Management of Patients With Graves Orbitopathy Using Endonasal Endoscopic Techniques.

OBJECTIVE: The aim of the authors' study is to show their surgical results in orbital decompression using different endonasal endoscopic techniques. These approaches are according to the degree of proptosis and the presence or not of sight threatening. METHODS: The authors performed 31 orbital decompressions on 20 Graves orbitopathy patients. Average age at surgery was 52 years. There were 5 males and 15 females. Five patients were diagnosed as having severe or for sight-threatening Graves orbitopathy. These included 3 men and 2 women having an average age of 54 years old. Minimum postsurgical follow-up was 12 months in all patients. RESULTS: Orbital decompression was performed in 15 patients for proptosis and in 5 patients for urgent sight threat. Thirteen orbits showed mild proptosis and 18 orbits presented moderate proptosis. In patients without sight threatening reduction of proptosis had a mean value of 2.8 mm as determined by exophtalmometry, being 3.3 mm when measured on magnetic resonance imaging. The mean millimeter in mild proptosis was between 1.5 and 1.7 and between 3.4 and 4.2 in moderate proptosis. In patients having sight threat mean visual acuity after surgery improved from 0.6 to 0.9.Only 1 patient without diplopia preoperative developed diplopia after surgery (17%). In 55% of patients strabismus and/or eyelid surgery were required.In postoperative follow-up, 2 patients developed a mucocele and 1 patient developed corneal erosion. CONCLUSION: The authors recommend the preservation of the periorbital sling and the anterior ethmoido-maxillary angle in patients with mild-moderate exophthalmos and without threatened vision. In case of sight threatening the authors resected the most periorbita as much as possible.Evidence-based medicine Level V.

Modifications in the treatment of advanced laryngeal cancer throughout the last 30 years.

In the last decades, the treatment schemes for patients with locally advanced laryngeal cancer have changed significantly. These changes may have an impact in the survival of these patients. Our objective is to review the treatments administered to patients with locally advanced larynx tumors during a period of 30 years in our institution and to evaluate the prognostic impact of the changes in treatment protocols. Retrospective analysis of a cohort of 830 consecutive patients with T3 or T4 laryngeal carcinomas diagnosed and treated between 1985 and 2014 with a minimum follow-up of 1.5 years. During the study period, we witnessed a reduction in surgery as the initial treatment, as well as a substitution of induction chemotherapy by chemoradiotherapy as an organ preservation strategy. For patients with T3 tumors, there were no differences in cancer-specific survival by type of treatment, while patients with T4 tumors treated surgically showed significantly better survival than those treated with preservation strategies. Patients treated in the last decade (2005-2014) showed worse cancer-specific survival than those treated in the previous decade (1995-2004). The multivariate analysis showed significant differences in cancer-specific survival for larger tumors, positive nodal extension, and treatment with radiotherapy alone. The main changes in the management of advanced laryngeal carcinomas are the implementation of organ preservation strategies that reduce the use of surgery and the progressive of chemoradiotherapy as a standard treatment. These changes may have had a negative impact in survival of these patients.

Adherencia crónica al humidificador de traqueostoma en pacientes laringectomizados / Chronic adherence to heat and moisture exchanger use in laryngectomized patients

Introducción y objetivos: La laringectomía total implica alteraciones en el sistema respiratorio como el aumento de las secreciones, la expectoración forzada y la tos. El humidificador de traqueostoma (Provox® HME) pretende minimizar estos efectos. El objetivo de este trabajo es valorar la adherencia a su uso crónico en pacientes laringectomizados. Pacientes y métodos: Se ha realizado un estudio prospectivo en 115 pacientes laringectomizados en nuestro centro durante el período 2005-2011. Resultados: De los 115 pacientes, 90 (78,2%) utilizaron el humidificador de traqueostoma de forma habitual, en tanto que 25 (21,8%) abandonaron su uso. Las causas más frecuentes del abandono fueron la no adherencia del parche por la mucosidad y los problemas dermatológicos. De los 30 pacientes portadores de prótesis fonatoria, el 90% utilizaron el sistema HME de forma habitual. La utilización de prótesis fonatoria (p = 0,05) y la indicación primaria en el postoperatorio de la laringectomía (p = 0,0001) fueron factores que se relacionaron de forma significativa con el uso crónico del sistema HME. Conclusiones: Existe una alta adherencia (78,2%) al uso crónico con el humidificador de traqueostoma (Provox® HME) en pacientes laringectomizados. La adherencia crónica al sistema HME es mayor en el grupo de pacientes con indicación primaría y en el de prótesis fonatoria. Las principales causas de abandono se relacionan con la adhesión del parche (AU)

Introduction and objective: Total laryngectomy leads to pulmonary problems such as excessive sputum production, forced expectoration and increased coughing. The use of a heat and moisture exchanger (Provox® HME) reduces these symptoms. The aim of this study was to quantify chronic adherence to HME use in laryngectomized patients. Methods: A prospective study of 115 patients laryngectomized at our centre during 2005-2011 was performed. Results: Of the 115 patients, 90 (78.2%) used the HME consistently and 25 (21.8%) abandoned its use. The most common causes of desertion were adhesion problems due to mucus and skin irritation. Of the 30 patients with voice prostheses, 90% of them used the HME system regularly. Voice prosthesis use (P=0.05) and early indication in postoperative laryngectomy (P=0.001) were factors significantly associated with chronic HME use. Conclusions: There is high adherence (78.2%) to heat and moisture exchanger (Provox® HME) use in laryngectomized patients. Chronic HME use was higher in patients with voice prosthesis and the ones with early indication in postoperative period. The major causes of abandonment were related to problems with the adhesive (AU)

Chronic adherence to heat and moisture exchanger use in laryngectomized patients.

INTRODUCTION AND OBJECTIVE: Total laryngectomy leads to pulmonary problems such as excessive sputum production, forced expectoration and increased coughing. The use of a heat and moisture exchanger (Provox(®) HME) reduces these symptoms. The aim of this study was to quantify chronic adherence to HME use in laryngectomized patients. METHODS: A prospective study of 115 patients laryngectomized at our centre during 2005-2011 was performed. RESULTS: Of the 115 patients, 90 (78.2%) used the HME consistently and 25 (21.8%) abandoned its use. The most common causes of desertion were adhesion problems due to mucus and skin irritation. Of the 30 patients with voice prostheses, 90% of them used the HME system regularly. Voice prosthesis use (P=.05) and early indication in postoperative laryngectomy (P=.001) were factors significantly associated with chronic HME use. CONCLUSIONS: There is high adherence (78.2%) to heat and moisture exchanger (Provox(®) HME) use in laryngectomized patients. Chronic HME use was higher in patients with voice prosthesis and the ones with early indication in postoperative period. The major causes of abandonment were related to problems with the adhesive.

Tratamiento endoscópico combinado vs. abierto en el divertículo de Zenker / Combined endoscopic treatment for Zenker's diverticulum versus open approach; review of our experience

Introducción: El divertículo de Zenker es una patología del esfínter esofágico superior susceptible de tratamiento quirúrgico en aquellos casos sintomáticos. Este tratamiento ha sufrido importantes cambios en los últimos años. Material y métodos: Se realizó un estudio retrospectivo de 16 pacientes tratados en nuestro servicio entre 2001 y 2008. Se utilizó el abordaje quirúrgico abierto y el abordaje endoscópico combinado mediante grapadora endoscópica y láser. Se analizó el tipo de tratamiento llevado a cabo, tamaño del divertículo, tiempo quirúrgico, tiempo hasta la ingesta oral, complicaciones quirúrgicas, estancia hospitalaria y la presencia de recidiva. Resultados: Se inició tratamiento endoscópico en 8 casos, siendo necesaria reconversión a técnica abierta en 2 casos. El tiempo operatorio fue de 90 min para el abordaje abierto y de 45 min en el endoscópico. La ingesta oral se reinició a las 36 horas en la abierta y a las 24h en la endoscópica, siendo el alta hospitalaria a los 3,8 días en la abierta y a los 2 días en la endoscópica. Aparecieron un 12,4% de complicaciones en relación con la cervicotomía. Se presentó recidiva de la patología en 2 pacientes que se habían sometido a tratamiento abierto, un caso fue tratado con abordaje endoscópico y otro con abierto. Conclusiones: El tratamiento endoscópico combinado parece ofrecer unos buenos resultados en aquellos enfermos con divertículo de Zenker sintomático que pueden ser sometidos a anestesia general. Si no es posible una buena exposición mediante el abordaje endoscópico se debe pasar a un abordaje mediante cervicotomía (AU)

Introduction: Zenker's diverticulum is a superior esophagus sphincter disease with a surgical management in symptomatic cases. This treatment has undergone important changes in recent years. Material and method: A retrospective review was carried out of 16 patients treated in our department between 2001 and 2008. Conventional open surgery was used as well as a combined endoscopic approach with stapler and CO2 laser. Type of treatment, diverticulum size, operating time, oral feeding time, surgical complications, hospital stay and occurrence of relapses were analyzed. Results: The endoscopic approach was used in 8 patients, with a conversion to conventional open surgery being necessary in 2 cases. Operating time was of 90min for the open approach and 45 in the endoscopic. Oral feeding could be reintroduced 36hours after open surgery and 24h after endoscopic treatment. The average discharge date was 3.8 days after the surgery in the open group and 2 days in the endoscopic group. Complications appeared in the 12.4% of the cases, all related to cervicotomy. There were 2 cases of relapse in the group treated with open surgery, one case was treated with the endoscopic approach and another with the open approach. Conclusions: The combined endoscopic approach offers good results in patients with symptomatic Zenker's diverticulum who can be under general anesthesia during the surgery. A conversion to open surgery with cervicotomy should be done when a good endoscopic exposure is not possible (AU)

[Combined endoscopic treatment for Zenker's diverticulum versus open approach; review of our experience]. / Tratamiento endoscópico combinado vs. abierto en el divertículo de Zenker.

INTRODUCTION: Zenker's diverticulum is a superior esophagus sphincter disease with a surgical management in symptomatic cases. This treatment has undergone important changes in recent years. MATERIAL AND METHOD: A retrospective review was carried out of 16 patients treated in our department between 2001 and 2008. Conventional open surgery was used as well as a combined endoscopic approach with stapler and CO(2) laser. Type of treatment, diverticulum size, operating time, oral feeding time, surgical complications, hospital stay and occurrence of relapses were analyzed. RESULTS: The endoscopic approach was used in 8 patients, with a conversion to conventional open surgery being necessary in 2 cases. Operating time was of 90 min for the open approach and 45 in the endoscopic. Oral feeding could be reintroduced 36 hours after open surgery and 24h after endoscopic treatment. The average discharge date was 3.8 days after the surgery in the open group and 2 days in the endoscopic group. Complications appeared in the 12.4% of the cases, all related to cervicotomy. There were 2 cases of relapse in the group treated with open surgery, one case was treated with the endoscopic approach and another with the open approach. CONCLUSIONS: The combined endoscopic approach offers good results in patients with symptomatic Zenker's diverticulum who can be under general anesthesia during the surgery. A conversion to open surgery with cervicotomy should be done when a good endoscopic exposure is not possible.

Colgajo de pectoral mayor: evolución de su uso en la era de los colgajos microanastomosados / Pectoralis major flaps. Evolution of their use in the age of microvascularized flaps

Introducción: La cirugía oncológica de cabeza y cuello ha ido avanzando a medida que se ha podido ofrecer una reconstrucción adaptada al acto quirúrgico. En los últimos 30 años se han desarrollado 2 técnicas fundamentales: el colgajo pediculado de pectoral mayor (CMPM) y los colgajos microanastomosados. El CMPM tuvo un papel preeminente en los años ochenta, y con posterioridad su uso disminuyó de forma progresiva a favor de los colgajos microanastomosados. Material y método: Se realizó una revisión de 351 actos reconstructivos en 317 pacientes en los que se llevó a cabo 275 CMPM y 76 colgajos libres. Analizamos la edad, el sexo, el tipo de colgajo, la indicación y el año de la cirugía. Resultados: De los colgajos revisados: el 34 % fueron de reconstrucción de hipofaringe; el 33 %, de orofaringe; el 21 %, de reparación de partes blandas, y el 12 %, de reparación de fístulas faringocutáneas. La incorporación en el uso de colgajos libres a partir del año 2001 ha supuesto en nuestro centro el incremento en el uso de procedimientos reconstructivos, así como la sustitución para una serie de indicaciones del CMPM por colgajos microanastomosados. Conclusiones: En la era de los colgajos libres, creemos que el CMPM sigue manteniendo un lugar privilegiado para la reconstrucción de la hipofaringe y defectos de la región cervical. Sin embargo, actualmente, en determinadas localizaciones, como la cavidad oral y la orofaringe y en defectos de las partes blandas faciales, preferimos el uso de colgajos microanastomosados para la reconstrucción

Introduction: Oncological head and neck surgery has progressed with the possibility of adapting reconstruction to the surgery effected. In the last 30 years, two basic techniques have been developed: the pectoralis major myocutaneous flaps (PMMF) and microvascularized flaps. PMMF had a leading role in reconstruction surgery during the 1980s, but this has subsequently diminished in favour of microvascularized flaps. Material and method: A review was conducted on 351 reconstructive surgeries in 317 patients, of which 275 were PMMF and 76 free flaps. We analyzed age, gender, flap type, indication, and year of the surgery in all cases. Results: 34 % of the revised flaps were used for reconstruction of the hypopharynx, 33 % for the oropharynx, 21 % for soft tissues, and 12 % for the repair of pharyngocutaneous fistulae. At our hospital, the introduction of the free flap technique from 2001 on has led to an increase in the use of reconstructive procedures as well as the replacement of PMMF by microvascularized flaps in a number of indications. Conclusions: In this age of microvascularized flaps, we believe that PMMF still has a privileged role in the repair of hypopharynx and cervical lesions. However, in such locations as the oral cavity or oropharynx and in facial soft- tissue reconstruction we prefer the use of microvascularized flaps