Solution to vessels mismatch in microsurgery: Vertical arteriotomy technique

Background: Microvascular anastomosis is the key for successful free flap transplantation. Ideally, the anastomosis should maintain the flow with minimal turbulence, disruption of endothelium, and minimizing the furrow to prevent thrombosis and failure of the flap. One of the main pitfalls of micro-anastomosis is vessels size mismatch. Method and Result: There are many ways to overcome this issue, which includes forced mechanical dilation of the smaller vessel, oblique cuts, fish mouth cuts, interposition grafts, end-to-side anastomosis, coupling device, and others. Here, we report a simple technique with single customizable longitudinal arteriotomy of the smaller vessel to achieve an adequate size match to the larger vessel. It has been used for more than 10 years at our institution that allow us to achieve an end-to-end patent anastomosis. Conclusion: Vertical arteriotomy is a simple technique that in our experience achieved end-to-end anastomosis high patency rate

Metastatic Renal Cell Carcinoma to the Parotid Gland in the Setting of Chronic Lymphocytic Leukemia

Renal cell carcinoma (RCC) is infamous for its unpredictable behavior and metastatic potential. We report a case of a patient with a complex history of multifocal renal cell carcinoma and chronic lymphocytic leukemia (CLL), who subsequently developed a parotid mass. Total parotidectomy revealed this mass to be an additional site of metastasis which had developed 19 years after his initial diagnosis of RCC

Vessel Ligation in Transoral Robotic Surgery: Survey of the American Head and Neck Society

Objectives: Hemorrhage after transoral robotic surgery (TORS) surgery ranges from minor self-limited bleeding to lethal complications. To decrease risk, several publications have suggested ligation of the external carotid artery or its branches, even though statistically it has not been shown to be effective. The current study anonymously surveyed members of American Head and Neck Society (AHNS) on how they manage vessel ligation in TORS for oncological indications to better understand this practice.Methods: AHNS sent an email invitation to members with 2 weekly follow-up emails. Participants anonymously completed 10 questions regarding how long they have performed TORS, how many cancer-related TORS they have performed both overall and within the past year, timing of neck dissection, ligation of vessels, and changes in their practice.Results: In total, 165 surveys were completed by AHNS surgeons. The average respondent had performed TORS for 3–5 years and performs \u3c20 of cases for oncological purposes per year. Of the respondents, 83.7% ligate vessels. The most frequent vessels ligated were the lingual artery (77.7%), facial artery (63.3%), ascending pharyngeal artery (30.1%), superior thyroid artery (13.3%), and external carotid artery (9%). The most common reason for surgeons to ligate vessels was that it was either learned during training (28.3%) or incorporated due to suggestion or discussion with peers (28.3). Additionally, 14% were found to ligate after experiences related to fatal or near fatal patient events. Conclusions: Prophylactic vessel ligation is a common practice among AHNS surgeons. Training or discussion with peers is the most common reason for vessel ligation given, with the lingual artery being the most commonly ligated. However, the choice of which vessel to be ligated remains controversial. Further investigation should focus on the different individual vessels that are ligated and the affect that has on complication rates.https://scholarlycommons.henryford.com/merf2019clinres/1066/thumbnail.jp

Ionic composition of endolymph and perilymph in the inner ear of the oyster toadfish, Opsanus tau

Author Posting. © Marine Biological Laboratory, 2008. This article is posted here by permission of Marine Biological Laboratory for personal use, not for redistribution. The definitive version was published in Biological Bulletin 214 (2008): 83-90.The concentrations of free Na+, K+, Ca2+, and Cl-in endolymph and perilymph from the inner ear of the oyster toadfish, Opsanus tau, were measured in vivo using double-barreled ion-selective electrodes. Perilymph concentrations were similar to those measured in other species, while endolymph concentrations were similar to those measured previously in elasmobranch fish, though significantly different from concentrations reported in mammals. Perilymph concentrations (mean ± std. dev.) were as follows: Na+, 129 mmol l-1 ± 20; K+, 4.96 mmol l-1 ± 2.67; Ca2+, 1.83 mmol l-1 ± 0.27; and Cl-, 171 mmol l-1 ± 20. Saccular endolymph concentrations were Na+, 166 mmol l-1 ± 22; K+, 51.4 mmol l-1 ± 16.7; Ca2+, 2.88 mmol l-1 ± 0.27; and Cl-, 170 mmol l-1 ± 12; and semicircular canal (utricular vestibule) endolymph concentrations were Na+, 122 mmol l-1 ± 15; K+, 47.7 mmol l-1 ± 13.2; Ca2+, 1.78 mmol l-1 ± 0.48; Cl-, 176 mmol l-1 ± 27. The relatively high concentrations of Ca2+ and Na+ in the endolymph may have significant implications for the physiological function of the mechanoelectrical transduction channels in the vestibular hair cells of fish compared to those of their mammalian counterparts.This work was supported by the National Institute of Deafness and Other Communications Disorders P01 DC01837, R01 DC06685, R01 DC04928, NASA NNA-04CK67H, and NSF Igert DGE9987616

Evaluating Quality of Life and Functional Outcomes in Salvage Surgery for Head and Neck Cancer

Background: Unique challenges surround treatment for residual or recurrent head and neck squamous cell carcinoma (HNSCC). Of the limited treatment options for residual or recurrent HNSCC, salvage surgery is often the best option. However, salvage surgery can result in significant morbidity, affecting both quality of life (QoL) and functional outcomes. Few studies have examined QoL outcomes following salvage surgery in the setting of HNSCC. Objectives: To analyze head and neck related quality of life and functional outcomes in patients with head and neck cancer who underwent salvage surgery. Methods: In this IRB approved study, FACT-HN Version 4 was administered pre-operatively and 6 months post-operatively to patients undergoing salvage surgery for HNSCC between November 4, 2014 and April 27, 2020. Retrospective cohort analysis was performed on this population with major outcome being postoperative QoL score. Functional outcomes included postoperative tracheostomy and feeding tube status. QoL outcomes were compared with paired t-tests. Univariate logistic regression was used to determine characteristics associated with presence of permanent tracheostomy and feeding tube, defined as presence greater than 30 days. Results: Overall, 25 patients undergoing salvage surgery for HNSCC were included in this analysis. Primary tumor sites were larynx/hypopharynx (44.0%), oral cavity (24.0%), oropharynx (20.0%), salivary (4.0%), skin (4.0%), and unknown primary (4.0%). Salvage surgeries consisted of total laryngectomy (36.0%), definitive neck dissection (24.0%), mandibulectomy (16.0%), parotidectomy (8.0%), with total laryngectomy/total glossectomy, radical tonsillectomy, TORS base of tongue excision, and transoral laser laryngeal excision all comprising 4% of cases. Total QoL scores were not significantly different preoperatively to postoperatively (mean 108.7, 95% CI=97.7 to 119.7 vs. 103.8, 95% CI: 93.1 to 114.5; P=0.436, with maximum total score of 148). Patients with lower preoperative Emotional Well-Being (EWB) subscores demonstrated significantly worse EWB subscores postoperatively (postoperative mean: 17.0, 95% CI: 14.5 to 19.4 vs. 21.7, 95% CI: 20.0 to 23.4; P=0.002). Of patients who underwent tracheostomy tube placement, 53.8% (N=7/13) remained tracheostomy dependent long-term (\u3e30 d). Of patients who underwent feeding tube placement, 81.0% (N=17/21) remained feeding tube dependent long-term (\u3e30 d). Tracheostomy and feeding tubes remained in place with median durations of 3.02 months (range 0.16 to 20.55) and 10.13 months (range 0 to 24.89), respectively. All patients with T3/4 disease undergoing salvage surgery required long-term feeding tube (N=6). Conclusions: This study provides important information about quality of life and functional outcomes for patients undergoing salvage surgery for HNSCC. There is a high rate of long-term tracheostomy and feeding tube dependence following salvage surgery. While no difference was found in head and neck related quality of life total score and sub-scores at 6 months postoperatively, general emotional well-being preoperatively was most associated with general emotional well-being postoperatively. This information should be taken into consideration when counseling and managing patients with residual or recurrent HNSCC

Assessing Oral Intake Outcomes in Head and Neck Cancer Patients Treated with Definitive Radiation with or Without Chemotherapy

Background: Head and neck cancer treatment modalities can significantly impact functional outcomes of patients, especially oral intake (Brizel, et al N Engl J Med 1998; Kamal, et al Support Care Cancer 2019). Radiation therapy in particular has been associated with posttreatment xerostomia and dysphagia (Adelstein, et al J Clin Oncol 2003; Hutcheson, et al Cancer 2013) which can affect quality of life and impair weight gain, contributing to worse long-term outcomes (Payakachat, et al Head Neck, 2013). Early speech-language pathology intervention has shown to be effective in improving these functional outcomes in this population (Greco, et al Int J Radiat Oncol Biol Phys 2018). Objectives: The purpose of this study is to evaluate oral intake outcomes of patients undergoing definitive radiation therapy with or without chemotherapy for head and neck squamous cell carcinoma. Methods: A cohort of patients with stage III or IV squamous cell carcinoma of the oropharynx, larynx, and hypopharynx treated with definitive radiation therapy with or without chemotherapy were extracted from system database. Patients with evidence of distant metastases were excluded. Swallow function was assessed both pre- and post-treatment (within four months of treatment initiation or conclusion) with the Functional Oral Intake Scale (FOIS) (Crary et al, Arch Phys Med Rehabil, 2005) as measured by a Speech-Language Pathologist (SLP) involved in the patient\u27s care. Body mass index (BMI) was evaluated within four months of treatment initiation and one year after treatment completion. The use of enteral feeding at one-year post-treatment was also assessed. Data was analyzed with descriptive statistical methods, Wilcoxon sign rank tests, and [chi]2d tests. Results: The sample included 152 patients. Table 1 highlights patient baseline characteristics, tumor location, and treatment. FOIS scores decreased from pre-treatment to post-treatment, with 75% of patients having a FOIS of 7 at pre-treatment compared with only 13.8% at the post-treatment time point (Table 1). Median BMI also decreased from pre-treatment to one-year post-treatment (Table 2). At one-year post-treatment, 23.7% patients (n=33) required enteral feeding. Conclusions: Definitive radiation therapy with or without chemotherapy in the treatment of head and neck cancer is associated with impaired oral intake. Treatment is also associated with decreases in BMI and longer use of enteral feeding, which may reflect sequelae of impaired oral intake. These factors have a negative impact on quality of life and can lead to long-term morbidity. Integrative treatment plans would therefore benefit from speech-language pathology interventions throughout the treatment process

Assessing Oral Intake Outcomes in Head and Neck Cancer Patients Treated with Definitive Radiation with or Without Chemotherapy

Background: Head and neck cancer treatment modalities can significantly impact functional outcomes of patients, especially oral intake (Brizel, et al N Engl J Med 1998; Kamal, et al Support Care Cancer 2019). Radiation therapy in particular has been associated with posttreatment xerostomia and dysphagia (Adelstein, et al J Clin Oncol 2003; Hutcheson, et al Cancer 2013) which can affect quality of life and impair weight gain, contributing to worse long-term outcomes (Payakachat, et al Head Neck, 2013). Early speech-language pathology intervention has shown to be effective in improving these functional outcomes in this population (Greco, et al Int J Radiat Oncol Biol Phys 2018). Objectives: The purpose of this study is to evaluate oral intake outcomes of patients undergoing definitive radiation therapy with or without chemotherapy for head and neck squamous cell carcinoma. Methods: A cohort of patients with stage III or IV squamous cell carcinoma of the oropharynx, larynx, and hypopharynx treated with definitive radiation therapy with or without chemotherapy were extracted from system database. Patients with evidence of distant metastases were excluded. Swallow function was assessed both pre- and post-treatment (within four months of treatment initiation or conclusion) with the Functional Oral Intake Scale (FOIS) (Crary et al, Arch Phys Med Rehabil, 2005) as measured by a Speech-Language Pathologist (SLP) involved in the patient\u27s care. Body mass index (BMI) was evaluated within four months of treatment initiation and one year after treatment completion. The use of enteral feeding at one-year post-treatment was also assessed. Data was analyzed with descriptive statistical methods, Wilcoxon sign rank tests, and [chi]2d tests. Results: The sample included 152 patients. Table 1 highlights patient baseline characteristics, tumor location, and treatment. FOIS scores decreased from pre-treatment to post-treatment, with 75% of patients having a FOIS of 7 at pre-treatment compared with only 13.8% at the post-treatment time point (Table 1). Median BMI also decreased from pre-treatment to one-year post-treatment (Table 2). At one-year post-treatment, 23.7% patients (n=33) required enteral feeding. Conclusions: Definitive radiation therapy with or without chemotherapy in the treatment of head and neck cancer is associated with impaired oral intake. Treatment is also associated with decreases in BMI and longer use of enteral feeding, which may reflect sequelae of impaired oral intake. These factors have a negative impact on quality of life and can lead to long-term morbidity. Integrative treatment plans would therefore benefit from speech-language pathology interventions throughout the treatment process

Burnout among surgeons before and during the SARS-CoV-2 pandemic: an international survey

Background: SARS-CoV-2 pandemic has had many significant impacts within the surgical realm, and surgeons have been obligated to reconsider almost every aspect of daily clinical practice. Methods: This is a cross-sectional study reported in compliance with the CHERRIES guidelines and conducted through an online platform from June 14th to July 15th, 2020. The primary outcome was the burden of burnout during the pandemic indicated by the validated Shirom-Melamed Burnout Measure. Results: Nine hundred fifty-four surgeons completed the survey. The median length of practice was 10 years; 78.2% included were male with a median age of 37 years old, 39.5% were consultants, 68.9% were general surgeons, and 55.7% were affiliated with an academic institution. Overall, there was a significant increase in the mean burnout score during the pandemic; longer years of practice and older age were significantly associated with less burnout. There were significant reductions in the median number of outpatient visits, operated cases, on-call hours, emergency visits, and research work, so, 48.2% of respondents felt that the training resources were insufficient. The majority (81.3%) of respondents reported that their hospitals were included in the management of COVID-19, 66.5% felt their roles had been minimized; 41% were asked to assist in non-surgical medical practices, and 37.6% of respondents were included in COVID-19 management. Conclusions: There was a significant burnout among trainees. Almost all aspects of clinical and research activities were affected with a significant reduction in the volume of research, outpatient clinic visits, surgical procedures, on-call hours, and emergency cases hindering the training. Trial registration: The study was registered on clicaltrials.gov "NCT04433286" on 16/06/2020