Comparative Evaluation of Nasolabial Flap, Buccal Fat Pad and Platysma Myocutaneous Flap for Reconstruction of Oral Sub Mucous Fibrosis Defects.

Moderately advanced (stage III) and advanced (stage IV a & b) OSMF requires surgical intervention for management A number of options are available for reconstruction of post OSMF oral cavity defects. In our study we retrospectively compared buccal fat pad, nasolabial flap and platysma flap for reconstruction of the buccal mucosal defects. Patient records were obtained from the medical records section of the Institute and divided into three groups; group A (buccal fat pad), group B (nasolabial group) and group C (platysma flap). Maximal mouth opening and intercommisural distance were the primary outcomes. Kruskal Wallis test was used to test the mean difference between three groups. Mann-Whitney test was used for intergroup comparisons. Wilcoxon signed rank test was used to evaluate the mean difference in outcomes at each follow up interval. A p value of < 0.05 was considered as statistically significant at 95% confidence interval. After 1 year follow up patients in platysma group had significantly better mouth opening (39.84 ± 1.65 mm) compared to both buccal fat pad (36.69 ± 3.41 mm) and nasolabial groups (37.94 ± 0.43 mm). Inter commisural distance was significantly better in patients reconstructed with platysma flap (59.21 ± 0.99 mm) compared to both buccal fat pad (54.11 ± 1 mm) and nasolabial flap (56.84 ± 1.48 mm). Platysma flap lead to significantly better maximal mouth opening compared to both nasolabial and buccal fat pad. Both buccal fat pad and nasolabial lead to comparable mouth opening. Inter commissural distance is maximum with platysma flap followed by nasolabial flap and buccal fat pad.

Cancer surgery during COVID increased the patient mortality and the transmission risk to healthcare workers: results from a retrospective cohort study (NCT05240378).

BACKGROUND: India encountered two waves of COVID-19 pandemic with variability in its characteristics and severity. Concerns were raised over the safety of treatment, and higher morbidity was predicted for oncological surgery. The present study was conducted to evaluate and compare the rate of morbidity and mortality in patients undergoing curative surgery for cancer before and during the COVID-19 pandemic. METHOD: The prospectively obtained clinical data of 1576 patients treated between April 2019 and May 2021 was reviewed; of these, 959 patients were operated before COVID-19 and 617 during the pandemic. The data on complications, deaths, confirmed or suspected COVID-19 cases, and COVID-19 infection among health workers (HCW) was extracted. RESULTS: A 35% fall in number of surgeries was seen during the COVID period; significant fall was seen in genital and esophageal cancer. There was no difference in postoperative complication; however, the postoperative mortality was significantly higher. A total of 71 patients had COVID-19, of which 62 were preoperative and 9 postoperative, while 30/38 healthcare workers contracted COVID-19, of which 7 had the infection twice and 3 were infected after two doses of vaccination; there was no mortality in healthcare workers. CONCLUSION: The present study demonstrates higher mortality rates after surgery in cancer patients, with no significant change in morbidity rates. A substantial proportion of HCWs were also infected though there was no mortality among this group. The results suggest higher mortality in cancer patients despite following the guidelines and protocols.

En Block Versus Separate Management of Cervical Nodes in Tongue and Floor of the Mouth Cancers- Is There a Difference? An Analysis of 85 Cases in a Tertiary Care Institute.

To evaluate difference in local recurrence, regional (neck) recurrence as well as distant metastases between cases operated with en-block excision of primary cancer and neck nodes versus their separate removal, in squamous cell carcinomas of anterior 2/3 of tongue and floor of the mouth. A total 85 patients of cT1-T4a N0-N2b of carcinoma anterior 2/3 of tongue and floor of mouth were evaluated. Amongst these patients 39 cases of in-continuity en-block neck dissection and 46 cases of discontinuous neck dissection were evaluated for post-operative complications as well as oncological outcome for a follow up period of 3 years. Patient population was similar in both groups with tongue cancers being the commonest site and tobacco being the most common addiction. Primary site hematoma was seen more in the in-continuity en-block neck dissection group with a p-value of 0.0276, which was statistically significant. Post-operative oro-cutaneous fistula occurred more in in-continuity enblock neck dissection as compared to discontinuous neck dissection, but the difference was not statistically significant. Local recurrence rate was significantly more in cases of discontinuous neck dissection (19.565) as compared to in-continuity en-block neck dissection (5.12%) with a p-Value 0.0481. A statistically non-significant but higher loco-regional recurrence was observed in cases of discontinuous neck dissection as compared to cases of in-continuity en-block neck dissection (10.56% vs 2.56). In the present study recurrence-free survival RFS 3 year in cases of en-block in-continuity neck dissection (84.06%) cases as compared to discontinuous neck dissection cases (63.04%) with p Value 0.025698. In-continuity en-block in continuity neck dissection has lower loco-regional recurrence and may impact overall distant metastases. Though early postoperative complications are more in in-continuity en-block in continuity neck dissection as compared to discontinuous neck dissection, most are managed conservatively. Further studies with a larger sample size are needed to evaluate its outcome in a comprehensive manner.

Mysterious alarming mucormycosis: Anesthetic challenges in a series of four cases.

The sudden epidemic of mucormycosis amid COVID-19 pandemic has significantly challenged our understanding of the disease while affecting the whole medical and surgical management. Overzealous use of steroids in the management of covid-19 and uncontrolled diabetes mellitus has resulted in a tremendous rise in mucormycosis cases further burdening the already strained health care infrastructure and health care workers, especially the anesthesiologists. While working in a tertiary care institute of the country, we have been facing multiple challenges in its anesthetic management on a daily basis. This article is a case series involving four different patients who were operated for rhino-orbito-cerebral mucormycosis with a brief discussion on various aspects of this multisystem epidemic.

Malignant thyroglossal duct cyst with synchronous occult thyroid gland papillary carcinoma.

A 52-year-old male was referred to our department with complaints of a painless midline neck swelling. Clinico-radiological evaluation suggested a 6 × 5 cm thyroglossal cyst with non-palpable nodules in isthmus and right lobe of thyroid gland. FNAC of the thyroglossal cyst was suggestive of papillary carcinoma. He underwent Sistrunk's operation, total thyroidectomy, and central compartment neck dissection. Co-existence of papillary carcinoma of thyroid gland and thyroglossal cyst is a rare presentation and in this report, we describe our management and propose an evidence-based algorithm to assist decision-making in the management of these patients in future.

Successful diagnosis and management of fistulas between the aorta and the tracheobronchial tree.

The patient presented in this report is unique in that he survived two aortobronchial fistulas. With such fistulas, intermittent hemoptysis is always present; pain is an infrequent symptom. Plain roentgenograms of the chest are helpful in denoting the presence of an aneurysm and the affected portion of the tracheobronchial tree. Aortography rarely demonstrates the fistula. Bronchoscopy should be conducted only with care when the diagnosis is in doubt since disaster can attend disruption of the clot in the fistula. Successful repair usually requires maintenance of distal circulation, repair of the aorta either by closure or by graft replacement, and repair of the tracheobronchial tree either by resection or primary suture. Anesthesia management should include selective endobronchial intubation to control possible intraoperative hemorrhage. Interposition of healthy living tissue to protect the suture lines is encouraged to prevent recurrence.

Prevention of pulmonary insufficiency through prophylactic use of PEEP and rapid respiratory rates.

This study evaluated the effectiveness of prophylactic positive end-expiratory pressure (PEEP) rapid respiratory rates (RRR), and high tidal volume (HTV) in prevention of congestive atelectasis. Measurements of pulmonary hemodynamics, mechanics, gas exchange, functional residual capacity (FRC), pathology, and cinemicroscopy were performed in 45 anesthetized dogs subjected to hemorrhagic hypotension. Randomly, the animals received control ventilation, HTV (20 ml. per kilogram), RRR (32 breaths per minute), or PEEP (5 cm. of water). Carbon dioxide was added as needed to maintain normocapnia. Control and HTV animals showed characteristic changes of congestive atelectasis (capillary congestion, stasis, interstitial edema, periarterial hemorrhage, alveolar edema, and hemorrhage). These microscopic and cinemicroscopic changes were prevented by PEEP and RRR and correlated with decreased physiological shunting (PEEP 10 percent, RRR 13 percent, HTV 22 percent; p less than 0.01) in the postshock phase. PEEP increased FRC by 40 percent (p less than 0.02) and reduced the pulmonary artery--small pulmonary vein gradient (PA-SPV), suggesting a direct effect on the capillary bed. RRR did not affect FRC but minimized the SPV-LA gradient. This effect on the pulmonary venules theoretically could be mediated by stimulating lymphatic flow, thereby decreasing interstitial edema. Thus PEEP and RRR are beneficial when used prophylactically but may work by widely differing mechanisms.

Artifacts in the measurement of pulmonary artery wedge pressure.

Pulmonary artery wedge pressure (PAWP) will only reflect left atrial pressure (LAP) if continuity of fluid exists from the catheter tip to the left atrium. Either increased airway pressure or decreased hydrostatic pressure may lead to discontinuity of the fluid column and midinterpretation of PAWP. Simultaneous measurements of PAWP and LAP were made in 19 anesthetized dogs. Placement of the pulmonary artery wedge catheter above the left atrium (West Zone I) in combination with the incremental addition of 5 cm H2O of PEEP caused a 5 mm Hg gradient between PAWP and LAP in the normovolemic animal. Augmenting PEEP further or hypovolemia (i.e., decrease in LAP) increased the gradient. Hypervolemia (increase in LAP) diminished the gradient. Fluid continuity between the PAW catheter and LA is a prerequisite for monitoring LAP with the Swan-Ganz catheter. Increases in PEEP, placement of the catheter above the left atrium and hypovolemia may occlude the fluid column and cause artifacts in the PAWP obtained.

The role of carbon dioxide in the development of pulmonary insufficiency.

The effects of carbon dioxide (PCO2 = 40 versus PCO2 = 20) on pulmonary function changes during 2 hours of hemorrhagic hypotension followed by resuscitation are evaluated in 21 dogs. Pulmonary hemodynamics, mechanics, gas exchange, functional residual capacity, and morphology are studied. In the preshock period, hypocapnia is associated with a decreased cardiac output, increased dead space, and increased alveolar-arterial (A-a) gradiant (room air). During the period of hypotension, all parameters in both groups changed similarly. After resuscitation, the A-a gradients in the two groups further widened. Following the return to control levels of normocapnia in all animals, the group which had been hypocapnic during the hypotensive episode continued to show increased shunting (20 versus 13 percent, p less than 0.05). These results correlated well with cinemicroscopic findings, which showed the normocapnic group to have less interstitial edema and better capillary flow.

Comparison of patients with coronary artery or valve disease: intraoperative differences in blood volume and observations of vasomotor response.

A review of 296 patients undergoing cardiac operations has shown that those with coronary artery disease have a blood volume deficit. The 148 patients with valve disease had a normal blood volume of 78 ml/kg (normal range, 68--88 ml/kg), while the 148 coronary artery disease had a blood volume of 69 ml/kg (p less than 0.001). Infusion of plasma prior to cardiopulmonary bypass as well as the total transfusion required afterward to maintain blood pressure indicated an important clinical difference in these two groups. Another finding was that the requirement for a drug to control blood pressure prior to use of cardiopulmonary bypass was greater in the coronary patients (p less than 0.01). Comparison of the requirement for a hypotensive agent before and after bypass showed a greater predictability in the valve group. This experience leads us to conclude that patients with coronary artery disease and angina not only have a low blood volume, but they also have a marked vasoactive lability which shows up in their hemodynamic response to the conduct of an operation and to anesthesia.

Management of acute aortic dissection.

The therapy for acute dissecting aneurysm of the aorta remains a difficult problem for thoracic surgeons. Because of an excessive operative mortality in patients with acute dissection who were operated on within 24 hours of hospital admission, we have utilized intensive medical management to delay surgical intervention. Even patients with acute aortic insufficiency can be supported medically, allowing their operations to be delayed at least 3 weeks or longer. Since this policy has been implemented, there has been no operative mortality in our last 13 patients with acute dissection. Medical therapy as the definitive treatment is now reserved solely for Type III dissections or for patients who cannot be operated on for other reasons. This report outlines our rationale for therapy and our current method of managing acute dissection.