Fluorescence Imaging of Nerves During Surgery Walsh, Erika M; Cole, Denzel; Tipirneni, Kiranya E ...
Annals of surgery,
2019-July, 2019-07-00, 20190701, Letnik:
270, Številka:
1
Journal Article
Recenzirano
OBJECTIVE:This review details the agents for fluorescence-guided nerve imaging in both preclinical and clinical use to identify factors important in selecting nerve-specific fluorescent agents for ...surgical procedures.
BACKGROUND:Iatrogenic nerve injury remains a significant cause of morbidity in patients undergoing surgical procedures. Current real-time identification of nerves during surgery involves neurophysiologic nerve stimulation, which has practical limitations. Intraoperative fluorescence-guided imaging provides a complimentary means of differentiating tissue types and pathology. Recent advances in fluorescence-guided nerve imaging have shown promise, but the ideal agent remains elusive.
METHODS:In February 2018, PubMed was searched for articles investigating peripheral nerve fluorescence. Key terms used in this search include“intraoperative, nerve, fluorescence, peripheral nerve, visualization, near infrared, and myelin.” Limits were set to exclude articles exclusively dealing with central nervous system targets or written in languages other than English. References were cross-checked for articles not otherwise identified.
RESULTS:Of the nonspecific agents, tracers that rely on axonal transport showed the greatest tissue specificity; however, neurovascular dyes already enjoy wide clinical use. Fluorophores specific to nerve moieties result in excellent nerve to background ratios. Although noteworthy findings on tissue specificity, toxicity, and route of administration specific to each fluorescent agent were reported, significant data objectively quantifying nerve-specific fluorescence and toxicity are lacking.
CONCLUSIONS:Fluorescence-based nerve enhancement has advanced rapidly over the past 10 years with potential for continued utilization and progression in translational research. An ideal agent would be easily administered perioperatively, would not cross the blood-brain barrier, and would fluoresce in the near-infrared spectrum. Agents administered systemically that target nerve-specific moieties have shown the greatest promise. Based on the heterogeneity of published studies and methods for reporting outcomes, it appears that the development of an optimal nerve imaging agent remains challenging.
Objective
To discuss the current available techniques for intraoperative margin assessment in the surgical treatment of oral squamous cell carcinoma (OSCC) through a review of the available ...literature.
Methods
A systematic review was undertaken of the available English literature between 2008 through 2018 regarding surgical margins in OCSS. A total of 893 relevant articles were returned; 144 met criteria for review; and 64 articles were included.
Results
In this review, we discuss the data surrounding the use of frozen section in OCSS. Additionally, alternative techniques for margin assessment are discussed, including Mohs, molecular analysis, nonfluorescent dyes, fluorescent dyes, autofluorescent imaging, narrow‐band imaging, optical coherence tomography, confocal microscopy, high‐resolution microendoscopy, and spectroscopy. For each technique, particular emphasis is placed on the local recurrence, disease‐free survival, and overall survival rates when available.
Conclusion
This review provides support for the practice of specimen‐driven margin assessment when using frozen section analysis to improve the utility of the results. Finally, several alternatives for intraoperative margin assessment currently under investigation, including pathologic, wide‐field imaging and narrow‐field imaging techniques, are presented. We aim to fuel further investigation into methods for margin assessment that will improve survival for patients with OSCC through a critical analysis of the available techniques.
Level of Evidence
NA Laryngoscope, 130:128–138, 2020
Background
Perioperative management of advanced osteoradionecrosis of the head and neck requiring free flap (FF) reconstruction varies. Our objectives included assessment of practice patterns and ...outcomes.
Methods
Multi‐institutional, retrospective review of FF reconstruction for head and neck osteoradionecrosis (n = 260).
Results
Administration of preoperative antibiotics did not correlate with reduction in postoperative complications. Preoperative alcohol use correlated with higher rates of hardware exposure (p = 0.03) and 30‐day readmission (p = 0.04). Patients with FF compromise had higher TSH (p = 0.04) and lower albumin levels (p = 0.005). Prealbumin levels were lower in patients who required neck washouts (p = 0.02) or a second FF (p = 0.03). TSH levels were higher in patients undergoing postoperative debridement (p = 0.03) or local flap procedures (p = 0.04).
Conclusion
Malnutrition, hypothyroidism, and substance abuse correlated with a higher incidence of postoperative wound complications in patients undergoing FF reconstruction for advanced osteoradionecrosis. Preoperative antibiotics use did not correlate with a reduction in postoperative wound complications.
To depict the current state of global surgery opportunities in United States ACGME-approved Otolaryngology residency programs and compare the characteristics of programs with and without these ...opportunities.
In this cross-sectional analysis, websites of ACGME-accredited Otolaryngology residency programs were analyzed for information on program size, rank, age, and geographic region as obtained through the Doximity platform in 2023. Additional parameters were obtained for programs listing global surgery opportunities such as funding, faculty oversight, location/region, focus, and relationship to the community served. Data were tabulated and analyzed in Microsoft Excel and Stata.
Of the 131 ACGME-accredited Otolaryngology residency programs, 26 (20%) of programs advertised a global surgery opportunity. Nine (35%) of these promoted funding, 15 (58%) offered a clinical focus, one (4%) offered a research focus, and 10 (38%) offered a combined approach. The Midwest region had the most programs with global surgery opportunities (n = 8, 31%). Less than half (42%) of programs had an established partnership with local partners within low and middle-income countries (LMICs). When comparing programs, the average Doximity rank, average program age, and average program size of programs that offered global surgery opportunities was significantly higher than those that did not (37.2 vs. 71.5, 54 vs. 41, 19.5 vs. 13.7; all p < 0.05).
Approximately one-fifth of Otolaryngology training programs have a global surgery opportunity. Programs that offer these opportunities had a higher Doximity ranking, older program age, and a larger trainee cohort. These results highlight potential areas for expanding global surgery opportunities in academic institutions.
N/A Laryngoscope, 2024.
Head and neck free-flap salvage Olinde, Lindsay M.; Farber, Nicole I.; Kain, Joshua J.
Current opinion in otolaryngology & head and neck surgery,
10/2021, Letnik:
29, Številka:
5
Journal Article
Purpose of review
To highlight three clinical arenas in which head and neck free-flap compromise is encountered and acted upon: nonoperative, operative and postoperative realms.
Recent findings
Time ...to identification and intervention is paramount to successful free-flap salvage. Surgical microvascular revision remains chief amongst strategies to revert vascular compromise of a free-flap. Adjuncts, such as thrombolytics and systemic anticoagulation have an important role in the complex work of microvascular free tissue care. Venous congestion of free flaps holds favorable for salvage when compared with arterial insufficiency.
Summary
Vascular compromise of head and neck free flaps is a rare and feared event for microvascular surgeons, with successful transfers rates approaching above 95%. Success in salvage is dependent on prompt identification of tissue compromise and timely, directed interventions to re-establish tissue perfusion.
Objective/Hypothesis
To appraise the utility of a novel EMR‐based checklist for complex head and neck microvascular free‐tissue reconstruction.
Study Design
A prospectively collected retrospective ...matched cohort study from a single tertiary care academic institution.
Methods
A retrospective matched cohort study from an academic tertiary care center with 76 total patients analyzed for disease‐specific and quality outcomes before and after implementation of an EMR‐based checklist tailored to complex head and neck care. The intervention group consisted of 38 consecutive patients undergoing microvascular free tissue reconstruction after implementation of the EMR‐based checklist strategy. A historic cohort of 38 patients was derived by matching patients meticulously for disease‐specific and surgical characteristics. Primary outcomes included post‐operative medical and surgical complications, intensive care requirements, 30‐day reoperation rates, hospital length of stay, and completion of preoperative metastatic evaluations. Secondary outcomes included patterns of antibiotic administration, ultimate discharge dispositions, flap survival, and recognition of preoperative hypothyroidism in previously radiated patients.
Results
Implementation of the perioperative checklist yielded an overall reduction in major medical complications (10.5% vs. 29.0%, P < .05*), post‐operative antibiotic administration (17.4% vs. 44.7%, P < .05*), hospital length of stay (median (IQR) days 6 (1) versus 7 (3.25), P < .05*), and improved metastatic evaluation completion (92.1% vs. 63.2%, P < .05*). There was an improved discharge disposition (92.1% vs. 73.7%, P < .05*). No difference was observed in major wound complications (50.0% vs. 57.9%, P = .49), 30‐day re‐operation rates (31.5% vs. 34.2%, P = .81), 30‐day readmission rates (21.1% vs. 21.1%, P > .99), escalations to intensive‐care (13.2% vs. 21.1%, P = .36), or flap survival (97.4% vs. 89.5%, P = .17).
Conclusions
Use of our EMR‐based perioperative checklist reduced major medical complications, post‐operative antibiotic administration, hospital length of stay, and improved discharge outcomes for patients undergoing microvascular free‐tissue reconstruction.
Level of Evidence
3 Laryngoscope, 131:E2251–E2256, 2021
Intravenous acetaminophen is a commonly prescribed analgesic for the prevention and treatment of postsurgical pain. Its efficacy in the context of endoscopic sinus surgery (ESS) has yielded mixed ...results.
To compare the efficacy of perioperative intravenous acetaminophen (IVAPAP) with that of placebo in improving early postoperative pain after endoscopic sinus surgery (ESS).
A prospective, randomized clinical trial including 62 patients undergoing ESS for chronic rhinosinusitis in a single tertiary referral hospital.
Participants were randomized to receive 1 g of IVAPAP or 100 mL of placebo consisting of saline infusions immediately before the start of surgery and 4 hours after the initial dose.
The primary outcome was postoperative pain measured by visual analog scale (VAS) scores up to 24 hours after surgery by blinded observers. Secondary endpoints included postoperative opioid (intravenous and oral) use and adverse events in the 24-hour postoperative period.
Of the 62 enrolled adult participants, 60 were randomized (31 to IVAPAP intervention and 29 to placebo). The mean (SD) age of participants was 53.7 (14.7) years and 35 (58%) of the participants were men and 25 (42%) were women. Within the first hour, mean pain scores were reduced in the IVAPAP group compared with the control group, reaching a maximum difference of 7.7 mm on a VAS scale favoring the treatment group with a true difference possibly as high as 22 mm, and the data are compatible with a clinically meaningful difference. At 12- and 24-hours, average pain scores were less in the placebo group and the data are compatible with a clinically meaningful difference of 5.8 (-5.2 to 16.8) and 8.2 (-1.9 to 18.4), respectively, favoring the placebo group. However, at all time points the CIs included the null value and were wide, thus preventing definitive conclusions. Inspection of the secondary outcomes favored IVAPAP, but the wide range of the CIs and inclusion of the null value prevent definitive conclusions.
The results of this study are inconclusive. The data suggest that perioperative intravenous acetaminophen may reduce immediate postoperative pain and opioid requirements compared with placebo and these differences could be clinically meaningful. Unfortunately, the imprecision of the estimates prevents definitive conclusion. Use of IVAPAP does not seem to increase adverse events.
clinicaltrials.gov Identifier: NCT01608308.
Abstract
Laryngeal cancers are one of the most common head and neck malignancies and can lead to significant morbidity and mortality. Although they most commonly originate from squamous cell ...carcinoma, there are multiple different pathologies that can arise. We present a patient with an atypical presentation of a glottic mass for which final pathology revealed a leiomyosarcoma (LMS). We report the first case in the English literature of a large bulky LMS that was removed entirely through a partial vertical laryngectomy and pharyngectomy, with maintained swallow and speech function postoperatively.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Abstract
Squamous cell carcinoma predominates as the most common malignant lesion of the oropharynx with human papilloma virus-associated disease now predominant over tobacco-related oropharynx ...cancer. Other rare malignant pathologies can manifest as visible neoplasms in these anatomic sites with varying degrees of symptoms such as dysphagia, odynophagia, otalgia, aspiration, hemorrhage, weight loss and dyspnea. We present a case of a rarely encountered primary oropharyngeal sarcoma managed by single-port transoral robotic resection and a selective cervical lymph node dissection followed by adjuvant radiotherapy.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Cases of delayed osteoradionecrosis (ORN) of the anterior skull base have unique management considerations. A 59-year-old woman with a history of basaloid squamous cell carcinoma of the sinonasal ...cavity with intracranial extension through the anterior skull base developed delayed radiation sequelae of anterior skull base ORN. She underwent an initial endoscopic resection in 2011 with persistent disease that required an anterior craniofacial resection with left medial maxillectomy in 2012. She had a radiologic gross total resection with microscopic residual disease at the histologic margins prompting adjuvant chemoradiotherapy to target volume doses of 66 to 70 Gy with concurrent cisplatin chemotherapy. She subsequently developed an intracranial abscess in 2021 along the anterior skull base that required a craniotomy and endoscopic debridement. Despite aggressive surgical and medical therapy, she had persistent intracranial infections and evidence of skull base ORN. She ultimately underwent a combined open bifrontal craniotomy and endoscopic resection of the necrotic frontal bone and dura followed by an anterolateral thigh free flap reconstruction with titanium mesh cranioplasty. The patient recovered well from a microvascular free-tissue reconstruction without concern for cerebrospinal fluid leak. Anterior skull base reconstruction with free tissue transfer is a commonly utilized method for oncologic resections. Here, an anterolateral free flap was effectively used to treat an anterior skull base defect secondary to a rare indication of skull base ORN.
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