KTP laser endoscopic cricopharyngeal myotomy and pharyngeal pouch diverticulotomy: how I do it.

BACKGROUND: Various endoscopic methods of dividing the cricopharyngeus muscle and the common wall of pharyngeal pouches have been described, most commonly the carbon dioxide laser and stapler. The potassium titanyl phosphate (KTP) laser is an alternate endoscopic method of treatment. METHODS: The KTP laser is used in a similar fashion to the carbon dioxide laser to carefully divide the cricopharyngeus muscle fibres ± the common wall of the pharyngeal pouch, under microscopic visualization. CONCLUSION: The KTP laser is an alternative and safe technique for these surgeries.

Pathophysiology of swallowing following oropharyngeal surgery for obstructive sleep apnea syndrome.

BACKGROUND: Uvulopalatopharyngoplasty (UPPP) and coblation channeling of the tongue (CCT) are oropharyngeal surgeries used to treat obstructive sleep apnea syndrome. The extent to which UPPP and CCT affect pharyngeal swallow has not been determined. We therefore conducted a novel case series study employing high-resolution impedance manometry (HRIM) to quantify the swallowing-related biomechanics following UPPP and/or CCT surgery. METHODS: Twelve patients who underwent UPPP+CCT or CCT only were assessed an average 2.5 years postsurgery. Swallow function data were compared with ten healthy controls. All patients completed the Sydney swallow questionnaire (SSQ). Pharyngeal pressure-flow analysis of HRIM recordings captured key distension, contractility and pressure-flow timing swallow parameters testing 5, 10, and 20 mL volumes of thin and thick fluid consistencies. KEY RESULTS: Postoperative patients had more dysphagia symptoms with five returning abnormal SSQ scores. Swallowing was biomechanically altered compared to controls, consistent with diminished swallowing reserve, largely driven by elevated hypopharyngeal intrabolus pressure due to a reduced capacity to open the upper esophageal sphincter to accommodate larger volumes. CONCLUSIONS & INFERENCES: Patients who have undergone UPPP and/or CCT surgery appear to have a deficiency in normal modulation of the swallowing mechanism and a reduced swallowing functional reserve. We speculate that these changes may become relevant in later life with the onset of age-related stressors to the swallowing mechanism. This case series strikes a note of caution that further studies are needed to determine the role of preoperative swallow assessment in patients undergoing UPPP and/or CCT surgery.

Cost analysis of injection laryngoplasty performed under local anaesthesia versus general anaesthesia: an Australian perspective.

OBJECTIVE: To conduct a cost analysis of injection laryngoplasty performed in the operating theatre under local anaesthesia and general anaesthesia. METHODS: The retrospective study included patients who had undergone injection laryngoplasty as day cases between July 2013 and March 2016. Cost data were obtained, along with patient demographics, anaesthetic details, type of injectant, American Society of Anesthesiologists score, length of stay, total operating theatre time and surgeon procedure time. RESULTS: A total of 20 cases (general anaesthesia = 6, local anaesthesia = 14) were included in the cost analysis. The mean total cost under general anaesthesia (AU$2865.96 ± 756.29) was significantly higher than that under local anaesthesia (AU$1731.61 ± 290.29) (p < 0.001). The mean operating theatre time, surgeon procedure time and length of stay were all significantly lower under local anaesthesia compared to general anaesthesia. Time variables such as operating theatre time and length of stay were the most significant predictors of the total costs. CONCLUSION: Procedures performed under local anaesthesia in the operating theatre are associated with shorter operating theatre time and length of stay in the hospital, and provide significant cost savings. Further savings could be achieved if local anaesthesia procedures were performed in the office setting.

A comparative study of voice outcomes and complication rates in patients undergoing injection laryngoplasty performed under local versus general anaesthesia: an Adelaide voice specialist's experience.

OBJECTIVE: To compare clinical outcomes and complication rates in patients undergoing injection laryngoplasty performed under local versus general anaesthesia. METHODS: A retrospective review was conducted of patients who underwent injection laryngoplasty performed by a single laryngologist in a tertiary Australian laryngology centre, between February 2013 and December 2014. Patient demographics, anaesthetic modality and complications were recorded. Voice Handicap Index 10 and the Grade, Breathiness, Roughness, Asthenia, Strain scale were evaluated. RESULTS: Thirty-four laryngoplasties were performed under general anaesthesia and 41 under local anaesthesia, with mean patient ages of 59.5 and 68.8 years, respectively. Voice Handicap Index 10 scores were significantly improved post-injection (p 0.05). All aspects of the Grade, Breathiness, Roughness, Asthenia, Strain scale showed significant improvement post-injection, except asthenia. There were seven (9.3 per cent) minor complications (five in the general anaesthesia group, two in the local anaesthesia group), all managed conservatively. CONCLUSION: Injection laryngoplasties performed under general anaesthesia and local anaesthesia offer similar voice outcomes, with comparable complication rates. Hence, development of a management algorithm for injection laryngoplasties performed under local anaesthesia is recommended.

Surgical management of airway stenosis by radiofrequency coblation.

BACKGROUND: Acquired airway stenosis can be challenging to manage endoscopically because of difficult field visualisation, instrument limitations and the risk of laser fire. At our institution, radiofrequency coblation has been successfully used for the resection of subglottic and tracheal stenosis in adults. This paper presents our experience with this technique. METHOD: A retrospective case note analysis of all cases of airway stenosis in adults from 2007 to 2012 was performed. RESULTS: Ten adult patients underwent coblation resection for airway stenosis. All lesions were classified as McCaffrey stage I (i.e. less than 1 cm long). Causes of stenosis included: idiopathic stenosis (40 per cent), previous tracheostomy (30 per cent) and endotracheal intubation (20 per cent). Six patients (60 per cent) required a single procedure and 4 (40 per cent) required multiple interventions. All patients reported significant improvement in their symptoms following treatment. All patients were alive at the time of writing and none have required open resection. CONCLUSION: Radiofrequency coblation is an attractive alternative technique for the treatment of idiopathic or acquired airway stenosis in adults.

Immunologic prognostic factors of renal allograft survival.

INTRODUCTION: Successful outcome of renal transplantation depends on various factors, of which immunologic is one of the most important. Accumulated experience of a single center, with the same surgical and immunological team contributes significantly to safe conclusions. Purpose of this study was the evaluation of potential factors, in particular immunologic, that influence renal allograft survival. PATIENTS AND METHODS: During the period 1991-2013, 20,784 surgical operations have been performed in our Department of Surgery - Transplant Unit, of which 575 were renal transplantations. We examined donor and recipient demographic factors, immunologic characteristics along with patient and graft survival. RESULTS: Renal allograft was retrieved from living-related donor in 103 cases and in 472 from cadaveric donor. Donor age was 46.7 ± 18.5 years old and 49.9% (287) were male. Recipient age was 48 ± 12.3 years old and 402 were male. HLA histocompatibility was carefully matched resulting in 85.5% renal transplants with 2-4 HLA mismatches and 93.8% renal transplants with at least one HLA-DR. Renal graft survival the first, fifth and tenth year was 89%, 76%, and 67% and patient survival was respectively 95%, 89% and 83%. Statistical analysis revealed that only donor age influenced renal graft survival (P < .05). HLA mismatches were not correlated with graft survival (log rank P = .495), but identification of panel reactive antibodies (PRA) class I and class II post transplantation had a statistically significant impact on long term renal graft survival (log rank P < .001 and P = .021, accordingly). CONCLUSIONS: Analysis of potential prognostic factor showed that only donor age was correlated with allograft survival. Development of PRA following renal transplantation influenced long term graft survival. Good HLA matching with at least one HLA DR resulted in excellent graft and patient survival.

TCRgammadelta + T lymphocytes in unexplained recurrent spontaneous abortions.

PROBLEM: It is generally accepted that the immune system and cellular immunity in particular are involved in the mechanisms affecting the outcome of gestation. In order to evaluate a putative role of lymphocytes in the immunological mechanisms of unexplained recurrent spontaneous abortions (URSA), we studied peripheral blood lymphocyte subpopulations in 244 women with URSA and 44 controls. METHOD OF STUDY: Direct immunofluorescence in whole blood with the appropriate combinations of monoclonal antibodies and flow cytometry was used. RESULTS: The study showed: a) a statistically significant increase of the mean CD4/CD8 ratio (2.12+/-0.84 vs 1.85+/-0.63, P = 0,039); b) a statistically significant decrease of the mean value of the percentage of CD5+ CD19+ lymphocytes (0.4+/-0.6 vs 1.4+/-0.78, P < 0.0001); and c) a statistically significant increase of the percentage of T lymphocytes expressing TCRgammadelta (4.68+/-3.19 vs 2.61+/-1.14, P < 0.0001). It should be noted that a statistically significant high number of women with URSA (72/195, 36.9%) showed an increased percentage of TCRgammadelta T cells (> or = 5%, where 5 equals the mean value + 2 standard deviations (SD) of the mean value of controls), whereas such a high percentage was not found in any control subject. CONCLUSIONS: It seems that women who experienced URSA comprise a heterogeneous population, as far as immunological parameters are concerned. At least in a subgroup of them, TCRgammadelta + T cells could be considered to play a role in the immune pathogenesis of fetal loss.