EVIDENCE: 3b.

Using all-cause mortality to define severe RV dilation with RV/LV volume ratio.

Right ventricular (RV) end-diastolic volume (EDV) to left ventricular (LV) EDV ratio using cardiovascular magnetic resonance imaging (CMR) is an important parameter for RV size evaluation in additional to indexed EDV. We explore the severity partition for RV dilation using mortality in a population of 62 patients with pulmonary hypertension (PH). Cine short-axis images were acquired with a 1.5 T MR scanner using a steady-state free precession sequence. The optimal cutoff to classify severe RV dilation was determined by a receiver-operating curve (ROC) analysis based on mortality. We further defined mild and moderate categories by the standard deviation distance between normal and severely dilated and found the categories RV dilation by RV/LV volume ratio to be "mild" (1.27-1.69), "moderate" (1.70-2.29) and "severe" (≥2.30). There were significant differences in RVEDV and RV ejection fraction between "mild", "moderate" and "severe" groups (p < 0.001). The "severe" category had a significantly higher mortality when compared to the "non-severe" categories (p < 0.001) while there was no difference among the "non-severe" dilated groups. We have shown that severe RV dilation partition can be defined using mortality with RV/LV volume ratio, which offers an outcome based grading of the "severe" category of RV dilation.

Perforation during esophageal dilatation: a 10-year experience.

BACKGROUND & AIM: Esophageal stenosis can be caused by malignant, postsurgical, benign diseases etc. Endoscopic treatment options consist primarily of balloon dilatation and bougination. Both interventions carry a certain risk of further complications such as perforations. We aimed to evaluate this risk in our patients. METHODS: Frequency, perforation rates, further diagnostics, therapy, outcome and underlying diseases in 368 patients who underwent endoscopic dilatation or bougination in a 10 year period were evaluated. RESULTS: Overall, 1497 endoscopic interventions were performed for treatment of esophageal stricture, causing 8 perforations (0.53% per intervention, 2.17% per patient) and one lethal outcome (0.05% per intervention, 0.27% per patient). In 1286 bouginations, 8 perforations (0.62%) and one death occurred (0.08%), whilst no perforation was noted during 211 balloon dilatations. Outcome of the 8 perforations was greatly influenced by co-morbidities, causing a prolonged hospitalization and the death of one patient. CONCLUSION: Although complication rates are fairly small, patients should be under supervision or in contact for 24-72 hours after each intervention. In cases where perforation is suspected, radiological examinations should be conducted early. The perforation rate and mortality per patient may be used for patient information. Therapy and prognosis depend on the cause of perforation, localization and size of the perforation site as well as concomitant diseases.

Balloon dilatation of anastomotic strictures secondary to surgical repair of oesophageal atresia: a systematic review.

Surgical repair of oesophageal atresia may result in anastomotic strictures. These strictures are often treated by balloon dilatation (BD) and currently balloon dilatation (fluoroscopic or endoscopic) is the preferred primary treatment method. Here we review the current evidence of the outcomes of balloon dilatation of anastomotic strictures secondary to surgical repair of oesophageal atresia. We searched the standard databases (January, 1960-May, 2012) to identify all studies that reported outcomes of balloon dilatation of anastomotic strictures secondary to surgical repair of oesophageal atresia in children. Data, reported as median (range), were analysed and compared. Outcomes were success of BD, number of BD sessions, number of oesophageal perforations, need for other surgical interventions and mortality. Five studies were found to be relevant (n = 139; 81 [58%] male children). The total number of dilatation sessions was 401 (2.9 dilatations per child patient). General anaesthesia was used in two (40%) studies; sedation in a further two (40%) studies and one (20%) study used a combination of both. The size of balloon catheter ranged from 4 mm to 22 mm. Seven perforations were reported (1.8% per dilatation session), of which only one (14%) required surgery. No deaths were recorded. Balloon dilatation for anastomotic strictures post-EA repair is safe, and associated with a low perforation and mortality rates. Most perforations are amenable to conservative management.

Corrosive oesophageal strictures in children: outcomes after timely or delayed dilatation.

BACKGROUND AND STUDY AIMS: Among benign oesophageal lesions, caustic strictures are the most difficult to dilate. In low-income countries, children suffering caustic oesophageal injury are frequently referred to the hospitals late, sometimes weeks after ingestion. Therefore, dilatation may be performed late and in highly fibrotic strictures. Reports about endoscopic and clinical outcome of such delayed dilatations are scanty. The aim of this study was to evaluate the safety and efficacy of late caustic stricture dilatations in children, comparing it with the results of timely dilatations, both performed at the Hospital of the Italian Non-Governmental Organization "Emergency" at Goderich, Sierra Leone. PATIENTS AND METHODS: From December 2005 to May 2007, 78 children (<15 years) complaining alkaline caustic ingestion were submitted to oesophageal dilatation, mainly (97%) using Savary dilators. Two groups were identified: children (group 1) with a late treatment (>6 weeks, 37+/-12 weeks), having arrived to the hospital late after ingestion, and children (group 2) dilated timely, i.e. at <6 weeks (4+/-1.4 weeks) after injury. RESULTS: Strictures were severe in all patients. Twenty-five children were dilated late after injury (6.4 dilatations/patient) with a follow-up of 11+/-2.5 months. A successful clinical outcome was observed in 91.6%. Four perforations (2.6% procedure-related) and one death (4.0%) were observed. Strictures recurred once in 72% of patients, twice in 31.8%. Thirty-one children were dilated timely (4.5 dilatations/patient) with a follow-up of 10+/-2.1 months and a clinical success rate of 96.7%. Procedure-related perforation rate was 0.7% with one death (3.2%). Stricture recurred once in 30% and twice in 3.3%. CONCLUSIONS: Delayed dilatation of caustic oesophageal strictures in children carries a higher risk of perforation and a higher recurrence rate.

[Aortic valve stenosis in children. Surgical valvuloplasty long-term results]. / Sténose valvulaire aortique chez l'enfant. Résultats à long terme de la valvuloplastie chirurgicale.

From 1960 through 1992, 67 children with congenital aortic stenosis aged 6-228 months (M 105.7 +/- 52) were submitted to aortic valvuloplasty at our institution. There was no hospital mortality. During the follow-up of 127.5 +/- 66.7 months, there were two late valve related deaths. Eight patients (11.9%) developed aortic regurgitation 5 to 125 months (M 66.6 +/- 35) following surgical valvuloplasty and one of them required aortic valve replacement. Because of restenosis, 15 patients required a second operation. Of them five children underwent a second aortic valvuloplasty without mortality and, in four of them, the functional result has been excellent after a mean follow-up of 75.4 +/- 12 months. Ten patients required an aortic valve replacement 62 to 208 months post-op (M 100.9 +/- 50.8). Mechanical prosthesis were used in 6 and bioprosthesis in 4. Two patients required a Konno and one patient a Ross procedure. There were no early nor late deaths following reoperations. The 20 year survival rate following the first valvuloplasty was 94%, the freedom from reoperation 63% and the freedom from aortic valve replacement 73% for the same time period. Our results demonstrate that congenital aortic valvar stenosis in children can be surgically well controlled until adulthood. Our study also illustrates that surgical valvuloplasty is a safe and efficacious procedure and that its beneficial effect is maintained over 20 years in the majority of children.