Pectoralis major myocutaneous flap for faringeal defects reconstruction. Case report

Introduction: Pharyngocutaneous fistula after total laryngectomy (TL) remains a hardly frequent complication especially after radiotherapy. When conservative measures fail, reconstructive procedures are necessary. Our institution has adopted the pharyngeal interposition graft (PIG) using a pectoralis major myocutaneous flap (PMMC), which has adequate blood flow, for treatment post-irradiation pharyngocutaneous fistula. Description: We present a case-patient with a pharyngocutaneous fistula after TL that requires an externsive reconstruction by PMMC flap and the important role of hyperbaric oxygen therapy in the management of radiation-induced injury. Conclusions: In this era of microvascular reconstruction, the PMMC flap can safely be used for reconstruction of head and neck defects, providing cover to pharyngeal repair following salvage laryngectomy in patients who are high risk for free flaps after organ preservation protocols or patiens with a history of vascular disease.Introducción: La fístula faringocutánea post-laringectomía total (LT) continúa siendo una complicación frecuente luego de esta intervención especialmente tras tratamiento radioterápico. Cuando fracasan las medidas conservadoras, es necesario recurrir a cirugía reconstructiva. En nuestro centro se utiliza el colgajo miocutáneo de pectoral mayor (CMPM), que asegura un flujo sanguíneo adecuado para el tratamiento fístulas post-irradiación. Descripción: Presentamos un paciente con una fístula faringocutánea tras LT que requirió una amplia reconstrucción mediante CMPM asimismo discutiremos el importante papel que juega el tratamiento con oxígeno hiperbárico en el manejo de las consecuencias post-radioterapia. Conclusión: En la era de la reconstrucción microvascular, el PMMC puede ser utilizado para la reconstrucción de grandes defectos de cabeza y cuello, consiguiendo una adecuada cobertura tras protocolos de preservación de órgano o pacientes con historia de enfermedad vascular

Incidence and risk factors of pharyngocutaneus fistula formation after total laryngectomy. Review

Introduction and objective: The pharyngocutaneous fistula is a troublesome complication after total laryngectomy, increasing morbidity and mortality. We aimed to determine the incidence of pharyngocutaneus fistula after total laryngectomy and to define the possible predictors for pharyngocutaneus fistula formation. Method: We conducted a review of 31 articles with a total of 1100 patients, to evaluate the incidence of fistula in patients with total laryngectomy and risks factors involved. Results: The overall incidence of pharyngocutaneus fistula is 22,3%, and ranges from 3 to 65%. The review revealed that prior radiation treatment was the most common antecedent, following this associated comorbidity, hypoalbuminemia, anemia, and history of tracheotomy prior to laryngectomy. Discussion: Among the series studied, there is significant heterogeneity in the results, because although irradiated patients have a greater number of pharyngostomas, in some studies no relationship was found, which could explain the association with other risk factors. Conclusions: The incidence of pharyngocutaneus fistula is very variable and there are a large number of risk factors involved, the most frequent is radiotherapy associated or not with chemotherapy.Introducción y objetivo: La fístula faringocutánea tras la laringectomía total es una complicación que conlleva un incremento de la morbilidad y mortalidad. Realizamos una revisión con el objetivo de identificar los factores que implican un aumento de su incidencia. Método: Se realizó una revisión de 31 artículos con un total 1100 pacientes con esta complicación, recogiéndose su incidencia del total de laringectomías totales realizadas, así como los factores de riesgo asociados a su aparición. Resultados: La incidencia de esta complicación se estima en un 22,3% con un rango que oscila de un 3 al 65% entre todas las series incluidas en la revisión. De la totalidad de factores de riesgo implicados, el que aparece con mayor frecuencia es la radioterapia preoperatoria, seguida de la comorbilidad asociada, hipoalbuminemia, anemia y antecedentes de traqueotomía previa a la laringectomía. Discusión: Los pacientes irradiados tienen mayor número de faringostomas. Aun así, según las series estudiadas, hay una heterogeneidad en los resultados pues en algunas no se encuentra relación, lo que podría explicarse por la asociación con otros factores de riesgo. Conclusiones: La incidencia en la formación de fístulas faringocutáneas es muy variable y existe un gran número de factores de riesgo implicados siendo el más frecuente la radioterapia asociada o no a quimioterapia

Geoeconomic variations in epidemiology, ventilation management, and outcomes in invasively ventilated intensive care unit patients without acute respiratory distress syndrome: a pooled analysis of four observational studies

Background: Geoeconomic variations in epidemiology, the practice of ventilation, and outcome in invasively ventilated intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) remain unexplored. In this analysis we aim to address these gaps using individual patient data of four large observational studies. Methods: In this pooled analysis we harmonised individual patient data from the ERICC, LUNG SAFE, PRoVENT, and PRoVENT-iMiC prospective observational studies, which were conducted from June, 2011, to December, 2018, in 534 ICUs in 54 countries. We used the 2016 World Bank classification to define two geoeconomic regions: middle-income countries (MICs) and high-income countries (HICs). ARDS was defined according to the Berlin criteria. Descriptive statistics were used to compare patients in MICs versus HICs. The primary outcome was the use of low tidal volume ventilation (LTVV) for the first 3 days of mechanical ventilation. Secondary outcomes were key ventilation parameters (tidal volume size, positive end-expiratory pressure, fraction of inspired oxygen, peak pressure, plateau pressure, driving pressure, and respiratory rate), patient characteristics, the risk for and actual development of acute respiratory distress syndrome after the first day of ventilation, duration of ventilation, ICU length of stay, and ICU mortality. Findings: Of the 7608 patients included in the original studies, this analysis included 3852 patients without ARDS, of whom 2345 were from MICs and 1507 were from HICs. Patients in MICs were younger, shorter and with a slightly lower body-mass index, more often had diabetes and active cancer, but less often chronic obstructive pulmonary disease and heart failure than patients from HICs. Sequential organ failure assessment scores were similar in MICs and HICs. Use of LTVV in MICs and HICs was comparable (42·4% vs 44·2%; absolute difference -1·69 [-9·58 to 6·11] p=0·67; data available in 3174 [82%] of 3852 patients). The median applied positive end expiratory pressure was lower in MICs than in HICs (5 [IQR 5-8] vs 6 [5-8] cm H2O; p=0·0011). ICU mortality was higher in MICs than in HICs (30·5% vs 19·9%; p=0·0004; adjusted effect 16·41% [95% CI 9·52-23·52]; p<0·0001) and was inversely associated with gross domestic product (adjusted odds ratio for a US$10 000 increase per capita 0·80 [95% CI 0·75-0·86]; p<0·0001). Interpretation: Despite similar disease severity and ventilation management, ICU mortality in patients without ARDS is higher in MICs than in HICs, with a strong association with country-level economic status