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.

The Pharyngostomy Tube: Indications, Technique, Efficacy, and Safety in Modern Surgical Practice.

BACKGROUND: Long-term nasogastric tubes are uncomfortable and associated with complications such as impairment with speech and swallowing, septum trauma, epistaxis, alar necrosis, and intubation of the trachea among others. Pharyngostomy tubes (PTs) are an alternative for prolonged enteral feeding, transluminal drainage of collections, and gastric decompression in patients with an intestinal obstruction and an inoperable abdomen. PATIENTS AND METHODS: This is a retrospective analysis of patients who had a PT placed at our institution from May 2005 to March 2015. The primary end point of the study was to establish the type and rate of complications and aspiration events related to PT use. RESULTS: During the specified period, a total of 84 PTs were placed. The most common indication for PT placement was enteric decompression in 65 (77.4%), followed by transluminal collection drainage in 12 (14.3%), and enteral access for nutrition in 7 (8.3%) patients. The mean time to tube removal was 17.8 days ± 17.1 (range, 2-119). We encountered 10 (11.2%) complications related to PT placement, including 7 cases of cellulitis, 2 superficial abscesses, and 1 patient with pharyngeal hemorrhage. CONCLUSION: PTs are a relatively simple, safe, and straightforward approach to achieve long-term enteral decompression, access for feeding or transluminal drainage, avoiding the complications associated with prolonged nasogastric tube placement. The complication rate is low and patient satisfaction and compliance appear to be higher than with nasogastric tubes. Modern surgeons should be familiar with the procedure and technique. PTs should be part of every surgeon's armamentarium.

Endoscopic Vacuum Therapy via Pharyngostomy: Novel Access for Management of Upper Gastrointestinal Defects.

BACKGROUND: Perforation and anastomotic leakage of the upper gastrointestinal tract (UGI) has a high mortality and morbidity rate. Recently, UGI leaks have been treated with endoscopic vacuum therapy (EVT). However, this technique traditionally requires multiple EVT changes and a prolonged and uncomfortable nasoenteric intubation. We describe our experience using EVT through a novel pharyngostomy access to manage UGI leaks. METHODS: We describe our development and implementation of EVT via a novel pharyngostomy access to treat a variety of UGI defects. Preoperative, perioperative, and postoperative data were analyzed. RESULTS: Six patients with UGI perforations or anastomotic leaks were treated with an EVT using a pharyngostomy access. The median age was 69 years (IQR 53-71). Four patients leaked after an Ivor Lewis esophagectomy, one after a robotic para-esophageal hernia repair, and another after a Roux en Y esophagojejunostomy. Defects were detected on a median of 11.5 days (IQR 3-21). Median values for the duration of the EVT therapy and the number of EVT changes were 19.5 days (IQR 14-31) and 7 (IQR 6.5-9), respectively. Four of the patients were discharged with an EVT in place and were successfully managed as outpatients. At a median follow-up of 8 months, two patients developed strictures. None of the patients required any surgical re-intervention, they tolerated oral intake, and all leakages were confirmed closed by imaging and endoscopy. DISCUSSION: Endoscopic vacuum therapy can be successfully managed through a pharyngostomy access, as described. This access is easy, comfortable, and reliable and allows for a transition to outpatient management.

Does the patch fit the stoma? A study on peristoma geometry and patch use in laryngectomized patients.

OBJECTIVE: To determine the geometry of (peri)stomas of laryngectomized patients in relation to patch use. This data will enable improvement of tracheostoma interfaces, specifically addressing patients currently unable to use stoma patches. The low use of Heat-and-Moisture-Exchange (HME) filters and (hands-free) speech valves, although very important to the quality of life of laryngectomized patients, is mainly attributed to poor fit of the adhesive patches to the stoma site. Current patch shapes are not based upon an objective (peri)stoma geometry because this geometry is unknown. DESIGN: Observational anthropometric study of the (peri)stoma of laryngectomized patients. SETTING: Ten hospitals or institutes in eight countries. PARTICIPANTS: About 191 laryngectomized patients, at least 1 year post operative. MAIN OUTCOME MEASURES: (Peri)stomas were photographed and measured. Patients completed a questionnaire on patch-use. Concavity of commercially available patches was measured. RESULTS: In countries with a financial reimbursement system 58% of the patients use patches, compares to only 9% in other countries. Patches stay in situ for an average of 33.3 h. Patch and non-patch users differ on five out of ten measured geometrical parameters. Most striking differences are that patch users have much shallower peristomas (13 versus 18 mm), and stomas far more parallel to the anterior neck plane. The deepest commercially available patch is only 7 mm deep. CONCLUSIONS: This study provides detailed (peri)stoma geometry data of a divers population, and for the first time in relation to patch-use. It reveals a serious mismatch between patients and patches. With these data new patches can be developed that could dramatically improve rehabilitation after laryngectomy.

Nasopharyngoscopic evaluation of oral appliance therapy for obstructive sleep apnoea.

This study aimed to explore the effect of mandibular advancement splints (MAS) on upper airway anatomy during wakefulness in obstructive sleep apnoea (OSA). Patients commencing treatment for OSA with MAS were recruited. Response to treatment was defined by a >or=50% reduction in the apnoea/hypopnoea index. Nasopharyngoscopy was performed in the supine position. Nasopharyngoscopy was performed in 18 responders and 17 nonresponders. Mandibular advancement caused an increase in the calibre of the velopharynx (mean+/- sem +40+/-10%), with relatively minor changes occurring in the oropharynx and hypopharynx. An increase in cross-sectional area of the velopharynx with mandibular advancement occurred to a greater extent in responders than nonresponders (+56+/-16% versus +22+/-13%; p<0.05). Upper airway collapse during the Müller manoeuvre, relative to the baseline cross-sectional area, was greater in nonresponders than responders in the velopharynx (-94+/-4% versus -69+/-9%; p<0.01) and oropharynx (-37+/-6% versus -16+/-3%; p<0.01). When the Müller manoeuvre was performed with mandibular advancement, airway collapse was greater in nonresponders than responders in the velopharynx (-80+/-11% versus +9+/-37%; p<0.001), oropharynx (-36+/-6% versus -20+/-5%; p<0.05) and hypopharynx (-64+/-6% versus -42+/-6%; p<0.05). These results indicate that velopharyngeal calibre is modified by MAS treatment and this may be useful for predicting treatment response.

[Reconstruction of the gastrointestinal tract in the absence of the oesophagus, stomach and colon, with preservation of the larynx]. / Ricostruzione del tratto alimentare in assenza dell'esofago, dello stomaco e del colon, con conservazione della laringe.

The authors report a case of reconstruction of the gastrointestinal tract in a young woman of 36 years of age who, after ingesting muriatic acid, and after a series of consecutive operations found herself without an oesophagus (from the hypopharynx) stomach and colon. She was fed with a jejunostomy and had a large pharyngostomy to prevent sialorrhoea. After one year, the patient manifested the need to resume eating by mouth. The problem was serious due both to the anastomosis above the level of the larynx and the very long period of rehabilitation. The technical problem included the need to avoid the thoracic cavity due to the previous empyema, and thus to bring a viable jejunal loop up to the neck in a subject already operated on four times. The solution was a Roux loop at the level of the 4th-5th jejunal arcade brought to the neck via a subcutaneous presternal route and anastomised in a supraglottic location at the level of the right pyriform sinus. The viability of the loop was guaranteed by an arterial shunt with a branch of the mesenteric artery by means of a segment of saphenous vein and a venous shunt over the right internal jugular vein to guarantee venous flow. The pharyngo-jejunal anastomosis was done with a 21 mm circular stapler with a rotary head after a partial parietal resection of the laryngeal cartilage and under the protection of a provisional tracheostomy. After 4 months' treatment, partly in intensive care and partly in a rehabilitation centre with logopaedic assistance, the tracheal cannula could be removed and the patient is now able to eat by mouth with normal phonation.

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.

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.

Management of an extensive tracheoesophageal fistula by cervical esophageal exclusion.

Giant tracheoesophageal fistulae occurring in ventilator-dependent patients usually result in significant ventilatory embarrassment. Cervical exclusion of the fistula can safely control the fistula and quickly restore adequate ventilation to these critically ill patients.

Gastric emptying of a radionuclide-labeled test meal after surgical correction of gastric dilatation-volvulus in dogs.

Gastric emptying of a radionuclide-labeled test meal was studied in 10 dogs that had been treated surgically for gastric dilatation-volvulus and in 10 clinically normal (control) dogs. There were no significant differences between the gastric emptying rates and patterns in treated and in control dogs. Thus, there are no indications that gastric emptying is delayed in dogs that have recovered from gastric dilatation-volvulus, and there is no reason for pyloric surgery in dogs with this condition.

[Enteral nutrition in the elderly]. / La nutrizione enterale dell'anziano.

Elderly is particularly at risk of malnutrition: he is not able to feed himself adequately, it is then important to attain correct intakes using also artificial enteral nutritional techniques (nasogastric tube, gastrostomy, etc.). These techniques may lead to complications (ab ingestis pneumonia, metabolic complications, alvus disorders): the use of artificially nutrition in the elderly must be carefully evaluated. 257 patients (M = 180, F = 77) aged 65 or more, mainly affected by neoplastic diseases (n 195) and by neurological and vascular diseases (n 62). The feeding route were evaluated in this study: 74% by nasogastric tube, 13% by gastrostomy, 11% by jejunostomy. In a group of 55 patients similar concerning clinical and nutritional conditions we evaluated at the beginning of enteral feeding and four months later, caloric/protein intake, body weight and plasmatic albumin. In patients fed by nasogastric tube a mean intake of 1300 +/- 365 Kcal n.p./die, with a protein rate of 58.5 +/- 16.9 g/die was attained; by gastrostomy 1450 +/- 324 Kcal n.p./die and 65.5 +/- 16 g/die; by jejunostomy 1219 +/- 398 Kcal n.p./die and 53.3 +/- 21 g/die. The compliance to enteral nutrition was well in 37% of patients night administration was performed. Clinical complications: nausea and vomiting were observed in 9 patients with nasogastric tube, in 1 patient with gastrostomy and in 3 patients with jejunostomy; diarrhea has been noticed in 6 patients with nasogastric tube and in 1 patient with jejunostomy. Mechanical complications; nasogastric tube (n 189): 35 displacements, 7 breakages, 4 obstructions; pharyngostomy (n 6): 2 displacements and 1 obstruction; gastrostomy (n 33): 3 displacements; jejunostomy (n 29): 2 misplacements.(ABSTRACT TRUNCATED AT 250 WORDS)

The principles and practical application of enteral nutrition.

The enteral route is the preferred method of nutritional support in patients with functional gastrointestinal tracts. Many techniques for obtaining enteral access are available, and the decision regarding which one to use depends on several issues, including the functional integrity of each part of the gastrointestinal tract, the duration of anticipated nutritional support, and the risk of aspiration and gastroesophageal reflux. Nasoesophageal tubes are useful for short-term supplementation; however, patients needing nutritional support for longer than 2 weeks may be better served with a more permanent tube. Blenderized pet food diets are recommended for nutritional support because these diets do not need to be supplemented with protein or micronutrients. Commercial human enteral formulas provide a useful alternative for patients with specific nutrient requirements or for feeding via nasoesophageal or jejunostomy tubes.

Is the laryngoplasty a successful method after total laryngectomy?

Laryngoplasty as outlined by STAFFIERI (1973) is a new surgical technique for vocal rehabilitation after total laryngectomy. After the creation of the neoglottis however many complications such as aspiration and narrowing occur. Out of 36 patients who underwent total laryngectomy and vocal rehabilitation with the technique of Staffieri 13 achieved a good result. Twenty-three patients failed to develop voice production as a result of altered swallowing function.

The feeding pharyngostomy: an alternative approach to enteral feeding.

We present a six-year retrospective review of feeding pharyngostomies as performed in this department. The indications, technique and complications of this procedure are discussed.

Laryngoplasty: results and problems after the creation of a neoglottis.

Voice rehabilitation in the laryngectomy patient has been a major goal of reconstructive laryngeal surgery. 36 patients underwent laryngectomy with the creation of a phonatory neoglottis as outlined by Staffieri. In 13 patients good voice rehabilitation was achieved. In 23 patients who failed to develop voice production, altered swallowing function was the major problem.

Swallowing in motor neurone disease.

Ninety-two patients with motor neurone disease have been assessed clinically and radiologically for evidence of swallowing problems. At the time of examination, moderate or severe swallowing difficulty was present in 89% of those whose disease had presented as bulbar palsy, in 45% of those in whom the disease began many months before as progressive muscular atrophy and in 29% of those with amyotrophic lateral sclerosis. Patients with more severe swallowing symptoms appeared more likely to have abnormal findings on videofluoroscopy overall. However, not all patients with an abnormal radiological picture had swallowing difficulties. It is suggested that radiological signs should only be used within the context of clinical symptoms and signs in the selection of patients for palliative surgery. Thirteen patients with pseudobulbar symptoms and signs had a cricopharyngeal myotomy performed: two suffered major post-operative complications. However, the satisfaction rate was 89% and we recommend cricopharyngeal myotomy for such patients. Pharyngostomy was performed for seven patients unable to initiate swallowing, six had post-operative complications.