Effectiveness of barbed repositioning pharyngoplasty for the treatment of obstructive sleep apnea (OSA): a prospective randomized trial.

PURPOSE: The aim of our randomized clinical trial is to produce stronger evidence supporting barbed repositioning pharyngoplasty (BRP) as a therapeutic option for the treatment of obstructive sleep apnea (OSA). METHODS: The trial was a single-center prospective controlled trial with two parallel arms (group A: BRP; group B: observation) and randomization. Baseline and 6-month polygraphy evaluating the apnea hypopnea index (AHI), oxygen desaturation index (ODI), and lowest oxygen saturation (LOS) were performed. To test the differences among groups of Student's t test, the role of each factor (univariate analysis) and their independent effect (multivariate analysis) was explored using logistic regression model as appropriate. Linear regression was also conducted. RESULTS: A significant reduction of AHI, ODI, LOS, and Epworth Sleepiness Scale (ESS) values was recorded in the BRP group. BRP showed to be more effective than observation. Logistic regression showed that preoperative AHI is related significantly to postoperative AHI within the BRP group. A linear regression showed that higher baseline AHI predicts more significant postoperative absolute AHI reduction. CONCLUSIONS: BRP appears to be a promising technique and might be included within the surgical armamentarium of a sleep surgeon. Patients affected by severe OSA may benefit from this surgery with more significant reduction of AHI values.

Manejo de la vía aérea a través de faringostoma cervical por radionecrosis / Management of the airway through cervical faringostoma by radionecrosis

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Nuestra técnica de colgajo miocutáneo de pectoral mayor para reconstrucción de defectos cervicales / Our technique of pectoralis major myocutaneous flap for reconstruction of cervical defects

Introducción y Objetivos. Las técnicas actuales para reconstrucción de cabeza y cuello se basan principalmente en colgajos libres, fasciocutáneos o viscerales según el defecto. La evolución de la microcirugía ha relegado a un segundo plano a los colgajos pediculados. El colgajo miocutáneo pediculado de pectoral mayor ha sido uno de los más empleados hasta que se ha extendido el uso de los colgajos libres. Las desventajas que presenta, tales como su volumen o sus secuelas funcionales y estéticas, son responsables de su desuso actual. Presentamos una modificación de la técnica clásica del pectoral mayor para minimizar sus desventajas. Material y Método. Hacemos una descripción técnica de la modificación desarrollada por Márquez-Cañada del colgajo de pectoral mayor para reconstrucción de defectos cervicales y un estudio descriptivo sobre un grupo de pacientes sometidos a la misma. Resultados. Recogimos 6 casos, 5 varones y 1 mujer (edad media de 52.5 años), en los que se empleó la técnica descrita. El defecto más frecuente (66.7%) fue el faringostoma secundario a laringuectomía total y vaciamiento cervical por carcinoma epidermoide de laringe. Tiempo medio entre intervenciones quirúrgicas de 5 semanas. En 2 casos hubo como complicación serohematoma en zona donante tras el primer tiempo quirúrgico, No hubo pérdida de injertos ni necrosis, fístulas o estenosis secundarias. Resultado estético aceptable; los pacientes conservaron movilidad completa del brazo. Conclusiones. Observamos una reducción en el número de complicaciones respecto del uso del pectoral mayor clásico y los colgajos libres Creemos que la modificación técnica que presentamos, por su reproducibilidad y su baja tasa de complicaciones, podría emplearse en reconstrucción de cuello como colgajo de elección en pacientes de alto riesgo, no candidatos a técnicas microquirúrgicas (AU)

Background and Objective. Current techniques for head and neck reconstruction are mainly based on free flaps, fasciocutaneous or visceral according to the defect. The evolution of microsurgery has relegated to the background the pedicled flaps. The pedicled myocutaneous pectoralis major flap has been one of the most employed until the generalization of free flaps. Their disadvantages such as bulky or functional and aesthetic sequelae, are responsible for its current disuse. We present a modification to the classic technique of pectoralis major flap to reduce its disadvantages. Methods. We make a technical description of the modification developed by Márquez-Cañada of the pectoralis major flap for cervical defects reconstruction and a descriptive study on a group of patients submitted to it. Results. We collected 6 cases, 5 males and 1 females (mean age 52.5 years), in which the described technique was used. The most frequent defect (66.7%) was the pharyngostoma secondary to total laryngectomy and cervical emptying secondary a epidermoid carcinoma of the larynx. Mean time between surgeries was 5-week. In 2 cases, there was serohematoma in the donor site after the first surgical time. There was no loss of grafts or necrosis, fistulas or secondary stenoses. Acceptable esthetic result; patients maintained complete arm mobility. Conclusions. We observed a reduction in the number of complications with respect to the use of the classic pectoralis and free flaps. We believe that the technical modification that we present, due to its reproducibility and its low complication rate, could be used in neck reconstruction as a flap of choice in patients of high risk, not candidates for microsurgical techniques (AU)

National Database Analysis of Single-Level versus Multilevel Sleep Surgery.

Objective Recent evidence suggests that multilevel sleep surgery improves outcomes when compared with palate surgery alone for most patients. The study objective was to compare demographic and outcomes data for palate surgery (uvulopalatopharyngoplasty [UPPP]) alone versus multilevel surgery through a national insurance claims database. Study Design Retrospective cohort study. Setting National insurance claims database. Subjects and Methods An adult cohort undergoing single-level UPPP versus UPPP with nasal and/or tongue/hypopharyngeal surgery was identified in the Truven Health Analytics MarketScan Research Databases for the years 2010 through 2012. Demographic and outcomes data were assessed at short-term (≤14 days), intermediate (15-60 days), and long-term (61-183 days) intervals via a multivariate regression model adjusted for age, sex, geographic region, insurance type, and the Charlson-Deyo comorbidity score. The primary long-term complication considered was positive airway pressure (PAP) equipment supply, implying possible treatment failure. Results The cohort included 14,633 patients: 7559 (51.6%), UPPP alone; 5219 (35.7%), UPPP + nasal surgery; 1164 (7.95%), UPPP + tongue/hypopharyngeal surgery; and 691 (4.7%), UPPP + nasal + tongue/hypopharyngeal surgery. Demographic data were similar among the groups. UPPP alone had lower rates of postoperative bleeding than UPPP + tongue/hypopharyngeal surgery (4.31% vs 6.19%, P = .004). Multivariate modeling indicated that the addition of either nasal surgery (odds ratio = 1.21, 95% CI = 1.10-1.34, P < .001) or tongue/hypopharyngeal surgery (odds ratio = 1.15, 95% CI = 1.00-1.32, P = .048) to UPPP was associated with increased odds of postoperative continuous positive airway pressure. Conclusions UPPP alone is currently the predominant form of sleep surgery in the United States. Multilevel surgery had greater odds of postoperative bleeding and positive airway pressure equipment supply than UPPP alone. Dedicated studies formally evaluating single- versus multilevel sleep surgery and the impact of possible surgeon/patient selection bias should be a priority.

Pharyngotomy for a swallowed denture.

The introduction of inhalation anaesthesia, first by the use of ether in 1845 and then of chloroform in the following year, saw an explosion in the range and extent of major surgical procedures as patients were spared the agonies of the surgeon's knife. A good example of this was the operation of pharyngotomy - opening the cervical oesophagus through a lateral incision of the neck - to remove an impacted foreign body. One cannot imagine a surgeon being able to do this without the benefit of an anaesthetic! Edward Cock, a surgeon at Guy's Hospital, performed this operation successfully on two occasions; the second was reported in detail in the Guy's Hospital Reports 1868, Volume 28.

Pharyngostomy.

A retrospective analysis of a prospective observational study of a cohort of patients who required prolonged foregut/midgut decompression/intraluminal stenting and/or enteral nutritional support was conducted. Those patients were intolerant of protracted nasogastric intubation. They also manifested hostile peritoneal cavities and therefore were not candidates for a laparoendoscopic gastrostomy or jejunostomy. Accordingly, they underwent insertion of a pharyngogastric or pharyngojejunal tube. With patients properly positioned and anesthetized and with attention to the anatomy of the superior carotid cervical triangle, those pharyngostomies and cannulations were performed safely and efficiently. The tubes remained indefinitely or were changed/removed ad libitum. Morbidity was nil and no mortality attributable to the procedure was observed. Pharyngostomy should be part of the armamentarium of all general surgeons.

A novel surgical method of managing a high output pharyngostome.

Pharyngocutaneous fistulas following large oncological surgical resection of the upper aerodigestive tract are common and typically heal over a number of weeks. A pharyngostome is a surgically created non-healing opening into the pharynx, which is far less common and often difficult to manage.

A novel surgical method of managing a high output pharyngostome.

Pharyngocutaneous fistulas following large oncological surgical resection of the upper aerodigestive tract are common and typically heal over a number of weeks. A pharyngostome is a surgically created non-healing opening into the pharynx, which is far less common and often difficult to manage.

Colgajo antebraquial radial en cabeza y cuello: nuestra experiencia / Free radial forearm flap in head and neck: our experience

Introducción: La cirugía oncológica conlleva a importantes defectos y secuelas, así como alteraciones funcionales y cosméticas notables. En este aspecto, la cirugía reconstructiva tiene un papel esencial, permitiendo mayor radicalidad en la exéresis y disminución de las morbilidades funcionales y cosméticas asociadas. El objetivo de este estudio es presentar y evaluar la experiencia y resultados de la Unidad de Microcirugía Reconstructiva del Servicio de Otorrinolaringología de nuestro centro. Métodos: Estudio retrospectivo de procedimientos realizado entre los años 2006-2012. Resultados: Un total de 36 casos fueron revisados. El tumor primario se localizó en la mayoría de los casos en orofaringe (58%). En 5 casos se realizó el procedimiento para reconstrucción y cierre de fístulas (4 faringostomas y una fístula traqueoesofágica). El fracaso por necrosis total fue del 16% (6/39). No se produjo mortalidad asociada. Las complicaciones postoperatorias más frecuentes fueron: dehiscencia de sutura en 5 pacientes y faringostoma (fístula) en 5 casos. La radioterapia previa influyó de forma significativa en el aumento de la incidencia global de las complicaciones (p < 0,05). Conclusiones: Actualmente, la cirugía reconstructiva juega un papel fundamental en la cirugía oncológica de cabeza y cuello. El colgajo radial es un método seguro y fiable para la reconstrucción de la mayoría de defectos en la esfera otorrinolaringológica. Asumir este tipo de intervención ofrece una mayor autonomía y seguridad en la cirugía oncológica (AU)

Introduction: Oncologic surgery leads to important defects and sequelae, as well as notable cosmetic and functional alterations. In this aspect reconstructive surgery has an essential role, allowing more radical excision and lower associated functional and cosmetic morbidities. The aim of this study was to present and evaluate the experience and results of the reconstructive microsurgery unit in our centre's ENT department. Methods: Retrospective study of procedures performed between 2006 and 2012. Results: A total of 36 cases were reviewed. The primary tumour was found in the oropharynx (58%) in the majority of cases. In 5 cases the procedure was performed for reconstruction and fistula closure (4 pharyngostoma and 1 tracheoesophageal fistula). Failure from total necrosis was 16% (6/36). No associated mortality has been reported. The most common postoperative complications were wound dehiscence in 5 patients and pharyngostoma (fistula) in 5 cases. Prior radiotherapy significantly influenced the increase in the overall incidence of complications (P<0.05). Conclusions: Reconstructive surgery currently plays an important role in surgery for head and neck cancer. The radial forearm flap is a safe, reliable method for reconstruction of most defects in the ENT field. This type of intervention provides greater autonomy and safety in surgical oncology (AU)

Tube pharyngostomy--a useful alternative for long-term enteric decompression or enteral feeding.

The tube pharyngostomy has been all but forgotten in recent years, and rightfully so when a PEG or PEJ is possible. Nevertheless, the tube pharyngostomy should remain in the armamentarium of the GI surgeon for selected patients in whom longer term enteral access is not available by PEG or PEJ for various technical reasons, for those who absolutely refuse a nasoenteric tube, or as terminal palliation in patients with nonoperable but obstructing intra-abdominal neoplasms. Not only is it easy to place (albeit requiring a brief general anesthetic), but these tubes are much more comfortable than the "misery" to the patient of a nasoenteric tube by avoiding the annoying nasal and nasopharyngeal irritation,sinusitis, trouble with speech and coughing, and general discomfort of a longer term, indwelling nasoenteric tube. Moreover, the tube can be hidden under a turtleneck-types weater, thereby avoiding the social discomfort of a tube exiting the nares. The overall lack of experience and ignorance, not only with these tubes but also with their concept, has precluded many surgeons from recognizing their usefulness,albeit in highly selected patients. With these advantages and caveats in mind, the tube pharyngostomy can prove a valuable adjunct in selected patients.

Free jejunal graft for esophageal reconstruction using end-to-side vascular anastomosis and extended pharyngo-jejunostomy.

BACKGROUND: Pharyngo-esophageal reconstruction using free jejunal grafts (FJGs) has been widely used, but the procedure is technically demanding and requires the involvement of multiple departments. We performed simplified reconstruction with FJGs using end-to-side vascular anastomosis and extended pharyngo-jejunostomy. METHODS: The jejunal artery and vein were anastomosed to the neck vessels in an end-to-side fashion without microvascular anastomosis. Pharyngo-jejunostomy with extended end-to-end anastomosis was performed to reduce size mismatch. We retrospectively analyzed the medical records of 32 patients diagnosed with pharyngeal, esophageal, or pyriform sinus cancer who received a FJG. RESULTS: The mean age was 61.5±9.4 years, and there were 25 male patients. Jejunal vessels were commonly anastomosed to the right common carotid artery and the right internal jugular vein (22, 68.8%). The mean ischemic times of the FJG and carotid artery clamping time were 46.5±8.1 and 15.8±4.4 minutes, respectively. During the procedure, 3 patients suffered from inadequate reperfusion of the FJG requiring removal of the initial graft and replacement with another FJG. There were no neurologic complications, postoperative deaths, or adverse events directly related to FJG except for leakage of the pharyngo-jejunostomy site in 1 patient, which was primarily repaired. During the follow-up period, 5 patients (15.6%) suffered from dysphagia, but only 3 patients had evidence of anastomotic strictures at the jejuno-esophagostomy site. Thirteen patients (40.6%) received postoperative adjuvant radiotherapy. CONCLUSIONS: Our technique of FJG with end-to-side vascular anastomosis and extended pharyngo-jejunostomy is simple and safe.

Assessment of obstruction level and selection of patients for obstructive sleep apnoea surgery: an evidence-based approach.

INTRODUCTION: Obstructive sleep apnoea has long been recognised as a clinical syndrome; however, high quality evidence on the effects of surgery for this condition is still missing. Despite this, a consensus seems to be evolving, albeit based on limited evidence, that surgery should be offered as a second line treatment to suitable patients with obstructive sleep apnoea. AIMS: This article aims to assess the different methods of investigating upper airway obstruction in patients with obstructive sleep apnoea, in respect to these methods' relevance to surgical treatment, via a systematic review of the literature. METHODS: The Cochrane Controlled Trials Register, Medline and EMBASE were searched from 1966 onwards. The search was performed in August 2008. A total of 2001 citations were retrieved. RESULTS AND CONCLUSION: There is not yet a generally accepted way to assess surgical candidacy based on the level of obstruction. Better organised clinical studies with well defined endpoints are needed. In the meanwhile, it appears that sleep nasendoscopy, acoustic reflectometry and pressure catheters can all provide useful information, and their use may be decided upon based on the experience and resources available in individual departments.

Cervical pharyngostomy: an old technique revisited.

OBJECTIVE: To review our experience with pharyngostomy tubes used to manage complications following foregut surgery and to discuss technical aspects of insertion. SUMMARY BACKGROUND DATA: Cervical pharyngostomy tubes are percutaneously placed through the hypopharynx and directed into the stomach or small bowel. Historically, these tubes were placed during resection of head and neck cancer for postoperative nutrition. The technique may also be used to manage a variety of complications following esophagectomy or gastric surgery. METHODS: A retrospective review identified all patients who underwent pharyngostomy tube placement at the University of Pittsburgh Medical Center from 1995 to 2007. Indications, procedure-related complications, and duration of tube placement were recorded. RESULTS: Thirty-eight patients were identified. Indications for tube placement were: access for enteral nutrition (n = 18), drainage of mediastinal abscess (n = 4), gastric decompression (n = 13), and other (n = 3). Procedure-related complications included: cellulitis (n = 1), esophagitis (n = 1), aspiration pneumonia (n = 1), and tube migration (n = 9). Duration of tube placement was 51 days (range 1-279). No major complications occurred. CONCLUSIONS: Pharyngostomy tubes may be useful in the management of complications following esophageal or gastric surgery. They are more comfortable than nasogastric tubes and may be kept in place for several months if necessary. Bleeding or other major complications have not occurred in our experience.

[Lateral pharyngotomy--a rare method of access for removing foreign bodies from the upper third of the esophagus]. / Die laterale Pharyngotomie--ein seltener Zugangsweg zur Fremdkörperentfernung im oberen Osophagusdrittel.

Esophageal foreign body impaction is a serious emergency. Diagnostic workup includes an exact history and physical examination as well as several imaging modalities. The extraction of an esophageal foreign body can be done using nonflexible or flexible esophagoscopy. We report on a 43-year-old patient with typical symptoms of esophageal foreign body impaction. The x-ray overview upon admission showed the adjustment wires of one component of a metal denture in the area of the upper esophagus. Extraction by nonflexible esophagoscopy was rendered impossible because parts of the denture had speared themselves into the esophageal wall. Safe and uncomplicated removal was then performed through a lateral pharyngotomy.

Cervical pharyngostomy: an alternative approach to enteral feeding.

Surgical patients may be unable or unwilling to feed normally, owing to mechanical obstruction to ingestion because of nausea or anorexia or secondary to neurologic abnormality. Such patients may be in a malnourished state that compromises their chances of successful recovery. The Nasogastric tube (NGT) has been the standard method of postoperative alimentation in head and neck cancer patients. However, prolonged use of an NGT has been associated with many problems. Percutaneous endoscopic gastrotomy (PEG) tubes are generally easier to manage and more esthetically pleasing than NGTs. However, they are associated with their own set of shortcomings. Problems and complications with traditional NGT led us to evaluate feeding tubes placed through a cervical pharyngostomy. We present our experience with this technique in 15 patients in whom it was used for postoperative feeding after oropharyngeal cancer resection and reconstruction. The cervical pharyngostomy technique has proven to be a safe, reliable, cost-effective and convenient method for postoperative feeding.

Tube pharyngostomy: a simple method for prolonged intubation of the foregut following oesophagogastric surgery.

Tube pharyngostomy involves the percutaneous passage of a tube through the pharynx as an alternative to nasogastric intubation. We use this method for upper gastrointestinal decompression after oesophagectomies and total gastrectomies where prolonged intubation of the foregut is anticipated. It is simple to perform and very well tolerated as compared to a nasogastric tube. The pharyngostomy tube can also be used for enteral feeding. We present here the technique in detail and our experience with 67 procedures over the last 6 years where only few minor complications were encountered. We also review the literature for previous reports of pharyngostomy.